Browsing by Author "Mandala, J."
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Item Analysis of HIV Early Infant Diagnosis Data to Estimate Rates of Perinatal HIV Transmission in Zambi(PLOS ONE, 2012) Torpey, K.; Mandala, J.; Kasonde, P.; et al.Background: Mother-to-child transmission of HIV (MTCT) remains the most prevalent source of pediatric HIV infection. Most PMTCT (prevention of mother-to-child transmission of HIV) programs have concentrated monitoring and evaluation efforts on process rather than on outcome indicators. In this paper, we review service data from 28,320 children born to HIV positive mothers to estimate MTCT rates. Method: This study analyzed DNA PCR results and PMTCT data from perinatally exposed children zero to 12 months of age from five Zambian provinces between September 2007 and July 2010. Results: The majority of children (58.6%) had a PCR test conducted between age six weeks and six months. Exclusive breastfeeding (56.8%) was the most frequent feeding method. An estimated 45.9% of mothers were below 30 years old and 93.3% had disclosed their HIV status. In terms of ARV regimen for PMTCT, 32.7% received AZT+single dose NVP (sdNVP), 30.9% received highly active antiretroviral treatment (HAART), 19.6% received sdNVP only and 12.9% received no ARVs. Transmission rates at six weeks when ARVs were received by both mother and baby, mother only, baby only, and none were 5.8%, 10.5%, 15.8% and 21.8% respectively. Transmission rates at six weeks where mother received HAART, AZT+sd NVP, sdNVP, and no intervention were 4.2%, 6.8%, 8.7% and 20.1% respectively. Based on adjusted analysis including ARV exposures and non ARV-related parameters, lower rates of positive PCR results were associated with 1) both mother and infant receiving prophylaxis, 2) children never breastfed and 3) mother being 30 years old or greater. Overall between September 2007 and July 2010, 12.2% of PCR results were HIV positive. Between September 2007 and January 2009, then between February 2009 and July 2010, proportions of positive PCR results were 15.1% and 11% respectively, a significant difference. Conclusion: The use of ARV drugs reduces vertical transmission of HIV in a program setting. Non-chemoprophylactic factors also play a significant role in HIV transmission. The overall change in the proportions of positive PCR results over time is more likely an indication of better PMTCT implementation. Determination of the outcomes of PMTCT in program settings is feasible but requires accurate documentation and analysis.Item HIV Retesting of HIV-Negative Pregnant Women in the Context of Prevention of Mother-to-Child Transmission of HIV in Primary Health Centers in Rural Zambia: What Did We Learn?(Journal of the International Association of Providers of AIDS Care, 2019-01) Mandala, J.; Kasonde, P.; Badru, T.; Dirks, R.; Torpey, K.Background:: This observational study describes implementation of HIV retesting of HIV-negative women in prevention of mother-to-child transmission (PMTCT) services in Zambia. Methods:: Uptake of retesting and PMTCT services were compared across age, parity, and weeks of gestation at the time of the first HIV test, antiretrovirals regime, and HIV early diagnosis results from infants born to HIV-positive mothers. Results:: A total of 19 090 pregnant women were tested for HIV at their first antenatal visit, 16 838 tested HIV-negative and were offered retesting 3 months later: 11 339 (67.3%) were retested; of those, 55 (0.5%) were HIV positive. Uptake of the PMTCT package by women HIV positive at retest was not different but HIV-exposed infants born to women who retested HIV positive were infected at a higher rate (11.1%) compared to those born to women who tested HIV positive at their initial test (3.2%). Conclusion:: We suggest rigorously (1) measuring the proportion of MTCT attributable to women who seroconvert during pregnancy and possibly adjust PMTCT approaches and (2) addressing the substantial loss to follow-up of HIV-negative pregnant women before HIV retesting.Item Playing the catch-up game: Accelerating the scale-up of prevention of mother-to-child transmission of HIV (PMTCT) services to eliminate new pediatric HIV infection in Nigeria(Public Library of Science, 2017) Oladele, E.A.; Khamofu, H.; Asala, S.; Saleh, M.; Opara, U.R.; Nwosisi, C.; Anyaike, C.; Gana, C.; Adedokun, O.; Dirks, R.; Adebayo, O.; Oduwole, M.; Mandala, J.; Torpey, K.Introduction As the world is making progress towards elimination of mother-to-child transmission of HIV, poor coverage of PMTCT services in Nigeria remains a major challenge. In order to address this, scale-up was planned with activities organized into 3 phases. This paper describes the process undertaken in eight high burden Nigerian states to rapidly close PMTCT coverage gaps at facility and population levels between February 2013 and March 2014. Methods Activities were grouped into three phases-pre-assessment phase (engagement of a wide range of stakeholders), assessment (rapid health facility assessment, a cross sectional survey using mixed methods conducted in the various states between Feb and May 2013 and impact modelling), and post-assessment (drawing up costed state operational plans to achieve eMTCT by 2015, data-driven smart scale-up). Results Over a period of 10 months starting June 2013, 2044 facilities were supported to begin provision of PMTCT services. This increased facility coverage from 8% to 50%. A 246% increase was also recorded in the number of pregnant women and their families who have access to HIV testing and counselling in the context of PMTCT. Similarly, access to antiretrovirals for PMTCT has witnessed a 152% increase in these eight states between October 2013 and October 2014 Conclusion A data-driven and participatory approach can be used to rapidly scale-up PMTCT services at community and facility levels in this region. These results present us with hope for real progress in Nigeria. We are confident that the efforts described here will contribute significantly to eliminating new pediatric HIV infection in Nigeria.Item Prevention of mother-to-child transmission of HIV in Zambia: implementing efficacious ARV regimens in primary health center(BMC Public Health, 2009) Mandala, J.; Torpey, K.; Kasonde, P.; et