Mother-to-Child Transmission of HIV and HIV-Free Survival in Swaziland: A Community-based Household Survey Dr. Caspian Chouraya: MD; Dip. HIV Man; MSc (Epidemiology) IAS 2017, Paris, France STUDY TEAM: Rhoderick Machekano1, Simangele Mthethwa2, Krysia Lindan3, Munamato Mirira4, Kwashie Kudiabor1; Michelle M Gill1; Gugu Maphalala2; Godfrey Woelk1; Laura Guay1 1 Elizabeth Glaser Pediatric AIDS Foundation 2 Swaziland Ministry of Health 3 University of California, San Francisco 4 USAID Swaziland

Conflict of interest No conflicts of interest to declare Mother-to-child transmission (MTCT) of HIV remains a global challenge with 150,000 new infections in children in 2015. UNAIDS targets for the virtual elimination of MTCT include reducing the rate to 5% or less among breastfeeding populations, and 2% or less among non-breastfeeding populations. The WHO recommends several methods to measure MTCT rates and HIV-free survival at the end of breastfeeding, including modeling; facility-based surveys and cohort data; use of early infant diagnosis (EID) and child HIV testing data; and population/community based surveys,

HIV epidemic in Swaziland Population = 1.3 million Is divided into 4 regions: Hhohho, Manzini, Shiselweni and Lubombo 52 constituencies HIV prevalence 27% among 15-49 years (SHIMS 2015/6) Prevalence of 41.1% among women attending ANC (ANC sentinel, 2010) Overall HIV Incidence = 1.4% (SHIMS 2015/6) Male- 1.0% Female- 1.7%

Introduction Mother-to-child transmission (MTCT) of HIV remains a global challenge with 150,000 new infections in children in 2015. UNAIDS targets for the virtual elimination of MTCT. WHO has also developed criteria for validation of eMTCT The WHO recommends several methods to measure MTCT rates and HIV-free survival at the end of breastfeeding, including population/community based survey Mother-to-child transmission (MTCT) of HIV remains a global challenge with 150,000 new infections in children in 2015. UNAIDS targets for the virtual elimination of MTCT include reducing the rate to 5% or less among breastfeeding populations, and 2% or less among non-breastfeeding populations. The WHO recommends several methods to measure MTCT rates and HIV-free survival at the end of breastfeeding, including modeling; facility-based surveys and cohort data; use of early infant diagnosis (EID) and child HIV testing data; and population/community based surveys,

Objectives To determine the following outcomes among HIV-exposed children identified in the community who were born 18-24 months prior to study initiation (PMTCT Option A period). Proportion of HIV-exposed study children who are alive and free of HIV at 18-24 months of age (HIV-free survival) Proportion of HIV-exposed children who are HIV-infected at 18-24 months of age, including children who have died but were known to be HIV-infected prior to death To explore factors associated with child HIV-free survival

Sampling We used a multi-stage sampling procedure to obtain a representative sample of HIV-infected mothers and exposed children from all four regions of the country. Constituencies within each region were stratified as urban, rural high or low-volume with one randomly selected constituency from each strata included (12 constituencies). We randomly selected an enumeration area (EA) in each constituency and then surveyed all households with a delivery between April 1 and October 30, 2013, regardless of whether the child was currently alive or not. We used a multi-stage sampling procedure to obtain a representative sample of HIV-infected mothers and exposed children from all four regions of the country. Regions were stratified as urban, rural high or low-volume with one randomly selected constituency from each strata included (12 constituencies). We randomly selected an enumeration area (EA) in each constituency and then surveyed all households. If the sample size for the constituency was not met, another EA was randomly selected until the desired sample size was achieved. Community health workers identified households with a delivery between April 1 and October 30, 2013, regardless of whether the child was currently alive or not.

