Prevention of Mother to Child Transmission PMTCT: The challenge of monitoring and evaluating a compl

1
Prevention of Mother to Child Transmission
(PMTCT) The challenge of monitoring and
evaluating a complex program

• Rosalind Carter, PhD
• Epidemiologist, PMTCT, Pediatrics and
• MTCT Plus Initiative Program
• Monitoring, Evaluation and Research Unit, ICAP NY

2
Timing of MTCT
Care and Treatment, Exposed Infant follow-up
PMTCT, Care Treatment
Maternity
Early Postpartum (0-1 mo)
Early Antenatal (lt36 wks)
Late Postpartum
Labor Delivery
Breast Feeding
Late Antenatal (36 wks to labor)
1-6 mos
6-24 mos
0
20
40
60
80
100
Proportion of infections
3
What is PMTCT?

• Routine HIV testing as part of pregnancy care
• Immediate CD4 staging
• ARV prophylaxis
• HAART if eligible (CD4lt350)
• Test partners and family members

4
Then

• Need to continue assessing maternal health
  (repeat CD4)
• CTX prophylaxis and follow-up of exposed infants

5
In summary, PMTCT isSystem of care for
pregnant/ postpartum women and their families,
using pregnancy as an entry point
6
Where do PMTCT indicators fit in?

• Measures activities in 4 areas of care system
• ANC
• Care and Treatment
• Maternity
• Exposed infant followup

7
Why collect PMTCT indicators?

• Evaluating progress of programs for best
  practices and quality care
• Donor (USAID, PEPFAR) reporting
• Assist with MOH reporting within countries

8
known positive tested/positive mothers receive
ARV infants receive ARV
women tested/positive documented CD4
receive Sd-NVP receive AZT Sd-NVP partners
tested
eligible who initiate HAART enrolled in
comprehensive care and treatment
initiating cotrimoxazole PCR tested confirmed
HIV diagnosis
9
Uses of aggregate data

• Comparisons across ICAP countries
• Comparisons over time and across sites/regions
  within a country

10
Pregnant women counseled and tested in ANC
atICAP-supported PMTCT facilities, April-June
2007
11
HIV-infected pregnant women receiving ART
prophylaxis in ANC at ICAP-supported PMTCT
facilities, April-June 2007
0
67
49
72
77
53
12
Women and infants receiving ART prophylaxis in
maternity at ICAP-supported PMTCT facilities,
April-June 2007
13
Antiretroviral prophylaxis HIV Mothers,
ICAP-Rwanda, July 06- June 07
Decreasing trend in Sd NVP administration Increas
ing trends in AZT and ART initiation since Q4 2006
14
CD4 screening and results among HIV pregnant
women in Gisenyi and Kibuye Regions, Rwanda,
Jan-June 2007
15
LINKAGES
16
LINKAGES
Partner testing
Known HIV
CD4lt350
Exposed infant
Infected children
17

• Retention in PMTCT context means.
• Retaining families in a care system

18

• Retention in ANC

• Does mother return to ANC after her HIV test?
• Does she return for CD4 results?
• Does she remain in care through third trimester
  when she is eligible for AZT prophylaxis (gt28
  weeks gestational age) or sd-NVP?

19
(No Transcript)
20
Evaluating retention in care system PMTCT ME
system exercise, Mozambique 2007

• Reviewed ANC paper register for 1st ANC visits,
  June 2007
• 39 women tested positive 32 received PMTCT or
  HAART
• Reasons why no PMTCT
• 2 women did not return to ANC
• 2 had follow-up visits, but none gt28 wks
  gestational age (when AZT prescribed)
• 3 unknown (documentation?)

21
Linkage between ANC and Care and Treatment
programs

• Indicator eligible women who initiate ART
• Methods Used electronic patient database for
  PMTCT and Care and Treatment to trace women with
  CD4 lt250 cells/mm3 to Care Treatment from
  June-Sept, 2007
• Matched records on point of entry and PMTCT code

22
June 2007 39 (37) women test positive in ANC
6 women CD4 lt 250 cells/mm3, eligible for HAART
and referred to Care and Treatment
23
PMTCT ART Clinic
ART
ART
ART
Electronic records, only 3/6 enrolled in ART
clinic
Using paper registers and charts, found 6/6
women.
Came to ART, not evaluated
No ART
No ART
24
ME systems

• Paper registers
• ANC Incomplete information on HAART initiation
  and date. Missing ART code.
• Care and Treatment Missing or incorrect PMTCT
  code, missing point of entry information
• Limitations of electronic systems
• Need to improve quality of paper registers before
  electronic records are useful. If no point of
  entry listed, missing CD4, or errors in PMTCT or
  ART code, records will not link.

25
Addressing linkage to Care and Treatment
programmatically

• Referral form from ANC to Day Hospital
• PMTCT point person in Day Hospital
• Register in Day Hospital for pregnant women
  implemented Sept. 2007
• Review ANC register to identify women with
  CD4lt250 and check Care and Treatment register
  against this list each month.

26
Linkages between ANC and Exposed infant program

• Reviewed ANC register, 1st visit January 1-30
• 59 positive mothers identified
• Reviewed Exposed Infant Follow-up register to
  identify babies enrolled January through thru
  Sept 24, 2007.
• Baby and mothers matched on PMTC code.
• Found matching mom/baby pairs for 12 (21) of 59
  positive mothers
• 6 of 12 pairs, mom had CD4 lt250

27
Assessment of linkages

• Possible to trace mothers from ANC to Care and
  treatment and Exposed infant follow-up
• Labor intensive using paper registers
• Electronic patient-level databases are limited by
  problems with accuracy of register, missing data,
  data entry errors

28
Retention in Care and Treatment

• Do pregnant women referred to Care and Treatment
  enroll?
• After delivery, do women remain in Care and
  treatment?
• If not eligible for ART, does she return for 6
  month CD4?

29
MTCT Plus Initiative cohort (February 1, 2003-
July 1,2006)
Enrolled by July 2006 6,007
Never on ART 3,575
Initiated ART by July 2006 2,255
108 (3) Died 233 (6.5) W/d 1248 (35) LTF
77 (3) Died 58 (2.6) W/d 192 (8.5) LTF
30
Summary

• PMTCT indicators
• Detailed, reflecting the complexity of PMTCT
  programming
• Requires close collaboration and teamwork between
  ME and Clinical units
• Aggregate data helps evaluate trends by site
  within a country, and between countries in
  implementation of complex regimens, initiation of
  women on ART----and over time
• Tracking women and their families between
  services to evaluate retention in care systems
  and treatment, and infant follow-up is possible,
  though challenging.

31
(No Transcript)
32
Many thanks..

• ICAP-Mozambique
• Lina Lince
• Isabelle Yersin
• Matthew Rosenthal
• ICAP-Rwanda
• Landry Tseague
• Veronicah Musigha

• ICAP-New York
• Monica Katyal
• Elaine Abrams
• Denis Nash
• Fatima Tsiouris

33
(No Transcript)