Articles tagged as "Preventing HIV infection in children"

Global programmes and local discrimination: the inadequate support of women living with HIV in West Papua and its impact on PMTCT

(Not) getting political: indigenous women and preventing mother-to-child transmission of HIV in West Papua.

Munro J, McIntyre L. Cult Health Sex. 2015 Aug 25:1-16. [Epub ahead of print]

This paper builds on critiques that call for a more nuanced and contextualised understanding of conditions that affect HIV prevention by looking at West Papuan women's experiences of prevention of mother-to-child transmission services. Drawing on qualitative, ethnographic research with indigenous women and health workers, the paper demonstrates that women experience poor-quality HIV education and counselling, and that indigenous practices and concerns are largely not addressed by HIV services. We attribute this to a combination of national anti-indigenous and anti-separatist political concerns with donor-led interventions that result in limited localisation and reduced effectiveness of HIV prevention measures. In West Papua, services are needed that enhance cooperation and shared commitment, and that acknowledge and work to overcome existing inequalities, ethnic tensions and discrimination in the health system. Beyond Indonesia, donor-led HIV programmes and interventions need to balance avoidance of politically sensitive issues with complicity in perpetuating health inequalities. Translating global health interventions and donor priorities into locally compelling HIV prevention activities involves more than navigating local cultural and religious beliefs. Programme development and implementation strategies that entail confronting structural questions as well as social hierarchies, cleavages and silences are needed to render more effective services; strategies that are inherently political.

Abstract access 

Editor’s notes: West Papua is witnessing one of the fastest growing HIV epidemics in the world, especially among its indigenous populations (prevalence is 2.9%). Translation of HIV prevention programmes to the local situation is complicated by unequal, discriminatory and racialised relationships between the Indonesian government and indigenous Papuans. This is made worse by the exclusion of indigenous Papuans from health services management and governance. Tensions between Papuan HIV NGO staff and Indonesian healthcare workers create obstacles to delivery of health promotion and HIV testing. International HIV agency funders and representatives ignore these tensions for political reasons.

Indigenous people are stigmatised as ‘hypersexual’ and ‘wild’ which causes poor service design and delivery of prevention of mother-to-child transmission. Because of racial stereotypes, Papuan women receive inadequate education and support in the healthcare system. Many women do not fully understand prevention of mother-to-child transmission, antiretroviral therapy, infant feeding choices, and delivery choices. Women are uncomfortable with healthcare workers and do not trust their advice, which is inadequate and does not consider peoples’ views. Women often drop out of HIV care after testing. Women were very isolated, with their partners often working far away. Women disclose their HIV status to very few people even with their families and usually do not know other positive mothers. International donor agencies need to engage with existing local political tensions that result in poor quality treatment of service users. HIV prevention programmes can exacerbate local inequalities if these are not recognised in HIV policy and service provision. 

Asia
Indonesia
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One in 10 mothers living with HIV are unaware of their status

Missed opportunities along the prevention of mother-to-child transmission services cascade in South Africa: uptake, determinants, and attributable risk (the SAPMTCTE).

Woldesenbet S, Jackson D, Lombard C, Dinh TH, Puren A, Sherman G, Ramokolo V, Doherty T, Mogashoa M, Bhardwaj S, Chopra M, Shaffer N, Pillay Y, Goga A, South African PET. PLoS One. 2015 Jul 6;10(7):e0132425. doi: 10.1371/journal.pone.0132425. eCollection 2015.

Objectives: We examined uptake of prevention of mother-to-child HIV transmission (PMTCT) services, predictors of missed opportunities, and infant HIV transmission attributable to missed opportunities along the PMTCT cascade across South Africa.

Methods: A cross-sectional survey was conducted among 4-8 week old infants receiving first immunisations in 580 nationally representative public health facilities in 2010. This included maternal interviews and testing infants' dried blood spots for HIV. A weighted analysis was performed to assess uptake of antenatal and perinatal PMTCT services along the PMTCT cascade (namely: maternal HIV testing, CD4 count test/result, and receiving maternal and infant antiretroviral treatment) and predictors of dropout. The population attributable fraction associated with dropouts at each service point are estimated.

