Articles tagged as "Eliminate new HIV infections among children"

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.

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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.

Abstract  Full-text [free] access

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.

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South Africa
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Further evidence to support Option B+: good HIV-free survival among children breastfed for a year with mothers on triple ART

Early infant feeding patterns and HIV-free survival: findings from the Kesho-Bora trial (Burkina Faso, Kenya, South Africa).

Cournil A, Van de Perre P, Cames C, de Vincenzi I, Read JS, Luchters S, Meda N, Naidu K, Newell ML, Bork K, Kesho Bora Study G. Pediatr Infect Dis J. 2015 Feb;34(2):168-74. doi: 10.1097/INF.0000000000000512.

Objective: To investigate the association between feeding patterns and HIV-free survival in children born to HIV-infected mothers and to clarify whether antiretroviral (ARV) prophylaxis modifies the association.

Methods: From June 2005 to August 2008, HIV-infected pregnant women were counseled regarding infant feeding options, and randomly assigned to triple-ARV prophylaxis (triple ARV) until breastfeeding cessation (BFC) before age 6 months or antenatal zidovudine with single-dose nevirapine (short-course ARV). Eighteen-month HIV-free survival of infants HIV-negative at 2 weeks of age was assessed by feeding patterns (replacement feeding from birth, BFC <3 months, BFC ≥3 months).

Results: Of the 753 infants alive and HIV-negative at 2 weeks, 28 acquired infection and 47 died by 18 months. Overall HIV-free survival at 18 months was 0.91 [95% confidence interval (CI): 0.88-0.93]. In the short-course ARV arm, HIV-free survival (0.88; CI: 0.84-0.91) did not differ by feeding patterns. In the triple ARV arm, overall HIV-free survival was 0.93 (CI: 0.90-0.95) and BFC <3 months was associated with lower HIV-free survival than BFC ≥3 months (adjusted hazard ratio: 0.36; CI: 0.15-0.83) and replacement feeding (adjusted hazard ratio: 0.20; CI: 0.04-0.94). In the triple ARV arm, 4 of 9 transmissions occurred after reported BFC (and 5 of 19 in the short-course arm), indicating that some women continued breastfeeding after interruption of ARV prophylaxis.

Conclusions: In resource-constrained settings, early weaning has previously been associated with higher infant mortality. We show that, even with maternal triple-ARV prophylaxis during breastfeeding, early weaning remains associated with lower HIV-free survival, driven in particular by increased mortality.

Abstract access 

Editor’s notes: Evaluating the impact of feeding patterns on infant HIV-free survival is essential for HIV prevention. This large, multi-country study was nested within the Kesha Bora randomised trial which found that triple ARV prophylaxis until cessation of breastfeeding was associated with lower rates of mother-to-child transmission than short-course ARV prophylaxis. Further analyses showed that in both arms, mortality in infants was highest when breastfeeding was stopped before three months of age. This analysis considered HIV-free survival and found that among mothers receiving triple ARV prophylaxis during breastfeeding, weaning before three months was associated with significantly lower HIV-free survival than longer breastfeeding or replacement feeding from birth. Overall, the results support the WHO 2013 ART guidelines which recommend initiation of triple ARV prophylaxis early in pregnancy, continued either through the breast feeding period (option B) or for life (option B+), and WHO recommendations for continued breastfeeding up to at least one year of age while on ART. 

Africa
Burkina Faso, Kenya, South Africa
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Abstinence from breastfeeding: further evidence of the risks

Morbidity in relation to feeding mode in African HIV-exposed, uninfected infants during the first 6 mo of life: the Kesho Bora study.

Bork KA, Cournil A, Read JS, Newell ML, Cames C, Meda N, Luchters S, Mbatia G, Naidu K, Gaillard P, de Vincenzi I. Am J Clin Nutr. 2014 Dec;100(6):1559-68. doi: 10.3945/ajcn.113.082149. Epub 2014 Oct 22.

Background: Refraining from breastfeeding to prevent HIV transmission has been associated with increased morbidity and mortality in HIV-exposed African infants.

