Effectiveness of the National PMTCT Program in Rwanda By Dr Alexandre LYAMBABAJE, School of Public Health/ National University of Rwanda Dr Placidie MUGWANEZA, Institute of HIV Diseases Prevention and Control (IHDPC/RBC), Rwanda

Male partner HIV counseling and testing, during ANC, Rwanda PMTCT program, 2005-2010 Population Coverage, HIV+ preg. Women receiving ARV, Rwanda PMTCT program, 2005-2010 Transitioning from Sd-NVP to Efficacious ARV regimens, Rwanda PMTCT program, 2005-2010

1st PMTCT Program Effectiveness Study - Household Survey (2008-2009)- Aim: HIV prevalence and key determinants among exposed children in the Rwanda PMTCT program. Methods Study design: cross sectional Inclusion criteria: 9-24 months children with their mother Sampling frame: Stratified 2-stage cluster sampling (1st unit: sites; 2nd unit: ANC mothers). Both HIV+ and –ves mothers were included to ensure community is blind about status of participants. Data collection: Interview with mothers at household, HIV testing of all children (rapid test and PCR)

Key findings -

Limitations of the 1st PMTCT effectiveness study Recall bias: 9 to 24 months is a long period after birth. Some mothers could not recall exactly events and treatments during pregnancy and delivery periods End point measurement: Wide interval (9-24 months) making it difficult to interpret the HIV free- survival rate, as we could not rule out exposure to breastfeeding Adherence to PMTCT regimens: Registries could not provide exhaustive information about the adherence of the mothers to PMTCT regimens.

2nd PMTCT 6-week Impact Study Facility-based, 2010-2012 Primary Objective To periodically measure rates of early mother-to-child transmission (MTCT) of HIV at 6-weeks postpartum Secondary Objectives To periodically estimate the national coverage of key PMTCT interventions, To estimate the association between early MTCT rate and maternal, infant and health system factors. Endpoints: 6-week infant HIV prevalence 6-week infant MTCT rate (Overall, PMTCT mother, non-PMTCT mother, Serodiscordant couples)

6-week facility based PMTCT Impact Study - Design Design: Cross-sectional Two-stage Stratified Cluster sampling design Primary units: Health facilities Stratified by (rural vs urban; PMTCT vs Non-PMTCT site) Probability proportional to size sampling: size estimated using historical DTP1 data (previous year) Secondary units: Mother-infant pairs Sample size 161 sites (36 non-PMTCT sites; 20 urban) 2,000 pairs (exposed infant, mother or legal caregiver)

6-week facility based PMTCT Impact Study - Data collection Age group: 6-10 weeks Where: Facility-based at MCH/EPI unit How: enrollment at DTP1 immunization visit By Who: Health facility personnel Main steps Screening based on standard algorithm (exposed infant) Interviews of mother or caregiver Blood sample collection (using DBS) Data collection started in June 13th 2011 Final results expected by May 2012

6-week facility based PMTCT Impact Study - Screening Algorithm for enrollment

Challenges and Potential Bias Outreach Immunization strategy How to integrate screening for the study? How to administer the questionnaire? Who will manage the transfer of potential eligible mothers and infants to Health facilities for further screening? Reaching the hardest to reach populations: do not participate in immunization campaigns (Beliefs, Ignorance, hard to reach areas) Long period for data collection (7 months) Health Center Personnel mobility

Advantages and Disadvantages compared to MRC Generic Protocol Low cost for blood samples collection and testing Zero risk for non-exposed children Capacity building for health facilities and better sustainability Better coverage by including recruitment from outreach immunization strategy Disadvantages Difficult screening phase to identify exposed children Long period for data collection (7 months) Mobility of trained personnel and need to retrain new people for data collection

Thank You For Your Attention - MURAKOZE Acknowledgements Rwanda Biomedical Center/ Institute of HIV, Diseases Prevention and Control (RBC/IHDPC) Rwanda School of Public Health LABORATOIRE NATIONAL DE REFERENCE NATIONAL REFERENCE LABORATORY Thank You For Your Attention - MURAKOZE