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HIV-free survival at 9-24 months among children born to HIV infected mothers in the National Program for the prevention of mother-to-child transmission of HIV in Rwanda: a household survey. - PowerPoint PPT PresentationTRANSCRIPT
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HIV-free survival at 9-24 months among children born to HIV infected mothers in the
National Program for the prevention of mother-to-child transmission of HIV inRwanda: a household survey
N. Shema1, L. Tsague2, J.D.D. Bizimana3, P. Mugwaneza1, A. Lyambabaje3, E. Munyana2, J. Condo3, J.C. Uwimbabazi4, E. Rugigana3, J. Muita2
1- TRACPlus/Ministry of Health; Kigali, Rwanda; 2- UNICEF – Rwanda; 3- National University of Rwanda, School of Public Health; 4 - National Reference Laboratory ; Kigali, Rwanda
ADD LOGO TRACPLUS and MOH
REPUBLIC OF RWANDA
MINISTRY OF HEALTH
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Maternal and Child Heath Indicators, Rwanda, (DHS 2005, Mini DHS 2008)
• Fertility rate– 6.1→ 5.5 children per woman
• At least 1 ANC visit uptake– 94% → 96%
• Delivery assisted by trained health care worker – 24% → 63%
• Immunization coverage in children– 94.8% for DPT1 ( DHS 2008)
2
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Rwandan National PMTCT program Millestones (1999-2009)
3
3. Initial sites expansion (GF, MAP)1. PMTCT pilot
project (Kicukiro)
2. TRAC definesNational PMTCT program based on Sd-NVP regimen
5 – Initial expansio of early infant HIV diagnostic (DBS-PCR)- Expansion of More Ef-
ARV - PMTCT Acceptability
study
1999 - 2000 2001 2002-2004 2005-2006 2007– 2008
4. - More Efficacious ARV regimens and early infant diagnostic using DBS-PCR introduced; - PMTCT and ART program Scale-up (GF, PEPFAR)
2009–
6. – Transition to MER-ARV; - Impact study of national
PMTCT program- Adaptation of 2009 WHO
ARV recommendations for PMTCT
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4
Package of services for Mother-infant pair in the PMTCT program, Rwanda, 2009
HIV+ pregnant women• Routine opt-out counseling and HIV testing
(Promotion of couple counseling and testing)• Laboratory investigation: FBC, CD4 count , routine
pregnancy check-up, liver function
• Routine pregnancy medications: Malaria prevention (Bed nets), anemia prevention (Iron/Folic acid), etc..
• ARV prophylaxis HAART for women eligible Bi-prophylaxis (AZT+SdNVP; Tail AZT/3TC) Sd-NVP ; Tail AZT/3TC (discordant couple, labor
room CT)
• Safe practices delivery• Infant feeding counseling and support• Family planning services• Psychosocial and adherence support
HIV exposed infants• Post-exposure ARV prophylaxis
– Sd-NVP + AZT (4 weeks)
• Drug package (CTX prophylaxis)– CTX starts at 6 weeks
• Clinical monitoring– Growth monitoring– Symptoms of early HIV infection
• Early Infant diagnostic (DBS-PCR)– DNA-PCR
• PCR1: at 6 weeks• PCR2: 6 weeks before end of BF
• Serology • 9 months (1rst)• 18 months (2nd)
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Study Objectives
• Evaluate the effectiveness of the national PMTCT program in Rwanda 8 years after its inception. – The outcome variables were:
Prevalence of HIV infection among 9-24 month old exposed children
Risk of dying by 9 months among HIV exposed children HIV-free survival at 9 months
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Methods (1)• Design: Cross-sectional household survey between February - May
2009
• Population: HIV+ and HIV- mothers who were expecting a child between March 2007 and June 2008 and have used antenatal services in Rwanda and their 9-24-month-old children.
• Sampling strategy: Two-stage cluster sampling (Health facilities; pregnant women in ANC)
• Ethical considerations: Study protocol was approved by the Rwanda National Ethics Committee and the National Institute of Statistics.
• Statistical analysis: Quantitative data was analyzed in Stata 10.1.
