1
|
Yeganeh N, Watts DH, Xu J, Kerin T, Joao EC, Pilotto JH, Theron G, Gray G, Santos B, Fonseca R, Kreitchmann R, Pinto J, Mussi-Pinhata MM, Veloso V, Camarca M, Mofenson L, Moye J, Nielsen-Saines K. Infectious Morbidity, Mortality and Nutrition in HIV-exposed, Uninfected, Formula-fed Infants: Results From the HPTN 040/PACTG 1043 Trial. Pediatr Infect Dis J 2018; 37:1271-1278. [PMID: 29750766 PMCID: PMC6226320 DOI: 10.1097/inf.0000000000002082] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND HIV-exposed uninfected (HEU) infants are a growing population with potentially poor health outcomes. We evaluated morbidity and mortality in HEU formula-fed infants enrolled in the NICHD HPTN 040/PACTG 1043 trial. METHODS Infectious morbidity, mortality and undernutrition were evaluated within a cohort of 1000 HEU infants enrolled between April 2004 and April 2010 in Brazil (n = 766) and South Africa (n = 234) as part of the NICHD/HPTN 040 trial of 3 different antiretroviral regimens to decrease intrapartum HIV vertical transmission. RESULTS Twenty-three percent of infants had at least 1 infectious serious adverse effect. Infants born to mothers with <12 years of education [adjusted odds ratio (AOR), 2.6; 95% confidence interval [CI], 1.2-5.9), with maternal viral load of >1,000,000 copies/mL at delivery (AOR, 9.9; 95% CI, 1.6-63.1) were more likely to have infectious serious adverse effects. At 6 months, the infant mortality rate per 1000 live births overall was 22 ± 2.6, 9.1 ± 1.8 in Brazil and 64.1 ± 3 in South Africa. Undernutrition and stunting peaked at 1 month of age with 18% having a weight-for-age Z score ≤-2, and 22% with height for Z score ≤-2. The likelihood of infant mortality was greater among infants born in South Africa compared with Brazil (AOR, 6.2; 95% CI, 2.5-15.8), high maternal viral load (AOR, 1.7; 95% CI, 1.01-2.9) and birth weight-for-age Z score ≤-2 (AOR, 5.2; 95% CI, 1.8-14.8). CONCLUSIONS There were high rates of undernutrition, stunting and infectious serious adverse effect in this study's formula-fed HEU population. Suppressing maternal HIV viral load during the peripartum period may be a modifiable risk factor to decrease infant mortality.
Collapse
Affiliation(s)
- Nava Yeganeh
- David Geffen UCLA School of Medicine, Los Angeles, CA
| | - D. Heather Watts
- Office of the Global AIDS Coordinator and Health Diplomacy, U.S. Dept. of State, Washington D.C
| | | | - Tara Kerin
- David Geffen UCLA School of Medicine, Los Angeles, CA
| | - Esau C. Joao
- Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
| | - Jose Henrique Pilotto
- Hospital Geral de Nova Iguaçu, Nova Iguaçu and Laboratório de AIDS e Imunologia Molecular, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, (Fiocruz), Rio de Janeiro, Brazil, Perinatal HIV Research Unit
| | - Gerhard Theron
- Stellenbosch University/Tygerberg Hospital, Cape Town, South Africa
| | - Glenda Gray
- University of Witwatersrand/Chris Hani Baragwanath Hospital, Johannesburg, South Africa
| | | | | | | | - Jorge Pinto
- Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | | | - Valdilea Veloso
- Laboratório de Pesquisa Clínica em DST e AIDS - Instituto de Pesquisa Clínica Evandro Chagas - Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, Brazil
| | | | - Lynne Mofenson
- Elisabeth Glaser Pediatric AIDS Foundation, Washington DC
| | - Jack Moye
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | | |
Collapse
|
2
|
