Can a routine peri-partum HIV counselling and testing service for women improve access to HIV prevention, early testing and treatment of children?

MSc (Med), Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, 2009Context Prevention of mother to child transmission (PMTCT) of HIV relies on identification of HIV-positive pregnant women at the first antenatal visit and at time points thereafter. As not all women who attend antenatal care initially agree to test or maintain an HIV-negative status the lack of re-establishing HIV prevalence at delivery may result in missed prevention opportunities and a false impression of PMTCT coverage. Objectives To assess whether a routine peri-partum HIV counseling and testing service improves access to HIV prevention, testing and care of infants by identifying additional HIV-positive women at the time of delivery. To assess the effect on the PMTCT coverage indicator when HIV prevalence is reestablished in the delivery population. Design and Patients All women 18 years or older with live births in the labour and postnatal wards of the Rahima Moosa Mother and Child Hospital (RMMCH) were interviewed and invited to enrol irrespective of their need to retest/test for HIV or their potential refusal of an HIV test. Rapid HIV antibody tests were offered to women who had no HIV result, reported an HIV-negative result performed more than six weeks prior to delivery or reported an HIV result discrepant with her documented result. vi Test acceptance and HIV prevalence were calculated for the enrolled population. The rate of return and results for early infant diagnosis in HIV-exposed infants and the follow-up of infected infants were documented. HIV polymerase chain reaction (PCR) results for infants not returning to the facility were retrieved from the National Health Laboratory Services database. Results Between 9th April 2008 and the 23rd of September 2008 there were 5169 women with live births. A total of 3684 (71.3%) of the 5169 women delivering were interviewed and 2419 (46.8%) were enrolled. Of the women enrolled, 2140 (88.5%) reported a known HIV status and 490 (22.9%) of these were HIV-positive. After counseling and testing, an additional 101 HIV-positive women were identified increasing the number of HIV-positive women by 20.6%. An additional 177 women were identified as being HIV-negative. The true infant PMTCT coverage increased by 17% as a result of newly identified HIV-positive women. Of 591 HIV-exposed infants identified, 284 (48.0%) underwent PCR testing at RMMCH or surrounding facilities and 16 (5.6%) tested PCR-positive. Of the infants expected to return to RMMCH for PCR testing 155/203 (76.4%) antenataly diagnosed versus 12/83 (14.5%) newly diagnosed women returned with their infants (p<0.001). Ten HIVinfected infants were diagnosed at RMMCH of which nine were in care with six initiated on antiretrovirals

Recommendations for the management of indeterminate HIV PCR results within South Africa’s early infant diagnosis programme

Indeterminate HIV PCR results represent missed diagnostic opportunities within South Africa’s early infant diagnosis programme. These results not only delay diagnosis and appropriate management but are also a source of confusion and apprehension amongst clinicians and caregivers. We describe the extent of indeterminate HIV PCR results within South Africa’s early infant diagnosis programme and provide recommendations for the management of these cases, both in terms of laboratory practice and the clinical care of the infants.They also thank the United Nations Children’s Emergency Fund (UNICEF) for partial funding of this work. A.H.M. acknowledges the Discovery Foundation for financial support.http://www.sajhivmed.org.zaam2016Medical Virolog

Virologic response to efavirenz-based first-line antiretroviral therapy in children with previous exposure to antiretrovirals to prevent mother-to-child transmission

Efavirenz-based first-line regimens have been widely used for children ≥3 years of age starting antiretroviral therapy, despite possible resistance with prior exposure to non-nucleoside reverse transcriptase inhibitors for prevention of mother-to-child transmission (PMTCT). We used logistic regression to examine the association between PMTCT exposure and viral failure (VF) defined as two consecutive viral loads (VL)>1000 copies/ml between 6–18 months on ART. Children with previous nevirapine exposure for PMTCT were not at higher risk of VF compared to unexposed children (adjusted Odds Ratio (aOR): 0.79; 95% CI:0.56, 1.11)

Cervical cancer prevention and care in HIV clinics across sub-Saharan Africa: results of a facility-based survey.

