Better retention in care among HIV-exposed infants whose mothers receive combination ART

Maternal combination antiretroviral therapy is associated with improved retention of HIV-exposed infants in Kinshasa, Democratic Republic of Congo.

Feinstein L, Edmonds A, Okitolonda V, Cole SR, Van Rie A, Chi BH, Ndjibu P, Lusiama J, Chalachala JL, Behets F. J Acquir Immune Defic Syndr. 2015 Apr 13. [Epub ahead of print]

Background: Programs to prevent mother-to-child HIV transmission (PMTCT) are plagued by loss to follow-up (LTFU) of HIV-exposed infants. We assessed if providing combination antiretroviral therapy (cART) to HIV-infected mothers was associated with reduced LTFU of their HIV-exposed infants in Kinshasa, DR Congo.

Methods: We constructed a cohort of mother-infant pairs using routinely collected clinical data. Maternal cART eligibility was based on national guidelines in effect at the time. Infants were considered LTFU following three failed tracking attempts after a missed visit or if more than six months passed since they were last seen in clinic. Statistical methods accounted for competing risks (e.g. death).

Results: 1318 infants enrolled at a median age of 2.6 weeks (interquartile range [IQR]: 2.1-6.9), at which point 24% of mothers were receiving cART. Overall, 5% of infants never returned to care following enrollment and 18% were LTFU by 18 months. The 18-month cumulative incidence of LTFU was 8% among infants whose mothers initiated cART by infant enrollment and 20% among infants whose mothers were not yet on cART. Adjusted for baseline factors, infants whose mothers were not on cART were over twice as likely to be LTFU, with a subdistribution hazard ratio of 2.75 (95% confidence limit: 1.81, 4.16). The association remained strong regardless of maternal CD4 count at infant enrollment.

Conclusion: Increasing access to cART for pregnant women could improve retention of HIV-exposed infants, thereby increasing the clinical and population-level impacts of PMTCT interventions and access to early cART for HIV-infected infants.

Abstract access  [1]

Editor’s notes: An estimated one third of all HIV-exposed infants are lost to follow up (LTFU) by three months in sub-Saharan Africa.  Regular follow-up of HIV-exposed infants is necessary to ensure that they are provided with prophylactic drugs, have an opportunity for early infant diagnosis, and if HIV-positive that they are started on combination antiretroviral treatment (cART) as soon as possible.  This study using routinely collected programmatic data (2007 - 2013) in Kinshasa found that infants whose mothers had not yet initiated cART were more than twice as likely to be LTFU as infants whose mothers had initiated cART. An important point to highlight is that this study was unable to tease out what proportion of the effect of maternal cART on infant LTFU was attributable to reduction in infant mortality. There are few data on factors that contribute to LTFU in HIV-exposed infants. The available evidence suggests that structural barriers, including transport, waiting time and cost, affect retention in care. 

Health care delivery [4], HIV Treatment [5]
Africa [6]
Democratic Republic of the Congo [7]
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