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Dr Nana K. Ayisi-Boateng (MBChB, MPhil,MGCP) Principal Investigator KNUST Hospital Kumasi

MEPI-FUNDED PROJECT Determinants of Outcome of PMTCT Measures at Three ART Centres in Kumasi over a Three Year Period. Dr Nana K. Ayisi-Boateng (MBChB, MPhil,MGCP) Principal Investigator KNUST Hospital Kumasi. Background. Training on HIV Research at Beige Village in September, 2015

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Dr Nana K. Ayisi-Boateng (MBChB, MPhil,MGCP) Principal Investigator KNUST Hospital Kumasi

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  1. MEPI-FUNDED PROJECTDeterminants of Outcome of PMTCT Measures at Three ART Centres in Kumasi over a Three Year Period Dr Nana K. Ayisi-Boateng (MBChB, MPhil,MGCP) Principal Investigator KNUST Hospital Kumasi

  2. Background • Training on HIV Research at Beige Village in September, 2015 • Call for research proposals in October 2015 • Award of GHS 10,000.00 in January 2016 • Project started on 02/02/16 and ended 30/04/16

  3. Research Team

  4. Introduction • HIV infection has been a problem of public health concern worldwide especially in Africa (Murray et al., 2014) • In 2015, national HIV prevalence in Ghana was 1.6% (UNAIDS, 2015) • HIV infection among pregnant women attending ANC is 1.9%. It was 2.1% in 2012 (Ghana AIDS Commission)

  5. Introduction • An estimated 11,682 mothers require PMTCT services (Ghana AIDS Commission, 2015). • HIV infection can be transmitted from a mother to her infant during pregnancy, during delivery and through breastfeeding • Without any intervention, HIV transmission from mother to child can be as high as 45% (WHO, 2010).

  6. 2011 PMTCT Policy (Option B) • Counselling on safe sex practices and contraceptive use • Initiation of cARTs to HIV pregnant women at 14 weeks • Administration of syrup zidovudine (within 48hrs of birth) to the HIV-exposed baby for 6 weeks . NVP if anaemic • Early infant diagnosis (EID) using DNA PCR at 6 weeks of age • Exclusive breastfeeding for 6 months and weaning at 1 year • Antibody test for baby at 18 months

  7. 2011 PMTCT Policy (Option B) • These guidelines have been implemented at various Anti-retroviral therapy (ART) centres across the country • However, research work to assess the success or otherwise of the policy is lacking

  8. Main Aim • To identify the factors that determine the outcome of measures to prevent Mother-to-child transmission of HIV infection at the University Hospital, Kumasi South Hospital and Bomso Clinic within a three-year period

  9. Specific Objectives • To determine the prevalence and transmission rates of HIV infection among pregnant women at KNUST, KSH and Bomso Clinic over a 3-year period 2. To determine the impact of treatment initiation at early maternal gestational age on the outcome of PMTCT measures at the 3 ART Centres 3. To determine the impact of mode of delivery and breastfeeding option on the outcome of PMTCT measures at the three ART centres

  10. Study Design • A retrospective study carried out from February to April, 2016 • Hospital records of HIV-positive pregnant women who received PMTCT services (from 2012 to 2014) at the three centres were reviewed

  11. Ethical Approval • Ethical Approval was obtained from the Committee of Human Research, Publication and Ethics (CHRPE), SMS, KNUST • No informed consent to be administered • Data to be obtained from patients’ medical records

  12. Study Site Chronic Care Unit, Kumasi South Hospital located at Atonsu Agogo A Regional Hospital under Ghana Health Services Started HIV Treatment in 2005 5,600 registered clients

  13. Study Site Bomso Clinic located near KNUST A private health facility Started HIV Treatment in 2006 1,321 registered clients

  14. Study Site Infectious Disease Unit, KNUST A quasi-government health facility Started HIV Treatment in 2010 801 registered HIV Clients