INTRODUCTION To eliminate cervical cancer (CC), access to and quality of prevention and care services must be monitored, particularly for women living with HIV (WLHIV). We assessed implementation practices in HIV clinics across sub-Saharan Africa (SSA) to identify gaps in the care cascade and used aggregated patient data to populate cascades for WLHIV attending HIV clinics. METHODS Our facility-based survey was administered between November 2020 and July 2021 in 30 HIV clinics across SSA that participate in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. We performed a qualitative site-level assessment of CC prevention and care services and analysed data from routine care of WLHIV in SSA. RESULTS Human papillomavirus (HPV) vaccination was offered in 33% of sites. Referral for CC diagnosis (42%) and treatment (70%) was common, but not free at about 50% of sites. Most sites had electronic health information systems (90%), but data to inform indicators to monitor global targets for CC elimination in WLHIV were not routinely collected in these sites. Data were collected routinely in only 36% of sites that offered HPV vaccination, 33% of sites that offered cervical screening and 20% of sites that offered pre-cancer and CC treatment. CONCLUSIONS Though CC prevention and care services have long been available in some HIV clinics across SSA, patient and programme monitoring need to be improved. Countries should consider leveraging their existing health information systems and use monitoring tools provided by the World Health Organization to improve CC prevention programmes and access, and to track their progress towards the goal of eliminating CC

COVID-19 in pregnancy in South Africa : tracking the epidemic and defining the natural history

South Africa (SA) has seen a rapid increase in COVID-19 infections in recent weeks, with cases exceeding 40 000 in early June and anticipated to escalate rapidly as lockdown is eased. The country also has the largest HIV burden globally, and poor maternal and child health indices in many parts. Although early indications were that COVID-19 infection does not worsen pregnancy and birth outcomes, recent reports have raised fresh concerns. Preterm birth, neonatal pneumonia[9-11] and cases of vertical transmission and postpartum infections have been reported, including in SA. Some maternal deaths related to COVID-19 have occurred, possibly linked to haemodynamic changes immediately postpartum and/or to the thrombogenic nature of both pregnancy and COVID- 19. Maternal wellbeing in pregnant women with COVID-19 infection is a major concern, as these women often have high anxiety about infecting their newborn child, and may experience challenging interactions with healthcare providers and community stigma. Most evidence on COVID-19 and pregnancy to date is limited to case series, involves only symptomatic women without HIV, and is almost exclusively from high-income countries. Cohort data across a range of settings and population groups are the only means of fully understanding the natural history, clinical disease spectrum and risks of COVID-19 in pregnant women, fetuses and infants.http://www.samj.org.zaam2021Obstetrics and Gynaecolog

Earlier Antiretroviral Therapy Initiation and Decreasing Mortality Among HIV-infected Infants Initiating Antiretroviral Therapy Within 3 Months of Age in South Africa, 2006-2017.

BACKGROUND Early infant diagnosis of HIV and antiretroviral therapy (ART) has been rapidly scaled-up. We aimed to examine the effect of expanded access to early ART on the characteristics and outcomes of infants initiating ART. METHODS From 9 cohorts within the International epidemiologic Databases to Evaluate AIDS-Southern Africa collaboration, we included infants with HIV initiating ART ≤3 months of age between 2006 and 2017. We described ART initiation characteristics and the probability of mortality, loss to follow-up (LTFU) and transfer out after 6 months on ART and assessed factors associated with mortality and LTFU. RESULTS A total of 1847 infants started ART at a median age of 60 days [interquartile range: 29-77] and CD4 percentage (%) of 27% (18%-38%). Across ART initiation calendar periods 2006-2009 to 2013-2017, ART initiation age decreased from 68 (53-81) to 45 days (7-71) (P < 0.001), median CD4% improved from 22% (15%-34%) to 32% (22-43) (P < 0.001) and the proportion with World Health Organization clinical disease stage 3 or 4 declined from 81.6% to 32.7% (P < 0.001). Overall, the 6-month mortality probability was 5.0% and LTFU was 20.4%. Mortality was 10.6% (95% confidence interval: 7.8%-14.4%) in 2006-2009 and 4.6% (3.1%-6.7%) in 2013-2017 (P < 0.001), with similar LTFU across calendar periods (P = 0.274). Pretreatment weight-for-age Z score <-2 was associated with higher mortality. CONCLUSIONS Infants with HIV are starting ART younger and healthier with associated declines in mortality. However, the risk of mortality remained undesirably high in recent years. Focused interventions are needed to optimize the benefits of earlier diagnosis and treatment