Results: Of 9803 mothers included, 31.7% were HIV-positive as identified by reactive infant antibody tests. Of these 80.4% received some form of maternal and infant antiretroviral treatment. More than a third (34.9%) of mothers dropped out from one or more steps in the PMTCT service cascade. In a multivariable analysis, the following characteristics were associated with increased dropout from the PMTCT cascade: adolescent (<20 years) mothers, low socioeconomic score, low education level, primiparous mothers, delayed first antenatal visit, homebirth, and non-disclosure of HIV status. Adolescent mothers were twice (adjusted odds ratio: 2.2, 95% confidence interval: 1.5-3.3) as likely to be unaware of their HIV-positive status and had a significantly higher rate (85.2%) of unplanned pregnancies compared to adults aged ≥20 years (55.5%, p = 0.0001). A third (33.8%) of infant HIV infections were attributable to dropout in one or more steps in the cascade.

Conclusion: A third of transmissions attributable to missed opportunities of PMTCT services can be prevented by optimizing the uptake of PMTCT services. Identified risk factors for low PMTCT service uptake should be addressed through health facility and community-level interventions, including raising awareness, promoting women education, adolescent focused interventions, and strengthening linkages/referral-system between communities and health facilities.

Abstract  Full-text [free] access

Editor’s notes: WHO recommends a comprehensive approach to prevention of mother-to-child transmission. This includes primary prevention of HIV among women of childbearing age, prevention of unintended pregnancies among women living with HIV, prevention of HIV transmission from a woman living with HIV to her infant and the provision of appropriate treatment, care and support to mothers living with HIV, their children and families.

This study assessed the uptake of antenatal and perinatal prevention of mother-to-child transmission services at four key stages along the prevention of mother-to-child transmission cascade (maternal HIV testing, CD4 count test/result, receiving maternal antiretroviral treatment and infant antiretroviral treatment).

Of all mothers included in the study, 31.7% were HIV-positive as identified by reactive infant antibody tests. Some 11% of HIV-positive mothers were reportedly unaware of their HIV-positive status. Being an adolescent was the strongest predictor of unawareness of HIV-positive status.

Overall 35% of mothers missed at least one step in the cascade. Dropout from the cascade, for all stages combined, accounted for 33.8% of HIV infections among infants, and maternal HIV status knowledge contributed to nearly half of this total.

The authors suggest that reported unawareness of being HIV-positive could be due to recent maternal infection or seroconversion during pregnancy. They call for improved repeat HIV testing during antenatal care and at delivery to identify new infections, and increased coverage of testing and counselling on safe sex for couples.

Interestingly the authors found that most pregnancies were unplanned (60%), demonstrating an important gap in the WHO prevention of mother-to-child transmission comprehensive strategy. Adolescent mothers (< 20 years) had a significantly higher rate of unplanned pregnancies compared to adult mothers. The authors suggest that programmes are necessary for sexually active adolescent girls to reduce both unplanned pregnancies and the risk of contracting HIV during conception or thereafter. 

Africa
South Africa
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Benefits to women and newborns by integrating HIV and ANC services

Integration of PMTCT and antenatal services improves combination antiretroviral therapy (cART) uptake for HIV-positive pregnant women in Southern Zambia - a prototype for option B+?

Herlihy JM, Hamomba L, Bonawitz R, Goggin CE, Sambambi K, Mwale J, Musonda V, Musokatwane K, Hopkins KL, Semrau K, Hammond EE, Duncan J, Knapp AB, Thea DM. J Acquir Immune Defic Syndr. 2015 Jul 15. [Epub ahead of print]

Background: Early initiation of combination anti-retroviral therapy (cART) for HIV-positive pregnant women can decrease vertical transmission to less than 5%. Programmatic barriers to early cART include decentralized care, disease stage assessment delays, and loss-to-follow-up.

Intervention: Our intervention had 3 components: integrated HIV and antenatal services in one location with one provider; lab courier to expedite CD4 counts; and community-based follow-up of women-infant pairs to improve PMTCT attendance. Pre-intervention HIV-positive pregnant women were referred to HIV clinics for disease stage assessment and cART initiation for advanced disease CD4< 350 or WHO stage >2.

Methods: We employed a quasi-experimental design with pre/post-intervention evaluations at 6 government antenatal clinics (ANC) in Southern Province, Zambia. Retrospective clinical data were collected from clinic registers during a 7-month baseline period. Post-intervention data were collected from all ART-naive, HIV-positive pregnant women and their infants presenting to ANC from December 2011-June 2013.

