Mother to child transmission of HIV : maternal and child characteristics.

A prospective study at the University Teaching Hospital of 306 women with their infants, who were enrolled at delivery, was conducted in 1997. The primary aim was to define the magnitude and effects of maternal human immuno-deficiency virus (HIV) infection on obstetric problems and infant outcome. Women were mainly over 19 years (87.3%), literate (73.7%) and married (91.4%), with no formal income (75.7%). 48.2% and 46.7% had antenatal or post-partum anaemia (PPA) and of these 1.8% and 6.2% were severely anaemic. Low post-partum (PP) serum retinol «0.7f.lmoI/L) and CD4 counts «400 cells/mm3 ) occurred in 12.8% and 16.2% of the women. The commonest obstetric problems were previous child death (32.4%), malaria treatment during pregnancy (32.6%), previous abortion (16.4%) and hypertension (13.7%). Post-partum, 30.1% of the women were HIV infected, 14.9% rapid plasma reagin (RPR) positive and 4.5% hepatitis B surface antigen (HBsAg) positive. Factors independently associated with HIV infection were: alcohol intake during pregnancy (RR 5.67); ante-partum haemorrhage (RR 5.85); PP HBsAg positivity (RR 27.45); low PP CD4 cell count (RR 10.63) and PPA (RR 3.99). Primigravidae had a lower risk ofHIV infection (RR OJ). For PPA independent risk factors were: caesarean section (RR 9.95); HIV infection (RR 2.81) and low PP mean corpuscular haemoglobin concentration (MCHC) (RR 8.33); mean corpuscular volume (MCV) (RR 2.39) and serum retinol (RR 3.03). Alcohol intake during pregnancy (RR 0.22) and low PP maternal weight (RR 0.10) were associated with reduced risk ofPPA. The prevalence of low birth weight (LBW; weight <2.5kg), pre-term delivery «37 weeks gestation) and intra-uterine growth retardation (IUGR; weight < lOth centile for gestational age) were 18.9%, 23.8% and 25.9%. These showed no association with maternal HIV infection although the mean birth weight was significantly lower in children born of HIV infected mothers (P=0.006). In HN non-infected women, antenatal anaemia was independently associated with increased risk pre-term delivery (RR 5.l2) and low birth weight (RR 5.08). Low PP serum retinol increased the risk of IUGR (RR 3.10). In HN infected women, lack of paternal income was associated with pre-term delivery (RR 11.7), IUGR with LBW (RR 3.59) and antibiotic treatment in pregnancy with IUGR (RR 5.85). The cumulative rate of HN mother to child transmission (MTCT) at 1 year of age was 31 %, with 10.3%, 1O.l% and 9.l% of infants DNA polymerase chain reaction (PCR) positive at birth, 1 month and 4 to 12 months respectively. On multivariate analysis, PP maternal viral load (>50,OOOcopies Iml) was the only risk factor associated with early infant HN acquisition (birth and 1 month) (P = 0.005) and cumulative infections at one year (P=O.OOI). At a year of age, HIV infected children were severely undernourished (weight for age median Z-score -3.46) and stunted (height for age median Z-score -4.44). Stunting was the main form of malnutrition in uninfected infants regardless of maternal HN status. Reported morbidity in infancy was unaffected by HN status. The infant mortality rate was 136 per 1000 live births, 85 per 1000 in HN uninfected children of uninfected mothers, 272 per 1000 in infants of infected mothers and 424 per 1000 in infected infants. After correcting for confounders, maternal HN infection (HR 0.28) and primigravidae (HR 0.20) were significant risk factors for infant survival. The population attributable risk percentage of infant mortality was 41.3% for maternal HN infection and 24.9% when the infant was HN infected as well

Scaling-up co-trimoxazole prophylaxis in HIV-exposed and HIV-infected children in high HIV-prevalence countries.

Co-trimoxazole (trimethoprim-sulfamethoxazole) is a widely available antibiotic that substantially reduces HIV-related morbidity and mortality in both adults and children. Prophylaxis with co-trimoxazole is a recommended intervention of proven benefit that could serve not only as an initial step towards improving paediatric care in young children with limited access to antiretroviral treatment, but also as an important complement to antiretroviral therapy in resource-limited settings. Despite co-trimoxazole's known clinical benefits, the potential operational benefits, and favourable recommendations by WHO, UNAIDS, and UNICEF, its routine use in developing countries--particularly sub-Saharan Africa--has remained limited. Out of an estimated 4 million children in need of co-trimoxazole prophylaxis (HIV-exposed and HIV-infected), only 4% are currently receiving this intervention. We discuss some of the major barriers preventing the scale-up of co-trimoxazole prophylaxis for children in countries with a high prevalence of HIV and propose specific actions required to tackle these challenges

Implementing services for Early Infant Diagnosis (EID) of HIV: a comparative descriptive analysis of national programs in four countries

