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Measuring coverage in MNCH: population HIV-free survival among children under two years of age in four African
Jeffrey S A Stringer1, Kathryn Stinson, Pius M Tih
1Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. jeff_stringer@unc.edu
Insights
Community surveys can effectively measure prevention of mother-to-child HIV transmission (PMTCT) coverage and HIV-free survival. More complex antiretroviral regimens show public health benefits, though facility data may overestimate population coverage.
Area of Science:
- Public Health
- Epidemiology
- Global Health
Background:
- Population-based evaluations of prevention of mother-to-child HIV transmission (PMTCT) programs are limited.
- This study assessed PMTCT service coverage, regimen use, and HIV-free survival in children up to 24 months in Cameroon, Côte d'Ivoire, South Africa, and Zambia.
Purpose of the Study:
- To evaluate PMTCT program effectiveness using community-based surveys.
- To compare community-based coverage estimates with facility-based data.
- To assess the impact of different antiretroviral regimens on HIV-free survival.
Main Methods:
- Random household sampling in 26 communities across four countries.
- HIV testing for mothers and HIV-exposed children (≤24 months).
- Survival analysis for 24-month HIV-free survival and regression analysis for regimen effectiveness and community coverage.
Main Results:
- Overall 24-month HIV-free survival was 79.7%. Country-specific survival ranged from 72.6% (Cameroon) to 84.4% (Côte d'Ivoire).
- Community PMTCT coverage varied significantly by country, with Cameroon highest (66%) and Côte d'Ivoire lowest (5.7%).
- Community PMTCT coverage correlated with facility coverage (r=0.85) and HIV-free survival (r=0.29). Facility data often overestimated community coverage.
Conclusions:
- Community surveys are valuable for monitoring PMTCT coverage and HIV-free survival.
- Facility-based coverage metrics may overestimate actual population-level program reach.
- More complex antiretroviral regimens appear to offer public health benefits, warranting further investigation.
Background:
Population-based evaluations of programs for prevention of mother-to-child HIV transmission (PMTCT) are scarce. We measured PMTCT service coverage, regimen use, and HIV-free survival among children ≤24 mo of age in Cameroon, Côte D'Ivoire, South Africa, and Zambia.
Methods And Findings:
We randomly sampled households in 26 communities and offered participation if a child had been born to a woman living there during the prior 24 mo. We tested consenting mothers with rapid HIV antibody tests and tested the children of seropositive mothers with HIV DNA PCR or rapid antibody tests. Our primary outcome was 24-mo HIV-free survival, estimated with survival analysis. In an individual-level analysis, we evaluated the effectiveness of various PMTCT regimens. In a community-level analysis, we evaluated the relationship between HIV-free survival and community PMTCT coverage (the proportion of HIV-exposed infants in each community that received any PMTCT intervention during gestation or breastfeeding). We also compared our community coverage results to those of a contemporaneous study conducted in the facilities serving each sampled community. Of 7,985 surveyed children under 2 y of age, 1,014 (12.7%) were HIV-exposed. Of these, 110 (10.9%) were HIV-infected, 851 (83.9%) were HIV-uninfected, and 53 (5.2%) were dead. HIV-free survival at 24 mo of age among all HIV-exposed children was 79.7% (95% CI: 76.4, 82.6) overall, with the following country-level estimates: Cameroon (72.6%; 95% CI: 62.3, 80.5), South Africa (77.7%; 95% CI: 72.5, 82.1), Zambia (83.1%; 95% CI: 78.4, 86.8), and Côte D'Ivoire (84.4%; 95% CI: 70.0, 92.2). In adjusted analyses, the risk of death or HIV infection was non-significantly lower in children whose mothers received a more complex regimen of either two or three antiretroviral drugs compared to those receiving no prophylaxis (adjusted hazard ratio: 0.60; 95% CI: 0.34, 1.06). Risk of death was not different for children whose mothers received a more complex regimen compared to those given single-dose nevirapine (adjusted hazard ratio: 0.88; 95% CI: 0.45, 1.72). Community PMTCT coverage was highest in Cameroon, where 75 of 114 HIV-exposed infants met criteria for coverage (66%; 95% CI: 56, 74), followed by Zambia (219 of 444, 49%; 95% CI: 45, 54), then South Africa (152 of 365, 42%; 95% CI: 37, 47), and then Côte D'Ivoire (3 of 53, 5.7%; 95% CI: 1.2, 16). In a cluster-level analysis, community PMTCT coverage was highly correlated with facility PMTCT coverage (Pearson's r = 0.85), and moderately correlated with 24-mo HIV-free survival (Pearson's r = 0.29). In 14 of 16 instances where both the facility and community samples were large enough for comparison, the facility-based coverage measure exceeded that observed in the community.
Conclusions:
HIV-free survival can be estimated with community surveys and should be incorporated into ongoing country monitoring. Facility-based coverage measures correlate with those derived from community sampling, but may overestimate population coverage. The more complex regimens recommended by the World Health Organization seem to have measurable public health benefit at the population level, but power was limited and additional field validation is needed.
