the 5th hiv transmission workshop, - welcome | virology education
TRANSCRIPT
To be presented at the 5th International Workshop on HIV Transmission
Evaluation of the Early Infant Diagnosis (EID) protocol in the Prevention of Mother to Child Transmission (PMTCT)
program in a resource-limited setting in Rwanda
Ali Kwizera1, Theogene Habiyambere1, Jean Claude Uwimbabazi2,Louiselle LeBlanc, MD1,Cyprien Baribwira, MD1: 1. University of Maryland School of Medicine, Institute of Human Virology, AIDSRelief Rwanda, 2. National Reference Laboratory-Kigali Rwanda
THE 5th HIV Transmission Workshop, Vienna Austria
To be presented at the 5th International Workshop on HIV Transmission
AIDSRelief - Rwanda
PEPFAR-funded implementing partner in Rwanda since 2004
Adult and Pediatric HIV and OI Care and Treatment
Prevention and PMTCT with community component
Laboratory Support: Emphasis on simple laboratory techniques to improve care and reduce mortality
Supporting 19 health facilities in Nyamasheke District and 1 health facility in Burera District
To be presented at the 5th International Workshop on HIV Transmission
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PROVINCE DE L'EST
PROVINCE DU SUD
PROVINCE DE L'OUEST
PROVINCE DU NORD
VILLE DE KIGALI
KAYONZA
GATSIBO
KIREHE
NYAGATARE
RUSIZI
RUTSIRO
BUGESERA
NGOMA
KARONGI
HUYE
GICUMBI
NYAMAGABE
NYAMASHEKENYANZA
NYARUGURU
BURERA
GAKENKE
KAMONYI
GISAGARA
MUHANGA
RULINDO
RUHANGO
NYABIHU
MUSANZE
RWAMAGANA
NGORORERO GASABO
RUBAVU
KICUKIRONYARUGENGE
.
Légende" Bureau de la Province
Limite de la région et la Ville de KigaliLimite de DistrictParcLac
PROVINCE DE L'ESTPROVINCE DE L'OUESTPROVINCE DU NORDPROVINCE DU SUDVILLE DE KIGALI
© Institut National de la Statistique du Rwanda, Novembre 2005
CARTE ADMINISTRATIVE DU RWANDA: PROVINCES, DISTRICTS ET LA VILLE DE KIGALI
10 0 105 Km
1. CS Bungwe
WHERE WE WORK LOCALLY in Rwanda
12. CS Bushenge13. CS Karengera14. CS Karambi15. CS Kibingo16. CS Mukoma17. CS Mugera18. CS Gisakura19. CS Hanika20. CS Rangiro
2. HD Bushenge3. HD Kibogora4. CS Gatare5. CS Mwezi6. CS Nyamasheke7. CS Kibogora8. CS Muyange9. CS Ruheru10. CS Kamonyi11. CS Yove
To be presented at the 5th International Workshop on HIV Transmission
Background: PMTCT in Rwanda before 2010
Mother:
HAART if indicated (CD4 < 350 or WHO 3-4)
If not indicated: Zidovudine (AZT) from 28 weeks + single-dose Nevirapine (NVP) at delivery with AZT/3TC for 7 days
Infant
Single-dose NVP at birth and AZT for 4 weeks
HIV DNA PCR on dried blood spot (DBS) sample at 6 weeks
If DBS negative, final serology at 18 months
To be presented at the 5th International Workshop on HIV Transmission
Background: Role of laboratory in the PMTCT program in Rwanda
Rwanda Laboratory standards on EID:
Training both on site and centralised
Sampling DBS samples
Storage of DBS samples prior to transportation
Transportation to National reference Laboratory
Collection of Results and reporting
To be presented at the 5th International Workshop on HIV Transmission
Objectives of this evaluation
Assessing quality and efficacy of PMTCT, EID and care of HIV-exposed infants
The Transmission rate?
The Quality of follow up and testing for exposed children in rural setting?
The Feasibility and laboratory quality aspects of DBS-PCR testing in context of logistical challenges?
Identifying remaining challenges and issues needing to be addressed further
To be presented at the 5th International Workshop on HIV Transmission
Methods
Cohort retrospective review:
Systematic chart review
721 HIV-exposed infants in 20 AIDSRelief supported LPTFs, born between January 2008 and June 2009
To be presented at the 5th International Workshop on HIV Transmission
Results
89% (642/721) HIV-exposed infants were enrolled in care and followed
94.7% (608/642) had DBS/PCR at 6 weeks
3.7% (32/721) were found to be HIV-infected
7/32 were on HAART at time of evaluation
Of total 721, 20 were lost-to-follow up and 20 had died (both rates below 3%)
To be presented at the 5th International Workshop on HIV Transmission
Results: Overall outcomes
0
100
200
300
400
500
600
700
800
Exposedinfants
Infantsfollowed
DBS‐PCR 6wks
HIV + HIV + onARV
OverallLTFU
Overallmortality
721 642608
32 7 20 20
To be presented at the 5th International Workshop on HIV Transmission
Results: Laboratory perspective
861 in total DBS samples (including doubles) were sent for testing at the national reference laboratory ( NRL)
4/20 LPTFs respected maximum delay time of 10 days for sending the samples
88.6% (763/861) received results
Average turnaround time: 6 weeks
10.1% (n=89) of samples were rejected
69 for poor sampling quality
18 for labeling errors
1.3% (n=11) were never received by NRL
To be presented at the 5th International Workshop on HIV Transmission
Discussion
In our resource-limited, rural and isolated setting, rolling out a DBS-PCR based EID protocol allows for early HIV diagnosis with a reasonable delay
Need for improvement in turnaround time
Good HIV-exposed infant follow-up coverage (89%) and testing rate at 6 weeks
Scored good in our setting
Remains room for improvement
To be presented at the 5th International Workshop on HIV Transmission
Discussions
Having only 21.9% (7/32) of HIV-infected infants on ARVs is suboptimal
Considering recent published data, 2008 WHO guidelines and 2009 Rwanda guidelines
HAART for all infected infants is indicated at diagnosis
Laboratory perspective quality improvement strategies:
Sample Collection, not yet 100% still needs improvement
Transport systems necessitating the need to follow-up all collected DBS samples to NRL to minimize the turnaround time
To be presented at the 5th International Workshop on HIV Transmission
Interventions and solutions
Coverage, follow-up and testing of all infants still not 100%
Possibility of home-testing/ in immunization setting
Education with community workers
Peri-natal education at health center
Relatively long turnaround time
Advocate for Increased number of tests done
Work more closely with the Rwanda National Reference lab
Adopting the new NRL strategy for DBS/PCR HAART coverage:
Education on pediatric HIV
To be presented at the 5th International Workshop on HIV Transmission
Conclusions
Implementation and monitoring of pre/peri-natal prevention programs must remain a priority to eliminate mother-to- child transmission, which remains unacceptably high in non-HAART PMTCT
Efforts must be focused on ensuring timely diagnosis to provide treatment early and reduce mortality
The 6 week turn around reinforces the need for laboratory quality systems improvements
To be presented at the 5th International Workshop on HIV Transmission
Thank you