pmtct program in arua uganda lessons learned after 5 years of experience experts roundtable 23-24...
TRANSCRIPT
PMTCT program in Arua Uganda Lessons learned after 5 years of
experience
Experts Roundtable 23-24 June 2008
Geneva
Arua PMTCT program (1)• Started in January 2000
• 1st ante-natal visit : HIV voluntary counselling & testing
• HIV+ enrolled in PMTCT program
Arua PMTCT program (2)
• National PMTCT protocol (2000 to 2005)
– Mother : NVP at labour onset
– Infant : AZT (1 wk) or NVP (<72 h)
• Follow-up
– Cotri prophylaxis + feeding education
– Infant formula (up to June 2004)
Arua PMTCT program (2)
• National PMTCT protocol
(2000 to 2005)
– Mother : AZT from 36 wk or NVP at
labour onset or ART
– Infant : AZT (1 wk) or NVP (<72 h)
• Follow-up
– Cotri prophylaxis + feeding
education
– Infant formula (up to June 2004)
Pregnant women in ANCn=30 536
Pre-test counselingn=22 105 (72%)
HIV-test refused Routine ANCn=3 088 (14%)
HIV-testedn=19 017 (62%)
HIV– n=17 980
(95%)
HIV +n=1 037 (5%)
PMTCT n=517
(49.8%)
Routine ANCn=520
(50.2%)
Objectives
• Describing characteristics of mothers & infants
• Quantifying and describing reasons for loss to
follow-up (LTFU)
• Estimating HIV transmission
Evaluate the performance of the PMTCT program of Arua by:
Methods (1)
• Retrospective cohort analysis
– Inclusion: Women enrolled in PMTCT between July 2000-July 2005
• Description of infant outcomes
• Active tracing of LTFU
• Cross-sectional survey
– Interview of caregivers (reasons for LFU)
– Clinical examination and HIV testing for infants
Methods (2)
• Survival Analyses (Kaplan-Meier)
• HIV transmission
– HIV testing for children alive
– HIV-related deaths*:
• severe infection or persistent diarrhoea AND
• > 1 HIV-related symptom at last MCH visit
• Risk factors for HIV-transmission (multiple logistic
regression)
* Ghent Int. Working Group on MTCT of HIV
Lost to follow-up
53%
Actively followed
16%
Died 17%
Follow-up completed
14%
Results: PMTCT Program (July 2000 – July 2005)
• Enrolled:
– Mothers (N=517)
– Infants (N=567)
Infant outcomes (n=567)
Lost to follow-up
untraceable30%
Lost to follow-up & traced
23%
Actively followed
16%
Died 17%
Follow-up completed
14%
Results: PMTCT Program (July 2000 – July 2005)
• Enrolled:
– Mothers (N=517)
– Infants (N=567)
• Cross-sectional survey
– Mothers (N= 327, 63%)
– Infants (N= 368, 65%)
Infant outcomes (n=567)
Maternal characteristics at PMTCT enrolment (N=327)
32 (10)On ART368 [200 -535]Median CD4+ cells/ml; n=201 [IQR]
5 (2) 164 (50) 144 (44)
13 (4)
WHO stage (%) Asymptomatic Stage I/II Stage III Stage IV
4 (1) 72 (22)
233 (71) 18 (6)
Trimester of pregnancy (%) First Second Third At/after birth
28 [25-32] Median age (yr) [IQR]
Newborn characteristics (N=368)
Place of delivery (%) Arua Regional Hospital Home/on the way Health centre/other hospital
280 (76)70 (19)
17 (5)
Female (%) 182 (50)
Median weight, kg [IQR] (n=334) 3 [2.7 - 3.4]
Timing of ARV start for mother ART ≥ 3 months before birth ART < 3 months before birth NVP prophylaxis at birth AZT prophylaxis at birth None
44 (12) 21 (6)
253 (69)19 (5) 24 (7)
ARV post-partum prophylaxis (%) NVP single dose AZT one week None
288 (78) 12 (3)
65 (18)
Follow-up characteristics of infants (N=368)
Median nb of post-natal consultation visits [IQR] 4 [0 -9]
Type of feeding received (%)
Exclusive breastfeeding
Exclusive infant milk formula
Mixed feeding
103 (29)
96 (27)
154 (44)
Median age at weaning start [IQR] (n=353) 6 [4 - 6]
HIV transmission
• 8.3% (24 / 288) of children were HIV+
• Overall transmission = 15.5% (57 / 367)
Risk factors for MTC HIV transmission*
CharacteristicsHIV+
(%)
Multivariate analysis
OR (95% CI) p-value
Age (yr) >=25 vs. <25 9 (9) 0.4 (0.1- 1.2) 0.09
WHO stage 3/4 vs 1/2 7 (9) 0.7 (.22 - 1.9) 0.45
CD4+ (cells/mm3) >=350 vs. < 350 11 (14) 1.7 (0.5 - 5.2) 0.38
Home delivery/on the way 7 (26) 3.7 (1.2 - 11.3) 0.03
Females 4 (6) 0.4 (0.1 - 1.4) 0.15
ARV prophylaxis vs. none 13 (10) 3.6 (0.6 - 23.1) 0.17
Type of feeding
Infant formula vs. breast feeding
Mixed feeding vs. breast feeding
2 (6)
10 (15)
1.14 (0.2 - 7.5)
2.6 (0.7 - 10.3)
0.30
Weaning at <6months vs. >6 months 7 (14) 1.5 (0.5 - 4.7) 0.46
*Among children tested for HIV (n=288)
Moth
er
Child
Infant survival
• 33 / 72 deaths were HIV-related
