IntroductionEarly infant diagnosis (EID) has been a component of Thailand's prevention of mother-to-child HIV transmission (PMTCT) programme since 2007. This study assessed the uptake, EID coverage, proportion of HIV-exposed infants receiving a definitive HIV diagnosis, mother-to-child transmission (MTCT) rates and linkage to HIV care and treatment.MethodsInfant polymerase chain reaction (PCR) testing data from the National AIDS Program database were analyzed. EID coverage was calculated as the percentage of number of HIV-exposed infants receiving ≥1 HIV PCR test divided by the number of HIV-exposed infants estimated from HIV prevalence and live-birth registry data. Definitive HIV diagnosis was defined as having two concordant PCR results. MTCT rates were calculated based on infants tested with PCR and applied as a best-case scenario, and a sensitivity analysis was used to adjust these rates in average and worst scenarios. We defined linkage to HIV care as infants with at least one PCR-positive test who were registered with Thailand's National AIDS Program. Chi-squared tests for linear trend were used to analyze changes in programme coverage.ResultsFor 2008 to 2011, the average EID coverage rate increased from 54 to 76% (p<0.001), with 65% coverage (13,761/21,099) overall. The number of hospitals submitting EID samples increased from 458 to 645, and the percentage of community hospitals submitting samples increased from 75 to 78% (p=0.044). A definitive HIV diagnosis was made for 10,854 (79%) infants during this period. The adjusted MTCT rates had significantly decreasing trends in all scenarios. Overall, an estimated 53% (429/804) of HIV-infected infants were identified through the EID programme, and 80% (341/429) of infants testing positive were linked to care. The overall rate of antiretroviral treatment (ART) initiation within one year of age was 37% (157/429), with an increasing trend from 28 to 52% (p<0.001).ConclusionsEID coverage increased and MTCT rates decreased during 2008 to 2011; however, about half of HIV-infected infants still did not receive EID. Most HIV-infected infants were linked to care but less than half initiated ART within one year of age. Active follow-up of HIV-exposed infants to increase early detection of HIV infection and early initiation of ART should be more widely implemented.
Background Early antiretroviral therapy (ART) restricts the size of the HIV reservoir in infants. However, whether antiretroviral (ARV) prophylaxis given to exposed vertically infected children exerts similar effects remains unknown. Methods We measured total and integrated HIV DNA, as well as the frequency of CD4 T-cells producing multiply-spliced RNA (msRNA) after stimulation (inducible reservoir) in vertically-infected Thai infants. Eighty-five infants were followed longitudinally for up to three years. We compared the size of the reservoir in children who received continuous prophylactic ARV since birth versus those who never received or discontinued prophylaxis before initiating ART. We used samples from a cross-sectional cohort of 37 Thai children who had initiated ART within 6 months of life to validate our findings. Results Before ART, levels of HIV DNA and the frequencies of cells producing msRNA were significantly lower in infants who received continuous prophylactic ARV since birth compared to those in whom prophylactic ARV was discontinued or never initiated (p<0.020 and p<0.001, respectively). Upon ART initiation, total and integrated HIV DNA levels decayed significantly in both groups (<0.01 in all cases). Interestingly, the initial differences in the frequencies of infected cells persisted during three years on ART. The beneficial effect of prophylaxis on the size of the HIV reservoir was confirmed in the cross-sectional study. Importantly, no differences were observed between children who discontinued prophylactic ARV before starting ART and those who delayed ART initiation without receiving prior prophylaxis. Conclusions Neonatal prophylactic ARV with direct transition to ART durably limits the size of the HIV reservoir.
