Missed opportunities for prevention of mother-to-child transmission of HIV-1 in the NISDI Perinatal and LILAC cohorts

Statewide Implementation of Universal Third-Trimester Repeat HIV Testing in Illinois

OBJECTIVE

 This article aims to assess statewide uptake of HIV repeat testing in the first 2 years after the implementation of an amendment to the Illinois Perinatal HIV Prevention Act (IPHPA) mandating universal repeat HIV testing in the third trimester.

STUDY DESIGN

 This is a retrospective, population-based study of all birthing individuals in Illinois (2018-2019). Data were collected using the state-mandated closed system of perinatal HIV test reporting. We evaluated the incidence of mother-infant pairs with negative early tests and repeat third-trimester tests (RTTTs) performed in adherence with the law, as well as the timing of the performance of the RTTTs (outpatient vs. inpatient). Chi-square tests of trend by quarter were performed to ascertain sustainability.

RESULTS

 Of 138,805 individuals delivered in 2018, 80.6% presented with early test and RTTTs. In 2018, outpatient RTTTs improved from 71.8% (quarter 1) to 85.1% (quarter 4; p < 0.001). In 2018, the proportion of mother-infant dyads who received testing that was adherent to the IPHPA Amendment was 92.1, 95.5, 96.7, and 96.4% in quarters 1 through 4, respectively (p < 0.001). In 2019, outpatient RTTTs performance remained high (87.4%) and stable (p = 0.06). In 2019, 99.9% of mother-infant dyads had testing adherent to the mandate in quarters 1 through 4 (p = 0.39). Of individuals who presented without RTTTs, 93.5% (2018) and 98.8% (2019) underwent inpatient testing before delivery.

CONCLUSION

 Implementation of RTTTs in Illinois was rapid, successful, and sustained in its first 2 years. Public health methodologies from Illinois may benefit other states implementing RTTT programs.

KEY POINTS

· In 2018, Illinois enacted statewide RTTT for HIV among all parturients.. · In 2019, over 99% of mother-infant dyads had documentation of both early and repeat HIV testing before hospital discharge.. · Implementation of repeat third-trimester HIV testing in Illinois was rapid, successful, and sustained in its first 2 years.. · Public health methodologies from Illinois may benefit other states implementing similar programs..

New diagnosis of mother-to-child transmission of HIV in 8 Latin-American countries during 2018

Background

Important prevention efforts have led to a reduction in mother-to-child transmission of HIV (MTCT) globally. However, new cases of paediatric HIV infections still occur. Early diagnosis of new HIV infections is essential to start an appropriate antiretroviral treatment to avoid childhood morbidity and mortality related to infection. The aim of this study was to describe the new cases of MTCT in Latin-American referral hospitals.

Methods

A retrospective, multicentre and descriptive study of the new cases of MTCT diagnosed during 2018 in 13 referral hospitals from 8 Latin-American countries (Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, and Panama) belonging to PLANTAIDS (Paediatric Network for Prevention, Early Detection and Treatment of HIV in Children), was conducted. PLANTAIDS is included in CYTED (Ibero-American Programme of Science and Technology for Development).

Results

Eighty-one children (40.7% males) were included, median age at diagnosis of 2.33 years (IQR:0.7–4.7). Less than 3% of women knew their HIV diagnosis before pregnancy. More than 80% of them were diagnosed after delivery, 8.7% during pregnancy, and 2.9% at delivery. Only one patient underwent antiretroviral therapy (ART) prior to pregnancy. At diagnosis, 50.0% of the children presented with an advanced stage of disease (stage C following the current CDC classification for HIV infection), and 34.4% had less than 15% CD4⁺ cells/mm³. The time elapsed between delivery and the maternal diagnosis was correlated with the age of children at diagnosis, ρ = 0.760, p < 0.001. Younger age at diagnosis (p = 0.03), a smaller number of previous hospitalizations (p < 0.01), and better immunovirological status (p < 0.01) were found in children whose mothers knew their HIV status at delivery, compared to mothers who were not aware of it.

Conclusions

Although MTCT in Latin America has declined in recent years, our series shows there are still cases that indicate some failures in prevention, being a critical point to improve an earlier diagnosis of pregnant women. Half of the children were diagnosed in an advanced stage of disease and the delay in maternal diagnosis entailed a worse clinical and immunological child’ prognosis.

