Eliminating HIV transmission through breast milk from women taking antiretroviral drugs

Goga, Ameena; Perre, Philippe Van de; Ngandu, Nobubelo K.; Nagot, Nicolas; Abrams, Elaine J.; Moodley, Dhayendre; King, Rachel; Molès, Jean‐Pierre; Chirinda, Witness; Scarlatti, Gabriella; Tylleskär, Thorkild; Sherman, Gayle; Pillay, Yogan; Dabis, François; Gray, Glenda

doi:10.1136/bmj.n1697

Cited by 4 publications

(8 citation statements)

References 38 publications

(68 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Our case rate is comparable to the 1,290 postnatal MTCT case rates observed in a South African study also done during this era of Option B +. In the same study, the postnatal MTCT was 1.7% which is also comparable to ours at 1.1% (45,50). These observations underscore the critical need to stop new postnatal HIV infections.…”

Section: Overall Transmission Ratesupporting

confidence: 83%

Mother-to-Child Transmission of HIV Within 24 Months After Delivery in Women Initiating Lifelong Antiretroviral Therapy Pre/Post-Conception or Postnatally; Effects of Adolescent Girl and Young Woman Status and Plasma Viremia Late in Pregnancy

Duri

Mataramvura²,

Chandiwana³

et al. 2022

Front. Virol.

View full text Add to dashboard Cite

IntroductionMother-to-child-transmission (MTCT) of human immunodeficiency virus (HIV) can occur in pregnancy/in utero (IU), during childbirth/intrapartum (IP), or postpartum (PP) through breastfeeding from an infected mother to her infant. Burden of PP-MTCT and associated risk factors remain poorly described, especially in adolescent girls and young women (AGYW) aged 15–24 years. Furthermore, despite concerns on high postnatal seroconversions, there is paucity of data on the burden of subsequent MTCT rates.MethodsPregnant women ≥20 weeks of gestation were enrolled into the University of Zimbabwe Birth Cohort from four primary health centers in Harare, Zimbabwe. Mother–infant dyads were followed up from delivery, week(s) 1, 6, 10, 14, 24, 36, 48, 72, and 96 after birth. Women who were uninfected at baseline were re-tested for HIV on subsequent visits. Plasma HIV RNA was quantified using reverse transcriptase polymerase chain reaction. Exposed babies were tested for HIV using qualitative/quantitative proviral DNA PCR on dried blood spots. Maternal–infant factors were tested in univariable/multivariable regression analyses for HIV-MTCT predictors.ResultsA total of 600 HIV-uninfected and 608 HIV-infected pregnant women on Tenofovir/Lamivudine/Efavirenz regimen were enrolled from 2016 to 2019. Postnatal HIV incidence was 0.42 cases/100 women-years [95% confidence interval (CI): 0.12–1.1]. Postnatal seroconverters were less likely to have children/pregnancies sharing same father and unaware of their spouses/intimate partner’s HIV status: p = 0.008 and p = 0.02, respectively, compared with non-seroconverters.Overall HIV-MTCT rate was (15/549): 2.7% (CI: 1.3–4.1%); (7/93) 7.5% observed in AGYW against 1.7%; in women aged >24, p = 0.008. PP-MTCT was the predominant 9/15 (60%) route, followed by IP-MTCT 4/15 (26.6%), whereas IU and postnatal MTCT rates each contributed 6.7% of all infant infections. Postnatal MTCT incidence was 12.8 (CI: 0.3–71.4) infant HIV infections/100 child-years of breastfeeding; a rate 14 times higher than PP-MTCT rate in babies born to women HIV-infected pre/post-conception whose babies were HIV DNA PCR–negative at six weeks.Antenatal HIV RNA >1,000 copies/ml was independently associated with MTCT; odds ratio [CI: 9.3 (2.6–43.1)]. Infected infants’ pre–HIV treatment HIV RNA levels correlated positively with maternal viral load; Spearman’s rank correlation. r = 0.6; p = 0.03.DiscussionMothers were 9.3 times more likely to transmit if HIV RNA was >1,000 copies/ml, disproportionately occurring in vulnerable AGYW. Breastfeeding-associated PP-MTCT remains high; therefore, it is imperative that HIV-infected women commence antiretroviral therapy early in pregnancy to suppress HIV RNA until weaning to decrease the risk of MTCT and possibly reduce the severity of disease in infected infants. HIV-uninfected lactating mothers should be continuously counseled on the risks of postnatal seroconversion.www.clinicaltrials.gov, trial registration number: NCT04087239.