Zash RM, Shapiro RL, Leidner J, Wester C, McAdam AJ, Hodinka RL, Thior I, Moffat C, Makhema J, McIntosh K, Essex M, Lockman S. The aetiology of diarrhoea, pneumonia and respiratory colonization of HIV-exposed infants randomized to breast- or formula-feeding. Paediatr Int Child Health 2016; 36:189-97. [PMID: 27595698 PMCID: PMC4673023 DOI: 10.1179/2046905515y.0000000038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Diarrhoea and pneumonia are common causes of childhood death in sub-Saharan Africa but there are few studies describing specific pathogens. OBJECTIVES The study aimed to describe the pathogens associated with diarrhoea, pneumonia and oropharyngeal colonization in children born to HIV-infected women (HIV-exposed infants). METHODS The Mashi Study randomized 1200 HIV-infected women and their infants to breastfeed for 6 months with ZDV prophylaxis or formula-feed with 4 weeks of ZDV. Children were tested for HIV by PCR at 1, 4, 7, 9 and 12 months and by ELISA at 18 months. Pre-defined subsets of children were sampled during episodes of diarrhoea (n = 300) and pneumonia (n = 85). Stool was tested for bacterial pathogens, rotavirus and parasites. Children with pneumonia underwent bacterial blood culture, and testing of nasopharyngeal aspirates for viral pathogens by PCR. Oropharyngeal swabs were collected from a consecutive subset of 561 infants at the routine 3-month visit for bacterial culture. RESULTS The median age (range) at sampling was 181 days for diarrhoea (0-730) and 140 days for pneumonia (2-551). Pathogens were identified in 55 (18%) children with diarrhoea and 32 (38%) with pneumonia. No differences in pathogens by child HIV status (HIV-infected vs HIV-uninfected) or feeding strategy were identified. Campylobacter was the most common diarrhoeal pathogen (7%). Adenovirus (22%) and other viruses (19%) were the primary pathogens isolated during pneumonias. More formula-fed infants had oropharyngeal colonization by pathogenic Gram-negative bacteria (16.8% vs 6.2%, P = 0.003), which was associated with a non-significant increased risk of pneumonia (OR 2.2, 95% CI 0.8-5.7). CONCLUSION A trend toward oropharyngeal bacterial colonization was observed in formula-fed infants. Although viruses were most commonly detected during pneumonia, respiratory colonization by Gram-negative bacteria may have contributed to pneumonia in formula-fed infants.
Collapse
Affiliation(s)
- Rebecca M. Zash
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA,Botswana Harvard Partnership, Gaborone, Botswana
| | - Roger L. Shapiro
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA,Botswana Harvard Partnership, Gaborone, Botswana
| | | | | | - Alexander J. McAdam
- Department of Laboratory Medicine, Children’s Hospital and Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Richard L. Hodinka
- Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia and Clinical Virology Laboratory, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ibou Thior
- Botswana Harvard Partnership, Gaborone, Botswana
| | | | | | - Kenneth McIntosh
- Department of Pediatrics, Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Max Essex
- Botswana Harvard Partnership, Gaborone, Botswana,Harvard School of Public Health and Harvard Medical School, Boston, MA, USA
| | - Shahin Lockman
- Botswana Harvard Partnership, Gaborone, Botswana,Division of Infectious Diseases, Brigham and Women’s Hospital and Harvard School of Public Health, Boston, MA, USA
| |
Collapse
|
3
|
