Rwanda Sam Kalibala HIVCore Population Council Godfrey Woelk HIVCore Elizabeth Glaser Pediatric AIDS Foundation 17 September 2015 IATT Webinar HIVCore background Improve the efficiency effectiveness scale and quality of HIV treatment care and support and ID: 739626
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Slide1
A secondary analysis of retention across the PMTCT cascade: Rwanda
Sam Kalibala,
HIVCore
/Population Council
Godfrey Woelk,
HIVCore
/Elizabeth Glaser Pediatric AIDS Foundation
17 September 2015
IATT WebinarSlide2
HIVCore background
Improve
the efficiency, effectiveness, scale, and quality of HIV treatment, care, and support, and
PMTCT programs by:
Conducting operations research and program evaluations
Promoting use of research and program results to enhance decision-making
Building local capacity to conduct operations research.
5-year
project (Oct 2011–Sep 2016),
19 studies in
portfolio
Funded by
USAID
Led by Population Council in partnership with
the
Elizabeth Glaser Pediatric AIDS Foundation
, Palladium, and University of WashingtonSlide3
HIVCore’s contribution in PMTCT Enhancing PMTCT program effectiveness
Identifying gaps and successes in
retention and adherence of PMTCT mothers and
HIV-exposed infants (HEI)
Example
:
Identifying
reasons for delays and loss to follow-up among each step of the PMTCT
cascade in Cote d’Ivoire
Measuring
MTCT
rates
Example: National PMTCT Evaluation in Zambia
Testing
new approaches for improving
HEI testing and treatment
Example: Testing
combined m-health and transport reimbursement approaches in TanzaniaSlide4
IntroductionGlobal consensus that pediatric AIDS can be eliminated.
Goal of elimination (transmission rate <5%) by 2015.
Retention in care is critical in achieving this goal.
In 2012, 62% of HIV+ pregnant women received the most efficacious regimes.
Paucity of knowledge on
retention.
Monitoring challenges.
4 country case studies: Kenya (Option A), Malawi (Option B+), Rwanda (Option B), Swaziland (Option A).
Rwanda (Option B) findings presented here.Slide5
Research questionsWhat are the levels of and factors related to retention among women and infants in PMTCT care? (retention = rates of program [clinic] attendance)
What are the levels of program attendance 30 days after entry into the PMTCT program at: delivery; 6 weeks; and 2, 3, 6, and 12 months post-delivery?
How do the levels of program attendance vary by demographic, clinical and facility characteristics?
What program characteristics are associated with retention?Slide6
MethodologyRetrospective chart (registers)
review and patient records:
(
ANC
, PMTCT, Labor and delivery, Child welfare,
post natal care [PNC], early infant diagnosis, pharmacy and laboratory).
Retrospective cohort constructed of HIV+ women attended ANC from 2010–2011.
In-charge i
nterviews to
obtain health facility
data.
Sampled from EGPAF-supported sites.
S
tratified by type and location (urban/rural) of facility.
Logistics such as number of HIV+ pregnant women, distance, quality of records considered.Slide7
Sampling and sample size (Rwanda)5 sites (2
urban and
3 rural) selected—minimum of 40
HIV+
pregnant women per site/year.
Sampled
proportional to
expected number of women
HIV
positive at ANC.
Expected 50% to attend 12 month
visit; proposed sample 474.
Sampled all HIV+ women attending ANC (Option B).
Interviewed
approximately 5–10 in-charges, speaking to at least one at each facility.Slide8
Derivation of endpointRetention estimated: from
the registration date to the end of the
study,
this
period
was divided into 6 non-overlapping time
segments
For
each time interval, if there is an indication
that
the mother/child made
a visit
to health
center or
clinic/hospital or pharmacy to pick up drugs, they
got 1 for the visit and 0 otherwise.
30 days after registration
Registration
Delivery
6 weeks
3 months
6 months
12 monthsSlide9
Derivation of endpoint (cont.)Retention 30 days after registration:
From
the registration date,
investigated
the
1
st
drug
receipt date. If
date was at
30 days or
within 2
weeks after the
30 days = retained.
Retention at delivery:
Used all possible record indications that delivery had occurred: place of delivery, delivery date (where available), child date of birth (if available). If any available, concluded mother was retained at delivery
.Slide10
Endpoint derivation (cont.)
Retention
after
delivery:
At
2-4 months, 5-7 months, and
11-13 months, any
indication of ART
receipt.
Retention of mother:
count
outcome indicating how many visits were accomplished out of a maximum of 6 visits that they were expected to attend.
If
a mother made
> 1
visit during a given time period, only indicated that she was retained (did not count multiple visits during the same period). Slide11
AnalysisConducted bivariate and multivariate analyses using Generalized Estimating Equations (GEE) to determine factors associated with retention.
