Percentage of HIV-infected pregnant women assessed for eligibility for antiretroviral therapy (CD4 count or clinical staging)

Export Indicator

Percentage of HIV-infected pregnant women assessed for eligibility for antiretroviral therapy (CD4 count or clinical staging)
What it measures

Coverage of eligibility assessment for antiretroviral therapy among HIV-infected pregnant women, either clinically by WHO clinical staging criteria or immunologically by CD4 testing. Assessments can be made on site or by referral.

HIV-infected pregnant women who meet the clinical and (when available) immunological criteria for antiretroviral therapy should receive it. Antiretroviral therapy preserves maternal health and reduces the risk for mother-to-child transmission. Services for the prevention of mother-to-child transmission of HIV should undertake such assessments. Women who are not yet eligible for antiretroviral therapy should receive antiretroviral drug prophylaxis for PMTCT according to the national guidelines and recommendations.

It is recommended that countries disaggregate by eligibility status for additional information on national trends in the percentage of pregnant women who are eligible for antiretroviral therapy. When HIV-infected pregnant women are referred to another health facility or another service unit within the same health facility, health providers should document the referrals and services received by these women in the antenatal care register and on the maternal health card for better patient tracking and monitoring.CD4 testing for HIV-infected pregnant women should be prioritized as many women who are eligible for ART will not have advanced HIV disease based on clinical staging.

Rationale
Numerator

Number of HIV-infected pregnant women assessed for eligibility for antiretroviral therapy by either clinical staging or CD4 testing, on site or by referral, in the past 12 months.

Denominator

Estimated number of HIV-infected pregnant women in the past 12 months

Calculation

Numerator / Denominator

Method of measurement

The numerator is calculated from national programme records aggregated from facility registers.
Assessment can be conducted in antenatal care clinics and HIV care and treatment units, on site or by referral. Data should be aggregated from the appropriate register, with consideration of which registers capture the data, where the assessment actually took place, possible double-counting or under-counting and the need for accurate data for the national level.
All public, private and nongovernmental organization-run health facilities that assess eligibility of HIV-infected pregnant women for antiretroviral therapy, either on site or by referral, should be included.
Two methods can be used to calculate the denominator:
• a projection model such as that provided by Spectrum software: use the output “number of pregnant woman needing prevention of mother-to-child transmission of HIV”; or
• multiply the number of women who gave birth in the past 12 months (which can be obtained from estimates of the central statistics office or the United Nations Population Division or pregnancy registration systems with complete data) by the most recent national estimate of HIV prevalence in pregnant women (which can be derived from HIV sentinel surveillance in antenatal care clinics), if Spectrum projections are unavailable.

Disaggregation: Method of ART eligibility assessment: Clinical staging, CD4 testing

Data Quality Control and Notes for the Reporting Tool: Please provide any comments that would help us interpret the data.

Measurement frequency

Periodic

Disaggregation
Explanation of the numerator

‘On site’ means that the service is offered in a health facility structure or compound. For instance, HIV clinical staging may be available in the antenatal care unit, while blood draw for CD4 testing is available at the HIV care and treatment unit in the same health facility. Both these services are considered to be on site.
Referral can be made on site or off site and is defined as sending a patient to a different service unit, health provider or health facility.
Often, patients return to the original health facility, service unit or provider, where the services received at the referral site are fed back to the original site, and the patient continues with follow-up care.
Referral facilities should document the services provided and patient outcomes. This indicator should be disaggregated by type of assessment (clinical staging or CD4 testing). Women who were assessed by CD4 testing and clinical staging should be counted only once as having been assessed by CD4 testing.

Explanation of the denominator
Strengths and weaknesses

The strength of this indicator is that it enables countries to monitor the extent to which HIV-infected pregnant women are receiving an intervention that is critical for accessing ART for their own health.
It does not capture whether HIV-infected pregnant women who were eligible for ART actually received it.
Although each category is mutually exclusive, there is a risk of double counting this indicator where HIV-infected pregnant women have been assessed both clinically and immunologically, as well as where women are assessed in different units or in a different facility. Countries should ensure systems are in place to minimize the risk of double counting.
This indicator does not capture women who may have been identified HIV-positive at labour and delivery and subsequently assessed for ART eligibility.

Further information

Monitoring and Evaluating the Prevention of Mother-to-Child Transmission of HIV: A guide for national programmes. Towards the Elimination of Mother-to-Child Transmission, 2011. Available at: http://www.who.int/hiv/pub/me/en/index.html.

Additional considerations:
It is recommended that countries disaggregate by eligibility status for additional information on national trends in the percentage of pregnant women who are eligible for ART.
In settings where HIV-infected pregnant women are referred out to another health facility or another service unit within the same health facility, health providers should make an effort to document referrals made and services received for these women in the ANC/PMTCT register for better patient tracking and monitoring of
HIV-infected pregnant women.

Data utilization: The goal would be to aim for 100%; once 100% is reached routinely, this indicator may become obsolete. Explore further information on disaggregated data on whether eligibility was assessed through clinical staging or CD4 tests and any data available on how long it takes to receive a CD4 test result in various places.