Recommendations for the management of indeterminate HIV PCR results within South Africa’s early infant diagnosis programme

CITATION: Mazanderani, A. H., et al. 2016. Recommendations for the management of indeterminate HIV PCR results within South Africa’s early infant diagnosis programme. Southern African Journal of HIV Medicine, 17(1), a451, doi:10.4102/sajhivmed.v17i1.451.The original publication is available at http://www.sajhivmed.org.za/ENGLISH ABSTRACT: Indeterminate HIV PCR results represent missed diagnostic opportunities within South Africa's early infant diagnosis (EID) programme. These results not only delay diagnosis and appropriate management but are also a source of confusion and apprehension amongst clinicians and caregivers. We describe the extent of indeterminate HIV PCR results within South Africa's EID programme and provide recommendations for the management of these cases, both in terms of laboratory practice and the clinical care of the infants.http://www.sajhivmed.org.za/index.php/hivmed/article/view/451Publisher's versio

Point-of-care HIV maternal viral load and early infant diagnosis testing around time of delivery at tertiary obstetric units in South Africa : a prospective study of coverage, results return and turnaround times

INTRODUCTION : Maternal viral load monitoring (mVL) and early infant diagnosis (EID) are necessary to achieve elimination of mother-to-child transmission of HIV. Point-of-care testing can achieve better outcomes compared to centralized laboratory testing (CLT). We describe the first implementation of point-of-care (POC) mVL and EID testing around delivery at four high volume tertiary obstetric units (TOUs) in Gauteng, South Africa. METHODS : Prospective study of pregnant women living with HIV (WLHIV) and their infants. During the period 1 June 2018 to 31 March 2019, routine staff collected blood specimens from women and their infants around delivery. Specimen collection occurred throughout the week while dedicated POC operators, conducted testing during working hours on weekdays. Descriptive statistics and multivariable Poisson regression with robust error variance were used to describe outcomes and associated factors. Outcomes determined were (i) coverage of mVL and EID testing defined as a proportion of live births to WLHIV admitted at each facility (ii) results returned prior to discharge (iii) turn-around time (TAT) and iv) performance of POC testing compared to CLT. RESULTS : In total, 8147 live births to pregnant WLHIV were recorded in the implementation period. Of these, 2912 mVL and 5074 EID specimens were included in the analysis, with 131 (4.5%) mVL and 715 (14.1%) EID specimens having initial invalid/ error results. Overall coverage of POC mVL and EID testing was 35.6% (range 20.9% to 60.1%) and 61.9% (range 47.0% to 88.0%) respectively. Proportions of POC tested mothers and infants with results returned prior to discharge were 74.3% (range 39.0% to 95.7%) and 73.0% (range 50.0 to 97.9%). Return of results was independently associated with TOU, afterhours specimen collection, having an initial invalid or error result and period of implementation. Overall TAT for specimens collected from mother-infant pairs where both had POC testing, during weekdays was longer for EID compared to mVL testing (median 3.3 hours vs. 2.9 hours, p-value sign test <0.001). POC results were comparable to those from laboratory testing. CONCLUSION : Accurate and timely POC mVL and EID testing around delivery was implemented with variable success across TOUs. Further scale up would need to address health system factors at facility level and high analytical error rates.This study was funded by the Clinton Health Access Initiative (CHAI)/UNITAID (Project ID CHSOAFHLSTP3).The Clinton Health Access Initiativehttps://onlinelibrary.wiley.com/journal/17582652am2020Medical Virolog

Point‐of‐care HIV maternal viral load and early infant diagnosis testing around time of delivery at tertiary obstetric units in South Africa: a prospective study of coverage, results return and turn‐around times

