Impact of the National PMTCT Program Measured at Six Weeks Postpartum in

South Africa, 2010

Thu-Ha Dinh, MD., MS., US CDC/GAP

Ameena Goga, MD., MS., MRC/HSRU, South Africa Debra Jackson, PhD., RN., UWC, MRC/HSRU, South Africa

and other co-authors

IAS 2011, Rome, July 17 to 20

Overview of Presentation

• Background• Objectives• Methods• Findings• Conclusions

Background• Live-birth: 1 mil/yrs• 1st immunization

(DPT) at 6 weeks– Coverage >98%

in 2010

• Antenatal HIV prevalence: 29% (range: 17-40)

• National PMTCT started in 2002

• 2010:

PMTCT at > 98% of facilities Decentralized ARV provision, nurse initiates ARV

2008: – Mothers: CD4 > 200 AZT from 28 wks + sd NVP in labour CD4< 200 ART/HAART

– Infant: sd NVP + AZT (7 - 28 days)– DNA PCR at 4-6 weeks of age - 1st immunization

2010: – Mothers CD4 > 350 AZT from 14 wks + sd NVP + TDF/FTC in labour CD4< 350 ART/HAART

– Infant: NVP throughout breastfeeding

2008 – present: DNA PCR at 4-6 weeks of age at the 1st immunization

Background: PMTCT guidelines

ObjectivesPrimary objectives• To estimate national and provincial perinatal MTCT

rates in 2009 and early 2010 • To identify associated factors with the MTCTSecondary questions • To estimate number of HIV acquisition during pregnancy

(poster # MOPE300; Mon 12.30 – 14:30)• To describe and identify re PMTCT missed opportunities –

PMTCT cascade (poster # TUPE285 , Tue 12:20-14:30)

Methods

• A cross-sectional facility-based survey • Sampling: Multi stage, PPS and systematic sampling

methods national and provincial estimates

– 565 facilities in all 9 provinces (range, 34-78/province)

– A total of 9915 eligible caregiver-infant pairs enrolled

• Data collection: Using cell-phone technology real time data collection (interview)

• Duration: Data collection: Jun 2010 to Dec 2010

establish a baseline to measure impact of Option A in South Africa (SA 2010 guidelines)

• HIV Exposed Infants identified using biomedical marker

• ELISA test (Genscreen HIV antibody assay) for Infant HIV Exposure• HIV ELISA test positive HIV DNA PCR

– Automated Ampliprep/Taqman v2.0 technology (Roche)

• All HIV tests were done at NHLS

Methods: Laboratory

0-1 m 1-2 m 2-6 m 6-9 m 9-12 m 12-18 m

Maternal HIV ABHIV DNAinf_HIV Ab

Blood sample of HIV-infected infant first 18 mths of age

HIV

ELI

SA

test

Findings

• Weighted for population live-birth in 2008• Survey analysis using SAS 9.2

Caregiver-infants - 4-8 wk old infant attending 1st DPT

(10 820)

Caregiver-infants interviewed & infant-DBS* (9915, 92%)

• Refused to participate, 84 (0.8%)• No or insufficient infant-DBS 821 (7.6%)

HIV exposed(3003; 30.3%)

No PCR test result, 35 (1.2%)

HIV exposed infants with PCR test result

(2958; 98.5%)

HIV not exposed, 6912 (69.7%)

Survey Profile

Inclusion: 4-8 week old attending clinic for 6wk

immunization

Exclusion: Severely ill infants needing emergency care

Characteristics HIV exposed infant

N=3003HIV unexposed infant

N=6912

% 95% CI % 95% CI

Brought by mother 96.8 96.2-97.4 97.9 96.4-97.7

Marital status of mother

Single 79.8 77.9-81.6

73.0 71.6-74.5

Married/cohabiting 20.2 18.4-22.0 26.9 25.5-28.4

Feeding practice (last 8 days)

