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Measuring the impact of PMTCT programmes

Measuring the impact of PMTCT programmes. Nigel Rollins Department of Child and Adolescent Health and Development WHO. MONITORING AND EVALUATING THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV A GUIDE FOR NATIONAL PROGRAMMES Preliminary Version for AIDS 2010. IMPACT data.

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Measuring the impact of PMTCT programmes

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  1. Measuring the impact of PMTCT programmes Nigel Rollins Department of Child and Adolescent Health and Development WHO

  2. MONITORING AND EVALUATING THE PREVENTION OFMOTHER-TO-CHILD TRANSMISSION OF HIVA GUIDE FOR NATIONAL PROGRAMMESPreliminary Version for AIDS 2010

  3. IMPACT data • Used to evaluate overall effectiveness of interventions • Often used for advocacy • Needs to tell the bottom line

  4. Process / Output data PMTCT Cascade Number of pregnant women tested for HIV Number of HIV infected pregnant women started on ART/ARV prophylaxis Non-HIV indicators Health system effects Immunisation rates Outcomes Infants Transmission rate No. infants infected annually Transmissions averted HIV-free survival Mothers Mortality among HIV-infected mothers Proportion of maternal deaths attributable to HIV Life expectancy of HIV-infected mothers Data presented as 'Impact' of PMTCT interventions / programmes

  5. Leading causes of death among women of reproductive age (15-44 yrs) Source: Women and Health report, WHO, 2009

  6. Maternal Mortality Trends, 1980-2008 Source: Hogan et al, 2010

  7. The global impact of ART & PMTCT scale up on child outcomes • 430,000 new paediatric infections in 2008 • 200,000 cumulative new HIV infections in children have been averted in the past 12 years UNAIDS, WHO AIDS epidemic update 2009 2

  8. Transmission rates as a measure of PMTCT impact • Transmission rate – 8.8% • But only measured in 410 infants of the 658 (62%) mothers originally identified

  9. DREAM study: HIV transmission in infants born to mothers on ART • 1,220 live born infants • 1,150 evaluable • 1 months • RF 0.8% • BF 1.2% • 6 months • RF 0.8% • BF 1.8% Concluded ART 'effective'

  10. Sampling bias if transmission only measured in those infants brought back to PMTCT services May omit infants of mothers who: Become infected after 1st HIV test Who never attend ANC Modelled approaches do not necessarily reflect real life e.g. non-adherence New guidelines re. ARVs for BF will require approaches to track HIV transmission until 18-24 months As a 'single' indicator or target, does not reflect … Maternal health and survival and benefits of interventions Success, or failure of identifying and initiating treatment of infected infants and improved survival Potential for improved survival if ARVs enable safer BF Challenges and limits of using infant transmission rates as a measure of PMTCT effectiveness

  11. Another way of telling the story … Shen. MOAE0101. IAS 2010

  12. Shen. MOAE0101. IAS 2010

  13. Under-2 mortality – measured through a demographic surveillance system In the context of a comprehensive programme offering ART to mothers and ARVs for prevention of MTCT including support for appropriate infant feeding practices, mainly BF Ndirangu. AIDS 2010

  14. Infant and Child mortality rates – measured through a demographic health survey 50% increase in IMR/CMR despite <4% transmission • Higher infant and young child mortality (x 1.6) in rural areas where 45% of the populations lives (BFHS 2007) (BDS 2006, BFHS 2007)

  15. J Acquir.Immune.Defic.Syndr. 2010;53(1):28-35 Decreased survival among infants who stopped BF early or who were never BF. AHR = 6.19; (95% CI 1.41–27.0, P = 0.015) 97% infants were tested at 6 wks – none infected. Difference was independent of maternal health or if receiving ART

  16. Proportion (%) Proportion (%) 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 25 25 25 25 20 20 20 20 15 15 15 15 Proportion (%) Proportion (%) 10 10 10 10 5 5 5 5 0 0 0 0 1993 1994 1995 2003 2004 2007 2003 2004 2006 2007 1992 1996 1999 2001 2002 2005 2006 1991 1992 1993 1994 1995 1997 1998 1999 2002 2005 1990 1991 1997 1998 2000 1990 1996 2000 2001 Proportion of HIV-related under-5 mortality in African sub-regions, 1990-2007 Central Africa West Africa East Africa Southern Africa

