Brief Report: Improving Early Infant Diagnosis Observations: Estimates of Timely HIV Testing and Mortality Among HIV-Exposed Infants.

BACKGROUND: Improving efforts toward elimination of mother-to-child transmission of HIV requires timely early infant diagnosis (EID) among all HIV-exposed infants, but the occurrence of timely EID and infant survival may be underascertained in routine, facility-bound program data. METHODS: From March 2015 to May 2015, we traced a random sample of HIV-positive mother and HIV-exposed infant pairs lost to follow-up for EID in facility registers in Zimbabwe. We incorporated updated information into weighted survival analyses to estimate incidence of EID and death. Reasons for no EID were surveyed from caregivers. RESULTS: Among 2651 HIV-positive women attending antenatal care, 1823 (68.8%) infants had no documented EID by 3 months of age. Among a random sample of 643 (35.3%) HIV-exposed infants lost to follow-up for EID, vital status was ascertained among 371 (57.7%) and updated care status obtained from 256 (39.8%) mothers traced. Among all HIV-infected mother-HIV-exposed infant pairs, weighted estimates found cumulative incidence of infant death by 90 days of 3.9% (95% confidence interval: 3.4% to 4.4%). Cumulative incidence of timely EID with death as a competing risk was 60%. The most frequently cited reasons for failure to uptake EID were "my child died" and "I didn't know I should have my child tested." CONCLUSIONS: Our findings indicate uptake of timely EID among HIV-exposed infants is underestimated in routine health information systems. High, early mortality among HIV-exposed infants underscores the need to more effectively identify HIV-positive mother-HIV exposed infant pairs at high risk of adverse outcomes and loss to follow-up for enhanced interventions

How are countries in sub-Saharan African monitoring the impact of programmes to prevent vertical transmission of HIV?

Vertical transmission of HIV can occur during pregnancy, delivery, or through breast feeding. The main driver of vertical transmission is a high maternal viral load. Between 2002 and 2016, low and middle income countries (LMICs) in sub-Saharan Africa with high HIV prevalence improved their policies to prevent vertical transmission of HIV. In 2002, national policies recommended single dose nevirapine at the onset of labour, with limited or no breast feeding. By 2016, all Global Plan priority countries in sub-Saharan Africa (where 90% of the world’s HIV positive pregnant women live) had adopted Option B+ with promotion of breast feeding. Option B+ was a dramatic policy change recommending lifelong triple antiretroviral therapy (ART) for all pregnant and lactating women living with HIV. The aim is to protect the child from HIV infection, ensure the mother’s future health, and prevent horizontal transmission of HIV.The South African Medical Research Council (SAMRC)http://www.bmj.com/thebmjam2020Paediatrics and Child Healt

Use of data from various sources to evaluate and improve the prevention of mother‐to‐child transmission of HIV programme in Zimbabwe: a data integration exercise

INTRODUCTION: Despite improvements in prevention of mother-to-child transmission (PMTCT) of HIV outcomes, there remain unacceptably high numbers of mother-to-child transmissions (MTCT) of HIV. Programmes and research collect multiple sources of PMTCT data, yet this data is rarely integrated in a systematic way. We conducted a data integration exercise to evaluate the Zimbabwe national PMTCT programme and derive lessons for strengthening implementation and documentation. METHODS: We used data from four sources: research, Ministry of Health and Child Care (MOHCC) programme, Implementer – Organization for Public Health Interventions and Development, and modelling. Research data came from serial population representative cross-sectional surveys that evaluated the national PMTCT programme in 2012, 2014 and 2017/2018. MOHCC and Organization for Public Health Interventions and Development collected data with similar indicators for the period 2018 to 2019. Modelling data from 2017/18 UNAIDS Spectrum was used. We systematically integrated data from the different sources to explore PMTCT programme performance at each step of the cascade. We also conducted spatial analysis to identify hotspots of MTCT. RESULTS: We developed cascades for HIV-positive and negative-mothers, and HIV exposed and infected infants to 24 months post-partum. Most data were available on HIV positive mothers. Few data were available 6-8 weeks post-delivery for HIV exposed/infected infants and none were available post-delivery for HIV-negative mothers. The different data sources largely concurred. Antenatal care (ANC) registration was high, although women often presented late. There was variable implementation of PMTCT services, MTCT hotspots were identified. Factors positively associated with MTCT included delayed ANC registration and mobility (use of more than one health facility) during pregnancy/breastfeeding. There was reduced MTCT among women whose partners accompanied them to ANC, and infants receiving antiretroviral prophylaxis. Notably, the largest contribution to MTCT was from postnatal women who had previously tested negative (12/25 in survey data, 17.6% estimated by Spectrum modelling). Data integration enabled formulation of interventions to improve programmes. CONCUSIONS: Data integration was feasible and identified gaps in programme implementation/documentation leading to corrective interventions. Incident infections among mothers are the largest contributors to MTCT: there is need to strengthen the prevention cascade among HIV-negative women

Viral load testing among women on 'option B+' in Mazowe, Zimbabwe: How well are we doing?

