Early infant feeding patterns and HIV-free survival: findings from the Kesho-Bora trial (Burkina Faso, Kenya, South Africa)

Feeding modalities, HIV transmission and its predictors among HIV-exposed infants visited Gamo and Gofa zones public health facilities, Southern Ethiopia: a retrospective follow up study

BACKGROUND

Despite the highest (88%) Prevention of Mother-To-Child Transmission (PMTCT) of HIV coverage in Eastern Africa, 50% of new HIV infections in children aged 0-14 years occur in the region.

OBJECTIVE

The aim of this study was to assess the feeding modalities, the rate of HIV transmission and its predictors among HIV exposed infants (HIV-EIs) visited Gamo and Gofa Zones public health facilities, Southern Ethiopia from January 2013 to February 2019.

METHOD AND MATERIALS

Institution-based retrospective follow up study was employed among 450 HIV-EIs having DNA/PCR test results. All infant-mother pair records in selected health facilities were reviewed using a standard data extraction tool from March to July 2019. HIV transmission probabilities were assessed by Kaplan-Meier time-to-event analysis method and log-rank tests were used to compare the risk among different groups. The Cox-proportional hazards model, adjusted on infant feeding modalities and other co-variants was used to identify predictors of HIV transmission, and statistical significance was declared at a p-value of < 0.05.

RESULTS

In total, 383 complete records were analyzed. In the study, 85.6% (95%CI: 81.6%, 89.1%) of HIV-EIs were exclusively breastfed in the first six months. The 18 months probability of infant HIV transmission was 64 (16.7%) (95%CI: 13.1%-20.8%). The risk of HIV-transmission was higher among infants who were delivered at the hospital than health centers/health posts (AHR = 3.07; 95%CI: 1.19, 7.95); discontinued Cotrimoxazole prophylaxis in at least one visit (AHR = 6.32; 95%CI: 3.35, 11.94); did not exclusively breastfeed (AHR = 3.07; 95%CI: 1.72, 5.47) and came from urban areas (AHR = 5.90; 95%CI: 1.40, 24.85).

CONCLUSIONS

The study showed that HIV-EIs had a greater rate of 18 months HIV transmission than the national pooled prevalence. The risk of transmission is higher among infants who do not breastfeed exclusively for the first 6 months, and the risk increases with the number of months spent by breastfeeding. Therefore, strengthening counselling on safer feeding options and Cotrimoxazole prophylaxis use; provision of quality PMTCT service with special focus in hospitals and urban residents were recommended.

Evolution of prevention of vertical HIV transmission in Uganda: 2008–2017

OBJECTIVES

Uganda adapted its policy for prevention of vertical transmission (VT) of HIV transmission as the World Health Organization released Options A, B and B+. We assessed trends in diagnostic testing, breastfeeding practices, maternal and infant antiretroviral therapy (ART), mortality, VT and HIV-free survival (HFS) among Ugandan infants born to women living with HIV during this period of successive guideline changes.

METHODS

This is is a retrospective observational study of infants attending early infant diagnosis clinics at two Ugandan hospitals.

RESULTS

A total of 1885 infants (48% female) were managed from 2009 to 2017. DNA polymerase chain reaction (PCR) for early infant diagnosis was performed on 1719 infants (92%, one or more PCR tests) and 676 infants (36%, two PCR tests). HIV serology was performed on 90 infants (4.8%). Testing increased over the study period but remained suboptimal, due to high loss to follow-up (LTFU). A total of 93% of infants were breastfed, for a median of 9.5 months. The duration of breast milk exposure increased over the study period, consistent with guidelines that increasingly encouraged breastfeeding. Nine cases (0.48%) of suspected breast milk transmission were observed. The use of ART increased significantly over the study period. Mortality (3.5%, 2.7% and 1.1%; p = 0.0076) and VT (17%, 12% and 7.4%; p < 0.0001) decreased over the study period (2008-2010, 2011-2012 and 2013-2017, respectively). LTFU values were 31%, 49% and 59% at 6, 12 and 18 months of age, respectively, with only modest improvements over time. HFS could only be conclusively documented in 532 infants (28%) because of LTFU.

CONCLUSIONS

From 2009 to 2017, outcomes improved among HIV-exposed infants in Uganda. LTFU remains a barrier to optimal care.

