24-month HIV-free survival among infants born to HIV-positive women enrolled in Option B+ program in Kigali, Rwanda

Abstract

Lifelong antiretroviral therapy (ART) provision to all pregnant HIV-positive women (“Option B+”) has been recommended by the World Health Organization since 2013, but there remain limited data on the effects of Option B+ on long-term HIV-free survival in breastfeeding HIV-exposed infants. The Kigali Antiretroviral and Breastfeeding Assessment for the Elimination of HIV (Kabeho) study enrolled HIV-positive women from the third trimester of pregnancy to 2 weeks postpartum in 14 heath facilities implementing Option B+ in Kigali, Rwanda. Mother–child pairs in the longitudinal observational cohort were followed until 24 months postpartum, with HIV diagnostic testing at 6 weeks, and 9, 18 and 24 months. The Kaplan–Meier method was used to estimate HIV transmission, survival, and HIV-free survival through 24 months. We enrolled 608 HIV-positive women in 2013–2014; birth outcome data were available for 600 women and 597 live-born infants. By 6 weeks, 11 infants had died and 3 infants had confirmed HIV infection (0.5% transmission; 95% confidence interval [CI] 0.2–1.6). At 9 months, there were 9 additional deaths and 2 new infections (cumulative transmission 0.9%, 95% CI 0.4–2.2). At 18 months, there were 6 additional deaths and no new infant infections. At 24 months, there were no additional child deaths and 1 new infection (cumulative 2.2%, 95% CI 0.7–7.0), for an overall 24-month HIV-free survival of 93.2% (95% CI 89.5–95.6). Low transmission rates and high HIV-free survival at 24 months were achieved in breastfeeding infants of HIV-positive mothers receiving universal ART in urban health facilities in Rwanda, though vigilance on maintaining viral suppression for ART-experienced women is needed.

HIV-free survival among breastfed infants born to HIV-positive women in northern Uganda: a facility-based retrospective study.

“…The 18-months HIV-free survival rate in the study setting only marginally falls short of the >95% HIV-free survival rate recommended among breastfeeding populations, and is lower than the 95.9% HIV-free survival rate reported in a community-based survey in Swaziland (13). However, the rate in the current study compares well with the 93.2% 24-month HIV-free survival under similar Option B+ program in Rwanda (14) and is higher than the pooled estimates of 89.8% and 85.8% for 12-month and 24-month HIV-free The mortality rate of 2.8% in the current study was generally low but higher than the 1.1% reported in Mma Bana trial in Botswana (16), a difference possibly explained by the fact that infants in the Mma Bana trial breastfed for a shorter duration of 6 months (median 5.8 months).…”

“…The similar benefit of prior ART maternal use was reported by Oluwayemi et al (2015) in Nigeria where the risk of transmission was significantly lower among babies whose mothers commenced HAART before pregnancy (3.4%) compared to those whose mothers initiated HAART during pregnancy (5.4%) (26). The above results could be explained by the fact that one of the hypothesized benefits of lifelong ART is protection against HIV transmission in subsequent pregnancies, resulting from greater chances of virologic suppression, as was also suggested by Gill et al (2017) in a Rwandan study where the substantial proportion of women on ART before pregnancy with suppressed viral load (VL) was thought to have contributed to the high effectiveness of PMTCT (14).…”

“…Likewise, available evidences also point to the fact that long duration of ART may be associated with high viral load (VL) or viral rebound postpartum which could be associated with increased risk of mother-to-child transmission (14,27,28), supporting the importance of VL monitoring during pregnancy and breastfeeding, and continued adherence counselling (14). In the current study, data on maternal viral load suppression was very limited (VL was not widely available in Uganda within the period for which data was collected for this study), making comparison of HIV-free survival based on maternal VL impossible.…”

Determinants of growth in HIV‐exposed and HIV‐uninfected infants in the Kabeho Study

“…Recruitment took place from April 2013 to January 2014, and 608 women were initially recruited into the study; however, 34 mothers left the study before the 6‐week visit. In addition, there were seven sets of twins, resulting in a total of 581 mother–infant pairs enrolled in the study at 6 weeks (Gill et al, ). Growth trajectories could be made for 578 infants included in final analysis; however, only 453 infants were retained through the entire 2 years of the study.…”

Comparison of 6-week PMTCT outcomes for HIV-exposed and HIV-unexposed infants in the era of lifelong ART: Results from an observational prospective cohort study

“…Intrauterine and perinatal HIV transmission measurement in the era of lifelong ART is limited. In Rwanda, a study measuring HIV-free survival in a cohort of HEI, found a 6-week Mother to child transmission rate of 0.5% (95% CI:0.2-1.6) demonstrating the effectiveness of lifelong ART for HIV-positive pregnant women in preventing perinatal HIV transmission [11]. UNAIDS spectrum data in Lesotho reported an estimated 6-week transmission of 6.9% in 2016 [1].…”