Objective: The objective was to assess risks of common and serious infectious morbidity by feeding mode in HIV-exposed, uninfected infants ≤6 mo of age with special attention to the issue of reverse causality.

Design: HIV-infected pregnant women from 5 sites in Burkina Faso, Kenya, and South Africa were enrolled in the prevention of mother-to-child transmission Kesho Bora trial and counseled to either breastfeed exclusively and cease by 6 mo postpartum or formula feed exclusively. Maternal-reported morbidity (fever, diarrhea, and vomiting) and serious infectious events (SIEs) (gastroenteritis and lower respiratory tract infections) were investigated for 751 infants for 2 age periods (0-2.9 and 3-6 mo) by using generalized linear mixed models with breastfeeding as a time-dependent variable and adjustment for study site, maternal education, economic level, and cotrimoxazole prophylaxis.

Results: Reported morbidity was not significantly higher in nonbreastfed compared with breastfed infants [OR: 1.31 (95% CI: 0.97, 1.75) and 1.21 (0.90, 1.62) at 0-2.9 and 3-6 mo of age, respectively]. Between 0 and 2.9 mo of age, never-breastfed infants had increased risks of morbidity compared with those of infants who were exclusively breastfed (OR: 1.49; 95% CI: 1.01, 2.2; P = 0.042). The adjusted excess risk of SIEs in nonbreastfed infants was large between 0 and 2.9 mo (OR: 6.0; 95% CI: 2.2, 16.4; P = 0.001). Between 3 and 6 mo, the OR for SIEs was sensitive to the timing of breastfeeding status, i.e., 4.3 (95% CI: 1.2, 15.3; P = 0.02) when defined at end of monthly intervals and 2.0 (95% CI: 0.8, 5.0; P = 0.13) when defined at the beginning of intervals. Of 52 SIEs, 3 mothers reported changes in feeding mode during the SIE although none of the mothers ceased breastfeeding completely.

Conclusions: Not breastfeeding was associated with increased risk of serious infections especially between 0 and 2.9 mo of age.

Abstract access 

Editor’s notes: Abstinence from breastfeeding or early weaning is known to be associated with higher mortality among infants born to women living with HIV. The risk of mother-to-child HIV transmission through breast-milk can be reduced by the use of antiretroviral therapies. Mothers living with HIV are advised to continue breastfeeding throughout infancy, while on therapy. The aim of this study was to investigate the association between breastfeeding and infection risk, accounting for reverse causality (i.e. mothers changing feeding mode in response to infant illness). Non-breastfed infants were at higher risk of serious infectious events than breastfed infants, as expected, and particularly among infants aged under three months. There was no evidence of a difference in reported morbidity. A qualitative assessment of the reverse causality found that some 94% of mothers reported not changing the feeding mode as a consequence of serious infectious events. The strengths of this study are that only HIV-exposed, but HIV-negative infants were included, and a range of sensitivity analyses were conducted. A limitation is that infant feeding data may be subject to reporting bias. This study has confirmed the findings of earlier research, and reassuringly found limited evidence to suggest reverse causality between breastfeeding and serious infectious outcomes.

Africa
Burkina Faso, Kenya, South Africa
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Mother’s HIV status has a major impact on child, but not neonatal mortality

Maternal HIV status associated with under-five mortality in rural northern Malawi: A prospective cohort study

Chihana ML, Price A, Floyd S, Mboma S, Mvula H, Branson K, Saul J, Zaba B, French N, Crampin AC, Glynn JR. J Acquir Immune Defic Syndr. 2014 Oct 15. [Epub ahead of print]

Background: Under-five mortality is decreasing but with little change in neonatal mortality rates. We examined the effect of maternal HIV-status on under-five mortality and cause of death since widespread availability of antiretroviral therapy in rural Malawi.

Methods: Children born in 2006-2011 in the Karonga demographic surveillance area were included. Maternal HIV-status was available from HIV sero-surveys. Age-specific mortality rate ratios for children born to HIV-positive and HIV-negative mothers were obtained by fitting a Poisson model accounting for child clustering by mother and adjusting for potential confounders. Cause of death was ascertained by verbal autopsy.

