Presented at the 2017 American Evaluation Association Conference

1. Use of Secondary Data Analysis to
Assess the Contribution of
Nutrition to the Global 90-90-90
HIV Treatment Targets
Emily A. Bobrow, PhD, MPH
MEASURE Evaluation
University of North Carolina at Chapel Hill
8 November 2017
American Evaluation Conference

2. Nutrition Assessment, Counseling and Support
(NACS) integration in the HIV treatment cascade
and the MNCH continuum

3. 1. Evaluation of the Partnership for HIV-Free
Survival (PHFS)
• Exploring how PHFS, which included NACS, was
implemented and how the outcomes were
achieved
2. Secondary data analysis of existing nutrition
data from the Kabeho Study in Rwanda
• Specifically focused on the contribution of
nutrition to 90-90-90
MEASURE Evaluation
NACS portfolio

4.  GOAL: To strengthen the integration of
• Prevention of mother-to-child transmission of HIV (PMTCT)
• Maternal, neonatal, and child health (MNCH)
• Nutrition assessment, counseling, and support (NACS)
through a quality improvement (QI) approach, in order to
eliminate HIV infections in children and reduce deaths among
positive mothers and children
 PEPFAR funding through the United States Agency for
Development (USAID) from 2013–2016
 Six countries in sub-Saharan Africa:
 3 in East Africa: Kenya, Tanzania, Uganda,
 3 in Southern Africa: Lesotho, Mozambique, South Africa
Partnership for HIV-Free Survival (PHFS)

5. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jun-13 Sep-13 Dec-13 Mar-14 Jun-14 Sep-14 Dec-14 Mar-15 Jun-15 Sep-15 Dec-15
10 facilities in Nzega District 10 facilities in Mufindi District 10 facilities in Mbeya Region
0
600
1200
1800
Jun-13 Sep-13 Dec-13 Mar-14 Jun-14 Sep-14 Dec-14 Mar-15 Jun-15 Sep-15 Dec-15
Number of HIV exposed infants who are registered and tested in Nzega, Mufindi, and Mbeya
July-Oct 2013: No
system in place for
mothers and babies
having the same
appointment
Dec 2013: Introduction
of QI principles and
formation of QI teams
Dec ‘13-Feb ‘14: Insertion of HEI cards in
mother’s CTC2 cards and orientation of H/C
staff on importance of M-B pair retention
Common changes
Giving same day
appointment for the
mother and infant to
come to the services
Tracked mothers with
missed appointments
through mobile
phones or HBC/CHWs
Stapling together
mother’s CTC2 cards
and the HIV Exposed
Infant (HEI) cards
Percentage of HIV-positive mother-baby pairs attending HIV
services in Nzega, Mufindi, and Mbeya, Tanzania
Jan-May 2014: Engaging CHWs

6. QI Documentation Journals

7. PHFS Evaluation
Goals
1. To assess the outcomes at the national and
district levels of PHFS on PMTCT programs in the
six countries
2. To capture key learnings from PHFS implementation that
can contribute to the scale-up of activities, particularly
with regard to the QI approach
Methods
• Rapid assessment in all six PHFS countries—interviews
with all partners and stakeholders at the national and
district levels
Country-Level Rapid Assessment

8. PHFS Themes and Country Examples
Integration
Partnership
• National steering committee—Tanzania, Uganda
• Decentralization—Kenya
• Governmental and nongovernmental organizations (NGOs)—Tanzania,
Kenya, Lesotho, Uganda
Community engagement
• Mentor mothers—Tanzania, Kenya
• Community health workers—Tanzania
• Support groups—Tanzania formally, Kenya and Uganda informally
NACS
• Improved, prioritized nutrition assessment —Tanzania, Kenya, Uganda
• Nutrition counseling —Tanzania, Kenya
Quality improvement
• Kenya—very context-dependent
• Tanzania—more formulaic
• Value of one-hour monthly meeting – every country
• Sharing and learning platforms – every country

9. PHFS Evaluation
Aims
1. Determine whether and to what degree the PHFS
approach achieved its intended outcomes in
terms of PMTCT implementation and maternal
and child health outcomes at the patient level.
2. Gather information on the successes and
challenges in the implementation of PHFS in
Uganda with a focus on the QI component and
the legacy of PHFS.
Outcome Evaluation in Uganda

10. PHFS Evaluation
Methods
• Mixed methods data collection in Uganda
• Aim 1:
• Retrospective quantitative chart reviews of patient-
level data from Feb 2011 to the present day
• Aim 2:
• In-depth interviews with health care workers and
district-level QI coaches
• Focus group discussions with QI teams at model
health facilities
Outcome Evaluation in Uganda

11. • Do not know number of unique mother-baby pairs
• Do not know how much observational data is contained
in the records over time – data quality and completeness
issues vary over time and with the existence of PHFS
• Different processes and timelines for scale-up of PHFS,
particularly since in Uganda the national policy was
changed to include integration of mother-baby pairs
into mother-baby care points
Therefore decided to use an innovative approach known as
synthetic control analysis (SCA)
Data challenges: Uncertainties about
individual data available

12. Timeline differentiating three types of
sites for analysis
Demonstration
sites (N=22)
Scale-up
sites (N=20)
Comparison
sites (N=20)
Feb. 2011
Begin data
collection
Feb. 2013
Start PHFS
Jan. 2015
End PHFS
Present
Pre-PHFS support
Post-PHFS support
Sept. 2012
Option B+
adopted
Aug. 2014
Official launch
of the PHFS
Note: Uganda changed
national policy to include
integration of services in
mother-baby care points

13. The Synthetic Control for the PHFS
Outcome Evaluation in Uganda
Y
Time
February
2013
August
2014
Initial
Demonstration
Group
December
2013
Initial
Non-
PHFS
Group
The Synthetic Control

14. 2 papers:
• Adherence to ART, maternal nutritional status
and viral load suppression in the context of
Option B+ : The Kabeho Study
• Diet patterns and growth outcomes among
HIV-exposed infants participating in the
Kabeho Study
Secondary data analysis of existing nutrition
data from the Kabeho Study in Rwanda

15. • One of the first studies to assess the implementation of
Option B+ as a national program and PMTCT outcomes:
• In a real world setting;
• Among a breastfeeding population; and
• Over a period of 2 years after delivery.
The Kabeho Study:
Kigali Antiretroviral and Breastfeeding
Assessment for the Elimination of HIV
This study was made possible by the United States Agency for International
Development and the generous support of the American people through USAID
Cooperative Agreement No.AID-OAA-A-12-00024.

16. • 608 HIV-positive women were followed in the
national program were enrolled in the study.
These women, who were in their third trimester of
pregnancy or up to 2 weeks postpartum, and
their infants were followed up to 24 months after
delivery in 14 health facilities in Kigali with
support of lifelong ART and IYCF counseling and
support.
The Kabeho Study

17. Current status
• PHFS Evaluation
• Completed 4 of the 6 PHFS country-level
assessments
• Beginning data collection for the Outcome
Evaluation of PHFS in Uganda in early 2018
• Secondary data analysis on the contribution of
nutrition to 90-90-90
• Will have drafts of the two Kabeho Study papers
ready for submission in early 2018

18. This presentation was produced with the support of the United States Agency for
International Development (USAID) under the terms of MEASURE Evaluation
cooperative agreement AID-OAA-L-14-00004. MEASURE Evaluation is
implemented by the Carolina Population Center, University of North Carolina at
Chapel Hill in partnership with ICF International; John Snow, Inc.; Management
Sciences for Health; Palladium; and Tulane University. Views expressed are not
necessarily those of USAID or the United States government.
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