  15. Study PopulationInclusionCriteria Pregnant women who; • Tested positive for HIV at the three study centres • Received antiretroviral medications at the three study centres during pregnancy • Presented their babies (post-delivery) for HIV testing at the three study areas in 2012, 2013 and 2014

  16. Study PopulationExclusion Criteria • Data of HIV positive mothers who did not present their babies post-delivery to any of the three ART centres were excluded from the study

  17. Sample Size • Sample size = Z2 (P) (1-P) E 2 = (1.96)2 (0.019) (1-0.019) (0.05) 2 = 28.9 ≈ 30 Multiplying the minimum justifiable sample size by 3 (number of study areas) yields 90 • Z – Confidence Interval of 95% is 1.96 • P - Proportion of HIV + pregnant women in Ghana which is 1.9%. • E - the proportion of acceptable error. (5% allowable limits)

  18. Data Collection • 2 well-trained research assistants were used • The patients’ hospital records for the years 2012, 2013 and 2014 were retrieved and the relevant data extracted • Project IDs were assigned to individual records to facilitate tracing of folders of both mothers and their corresponding children’s data. • Some mothers whose relevant data were missing were contacted on phone

  19. HIV EXPOSED INFANT FORM

  20. Patient Records

  21. Patient Records

  22. Statistical Analysis • SPSS version 22 was used to analyse data imported from Excel Sheet • Descriptive statistics and graphs were used to describe the distribution of the independent variables and outcome variables • Quality control measures were implemented to ensure accuracy of results

  23. RESULTS

  24. Data Distribution from Study Sites

  25. Data Distribution in 3 Years

  26. Age at Pregnancy Majority (63.4%) of them were between 26 to 33 years, 25.5% between 34 to 41 years, 8.3 % between 18 to 25 years and 2.8% were above 41 years

  27. Duration of Infection Approximately 44.1% (64)of the HIV positive mothers have had the infection for 1-3 years prior to becoming pregnant. 27.6% (40) of them were diagnosed at pregnancy

  28. CD4 Count at Pregnancy

  29. Gestational Age at ARV Initiation The 3 facilities are initiating ARVs early

  30. DURATION OF PREGNANCY 74.48% of the babies were delivered at term (37-40 weeks), 12.41% were preterm (< 37 weeks), and 13.10% posterm (> 40 weeks)

  31. Mode of Delivery

  32. Infant Feeding Option

  33. Infant ARV Prophylaxis

  34. Infant HIV Test at 6 weeks

  35. Infant HIV Test at 18 months

  36. 2012 HIV Prevalence Among Pregnant Women

  37. 2013 HIV Prevalence Among Pregnant Women

  38. 2014 HIV Prevalence Among Pregnant Women

  39. These results were all within the national and regional prevalence rates for the respective years

  40. Mother-to-Child Transmission Rates

  41. HIV Positive Child • Born (SVD at term) to a 38 year old HIV-positive mother who had been diagnosed of HIV infection 3 years prior to getting pregnant and was put on cART • Maternal CD4 count at 28 weeks gestation was 502 cells/mm3. • Baby received zidovudine syrup as prophylaxis for 6 weeks • DNA PCR test done was negative for HIV infection.

  42. HIV Positive Child • The mother exclusively breastfed her baby for 6 months before introducing complementary feeding • Continued breastfeeding till the baby was 16 months old • At 18 months, the baby was HIV-positive for an antibody test • prolonged breastfeeding for 15 months or longer is associated with a two-fold increased transmission rate (Kreiss, 1997).

  43. Discussions • The national transmission rates at 6 weeks in 2012, 2013 and 2014 were 2.74%, 8.26% and 4.26% (NACP, 2015). • Transmission rates recorded in this study were much lower •  22.9% of the mothers breastfed their babies for less than 1 year, 64.6% for up to 1 year and 12.5% for more than 1 year. • A substantial number of HIV-positive mothers do not adhere strictly to the guidelines on breastfeeding policy.