Findings: There were 352 deaths among 6913 under-five singleton children followed for 20 754 person-years (py), giving a mortality rate of 17.0/1000py overall, 218/1000py (16.5/1000 live births) in neonates, 20/1000py (17.4/1000 live births) in post-neonatal infants and 8/1000py in 1-4 year-olds. Comparing those born to HIV-positive and HIV-negative mothers, the rate ratio, adjusted for child age, sex, maternal age, parity and drinking water source was 1.5 (95%CI 0.6-3.7) in neonates, 11.5 (95%CI 7.2-18.5) in post-neonatal infants and 4.6 (95%CI 2.7-7.9) in 1-4 year-olds. Birth injury/asphyxia, neonatal sepsis and prematurity contributed >70% of neonatal deaths, while acute infections, malaria, diarrhoea and pneumonia accounted for most deaths in older children.

Conclusions: Maternal HIV status had little effect on neonatal mortality but was associated with much higher mortality in the post-neonatal period and among older children. Greater attention to HIV care in pregnant women and mothers should help improve child survival but broader interventions are needed to reduce neonatal mortality.

Abstract access 

Editor’s notes: Child mortality remains a major public health problem in sub-Saharan Africa. A substantial proportion of under-five deaths are attributable to HIV in some countries, estimated as 13% in Malawi, where HIV prevalence is 10-14%.  Child mortality has declined in Malawi, and this large population-based study looked at causes of death from 2006-2012 when antiretroviral therapy (ART) was widely available.  Overall, child mortality was higher in children born to women living with HIV than women without HIV, but this effect was only seen after the neonatal period.  As expected, there were clear differences in causes of death by age. About half of the neonatal deaths were due to infections or prematurity, where HIV status may play a role. Therefore the small effect of the mother’s HIV status in this age group is interesting, although in line with other studies from sub-Saharan Africa.  Older children tended to die from acute infections such as pneumonia, diarrhoea and acute febrile diseases. Maternal HIV positive status was estimated to account for most of these deaths. Strengths of this study are the large number of children included and the length of follow up. The study was not designed to define the mechanisms underlying the excess mortality, and did not include data on child HIV status and other programmes such as vitamin supplementation, vaccination and duration of breast feeding. Optimisation of Option B+ will prevent further children from acquiring HIV and maintain the health of their mothers, but this study illustrates the need for a continued focus on other causes of neonatal mortality.

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Malawi
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HIV prevalence of HIV among children in Zimbabwe, justifies the need for provider initiated testing and counselling

Barriers to provider-initiated testing and counselling for children in a high HIV prevalence setting: a mixed methods.

Kranzer K, Meghji J, Bandason T, Dauya E, Mungofa S, Busza J, Hatzold K, Kidia K, Mujuru H, Ferrand RA. PLoS Med. 2014 May 27;11(5):e1001649. doi: 10.1371/journal.pmed.1001649. eCollection 2014.

Background: There is a substantial burden of HIV infection among older children in sub-Saharan Africa, the majority of whom are diagnosed after presentation with advanced disease. We investigated the provision and uptake of provider-initiated HIV testing and counselling (PITC) among children in primary health care facilities, and explored health care worker (HCW) perspectives on providing HIV testing to children.

Methods and findings: Children aged 6 to 15 y attending six primary care clinics in Harare, Zimbabwe, were offered PITC, with guardian consent and child assent. The reasons why testing did not occur in eligible children were recorded, and factors associated with HCWs offering and children/guardians refusing HIV testing were investigated using multivariable logistic regression. Semi-structured interviews were conducted with clinic nurses and counsellors to explore these factors. Among 2 831 eligible children, 2 151 (76%) were offered PITC, of whom 1 534 (54.2%) consented to HIV testing. The main reasons HCWs gave for not offering PITC were the perceived unsuitability of the accompanying guardian to provide consent for HIV testing on behalf of the child and lack of availability of staff or HIV testing kits. Children who were asymptomatic, older, or attending with a male or a younger guardian had significantly lower odds of being offered HIV testing. Male guardians were less likely to consent to their child being tested. 82 (5.3%) children tested HIV-positive, with 95% linking to care. Of the 940 guardians who tested with the child, 186 (19.8%) were HIV-positive.

