HIV-free survival at 9-24 months among children born to HIV infected mothers in the

National Program for the prevention of mother-to-child transmission of HIV inRwanda: a household survey

N. Shema1, L. Tsague2, J.D.D. Bizimana3, P. Mugwaneza1, A. Lyambabaje3, E. Munyana2, J. Condo3, J.C. Uwimbabazi4, E. Rugigana3, J. Muita2

1- TRACPlus/Ministry of Health; Kigali, Rwanda; 2- UNICEF – Rwanda; 3- National University of Rwanda, School of Public Health; 4 - National Reference Laboratory ; Kigali, Rwanda

ADD LOGO TRACPLUS and MOH

REPUBLIC OF RWANDA

MINISTRY OF HEALTH

Maternal and Child Heath Indicators, Rwanda, (DHS 2005, Mini DHS 2008)

• Fertility rate– 6.1→ 5.5 children per woman

• At least 1 ANC visit uptake– 94% → 96%

• Delivery assisted by trained health care worker – 24% → 63%

• Immunization coverage in children– 94.8% for DPT1 ( DHS 2008)

2

Rwandan National PMTCT program Millestones (1999-2009)

3

3. Initial sites expansion (GF, MAP)1. PMTCT pilot

project (Kicukiro)

2. TRAC definesNational PMTCT program based on Sd-NVP regimen

5 – Initial expansio of early infant HIV diagnostic (DBS-PCR)- Expansion of More Ef-

ARV - PMTCT Acceptability

study

1999 - 2000 2001 2002-2004 2005-2006 2007– 2008

4. - More Efficacious ARV regimens and early infant diagnostic using DBS-PCR introduced; - PMTCT and ART program Scale-up (GF, PEPFAR)

2009–

6. – Transition to MER-ARV; - Impact study of national

PMTCT program- Adaptation of 2009 WHO

ARV recommendations for PMTCT

4

Package of services for Mother-infant pair in the PMTCT program, Rwanda, 2009

HIV+ pregnant women• Routine opt-out counseling and HIV testing

(Promotion of couple counseling and testing)• Laboratory investigation: FBC, CD4 count , routine

pregnancy check-up, liver function

• Routine pregnancy medications: Malaria prevention (Bed nets), anemia prevention (Iron/Folic acid), etc..

• ARV prophylaxis HAART for women eligible Bi-prophylaxis (AZT+SdNVP; Tail AZT/3TC) Sd-NVP ; Tail AZT/3TC (discordant couple, labor

room CT)

• Safe practices delivery• Infant feeding counseling and support• Family planning services• Psychosocial and adherence support

HIV exposed infants• Post-exposure ARV prophylaxis

– Sd-NVP + AZT (4 weeks)

• Drug package (CTX prophylaxis)– CTX starts at 6 weeks

• Clinical monitoring– Growth monitoring– Symptoms of early HIV infection

• Early Infant diagnostic (DBS-PCR)– DNA-PCR

• PCR1: at 6 weeks• PCR2: 6 weeks before end of BF

• Serology • 9 months (1rst)• 18 months (2nd)

Study Objectives

• Evaluate the effectiveness of the national PMTCT program in Rwanda 8 years after its inception. – The outcome variables were:

Prevalence of HIV infection among 9-24 month old exposed children

Risk of dying by 9 months among HIV exposed children HIV-free survival at 9 months

Methods (1)• Design: Cross-sectional household survey between February -

May 2009

• Population: HIV+ and HIV- mothers who were expecting a child between March 2007 and June 2008 and have used antenatal services in Rwanda and their 9-24-month-old children.

• Sampling strategy: Two-stage cluster sampling (Health facilities; pregnant women in ANC)

• Ethical considerations: Study protocol was approved by the Rwanda National Ethics Committee and the National Institute of Statistics.

• Statistical analysis: Quantitative data was analyzed in Stata 10.1.

Results

HIV + mothers

HIV – mothers

P-value

Age, %, y (n=2969)15-2425-2930-3435-3940-4445-49

Mean age, y

9.9924.7429.0024.53

9.851.89

32.18

21.4630.7522.5615.54

7.801.89

30.09

0.000

Marital status, % (n=2963)Single/never marriedLives with a partner

Separated/divorced/widowed

8.5469.0022.46

6.3287.68

6.00

0.000

Religion, % (n=2970)No religion

AdventistCatholic

ProtestantMuslimOthers

1.619.85

42.5340.64

4.191.19

0.919.88

45.7141.03

1.690.78

0.001

Socio-demographic characteristics of the respondents by HIV status

HIV + mothers

HIV – mothers

P-value

Educational attainment, % (n=2965)Never attended school

Primary schoolVocational/technical

Secondary schoolUniversity

24.7267.58

2.594.830.28

23.0369.49

1.765.660.07

0.155

Literacy, % (n=2969)can't or have difficult reading and/or writing

can read but can't or have difficult writing can read and write easily

40.044.82

55.14

36.153.97

59.88

0.029

Socio-demographic characteristics of the respondents by HIV status

Among HIV+ mothers, having completed at least four ANC visit is associated with delivering at the health

centersHIV + Mothers Total (n=1434)