Kuhn L, Kim HY, Hsiao L, Nissan C, Kankasa C, Mwiya M, Thea DM, Aldrovandi GM, Bode L. Oligosaccharide composition of breast milk influences survival of uninfected children born to HIV-infected mothers in Lusaka, Zambia. J Nutr 2015; 145:66-72. [PMID: 25527660 PMCID: PMC4264023 DOI: 10.3945/jn.114.199794] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Human milk oligosaccharides (HMOs) have multiple immunomodulatory functions that influence child health. OBJECTIVE In this study we investigated whether HMO composition influences survival to 2 y of age in HIV-infected and HIV-exposed, uninfected (HEU) children during and after breastfeeding. METHODS In the context of an early weaning trial in 958 HIV-infected women in Lusaka, Zambia, we conducted a nested case-cohort analysis of mortality to 2 y of age among 103 HIV-infected and 143 HEU children. Breast-milk samples collected at 1 mo postpartum were analyzed for HMO content. Samples were selected to include mothers of all HIV-infected children detected by 6 wk of age, of whom 63 died at <2 y of age; mothers of all HEU children who died at <2 y of age (n = 66); and a random sample of 77 HEU survivors. Associations before and after weaning in HIV-infected and HEU infants separately were investigated by using Cox models. RESULTS Among HEU children, higher maternal breast-milk concentrations of 2-linked fucosylated HMOs [2'-fucosyllactose and lacto-N-fucopentaose (LNFP) I] (HR: 0.33; 95% CI: 0.14, 0.74) as well as non-2-linked fucosylated HMOs (3-fucosyllactose and LNFP II/III; HR: 0.28; 95% CI: 0.13, 0.67) were significantly associated with reduced mortality during, but not after, breastfeeding after adjustment for confounders. Breastfeeding was protective against mortality only in HEU children with high concentrations of fucosylated HMOs. Among HIV-infected children, no consistent associations between HMOs and mortality were observed, but breastfeeding was protective against mortality. CONCLUSIONS The oligosaccharide composition of breast milk may explain some of the benefits of breastfeeding in HEU children. HIV infection may modulate some of the consequences of HMOs on child survival.
Collapse
Affiliation(s)
- Louise Kuhn
- Gertrude H Sergievsky Center and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Hae-Young Kim
- Gertrude H Sergievsky Center and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Lauren Hsiao
- Division of Neonatal Medicine and Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of California, San Diego, San Diego, CA
| | - Caroline Nissan
- Division of Neonatal Medicine and Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of California, San Diego, San Diego, CA
| | - Chipepo Kankasa
- University Teaching Hospital, University of Zambia, Lusaka, Zambia
| | - Mwiya Mwiya
- University Teaching Hospital, University of Zambia, Lusaka, Zambia
| | - Donald M Thea
- Center for International Health and Development, Boston University School of Public Health, Boston, MA; and
| | - Grace M Aldrovandi
- Department of Pediatrics, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | - Lars Bode
- Division of Neonatal Medicine and Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of California, San Diego, San Diego, CA;
| |
Collapse
|
4
|
Abstract
Severe acute malnutrition (SAM) is associated with increased severity of common infectious diseases, and death amongst children with SAM is almost always as a result of infection. The diagnosis and management of infection are often different in malnourished versus well-nourished children. The objectives of this brief are to outline the evidence underpinning important practical questions relating to the management of infectious diseases in children with SAM and to highlight research gaps. Overall, the evidence base for many aspects covered in this brief is very poor. The brief addresses antimicrobials; antipyretics; tuberculosis; HIV; malaria; pneumonia; diarrhoea; sepsis; measles; urinary tract infection; nosocomial Infections; soil transmitted helminths; skin infections and pharmacology in the context of SAM. The brief is structured into sets of clinical questions, which we hope will maximise the relevance to contemporary practice.