Conclusions: The HIV prevalence among children tested was high, highlighting the need for PITC. For PITC to be successfully implemented, clear legislation about consent and guardianship needs to be developed, and structural issues addressed. HCWs require training on counselling children and guardians, particularly male guardians, who are less likely to engage with health care services. Increased awareness of the risk of HIV infection in asymptomatic older children is needed.

Abstract  Full-text [free] access

Editor’s notes: An estimated 700 infant HIV infections occur every day. In many priority countries, relatively few of these are diagnosed in early infancy. Subsequent diagnosis largely depends on HIV testing in health care facilities during childhood and adolescence. This is the first study examining Provider Initiated Testing and Counselling (PITC) provision among older children, aged six to 15 years. The study shows high prevalence of HIV infection among those attending primary care services in Harare, Zimbabwe, and among their accompanying caregivers. The paper highlights the challenges of implementing PITC to this age-group, including lack of consent from the guardian, especially male guardians, counsellor non-availability or unwillingness to perform the test. Policy implications from this work include the need to develop clear HIV testing policies and guidance around consent and testing of older children, and the need to address supply-side challenges around the PITC process. An example might be by way of task-shifting through use of lay counsellors or opt-out HIV testing.

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Zimbabwe
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Shorter duration of seroprotection following vaccination in people living with HIV

Long-term immune responses to vaccination in HIV-infected patients: a systematic review and meta-analysis.  

Kerneis S, Launay O, Turbelin C, Batteux F, Hanslik T, Boelle P. Clin Infect Dis. 2014 Apr;58(8):1130-9. doi: 10.1093/cid/cit937. Epub 2014 Jan 10.

Vaccine-induced antibodies may wane more quickly in persons living with human immunodeficiency virus (HIV) than in healthy individuals. We reviewed the literature on vaccines routinely recommended in HIV-infected patients to estimate how seroprotection decreases over time in those who initially responded to immunization. For each study retrieved from the literature, the decrease of seroprotection was modeled with a log binomial generalized linear model, and data were pooled in a meta-analysis to provide estimates of seroprotection 2 and 5 years after the last vaccine administration. Our analyses confirmed that the duration of seroprotection was shorter in HIV-infected patients and that with current guidelines, a substantial proportion of patients would have lost protective antibodies before a booster was proposed. We therefore discuss the implications for the monitoring of antibody levels and timing of revaccination in these patients.

 Abstract access 

Editor’s notes: People living with HIV are recognised to have suboptimal immune responses to vaccination. In particular little is known about the long-term persistence of protection following a primary immune response. This systematic review included original experimental and observational studies of licensed vaccines in people living with HIV which were published prior to January 2012. Studies were eligible for inclusion if participants had a primary response to vaccination and antibody titres measured six months or more following the last dose. Meta-analyses were conducted where there were ≥2 prospective studies available (hepatitis B, hepatitis A, measles, tetanus). The analyses confirmed that the duration of seroprotection was shorter in people living with HIV than the general population. For example, some 61% of children and less than half of adult primary responders maintained seroprotection two years after hepatitis B vaccination and only 17% by five years for both children and adults. In contrast persistence of antibody response to hepatitis A was far higher (92% after two years and 82% after five years). Immune status and antiretroviral therapy appeared to play a role in persistence of immune response. However there was no evidence to suggest that double dosing or increasing the number of doses prolonged the period of protection. The authors discuss the limitations of the published studies and discuss the implications of their findings in terms of monitoring of antibody response and timing of revaccinations. 

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Late maternal diagnosis results in mother-to-child transmission in Johannesburg, South Africa

Timing of maternal HIV testing and uptake of prevention of mother-to-child transmission interventions among women and their infected infants in Johannesburg, South Africa.

Technau KG, Kalk E, Coovadia A, Black V, Pickerill S, Mellins CA, Abrams EJ, Strehlau R, Kuhn L. P. J Acquir Immune Defic Syndr. 2014 Apr 15;65(5):e170-8. doi: 10.1097/QAI.0000000000000068.