Testing strategies for couple engagement in prevention of mother-to-child transmission of HIV and family health in Kenya: study protocol for a randomized controlled trial

Background

HIV-related maternal deaths and HIV infection among infants remain unacceptably high across sub-Saharan Africa despite increased antenatal care attendance and provision of antiretroviral therapy to pregnant women. In the Jamii Bora (“Better Family” in Swahili) Study, we seek to test the efficacy of an interdependence theory-based couple intervention. The intervention reaches pregnant women and male partners through home visits by male-female pairs of lay health workers. The aim is to increase access to home-based couples’ HIV testing and counseling services to improve family health.

Methods

This is a three-arm randomized control trial among 1080 pregnant women 15 years of age or older, living with their male partners, and who have not undergone couples’ HIV testing and counseling in Kisumu and Migori Counties in Kenya. Couples will be randomized into three groups: home-based couple visits, HIV self-testing kits for couple use, or standard care (male partner clinic invitation letters). Participants will be followed up to 18 months postpartum. The study has three aims: in aim 1, we will determine the effects of the intervention on our primary outcome of couple HIV testing, compared to HIV self-testing kits and standard care; in aim 2, we will examine the intervention impact on HIV prevention behaviors, facility delivery, and postnatal healthcare utilization, as well as secondary health outcomes of maternal viral suppression and HIV-free child survival up to 18 months for couples living with HIV; and in aim 3, we will compare the cost-effectiveness of the home-based couple intervention to the less resource-intensive strategies used in the other two study arms. Assessments with couples are conducted at baseline, late pregnancy, and at months 3, 6, 12, and 18 after birth.

Discussion

The results from this study will inform decision-makers about the cost-effective strategies to engage pregnant couples in the prevention of mother-to-child transmission and family health, with important downstream benefits for maternal, paternal, and infant health.

Trial registration

ClinicalTrials.gov NCT03547739. Registered on May 9, 2018

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-020-04956-1.

Combination antiretroviral treatment use in prevention of mother-to-child transmission programmes: 6-week HIV prevalence and relationship to time of antiretroviral treatment initiation and mixed feeding

Background

In Zimbabwe, 16% of pregnant women aged 15-49 years are infected with HIV. More than 90% of HIV infection in children is through mother-to-child transmission (MTCT). We investigated the effectiveness of the Option B+ in reducing HIV infection and factors associated with HIV transmission among infants born to mothers enrolled in the prevention of mother-to-child transmission (PMTCT) programme.

Methods

We randomly selected 1204 early infant HIV diagnosis test results for HIV-exposed infants and linked these results to maternal clinical records at primary healthcare clinics in Harare to estimate the prevalence of MTCT and to determine the clinical factors associated with MTCT of HIV at 6 weeks.

Results

Of the 1204 infants in the study, 2.5% (95% confidence interval [CI], 1.7-3.5) were infected with HIV at 6 weeks post-delivery. Antiretroviral adherence reduced the odds of HIV infection by about 99% (odds ratio [OR] 0.01 [95% CI, 0.00-0.06]). Both mixed feeding (OR 3.89 [95% CI, 0.92-16.50]) and late initiation of antiretroviral treatment (ART) (after delivery) (OR 3.18 [95% CI, 0.42-23.94]) increased the odds of HIV infection.

Conclusion

Early initiation of combination ART reduces 6-week MTCT of HIV in PMTCT programmes to levels similar to those found in controlled trial settings. Exclusive breastfeeding remains important even in the presence of ART.

Prevention of mother-to-child transmission (PMTCT) of HIV: a review of the achievements and challenges in Burkina-Faso

BACKGROUND

Burkina-Faso's HIV/AIDS program is one of the most successful in Africa, with a declining HIV prevalence and treatment outcomes that rival those of developed countries. Prevention of mother-to-child transmission (PMTCT) guidelines in Burkina-Faso, initiated in the year 2000, were revised in 2004, 2006 and 2010. The guideline document has since undergone several stages of improvement, largely based on recommendations from WHO, with adaptations by local experts in the field. Option B+ adopted since August 2014 in Burkina-Faso has enabled maintenance of mothers on longer treatment and increasing their survival and that of their children. Through this review, we describe the achievements and challenges of HIV PMTCT programs in Burkina-Faso.

