pmtct decentralization does not assure optimal service delivery :

Washington D.C., USA, 22-27 July 2012www.aids2012.org

PMTCT decentralization does not assure optimal service delivery:

revelations from successful individual-level tracking of HIV-infected mothers and their infants

Andrew EdmondsDeidre ThompsonVitus OkitolondaLydia FeinsteinBienvenu KawendeFrieda Behets

for the PMTE team

Background• Essential services for the prevention mother-to-child

HIV transmission (PMTCT) are being increasingly decentralized to antenatal care (ANC) sites

• However, the consequences of shifting services from dedicated HIV care and treatment (C&T) clinics remain incompletely explored– Rwanda: differences between stand-alone and full package

sites (Tsague et al. BMC Public Health 2010, 10:753)– HIV-exposed infants are often not DNA PCR tested at ANC or

immunization sites (Ciaranello et al. BMC Medicine 2011, 9:59)

Context• The University of North Carolina at Chapel Hill (UNC)

has assisted with implementation of HIV prevention, care, and treatment the Democratic Republic of Congo (DRC) since 2003

• PMTCT activities– HIV testing ~63,000 women/year

(49 sites)– Scaling up to ~100,000 women/year

(105 sites)– HIV prevalence ~1.3%

Locations and characteristics of 44 maternities providing vertical HIV prevention services and 2 comprehensive care and treatment sites

PMTCT Ya Sika• In October 2010, an enhanced standard of care was

introduced at the UNC-supported ANC sites– Personnel were retrained to implement co-located post-

delivery care and the 2010 World Health Organization PMTCT guidelines including Option A

– They were also provided with new individual-level tracking tools and supportive supervision

– HIV-infected “mother-mentor” clinic volunteers

• The ANC sites became decentralized in waves– Sites that had not yet been fully decentralized continued to

refer all HIV-infected women to the care and treatment sites

Purpose

• We compared service delivery at ANC and HIV C&T clinics in Kinshasa, DRC, a low HIV prevalence, resource-deprived setting

Mother Infant Register

Tracking of individual-level data for the mother-infant pair across the PMTCT spectrum

Epi Info database for Mother Infant Register (mother data)

Epi Info database for Mother Infant Register (infant data)

New or previous HIV diagnosis

Pregnancy stage at arrival

CD4 test during pregnancy

ARVs before delivery

Referred to C&T

Accepted C&T referral

Referral location

Arrival at KLL/Bomoi

Projected Delivered

Complete maternal regimen

Infant delivery outcome

Infant NVP at delivery

Infant ≥ 1 month of age

Visit ≥ 1 month of age

Infant extended NVP

PCR test

Infant cotrimoxazole

0 200 400 600 800 1000 1200 1400 1600

1573 HIV+ women (and their infants) individually tracked at 49 maternities in Kinshasa, DRC, 10/2010-4/2012 (includes follow-up data from 2 care and treatment centers)

New Previous1573

≤ 28 weeks >28 weeks, before L&D L&D Other before L&D

Projected delivered

Facility, paid deliveryFacility, free delivery

Projected not deliv-ered

No information

Non-facility

None AZT ART

KLL/Bo-moi

Other Unknown

LTF Under tracking At maternity

None NVP only ARTAZT

LTF Under tracking

(some women are still preg-nant)

88 of 1047 infants died, 8% of the total

28 of 523 infants positive (5%). 5 in-fants had mothers who received AZT+NVP; 17 infants had mothers who received NVP only; 3 infants had mothers who receievd ART.

(212 ≤ 350; 254 > 350; 64 no re-sult)

40% of women who presented while pregnant

93% of women

89% of referred women

87% of infants

57% of infants ≥ 1 month of age

Referred to C&T

Referral location

Projected Delivered

Infant extended NVP

PCR test

0 200 400 600 800 1000 1200 1400 1600

New Previous1573

Projected delivered

No information

Non-facility

None AZT ART

KLL/Bo-moi

Other Unknown

LTF Under tracking

(212 ≤ 350; 254 > 350; 64 no re-sult)

93% of women

87% of infants

Referred to C&T

Referral location

Projected Delivered

Infant extended NVP

PCR test

0 200 400 600 800 1000 1200 1400 1600

New Previous1573

Projected delivered

No information

Non-facility

None AZT ART

KLL/Bo-moi

Other Unknown

LTF Under tracking

(212 ≤ 350; 254 > 350; 64 no re-sult)

93% of women

87% of infants

Referred to C&T

Referral location

Projected Delivered

Infant extended NVP

PCR test

0 200 400 600 800 1000 1200 1400 1600

New Previous1573

Projected delivered

No information

Non-facility

None AZT ART

KLL/Bo-moi

Other Unknown

LTF Under tracking

(212 ≤ 350; 254 > 350; 64 no re-sult)

93% of women

87% of infants

• No evident improvement over time in CD4 test provision• Decentralization did provide a new point of access

– Several hundred women and infants received services at the level of the maternity

Conclusions• Detailed individual-level tracking of mothers and infants

was feasible in Kinshasa • It revealed that PMTCT services were delivered less

effectively at sites historically focused on ANC rather than HIV C&T

• Logistical barriers pose a significant challenge but can be overcome

• While decentralization increased access to services, its potential to further reduce vertical transmission cannot be fully realized without sustained training, supervisory support, and site-specific real-time data quality monitoring

pmtct decentralization does not assure optimal service delivery :

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