Results: Data from 510 baseline women-infant pairs were analyzed and 624 pregnant women were enrolled during the intervention period. Proportion of HIV-positive pregnant women receiving CD4 counts increased from 50.6% to 77.2%, RR=1.81 95% CI: 1.57-2.08; p<0.01. Proportion of cART-eligible pregnant women initiated on cART increased from 27.5% to 71.5% RR=2.25, 95% CI: 1.78-2.83; p<0.01. Proportion of eligible HIV-exposed infants with documented 6-week HIV PCR test increased from 41.9% to 55.8%, RR=1.33, 95% CI: 1.18-1.51; p<0.01.

Conclusion: Integration of HIV care into ANC and community-based support improved uptake of CD4 counts, proportion of cART-eligible women initiated on cART and infants tested.

Abstract access 

Editor’s notes: Integrating HIV services into other elements of health care, such as family planning or maternal health services, can increase uptake of HIV testing and antiretroviral therapy (ART) initiation. For pregnant women, timely HIV diagnosis and treatment can greatly reduce the probability of mother-to-child transmission. Integrating HIV services into maternal antenatal clinic (ANC) services therefore has potential to bring benefit to women living with HIV and their newborns. This paper describes an experimental study in which six ANC clinics in Zambia – all with high attendance and in provinces with high HIV prevalence – integrated HIV testing and treatment into their routine ANC services. This integration took the form of training existing ANC providers in HIV diagnosis and management; providing a rapid CD4 measurement service; and training volunteer lay counsellors to maintain regular contact with mothers living with HIV to improve ART initiation and adherence. The programme was associated with dramatic increases in ART initiation, early testing of infants and early ART initiation. The integrated approach used here has potential to improve prevention of mother-to-child transmission services. This is done through streamlined combination antiretroviral therapy (cART) initiation and decreasing time gaps in referral models. The approach assists in reducing HIV associated stigma and fear as the clinics offer maternal/child health services as well as HIV care. The clinics offer continuity through a community lay counsellor who follows the mother infant pair through pregnancy, delivery and breastfeeding. Further work is necessary to evaluate strategies for HIV care retention through similar models using community health workers and family-centric HIV care.

Africa
Zambia
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Careful planning may be the best strategy for safer conception

Benefits of PrEP as an adjunctive method of HIV prevention during attempted conception between HIV-uninfected women and HIV-infected male partners.

Hoffman RM, Jaycocks A, Vardavas R, Wagner G, Lake JE, Mindry D, Currier JS, Landovitz RJ. J Infect Dis. 2015 Jun 19. pii: jiv305. [Epub ahead of print]

Background: Data on effectiveness of preexposure prophylaxis (PrEP) for human immunodeficiency virus (HIV)-uninfected women attempting conception with HIV-infected male partners are limited to observational studies.

Methods: To explore the benefits of PrEP for conception, we developed a model to estimate the average annual probability of a woman remaining HIV-uninfected and having a child ("successful" outcome) via condomless sex with an HIV-infected male. The outcome likelihood is dependent upon parameters defining HIV-1 infectivity. We simulated 2 scenarios: optimal (condomless sex acts limited to the ovulation window), and suboptimal (acts not limited to ovulation).

Results: In the optimal scenario when the male is on antiretroviral therapy (ART), the average annual probability of the successful outcome is 29.1%, increasing to 29.2% with the addition of PrEP (P = .45). In the suboptimal scenario, the probability is 26.8% with ART alone versus 27.3% with ART/PrEP (P < .0001). Older maternal age reduces the probability of success in both scenarios, particularly after age 30.

Conclusions: In our model, PrEP provides little added benefit when the HIV-infected male partner is on ART, condomless sex is limited to the ovulation window, and other modifiable transmission risks are optimized. Older female age decreases the probability of success by increasing the number of condomless sex acts required for conception.

Abstract access

Editor’s notes: Antiretrovirals (ARVs) have been shown in several studies to be highly effective in preventing both the acquisition of HIV in HIV negative individuals, and the transmission of HIV from HIV positive people to HIV negative people. However, the real-world application of these activities is still being investigated. This paper explores a strategy currently in discussion to use ARVs for safer conception in which the HIV negative partner might take pre-exposure prophylaxis (PrEP) and the HIV positive partner may be taking HIV treatment. The model employed in this paper looked specifically at the added benefit of the HIV negative woman taking PrEP. The results of the model illustrated that there was no added benefit of the woman taking PrEP if her HIV positive partner was taking HIV treatment consistently and they kept the number of condomless sex acts to the minimum required for the best chance of conception. Interestingly, as the woman in the model increases in age so do the number of condomless sex acts required to conceive, thus increasing the risk of acquiring HIV. While this paper illustrated that PrEP may not be worth the added expense, there may be situations where it still can provide added security to couples. Ultimately, models cannot completely account for what happens in real-life, and as the paper counsels, it will be up to physicians and their patients to decide what is best on a case by case basis. 

