Operational challenge: Linkages from prevention of mother-to-child transmission services to care and treatment services in Zambia S. Okawa, M. Chirwa, N. Ishikawa, F. Pande, H. Kapyata, C. Msiska, K. Komada, H. Miyamoto, A. Mwango ▪Chongwe District Community Health Office ▪Ministry of Health Zambia - Japan International Cooperation Agency SHIMA project, Lusaka, Zambia

Background  Great success in scale-up of the PMTCT program in Zambia  PMTCT ARV coverage: 97% (UNAIDS, 2012)  There is a need to take advantage by referring all HIV-positive women from PMTCT to HIV care/treatment  Few studies on linkages between PMTCT and HIV care/treatment in Zambia

Study design  Design: Prospective cohort study  Period: ▶ Enrolment: June 2011 – May 2012 ▶ Follow up: June 2011 – January 2014  Site: Chongwe district, Lusaka province ▶ Referral health center ▶ 5 rural health centers (RHCs) with ART services ▶ 5 RHCs without ART services  WHO 2010 guidelines Option A  Participants: 195 mothers newly diagnosed as HIV- positive in PMTCT program

Data Collection  Face-to-face interview ‒ Basic characteristics of mothers  Review of clinical record and electronic database of clients on HIV care/treatment ‒ Date of enrolment in HIV care/treatment ‒ Date of ART initiation ‒ Date of the last visit to the services

Analysis  Probability of enrolment in HIV care/treatment  Kaplan-Meier survivor function  Predictors of enrolment in HIV care/treatment  Cox proportional hazards model  Observation time:  Entry point: from HIV diagnosis at antenatal clinic  End point: enrolment in HIV care/treatment  Censored point: 20 January 2014

Results

Participants Characteristics Characteristics N% Age Median (IQR)27(22-32) ≤ ≥ Education (years) None ≥8≥ Marital status Married/Cohabit Not married Parity Primigravida ≥4≥

Participants Characteristics cont. N% Paid work of partner No Once in a while Part of the year178.8 Throughout the year Time to access heath facility (minutes) ≤ ≥ Perception on taking ARVs Positive Negative Place of receiving PMTCT service Referral health center RHCs with HIV care/treatment RHCs without HIV care/treatment

Linkage from PMTCT to HIV care/treatment 195 Newly diagnosed in PMTCT program 92 enrolled in HIV care/treatment (47.2%) 48 initiated ART (24.6%) 44 not initiated ART (22.6%) 103 not enrolled (52.8%) As of 20 January, 2014

Probability of enrolment in HIV care/treatment Time from HIV diagnosisProbability95%CI at 6 months at 12 months at 18 months

From HIV Diagnosis to ART initiation 195 newly diagnosed 87 tested CD4 48 CD4< started ART 21 not started ART 39 CD4 ≥ started ART 28 not started ART 108 not tested CD4 (No data) 10 started ART 98 not started ART As of 20 January 2014 *108/195 (55.4%) *21/48 (43.8%)

Predictors for enrolment in HIV care/treatment PredictorsHazard ratio 95% CI Age ≤ † ≥ Education None ≥8≥ Marital status Married/Cohabit1.00 Not married Parity Primigravida ≥4≥

Predictors for enrolment in HIV care/treatment (cont.) PredictorsHazard ratio 95% CI Paid work of partner No1.00 Once in a while Part of the year Throughout the year Time to access heath facility (minutes) ≤ ≥ Perception on taking ARVs Positive Negative1.00 Place of receiving PMTCT service Referral health center1.00 RHCs with HIV care/treatment RHCs without HIV care/treatment †

Summary

Poor linkage from PMTCT to HIV care/treatment ▪53% of new HIV-positive mothers have not enrolled in HIV care/treatment ▪55% of new HIV-positive mothers were not tested CD4 count after diagnosis of HIV ▪44% of mothers with CD4<350 have not started ART

Risk factors for not enrolled in HIV care/treatment ▪Younger maternal age ▪Attending rural health centers not providing HIV care/treatment

Conclusion Strengthening linkage between PMTCT and HIV care and treatment services needed - Option B+ implementation (Apr 2014-) - Treatment is offered to HIV + partners regardless of CD4 count - Future evaluation of Option B+ implementation needed

Acknowledgements  Study participants  Ministry of Health, Zambia  Ministry of Community Development, Mother and Child Health, Zambia  Japan International Cooperation Agency (JICA)  National Center for Global Health and Medicine, Japan (NCGM)  The University of Tokyo  Midwives and community-based volunteers at study sites

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