Effectiveness of the National PMTCT Program in Rwanda

By

Dr Alexandre LYAMBABAJE, School of Public Health/ National University of Rwanda

Dr Placidie MUGWANEZA, Institute of HIV Diseases Prevention and Control (IHDPC/RBC), Rwanda

16%

26%33%

53%

63%

78%84%81%

0%

20%

40%

60%

80%

100%

2003 2004 2005 2006 2007 2008 2009 2010

Male partner HIV counseling and testing, during ANC, Rwanda PMTCT program,

2005-2010

Population Coverage, HIV+ preg. Women receiving ARV, Rwanda PMTCT program,

2005-2010

2005 2006 2007 2008 2009 20100%

20%

40%

60%

80%

100%

100% 100%

16% 8% 8% 10%

0.637240650191622 0.51981205

95144880.48719043

5525192 0.329410307234887

0.103475617814193 0.21331245

10571660.210788499857672 0.37797324

0832508

0.103872076119995 0.19075959

27956150.224167378309138

0.196110009910803

HIV+ pregnant women receiving HAART for life

HIV+ pregnant women receiving HAART prophylaxis

HIV+ pregnant women receiving Dual ARV prophylaxis

HIV+ pregnant women receiving NVP only

Transitioning from Sd-NVP to Efficacious ARV regimens, Rwanda PMTCT program, 2005-2010

Aim: HIV prevalence and key determinants among exposed children in the Rwanda PMTCT program.

Methods◦ Study design: cross sectional

◦ Inclusion criteria: 9-24 months children with their mother

◦ Sampling frame: Stratified 2-stage cluster sampling (1st unit: sites; 2nd unit: ANC mothers).

◦ Both HIV+ and –ves mothers were included to ensure community is blind about status of participants.

◦ Data collection: Interview with mothers at household, HIV testing of all children (rapid test and PCR)

1st PMTCT Program Effectiveness Study- Household Survey (2008-2009)-

Key findings -

Recall bias: 9 to 24 months is a long period after birth. Some mothers could not recall exactly events and treatments during pregnancy and delivery periods

End point measurement: Wide interval (9-24 months) making it difficult to interpret the HIV free-survival rate, as we could not rule out exposure to breastfeeding

Adherence to PMTCT regimens: Registries could not provide exhaustive information about the adherence of the mothers to PMTCT regimens.

Limitations of the 1st PMTCT effectiveness study

Primary Objective◦ To periodically measure rates of early mother-to-child transmission (MTCT)

of HIV at 6-weeks postpartum

Secondary Objectives◦ To periodically estimate the national coverage of key PMTCT interventions,

◦ To estimate the association between early MTCT rate and maternal, infant and health system factors.

Endpoints: ◦ 6-week infant HIV prevalence

◦ 6-week infant MTCT rate (Overall, PMTCT mother, non-PMTCT mother, Serodiscordant couples)

2nd PMTCT 6-week Impact Study Facility-based, 2010-2012

Design: Cross-sectional Two-stage Stratified Cluster sampling design

◦ Primary units: Health facilities Stratified by (rural vs urban; PMTCT vs Non-PMTCT site)

Probability proportional to size sampling: size estimated using historical DTP1 data (previous year)

o Secondary units: Mother-infant pairs

Sample size◦ 161 sites (36 non-PMTCT sites; 20 urban)

◦ 2,000 pairs (exposed infant, mother or legal caregiver)

6-week facility based PMTCT Impact Study - Design

Age group: 6-10 weeks Where: Facility-based at MCH/EPI unit How: enrollment at DTP1 immunization visit By Who: Health facility personnel Main steps

◦ Screening based on standard algorithm (exposed infant)◦ Interviews of mother or caregiver◦ Blood sample collection (using DBS)

Data collection started in June 13th 2011 Final results expected by May 2012

6-week facility based PMTCT Impact Study - Data collection

Evaluation of the Effectiveness of the National Prevention of Mother-to-Child Transmission (PMTCT) Programme on Infant HIV at 6 weeks Postpartum in South Africa.

IRB identifier: FWA00002753 Cooperative Agreement no. CDC U2G/PS001137·01 Version 1.2 (23 November 2009) Figure 8 outline the overall approach and conceptual framework for this evaluation.

ALL caregiver- infant pairs attending for their six- week immunization (1st

DTP Dose) to Sampled HF

Screening – consent if Eligible

HIV+ mother

DBS Infant + Quest

PCR on DBS at NRL

NRL

send

s inf

ant

resu

lt ba

ck to

HF

& SP

H

Mother Knows Her HIV Status Mother Status Unknown

Discordant PartnerUnknown Status

Mother Rapid test

HIV - mother

Quest+Inf DBS

Not Enrolled

Mother Not Available or

Mother Refuses HIV Testing

Mother Available &

Accepts HIV Testing HIV - partner

Mother HIV -Mother HIV +DBS Infant + Quest

Infant DBS Elisa

Infant DBS Elisa -

Infant DBS Elisa +

6-week facility based PMTCT Impact Study - Screening Algorithm for enrollment

Outreach Immunization strategy◦ How to integrate screening for the study?◦ How to administer the questionnaire?◦ Who will manage the transfer of potential eligible mothers and

infants to Health facilities for further screening?

Reaching the hardest to reach populations: do not participate in immunization campaigns (Beliefs, Ignorance, hard to reach areas)

Long period for data collection (7 months) Health Center Personnel mobility

Challenges and Potential Bias

Advantages◦ Low cost for blood samples collection and testing◦ Zero risk for non-exposed children◦ Capacity building for health facilities and better

sustainability◦ Better coverage by including recruitment from outreach

immunization strategy

Disadvantages◦ Difficult screening phase to identify exposed children◦ Long period for data collection (7 months)◦ Mobility of trained personnel and need to retrain new

people for data collection

Advantages and Disadvantages compared to MRC Generic Protocol

Thank You For Your Attention - MURAKOZE

Acknowledgements

Rwanda School of Public Health

NNRLR

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Rwanda Biomedical Center/Institute of HIV, Diseases Prevention and Control (RBC/IHDPC)