For
mothers’
retention:
visits
1
and
2
have the total number of those who registered as denominator. The remaining visits have the number of those who made it to visit
2 (those delivered) as
the
denominator.Slide12
FindingsSlide13
Proposed versus actual sample size
Type of site
*
Proposed (women)
N (%)
Actual (women)
N (%)
Actual (infants)
†
N (%)
Site #1: Urban
65 (13.7)
60 (13.1)
61 (13.2
Site #2: Urban
211 (44.5)
207 (45.3)
210 (45.5)
Site #3: Rural
44 (9.3)
43 (9.4)
44 (9.5)
Site #4: Rural
111 (23.4)
109 (23.9)
109 (23.6)
Site #5: Rural
43 (9.1)
38 (8.3)
38 (8.2)
Total
474
(100.0)
457 (96.4)
462 (97.5)
*
All the sites are health centers
†
There are more infants than mothers due to multiple births.Slide14
Description of HIV+ women attending ANC 2010-2012 (N=457)
Variable
%
Age:
median, (Q1, Q3)
28.5
(23.5, 32.9)
Parity:
median
, (Q1, Q3)
2.0
(1.0, 4.0)
Marital status (N=455)
Married
203
44.6
Living as married
192
42.2
Single
36
7.9
Divorced/separated
22
4.8
Widowed
2
0.4
Education—highest
level completed (N=421)
None
60
14.3
Primary
310
73.6
Secondary
51
12.1
Employment status (N=420)
Farmer
222
52.8
Housewife
123
29.3
Trader
53
12.6
Other
22
5.21
Referred
to ART initiating site (N=206)
Yes
100
48.5
No
106
51.5
Number of ANC visits for this pregnancy (N=369)
1
75
20.3
2
101
27.4
3
125
33.9
4 or more
68
18.4Slide15
Description of the women (N=457) (con’t)
Variable
N
%
Known HIV positive at first ANC (N=457)
Yes
272
59.5
No
185
40.5
CD4 tested this pregnancy (N=456)
Yes
339
74.3
No
117
25.6
WHO staging at baseline (N=324)
Stage 1
291
89.8
Stage 2
20
6.2
Stage 3 or 4
13
4.0
Type of regimen (N=364)
TDF/3TC/EFV
196
53.8
TDF/3TC/NVP
84
23.0
AZT/3TC/EFV
55
15.1
Other
28
7.7
Toxicities/side effects (N=247)
No
243
98.4
Slide16
Variable
N
%
Place of delivery (N=290)
Health center
288
99.3
Gender (N=289)
Male
155
53.6
Female
134
46.4
Mode of delivery (N=284)
Normal vaginal delivery
244
85.9
C-section
34
12.0
Other
6
2.1
Infant DNA PCR (N=292)
Yes
286
97.9
Co-
trimoxazole
(N=294)
Yes
283
96.3
Mode of feeding (N=285)
Exclusive breast feeding
279
97.8
HIV antibody testing at 18 months (N=254)
Yes11143.7No 6 2.4Not applicable13753.9
Description of the infants (n=462)Slide17
Description of the health facilities (N=5)
Variable
*
Site 1
Site 2
Site 3
Site 4
Site 5
Mean
(
sd
)
Urban
Urban
Urban
Rural
Rural
No. of ANC clients
880
1,124
2,254
1,885
1,350
1,498.6 (562.4)
No. of HIV+ pregnant
women
31
34
156
81
50
70.4 (51.8)
No. of deliveries
393
403
1,086
713
640
647.0
(283.4)
Ratio
of health staff: ANC clients 1:49 1:47 1:59 1:54 1:431:51Ratio of HIV trained nurses: HIV+ pregnant women 1:3 1:3 1:16 1:10 1:4 1:7No. of doctor visits† last quarter 0 8 — 12 9 7.3 (5.1)CD4 test TAT‡ 7 2 14 3 77Follow up starts <weekYesYesNoNoYesNA*Data for 2011. †Doctors normally visit health facilities for consultation, supervision, and support purposes. ‡Turn-around-time (days): This is the amount of time taken from receipt of samples at the health facility to the availability of the test results at the same health facility.Slide18
Women’s and infant’s retention
Time period
N expected
N observed
Prop.
95% CIs
30 days
348
175
0.51
0.46, 0.56
Delivery
348
204
0.59
0.54, 0.64
6
wks
202
151
0.75
0.69, 0.81
2–4 m
202
169
0.84
0.79, 0.89
5–7 m
202
158
0.78
0.73, 0.84
11–13 m
202
136
0.67
0.61, 0.74
Time period
N expected
N observed
Prop.