AIMS OF STUDY

This study had the following objectives: 1) describing the historical perspective of PMTCT implementation in Burkina-Faso; 2) presenting the effectiveness of interventions at improving PMTCT service delivery and promoting retention of mothers and babies in care; and 3) determining the impact of male partner involvement on PMTCT in Burkina-Faso.

METHODOLOGY

A literature search was conducted in PubMed and Google. Search terms included the following keywords: "HIV testing"; "prevention"; "mother"; "child"; "male partner"; "counseling"; "involvement"; "participation"; and the grouped terms "PMTCT and partners"; "VCT"; "barriers and/or factors"; "Male involvement in PMTCT"; and "Burkina-Faso". Data collection took place from May to October 2015. The search was limited to articles published between January 2002 and December 2015. UNICEF and UNAIDS web sites were also used to find relevant abstracts and documents.

RESULTS

Studies have revealed that with PMTCT, HIV transmission rate moved from 10.4% in 2006 to 0% in 2015. The PMTCT program remains the best way to care for HIV-infected pregnant women and their babies. The current PMTCT policy is based on evidence that male partner involvement is associated with women's completion of PMTCT.

CONCLUSION

This study shows that the reduction in mother to child transmission of HIV in Burkina-Faso over the years is mainly due to the improvement of PMTCT programs. Efforts still need to be made about the involvement of male partners.

Infant Human Immunodeficiency Virus-free Survival in the Era of Universal Antiretroviral Therapy for Pregnant and Breastfeeding Women: A Community-based Cohort Study From Rural Zambia

BACKGROUND

Lifelong antiretroviral therapy (ART) is now recommended for all human immunodeficiency virus (HIV)-infected pregnant and breastfeeding women; however, few have described overall infant outcomes in this new era for the prevention of mother-to-child HIV transmission (PMTCT).

METHODS

As part of an assessment of PMTCT program impact, we enrolled a prospective cohort study in 4 predominantly rural districts in Zambia. HIV-infected mothers and their newborns (≤30 days old) were recruited and followed at 6 weeks, 6 months and 12 months postpartum; infant specimens were tested via HIV DNA polymerase chain reaction. In Kaplan-Meier analyses, we estimated overall infant HIV-free survival and then stratified by district, community and maternal ART use. We investigated the relationship between community-level 12-month, self-reported maternal ART use and infant HIV-free survival via linear regression.

RESULTS

From June 2014 to November 2015, we enrolled 827 mother-infant pairs in 33 communities. At 12 months, small proportions of infants had died (2.8%), were HIV-infected (3.0%) or were lost to follow-up (4.3%). Overall, infant HIV-free survival was 99.0% [95% confidence interval (CI): 98.0%-99.5%] at 6 weeks, 97.5% (95% CI: 96.1%-98.4%) at 6 months and 96.3% (95% CI: 94.8%-97.4%) at 12 months. Women reporting ART use at enrollment had higher infant HIV-free survival than those who did not (97.4% vs. 89.0%, P = 0.01). Differences were noted at the district and site levels (P = 0.01). In community-level analysis, no relationship was observed between 12-month infant HIV-free survival and self-reported maternal ART use (P = 0.65).

CONCLUSION

Although encouraging, these findings highlight the need for rigorous monitoring and evaluation of PMTCT services at the population level.

HIV-1 transmission and survival according to feeding options in infants born to HIV-infected women in Yaoundé, Cameroon

Background

Evidence of 24-months survival in the frame of prevention of mother-to-child transmission (PMTCT) cascade-care is scare from routine programs in sub-Saharan African (SSA) settings. Specifically, data on infant outcomes according to feeding options remain largely unknown by month-24, thus limiting its breath for public-health recommendations toward eliminating new pediatric HIV-1 infections and improving care. We sought to evaluate HIV-1 vertical transmission and infant survival rates according to feeding options.

Methods

A retrospective cohort-study conducted in Yaounde from April 2008 through December 2013 among 1086 infants born to HIV-infected women and followed-up throughout the PMTCT cascade-care until 24-months. Infants with documented feeding option during their first 3 months of life (408 on Exclusive Breastfeeding [EBF], 663 Exclusive Replacement feeding [ERF], 15 mixed feeding [MF]) and known HIV-status were enrolled. HIV-1 vertical transmission, survival and feeding options were analyzed using Kaplan Meier Survival Estimate, Cox model and Schoenfeld residuals tests, at 5% statistical significance.

