CROI 2018 Abstract eBook

Abstract eBook

Poster Abstracts

819 DOES QI IMPROVE PMTCT PROCESSES IN RURAL SOUTH AFRICA? A STEPPED WEDGE CLUSTER RCT H. Manisha N. Yapa 1 , Jan-Walter De Neve 2 , Terusha Chetty 3 , Carina Herbst 4 , Frank Post 5 , David A. Cooper 1 , Awachana Jiamsakul 1 , Pascal Geldsetzer 6 , Guy Harling 7 , Philippa Matthews 4 , Frank Tanser 4 , Kobus Herbst 4 , Dickman Gareta 4 , Deenan Pillay 4 , Till Bärnighausen 2 1 Kirby Institute, Sydney, NSW, Australia, 2 Heidelberg University, Heidelberg, Germany, 3 University of KwaZulu-Natal, Durban, South Africa, 4 Africa Health Research Institute, Mtubatuba, South Africa, 5 King’s College Hospital NHS Foundation Trust, London, UK, 6 Harvard University, Cambridge, MA, USA, 7 University College London, London, UK Background: Health systems imperfections continue to lead to preventable HIV vertical transmission in many countries. In sub-Saharan Africa ~4%women are newly infected during the pregnancy or breastfeeding (PBF) period, accounting for ~37% PBF women with viral loads (VL) >1000 copies/mL. VL and repeat HIV testing are key processes in ensuring prevention of mother-to-child transmission (PMTCT) success and maternal health. We test the effectiveness of quality improvement (QI) in increasing VL and repeat HIV testing in PMTCT in rural South Africa. Methods: The MONARCH stepped-wedge randomised trial (NCT02626351) of a QI intervention was conducted at seven primary health care clinics in a rural community of northern KwaZulu-Natal, South Africa, from July 2015-January 2017. All women aged ≥18 years who delivered during the study were eligible for enrollment. We performed intent-to-treat analyses using Poisson mixed effects hierarchical models, with time fixed effects and clinic random effects. Extracted from routine antenatal medical records, our two pre-registered primary endpoints were: (i) proportion of HIV-positive pregnant women with an up-to-date (within the past 90 days) VL test; (ii) proportion of HIV-negative pregnant women with an up-to-date repeat HIV test. Results: We report preliminary results. Of 2162 study participants, 54%were exposed to the intervention. Median age was 25 years (interquartile range [IQR] 21-30); median gestational age at first booking was 19 weeks (IQR 15-24); median parity was 1 (IQR 0-2). Overall HIV prevalence was 47% (95% confidence interval [CI] 45-50%): prevalence was highest amongst 30-34 year-olds (70%, 95%CI 65-75%). The proportion of HIV-positive pregnant women (n=1026) receiving VL tests and HIV-negative pregnant women (n=1136) receiving repeat HIV tests increased over calendar time. The QI intervention significantly increased VL testing (risk ratio (RR) 1.26, 95%CI 1.06-1.49, p=0.01), but did not increase repeat HIV testing (RR 1.13, 95%CI 0.96-1.33, p=0.13). Conclusion: QI led to improvement in VL testing in PMTCT in this rural community in South Africa. This intervention holds promise for improving HIV VL control during pregnancy, helping eliminate mother-to-child HIV transmission and improve maternal health, by strengthening essential antenatal and HIV clinical processes. Future research should identify mechanisms of action to explain differential effects on endpoints. 820 IMPROVED POSTPARTUM HIV OUTCOMES AFTER CARE COORDINATION TEAM INTERVENTION Anandi N. Sheth 1 , Stephanie Hackett 2 , Christina M. Meade 1 , Jennifer M. Davis 1 , Joy Ford 2 , Jeronia Blue 2 , Lisa Curtin 2 , Andres Camacho-Gonzalez 1 , Ann Chahroudi 1 , Rana Chakraborty 1 , Melody P. Palmore 1 , Martina L. Badell 1 1 Emory University, Atlanta, GA, USA, 2 Grady Health System, Atlanta, GA, USA Background: While increased health care engagement and antiretroviral therapy (ART) adherence may occur during pregnancy, HIV-infected women are at risk for loss to follow-up and ART discontinuation after delivery. Prompt HIV care after delivery has been associated with improved short- and long-term HIV outcomes. However, targeted interventions to improve such outcomes are lacking. Methods: In Sept 2015, we assembled a care coordination team of obstetric, adult, and pediatric HIV clinicians, a nurse, and a social worker, to develop monthly care plans for HIV-infected pregnant women seen in a large, safety- net, public hospital in Atlanta. We conducted a retrospective analysis of data collected fromwomen who delivered at ≥24 weeks gestation from Jan 2011-Aug 2017. Using multivariable logistic regression models, we compared the following HIV outcomes pre- vs. post-intervention implementation: viral suppression (VS; HIV RNA <200 copies/mL) at delivery, attendance of an HIV care visit within 90 days of delivery, 12-month retention in care (two HIV care visits or viral load measurements at least 90 days apart) and 6- and 12-month VS.