Filling the gaps in the Peruvian care continuum for HIV-infected pregnant mothers: a case-control study in metropolitan Lima-Callao, Peru

Mother-to-child transmission of HIV (MTCT) accounts for a significant proportion of new HIV infections in Peru. The purpose of this case-control study was to examine maternal and infant factors associated with MTCT in Peru from 2015 to 2016. For each biologically confirmed case infant, we randomly selected four birth year- and birth hospital-matched controls from five hospitals in Lima-Callao. Maternal and infant information were gathered from medical records. Simple conditional logistic regression was utilized to examine possible maternal and infant characteristics associated with MTCT. The rate of MTCT was 6.9% in 2015 and 2.7% in 2016. A total of 63 matched controls were identified for 18 cases. Protective factors included higher number of prenatal visits (odds ratio [OR]: 0.72; 95% confidence interval [CI]: 0.55-0.94, p = 0.012) and having more children (OR: 0.10, 95% CI: 0.01-0.79, p = 0.029). Risk factors included later maternal diagnosis (OR: 1.19; 95% CI: 1.06-1.34; p = 0.001) and greater viral load at the time of maternal diagnosis (OR: 1.05; 95% CI: 1.01-1.10; p = 0.022). Our study highlights the importance of targeting early and continued prenatal care as specific areas to target to prevent gaps in the HIV treatment cascade for pregnant HIV-infected women. These strategies can ensure early screening and initiation of antiretroviral therapy to reduce MTCT rates.

HIV Screening During Pregnancy in a U.S. HIV Epicenter

Background

The CDC and ACOG have issued guidelines for HIV screening in pregnancy for patients living in areas with high prevalence of HIV in order to minimize perinatal vertical transmission. There is a lack of data examining providers' compliance with these guidelines in at-risk patient populations in the United States.

Objective

To evaluate if HIV screening in pregnant women was performed according to guidelines at a large, urban, tertiary care medical center in South Florida. Study Design. A retrospective review was performed on 1270 prenatal and intrapartum records from women who delivered a live infant in 2015 at a single institution. Demographic and outcome data were chart abstracted and analyzed using arithmetic means and standard deviations.

Results

Of the 1270 patients who met inclusion criteria, 1090 patients initiated prenatal care in the first or second trimester and delivered in the third trimester. 1000 (91.7%) patients were screened in the first or second trimester; however, only 822 (82.2%) of these were retested in the third trimester during prenatal care. Among the 178 patients lacking a third trimester test, 159 (89.3%) received rapid HIV testing upon admission for delivery. Of the 1090 patients who initiated prenatal care in the first or second trimester and delivered in the third trimester, 982 (90.1%) were screened in accordance with recommended guidelines. Of the 1270 patients initiating care in any trimester, 24 (1.9%) had no documented prenatal HIV test during prenatal care, however 22 (91.7%) had a rapid HIV test on admission for delivery. Two (0.16%) patients were not tested prenatally or prior to delivery.

Conclusion

Despite 99.8% of women having at least one HIV screening test during pregnancy, there is room for improvement in routine prenatal screening in both early pregnancy and third trimester prior to onset of labor in this high-risk population.

Missed opportunities for prevention of vertical HIV transmission in Canada, 1997-2016: a surveillance study

BACKGROUND

Vertical HIV transmission has declined in Canada, but missed opportunities for prevention continue to occur. We sought to determine the adequacy, and changes over time in adequacy, of uptake of maternal and neonatal antiretroviral therapy for the prevention of vertical HIV transmission, and to determine the vertical transmission rate over time and according to adequacy of antenatal antiretroviral therapy during the combination antiretroviral therapy era in Canada.

METHODS

The Canadian Perinatal HIV Surveillance Program collects data annually through retrospective chart review concerning HIV-infected women and their infants. We determined receipt of adequate antiretroviral treatment (antenatal combination antiretroviral treatment for ≥ 4 wk, intrapartum intravenous zidovudine treatment and 4-6 wk of infant oral zidovudine treatment) and predictors of inadequate antenatal combination antiretroviral therapy (none or < 4 wk) in Canada in 1997-2016.