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Where are the weak links in prevention of mother-to-child HIV transmission programmes?

Reconstructing the PMTCT cascade using cross-sectional household survey data: The PEARL Study.

Chi BH, Tih PM, Zanolini A, Stinson K, Ekouevi DK, Coetzee D, Welty TK, Bweupe M, Shaffer N, Dabis F, Stringer EM, Stringer JS. J Acquir Immune Defic Syndr. 2015 Jun 11. [Epub ahead of print]

Background: Given the ambitious targets to reduce pediatric AIDS worldwide, ongoing assessment of programs to prevent mother-to-child HIV transmission (PMTCT) is critical. The concept of a "PMTCT cascade" has been used widely to identify bottlenecks in program implementation; however, most efforts to reconstruct the cascade have relied on facility-based approaches that may limit external validity.

Methods: We analyzed data from the PEARL household survey, which measured PMTCT effectiveness in 26 communities across Zambia, South Africa, Cote d'Ivoire, and Cameroon. We recruited women who reported a delivery in the past two years. Among mothers confirmed to be HIV-infected at the time of survey, we reconstructed the PMTCT cascade with self-reported participant information. We also analyzed data about the child's vital status; for those still alive, HIV testing was performed via DNA PCR.

Results: Of the 976 eligible women, only 355 (36%) completed every step of the PMTCT cascade. Among the 621 mother-child pairs who did not, 22 (4%) reported never seeking antenatal care, 103 (17%) were not tested for HIV during pregnancy, 395 (64%) reported testing but never received their HIV-positive result, 48 (8%) did not receive maternal antiretroviral prophylaxis, and 53 (9%) did not receive infant antiretroviral prophylaxis. The lowest prevalence of infant HIV infection or death was observed in those completing the cascade (10%, 95%CI: 7%-12%).

Conclusions: Future efforts to measure population PMTCT impact should incorporate dimensions explored in the PEARL Study - including HIV testing of HIV-exposed children in household surveys - to better understand program effectiveness.

Abstract access 

Editor’s notes: Programmes to prevent the transmission of HIV from mother-to-child can virtually eliminate transmission when conducted with adequate coverage and quality. This population-based study recruited women living with HIV who had given birth in the past 24 months from four sub-Saharan African countries including Cameroon, Côte d’Ivoire, South Africa and Zambia. The 976 mothers allowed their children to be tested for HIV, and reported on the level of maternal health services they received for that child, the “prevention of mother-to-child HIV transmission cascade”. While 98% of mothers had at least one contact with antenatal care services, only 36% eventually received services considered to be adequate for preventing transmission of HIV to their children. This study is notable for highlighting exactly where coverage gaps exist along the treatment pathway. In particular, 53% of mothers did not receive the result of an HIV test, and so would not have received follow-up services to prevent transmission. As a population-based study, these data provide a fuller picture of service coverage which cannot be captured by traditional monitoring and evaluations systems. These results can inform where systems strengthening must occur along the “prevention of mother-to-child HIV transmission cascade”, so that transmission risk is minimized for all children born to women living with HIV.

Africa
Cameroon, Côte d'Ivoire, South Africa, Zambia
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Early postnatal cytomegalovirus infection may predict subsequent HIV transmission through breastfeeding

Effect of cytomegalovirus infection on breastfeeding transmission of HIV and on the health of infants born to HIV-infected mothers.

Chang TS, Wiener J, Dollard SC, Amin MM, Ellington S, Chasela C, Kayira D, Tegha G, Kamwendo D, Jamieson DJ, van der Horst C, Kourtis AP; BAN Study Team. AIDS. 2015 Apr 24;29(7):831-6. doi: 10.1097/QAD.0000000000000617

Background: Cytomegalovirus (CMV) infection can be acquired in utero or postnatally through horizontal transmission and breastfeeding. The effect of postnatal CMV infection on postnatal HIV transmission is unknown.

Methods: The Breastfeeding, Antiretrovirals and Nutrition study, conducted in Malawi, randomized 2369 mothers and their infants to three antiretroviral prophylaxis arms - mother (triple regimen), infant (nevirapine), or neither - for 28 weeks of breastfeeding, followed by weaning. Stored plasma and peripheral blood mononuclear cell specimens were available for 492 infants at 24 weeks and were tested with CMV PCR. Available samples from infants who were CMV PCR-positive at 24 weeks were also tested at birth (N = 242), and from infants PCR-negative at 24 weeks were tested at 48 weeks (N = 96). Cox proportional-hazards models were used to determine if CMV infection was associated with infant morbidity, mortality, or postnatal HIV acquisition.