Results

Overall HIV-1 vertical transmission was 3.59% (39), and varied by feeding options: EBF (2.70%), ERF (3.77%), MF (20%), p = 0.002; without significance between EBF and ERF (p = 0.34). As expected, HIV-1 transmission also varied with PMTCT-interventions: 1.7% (10/566) from ART-group, 1.9% (8/411) from AZT-group, and 19.2% (21/109) from ARV-naïve group, p < 0.0001. Overall mortality was 2.58% (28), higher in HIV-infected (10.25%) vs. uninfected (2.29%) infants (p = 0.016); with a survival cumulative probability of 89.3% [79.9%–99.8%] vs. 96.4% [94.8%–97.9% respectively], p = 0.024. Mortality also varied by feeding option: ERF (2.41%), EBF (2.45%), MF (13.33%), p = 0.03; with a survival cumulative probability of 96% [94%–98%] in ERF, 96.4% [94.1%–98.8%] in EBF, and 86.67% [71.06%–100%] in MF, p = 0.04. Using Schoenfeld residuals test, only HIV status was a predictor of survival at 24 months (hazard ratio 0.23 [0.072–0.72], p = 0.01).

Conclusion

Besides using ART for PMTCT-interventions, practice of MF also drives HIV-1 vertical transmission and mortality among HIV-infected children. Thus, throughout PMTCT option B+ cascade-care, continuous counseling on safer feeding options would to further eliminating new MTCT, optimizing response to care, and improving the life expectancy of these children in high-priority countries.

What influences feeding decisions for HIV-exposed infants in rural Kenya?

BACKGROUND

Infant feeding in the context of human immunodeficiency virus (HIV) poses unique challenges to mothers and healthcare workers in balancing the perceived risks of HIV transmission and nutritional requirements. We aimed to describe the decision-making processes around infant feeding at a rural HIV clinic in Kenya.

METHODS

We used a qualitative study design. Between March and August 2011, we conducted in-depth interviews (n = 9) and focus group discussions (n = 10) with purposively selected hospital and community respondents at Kilifi County Hospital, Kenya. These respondents had all experienced of infant feeding in the context of HIV. These interviews were informed by prior structured observations of health care worker interactions with carers during infant feeding counselling sessions.

RESULTS

Overall, women living with HIV found it difficult to adhere to the HIV infant feeding guidance. There were three dominant factors that influenced decision making processes: 1) Exclusive breastfeeding was not the cultural norm, therefore practising it raised questions within the family and community about a mother's parenting capabilities and HIV status. 2) Women living with HIV lacked autonomy in decision-making on infant feeding due to socio-cultural factors. 3) Non-disclosure of HIV status to close members due to the stigma.

CONCLUSION

Infant feeding decision-making by women living with HIV in rural Kenya is constrained by a lack of autonomy, stigma and poverty. There is an urgent need to address these challenges through scaling up psycho-social and gender empowerment strategies for women, and introducing initiatives that promote the integration of HIV infant feeding strategies into other child health services.

Formula-Feeding of HIV-Exposed Uninfected African Children Is Associated with Faster Growth in Length during the First 6 Months of Life in the Kesho Bora Study

