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Operational challenge: Linkages from prevention of mother-to-child transmission services to care and
treatment services in Zambia
S. Okawa, M. Chirwa, N. Ishikawa, F. Pande,
H. Kapyata, C. Msiska, K. Komada, H. Miyamoto,
A. Mwango▪ Chongwe District Community Health Office▪ Ministry of Health Zambia - Japan International Cooperation
Agency SHIMA project, Lusaka, Zambia
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Background
Great success in scale-up of the PMTCT program in Zambia PMTCT ARV coverage: 97% (UNAIDS, 2012)
There is a need to take advantage by referring all HIV-positive women from PMTCT to HIV care/treatment
Few studies on linkages between PMTCT and HIV care/treatment in Zambia
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Study design Design: Prospective cohort study Period:
▶ Enrolment: June 2011 – May 2012▶ Follow up: June 2011 – January 2014
Site: Chongwe district, Lusaka province▶ Referral health center ▶ 5 rural health centers (RHCs) with ART services▶ 5 RHCs without ART services
WHO 2010 guidelines Option A Participants: 195 mothers newly diagnosed as HIV-
positive in PMTCT program
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Data Collection Face-to-face interview
‒ Basic characteristics of mothers Review of clinical record and electronic
database of clients on HIV care/treatment‒ Date of enrolment in HIV care/treatment‒ Date of ART initiation‒ Date of the last visit to the services
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Analysis
Probability of enrolment in HIV care/treatment Kaplan-Meier survivor function
Predictors of enrolment in HIV care/treatment Cox proportional hazards model
Observation time: Entry point: from HIV diagnosis at antenatal clinic End point: enrolment in HIV care/treatment Censored point: 20 January 2014
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Results
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Participants CharacteristicsCharacteristics N % Age
Median (IQR) 27 (22-32)
≤20 27 13.9
21-30 104 53.3
≥31 64 32.8
Education (years)None 17 8.91-7 105 54.7≥8 70 36.5
Marital statusMarried/Cohabit 159 82.0Not married 35 18.0
ParityPrimigravida 35 18.41-3 109 57.4
≥4 46 24.2
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Participants Characteristics cont. N % Paid work of partner
No 49 25.3Once in a while 34 17.5Part of the year 17 8.8Throughout the year 94 48.5
Time to access heath facility (minutes)≤29 28 14.630 - 59 53 27.660 - 119 69 35.9≥120 42 21.9
Perception on taking ARVsPositive 150 76.9Negative 45 23.1
Place of receiving PMTCT serviceReferral health center 79 40.5RHCs with HIV care/treatment 55 28.2
RHCs without HIV care/treatment 61 31.3
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Linkage from PMTCT to HIV care/treatment
195 Newly diagnosed in
PMTCT program
92 enrolled in HIV
care/treatment (47.2%)
48 initiated ART (24.6%)
44 not initiated ART (22.6%)
103 not enrolled (52.8%)
As of 20 January, 2014
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Probability of enrolment in HIV care/treatment
0.0
00.2
50.5
00.7
51.0
0pro
babili
ty o
f enro
lment
in H
IV c
are
/tre
atm
ent
0 500 1000 1500time from HIV diagnosis to enrolment in HIV care/treatment
Kaplan-Meier failure estimate
Time from HIV diagnosis
Probability 95%CI
at 6 months 0.32 0.26 - 0.40at 12 months 0.42 0.35 - 0.50at 18 months 0.44 0.37 - 0.52
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From HIV Diagnosis to ART initiation
195 newly diagnosed
87 tested CD4
48 CD4<350
27 started ART
21 not started ART
39 CD4≥350
11 started ART
28 not started ART
108 not tested CD4 (No data)
10 started ART
98 not started ART
As of 20 January 2014
*108/195 (55.4%)
*21/48 (43.8%)
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Predictors for enrolment in HIV care/treatment
Predictors Hazard ratio 95% CI Age
≤20 0.26 0.09- 0.71†21-30 1.00≥31 0.79 0.44- 1.42
EducationNone 1.001-7 0.80 0.32- 2.00≥8 1.59 0.62- 4.08
Marital statusMarried/Cohabit 1.00Not married 0.65 0.29- 1.44
ParityPrimigravida 1.001-3 0.93 0.41- 2.12 ≥4 1.21 0.43- 3.46
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Predictors for enrolment in HIV care/treatment (cont.)
Predictors Hazard ratio 95% CI Paid work of partner
No 1.00Once in a while 1.45 0.63- 3.35Part of the year 1.03 0.40- 2.61Throughout the year 0.60 0.29- 1.24
Time to access heath facility (minutes)≤29 1.0030 - 59 1.36 0.63- 2.9660 - 119 1.47 0.67- 3.23≥120 0.96 0.37- 2.44
Perception on taking ARVsPositive 1.17 0.67- 2.05Negative 1.00
Place of receiving PMTCT serviceReferral health center 1.00RHCs with HIV care/treatment 1.39 0.76- 2.54RHCs without HIV care/treatment 0.51 0.27- 0.96†
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Summary
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Poor linkage from PMTCT to HIV care/treatment
▪ 53% of new HIV-positive mothers have not enrolled in HIV care/treatment
▪ 55% of new HIV-positive mothers were not tested CD4 count after diagnosis of HIV
▪ 44% of mothers with CD4<350 have not started ART
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Risk factors for not enrolled in HIV care/treatment
▪ Younger maternal age
▪ Attending rural health centers not providing HIV care/treatment
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Conclusion
Strengthening linkage between PMTCT and HIV care and treatment services needed
- Option B+ implementation (Apr 2014-)
- Treatment is offered to HIV + partners regardless of CD4 count
- Future evaluation of Option B+ implementation needed
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Acknowledgements
Study participants Ministry of Health, Zambia Ministry of Community Development, Mother and
Child Health, Zambia Japan International Cooperation Agency (JICA) National Center for Global Health and Medicine,
Japan (NCGM) The University of Tokyo Midwives and community-based volunteers at
study sites