Results: At 24 weeks of age, CMV DNA was detected in 345/492 infants (70.1%); the estimated congenital CMV infection rate was 2.3%, and the estimated rate of CMV infection at 48 weeks was 78.5%. CMV infection at 24 weeks was associated with subsequent HIV acquisition through breastfeeding or infant death between 24 and 48 weeks of age (hazard ratio 4.27, P = 0.05).

Conclusion: Most breastfed infants of HIV-infected mothers in this resource-limited setting are infected with CMV by 24 weeks of age. Early CMV infection may be a risk factor for subsequent infant HIV infection through breastfeeding, pointing to the need for comprehensive approaches in order to achieve elimination of breastfeeding transmission of HIV.

Abstract access 

Editor’s notes: Studies have illustrated that mother-to-child HIV transmission is more frequent among neonates with congenital cytomegalovirus (CMV) infection. Infants co-infected with HIV and CMV have higher rates of HIV disease progression and death. This study using data and samples of infant plasma and peripheral blood mononuclear cells are from the Breastfeeding, Antiretrovirals and Nutrition (BAN) randomised, controlled clinical trial (RCT). The study examines whether postnatal CMV infection in the infant is associated with HIV transmission through breastfeeding. The study investigates the relationship between postnatal antiretroviral therapy and postnatal CMV acquisition. The data suggests that early postnatal CMV infection in an HIV-exposed uninfected infant may predict subsequent HIV transmission through breastfeeding and infant mortality. The study confirmed previous findings that approximately 70% of breastfed infants born to mothers living with HIV in low-income settings acquire CMV infection by six months of age. However, the study did not find an association between maternal antiretroviral therapy and the risk of postnatal CMV transmission. It is important to note that in the RCT, antiretroviral therapy was only initiated at the onset of labour.  The effect of maternal antiretroviral therapy taken earlier in pregnancy on the prevention or delay of CMV acquisition remains unknown, although a few observational studies have found that maternal antiretroviral therapy reduces congenital and early postnatal CMV infection. It is biologically plausible that antiretroviral therapy reduces or prevents CMV reactivation in the mother, thus preventing transient episodes of maternal CMV viraemia. This mechanism could explain reduced CMV transmission to the infant (be that before or after birth). HIV-exposed but uninfected infants experience higher morbidity and mortality; any such disease attributable to CMV could therefore potentially be reduced by initiation of antiretroviral therapy earlier in pregnancy.

Africa
Malawi
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Elimination of mother-to-child HIV transmission: still a pipe dream?

HIV testing among pregnant women who attend antenatal care in Malawi.

Tenthani L, Haas AD, Egger M, van Oosterhout JJ, Jahn A, Chimbwandira F, Tal K, Myer L, Estill J, Keiser O. J Acquir Immune Defic Syndr. 2015 May 6. [Epub ahead of print] 

Malawi adopted the Option B+ strategy in 2011. Its success in reducing MTCT depends on coverage and timing of HIV testing. We assessed HIV status ascertainment and its predictors during pregnancy. HIV status ascertainment was 82.3% (95%-CI 80.2-85.9) in the pre-Option B+ period and 85.7% (95%-CI 83.4-88.0) in the Option B+ period. Higher HIV ascertainment was independently associated with higher age, attending ANC more than once, and registration in 2010. The observed high variability of HIV ascertainment between sites (50.6%-97.7%) and over time suggests that HIV test kits shortages and insufficient numbers of staff posed major barriers to reducing MTCT.

Abstract access 

Editor’s notes: UNAIDS has called for an end to mother-to-child HIV transmission through the Global Plan towards the elimination of new infections among children and keeping their mothers alive. WHO guidelines on the use of antiretroviral medicines for treating and preventing HIV infection in 2013 recommends two options for pregnant and breastfeeding women. One of which is lifelong antiretroviral therapy (ART) for all pregnant women living with HIV regardless of CD4 count or disease stage, commonly referred to as Option B+. The Global Plan requires that 90% of all women living with HIV have access to ART. The success of the Global Plan will depend on sufficient numbers of women being tested for HIV.