Background: Early feeding patterns may affect the growth of HIV-exposed children and thus their subsequent health and cognition.Objective: We assessed the association of infant feeding (IF) mode with length-for-age z score (LAZ) and stunting from age 2 d to 18 mo in HIV-exposed African children within a controlled randomized trial, which evaluated triple antiretrovirals initiated during pregnancy and continued for 6 mo postpartum to prevent HIV transmission.Methods: HIV-infected pregnant women with CD4⁺ counts of 200-500 cells/mm³ from Burkina Faso, Kenya, and South Africa were advised to exclusively breastfeed for up to 6 mo or to formula-feed from birth. Factors associated with LAZ were investigated in all uninfected children by using mixed-effects linear models; those associated with stunting (LAZ <-2) at 6 or 12 mo were assessed in multiple logistic regression after exclusion of children stunted at age 2 d. Independent variables were IF mode: formula feeding (FF), exclusive breastfeeding (EBF) <3 mo, or EBF ≥3 mo (reference); sex; trial arm; maternal characteristics; and site.Results: Among 728 children, FF was associated with a greater increase in LAZ from 2 d to 6 mo (+0.07 z score/mo, P < 0.001). Between 6 and 18 mo, FF and EBF <3 mo were both associated with greater mean LAZ than was EBF ≥3 mo (+0.52 z scores and +0.43 z scores, respectively, P < 0.001). Among children not stunted at 2 d, FF was independently associated with a reduced risk of stunting at 6 mo (OR: 0.24; 95% CI: 0.07, 0.81; P = 0.021), whereas EBF <3 mo was not (OR: 0.49; 95% CI: 0.22, 1.10; P = 0.09).Conclusions: In this observational study of HIV-exposed uninfected infants, growth in length in the first 6 mo of life was faster in formula-fed infants than in exclusively breastfed infants. The plausibility of residual confounding and reverse causality is discussed. This trial was registered at www.controlled-trials.com as ISRCTN71468401.

HIV-free survival at 12-24 months in breastfed infants of HIV-infected women on antiretroviral treatment

Objective

To provide estimates of HIV‐free survival at 12–24 months in breastfed children by maternal ART (6 months or lifelong) to inform WHO HIV and Infant Feeding guidelines.

Methods

Eighteen studies published 2005–2015 were included in a systematic literature review (1295 papers identified, 156 abstracts screened, 55 full texts); papers were analysed by narrative synthesis and meta‐analysis of HIV‐free survival by maternal ART regimen in a random effects model. We also grouped studies by feeding modality. Study quality was assessed using a modified Newcastle–Ottawa Scale (NOS) and GRADE.

Results

The pooled estimates for 12‐month HIV‐free survival were 89.8% (95% confidence interval, CI: 86.5%, 93.2%) for infants of mothers on ART for 6 months post‐natally (six studies) and 91.4% (95% CI 87.5%, 95.4%) for infants of mothers on lifelong ART (three studies). Eighteen‐month HIV‐free survival estimates were 89.0% (95% CI 83.9%, 94.2%) with 6 months ART (five studies) and 96.1% (95% CI 92.8%, 99.0%) with lifelong ART (three studies). Twenty‐four‐month HIV‐free survival for infants whose mothers were on ART to 6 months post‐natally (two studies) was 89.2% (95% CI 79.9%, 98.5%). Heterogeneity was considerable throughout. In four studies, HIV‐free survival in breastfed infants ranged from 87% (95% CI 78%, 92%) to 96% (95% CI 91%, 98%) and in formula‐fed infants from 67% (95% CI 35.5%, 87.9%) to 97.6% (95% CI 93.0%, 98.2%).

Conclusion

Our results highlight the importance of breastfeeding for infant survival and of ART in reducing the risk of mother‐to‐child HIV transmission and support the WHO recommendation to initiate ART for life immediately after HIV diagnosis.

Sexuality and Reproduction in HIV-Positive Women: A Meta-Synthesis

The increased access to effective antiretroviral treatment (ART) has made HIV comparable to a chronic disease in terms of life expectancy. Needs related to sexuality and reproduction are central to overall health and well-being. An interpretative meta-synthesis was performed to synthesize and assess how HIV-positive women's experiences of sexuality and reproduction have been described in qualitative studies. A total of 18 peer-reviewed qualitative studies were included, which comprised a total of 588 HIV-positive interviewed women. The studies originated from resource-rich countries outside the Asian and African continents. The analysis, resulting in a lines-of-argument synthesis, shows that HIV infection was a burden in relation to sexuality and reproduction. The weight of the burden could be heavier or lighter. Conditions making the HIV burden heavier were: HIV as a barrier, feelings of fear and loss, whereas motherhood, spiritual beliefs, and supportive relationships made the HIV burden lighter. The findings are important in developing optimal health care by addressing conditions making the burden of HIV infection lighter to bear. In future research there is a need to focus not only on examining how HIV-positive women's sexual and relationships manifest themselves, but also on how health care professionals should provide adequate support to the women in relation to sexuality and reproduction.