RESULTS

We identified 3785 mother-infant pairs. Uptake of 4 weeks or more of antenatal combination antiretroviral therapy increased over time across all provinces/territories and regardless of maternal race/ethnicity or risk category (p < 0.001). During 2011-2016, 92 women (6.5%) received no or less than 4 weeks of antenatal combination antiretroviral therapy, 146 women (10.7%) received no intrapartum zidovudine treatment, and 43 infants (3.1%) received less than 4 weeks of zidovudine treatment. In multivariate analysis restricted to 2011-2016, higher uptake of adequate antenatal combination antiretroviral therapy was seen among black women than among Indigenous (odds ratio [OR] 2.99, 95% confidence interval [CI] 1.23-7.26) or white (OR 1.87, 95% CI 0.99-1.27) women and in British Columbia/Yukon Territory than in Alberta (OR 3.31, 95% CI 1.06-10.32), Ontario (OR 3.16, 95% CI 1.08-9.26) or Quebec (OR 3.44, 95% CI 1.09-10.84). Among the 14 vertical HIV transmission events during 2011-2016 (vertical transmission rate 1.0%), maternal HIV infection was diagnosed before the onset of labour in 5 cases, and only 2 women received adequate antenatal combination antiretroviral therapy.

INTERPRETATION

Efforts to improve timely access to care, HIV screening and treatment for all women, combined with enhanced resources targeting populations at increased risk for HIV infection, will be needed if vertical HIV transmission is to be eliminated in Canada.

Sustainability of Statewide Rapid HIV Testing in Labor and Delivery

The objective was to assess sustainability of a statewide program of HIV rapid testing (RT) for pregnant women presenting for delivery with unknown HIV status. This is a population-based retrospective cohort study of women delivered in Illinois hospitals (2012-15). Deidentified data on RT metrics from state-mandated surveillance reports were compared using descriptive statistics and non-parametric tests of trend. Over 95% of the 608,408 women delivered had documented HIV status at presentation. The rate of undocumented HIV status rose from 4.19 to 4.75% (p < 0.001). However, overall 99.60% of women with undocumented status appropriately received RT and the proportion who did not receive RT declined (p = 0.003). The number of neonates discharged with unknown HIV status declined (p = 0.011). RT identified 23 new HIV diagnoses, representing 4.62% of maternal HIV diagnoses. In conclusion, statewide perinatal HIV RT resulted in nearly 100% of Illinois mother-infant dyads with known HIV status. Sustained RT completion represents an important prevention safety net.

The cascade of care to prevent mother-to-child transmission in Rio de Janeiro, Brazil, 1996-2013: improving but still some way to go

OBJECTIVE

To describe the cascade of care to HIV mother-to-child transmission (PMTCT) in a Rio de Janeiro reference paediatric clinic and evaluate the main factors possibly associated with HIV transmission.

METHODS

Data on antenatal care (ANC), perinatal and neonatal assistance to HIV-infected and HIV-exposed but uninfected children assisted in the clinic from 1996 to 2013 were collected. The cascade of care was graphically demonstrated, and possible factors associated with HIV infection were described using regression models for bivariate and multivariate analysis. We imputed missing values of explanatory variables for the final model.

RESULTS

A total of 989 children were included in the analysis: 211 were HIV and 778 HEU. Graphically, the HIV PMTCT cascade of care improved from 1996/2000 to the later periods, but not from 2001/2006 to 2007/2013. The main factor independently associated with the HIV infection over time was breastfeeding. In the period 1996/2000, the lack of antiretroviral use during labour was associated HIV transmission. While in 2001/2007, other modes of delivery but elective Caesarean section, and lack of maternal antiretroviral use during ANC were associated with HIV transmission. In the last period, the main factor associated with transmission was the lack of maternal ANC.

CONCLUSIONS

The HIV PMTCT cascade improved over time, but HIV vertical transmission remains a problem, and better access to ANC is needed.

Missed Opportunities for Prevention of Mother-to-Child Transmission of Human Immunodeficiency Virus

OBJECTIVE

To identify missed opportunities for prevention of mother-to-child transmission of human immunodeficiency virus (HIV).