This study includes data from 19 secondary and primary health facilities offering antenatal care in Malawi, the first country to introduce the Option B+ strategy in 2011. Introduction of the Option B+ strategy did not result in a significant change in the proportion of women who underwent HIV testing.  HIV ascertainment varied widely across facilities from 50% to 98%, and fluctuated greatly within sites over short time periods. The observed sudden decreases in numbers of women who received an HIV test suggest that important barriers to HIV testing exist at facility level. Previous studies have illustrated that temporary shortages of HIV testing kits and staff interrupt regular antenatal (ANC) HIV testing in health facilities. Women who had had multiple ANC visits were more likely to have had their HIV status ascertained, likely because multiple visits increased their chance to attend when staff and kits were available. Unfortunately, this study was unable to determine individual-level factors associated with HIV testing not having occurred.

We now have highly effective programmes that can virtually eliminate new HIV infections  among children globally. To attain this goal, urgent attention must be paid to strengthening health systems. Elimination of new infections among children will require attention to the whole cascade of care from diagnosis of HIV, through to provision of results and treatment and supporting women to take ART consistently.   

Africa
Malawi
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Negative HIV antibody test results among children living with HIV

Young age at start of antiretroviral therapy and negative HIV antibody results in HIV-infected children when suppressed.

Kuhn L, Schramm DB, Shiau S, Strehlau R, Pinillos F, Technau K, Coovadia A, Abrams EJ, Puren A, Tiemessen CT. AIDS. 2015 Apr 13. [Epub ahead of print]

Background: Negative results on standard HIV antibody tests have been described among HIV-infected children suppressed on antiretroviral therapy (ART) started early in life. Here, we describe the frequency and predictors of this phenomenon in a well characterized cohort of treated children.

Methods: We selected samples from 103 HIV-infected children who started ART 14 months of age or less and from 122 children who started 6 months of age or less followed as part of two sequential clinical trials in Johannesburg, South Africa. Children had attained viral suppression on ART and had received ART for between 3 and 6.4 years (mean 4.3 years) when tested for HIV antibody using a standard ELISA (Genescreen HIV1/2 version 2; Bio-rad).

Results: Only children 6 months of age or less when ART was started had negative antibody results when tested after suppression on ART several years later. Negative or low-positive antibody results were observed in 40.0, 37.0 and 27.8% of children starting ART less than 2 months of age, or starting during month 2 or 3, respectively. This dropped to 5.9, 3.5 and 5.3% if ART was started during month 4, 5 and 6, respectively. Higher CD4 percentage prior to ART initiation and no recorded intermittent viremia also predicted negative antibody results.

Conclusion: Testing negative on standard HIV antibody tests occurs fairly commonly among HIV-infected children who started ART by 3 months of age or less and are virally suppressed. It would be prudent in clinical practice to avoid HIV antibody tests among virally suppressed, early-treated children to prevent unnecessary confusion.

Abstract access 

Editor’s notes: After 18 months of age, HIV antibody tests are used routinely for diagnosis in children, as in adults, with the typical expectation that antibody status does not revert to negative after a positive result.

This study illustrated that 34% of HIV-positive children who had started antiretroviral therapy (ART) by three months of age and were virally suppressed at the time of antibody testing, tested HIV antibody negative and/or had low-positive antibody results when tested several years later.

Negative HIV antibody test results were strongly related to the age of starting ART. The proportion of children who had a negative antibody test result dropped to approximately 5% if they had started ART between three and six months of age. No negative HIV antibody tests were observed among children who started ART after six months of age. Several studies have illustrated that younger age at starting ART is associated with a reduced size of the viral reservoir, and that this may be associated with better longer term outcomes. Assuming that a negative antibody response indicates a smaller viral reservoir, these findings suggest that the benefit of immediate ART after diagnosis may be attenuated in children who start ART after three months of age.

Notably, a higher pre-treatment CD4 percentage was independently associated with a greater likelihood of a negative HIV antibody test. Given that ART is now recommended in infants regardless of clinical and immunological status, it is likely that there may be higher rates of antibody negativity than those reported in this study, as the study cohort started ART before universal treatment guidelines were implemented.

In a clinical setting, a negative HIV antibody test in a child treated with antiretroviral therapy will raise concern among clinicians and parents about whether the child was initially misdiagnosed with HIV infection. Indeed there have been anecdotal reports of healthcare workers stopping ART in children testing HIV antibody negative based on mistaken assumptions. Great attention should be paid to ensuring that the initial diagnosis prior to ART initiation in a child under 18 months of age is based on adequate virological tests. Use of HIV antibody tests in children who initiated ART under six months of age should be avoided, given the high chance of the test being falsely negative and the considerable potential for misinterpretation.

