Optimizing Prenatal HAART in Mozambique

1. Optimizing Prenatal HAART in Mozambique Research in Progress � March 4, 2009 Christian B. Ramers, MD ramers@u.washington.edu

2. Objective To determine whether recent changes in the process of care in PMTCT clinics in central Mozambique have resulted in increased proportions of eligible women starting HAART

3. Introduction � Specific Aims To quantify �process of care� at PMTCT clinics with varying health systems characteristics To describe demographic/clinical characteristics of PMTCT attendees in central Mozambique To assess the effect of decentralization of HIV/CD4 testing & HAART services on rates of initiation of HAART and on ARV�s for PMTCT among pre-natal clinic attendees in Mozambique

4. Background � What is Operations Research? �Use of systematic research techniques for program decision-making to achieve a specified outcome.� Population Council, 2006 �How can I make my health program better?� Mark Micek, MD, MPH 2009

5. Background � What is PMTCT?

6. Background � Leveraging PMTCT Abrams EJ, et al 2007 AJOG; 197(3); S1: S101-S106

7. Background � Mozambique Population � 19.2 million 78% live on < $2/day Life expectancy 45 yrs Adult HIV prevalence 12.5% 1.65 million PLWHA ~300,000 eligible for HAART 60% women 150,995 HIV+ births in 2007

8. HAART/PMTCT in Mozambique MOH developed HAART roll-out plan in 2003 HAI, Clinton Foundation, PEPFAR, MSF 7,710 people on HAART in first year (2004) 88,200 people on HAART (April 1, 2008) 83% of women have at least 1 ante-natal visit 35% of HIV+ women received PMTCT drugs

9. Methods � study design Quasi-experimental, retrospective, longitudinal Step Wedge Time Series Target population: PMTCT attendees Subgroups: HIV+, HIV+ HAART-eligible

10. Methods � study design Interventions Decentralization of ART from larger �day hospitals� to the surrounding PMTCT clinics Greater availability of CD4 testing at local level Variables Independent: pre- vs. post-intervention, clinic, clinical stage, CD4 count Dependent: % on HAART, % PMTCT drugs, % with timely CD4 testing, % lost to follow-up, % Denominators: # HIV+ women, # HIV+ HAART eligible women

11. Study Design � Stepped Wedge Time Series Time Clinic 1 - T1 T2 T3 T4 T5 T6 T7 T8 Clinic 2 - T1 T2 T3 T4 T5 T6 T7 T8 Clinic 3 - T1 T2 T3 T4 T5 T6 T7 T8 Clinic 4 - T1 T2 T3 T4 T5 T6 T7 T8 Clinic 5 - T1 T2 T3 T4 T5 T6 T7 T8

12. Study Design � Stepped Wedge Time Series Time Clinic 1 - T1 T2 x T3 T4 T5 T6 T7 T8 Clinic 2 - T1 T2 T3 x T4 T5 T6 T7 T8 Clinic 3 - T1 T2 T3 T4 x T5 T6 T7 T8 Clinic 4 - T1 T2 T3 T4 T5 x T6 T7 T8 Clinic 5 - T1 T2 T3 T4 T5 T6 x T7 T8

13. Study Design � Stepped Wedge Time Series Time Clinic 1 - T1 T2 x T3 T4 T5 T6 T7 T8 Clinic 2 - T1 T2 T3 x T4 T5 T6 T7 T8 Clinic 3 - T1 T2 T3 T4 x T5 T6 T7 T8 Clinic 4 - T1 T2 T3 T4 T5 x T6 T7 T8 Clinic 5 - T1 T2 T3 T4 T5 T6 x T7 T8

17. Methods � data collection Routine data available from PMTCT clinic monthly reports Clinic-level data (# pts, #HIV+, # on HAART) Patient-level data (CD4, stage, HAART, sdNVP) Cross-referenced with lab records Date range roughly 2006-2008 Entered into Access database (PW protected)

18. Methods � study design Main Outcome: Proportion of HIV+ HAART-eligible women on HAART

20. Methods � Analysis [dummy table] Percentage of eligible women on HAART

21. Methods � Analysis [dummy table] �Table 1A� � HIV + PMTCT Attendees

22. Methods � Analysis [dummy table] �Table 1B� � Site Characteristics

23. Methods � Analysis [dummy table]

24. Limitations Retrospective Quasi-experimental design Selection Bias Historical Bias Limited by �real-life� setting (n = 9, 18) Many simultaneous process changes � difficult to differentiate CD4 testing from on-site ART Sample size and power not under my control Uncertainty regarding data quality

25. Timeline

26. Dissemination & Policy Impact Plan Results are to be communicated directly back to Mozambique MoH officials & HAI staff to inform policy & resource allocation May identify underperforming clinics May lead to further �case control� analyses comparing high-performing and low performing clinics Published manuscript may be applicable to PMTCT clinics in other settings

27. Muito Obrigado!