Session Date: 6/11/2009 Abstract Number: 1765 Contact: fao2001@columbia.edu
Follow the Paper Trail: Simple Assessment of PMTCT Program Operational Effectiveness
1International
Oliveira-Tsiouris F1, Carter RJ1, Yersin I2, Tsague L3, and Abrams EJ1 Center for AIDS Care and Treatment Programs (ICAP), Columbia University, New York, 2ICAP Mozambique, and 3ICAP Rwanda
BACKGROUND
The Desired Outcomes for prevention of mother-to-child transmission (PMTCT) of HIV programs are: • Decrease morbidity and mortality in HIV infected women - Provision of HAART to pregnant women with advanced disease and enrollment of all women into long term HIV care • Increase HIV Free Child Survival – preventing HIV infection and decreasing mortality in HIV- exposed infants - Provision of effective PMTCT including multidrug regimens and optimized infant feeding support - Enhance care and treatment for HIV exposed (HEI) and infected children Current Challenges: Efforts aimed at PMTCT of HIV have been implemented as a set of vertical programs often within different maternal child health (MCH) service areas within health facilities making tracking of mother-infant pairs and evaluation of maternal and infant outcomes quite difficult.
Antenatal Care Labor and Delivery HIV Positive woman HIV Care & Treatment Post Partum Care
RESULTS
Starting with maternal records in ANC at 3 sites in Mozambique and Rwanda, 21 (70%) mothers were effectively linked to their infant records (Table 1).
Table 1: Results: starting with Maternal records and linking to infant records in HEI follow-up Mom to Baby n % HIV Positive Women 30 NA Mean Gestational age at 1st ANC visit 22.9 NA On HAART prior to pregnancy 4 10 Documented CD4 24 80 HAART Eligible 6 25 Initiated HAART 6 100 PMTCT Prophylaxis 17 57 No Regimen Documented in chart 3 10 Total receiving any ART Regimen 27 90 Mother –Infant Pairs linked 21 70 Infant received PMTCT prophylaxis 21 100 Infant PCR tested ≤ 8 weeks 19 90 Infant 8 week outcomes 18 86
HIV Exposed Infant EPI Clinic HEI follow-up HIV Care & Treatment
The inverse was done at 4 sites in Rwanda and Mozambique where outcome tracking was initiated with infant records from HEI follow-up. In a sample of 40 infant records reviewed, 40/40 (100%) mother-infant pairs were successfully linked using maternal ANC or HIV Care ID as documented in infant record. In this sample, 90% (36/40) of infants were tested using DNA PCR, but only 69% (25/36) had documented 8 week infant outcomes (Table 2).
Table 2: Outcome tracking
OBJECTIVES
• Develop a simple data abstraction tool to examine clinical care components
recorded in multiple log books for an individual patient • Assess feasibility of existing paper systems to track patient across various service areas • Assess whether mother-infant pairs can be linked using routinely collected maternal and infant information • Evaluate PMTCT program operational effectiveness using routinely collected data
METHODS
• A simple data collection instrument was developed to abstract routinely collected maternal and infant patient care information from facility registers. - Variables included routine antenatal care (ANC) components as well as HIV care and treatment, partner testing and maternal post partum follow-up • All available registers, patient charts or logbooks in ANC, HIV Care and Treatment Clinic and HEI infant follow-up were used to complete maternal and infant sections of the tool. • Appropriate identifiers, such as mother’s unique ANC ID or HIV Care ID, mother’s name, infant date of birth or estimated date of delivery, were used to establishing link between mother-infant pairs. • The tool was pilot tested at 6 comprehensive care sites in 2 countries (Mozambique and Rwanda) where ICAP has been supporting PMTCT services for >2 years. • We reviewed sequential charts of all HIV positive women during a 3 month time period until a total sample of 10 charts was obtained.
120%
Baby to Mom Infant/mom pairs linked Mean gestational age at 1st ANC visit Women on HAART prior to pregnancy Documented CD4 HAART Eligible Initiated HAART PMTCT Prophylaxis No Regimen Documented in chart Total receiving any ART Regimen Infant received PMTCT prophylaxis Infant PCR tested ≤ 8 weeks Infant 8 week outcomes
n 40 25.5 3 35 11 8 23 3 34 39 36 25
% 100 8 95 31 77 58 8 85 98 90 69
Summary Quality of Care indices for 70 women and their infants accessing PMTCT services
100%
80%
60%
40%
20%
0%
Sample of Mother-Infant Data Abstraction Tool Developed
Mothers with CD4 count documented
Mothers Eligible for HAART
Eligible Mothers who Mothers who initiated any Initiated HAART prior to ART Regimen (HAART or delivery Prophylaxis) prior to delivery
Infants who received Propylaxis
Infants who were tested Infants who had a 6 week by HIV PCR outcome available
CONCLUSIONS
Paper systems can be used to assess PMTCT program operational effectiveness under certain circumstances: A unique patient ID is critical and maternal ID must be included on infant card/register in order to go from mom through baby outcome in HEI follow-up. Inconsistency in documentation and/or missing maternal/infant unique ID made it difficult to start in ANC and track mothers across MCH service points. Starting with infants and working backwards to identify mothers in PMTCT offers a snapshot of PMTCT cascade but is biased due to evaluation of infant survivors enrolled in care. The tool was especially useful in identifying programmatic strengths and weaknesses in terms of maternal care and weak infant follow-up. Overall, chart review conducted at sites experienced in implementing comprehensive package of PMTCT services showed >85% of pregnant received a PMTCT regimen and >90% of women received CD4 testing within 2 weeks of HIV diagnosis, but this may not be representative of the majority of sites in those respective countries.
ACKNOWLEDGEMENTS