1. N. Shema 1, L. Tsague 2, J.D.D. Bizimana 3, P. Mugwaneza 1, A. Lyambabaje 3, E. Munyana 2, J. Condo 3, J.C. Uwimbabazi 4, E. Rugigana 3, J. Muita 2 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

2. 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

3. Rwandan National PMTCT program Millestones (1999-2009) 3 3. Initial sites expansion (GF, MAP) 1. PMTCT pilot project (Kicukiro) 2. TRAC defines National PMTCT program based on Sd- NVP regimen 2. TRAC defines National 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 5 – Initial expansio of early infant HIV diagnostic (DBS- PCR) - Expansion of More Ef-ARV -PMTCT Acceptability study 1999 - 2000 20012002-2004 2005-20062007– 2008 4. - More Efficacious ARV regimens and early infant diagnostic using DBS-PCR introduced; - PMTCT and ART program Scale- up (GF, PEPFAR) 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 6. – Transition to MER-ARV; - Impact study of national PMTCT program - Adaptation of 2009 WHO ARV recommendations for PMTCT

4. 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 (2 nd )

5. 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

6. 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.

7. Results

8. HIV + mothers HIV – mothers P-value Age, %, y (n=2969) 15-24 25-29 30-34 35-39 40-44 45-49 Mean age, y 9.99 24.74 29.00 24.53 9.85 1.89 32.18 21.46 30.75 22.56 15.54 7.80 1.89 30.09 0.000 Marital status, % (n=2963) Single/never married Lives with a partner Separated/divorced/widowed 8.54 69.00 22.46 6.32 87.68 6.00 0.000 Religion, % (n=2970) No religion Adventist Catholic Protestant Muslim Others 1.61 9.85 42.53 40.64 4.19 1.19 0.91 9.88 45.71 41.03 1.69 0.78 0.001 Socio-demographic characteristics of the respondents by HIV status

9. HIV + mothers HIV – mothers P-value Educational attainment, % (n=2965) Never attended school Primary school Vocational/technical Secondary school University 24.72 67.58 2.59 4.83 0.28 23.03 69.49 1.76 5.66 0.07 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 40.04 4.82 55.14 36.15 3.97 59.88 0.029 Socio-demographic characteristics of the respondents by HIV status

10. Among HIV+ mothers, having completed at least four ANC visit is associated with delivering at the health centers HIV + Mothers Total (n=1434) All Less than 4 ANC visits4 or more ANC visitsP-value Child given ARV at birth, (n=1394) None NVP Dual therapy Don’t know 5.67 38.45 34.58 21.31 6.68 38.92 34.51 19.90 4.33 37.83 34.67 23.17 0.0955 Mother delivered at health center, (n=1445) Yes No 89.48 10.52 86.63 13.27 93.33 6.67 0.0000 Feeding options at birth, (n=1352) EBF BF and early cessation Formula Animal modified milk 50.15 33.14 10.06 6.66 57.96 57.37 58.09 47.78 42.04 42.63 41.91 52.22 0.328

11. 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.

12. 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.

13. 9-24 month HIV-free survival in National PMTCT program, Rwanda, 2009 Unweighted Total No %(95%CI) Yes %(95%CI) Death145597.25 (96.34-98.16)2.75(1.84-3.65) HIV infection134096.04(95.28-.96.81)3.96(3.19-4.72) HIV infection and death among exposed children 138093.26(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.

14. Multivariate analysis of determinants of HIV infection or death among HIV exposed children, National PMTCT program, Rwanda, 2009 Child HIV infection or death Adjusted OR95% CI ARV taken by the mother, (reference: none) NVP alone Dual therapy Triple therapy 1.61 0.59 0.49 0.98 – 2.65 0.27 – 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.

15. 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).

16. 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