All Less than 4 ANC visits 4 or more ANC visits P-value

Child given ARV at birth, (n=1394)

NoneNVP

Dual therapyDon’t know

5.6738.4534.58

21.31

6.6838.9234.51

19.90

4.3337.8334.67

23.17

0.0955

Mother delivered at health center, (n=1445)

YesNo

89.48 10.52

86.63 13.27

93.33 6.67

0.0000

Feeding options at birth, (n=1352)

EBFBF and early cessation

FormulaAnimal modified milk

50.1533.1410.06

6.66

57.9657.3758.0947.78

42.0442.6341.9152.22

0.328

24 months Child survival by maternal HIV status, Rwanda National PMTCT program , 2009

• Kaplan-Meier survival analysis shows that children whose mothers are HIV negative are more likely to survive longer than children born to HIV+ mothers (p<0.001).

• Between 0-6 months, child survival is comparable.

• Note that survival deteriorates between 6-18 months among children born to HIV positive mothers.

24 months Child survival by maternal ANC visits, Rwanda National PMTCT program , 2009

• Kaplan-Meier survival analysis shows that children whose mothers attended less than 4 ANC visits had poorer survival than children whose mothers attended more ANC visits (p=0.02).

• This factor seems to be associated to early child mortality (0-6 months).

• Survival deteriorates further between 6-18 months among children born to HIV positive mothers.

0.90

0.92

0.94

0.96

0.98

1.00

Cum

ulat

ive

surv

ival

0 2 4 6 8 10 12 14 16 18 20 22 24Child Age

less than 4 ANC 4 or more ANC visits

Child survival by number of ANC visits

9-24 month HIV-free survival in National PMTCT program, Rwanda, 2009

  Unweighted Total

No

%(95%CI)

Yes

%(95%CI)

Death 1455 97.25 (96.34-98.16) 2.75(1.84-3.65)

HIV infection 1340 96.04(95.28-.96.81) 3.96(3.19-4.72)

HIV infection and death among

exposed children

1380 93.26(92.05-.94.47) 6.74(5.53-7.95)

• 2.75% exposed children died by the age of 9 months • 3.96% among the 1340 exposed children alive were HIV infected. • HIV-free survival was estimated at 93.26 %( 95%CI: 92.05%-94.47%) at 9-24

months• The risk of death in children born to HIV+ mothers is 3.5 times higher as

compared to children born to HIV- mothers (aHR: 3.51, 95% CI: 1.73-7.10) independently of child HIV status.

Multivariate analysis of determinants of HIV infection or death among HIV exposed children, National PMTCT program, Rwanda, 2009

Child HIV infection or death Adjusted OR 95% CI

ARV taken by the mother, (reference: none)NVP alone

Dual therapyTriple therapy

1.610.590.49

0.98 – 2.650.27 – 1.29

0.28 – 0.86

Location, (reference: rural)Urban

0.47

0.18 – 1.25

Membership to a PLWH association, (reference: no)

Yes

0.61

0.39 – 0.94

• Children whose mothers received highly active antiretroviral therapy (HAART) were 50% less likely to be infected by HIV and/or died compared to children whose mothers did not receive any ARV during pregnancy (adjusted Odd Ratio (aOR): 0.49, 95%CI:0.28-0.86).

• Being a member of an association of people living with HIV (PLWH) (aOR=0.61, 95%CI: 0.39-94) was also associated with a 39% reduced likelihood of HIV infection or death in children.

Conclusions • HIV free-survival among HIV exposed children is high (93.3%) by 9-24 months in

Rwanda,

• However, survival among children born to HIV infected mothers decreases overtime as compared to the one of children born to HIV- mothers. Survival deteriorates further after 6 months of age among HIV exposed infants.

• The risk of death in children born to HIV+ mothers is 3.5 times as higher as in children born to HIV- mothers (aHR: 3.51, 95% CI: 1.73-7.10) independently of child HIV status.

• The key determinants of HIV free-survival in the national PMTCT program include maternal initiation of highly active antiretroviral therapy (HAART) during pregnancy (adjusted Odd Ratio (aOR): 0.49, 95%CI:0.28-0.86) and being a member of an association of people living with HIV (PLWH) (aOR=0.61, 95%CI: 0.39-94).

Acknowledgments

• All mothers and family who participated in the study• All staff from the selected sites• Staff at the National Reference Laboratory• All HIV&AIDS implementing partners• National University of Rwanda School of Public Health• UNICEF for technical and financial support

School of Public Health

N

N

R

LR

L