PMTCT Impact Measurement and EMTCT Validation

Update on Global Guidance

Chika Hayashi, World Health Organization

Outline

1. Background

2. Measuring PMTCT Impact

3. EMTCT Validation

Background

WHO – PMTCT Impact Measurement and EMTCT Validation: Update on Global Guidance

• Global Plan sets 10 ambitious targets for 2015.

Exciting:Intervention coverage Outcome Measures• New Child HIV Infections• HIV-associated deaths in pregnancy• MTCT rate

Problem:• PMTCT outcomes are not reported routinely, and

available data in the 22 priority countries does not represent population-level outcomes.

Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive, launched June 2011.

n

Attrition means available facility-based PMTCT data does not capture the full target

population

Short Guide: 5 Methods to Measure PMTCT Impact 1. Modelling

2. Facility-based Survey and Follow-Up

3. Cohort Approach

4. Population-based Surveys

5. Use of EID/Child HIV Testing Data

1.Short Guide 2. Detailed

Guidance 3. Write some texthere

WHO – PMTCT Impact Measurement and EMTCT Validation: Update on Global Guidance

Population-based Surveys to

Measure PMTCT Impact

March 2012 Consultation

1. HIV prevalence among all children 1-23 months (by age groups: 1-11 months; 12-23 months)

2. HIV prevalence among HIV-exposed children 11-23 months (born to an HIV+ mother)

3. Proportion of HIV- children 12-23

months born to women who are currently HIV+ (HIV-free survival)

4. Infant Mortality Rate among children born to HIV+ mothers (deaths due to any cause)

WHO – PMTCT Impact Measurement and EMTCT Validation: Update on Global GuidanceExisting Population-based Surveys for Measuring PMTCT Impact

Indicators

WHO – PMTCT Impact Measurement and EMTCT Validation: Update on Global Guidance

WHO – PMTCT Impact Measurement and EMTCT Validation: Update on Global Guidance

Indicator CalculationsPreliminary CalculationsReference: Bernard Barrere , M EASURE DHS, ICFI.

0

50

100

150

200

250

Malawi DHS 2010

Deaths per 1,000

Preliminary Calcula-tionsReference: Bernard Barrere, MEASURE DHS, ICFI.

<1 1-2 <5

• 4 proposed indicators calculated using data from existing surveys with child HIV testing

• Uganda AIS 2004-05, Malawi DHS 2010, Mozambique AIS 2009,

Rwanda DHS 2010

• Keep in mind surveys were not sampled for the proposed PMTCT indicators; that was not the primary objective

U5MR by mother’s current HIV status

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WHO – PMTCT Impact Measurement and EMTCT Validation: Update on Global Guidance

Considerations

Mozambique AIS 2009(child testing in only half the households), Uganda AIS 04-05• HIV prevalence 1-23 month:

Mz 2.1% (0.7% - 3.6%)Ug 0.9% (0.5% - 1.3%)

• HIV prevalence 1-23 month among children with HIV+ mothers(MTCT) :

Mz 18.5% (3.3% - 33.7%), n=62Ug 15.1% (9% - 21%), n=123

• Proportion of HIV negative children 12-23 born to women currently HIV+ (HIV-free surival):

Mz 68.3% (42.4%-94.2%), n=28Ug 89.8% (82.5%-97.0%), n=61

• Large confidence intervals for most of the suggested indicators and large sample required to provide reliable point estimates.

• Low testing coverage rate among young children may introduce a bias.

• Large sample sizes have serious cost implications for the surveys, and put additional burden on survey logistics, such as training, fieldwork and supervision.

• Hypothetical cost, 10% adult prevalence$1.4 million (n= 9,000 households) $1.8 million (n= 13,000 households) $ 2.2 million (n=18,000 households)

Preliminary CalculationsReference: Bernard Barrere, MEASURE DHS, ICFI.

Small numbers

Large CI

Cohort Approachto

Measure PMTCT ImpactJune 2012 Consultation

Routine Cohort Outcome Monitoring SystemPreviously, we described how to overcome the lack of cohort data (link existing records, or active follow-up).After the consultation, emphasis is on establishing systems to routinely collect cohort data.

WHO - Repeat the Main title here

HIV+ preg women (PW)

Identified HIV+ PW women

ARV

EID

EID

Final Outcome

WHO - Repeat the Main title here

1. Key indicators and time points to meausre them

2. Routine cohort outcome monitoring system as ideal system, in both low and high prevalence countries

3. Minimum essential elements to set up a routine system.

(e.g. Unique IDs, tracking strategy)

4. Other ways to construct cohort data if routine system does not exist, with real examples

5. Handling missing data and

approaches to estimate outcomes of those LFU; sensitivity analyses

6. Annexes

1. Sampling considerations for representativeness

2. Patient confidentiality

3. Standard way to report results

Guidance Document for the Cohort Approach (Mother-Child Follow Up)

Detailed Guidance documents for comment1. Generic protocol to measure the

effectiveness and impact of national PMTCT programmes at population-level using a facility-based survey approach.

2. Considerations for measuring the impact of PMTCT programmes using standard population-based surveys in selected high HIV prevalence countries

3. Guidance on cohort/mother-baby pair follow-up .4. Guidance on management, analysis and interpretation of EID/child HIV

testing data

Next Steps: Impact Guidance

WHO - Repeat the Main title here

Send email to:

pmtctmoneval@who.intto join:EZ-Collab workspace on PMTCT impact measurement

EMTCT Validation Consultation

June 2012 Consultation

What are the criteria and processes to validated EMTCT of HIV and syphilis?

WHO - Repeat the Main title here

Impact measure with process measures, e.g. <0.5 new cases/1,000 births, with >95% ANC,>95% testing coverage> 90% ARV coverage

• How to define EMTCT?< 5% MTCT rate?

Zero child HIV cases from MTCT?All 4 prong targets?

High intervention coverage for 3 years?

Same criteria for all countries?

Acceptable measurement method? Quality?

Impact data must be directly measured through active case

reporting/monitoring system or special studies, triangulate with

modelling.Detailed guidance on data

standards to review and report.

Processes to validate EMTCT?

WHO - Repeat the Main title here

NVC responsible for preparing validation background work, including ensuring EMTCT criteria is met in selected geographical areas and key populations.

Review programme indicators every year and impact every

3 years until routine system is available

Ministry of Health

National Validation Committee (NVC)Collects, reviews and decides on the national

documentation through consultations

Regional Validation Committee (RVC) Reviews country reports and country

surveillance system comply with global and regional minimum validation

standards

Global Validation Committee (GVC)

Reviews country/RVC reports (including any data from field visits) to ensure consistency and compliance with the

minimum global criteria.

WHO

Also an opportunity to improve data and

programmes

Acknowledgements• Experts and national MOH and programme staff sharing

their experiences, thoughts and time in all related PMTCT Impact and EMTCT Validation Consultations

• IATT PMTCT M&E WG Members: CHAI (Kate Sabot), ICAP (Fatima Tsouiris, Rosalind Carter)

• CDC: Thu-Ha Dinh, Eddas Bennett• Measure DHS, ICFI: Bernard Barrere• UNAIDS: Mary Mahy• UNICEF: Pricilla Idele, consultant: Zhuzhi Moore• WHO: Nathan Shaffer, Yves Souteyrand, Nigel Rollins,

Txema Calleja, Lori Newman, Monica Alonso