National estimates and risk factors associated with early mother-to-child transmission of HIV after implementation of option B+: a cross-sectional analysis

Abstract

Summary Background Routine data from Malawi’s prevention of mother-to-child transmission (MTCT) option B+ programme suggest high uptake of antiretroviral therapy (ART) among pregnant women. Malawi’s Ministry of Health led the National Evaluation of Malawi’s PMTCT Program to obtain nationally representative data on maternal ART coverage and prevention of MTCT effectiveness. Here, we present the early transmission data for infants aged 4–12 weeks. Methods We used a multistage cluster design to recruit a nationally representative sample of HIV-exposed infants and their mothers in Malawi. Between October 16, 2014, and May 17, 2016, we screened for HIV in all mothers attending an under-5 vaccination or outpatient sick-child clinic with infants aged 4–26 weeks at 54 health facilities selected across ten districts and four regional sampling zones. Infants with mothers identified as HIV-infected were enrolled in the cohort. We calculated weighted MTCT rates for only the subset of infants aged 4–12 weeks at screening, thereby capturing MTCT from early pregnancy, to delivery, and early breastfeeding. We collected data on maternal and infant demographics and self-reported use of HIV services, ART, and antenatal clinics. We tested HIV-exposed infants for the virus and assessed associations of certain variables with infant HIV status. Findings We confirmed HIV exposure in 3542 (10.4%) of 33 980 mother (guardian)-infant pairs with infants aged 4–26 weeks. Of those, 2530 (2514 mothers and 16 guardians) had infants aged 4–12 weeks at the time of screening (2498 singlets and 32 twins). We excluded 25 infants from the analysis because no information was available about their HIV status. 91.3% (95% CI 85.6–96.9) of mothers were on ART during pregnancy. The MTCT rate was 3.7% (2.3–6.0) overall and ranged from 1–4% (0.4–4.4) in women who initiated ART before pregnancy to 19–9% (13.4–28.6) in women not on ART. In multivariable logistic regression analysis, the odds of early MTCT were higher in mothers starting ART post partum (adjusted odds ratio 16.7, 95% CI 1–6-171.5; p=0–022) and in those not on ART with an unknown HIV status during pregnancy (19.1, 8–5.43–0; p<0–0001) than in mothers on ART before pregnancy. Among HIV-exposed infants, 98–0% (95% CI 96.9–99-1) were reported by the mother to have received infant nevirapine prophylaxis, and only 45–6% (34.8–56.4) were already enrolled in an exposed infant HIV care clinic at the time of study screening. Interpretation These data suggest that Malawi’s decentralisation of ART services has resulted in higher ART coverage and lower early MTCT. However, the uptake of services for HIV-exposed infants remains suboptimal.

<p>Mother-to-Child Transmission of HIV and Its Predictors Among HIV-Exposed Infants at an Outpatient Clinic for HIV/AIDS in Vietnam</p>

“…This study shows the overall rate of MTCTof HIV was 8.9% in our setting from 2007 to 2018. This rate is higher than that of many recent studies done across the world; [12][13][14][15][16][17] however, the rate of MTCT, which was reduced from 27.9% in 2007 to 0% in 2018, achieved the MTCT elimination target of 2% by 2020 as recommended by WHO and by the Vietnam National Strategy on HIV/AIDS Prevention and Control. 18 In our study, the rate of MTCT has been decreasing through time in parallel with the increased coverage of ART intervention for women during pregnancy.…”

“…This figure is consistent with other studies in African countries. 12,22 Nevertheless, the coverage of ART (81%) intervention for pregnant women in our setting has not yet met the target of >90% using ARV, which was lower than the number in many countries in Africa 12,14,16 and in Asia, 19,20 where the coverage of ART intervention for pregnant women ranged from 91-96%. Maintenance and a gradual increase in maternal ARV coverage to attain the elimination target of zero transmission of HIV from mother to child by 2030 are challenging.…”

Low detectable postpartum viral load is associated with HIV transmission in Malawi's prevention of mother‐to‐child transmission programme

“…This is a nested cross‐sectional study of HIV‐infected mothers presenting with their four to twenty‐six week old infants at outpatient clinics who were enrolled in longitudinal follow‐up in the National Evaluation of the Malawi PMTCT Programme (NEMAPP) study between October 2014 and May 2016. NEMAPP used a multistage cluster design to sample 54 sites across Malawi and this sub‐set was derived using probability proportionate‐to‐size sampling methods to select 13 sites across the eight districts from the original sites. Women in these selected sites were simultaneously consented for enrolment in both the main study and in this subset for intensive clinical and laboratory monitoring.…”

Diagnosis and management of community-acquired pneumonia in children: South African Thoracic Society guidelines

“…[247] Women who tested HIVnegative during pregnancy may acquire HIV infection late in gestation or while breastfeeding -their infants are at risk of PCP (evidence level Ib). [248][249][250][251] Some children with primary immunodeficiencies or severe malnutrition are also at risk of PCP (evidence level IIb). [252] Empiric therapy for PCP should not be withheld pending results of confirmatory laboratory testing.…”