INTRODUCTION : Maternal viral load monitoring (mVL) and early infant diagnosis (EID) are necessary to achieve elimination of mother-to-child transmission of HIV. Point-of-care testing can achieve better outcomes compared to centralized laboratory testing (CLT). We describe the first implementation of point-of-care (POC) mVL and EID testing around delivery at four high volume tertiary obstetric units (TOUs) in Gauteng, South Africa. METHODS : Prospective study of pregnant women living with HIV (WLHIV) and their infants. During the period 1 June 2018 to 31 March 2019, routine staff collected blood specimens from women and their infants around delivery. Specimen collection occurred throughout the week while dedicated POC operators, conducted testing during working hours on weekdays. Descriptive statistics and multivariable Poisson regression with robust error variance were used to describe outcomes and associated factors. Outcomes determined were (i) coverage of mVL and EID testing defined as a proportion of live births to WLHIV admitted at each facility (ii) results returned prior to discharge (iii) turn-around time (TAT) and iv) performance of POC testing compared to CLT. RESULTS : In total, 8147 live births to pregnant WLHIV were recorded in the implementation period. Of these, 2912 mVL and 5074 EID specimens were included in the analysis, with 131 (4.5%) mVL and 715 (14.1%) EID specimens having initial invalid/ error results. Overall coverage of POC mVL and EID testing was 35.6% (range 20.9% to 60.1%) and 61.9% (range 47.0% to 88.0%) respectively. Proportions of POC tested mothers and infants with results returned prior to discharge were 74.3% (range 39.0% to 95.7%) and 73.0% (range 50.0 to 97.9%). Return of results was independently associated with TOU, afterhours specimen collection, having an initial invalid or error result and period of implementation. Overall TAT for specimens collected from mother-infant pairs where both had POC testing, during weekdays was longer for EID compared to mVL testing (median 3.3 hours vs. 2.9 hours, p-value sign test <0.001). POC results were comparable to those from laboratory testing. CONCLUSION : Accurate and timely POC mVL and EID testing around delivery was implemented with variable success across TOUs. Further scale up would need to address health system factors at facility level and high analytical error rates.This study was funded by the Clinton Health Access Initiative (CHAI)/UNITAID (Project ID CHSOAFHLSTP3).The Clinton Health Access Initiativehttps://onlinelibrary.wiley.com/journal/17582652am2020Medical Virolog

Earlier Antiretroviral Therapy Initiation and Decreasing Mortality Among HIV-infected Infants Initiating Antiretroviral Therapy Within 3 Months of Age in South Africa, 2006–2017

Background: Early infant diagnosis of HIV and antiretroviral therapy (ART) has been rapidly scaled-up. We aimed to examine the effect of expanded access to early ART on the characteristics and outcomes of infants initiating ART. Methods: From 9 cohorts within the International epidemiologic Databases to Evaluate AIDS-Southern Africa collaboration, we included infants with HIV initiating ART ≤3 months of age between 2006 and 2017. We described ART initiation characteristics and the probability of mortality, loss to follow-up (LTFU) and transfer out after 6 months on ART and assessed factors associated with mortality and LTFU. Results: A total of 1847 infants started ART at a median age of 60 days [interquartile range: 29–77] and CD4 percentage (%) of 27% (18%–38%). Across ART initiation calendar periods 2006–2009 to 2013–2017, ART initiation age decreased from 68 (53–81) to 45 days (7–71) (P < 0.001), median CD4% improved from 22% (15%–34%) to 32% (22–43) (P < 0.001) and the proportion with World Health Organization clinical disease stage 3 or 4 declined from 81.6% to 32.7% (P < 0.001). Overall, the 6-month mortality probability was 5.0% and LTFU was 20.4%. Mortality was 10.6% (95% confidence interval: 7.8%–14.4%) in 2006–2009 and 4.6% (3.1%–6.7%) in 2013–2017 (P < 0.001), with similar LTFU across calendar periods (P = 0.274). Pretreatment weight-for-age Z score <−2 was associated with higher mortality. Conclusions: Infants with HIV are starting ART younger and healthier with associated declines in mortality. However, the risk of mortality remained undesirably high in recent years. Focused interventions are needed to optimize the benefits of earlier diagnosis and treatment