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Mallampati D, MacLean RL, Shapiro R, Dabis F, Engelsmann B, Freedberg KA, Leroy V, Lockman S, Walensky R, Rollins N, Ciaranello A. Optimal breastfeeding durations for HIV-exposed infants: the impact of maternal ART use, infant mortality and replacement feeding risk. J Int AIDS Soc 2019; 21:e25107. [PMID: 29667336 PMCID: PMC5904528 DOI: 10.1002/jia2.25107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 03/12/2018] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION In 2010, the WHO recommended women living with HIV breastfeed for 12 months while taking antiretroviral therapy (ART) to balance breastfeeding benefits against HIV transmission risks. To inform the 2016 WHO guidelines, we updated prior research on the impact of breastfeeding duration on HIV-free infant survival (HFS) by incorporating maternal ART duration, infant/child mortality and mother-to-child transmission data. METHODS Using the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-Infant model, we simulated the impact of breastfeeding duration on 24-month HFS among HIV-exposed, uninfected infants. We defined "optimal" breastfeeding durations as those maximizing 24-month HFS. We varied maternal ART duration, mortality rates among breastfed infants/children, and relative risk of mortality associated with replacement feeding ("RRRF"), modelled as a multiplier on all-cause mortality for replacement-fed infants/children (range: 1 [no additional risk] to 6). The base-case simulated RRRF = 3, median infant mortality, and 24-month maternal ART duration. RESULTS In the base-case, HFS ranged from 83.1% (no breastfeeding) to 90.2% (12-months breastfeeding). Optimal breastfeeding durations increased with higher RRRF values and longer maternal ART durations, but did not change substantially with variation in infant mortality rates. Optimal breastfeeding durations often exceeded the previous WHO recommendation of 12 months. CONCLUSIONS In settings with high RRRF and long maternal ART durations, HFS is maximized when mothers breastfeed longer than the previously-recommended 12 months. In settings with low RRRF or short maternal ART durations, shorter breastfeeding durations optimize HFS. If mothers are supported to use ART for longer periods of time, it is possible to reduce transmission risks and gain the benefits of longer breastfeeding durations.
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Affiliation(s)
- Divya Mallampati
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL, USA
| | - Rachel L MacLean
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Divisions of General Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Roger Shapiro
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Immunology and Infectious Diseases, Harvard T.H, Chan School of Public Health, Boston, MA, USA.,The Botswana-Harvard School of Public Health AIDS Institute Partnership for HIV Research and Education, Gaborone, Botswana
| | - Francois Dabis
- Université Bordeaux, Institut de Santé Publique, d'Epidémiologie et de Dévelopement (ISPED), Centre INSERM, U1219-Bordeaux Population Health, Bordeaux, France
| | - Barbara Engelsmann
- Organization for Public Health Interventions and Development, Harare, Zimbabwe
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Divisions of General Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Harvard University Center for AIDS Research Boston, MA, USA
| | | | - Shahin Lockman
- Department of Immunology and Infectious Diseases, Harvard T.H, Chan School of Public Health, Boston, MA, USA.,The Botswana-Harvard School of Public Health AIDS Institute Partnership for HIV Research and Education, Gaborone, Botswana.,Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - Rochelle Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Divisions of General Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Harvard University Center for AIDS Research Boston, MA, USA.,Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA, USA.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nigel Rollins
- Department of Maternal Newborn, Child and Adolescent Health World Health Organization, Geneva, Switzerland
| | - Andrea Ciaranello
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Neilan AM, Patel K, Agwu AL, Bassett IV, Amico KR, Crespi CM, Gaur AH, Horvath KJ, Powers KA, Rendina HJ, Hightow-Weidman LB, Li X, Naar S, Nachman S, Parsons JT, Simpson KN, Stanton BF, Freedberg KA, Bangs AC, Hudgens MG, Ciaranello AL. Model-Based Methods to Translate Adolescent Medicine Trials Network for HIV/AIDS Interventions Findings Into Policy Recommendations: Rationale and Protocol for a Modeling Core (ATN 161). JMIR Res Protoc 2019; 8:e9898. [PMID: 30990464 PMCID: PMC6488956 DOI: 10.2196/resprot.9898] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 12/12/2022] Open
Abstract
Background The United States Centers for Disease Control and Prevention estimates that approximately 60,000 US youth are living with HIV. US youth living with HIV (YLWH) have poorer outcomes compared with adults, including lower rates of diagnosis, engagement, retention, and virologic suppression. With Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) support, new trials of youth-centered interventions to improve retention in care and medication adherence among YLWH are underway. Objective This study aimed to use a computer simulation model, the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-Adolescent Model, to evaluate selected ongoing and forthcoming ATN interventions to improve viral load suppression among YLWH and to define the benchmarks for uptake, effectiveness, durability of effect, and cost that will make these interventions clinically beneficial and cost-effective. Methods This protocol, ATN 161, establishes the ATN Modeling Core. The Modeling Core leverages extensive data—already collected by successfully completed National Institutes of Health–supported studies—to develop novel approaches for modeling critical components of HIV disease and care in YLWH. As new data emerge from ongoing ATN trials during the award period about the effectiveness of novel interventions, the CEPAC-Adolescent simulation model will serve as a flexible tool to project their long-term clinical impact and cost-effectiveness. The Modeling Core will derive model input parameters and create a model structure that reflects key aspects of HIV acquisition, progression, and treatment in YLWH. The ATN Modeling Core Steering Committee, with guidance from ATN leadership and scientific experts, will select and prioritize specific model-based analyses as well as provide feedback on derivation of model input parameters and model assumptions. Project-specific teams will help frame research questions for model-based analyses as well as provide feedback regarding project-specific inputs, results, sensitivity analyses, and policy conclusions. Results This project was funded as of September 2017. Conclusions The ATN Modeling Core will provide critical information to guide the scale-up of ATN interventions and the translation of ATN data into policy recommendations for YLWH in the United States.