  17. Challenges and limits of using infant / child mortality as a measure of PMTCT effectiveness • Demographic surveillance systems reflect population effects (universal coverage) but cannot be generalized as a measure of national impact • Demographic health surveys are large scale national initiatives but difficult to repeat regularly in order to assess progress • The prevalence of HIV will influence whether HIV-related mortality will ever contribute significantly to national mortality rates esp. in low prevalence settings

  18. HIV free survival or a proxy …to reflect both transmission and survival • To have children of mothers known to be HIV-infected survive while remaining HIV uninfected is the top priority • The success of PMTCT activities , including cost-effectiveness, needs to be measured in terms of HIV-free survival and not just transmissions averted

  19. Impact assessments • Meaningful • Tells the full story • Measurable • ?HIV-FS • Population-based. • Achieving 'Universal coverage'. • Robust • Snapshots ……. Trends • Replicable within a reasonable timeline • Within country or district health systems • Between countries • Relevant for high and low prevalence settings

  20. Recent approaches • Identified HIV-free survival as the most important outcome but recognised that difficult to measure outside of cohorts and clinical studies • Require several years to establish cohorts in a specific population

  21. Recent approaches • Cord blood samples • Transmission rates and presence of NVP / AZT

  22. Using attendance at immunisation clinics to assess infant 6 week HIV prevalence and estimate trends in infant mortality rates If immunisation attendance is high, then = a proxy for population vertical transmission rates and major effects of HIV and PMTCT interventions on infant outcomes • Dried blood spots requested from all infants attending 6 week immunisation clinics • DBS tested for HIV antibodies (maternal) = infant exposure • Where antibodies detected, same sample tested for HIV by DNA PCR = infant infection • All mothers interviewed about deaths in other children • Other information e.g. ARVs taken can also be captured • In 2009, KZN DoH assessed 6 Districts, 347 clinics • 38,113 interviews, 8013 DBS samples from infants 6wk old • Funded through GFATM Lancet 2002; 360:389 AIDS 2007;21(10):1341-1347 AIDS 2009;23(14):1851-7

  23. Maternal HIV prevalence (DBS antibodies) Impact KZN 2009. http://crh.ukzn.ac.za

  24. HIV transmission rate by district *excludes 33 babies where PCR result not obtained due to insufficient sample Impact KZN 2009. http://crh.ukzn.ac.za

  25. HIV transmission rates by PMTCT regimen Impact KZN 2009. http://crh.ukzn.ac.za

  26. Infant mortality rates 1997- 2007 Impact KZN 2009. http://crh.ukzn.ac.za

  27. Results: Infant mortality rate by district Impact KZN 2009. http://crh.ukzn.ac.za

  28. Same methodology applied in a community-based evaluation4258 households visited • Number of children <18mo tested for HIV w/ evaluable EIA - 889/912 (97.5%) • 58/885 (6.6%) HIV-infected by PCR • IMR 67/1000 LB • 36% at home

  29. Proportion (%) Proportion (%) 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 25 25 25 25 20 20 20 20 15 15 15 15 Proportion (%) Proportion (%) 10 10 10 10 5 5 5 5 0 0 0 0 1993 1994 1995 2003 2004 2007 2003 2004 2006 2007 1992 1996 1999 2001 2002 2005 2006 1991 1992 1993 1994 1995 1997 1998 1999 2002 2005 1990 1991 1997 1998 2000 1990 1996 2000 2001 Low vs. high prevalence settings Proportion of HIV-related under-5 mortality in African sub-regions Central Africa West Africa East Africa Southern Africa Consider IMR restricted to HIV-exposed infants

  30. Maternal AIDS Free survival Rate of progression from delivery 12.4% 19.6% Kesho Bora. Th LB B105. Vienna IAS. 2010

  31. Implication for evaluating the cost benefit of PMTCT investment • Cost : benefit analyses of PMTCT investments should reflect the lifetime gains of mothers and infants surviving while being AIDS- or HIV-free and the interaction between the two • Putting a value only on infant transmissions averted underestimates the investment • Strengthens the argument and justification for HIV investment as a contribution to achieving MDGs 4 and 5

  32. Conclusions • Impact assessments need to reflect the full scope of what PMTCT aims to achieve • Robust, simple, combined methods are available but need investment to perform • Impact assessments need to be repeated to monitor progress towards targets and to hold global and national authorities accountable for investments made/needed • WHO is developing protocols for national or sub-national impact assessments

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