Evaluation of pmtct coverage in four african countries the pearl study
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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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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

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)


Pearl study

PEARL study

  • Methodology developed with CDC in “die Paarl” over a bottle or two of red wine

  • Hence PEARL study


Pearl study1

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)


Pearl study2

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)


Pmtct interventions

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.


Cord blood surveillance methodology

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


Methodology 2

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)


Methodology 3

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


Definitions

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


Specimen collection rate

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%)


Hiv prevalence

HIV prevalence

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


Coverage cascade

Coverage Cascade


Evaluation of pmtct coverage in four african countries the pearl study

Maternal coverage by site


Factors associated with failed coverage

Factors associated with failed coverage


Evaluation of pmtct coverage in four african countries the pearl study

Maternal adherence across sites


Factors associated with maternal non adherence

Factors associated with maternal non-adherence


Western cape pmtct guidelines

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


Maternal adherence western cape

Maternal adherence – Western Cape

HAART 12%

ZDV and NVP47%

Standard of care59%

NVP only6%

At least NVP65%

ZDV only8%

Nothing27%


Conclusions

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


Acknowledgements

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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