al.Background: Safety and effectiveness of efficacious antiretroviral (ARV) regimens beyond single-dose nevirapine (sdNVP) for prevention of mother-to-child transmission (PMTCT) have been demonstrated in well-controlled clinical studies or in secondary- and tertiary-level facilities in developing countries. This paper reports on implementation of and factors associated with efficacious ARV regimens among HIV-positive pregnant women attending antenatal clinics in primary health centers (PHCs) in Zambia. Methods: Blood sample taken for CD4 cell count, availability of CD4 count results, type of ARV prophylaxis for mothers, and additional PMTCT service data were collected for HIV-positive pregnant women and newborns who attended 60 PHCs between April 2007 and March 2008. Results: Of 14,815 HIV-positive pregnant women registered in the 60 PHCs, 2,528 (17.1%) had their CD4 cells counted; of those, 1,680 (66.5%) had CD4 count results available at PHCs; of those, 796 (47.4%) had CD4 count d 350 cells/mm3 and thus were eligible for combination antiretroviral treatment (cART); and of those, 581 (73.0%) were initiated on cART. The proportion of HIV-positive pregnant women whose blood sample was collected for CD4 cell count was positively associated with (1) blood-draw for CD4 count occurring on the same day as determination of HIV-positive status; (2) CD4 results sent back to the health facilities within seven days; (3) facilities without providers trained to offer ART; and (4) urban location of PHC. Initiation of cART among HIV positive pregnant women was associated with the PHC's capacity to provide care and antiretroviral treatment services. Overall, of the 14,815 HIV-positive pregnant women registered, 10,015 were initiated on any type of ARV regimen: 581 on cART, 3,041 on short course double ARV regimen, and 6,393 on sdNVP. Conclusion: Efficacious ARV regimens beyond sdNVP can be implemented in resource-constrained PHCs. The majority (73.0%) of women identified eligible for ART were initiated on cART; however, a minority (11.3%) of HIV-positive pregnant women were assessed for CD4 count and had their test results available. Factors associated with implementation of more efficacious ARV regimens include timing of blood-draw for CD4 count and capacity to initiate cART onsite where PMTCT services were being offered.Item Progress toward elimination of perinatal HIV transmission in Kenya: Analysis of early infant diagnosis data(International Journal of STD and AIDS, 2018-06) Achwoka, D.; Mandala, J.; Muriithi, M.; Zeng, Y.; Chen, M.; Dirks, R.; Sirengo, M.; Wafula, R.; Torpey, K.Interrupting vertical transmission of HIV from mothers to infants provides opportunity to transform the HIV/AIDS epidemic by eliminating new infections among children. We estimate mother-to-child transmission rates of infants born to known HIV-positive mothers offered prevention of mother-to-child transmission interventions and provide an indication of Kenya’s progress toward elimination of perinatal transmission. We obtained from the Kenya National Early Infant Diagnosis (EID) database, all 131,451 DNA polymerase chain reaction test results of HIV-exposed infants aged 0–18 months who had dried blood spot samples taken between January 2008 and October 2013. The majority of samples were from infants aged 0–6 months (81.0%). Infants aged 6–12 months comprised 15.5%, while those aged 12–18 months were 3.5%. Overall, 11,439 (8.7%) were HIV-positive. Positivity rates were higher among older age groups: 6.8, 14.6, and 27.5% in age groups 0–6 months, 6–12 months, and 12–18 months old, respectively. In Kenya, scale-up and decentralization to primary health centers of EID services has been remarkable. Both increasing HIV-positivity trends in age groups 12–18 months and differences between provinces require further interrogation. Although significant, declining HIV-positivity trends in age groups 0–6 months and 6–12 months old observed between 2008 and 2013 is insufficient to achieve the elimination agenda.Item Use of service data to inform pediatric HIV-free survival following prevention of mother-to-child transmission programs in rural Malawi(BMC Public Health, 2012) Mandala, J.; Moyo, T.; Torpey, K.; et al.Background: Recent years have seen rapid and significant progress in science and implementation of programs to prevent mother-to-child transmission of HIV. Programs that support PMTCT routinely monitor service provision but very few have measured their effectiveness. The objective of the study was to use service data to inform HIV-free survival among HIV exposed children that received antiretroviral drugs to prevent mother-to-child transmission (PMTCT) of HIV. The study was conducted in two rural districts in Malawi with support from FHI 360. Methods: A descriptive observational study of PMTCT outcomes was conducted between June 2005 and June 2009. The dataset included patient-level data of all pregnant women 1) that tested HIV-positive, 2) that were dispensed with antiretroviral prophylaxis, and 3) whose addresses were available for home visits. The data were matched to each woman’s corresponding antenatal clinic data from home visit registers. Results: Out of 438 children whose home addresses were available, 33 (8%) were lost to follow-up, 35 (8%) were alive but not tested for HIV by the time home visit was conducted, and 52 (12%) were confirmed deceased. A total of 318 children were alive at the time of the home visit and had an HIV antibody test done at median age 15 months. The resulting estimated 24-month probability of HIV-free survival over all children was 78%. Among children who did not receive nevirapine, the estimated 24-month probability of HIV-free survival was 61%, and among those who did receive NVP syrup the estimate was 82%. Conclusions: When mothers and newborns received nevirapine, the estimated 24-month probability of HIV-free survival among children was high at 82% (CI: 54% to 99%). However this conclusion should be interpreted cautiously 1) due to the wide confidence interval; and 2) because the confidence interval range includes 55%, which is the natural HIV-free survival rate in the absence of a PMTCT intervention. This analysis highlighted the need of quality data and well-structured home visits to assess PMTCT effectiveness.