BackgroundGlobally, ten percent of new HIV infections are among children and most of these children acquire infection through mother-to-child transmission. To prevent this, lifelong ART among pregnant and breast feeding (PBF) women living with HIV, irrespective of the WHO clinical stage, was adopted (option B+). There is limited cohort-wise assessment of VL testing among women on 'option B+'.ObjectiveAmong a pregnancy cohort on antiretroviral therapy in public hospitals and clinics of Mazowe district, Zimbabwe (2017), to determine the i) proportion undergoing VL testing anytime up to six months post child birth and associated factors; ii) turnaround time (TAT) from sending the specimen to results receipt and VL suppression among those undergoing VL testing.MethodsThis was a cohort study involving secondary programme data. Modified Poisson regression using robust variance estimates was used to determine the independent predictors of VL testing.ResultsOf 1112 women, 354 (31.8%, 95% CI: 29.2-34.6) underwent VL testing: 113 (31.9%) during pregnancy, 124 (35%) within six months of child birth and for 117 (33.1%), testing period was unknown. Of 354, VL suppression was seen in 334 (94.4%) and 13 out of 20 with VL non-suppression underwent repeat VL testing. Among those with available dates (125/354), the median TAT was 93 days (IQR 19.3-255). Of 1112, VL results were available between 32 weeks and child birth in 31 (2.8%) women. When compared to hospitals, women registered for antenatal care in clinics were 36% less likely to undergo VL testing [aRR: 0.64 (95% CI: 0.53, 0.76)].ConclusionAmong women on option B+, the uptake of HIV VL testing was low with unacceptably long TAT. VL suppression among those tested was satisfactory. There is an urgent need to prioritize VL testing among PBF women and to consider use of point of care machines. There is a critical need to strengthen the recording and local utilisation of routine clinic data in order to successfully monitor progress of healthcare services provided

Identifying high or low risk of mother to child transmission of HIV: How Harare City, Zimbabwe is doing?

BackgroundDespite high antiretroviral (ARV) treatment coverage among pregnant women for prevention of mother-to-child transmission (PMTCT) of Human Immunodeficiency Virus (HIV) in Zimbabwe, the MTCT rate is still high. Therefore in 2016, the country adopted World Health Organization recommendations of stratifying pregnant women into "High" or"Low" MTCT risk for subsequent provision of HIV exposed infant (HEI) with appropriate follow-up care according to risk status.ObjectiveThe study sought to ascertain, among pregnant women who delivered in clinics of Harare in August 2017: the extent to which high risk MTCT pregnancies were identified at time of delivery; and whether their newborns were initiated on appropriate ARV prophylaxis, cotrimoxazole prophylaxis, subjected to early HIV diagnostic testing and initiated on ARV treatment.MethodsCross-sectional study using review of records of routinely collected program data.ResultsOf the 1,786 pregnant women who delivered in the selected clinics, HIV status at the time of delivery was known for 1,756 (98%) of whom 197 (11%) were HIV seropositive. Only 19 (10%) could be classified as "high risk" for MTCT and the remaining 90% lacked adequate information to classify them into high or low risk for MTCT due to missing data. Of the 197 live births, only two (1%) infants had a nucleic-acid test (NAT) at birth and 32 (16%) infants had NAT at 6 weeks. Of all 197 infants, 183 (93%) were initiated on single ARV prophylaxis (Nevirapine), 15 (7%) infants' ARV prophylaxis status was not documented and one infant got dual ARV prophylaxis (Nevirapine+Zidovudine).ConclusionThere was paucity of data requisite for MTCT risk stratification due to poor recording of data; "high risk" women were missed in the few circumstances where sufficient data were available. Thus "high risk" HEI are deprived of dual ARV prophylaxis and priority HIV NAT at birth and onwards which they require for PMTCT. Health workers need urgent training, mentorship and supportive supervision to master data management and perform MTCT risk stratification satisfactorily

How are countries in sub-Saharan African monitoring the impact of programmes to prevent vertical transmission of HIV?

Vertical transmission of HIV can occur during pregnancy, delivery, or through breast feeding. The main driver of vertical transmission is a high maternal viral load. Between 2002 and 2016, low and middle income countries (LMICs) in sub-Saharan Africa with high HIV prevalence improved their policies to prevent vertical transmission of HIV. In 2002, national policies recommended single dose nevirapine at the onset of labour, with limited or no breast feeding. By 2016, all Global Plan priority countries in sub-Saharan Africa (where 90% of the world’s HIV positive pregnant women live) had adopted Option B+ with promotion of breast feeding. Option B+ was a dramatic policy change recommending lifelong triple antiretroviral therapy (ART) for all pregnant and lactating women living with HIV. The aim is to protect the child from HIV infection, ensure the mother’s future health, and prevent horizontal transmission of HIV.The South African Medical Research Council (SAMRC)http://www.bmj.com/thebmjam2020Paediatrics and Child Healt

Three lessons for the COVID-19 response from pandemic HIV

The HIV pandemic provides lessons for the response to the novel coronavirus disease 2019 (COVID-19) pandemic: no vaccine is available for either and there are no licensed pharmaceuticals for COVID-19, just as there was not for HIV infection in the early years. Population behaviour will determine the pandemic trajectory of COVID-19,1 just as it did for HIV