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Affiliation(s)
- Anne M Neilan
- Division of General Academic Pediatrics, Massachusetts General Hospital, Boston, MA, United States.,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, United States
| | - Kunjal Patel
- Department of Epidemiology and Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Allison L Agwu
- Departments of Pediatric and Adult Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ingrid V Bassett
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, United States.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - K Rivet Amico
- University of Michigan School of Public Health, Ann Arbor, MI, United States
| | - Catherine M Crespi
- Department of Biostatistics, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, United States
| | - Aditya H Gaur
- St. Jude's Children's Research Hospital, Memphis, TN, United States
| | - Keith J Horvath
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Kimberly A Powers
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - H Jonathon Rendina
- Hunter College of the City University of New York, New York, NY, United States
| | - Lisa B Hightow-Weidman
- Institute for Global Health & Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Xiaoming Li
- Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
| | - Sylvie Naar
- Center for Translational Behavioral Research, Florida State University, Tallahassee, FL, United States
| | - Sharon Nachman
- State University of New York, Stony Brook, NY, United States
| | - Jeffrey T Parsons
- Hunter College of the City University of New York, New York, NY, United States
| | - Kit N Simpson
- Medical University of South Carolina, Charleston, SC, United States
| | - Bonita F Stanton
- Hackensack Meridian School of Medicine at Seton Hall University, Nutley, NJ, United States
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, United States.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Audrey C Bangs
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, United States
| | - Michael G Hudgens
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Andrea L Ciaranello
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, United States.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
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HIV-1 transmission and survival according to feeding options in infants born to HIV-infected women in Yaoundé, Cameroon. BMC Pediatr 2018; 18:69. [PMID: 29458337 PMCID: PMC5817808 DOI: 10.1186/s12887-018-1049-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 02/06/2018] [Indexed: 11/17/2022] Open
Abstract
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.
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Health and survival of HIV perinatally exposed but uninfected children born to HIV-infected mothers. Curr Opin HIV AIDS 2017; 11:465-476. [PMID: 27716731 DOI: 10.1097/coh.0000000000000300] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The number of HIV-exposed but uninfected (HEU) infants exposed to both HIV and multiple antiretroviral drugs in utero and during prolonged breastfeeding is increasing in low-income countries where HIV prevalence is the highest. We review recent evidence on the effects of perinatal/postnatal exposure to maternal HIV and combined antiretroviral therapy (cART) on health outcomes of HEU children (mitochondrial and metabolic toxicity, adverse pregnancy outcomes, neurodevelopment, growth, infectious morbidity, and mortality). RECENT FINDINGS Several studies have reported ART-associated mitochondrial toxicity and metabolic disorders with conflicting results on adverse pregnancy outcomes, underscoring the need to conduct further investigations on these questions. Studies about congenital abnormalities report no significant differences between HEU exposed to ART and HIV-unexposed (HUU) children. Updated French data showed no significant difference in cancer incidence between HEU cART-exposed children and the general paediatric population. Furthermore, HEU children exposed to maternal cART have modest but significant impairment of development and a higher risk of growth impairment. Finally, HEU have higher risks of infections (mainly low respiratory tract infections and diarrhoea) and malaria than HUU children, particularly in children not breastfed or after early weaning. Higher mortality risk from infectious disease is reported in HEU compared to HUU children. SUMMARY As we move toward the elimination of mother-to-child transmission of HIV, HEU children are an emerging population whose health outcomes remain to be fully described. Future large cohorts of HEU children using careful comparison groups of HUU in the post-ART era are needed to better understand their long-term health outcomes.
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