  44. Discussions • All 145 HIV-positive mothers received cARTs during pregnancy and 98.9% of the babies received Zidovudine syrup for 6 weeks immediately after delivery. • ARTs are available at our facilities • Each additional week of treatment corresponds to 10% reduction in risk of transmission(Townsend et al., 2008) • Starting ARTs at 14 weeks appears to have contributed to the low MTCT during the period

  45. Conclusion • Study has revealed that PMTCT measures instituted 5 years ago have generally been successful in the 3 facilities • mode of delivery, breastfeeding practices and gestational age at which ARVs are initiated are important factors that determine the outcome of PMTCT interventions • it could not be concluded in this study that those factors contributed to the 1 out of 145 babies who tested HIV positive after 18 months

  46. Conclusion • This study has highlighted key PMTCT goals which have been achieved at the 3 facilities • It has also revealed some challenges that need to be addressed • Goal of PMTCT in Ghana • To provide a comprehensive family centred continuum of promotive, preventive, clinical and supportive services inconjunction with other public health interventions to maintain the health of the mother and prevent HIV transmission to her infants

  47. Challenges & Recommendations • Inadequate documentation of patients’ information • Electronic medical software would be useful • Viral Load testing is not being done at the 3 facilities • This should be done at the initiation of ARVs to assess maternal risk of transmission • No definite conclusions could be drawn from this pilot study • More funds needed to conduct a bigger study and follow up on the 1 HIV positive child

  48. Acknowledgement • Medical Education Partnership Initiative (MEPI) • Management of the three study sites • NACP and Ghana AIDS Commission • Faculty of Family Medicine and GCPS

  49. REFERENCES • REFERENCES • Coovadia, H. M., Rollins, N. C., Bland, R. M., Little, K., Coutsoudis, A., Bennish, M. L., & Newell, M.-L. (2007). Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study. The Lancet, 369(9567), 1107–1116. http://doi.org/10.1016/S0140-6736(07)60283-9 • Ghana AIDS Commission. (2015, April). SUMMARY OF THE 2013 HIV SENTINEL SURVEY REPORT. Retrieved from http://ghanaids.gov.gh/gac1/aids_info.php • Kilewo, C., Karlsson, K., Massawe, A., Lyamuya, E., Swai, A., Mhalu, F., … others. (2008). Prevention of mother-to-child transmission of HIV-1 through breast-feeding by treating infants prophylactically with lamivudine in Dar es Salaam, Tanzania: the Mitra Study. JAIDS Journal of Acquired Immune Deficiency Syndromes, 48(3), 315–323. • MOH. (2014, September). National Guidelines for prevention of mother to child transmission of HIV. Ministry of Health, Ghana. • Murray, C. J. L., Ortblad, K. F., Guinovart, C., Lim, S. S., Wolock, T. M., Roberts, D. A., … Vos, T. (2014). Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet, 384(9947), 1005–1070. http://doi.org/10.1016/S0140-6736(14)60844-8 • NACP/GHS. (2010). National Guidelines For Prevention of Mother to Child Transmisiion of HIV. NACP/GHS. • UNAIDS. (2013). UNAIDS: Progress Report on the Global plan towards the Elimination of New infections among children by 2015 and Keeping te mothers alive. UNAIDS. • UNAIDS. (2014). Global AIDS response progress reporting 2013: construction of core indicators for monitoring 2011 political declaration on HI. Retrieved from http://apps.who.int/iris/handle/10665/78126 • WHO. (2010). PMTCT strategic vision 2010-2015 preventing mother-to-child transmission of HIV to reach the UNGASS and Millennium Development Goals: moving towards the elimination of paediatric HIV. Geneva: World health organization. Retrieved from http://www.who.int/hiv/pub/mtct/strategic_vision.pdf • WHO, W. P. (2012). Use of Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants. WHO, Geneva, April. Retrieved from http://www.who.int/entity/hiv/pub/pmtct_update.pdf

  50. THANK YOU

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