Thailand has been one of the leading developing countries to implement a national program to prevent mother-to-child transmission (MTCT) of HIV. Although the recent transmission rate has been low, the goal is to eliminate MTCT altogether. The Thai National HIV Guidelines Working Group issued treatment guidelines to prevent MTCT in Thailand in March 2010. These guidelines will be implemented nationwide within a year. The most important aspects of these new guidelines are as follows: Treatment in HIV-infected pregnant women who have not been on antiretroviral treatment prior to pregnancy. Antepartum treatment is recommended for all pregnant women regardless of CD4 count with highly active antiretroviral therapy (HAART) containing zidovudine (AZT) + lamivudine (3TC) + lopinavir/ritonavir (LPV/r). Treatment should be started immediately irrespective of gestational age in women with CD4 count <350 cells/ mm3, and as early as 14 weeks of gestation in those with CD4 count >350 cells/mm3. After delivery, women with baseline CD4 count <350 cells/mm3 are referred for long-term care and HAART according to the National Adult HIV Treatment and Care Guidelines 2010. Women with CD4 count >350 cells/mm3 do not need HAART and can stop all drugs after delivery. The treatment in infants includes AZT syrup for four weeks and exclusive formula feeding. Treatment in HIV-infected pregnant women who conceive while on HAART. Women who are stable on HAART should continue the treatment during the whole period of pregnancy. Those who are taking efavirenz (EFV) and present during the first trimester should have EFV switched to another drug. Whenever possible, AZT should be used during pregnancy. Treatment in infants is similar to the above scenario. Treatment in women who present in labor without antenatal care. Single-dose nevirapine (SD-NVP) 200 mg must be given immediately along with oral AZT 300 mg every three hours until delivery, or oral AZT 600 mg given as a single dose. The tail therapy of AZT + 3TC + LPV/r for four weeks should be given unless these women have a CD4 count of <350 cells/mm3 and therefore require life-long HAART. SD-NVP should not be given if the women are to deliver within two hours. The infants in this situation should receive AZT + 3TC + NVP for four weeks. Treatment during delivery and mode of delivery. During labor, oral AZT 300 mg every three hours or oral AZT 600 mg given as a single dose is recommended regardless of antepartum antiretroviral (ARV) regimen or the woman’s history of AZT resistance. Elective caesarean section is suggested in women who did not receive HAART (including those without antenatal care), received HAART for less than four weeks prior to delivery, had poor adherence, or had incomplete viral suppression at 36 weeks of gestation.
Introduction Early initiation of antiretroviral therapy (ART) can reduce HIV‐related morbidity and mortality in HIV‐positive infants. We implemented an Active Case Management Network to promote early ART initiation Aiming for Cure (ACC) in August 2014. We describe ACC implementation, early infant diagnosis (EID) coverage and ART initiation during August 2014 to July 2018 compared with a national EID survey during October 2007 to September 2011 (pre‐ACC). Methods Thailand's 2014 HIV Treatment Guidelines recommend that HIV‐exposed infants have HIV polymerase chain reaction (PCR) testing at birth, one month and at two to four months. Testing is done at 14 national HIV PCR laboratories. When an HIV‐positive infant (HIV PCR+) is identified, PCR laboratory staff send the result to the hospital staff responsible for the infant's care and to the national laboratory case manager (CM). As part of ACC, the national laboratory CM alerts a regional CM who contacts the hospital staff caring for the infant to offer technical support with ART initiation and ART adherence. CMs enter clinical, demographic and laboratory data into the national ACC database. We analysed the ACC data from August 2014 to July 2018 to assess the ACC's impact on EID coverage, ART initiation and time‐to‐ART initiation. Results The uptake of EID increased from 64% (pre‐ACC) to >95% in 2018 (ACC). The number of HIV‐positive infants born declined from 429 cases (pre‐ACC) to 267 cases (ACC). Median age at the first‐positive PCR declined from 75 days (pre‐ACC) to 60 days (ACC); P < 0.001. Among 429 infants diagnosed before ACC was started, 241 (56%) received ART; during ACC, 235 (88%) of 267 HIV‐positive infants received ART. The median age at ART initiation declined from 282 days before ACC to 83 days during ACC (P < 0.001) and the median time from blood collection to ART initiation declined from 168 days before ACC to 23 days during ACC (P < 0.001). Conclusions An innovative case management network (ACC) has been established in Thailand and results suggest that the network is promoting EID and early ART initiation. The ACC model, using case‐managed PCR notification and follow‐up, may speed ART initiation in other settings.
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