Results: 196 and 77 women delivered pre- and post-intervention, respectively. Age, race, HIV transmission category, duration of HIV diagnosis, number of previous births, timing/ number of prenatal care visits, pre-pregnancy ART use, and CD4 count/ VS at pregnancy diagnosis were not significantly different in the pre- and post-intervention groups. VS at delivery, HIV care visit attendance within 90 days of delivery and VS at 6 months after delivery all significantly improved in the post-intervention group (Figure 1); HIV care visits occurred on average 146 vs. 73 days after delivery in the pre- vs. post-intervention groups (p<0.0001). Increases noted in 12-month retention and VS were not statistically significant. After adjusting for relevant demographic, HIV, and pregnancy factors, delivery after intervention implementation strongly predicted VS at delivery (OR 2.2, 95%CI 1.0-4.8), HIV care visit attendance within 90 days of delivery (OR 8.2, 95%CI 4.0-16.9), and 6-month VS (OR 3.1, 95%CI 1.6-6.2). Conclusion: In this population of postpartum HIV-infected women at high risk for disengagement in care, a team-based, care coordination intervention significantly improved short-term HIV outcomes. Timely transition from obstetric to HIV care after delivery in the post-intervention group highlights the potential benefits of care coordination teams to improve long-term outcomes.

Poster Abstracts

821 MATERNAL VIRAL LOAD SUPPRESSION AND VERTICAL TRANSMISSION IN MALAWI’S PMTCT PROGRAM Ernest Nkhoma 1 , Monique van Lettow 2 , Beth A. Tippett Barr 3 , Joep J. van Oosterhout 2 , Eunice Mwandira 1 , Lloyd Chilikutali 1 , Annie Kanyemba 1 , Zinenani T. Truwah 1 , Andrew F. Auld 4 , Megan Landes 2 1 Management Sciences for Health, Lilongwe, Malawi, 2 Dignitas International, Zomba, Malawi, 3 CDC, Atlanta, GA, USA, 4 CDC Malawi, Lilongwe, Malawi Background: In 2011, Malawi implemented Option B+, a universal test and treat strategy for the prevention of maternal to child transmission of HIV (PMTCT), which resulted in marked increases in ART uptake by pregnant and breastfeeding women. We describe viral load (VL) suppression in a nationally representative cohort of HIV-positive women at 4-26 weeks post-partum, along with factors associated with VL suppression and the association between VL suppression and early vertical transmission. Methods: Known HIV-positive mothers were enrolled at 4-26 weeks post- partum in a cross-sectional sub-study of the national evaluation of Malawi’s PMTCT program. Mothers were consented and screened for HIV while attending under-5 clinics in 13 health facilities across 8 districts; HIV-exposed infants received HIV-1 DNA testing. Data collected at the time of enrollment included socio-demographic and PMTCT indicators. Maternal VL testing was conducted from plasma samples using Abbott RealTime HIV-1 Assay. Results: Among 1154 HIV-positive women on ART; 573 (49.7%) had started ART prior to- and 569 (49.3%) during their last pregnancy. Twelve (1%) had started ART post-partum. At 4-26 weeks of age, 34 (2.9%) infants were HIV-infected. VL data were available for 1124 women; 136 (12.1%) had a VL >1000 copies (i.e., unsuppressed VL). In multivariable analysis, suboptimal adherence (missing >2 days of ART in the past month) was associated with unsuppressed VL (n=35/134 vs 89/886; adjusted odds ratio (aOR) 4.3; 95% confidence interval (CI) 2.5-7.4). Women with unsuppressed VL load were over 16 times more likely to transmit HIV to their infants (n=19/136 vs 14/988; aOR 16.7; 95% CI 6.6-41.8). Maternal age <19 years (n=4/74 vs. 11/535; aOR 6.6; 95% 1.1-39.8) and non-exclusive breastfeeding (n=6/88 vs 27/1064; aOR 4.0; 95% CI 1.2-13.8) were also associated with vertical transmission.

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