show abstract

Section: Overall Transmission Ratesupporting

confidence: 83%

Mother-to-Child Transmission of HIV Within 24 Months After Delivery in Women Initiating Lifelong Antiretroviral Therapy Pre/Post-Conception or Postnatally; Effects of Adolescent Girl and Young Woman Status and Plasma Viremia Late in Pregnancy

Duri

Mataramvura²,

Chandiwana³

et al. 2022

Front. Virol.

View full text Add to dashboard Cite

show abstract

“…One likely underlying driver of high mVL association with first-line ART is the 6-months long window recommended for following up those with low-level viraemia (50–1000 copies/mL), who however, are at risk of higher VL during this period. The 6 months window of routine follow-up visit when VL ≤1000 copies/mL, was too long considering that it included low-level viraemia which may account for over 40% of early MTCT in some settings 3 6 22 25. Given the new policies emphasising targeting complete viral suppression of <50 copies/mL as opposed to VL <1000 copies/mL, our results of 71.5% complete viral suppression shows that more work remains to be done 29.…”

Section: Discussionmentioning

confidence: 86%

“…2 In addition, the MTCT risk during the breastfeeding period is critical, because breast milk transmission globally is declining at a slower rate than in utero and intrapartum transmission. 3 Postpartum transmission is perpetuated by incident maternal HIV infection during the breastfeeding period combined with low use of repeat HIV testing among previously uninfected mothers; inadequate monitoring of maternal VL (mVL) and poor postpartum ART adherence. [4][5][6][7][8][9][10][11][12] Antenatal HIV prevalence has remained around 30% over the past decade in South Africa, and as high as 45% in some districts, making monitoring of mVL a necessity to ensure corrective measures in order to reduce MTCT risk.…”

Section: Strengths and Limitations Of This Studymentioning

confidence: 99%

“…In South Africa, the national average MTCT rate has reduced to <2% at birth, but heterogeneity exists at subregional levels with much higher intrauterine infections in some districts 2. In addition, the MTCT risk during the breastfeeding period is critical, because breast milk transmission globally is declining at a slower rate than in utero and intrapartum transmission 3. Postpartum transmission is perpetuated by incident maternal HIV infection during the breastfeeding period combined with low use of repeat HIV testing among previously uninfected mothers; inadequate monitoring of maternal VL (mVL) and poor postpartum ART adherence 4–12.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

HIV viral load non-suppression and associated factors among pregnant and postpartum women in rural northeastern South Africa: a cross-sectional survey