• Most frequent causes of death – Acute or chronic diarrhoea (34.7%)– Respiratory tract infections (20.8%)
0.0
00.2
50.5
00.7
51.0
0P
rob
ab
ilitie
s
0 10 20 30 40Follow-up (months)
Kaplan-Meier survival estimate
0.81 (95% 0.77 – 0.85)
Mother/baby pair LTFU
• Median time at LTFU was 1 month (IQR : 0 – 5)
• Reasons for LFU (n=197)
– 30% mothers' ignorance of the importance of FU
– 27 % infant death
– 13 % discouraged by the partner
– 12 % address change
Discussion (1)
Mothers
• 40% women refused to be tested
• Among the HIV +, 50% refused to be enrolled in the PMTCT
• Among the enrolled women , 50% drop out
• First visit in third trimester of pregnancy
• 50% accessed ANC in earlier HIV disease
• 21% home delivery
Discussion (2)Infants
• 18% did not receive PMTCT prophylaxis
• HIV transmission rate reduced from 35% to 15.5%
Mother/baby pairs LTFU
• 53% LTFU before tracing
• Main reasons for LTFU = mother’s ignorance of importance of FU & infant death
BUT 30% of pairs untraced
Recommendations
• Improve the message delivered to mothers
at enrolment
• Increase resources for PMTCT (HR, logistics…)
• Reconsider Feeding strategy
• Early diagnosis and treatment for children
Acknowledgments
• Ugandan Ministry of Health in Arua and
Kampala
• MSF team in Arua and Kampala
• Epicentre in Kampala and Paris
• CDC laboratory in Entebbe (Ugandan Virus
Institute)
ARUA REFFERAL REGIONAL HOSPITAL
PMTCT From May 2007 to end of February 2008
Organigram
Flow of patient
PMTCTAN +HIV f/up
Mother and child f/up until 1 year
ANCVCT
HIV clinicWomen became pregnant
Maternity wardLabour suite
Homedelivery
Mother 1year after deliveryChild+ after 1 year
Treatment protocol
Antepartum
treatment
Labour
treatment
Postpartum
treatment
Child
treatment
Pregnant
women
Cd4<350
HAART HAART HAART AZT 1ml bd
7 days
( *4 weeks if the mother begins treatment less than 1 month before delivery)
Pregnant women Cd4>350
AZT 300mg bd
>28 WA
Sd NVP 200mg
+
(AZT-3TC)
(600/300) stat
Tail
AZT-3TC (300/150) bd
7 days
Sd NVP 0.6ml
+
AZT 1ml bd
7 days ( or *)
Data from ANCfrom May 2007 to end of February
2008
• 63% women accept to be tested
• 75% of mother tested HIV+ are enrolled in PMTCT
• HIV prevalence at ANC is 4 % during the period
Total first ANC 9923
Total pregnant women tested 6252
Total tested HIV + 256
Total enrolled in PMTCT 191
Mothers enrolled in PMTCT May 2007 to End of February 2008 (1)
Weeks in pregnancy Total (%)
< 28 weeks 273 (54%)
> 28 weeks and < 36 weeks 83 (16%)
> 36 weeks 48 (9%)
With baby 99 (20%)
Total 503 (100%)
Mothers enrolled in PMTCT May 2007 to End of February 2008 (2)
• Median CD4 : 448 /mm3
WHO staging (from ANC only ) Total (%)
Stage 1 125 (64%)
Stage 2 38 (20%)
Stage 3 19 (10%)
Stage 4 9 (5%)
Total 191 (100%)
85%
Mothers enrolled in PMTCT May 2007 to End of February 2008 (3)
• 8% are lost to follow-up • 40% are on ARVs (10% in 2000-2005) • 62% of the mothers enrolled in PMTCT are coming from HIV
clinic
Total (%)
Total enrolled 503 (100%)
death 1 (0%)
Lost of follow-up 41 (8%)
Transfered 4 (1%)
Followed with no ttt 252 (50%)
Followed on ARV 203 (40%)
Unspecified 2 (0%)
Prophylaxis and treatment (1)Ante partum drugs %HAART 40%
AZT (> 28 weeks) 33%
None 25%
Unknown 1.5%
Intra partum drugs
HAART 40%
NVP+ (AZT/3TC) 13%
AZT+NVP 4%
Stat NVP 10%
AZT 13%
None 17%
73%
57%
Prophylaxis and treatment (2)Post partum prophylaxis
HAART 43%
Tail AZT/3TC 19%
None 20%
Baby prophylaxis
Stat NVP+ AZT 37%
Stat NVP 17%
None 26%
Location of delivery May 2007 to End of February 2008
85%
15%
In Maternity/Hospit
Other
Feeding Option PMTCT May 2007 to End of February 2008
85%
10%
4% 1%
0%
Breast FeedingInfant formulaMixedOtherUnspecified
Outcome of children
• Will need to wait 2009 regional meeting….
Thanks
WHO stage & CD4 at PMTCT enrolment
<350 CD4 cells/ml
>=350 CD4 cells/ml
No CD4 Total
Stage 1&2 37 (21.9)
61(36.1)
71 (42.0)
169
Stage3 54 (37.5)
44(30.5)
46 (32.0)
144
Stage4 2 (15.4)
3 (23.1)
8 (61.5)
13
No staging 0 (0)
0 (0)
1 (100)
1
Total 93 (28.4)
108 (33.0)
126 (38.6)
327
Maternal characteristics at follow-up (N=327)
• Partner/family aware of HIV status : 297 (90.8%)
• Partner aware of PMTCT enrolment : 242 (74.0%)
• Participation in PMTCT
No problems : 279 (85.3%)
Separation/divorce : 22 (6.7%)
No male involvement/conflict : 15 (4.6%)
Family stigma/conflict : 9 (2.8%)
Other : 2 (0.6%)