<p>Abstract</p> <p>Background</p> <p>There is a significant increase in survival for HIV-infected children who have early access to diagnosis and treatment. The goal of this multi-country review was to examine when and where HIV-exposed infants and children are being diagnosed, and whether the EID service is being maximally utilized to improve health outcomes for HIV-exposed children.</p> <p>Methods</p> <p>In four countries across Africa and Asia existing documents and data were reviewed and key informant interviews were conducted. EID testing data was gathered from the central testing laboratories and was then complemented by health facility level data extraction which took place using a standardized and validated questionnaire</p> <p>Results</p> <p>In the four countries reviewed from 2006 to 2009 EID sample volumes rose dramatically to an average of >100 samples per quarter in Cambodia and Senegal, >7,000 samples per quarter in Uganda, and >2,000 samples per quarter in Namibia. Geographic coverage of sites also rapidly expanded to 525 sites in Uganda, 205 in Namibia, 48 in Senegal, and 26 in Cambodia in 2009. However, only a small proportion of testing was done at lower-level health facilities: in Uganda Health Center IIs and IIIs comprised 47% of the EID collection sites, but only 11% of the total tests, and in Namibia 15% of EID sites collected >93% of all samples. In all countries except for Namibia, more than 50% of the EID testing was done after 2 months of age. Few sites had robust referral mechanisms between EID and ART. In a sub-sample of children, we noted significant attrition of infants along the continuum of care post testing. Only 22% (Senegal), 37% (Uganda), and 38% (Cambodia) of infants testing positive by PCR were subsequently initiated onto treatment. In Namibia, which had almost universal EID coverage, more than 70% of PCR-positive infants initiated ART in 2008.</p> <p>Conclusions</p> <p>While EID testing has expanded dramatically, a large proportion of PCR- positive infants are initiated on treatment. As EID services continue to scale-up, more programmatic attention and support is needed to retain HIV-exposed infants in care and ensure that those testing positive initiate treatment in a timely manner. Namibia's experience demonstrates that it is feasible for a rural, low-income country to achieve high national coverage of infant testing and treatment.</p

MRC Clinical Trials Unit, UK

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Pregnant and postpartum women's experiences and perspectives on the acceptability and feasibility of copackaged medicine for antenatal care and PMTCT in Lesotho

Objective: To improve PMTCT and antenatal care-related service delivery, a pack with centrally prepackaged medicine was rolled out to all pregnant women in Lesotho in 2011. This study assessed acceptability and feasibility of this copackaging mechanism for drug delivery among pregnant and postpartum women. Methods: Acceptability and feasibility were assessed in a mixed method, cross-sectional study through structured interviews (SI) and semistructured interviews (SSI) conducted in 2012 and 2013. Results: 290 HIV-negative women and 437 HIV-positive women (n = 727) participated. Nearly all SI participants found prepackaged medicines acceptable, though modifications such as size reduction of the pack were suggested. Positive experiences included that the pack helped women take pills as instructed and contents promoted healthy pregnancies. Negative experiences included inadvertent pregnancy disclosure and discomfort carrying the pack in communities. Implementation was also feasible; 85.2% of SI participants reported adequate counseling time, though 37.8% felt pack use caused clinic delays. SSI participants reported improvement in service quality following pack introduction, due to more comprehensive counseling. Conclusions: A prepackaged drug delivery mechanism for ANC/PMTCT medicines was acceptable and feasible. Findings support continued use of this approach in Lesotho with improved design modifications to reflect the current PMTCT program of lifelong treatment for all HIV-positive pregnant women

Progress, Challenges, and New Opportunities for the Prevention of Mother-to-Child Transmission of HIV Under the US Presidentʼs Emergency Plan for AIDS Relief

In June 2011, the Joint United Nations Programme on HIV/AIDS, the US President’s Emergency Plan for AIDS Relief (PEPFAR), and other collaborators outlined a transformative plan to virtually eliminate pediatric AIDS worldwide. The ambitious targets of this initiative included a 90% reduction in new pediatric HIV infections and a 50% reduction in HIV-related maternal mortality—all by 2015. PEPFAR has made an unprecedented commitment to the expansion and improvement of prevention of mother-to-child HIV transmission (PMTCT) services globally and is expected to play a critical role in reaching the virtual elimination target. To date, PEPFAR has been instrumental in the success of many national programs, including expanded coverage of PMTCT services, an enhanced continuum of care between PMTCT and HIV care and treatment, provision of more efficacious regimens for antiretroviral prophylaxis, design of innovative but simplified PMTCT approaches, and development of new strategies to evaluate program effectiveness. These accomplishments have been made through collaborative efforts with host governments, United Nations agencies, other donors (eg, the Global Fund for AIDS, Tuberculosis, and Malaria), nongovernmental organizations, and private sector partners. To successfully meet the ambitious global targets to prevent new infant HIV infections, PEPFAR must continue to leverage the existing PMTCT platform, while developing innovative approaches to rapidly expand quality HIV services. PEPFAR must also carefully integrate PMTCT into the broader combination prevention agenda for HIV, so that real progress can be made toward an “AIDS-free generation” worldwide