et al. 2022

Self Cite

View full text Add to dashboard Cite

ObjectivesWe aimed to measure the prevalence of maternal HIV viral load (VL) non-suppression and assess associated factors, to evaluate progress towards United Nations-AIDS (UNAIDS) targets.DesignCross-sectional study.SettingThe eight largest community health centres of Ehlanzeni, a rural district in northeast South Africa.ParticipantsPregnant women living with HIV (WLHIV) in their third trimester and postpartum WLHIV and their biological infants, recruited equally across all stages of the first 24 months post partum, were included. A sample of 612 mothers participated from a target of 1000.Primary outcome measuresThe primary outcome was maternal VL (mVL) non-suppression (defined here as mVL >1000 copies/mL). We collected information on antiretroviral use, healthcare visits and sociodemographics through interviews and measured plasma mVL. Descriptive statistics, χ2 tests and multivariable logistic regression analysis were conducted.ResultsAll mothers (median age: 30 years) were on antiretroviral therapy (ART) and 24.9% were on ART ≤12 months. The prevalence of mVL non-suppression was 14.7% (95% CI: 11.3% to 19.0%), while 13.8% had low-level viraemia (50–1000 copies/mL). Most (68.9%) women had initiated breast feeding and 37.6% were currently breast feeding their infants. Being younger than 25 years (adjusted odds ratio (AOR): 2.6 (95% CI: 1.1 to 6.4)), on first-line ART (AOR: 2.3 (95% CI: 1.1 to 4.6)) and married/cohabiting (AOR: 1.9 (95% CI: 1.0 to 3.7)) were significantly associated with increased odds of mVL non-suppression.ConclusionsThe prevalence of mVL ≤1000 copies/mL of 85.3% among pregnant and postpartum WLHIV and attending public healthcare centres in this rural district is below the 2020 90–90–90 and 2030 95–95–95 UNAIDS targets. Given that low-level viraemia may also increase the risk of vertical HIV transmission, we recommend strengthened implementation of the new guidelines which include better ART options, improved ART regimen switching and mVL monitoring schedules, and intensified psychosocial support for younger women, while exploring district-level complementary interventions, to sustain VLs below 50 copies/mL among all women.

show abstract

“…Postnatal transmission usually occurs through breastfeeding. Maternal CD4 cells associated with an actively replicating or quiescent virus have been detected in breast milk [18], and HIV RNA has even been detected in cell-free breast milk [19,20]. There has been no trial that has been successful in completely eliminating HIV from breast milk [18], and the VT rate via this route is estimated to be 16% [21].…”

Section: Pathophysiology Of Vertical Transmissionmentioning

confidence: 99%

Prevention of the Vertical Transmission of HIV; A Recap of the Journey so Far

Cárdenas

Farnan

Hamel

et al. 2023

Viruses

View full text Add to dashboard Cite

In 1989, one in four (25%) infants born to women living with HIV were infected; by the age of 2 years, there was 25% mortality among them due to HIV. These and other pieces of data prompted the development of interventions to offset vertical transmission, including the landmark Pediatric AIDS Clinical Trial Group Study (PACTG 076) in 1994. This study reported a 67.5% reduction in perinatal HIV transmission with prophylactic antenatal, intrapartum, and postnatal zidovudine. Numerous studies since then have provided compelling evidence to further optimize interventions, such that annual transmission rates of 0% are now reported by many health departments in the US and elimination has been validated in several countries around the world. Despite this success, the elimination of HIV’s vertical transmission on the global scale remains a work in progress, limited by socioeconomic factors such as the prohibitive cost of antiretrovirals. Here, we review some of the key trials underpinning the development of guidelines in the US as well as globally, and discuss the evidence through a historic lens.

show abstract

Eliminating HIV transmission through breast milk from women taking antiretroviral drugs

Abstract: Ameena Goga and colleagues argue that frequent testing of maternal viral load is needed to eliminate HIV transmission through breast milk in low and middle income settings

Cited by 4 publications

References 38 publications

Mother-to-Child Transmission of HIV Within 24 Months After Delivery in Women Initiating Lifelong Antiretroviral Therapy Pre/Post-Conception or Postnatally; Effects of Adolescent Girl and Young Woman Status and Plasma Viremia Late in Pregnancy

Mother-to-Child Transmission of HIV Within 24 Months After Delivery in Women Initiating Lifelong Antiretroviral Therapy Pre/Post-Conception or Postnatally; Effects of Adolescent Girl and Young Woman Status and Plasma Viremia Late in Pregnancy

HIV viral load non-suppression and associated factors among pregnant and postpartum women in rural northeastern South Africa: a cross-sectional survey

Prevention of the Vertical Transmission of HIV; A Recap of the Journey so Far

Contact Info

Product

Resources

About