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Evaluation of PMTCT coverage in four African countries: The PEARL Study

Evaluation of PMTCT coverage in four African countries: The PEARL Study. D Coetzee, EM Stringer, BH Chi, N Chintu, TL Creek, DK Efouevi, K Stinson, P Thi, T Welty, F Dabis, N Shaffer, CM Wilfert, JSA Stringer. University of Alabama – Center for Infectious Disease Research Zambia

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Evaluation of PMTCT coverage in four African countries: The PEARL Study

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  1. Evaluation of PMTCT coverage in four African countries:The PEARL Study D Coetzee, EM Stringer, BH Chi, N Chintu, TL Creek, DK Efouevi, K Stinson, P Thi, T Welty, F Dabis, N Shaffer, CM Wilfert, JSA Stringer University of Alabama – Center for Infectious Disease Research Zambia University of Bordeaux (France) – PAC-CI (Cote d’Ivoire)Elizabeth Glazer Pediatric AIDS Foundation and Cameroon Baptist Health Convention University of Cape Town – Infectious Disease Epidemiology Unit (South Africa)

  2. PEARL study • Methodology developed with CDC in “die Paarl” over a bottle or two of red wine • Hence PEARL study

  3. PEARL Study • 4-country effectiveness evaluation • Facilities and their catchment populations randomly identified in each country • Facility-based evaluations • Cord Blood Surveillance • Facility Survey – exit and informant interviews • Community-based evaluations • Community Survey to identify HIV-free survival • Cost-effectiveness evaluation ________________________________________ • Funding: CDC-GAP (ZM, CI, RSA) EGPAF (Cam)

  4. PEARL Study • An effectiveness evaluation • Facilities and their catchment populations randomly identified in each country • Facility-based evaluations • Cord Blood Surveillance – preliminary data • Facility Survey • Community-based evaluations • Community Survey • Cost-effectiveness evaluation ________________________________________ • Funding: CDC-GAP (ZM, CI, RSA) EGPAF (Cam)

  5. PMTCT interventions • All sites used at least single-dose nevirapine (SD-NVP) for PMTCT; • Some also used short course zidovudine SC-ZDV+SD-NVP and/or HAART.

  6. Cord Blood Surveillance Methodology Anonymous consecutive cord blood specimens from all live-births – (except Cameroon) April 2007 and October 2008 43 randomly selected sites in 4 countries Zambia Cote d’Ivoire South Africa Cameroon

  7. Methodology (2) Cord blood collected anonymously from every delivery Tested for HIV If cord blood (mother) was HIV-infected, then cord blood tested for NVP by high-performance liquid chromatography And ZDV + 3TC (where applicable)

  8. Methodology (3) Key PMTCT information (from folder) collected anonymously age of mother parity acceptance of HIV testing result received mother documented as having received NVP infant documented as having received NVP

  9. Definitions • Coverage = maternal & infant ingestion of NVP • Maternal ingestion = NVP present in cord blood if HIV-infected • Infant ingestion = documentation of the infant having received NVP

  10. Specimen collection rate 28, 955 Live births (100%) 28,060 Specimens Obtained (96.9%) 27,996 Specimens Tested (96.7%) 3,250 Cord blood HIV Positive (12.2%)

  11. HIV prevalence • HIV prevalence was typical of that observed in each area in the particular country

  12. Coverage Cascade

  13. Maternal coverage by site

  14. Factors associated with failed coverage

  15. Maternal adherence across sites

  16. Factors associated with maternal non-adherence

  17. Western Cape PMTCT guidelines • Guidelines 2007/08 • SC-ZDV+SD-NVP for women with CD4 > 200 • HAART for women with CD4 <200 • No data collected on CD4+ cell count in this study

  18. Maternal adherence – Western Cape HAART 12% ZDV and NVP 47% Standard of care 59% NVP only 6% At least NVP 65% ZDV only 8% Nothing 27%

  19. Conclusions PMTCT involves a cascade of interventions All sites: only 50% coverage Failures occur along each step of the cascade Interventions are required at each point Even in settings with dual therapy and HAART to target high risk women, more than 25% of women are not covered with PMTCT prophylaxis

  20. Acknowledgements Cameroon Pius Tih Tom Welty Cote d’Ivoire Francois Dabis Didier Ekouevi Serge Kahon South Africa Andrew Boulle David Coetzee Kathryn Stinson Zambia Max Bweupe Ben Chi Namwinga Chintu Mark Giganti Jeffrey Stringer Wendy Mazimba Centers for Disease Control Mark Bulterys Tracy Creek Nathan Shaffer EGPAF Allison Spensley Christophe Grundmann Cathy Wilfert Others Cameroon Baptist Health Convention Elliott Marseille Mary Louise Newell MOH Cote d’Ivoire Zambian MOH

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