METHODS

Data regarding HIV-infected children born between 2002 and 2009 to HIV-infected women enrolled in the U.S. International Maternal Pediatric Adolescent AIDS Clinical Trials prospective cohort study (protocol P1025) were reviewed. The characteristics of the HIV-infected infants and their mothers and the mothers' clinical management are described.

RESULTS

Twelve cases of mother-to-child transmission of HIV occurred among 1,857 liveborn neonates, for a prevalence of 0.65 per 100 live births to HIV-infected women (95% confidence interval 0.33-1.13). Four transmissions occurred in utero, three were peripartum transmissions, and the timing of transmission for five neonates was unable to be determined. None were breastfed. Seven women had plasma viral loads greater than 400 copies/mL near delivery. Six women had less than 11 weeks of antiretroviral therapy during pregnancy; three of these women had premature deliveries. One woman received no antiretroviral therapy during pregnancy because she was diagnosed with HIV postpartum. Six had poor to moderate adherence to antiretroviral therapy. Four of the five mothers with viral loads greater than 1,000 copies/mL delivered preterm neonates. There were five women who delivered by cesarean; four were nonelective cesarean deliveries and only one was an elective cesarean delivery for HIV prevention.

CONCLUSION

Despite access to high-level care and follow-up, a small proportion of HIV-infected women transmitted the virus to their neonates. This case series provides insight into factors contributing to HIV perinatal transmission and can inform the development of new strategies for prevention of mother-to-child transmission of HIV.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, https://clinicaltrials.gov, NCT00028145.

Timely antiretroviral prophylaxis during pregnancy effectively reduces HIV mother-to-child transmission in eight counties in China: a prospective study during 2004-2011

This study investigates the improvement of the prevention of mother-to-child transmission (PMTCT) of Human Immunodeficiency Virus (HIV) in China during 2004-2011. A clinic-based prospective study was conducted among HIV-positive pregnant women and their children in eight counties across China. Associated factors of mother-to-child transmission were analyzed using regression analysis. A total of 1,387 HIV+ pregnant women and 1,377 HIV-exposed infants were enrolled. The proportion of pregnant women who received HIV testing increased significantly from 45.1% to 98.9% during 2004-2011. Among whom, the proportion that received antiretroviral (ARV) prophylaxis increased from 61% to 96%, and the corresponding coverage in children increased from 85% to 97% during the same period. In contrast, single-dose nevirapine treatment during delivery declined substantially from 97.9% to 12.7%. Vertical transmission of HIV declined from 11.1% (95% confidence interval [CI]: 5.7-23.3%) in 2004 to 1.2% (95% CI: 0.1-5.8%) in 2011. Women who had a vaginal delivery (compared to emergency caesarian section (odds ratio [OR] = 0.46; 0.23-0.96)) and mothers on multi-ARVs (OR = 0.11; 0.04-0.29) were less likely to transmit HIV to their newborns. Increasing HIV screening enabled timely HIV care and prophylaxis to reduce vertical transmission of HIV. Early and consistent treatment with multi-ARVs during pregnancy is vital for PMTCT.

A case series of third-trimester raltegravir initiation: Impact on maternal HIV-1 viral load and obstetrical outcomes

OBJECTIVE

To describe the impact of initiating raltegravir (RAL)-containing combination antiretroviral therapy (cART) regimens on HIV viral load (VL) in pregnant women who have high or suboptimal VL suppression late in pregnancy.

METHODS

HIV-infected pregnant women who started RAL-containing cART after 28 weeks' gestation from 2007 to 2013 were identified in two university hospital centres.

RESULTS AND DISCUSSION

Eleven HIV-infected women started RAL at a median gestational age of 35.7 weeks (range 31.1 to 38.0 weeks). Indications for RAL initiation were late presentation in pregnancy (n=4) and suboptimal VL suppression secondary to poor adherence or viral resistance (n=7). Mean VL at the time of RAL initiation was 73,959 copies/mL (range <40 to 523,975 copies/mL). Patients received RAL for a median of 20 days (range one to 71 days). The mean decline in VL from the time of RAL initiation to delivery was 1.93 log, excluding one patient who received only one RAL dose and one patient with undetectable VL at the time of RAL initiation. After eight days on RAL, 50% of the women achieved a VL <1000 copies/mL (the threshold for recommended Caesarean section to reduce the risk for perinatal transmission). There were no cases of perinatal HIV transmission.