Collapse
Key Words
- Antibiotics,
- Children,
- Diarrhoea,
- HIV,
- Infection,
- Malaria
- Malnutrition,
- Measles,
- Pneumonia,
- Sepsis,
- Tuberculosis,
- Urinary tract infection,
Collapse
|
5
|
Breastfeeding is associated with decreased pneumonia incidence among HIV-exposed, uninfected Kenyan infants. AIDS 2013; 27:2809-15. [PMID: 23921609 DOI: 10.1097/01.aids.0000432540.59786.6d] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE HIV-exposed uninfected (HEU) infants have higher infectious disease morbidity and mortality than unexposed infants. We determined the incidence and risk factors for pneumonia, a leading cause of infant mortality worldwide, in a cohort of HEU infants. Identifying predictors of pneumonia among HEU infants may enable early identification of those at highest risk. DESIGN A retrospective cohort of HEU infants participating in a Kenyan perinatal HIV study, enrolled between 1999 and 2002. METHODS Infants were followed monthly from birth to 12 months. Incidence of pneumonia diagnosed at monthly study visits, sick-child visits or by means of averbal autopsy was estimated with a 14-day window for new episodes. Cox proportional hazards regression was used to identify predictors of first pneumonia occurrence. RESULTS Among 388 HEU infants with 328 person-years of follow-up, the incidence of pneumonia was 900/1000 child-years [95% confidence interval (CI) 800-1000]. Maternal HIV viral load at 32 weeks' gestation [hazard ratio 1.2 (1.0-1.5) per log10 difference] and being underweight (weight-for-age Z-score <-2) at the previous visit [hazard ratio 1.8 (1.1-2.8)] were associated with increased risk of pneumonia. Breastfed infants had a 47% lower risk of pneumonia than those never breastfed [hazard ratio 0.53 (0.39-0.73)], independent of infant growth, maternal viral load and maternal CD4%. Breastfeeding was also associated with a 74% lower risk of pneumonia-related hospitalization [hazard ratio 0.26 (0.13-0.53)]. CONCLUSIONS The incidence of pneumonia in this cohort of HEU infants was high. Our observations suggest that maternal viral suppression and breastfeeding may reduce the burden of pneumonia among HEU infants.
Collapse
|
6
|
Permar SR, Salazar MG, Gao F, Cai F, Learn GH, Kalilani L, Hahn BH, Shaw GM, Salazar-Gonzalez JF. Clonal amplification and maternal-infant transmission of nevirapine-resistant HIV-1 variants in breast milk following single-dose nevirapine prophylaxis. Retrovirology 2013; 10:88. [PMID: 23941304 PMCID: PMC3765243 DOI: 10.1186/1742-4690-10-88] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 08/06/2013] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Intrapartum administration of single-dose nevirapine (sdNVP) reduces perinatal HIV-1 transmission in resource-limiting settings by half. Yet this strategy has limited effect on subsequent breast milk transmission, making the case for new treatment approaches to extend maternal/infant antiretroviral prophylaxis through the period of lactation. Maternal and transmitted infant HIV-1 variants frequently develop NVP resistance mutations following sdNVP, complicating subsequent treatment/prophylaxis regimens. However, it is not clear whether NVP-resistant viruses are transmitted via breastfeeding or arise de novo in the infant. FINDINGS We performed a detailed HIV genetic analysis using single genome sequencing to identify the origin of drug-resistant variants in an sdNVP-treated postnatally-transmitting mother-infant pair. Phylogenetic analysis of HIV sequences from the child revealed low-diversity variants indicating infection by a subtype C single transmitted/founder virus that shared full-length sequence identity with a clonally-amplified maternal breast milk virus variant harboring the K103N NVP resistance mutation. CONCLUSION In this mother/child pair, clonal amplification of maternal NVP-resistant HIV variants present in systemic and mammary gland compartments following intrapartum sdNVP represents one source of transmitted NVP-resistant variants that is responsible for the acquisition of drug resistant virus by the breastfeeding infant. This finding emphasizes the need for combination antiretroviral prophylaxis to prevent mother-to-child HIV transmission.