Africa
South Africa
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Missed opportunities for early infant diagnosis in South Africa

Missed opportunities for early infant HIV diagnosis: results of a national study in South Africa.

Woldesenbet SA, Jackson D, Goga AE, Crowley S, Doherty T, Mogashoa MM, Dinh TH, Sherman GG. J Acquir Immune Defic Syndr. 2015 Mar 1;68(3):e26-32. doi: 10.1097/QAI.0000000000000460.

Background: Services to diagnose early infant HIV infection should be offered at the 6-week immunization visit. Despite high 6-week immunization attendance, the coverage of early infant diagnosis (EID) is low in many sub-Saharan countries. We explored reasons for such missed opportunities at 6-week immunization visits.

Methods: We used data from 2 cross-sectional surveys conducted in 2010 in South Africa. A national assessment was undertaken among randomly selected public facilities (n = 625) to ascertain procedures for EID. A subsample of these facilities (n = 565) was revisited to assess the HIV status of 4- to 8-week-old infants receiving 6-week immunization. We examined potential missed opportunities for EID. We used logistic regression to assess factors influencing maternal intention to report for EID at 6-week immunization visits.

Results: EID services were available in >95% of facilities and 72% of immunization service points (ISPs). The majority (68%) of ISPs provide EID for infants with reported or documented (on infant's Road-to-Health Chart/booklet-iRtHC) HIV exposure. Only 9% of ISPs offered provider-initiated counseling and testing for infants of undocumented/unknown HIV exposure. Interviews with self-reported HIV-positive mothers at ISPs revealed that only 55% had their HIV status documented on their iRtHC and 35% intended to request EID during 6-week immunization. Maternal nonreporting for EID was associated with fear of discrimination, poor adherence to antiretrovirals, and inadequate knowledge about mother-to-child HIV transmission.

Conclusions: Missed opportunities for EID were attributed to poor documentation of HIV status on iRtHC, inadequate maternal knowledge about mother-to-child HIV transmission, fear of discrimination, and the lack of provider-initiated counseling and testing service for undocumented, unknown, or undeclared HIV-exposed infants.

Abstract  Full-text [free] access                           

Editor’s notes: Early infant diagnosis (EID) in HIV-exposed infants is important for a number of reasons. Most importantly, it allows early identification and antiretroviral treatment of HIV-positive infants, resulting in markedly reduced morbidity and mortality. It also allows objective assessment of the effectiveness of prevention efforts to eliminate mother-to-child transmission. 

In South Africa, EID services are widely available at immunization service points in public primary healthcare facilities, with 68% offering focussed testing of HIV-exposed infants. This strategy relies on maternal reporting or documentation of maternal HIV status on the “infant’s road to health chart” (iRtHC). This study found that neither the iRtHC nor the maternal reporting were used effectively for conveying HIV exposure status of infants to health workers responsible for EID. Nearly half, 45%, of mothers self-reporting HIV-positive status, had no documentation of their positive status on the iRtHC. In addition, very few healthcare facilities offered provider-initiated counselling and testing for infants of unknown HIV exposure status.

HIV-positive mothers were less likely to disclose their HIV status at six-week immunisation visits if they had limited knowledge of risk of transmission to their child, had missed doses of maternal or infant antiretroviral therapy or reported fear of discrimination and stigma. These results suggest that improving EID requires improving identification of HIV-exposed infants at the six-week immunisation visit and improving maternal education about infant testing during antenatal care. Other strategies include reducing stigma and discrimination through community-level educational campaigns, improving privacy at immunisation facilities and improving provider-initiated counselling and testing of all infants with undocumented or unknown HIV status.

Africa
South Africa
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Low mother-to-child HIV transmission using Option A in South Africa

First population-level effectiveness evaluation of a national programme to prevent HIV transmission from mother to child, South Africa.

Goga AE, Dinh TH, Jackson DJ, Lombard C, Delaney KP. J Epidemiol Community Health. 2015 Mar;69(3):240-8. doi: 10.1136/jech-2014-204535. Epub 2014 Nov 4.

Background: There is a paucity of data on the national population-level effectiveness of preventing mother-to-child transmission (PMTCT) programmes in high-HIV-prevalence, resource-limited settings. We assessed national PMTCT impact in South Africa (SA), 2010.