Exclusively breast-feeding 20.0 18.2-21.8 30.3 28.7-32.0

Mixed Feeding 17.9 16.4-19.5 58.4 56.7-60.1

No breast-milk feeding 62.0 59.8-64.2 11.2 10.5-12.0

Food insecurity (episode)

Yes 20.6 18.1-23.1 15.5 14.0-16.9

No 79.0 76.5-81.5 84.0 82.5-85.4

Planned pregnancy

Yes 34.8 32.7-36.9 38.3 36.8-39.7

No 62.0 59.9-64.2 58.4 56.9-59.8

Mother’s characteristics by HIV-exposure status

Weighted perinatal MTCT Rate Province Infant HIV exposure

% (95% CI) N=2958Perinatal MTCT

% (95% CI)Eastern Cape 30.0 (26.3-33.7) 4.1 (1.7-6.3)

Free State 31.1 (28.9-33.3) 6.0 (3.8-8.2)

Gauteng 30.2 (27.7-32.8) 2.2 (1.2-3.2)

KwaZulu-Natal 43.9 (39.7-48.0) 2.8 (1.7-4.0)

Limpopo 22.6 (20.4-24.8) 3.5 (1.2-5.8)

Mpumalanga 36.2 (33.6-38.9) 5.9 (4.3-7.6)

Northern Cape 15.6 (13.0-18.3) 1.7 (0.1-4.2)

Northwest 30.9 (28.6-33.1) 4.5 (2.9-6.1)

Western Cape 20.8 (16.8-24.9) 3.3 (1.3-5.2)

National 31.4 (30.1-32.6) 3.5 (2.9-4.1)

Factors associated with perinatal MTCTFactors Adj OR 95% CIARV prophylaxis or ART/HAART

Maternal ART (HAART) 1.0 --

Either maternal ARV OR infant ARV 5.2 2.7-10.0

≤10 week maternal ARV AND infant ARV 2.4 1.2-5.1

11-30 week maternal ARV AND infant ARV 1.7 0.9-3.5

Feeding practices (last 8 days)

EBF or no breast-milk 1.0 --

Mixed breast-feeding 1.6 1.0-2.5

Planned pregnancy Yes 1.0 --

No 1.4 0.8-2.3

Delivery method C-section 1.0 --

Not C-section

1.1 0.4-2.9

Birth attendant Non-doctor 1.0 --

Doctor 1.2 0.5-2.9

Limitations

• Selection bias – Representative population attending primary health

care – Excluded sick infants needing emergency care

• Potential recall bias bias associated factors• Sample realization in 3 provinces <75%

estimates were not stable in that 3 provinces (NC, EC and LP)

Conclusions

1. Nationally, the perinatal MTCT rate was < 4% in South Africa

2. C-section and having birth attendant as a doctor may not be optimal options to reduce MTCT

3. Mixed feeding is a strong indicator to increase MTCT in this population

4. No breast-milk feeding to exposed infants (62%) can reduce MTCT but will increase mortality

5. HIV test uptake in infant was high (92%) if offered to all infants at routine immunisation services

“The findings and conclusions on this report are those of the authors and do not necessarily present the official position of the US Centers for Disease Control and Prevention”

Acknowledgements

Nurse Data collectorsRoutine health workers

Medical Research Council: •Carl Lombard (Statistician)• Selamawit Woldesenbet• Wesley Solomon • Vundli Ramokolo• Nothemba Kula•Tanya Doherty

National Department of Health: • Yogan Pillay, • Nonhlanhla Dlamini•Thabang Mosala

Provincial Departments of Health

University of the Western Cape: • Wondwossen LereboUNICEF (SA): • Siobhan CrowleyCDC: • Katherine Robinson• Jeff Klausner• Thurma GoldmanInfant Diagnosis: • Gayle Sherman• Adrian PurenTechnical Advisors:• Mickey Chopra (UNICEF)• Nathan Shaffer (WHO)

Caregiver-infant pairs