Population HIV-free survival among HIV-exposed children in four African

countries: the PEARL community survey

CBCHB and EGPAF (Cameroon)U. Bordeaux – PAC-CI (Cote d’Ivoire)

University of Cape Town (South Africa)UAB – CIDRZ (Zambia)

Pius Tih, David Coetzee, Didier K. Ekouevi, Kathryn Stinson, Elizabeth

Stringer, Tracy Creek, Mark Giganti, Thomas Welty, Namwinga Chintu,

Benjamin H. Chi, Francois Dabis, Cathy Wilfert, Nathan Shaffer, Jeff

Stringer

The PEARL Study

• 4-Country PMTCT effectiveness study

• Facility-based evaluations– Cord Blood Surveillance– Facility Survey

• Community-based evaluations– Household Survey

The PEARL Study

• 4-Country PMTCT effectiveness study

• Facility-based evaluations– Cord Blood Surveillance– Facility Survey

• Community-based evaluations– Household Survey

Our Objective

• To estimate HIV-free survival among HIV-exposed infants under 2 years of age

Two-stage sampling method

• Stage 1: Facilities– 25 sites* were chosen randomly in the 4 countries

• Stage 2: Communities – The catchment area of each site was identified

and household surveys conducted within it• We only included sites that were providing PMTCT

services

*some “sites” comprised clusters of small facilities

Household eligibility

• Households were eligible if child born within it in the past 24 months

Questionnaire

• Adapted from the Demographics and Health Survey (DHS)

• Primary respondent was the mother of the eligible child or caregiver if mother deceased or not available

Specimen collection for HIV testing

• Informed consent obtained• Mothers

– Blood drawn in the home– In-home results (Cameroon)– Referral slip for results (RSA, ZM, CI)

• Infants– Whole blood dried blood spots (DBS)– HIV DNA PCR if mother antibody positive or

deceased

Analysis• Eligible children in the sample (< 2 years) were

classified as: – HIV-exposed – HIV unexposed

• If HIV-exposed, further classified as: – dead– alive and HIV infected– alive and HIV uninfected

• 2 year HIV-free survival was estimated with a Weibull regression model

9,120 Children < 2 yrs

Study Schema

(May 2008 – April 2009)

9,120 Children < 2 yrs

7,667 (84%)Complete maternal and child data

Study Schema

1,453Maternal and/or child lab

data not collected

•381 refused participation•609 refused maternal test•40 refused child test•43 mother dead•150 mother not home•114 maternal test result not available •16 maternal test result unknown / indeterminate•50 child test result not available

(May 2008 – April 2009)

9,120 Children < 2 yrs

7,667Complete maternal and child data

1,002 (13%)Children < 2 yrs with HIV exposure

1,453Maternal and/or child lab

data not collected

Study Schema

6,665Unexposed children

(May 2008 – April 2009)

9,120 Children < 2 yrs

7,667Complete maternal and child data

1,002Children < 2 yrs with HIV exposure

844HIV (-)

105HIV (+)

53Dead

1,453Maternal and/or child lab

data not collected

Study Schema

6,665Unexposed children

(May 2008 – April 2009)

HIV-free survival (at 2 years among exposed infants)

Estimate HIV-free survival (95% CI)

Cameroon 68% (56%, 78%)

South Africa 78% (72%, 82%)

Ivory Coast 81% (65%, 90%)

Zambia 82% (78%, 87%)

Overall 79% (76%, 82%)

Conclusions

• Population HIV-free survival can be measured in the community

• This study provides community-level evidence that more potent PMTCT regimens result in measurably better outcomes

• National decision makers should consider incorporating the PEARL methodology into ongoing DHS and/or AIDS indicator surveys

AcknowledgementsCameroon• Pius Tih• Tom WeltyCote d’Ivoire• Francois Dabis• Didier Ekouevi• Serge KahonSouth Africa• Andrew Boulle• David Coetzee• Kathryn StinsonZambia• Zambian MOH• Max Bweupe• Ben Chi• Namwinga Chintu• Mark Giganti• Jeff Stringer• Wendy Mazimba

Centers for Disease Control• Mark Bulterys• Tracy Creek• Nathan ShafferEGPAF• Allison Spensley• Christophe Grundmann• Cathy WilfertOthers• Cameroon Baptist Health Convention• Elliott Marseille• Mary Louise Newell• MOH Cote d’Ivoire

THANK YOU