Highest risk of mother-to-child transmission of HIV or
Highest risk of mother-to-child transmission of HIV or death in the first 6 months postpartum: Results from 18 month follow-up of an HIV-exposed national cohort, South Africa AIDS 2016 Goga AE, Jackson DJ, Lombard C, Ramokolo V, Ngandu N, Sherman G, Puren A, Doherty T, Bhardwaj S, Noveve N, Ramraj T, Magasana V, Singh Y, Pillay, Dinh T for the SAPMTCTE study group. BACKGROUND 18-24 months HIV-free survival = Gold standard measuring PMTCT impact + Few low-middle income, high HIV prevalence countries produce these data, nationally 2001: PEARL study: 79.7% (76.4-82.6) at 24 months 2004-7: SWEN study: 92% HIV-free survival at 6 months. Ethiopia, India, Uganda 2008-2009: Ngoma et.al. Zambia (maternal ART): 87.2% (79.1-93.5) at 18 months 2012: Buzdugan R et.al. Zimbabwe (Option A context): 90.9% (88.7-92.7%) at 9-18
months. Com-based survey 5 districts SA: Option A (2010-April 2013) Option B (2013) PRIMARY QUESTION What is the risk of MTCT and MTCT or death at 3, 6, 9, 12, 15 and 18 months, amongst a nationally representative sample of HEU infants METHODS Multistage PPS sampling Consecutive or systematic sampling of participants to establish cohort C/S surveillance at 580 EPI sites.
Target: 12 200 infants aged 4-8 weeks - national and provincial estimates Closed POC of HEU infants. Target: 1620 HEU at 18 months for national estimates NICD HIV Ab TNA PCR Rapid HIV tests PHC / CHC METHODS: DATA ANALYSIS Weighted for: South African live births, non consented eligible infants,
consented infants who were lost to follow-up Adjusted for survey design and competing risks Conducted using SAS version 9.2 Study Profile: 2811 eligible HEU infants 6% no f-up consent 1600-1700 f-up at each time point 1797 (71%) f-up at 18 mo Cumulative HIV incidence till 18 months 4.3 (3.7-5.0) n =1797 = 71% 2.6% Age in months
1.1% 12 3.9 (3.4-4.7) 1.3% 15 4.1 (3.5-4.8) 1.5% 18 4.3 (3.7-5.0) 1.6% age in weeks 81% cumulative MTCT by 6 months
56% PN MTCT occurred by 6 months; 68% by 9 months PN MTCT accounted for 37% of 18-month MTCT HIV/Mortality incidence till 18 months % HIV or Mortality Failure 10 9 8 6.3% 7 6 (5.2-7.8%) 5 4 3 2 1
0 0 Amongst infants alive at 6 weeks with followed-up till 18 months 93.7% (92.2-94.8%) were alive and HIV-free 10 20 30 40 50 60 70 80 Infant age in weeks 90 LIMITATIONS AND STRENGTHS Limitations Excluded infants without consent or who died < 6 weeks Closed cohort
MTCT and HIV-free survival could be under-estimated Strengths Cohort drawn from nationally representative sample 94.1% of eligible population participated in f-up Infants could enter and exit cohort Attained >1620 (estimated sample size) 71% interviewed at 18 months 96% tracked for survival Analysis adjusted for no consent and loss to follow-up SUMMARY At population level <5% MTCT was achieved in a BF- national setting by 2014 The first 6 months postpartum is a critical period for HEU infants ACKNOWLEDGMENTS MRC Team: Ameena Goga Carl Lombard Nobuntu Noveve
Vundli Ramokolo Tanya Doherty Yages Singh Nobubelo Ngandu Vuyolwethu Magasana Trisha Ramraj Duduzile Nsibande Natasha Titus Jazelle Kiewitz Lucille Heyns Survey supervisors The SAPMTCTE was supported by: The Presidents Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) NDoH NICD/NHLS SANAC
Global Fund EU (through NDoH) SAMRC Caregiver-infant pairs Research nurses NDoH Nurses CDC: Thu-Ha Dinh Mireille Cheyip Mary Mogashoa NDoH: Yogan Pillay Provincial DoHs UWC/ UNICEF NY: Debra Jackson UNICEF (SA) Sanjana Bhardwai NICD/NHLS: Adrian Puren Gayle Sherman
Beverley Singh Ushmita Patel Ewalde Cutler Contact details UNIT : Ameena Goga : Health Systems Research Unit E-MAIL : [email protected]
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