Background: By 2011, South African prevention of mother-to-child transmission (PMTCT) of HIV programs had reduced perinatal HIV transmission at 6 weeks of age to 2.7%. We investigated the profile of newly diagnosed vertically infected children and their mothers to identify shortfalls in the PMTCT program.

Methods: In this operational follow-up study, fieldworkers enrolled mothers of newly diagnosed HIV-infected children up to 2 years of age at 5 major health care facilities in Johannesburg. Structured questionnaires and clinical record reviews were conducted and analyzed to describe the population and assess factors associated with PMTCT uptake.

Results: Two hundred eighty-nine mother-child pairs were enrolled. Timing of maternal HIV diagnosis influenced PMTCT access and feeding choices and was associated with infants' age at HIV diagnosis (7 vs. 11 vs. 31 weeks where mothers tested before, during, or after the pregnancy, respectively; P < 0.0001). Women diagnosed before pregnancy (12%) were older (median, 31 years) than those diagnosed during the index pregnancy (53%; median, 27 years). Women diagnosed after delivery (35%) were younger (median, 25 years, P < 0.0001), of lower parity, and less likely to be South African citizens. In 81 cases (29%), late maternal diagnosis precluded any PMTCT access. Where women were diagnosed during or before pregnancy, the recommended PMTCT guidelines for mother and infant were followed in 86 (61%) pairs.

Conclusions: Failure to diagnose maternal HIV infection before delivery was the main reason for missing PMTCT prophylaxis and early infant testing. Timely maternal diagnosis enables PMTCT uptake, but implementation and follow-up gaps require attention to improve infant outcomes.

Abstract access

Editor’s notes: Significant numbers of infants continue to be HIV-positive despite high coverage of antiretroviral therapy for pregnant women in South Africa.  A combination of psychosocial, biological and health system factors were identified to have contributed to the failure of preventing infant infections in this operational study. Prevention of postnatal transmission requires retesting HIV negative women at delivery and at immunisation visits. This is to identify recently acquired HIV infection during late pregnancy and breastfeeding. Even when women are identified during pregnancy, health system and individual psychosocial factors result in suboptimal care, culminating in transmission.  Simplification of guidelines, increasing public awareness of benefits of early antenatal care, retesting HIV negative pregnant women and better patient support should improve effectiveness of programmes to prevent new infections in children.

Africa
South Africa
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Peer mentors improve infant well-being and reduce depression symptoms of HIV-positive mothers in South Africa

A cluster randomized controlled trial evaluating the efficacy of peer mentors to support South African women living with HIV and their infants.

Rotheram-Borus MJ, Richter LM, van Heerden A, van Rooyen H, Tomlinson M, Harwood JM, Comulada WS, Stein A. PLoS One 2014 Jan 22;9(1):e84867. doi: 10.1371/journal.pone.0084867.

Objective: We evaluate the effect of clinic-based support by HIV-positive Peer Mentors, in addition to standard clinic care, on maternal and infant well-being among Women Living with HIV (WLH) from pregnancy through the infant's first year of life.

Methods: In a cluster randomized controlled trial in KwaZulu-Natal, South Africa, eight clinics were randomized for pregnant WLH to receive either: a Standard Care condition (SC; 4 clinics; n = 656 WLH); or an Enhanced Intervention (EI; 4 clinics; n = 544 WLH). WLH in the EI were invited to attend four antenatal and four postnatal meetings led by HIV-positive Peer Mentors, in addition to SC. WLH were recruited during pregnancy, and at least two post-birth assessment interviews were completed by 57% of WLH at 1.5, 6 or 12 months. EI's effect was ascertained on 19 measures of maternal and infant well-being using random effects regressions to control for clinic clustering. A binomial test for correlated outcomes evaluated EI's overall efficacy.

Findings: WLH attended an average of 4.1 sessions (SD = 2.0); 13% did not attend any sessions. Significant overall benefits were found in EI compared to SC using the binomial test. Secondarily, over time, WLH in the EI reported significantly fewer depressive symptoms and fewer underweight infants than WLH in the SC condition. EI WLH were significantly more likely to use one feeding method for six months and exclusively breastfeed their infants for at least 6 months.

