1. Evaluation of PMTCT coverage in four African countries: The PEARL Study D Coetzee, EM Stringer, BH Chi, N Chintu, TL Creek, DK Efouevi, K Stinson, P Thi, T Welty, F Dabis, N Shaffer, CM Wilfert, JSA Stringer University of Alabama – Center for Infectious Disease Research Zambia University of Bordeaux (France) – PAC-CI (Cote d’Ivoire) Elizabeth Glazer Pediatric AIDS Foundation and Cameroon Baptist Health Convention University of Cape Town – Infectious Disease Epidemiology Unit (South Africa)

2. PEARL study Methodology developed with CDC in “die Paarl” over a bottle or two of red wine Hence PEARL study

3. PEARL Study 4-country effectiveness evaluation Facilities and their catchment populations randomly identified in each country Facility-based evaluations Cord Blood Surveillance Facility Survey – exit and informant interviews Community-based evaluations Community Survey to identify HIV-free survival Cost-effectiveness evaluation ________________________________________ Funding: CDC-GAP (ZM, CI, RSA) EGPAF (Cam)

4. PEARL Study An effectiveness evaluation Facilities and their catchment populations randomly identified in each country Facility-based evaluations Cord Blood Surveillance – preliminary data Facility Survey Community-based evaluations Community Survey Cost-effectiveness evaluation ________________________________________ Funding: CDC-GAP (ZM, CI, RSA) EGPAF (Cam)

5. PMTCT interventions All sites used at least single-dose nevirapine (SD-NVP) for PMTCT; Some also used short course zidovudine SC-ZDV+SD-NVP and/or HAART.

6. Cord Blood Surveillance Methodology Anonymous consecutive cord blood specimens from all live-births – (except Cameroon) April 2007 and October 2008 43 randomly selected sites in 4 countries Zambia Cote d’Ivoire South Africa Cameroon

7. Methodology (2) Cord blood collected anonymously from every delivery Tested for HIV If cord blood (mother) was HIV-infected, then cord blood tested for NVP by high-performance liquid chromatography And ZDV + 3TC (where applicable)

8. Methodology (3) Key PMTCT information (from folder) collected anonymously age of mother parity acceptance of HIV testing result received mother documented as having received NVP infant documented as having received NVP

9. Definitions Coverage = maternal & infant ingestion of NVP Maternal ingestion = NVP present in cord blood if HIV-infected Infant ingestion = documentation of the infant having received NVP

10. 28, 955 Live births (100%) 28,060 Specimens Obtained (96.9%) 27,996 Specimens Tested (96.7%) 3,250 Cord blood HIV Positive (12.2%) Specimen collection rate

11. HIV prevalence HIV prevalence was typical of that observed in each area in the particular country

12. Coverage Cascade

13. Maternal coverage by site

14. Factors associated with failed coverage Adjusted OR Mother’s Age > 30 1.0 26-30 1.22 (1.04 - 1.44) 20-25 1.33 (1.08 - 1.64) <= 20 1.58 (1.23 - 2.02) Gravidity 1 1.0 2-3 1.08 (0.88 - 1.33) 4+ 1.14 (0.89 - 1.45) Number of ANC Visits 6+ 1.0 4 or 5 1.47 (1.27 - 1.70) 2 or 3 1.68 (1.38 - 2.05) 0 or 1 2.92 (2.22 - 3.84)

15. Maternal adherence across sites

16. Factors associated with maternal non-adherence Adjusted OR Mother’s Age > 30 1.0 26-30 1.42 (1.04 - 1.93) 20-25 1.28 (0.92 - 1.78) <= 20 1.30 (0.90 – 1.90) Gravidity 1 1.0 2-3 1.33 (0.95 - 1.85) 4 1.62 (1.12 - 2.34) Number of ANC Visits 6+ 1.0 4 or 5 1.71 (1.33 - 2.20) 2 or 3 2.04 (1.48 - 2.83) 0 or 1 2.98 (2.07 - 4.28) Delivery Method Cesarean 1.0 Vaginal 1.51 (1.11 - 2.05) Prophylaxis Type NVP only 1.0 NVP and AZT 1.42 (1.04 - 1.93) HAART 1.28 (0.92 - 1.78)

17. Western Cape PMTCT guidelines Guidelines 2007/08 SC-ZDV+SD-NVP for women with CD4 > 200 HAART for women with CD4 <200 No data collected on CD4+ cell count in this study

18. Maternal adherence – Western Cape HAART 12% ZDV and NVP47% Standard of care59% NVP only6% At least NVP65% ZDV only8% Nothing27%

19. Conclusions PMTCT involves a cascade of interventions All sites: only 50% coverage Failures occur along each step of the cascade Interventions are required at each point Even in settings with dual therapy and HAART to target high risk women, more than 25% of women are not covered with PMTCT prophylaxis

20. Acknowledgements Cameroon Pius Tih Tom Welty Cote d’Ivoire Francois Dabis Didier Ekouevi Serge Kahon South Africa Andrew Boulle David Coetzee Kathryn Stinson Zambia Max Bweupe Ben Chi Namwinga Chintu Mark Giganti Jeffrey Stringer Wendy Mazimba Centers for Disease Control Mark Bulterys Tracy Creek Nathan Shaffer EGPAF Allison Spensley Christophe Grundmann Cathy Wilfert Others Cameroon Baptist Health Convention Elliott Marseille Mary Louise Newell MOH Cote d’Ivoire Zambian MOH