*Only DBS was done for infected children already on ART Selected EA All households Confirmed birth in past 18-24m (whether dead or alive)? Yes and mother available Yes but mother unavailable No Documented HIV positive result for mother? 1. Administer questionnaire to available caregiver whether baby alive or dead 2. *Test child (rapid + DBS) Thank household and exit Yes No Test mother 1. Administer questionnaire whether baby alive or dead 2. *Test child (rapid + DBS) if alive with a delivery between April 1 and October 30, 2013, regardless of whether the child was currently alive or not. HIV-positive HIV-negative 1. Administer questionnaire whether baby alive or dead 2. *Test child (rapid + DBS) if alive Administer questionnaire whether baby alive or dead *Only DBS was done for infected children already on ART

Findings

Characteristics of HIV-positive mothers The mean (±SD) age was 28.8 ± 5.8 years. Almost all mothers (99.7%) attended ANC at least once; mean (±SD) gestational age at first ANC visit was 15.9 ± 6.2 weeks. The mean (±SD) CD4 cell count at baseline (first ANC): 493.7 ± 264.3 copies/ml. Most HIV-positive mothers (91.8%), excluding the 35 newly diagnosed, received PMTCT drugs during pregnancy; 41.0% received AZT prophylaxis, 14.2% were on ART at the time of pregnancy, 41.6% initiated ART during ANC. Most mothers (89.4%) delivered their child at a health facility; At time of survey, 7.6% of mothers were still breastfeeding their child.

HIV-negative and alive (n) Main outcomes Outcome N HIV-negative and alive (n)  HIV-infected (n) Estimate (95% CI) HIV-free survival at 18-24 months 724 694   95.9% (94.1-97.2) MTCT rate in known HIV-exposed children 720a 26 3.6% (2.4-5.2) MTCT rate assuming all dead children were infected 30 4.1% (2.7-5.5) a Excludes 4 children who died (as HIV status was unknown)

Factors Associated with HIV-free survival Risk of child HIV infection or death was significantly associated with mother’s age, receipt of PMTCT drugs by mother, and facility delivery. For every 10-year increase in the mother’s age, the odds of child HIV infection or death were reduced by 58% (aOR=0.42; 95% CI [0.17-1.00]). Women’s receipt of AZT only (aOR=0.15; 95% CI=[0.04-0.62]), ART initiation during pregnancy (aOR=0.14; 95% CI=[0.03-0.58]), and being ART experienced (aOR=0.08; 95% CI=[0.01-078]) were protective against child HIV infection or death compared to no PMTCT drugs. Delivery in a health facility reduced the odds of HIV infection or death of the child (aOR=0.33; 95% CI [0.12-0.92]). Mother’s education, marital status, gestational age at first ANC visit, and breastfeeding duration were not associated with child HIV infection or death. Adjusting for facility delivery, infant nevirapine duration and mother’s PMTCT regimen, for Adjusting for maternal age, facility delivery, and duration of infant nevirapine,

Main limitation The study captured information on very few children who had died. This may be due to poor identification of households with child deaths by the study team or due to discomfort in talking about child deaths by either or both the study team and household members. This likely underestimated the mortality rates and overestimated HIV-free survival rates found in the study.

Conclusion This is the first community survey done in Swaziland to assess the effectiveness of the PMTCT program under Option A. Findings from our study indicate that Swaziland’s PMTCT program has been effective, with a high HIV-free survival of 95.9% and low MTCT at 18-24 months of 3.6%. Given the national roll-out of Option B+ in late 2014, undertaking a similar household survey in two years to measure effectiveness of the most recent guidelines is recommended. In subsequent surveys, efforts should be intensified to identify all households with a child death.

ACKNOWLEDGEMENTS All study participants Ministry of Health, Swaziland This study was made possible through funding from PEPFAR through USAID under the Eliminating Paediatric AIDS in Swaziland (EPAS) Project Cooperative Agreement #674-A-00-11-00009-00. Disclaimer: The contents of this report are solely the responsibility of the authors and do not necessarily represent the official views of USAID, PEPFAR, or the U.S. Government. We wish to acknowledge support from the University of California, San Francisco’s International Traineeships in AIDS Prevention Studies (ITAPS), U.S. NIMH, R25MH064712 Study coordinator (Samkelo Dladla) and entire study team