CONCLUSION

The present study provides preliminary data to support the use of RAL-containing cART to expedite HIV-1 VL reduction in women who have a high VL or suboptimal VL suppression late in pregnancy, and to decrease the risk of HIV perinatal transmission while avoiding Caesarean section. Further assessment of RAL safety during pregnancy is warranted.

Experiences of coercion to sterilize and forced sterilization among women living with HIV in Latin America

Introduction

Forced and coerced sterilization is an internationally recognized human rights violation reported by women living with HIV (WLHIV) around the globe. Forced sterilization occurs when a person is sterilized without her knowledge or informed consent. Coerced sterilization occurs when misinformation, intimidation tactics, financial incentives or access to health services or employment are used to compel individuals to accept the procedure.

Methods

Drawing on community-based research with 285 WLHIV from four Latin American countries (El Salvador, Honduras, Mexico and Nicaragua), we conduct thematic qualitative analysis of reports of how and when healthcare providers pressured women to sterilize and multivariate logistic regression to assess whether social and economic characteristics and fertility history were associated with pressure to sterilize.

Results

A quarter (23%) of the participant WLHIV experienced pressure to sterilize post-diagnosis. WLHIV who had a pregnancy during which they (and their healthcare providers) knew their HIV diagnosis were almost six times more likely to experience coercive or forced sterilization than WLHIV who did not have a pregnancy with a known diagnosis (OR 5.66 CI 95% 2.35–13.58 p≤0.001). WLHIV reported that healthcare providers told them that living with HIV annulled their right to choose the number and spacing of their children and their contraceptive method, employed misinformation about the consequences of a subsequent pregnancy for women's and children's health, and denied medical services needed to prevent vertical (mother-to-child) HIV transmission to coerce women into accepting sterilization. Forced sterilization was practiced during caesarean delivery.

Conclusions

The experiences of WLHIV indicate that HIV-related stigma and discrimination by healthcare providers is a primary driver of coercive and forced sterilization. WLHIV are particularly vulnerable when seeking maternal health services. Health worker training on HIV and reproductive rights, improving counselling on HIV and sexual and reproductive health for WLHIV, providing State mechanisms to investigate and sanction coercive and forced sterilization, and strengthening civil society to increase WLHIV's capacity to resist coercion to sterilize can contribute to preventing coercive and forced sterilization. Improved access to judicial and non-judicial mechanisms to procure justice for women who have experienced reproductive rights violations is also needed.

Effectiveness of a prevention of mother-to-child HIV transmission program in Guangdong province from 2007 to 2010

Background

To achieve the goal of United Nations of elimination of new HIV infections, a program of prevention of mother-to-child transmission (PMTCT) was launched in Guangdong province. The objective of this study is to evaluate the effectiveness of the PMTCT program.

Methods

The retrospective cross-section analysis was conducted using the data of case reported cards of HIV positive mothers and their infants from 2007 to 2010 in Guangdong province, and 108 pairs of eligible subjects were obtained. We described the data and compared the rates of MTCT by various PMTCT interventions respectively.

Results

The overall rate of HIV MTCT was 13.89% (15) among 108 pairs of HIV positive mothers and their infants; 60.19% (65) of the mothers ever received ARVs, 80.56% (87) of infants born to HIV positive mothers ever received ARVs, but 16.67% (18) of the mothers and infants neither received ARVs. Among all the mothers and infants, who both received ARVs, received triple ARVs, mother received ARVs during pregnancy, and both received ARVs and formula feeding showed the lower rates of HIV MTCT, and the rates were 8.06%, 2.50%, 5.77%, and 6.67% respectively. In infants born to HIV positive mother, who received mixed feeding had a higher HIV MTCT up to 60.00%. Delivery mode might not relative to HIV MTCT.

Conclusions

The interventions of PMTCT program in Guangdong could effectively reduce the rate of HIV MTCT, but the effectiveness of the PMTCT program were heavily cut down by the lower availability of the PMTCT interventions.