95% CIs
6
wks
3481400.400.34, 0.462–4 m3483100.890.85, 0.935–7 m3483030.870.83, 0.9111–13 m3482650.760.71, 0.81Women’s retention by specified time intervals*Infants’ retention at specified time intervals *The retention analysis for the women is from 4 instead of the 5 selected health facilities as it was discovered that one of the facilities (Site #4) was not an ART site during the records review period (2011). This facility referred HIV-positive women to a nearby hospital for follow up. However, the facility retained the infants for follow-up.Slide19
Retention, demographic, and clinical characteristics
Marital status by levels of retention
Retention by employment status
Referral to ART initiating site by retention levels
D/S
95% CIs
LM
95% CIs
M
95% CIs
S
95% CIs
30 days
0.27
0.14, 0.54
0.52
0.47, 0.60
0.29
0.23, 0.36
0.42
0.28, 0.61
Delivery
0.73
0.56, 0.94
0.57
0.51, 0.65
0.72
0.66, 0.79
0.44
0.31, 0.64
6
wks
0.40
0.22, 0.74
0.70
0.62, 0.79
0.44
0.36, 0.53
0.53
0.33, 0.86
2–4 m
0.33
0.16, 0.68
0.820.75, 0.900.480.40, 0.570.600.40, 0.915–7 m0.330.16, 0.680.780.70, 0.860.460.38, 0.550.050.27, 0.8011–13 m0.470,27, 0.800.640.56, 0.740.390.32, 0.480.400.22, 0.74D/S: Divorced/separated; LM: Living as married; M: Married; S: Single Farmer95% CIsHousewife95% CIsOther95% CIs30 days 0.290.23, 0.360.490.41, 0.590.510.41, 0.63Delivery0.730.68, 0.790.47
0.39, 0.57
0.52
0.42, 0.65
6
wks
0.43
0.36, 0.51
0.69
0.58, 0.82
0.71
0.58, 0.87
2–4 m
0.45
0.38, 0.53
0.86
0.78, 0.960.760.64, 0.915–7 m0.440.37, 0.520.760.66, 0.880.740.61, 0.8911–13 m0.350.29, 0.430.730.62, 0.850.630.50, 0.81
Yes
95% CIs
No
95% CIs
30 days
0.05
0.02, 0.12
0.51
0.43, 0.62
Delivery
0.80
0.72, 0.88
0.71
0.626, 0.80
6
wks
0.05
0.02, 0.12
0.81
0.731, 0.91
2–4 m
0.07
0.03, 0.16
0.90
0.827, 0.97
5–7 m
0.09
0.04, 0.18
0.84
0.762, 0.93
11–13 m
0.07
0.03, 0.16
0.65
0.555, 0.77Slide20
Factors associated with retention among women
Variable
Odds ratio
95% CIs
for odds
ratio
p-value
Facility location (rural)
29.37
2.079, 4.682
<0.001
ANC clients 2011
0.996
0.995, 0.998
<0.001
Deliveries 2011
1.001
1.0004, 1.0025
0.007
Doctor visits
0.999
0.9998,
0
.9999
<0.001
Rural location
positively
associated with retention with an odds ratio of
29.37
Deliveries
in
2011 (per each delivery) also positively associated with retention
ANC
clients
(per client) and
doctor visits
(per visit) in
2011
inversely related to retention. Slide21
SummaryWomen: 67% retained at 12 months
postpartum
.
Infants: 76%
at 12 months of age.
Characteristics associated with
retention:
Facility
location (rural) and number of deliveries (positively associated
).
ANC
clients and doctor visits
(inversely associated). Slide22
Discussion67% retention similar to 70% reported by MOH.Retention improvement after delivery; women may deliver elsewhere; implications for tracking and tracing.
Better retention in rural areas; greater mobility in urban.
Inverse association with ANC clients and doctor visits; association
with
larger facilities where women come to deliver
from other
areas, more doctor visits where fewer doctors.Slide23
ConclusionPatient files helped in assessing retention.Yet much missing data.
Facility characteristics important.
Inverse
association of ANC clients, but positive association with number of deliveries,
suggests association
with
larger and more comprehensive facilities, where
women come to deliver from other areas.
Retention associated
with fewer doctor
visits. Sites
may have more doctor visits where there is insufficient staff and doctors, and these sites may tend to be smaller. Slide24
Factors associated with retention overallRural location Lower workload
Faith-based facilities
Provision of comprehensive services may be also associated positively with retention
Active follow-up
Availability of doctorsSlide25
AcknowledgementsMartha MukaminegaDieudonne
Ndatimana
Epiphanie Nyirabahizi
Heather
Hoffman
Placidie
Mugwaneza
Muhayimpundu
Ribakare
Ministry of
Health Rwanda
Elizabeth
Glaser Pediatric AIDS Foundation RwandaSlide26
Thank you!
Full report is
available
at
hivcore.orgSlide27
Analysis(2)
Computed
pairwise correlation between variables. For any
2
pairwise correlation of above
0.8
,
one variable
was dropped based on what
was
judged as
clinically important.
Variable
selection was based on fitting a sequence of models beginning with a simple model with only an intercept term, and then includes
1
additional explanatory variable in each successive model. The importance of the additional explanatory variable was assessed by the difference in deviances between successive models.