Methods: A facility-based survey was conducted using a stratified multistage, cluster sampling design. A nationally representative sample of 10 178 infants aged 4-8 weeks was recruited from 565 clinics. Data collection included caregiver interviews, record reviews and infant dried blood spots to identify HIV-exposed infants (HEI) and HIV-infected infants. During analysis, self-reported antiretroviral (ARV) use was categorised: 1a: triple ARV treatment; 1b: azidothymidine >10 weeks; 2a: azidothymidine ≤10 weeks; 2b: incomplete ARV prophylaxis; 3a: no antenatal ARV and 3b: missing ARV information. Findings were adjusted for non-response, survey design and weighted for live-birth distributions.

Results: Nationally, 32% of live infants were HEI; early mother-to-child transmission (MTCT) was 3.5% (95% CI 2.9% to 4.1%). In total 29.4% HEI were born to mothers on triple ARV treatment (category 1a) 55.6% on prophylaxis (1b, 2a, 2b), 9.5% received no antenatal ARV (3a) and 5.5% had missing ARV information (3b). Controlling for other factors groups, 1b and 2a had similar MTCT to 1a (Ref; adjusted OR (AOR) for 1b, 0.98, 0.52 to 1.83; and 2a, 1.31, 0.69 to 2.48). MTCT was higher in group 2b (AOR 3.68, 1.69 to 7.97). Within group 3a, early MTCT was highest among breastfeeding mothers [11.50% (4.67% to 18.33%) for exclusive breast feeding, 11.90% (7.45% to 16.35%) for mixed breast feeding, and 3.45% (0.53% to 6.35%) for no breast feeding]. Antiretroviral therapy or >10 weeks prophylaxis negated this difference (MTCT 3.94%, 1.98% to 5.90%; 2.07%, 0.55% to 3.60% and 2.11%, 1.28% to 2.95%, respectively).

Conclusions: SA, a high-HIV-prevalence middle income country achieved <5% MTCT by 4-8 weeks postpartum. The long-term impact on PMTCT on HIV-free survival needs urgent assessment.

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Editor’s notes: WHO recommends a comprehensive approach to preventing mother-to-child HIV transmission. These include primary prevention of HIV among women of childbearing age, prevention of unintended pregnancies among women living with HIV, prevention of HIV transmission from a woman living with HIV to her infant and the provision of appropriate treatment, care and support to mothers living with HIV, their children and families. In 2010 WHO revised their ART guidelines on preventing mother-to-child HIV transmission. The guidelines distinguished two groups of women. The first group with low CD4 cell counts were eligible for ART for their own health (≤350 cells/mm³) and were started on ART, and the second group with higher CD4 cell counts (>350 cells/mm³) were not yet eligible for ART and were initiated on short-course ARV prophylaxis. South Africa’s national programme adopted WHO Option A: antepartum daily zidovudine (AZT) from 14 weeks onwards for the mother and daily nevirapine (NVP) prophylaxis for six weeks postpartum for the infant.

This study assessed the early population-level effectiveness looking at mother-to-child HIV transmission between four to eight weeks, by examining about 10 000 mother-infant pairs from the nine provinces in South Africa in 2010. The study therefore provides a countrywide estimate of the effectiveness of the South African programme for the prevention of mother-to-child HIV transmission in 2010.

The study found low levels of early mother-to-child HIV transmission, 3.5% at four to eight weeks post-partum, in this high-prevalence setting. About one third of infants were HIV exposed infants (HEI). The authors postulate that these low levels of mother-to-child HIV transmission are driven by a high proportion of women receiving ART or ARV prophylaxis, 85%, combined with the low levels of breastfeeding. Some 61% of mothers reported formula feeding.

However, in many countries in sub-Saharan Africa, breastfeeding is judged to be the most appropriate choice of infant feeding for women living with HIV, which limits the generalisability of these findings. Moreover, the authors acknowledge that the study reports on early transmission, four to eight weeks post-partum, and emphasize that more data is urgently needed on long-term effectiveness of preventing mother-to-child HIV transmission, using infant HIV-free survival by 24 months postpartum. 

Interestingly the authors found a high proportion of unintended pregnancies. Some 61% of HEI were unplanned, demonstrating an important gap in WHO’s comprehensive strategy on preventing mother-to-child HIV transmission.

In January 2015, the South African Department of Health replaced Option A with Option B+. Now all pregnant and breastfeeding women living with HIV are eligible for lifelong ART irrespective of clinical or immunological stage.

Africa
South Africa
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