1. Washington D.C., USA, 22-27 July 2012www.aids2012.org PMTCT decentralization does not assure optimal service delivery : revelations from successful individual-level tracking of HIV-infected mothers and their infants Andrew Edmonds Deidre Thompson Vitus Okitolonda Lydia Feinstein Bienvenu Kawende Frieda Behets for the PMTE team

2. Washington D.C., USA, 22-27 July 2012www.aids2012.org Background Essential services for the prevention mother-to-child HIV transmission (PMTCT) are being increasingly decentralized to antenatal care (ANC) sites However, the consequences of shifting services from dedicated HIV care and treatment (C&T) clinics remain incompletely explored –Rwanda: differences between stand-alone and full package sites (Tsague et al. BMC Public Health 2010, 10:753) –HIV-exposed infants are often not DNA PCR tested at ANC or immunization sites (Ciaranello et al. BMC Medicine 2011, 9:59)

3. Washington D.C., USA, 22-27 July 2012www.aids2012.org Context The University of North Carolina at Chapel Hill (UNC) has assisted with implementation of HIV prevention, care, and treatment the Democratic Republic of Congo (DRC) since 2003 PMTCT activities –HIV testing ~63,000 women/year (49 sites) –Scaling up to ~100,000 women/year (105 sites) –HIV prevalence ~1.3%

4. Washington D.C., USA, 22-27 July 2012www.aids2012.org Locations and characteristics of 44 maternities providing vertical HIV prevention services and 2 comprehensive care and treatment sites

5. Washington D.C., USA, 22-27 July 2012www.aids2012.org PMTCT Ya Sika In October 2010, an enhanced standard of care was introduced at the UNC-supported ANC sites –Personnel were retrained to implement co-located post- delivery care and the 2010 World Health Organization PMTCT guidelines including Option A –They were also provided with new individual-level tracking tools and supportive supervision –HIV-infected “mother-mentor” clinic volunteers The ANC sites became decentralized in waves –Sites that had not yet been fully decentralized continued to refer all HIV-infected women to the care and treatment sites

6. Washington D.C., USA, 22-27 July 2012www.aids2012.org Purpose We compared service delivery at ANC and HIV C&T clinics in Kinshasa, DRC, a low HIV prevalence, resource-deprived setting

7. Washington D.C., USA, 22-27 July 2012www.aids2012.org Mother Infant Register Tracking of individual-level data for the mother-infant pair across the PMTCT spectrum

8. Washington D.C., USA, 22-27 July 2012www.aids2012.org

9. Washington D.C., USA, 22-27 July 2012www.aids2012.org Epi Info database for Mother Infant Register (mother data)

10. Washington D.C., USA, 22-27 July 2012www.aids2012.org Epi Info database for Mother Infant Register (infant data)

11. Washington D.C., USA, 22-27 July 2012www.aids2012.org

12. Washington D.C., USA, 22-27 July 2012www.aids2012.org

13. Washington D.C., USA, 22-27 July 2012www.aids2012.org

14. Washington D.C., USA, 22-27 July 2012www.aids2012.org

15. Washington D.C., USA, 22-27 July 2012www.aids2012.org

16. Washington D.C., USA, 22-27 July 2012www.aids2012.org No evident improvement over time in CD4 test provision Decentralization did provide a new point of access –Several hundred women and infants received services at the level of the maternity

17. Washington D.C., USA, 22-27 July 2012www.aids2012.org Conclusions Detailed individual-level tracking of mothers and infants was feasible in Kinshasa It revealed that PMTCT services were delivered less effectively at sites historically focused on ANC rather than HIV C&T Logistical barriers pose a significant challenge but can be overcome While decentralization increased access to services, its potential to further reduce vertical transmission cannot be fully realized without sustained training, supervisory support, and site-specific real-time data quality monitoring