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

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Evaluation of PMTCT coverage in four African
countriesThe 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 dIvoire)Elizabeth
Glazer Pediatric AIDS Foundation and Cameroon
Baptist Health Convention University of Cape
Town Infectious Disease Epidemiology Unit
(South Africa)
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PEARL study

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

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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)

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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)

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PMTCT interventions

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

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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 dIvoire
• South Africa
• Cameroon

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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)

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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

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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

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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)
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HIV prevalence

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

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Coverage Cascade
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Maternal coverage by site
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Factors associated with failed coverage
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Maternal adherence across sites
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Factors associated with maternal non-adherence
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Western Cape PMTCT guidelines

• Guidelines 2007/08
• SC-ZDVSD-NVP for women with CD4 gt 200
• HAART for women with CD4 lt200
• No data collected on CD4 cell count in this study

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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

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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

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Acknowledgements

• Cameroon
• Pius Tih
• Tom Welty
• Cote dIvoire
• 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 dIvoire
• Zambian MOH