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Results
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HIV + mothers
HIV – mothers
P-value
Age, %, y (n=2969)15-2425-2930-3435-3940-4445-49
Mean age, y
9.9924.7429.0024.53
9.851.89
32.18
21.4630.7522.5615.54
7.801.89
30.09
0.000
Marital status, % (n=2963)Single/never marriedLives with a partner
Separated/divorced/widowed
8.5469.0022.46
6.3287.68
6.00
0.000
Religion, % (n=2970)No religion
AdventistCatholic
ProtestantMuslimOthers
1.619.85
42.5340.64
4.191.19
0.919.88
45.7141.03
1.690.78
0.001
Socio-demographic characteristics of the respondents by HIV status
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HIV + mothers
HIV – mothers
P-value
Educational attainment, % (n=2965)Never attended school
Primary schoolVocational/technical
Secondary schoolUniversity
24.7267.58
2.594.830.28
23.0369.49
1.765.660.07
0.155
Literacy, % (n=2969)can't or have difficult reading and/or writing
can read but can't or have difficult writing can read and write easily
40.044.82
55.14
36.153.97
59.88
0.029
Socio-demographic characteristics of the respondents by HIV status
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Among HIV+ mothers, having completed at least four ANC visit is associated with delivering at the health
centersHIV + Mothers Total (n=1434)
All Less than 4 ANC visits 4 or more ANC visits P-value
Child given ARV at birth, (n=1394)
NoneNVP
Dual therapyDon’t know
5.6738.4534.5821.31
6.6838.9234.5119.90
4.3337.8334.67
23.17
0.0955
Mother delivered at health center, (n=1445)
YesNo
89.48 10.52
86.63 13.27
93.33 6.67
0.0000
Feeding options at birth, (n=1352)
EBFBF and early cessation
FormulaAnimal modified milk
50.1533.1410.06
6.66
57.9657.3758.0947.78
42.0442.6341.9152.22
0.328
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24 months Child survival by maternal HIV status, Rwanda National PMTCT program , 2009
• Kaplan-Meier survival analysis shows that children whose mothers are HIV negative are more likely to survive longer than children born to HIV+ mothers (p<0.001).
• Between 0-6 months, child survival is comparable.
• Note that survival deteriorates between 6-18 months among children born to HIV positive mothers.
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24 months Child survival by maternal ANC visits, Rwanda National PMTCT program , 2009
• Kaplan-Meier survival analysis shows that children whose mothers attended less than 4 ANC visits had poorer survival than children whose mothers attended more ANC visits (p=0.02).
• This factor seems to be associated to early child mortality (0-6 months).
• Survival deteriorates further between 6-18 months among children born to HIV positive mothers.
0.90
0.92
0.94
0.96
0.98
1.00
Cum
ulat
ive
surv
ival
0 2 4 6 8 10 12 14 16 18 20 22 24Child Age
less than 4 ANC 4 or more ANC visits
Child survival by number of ANC visits
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9-24 month HIV-free survival in National PMTCT program, Rwanda, 2009
Unweighted Total
No%(95%CI)
Yes%(95%CI)
Death 1455 97.25 (96.34-98.16) 2.75(1.84-3.65)
HIV infection 1340 96.04(95.28-.96.81) 3.96(3.19-4.72)
HIV infection and death among
exposed children
1380 93.26(92.05-.94.47) 6.74(5.53-7.95)
• 2.75% exposed children died by the age of 9 months • 3.96% among the 1340 exposed children alive were HIV infected. • HIV-free survival was estimated at 93.26 %( 95%CI: 92.05%-94.47%) at 9-24
months• The risk of death in children born to HIV+ mothers is 3.5 times higher as
compared to children born to HIV- mothers (aHR: 3.51, 95% CI: 1.73-7.10) independently of child HIV status.
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Multivariate analysis of determinants of HIV infection or death among HIV exposed children, National PMTCT program, Rwanda, 2009
Child HIV infection or death Adjusted OR 95% CI
ARV taken by the mother, (reference: none)NVP alone
Dual therapyTriple therapy
1.610.590.49
0.98 – 2.650.27 – 1.29
0.28 – 0.86
Location, (reference: rural)Urban
0.47
0.18 – 1.25
Membership to a PLWH association, (reference: no)
Yes
0.61
0.39 – 0.94
• Children whose mothers received highly active antiretroviral therapy (HAART) were 50% less likely to be infected by HIV and/or died compared to children whose mothers did not receive any ARV during pregnancy (adjusted Odd Ratio (aOR): 0.49, 95%CI:0.28-0.86).
• Being a member of an association of people living with HIV (PLWH) (aOR=0.61, 95%CI: 0.39-94) was also associated with a 39% reduced likelihood of HIV infection or death in children.
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Conclusions • HIV free-survival among HIV exposed children is high (93.3%) by 9-24 months in
Rwanda,
• However, survival among children born to HIV infected mothers decreases overtime as compared to the one of children born to HIV- mothers. Survival deteriorates further after 6 months of age among HIV exposed infants.
• The risk of death in children born to HIV+ mothers is 3.5 times as higher as in children born to HIV- mothers (aHR: 3.51, 95% CI: 1.73-7.10) independently of child HIV status.
• The key determinants of HIV free-survival in the national PMTCT program include maternal initiation of highly active antiretroviral therapy (HAART) during pregnancy (adjusted Odd Ratio (aOR): 0.49, 95%CI:0.28-0.86) and being a member of an association of people living with HIV (PLWH) (aOR=0.61, 95%CI: 0.39-94).
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Acknowledgments
• All mothers and family who participated in the study• All staff from the selected sites• Staff at the National Reference Laboratory• All HIV&AIDS implementing partners• National University of Rwanda School of Public Health• UNICEF for technical and financial support
School of Public Health
NNRLR
L