Conclusions: WLH benefit by support from HIV-positive Peer Mentors, even though EI participation was partial, with incomplete follow-up rates from 6-12 months.

Abstract   Full-text [free] access

Editor’s notes: This work extends the Mothers2Mothers (M2M) programme which is currently active in nine countries, training clinic-based HIV positive peer mentors to help protect their baby from HIV and keep themselves and their family healthy.  This study examines the potential benefits of Peer Mentors in South Africa, on a range of health benefits in the first year of life. The results are generally positive, with women in the intervention arm more likely to have breastfed exclusively for at least 6 months, to have had at least one postnatal clinic visit, to have adhered completely to antiretroviral therapy in the past week (at 12 months), have a healthy weight-for-age, and were less likely to be depressed. These results are encouraging, (especially given that most women attended only about four of the eight intervention sessions. It also suggests that this type of Peer Mentor intervention may lead to other health benefits, e.g., postnatal depression has detrimental effects on the child’s cognitive and emotional development. Despite these encouraging findings, the results should be taken as preliminary due to the small number of clusters involved and the low follow-up rate.  Further research of the effectiveness on infant outcomes following a Peer Mentor programme would be very useful.

Africa
South Africa
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Outcomes up to five years among children exposed to zidovudine or nevirapine at birth

Long-term follow-up of children in the HIVNET 012 perinatal HIV prevention trial: five-year growth and survival.

Owor M, Mwatha A, Donnell D, Musoke P, Mmiro F, Allen M, Jackson JB, Fowler MG, Guay LA. J Acquir Immune Defic Syndr. 2013 Dec 15;64(5):464-71. doi: 10.1097/QAI.0000000000000015.

Objectives: To describe 5-year growth, survival, and long-term safety among children exposed to nevirapine or zidovudine in an African perinatal prevention trial, HIVNET 012.

Methods: All study children who were alive at the age 18 months were eligible for an extended follow-up study. Children whose families consented were enrolled and evaluated every 6 months from 24 to 60 months. At each visit, history, physical examination, and growth measures were taken. From these measurements, Z scores based on World Health Organization (WHO) standards were computed. Serious adverse event data were collected. Data from the initial and extended follow-up cohorts were included in the analysis.

Results: Five hundred twenty-eight study children were alive at the age 18 months and 491 (426 HIV uninfected and 65 infected) were enrolled into the follow-up study. Both exposed but uninfected children and HIV-infected children were substantially below WHO growth standards for weight and height. Head circumference Z scores for uninfected children were comparable with WHO norms. Five-year survival rates were 93% for uninfected children versus 43% for infected children. Long-term safety and growth outcomes in the 2 study arms were similar.

Conclusions: Both infected and uninfected children in the 5-year HIVNET 012 follow-up showed poor height and weight growth outcomes, underscoring the need for early nutritional interventions to improve long-term growth of all infants born to HIV-infected women in resource-limited settings. Similarly, the low 5-year survival among HIV-infected children supports the importance of early initiation of antiretroviral therapy. Both peripartum nevirapine and zidovudine were safe.

Abstract access 

Editor’s notes: There are limited studies on outcomes in HIV exposed/negative and positive children beyond infancy in the pre-ART era in Africa. As expected, HIV positive children were twice as likely to die as HIV negative children. The five-year survival was significantly higher among children infected postnatally (after eight weeks) than among those infected perinatally. Notably, more than 50% of deaths among HIV positive children occurred in the first two years of life; HIV negative children who managed to survive to two years had a greater than 70% probability of survival to five years, irrespective of the timing of infection. Overall, poor growth (stunting and underweight) was common, but growth failure rates remained significantly higher in HIV positive children throughout the period of follow-up. Importantly, use of peripartum zidovudine or nevirapine did not result in any longterm adverse outcomes.  

This study underscores the importance of early identification of HIV and timely institution of ART. However, a significant number of children do survive beyond infancy even without treatment, and therefore HIV testing strategies should also target older children who may have missed testing during infancy. Children in this setting remain highly vulnerable and growth monitoring and nutritional interventions are crucial. These should also be integrated within paediatric HIV care services.

Africa
Uganda
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