Collapse
Affiliation(s)
- Sallie R Permar
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Kim HY, Kasonde P, Mwiya M, Thea DM, Kankasa C, Sinkala M, Aldrovandi G, Kuhn L. Pregnancy loss and role of infant HIV status on perinatal mortality among HIV-infected women. BMC Pediatr 2012; 12:138. [PMID: 22937874 PMCID: PMC3480840 DOI: 10.1186/1471-2431-12-138] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 08/17/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV-infected women, particularly those with advanced disease, may have higher rates of pregnancy loss (miscarriage and stillbirth) and neonatal mortality than uninfected women. Here we examine risk factors for these adverse pregnancy outcomes in a cohort of HIV-infected women in Zambia considering the impact of infant HIV status. METHODS A total of 1229 HIV-infected pregnant women were enrolled (2001-2004) in Lusaka, Zambia and followed to pregnancy outcome. Live-born infants were tested for HIV by PCR at birth, 1 week and 5 weeks. Obstetric and neonatal data were collected after delivery and the rates of neonatal (<28 days) and early mortality (<70 days) were described using Kaplan-Meier methods. RESULTS The ratio of miscarriage and stillbirth per 100 live-births were 3.1 and 2.6, respectively. Higher maternal plasma viral load (adjusted odds ratio [AOR] for each log10 increase in HIV RNA copies/ml = 1.90; 95% confidence interval [CI] 1.10-3.27) and being symptomatic were associated with an increased risk of stillbirth (AOR = 3.19; 95% CI 1.46-6.97), and decreasing maternal CD4 count by 100 cells/mm3 with an increased risk of miscarriage (OR = 1.25; 95% CI 1.02-1.54). The neonatal mortality rate was 4.3 per 100 increasing to 6.3 by 70 days. Intrauterine HIV infection was not associated with neonatal morality but became associated with mortality through 70 days (adjusted hazard ratio = 2.76; 95% CI 1.25-6.08). Low birth weight and cessation of breastfeeding were significant risk factors for both neonatal and early mortality independent of infant HIV infection. CONCLUSIONS More advanced maternal HIV disease was associated with adverse pregnancy outcomes. Excess neonatal mortality in HIV-infected women was not primarily explained by infant HIV infection but was strongly associated with low birth weight and prematurity. Intrauterine HIV infection contributed to mortality as early as 70 days of infant age. Interventions to improve pregnancy outcomes for HIV-infected women are needed to complement necessary therapeutic and prophylactic antiretroviral interventions.
Collapse
Affiliation(s)
- Hae-Young Kim
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | | | | | | | | | | | | |
Collapse
|
8
|
Alvarez-Uria G, Midde M, Pakam R, Bachu L, Naik PK. Effect of Formula Feeding and Breastfeeding on Child Growth, Infant Mortality, and HIV Transmission in Children Born to HIV-Infected Pregnant Women Who Received Triple Antiretroviral Therapy in a Resource-Limited Setting: Data from an HIV Cohort Study in India. ISRN PEDIATRICS 2012; 2012:763591. [PMID: 22701801 PMCID: PMC3371722 DOI: 10.5402/2012/763591] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Accepted: 04/04/2012] [Indexed: 11/23/2022]
Abstract
We describe a programme for the prevention of mother-to-child transmission (PMTCT) of HIV that provided universal antiretroviral therapy (ART) to all pregnant women regardless of the CD4 lymphocyte count and formula feeding for children with high risk of HIV transmission through breastfeeding in a district of India. The overall rate of HIV transmission was 3.7%. Although breastfeeding added a 3.1% additional risk of HIV acquisition, formula-fed infants had significantly higher risk of death compared to breastfed infants. The cumulative 12-month mortality was 9.6% for formula-fed infants versus 0.68% for breastfed infants. Anthropometric markers (weight, length/height, weight for length/height, body mass index, head circumference, mid-upper arm circumference, triceps skinfold, and subscapular skinfold) showed that formula-fed infants experience severe malnutrition during the first two months of life. We did not observe any death after rapid weaning at 5-6 months in breastfed infants. The higher-free-of HIV survival in breastfed infants and the low rate of HIV transmission found in this study support the implementation of PMTCT programmes with universal ART to all HIV-infected pregnant women and breastfeeding in order to reduce HIV transmission without increasing infant mortality in developing countries.
Collapse
Affiliation(s)
- Gerardo Alvarez-Uria
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, Kadiri Road, Bathalapalli 515661, India
| | - Manoranjan Midde
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, Kadiri Road, Bathalapalli 515661, India
| | - Raghavakalyan Pakam
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, Kadiri Road, Bathalapalli 515661, India
| | - Lakshminarayana Bachu
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, Kadiri Road, Bathalapalli 515661, India
| | - Praveen Kumar Naik
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, Kadiri Road, Bathalapalli 515661, India
| |
Collapse
|
9
|
Venkatesh KK, de Bruyn G, Marinda E, Otwombe K, van Niekerk R, Urban M, Triche EW, McGarvey ST, Lurie MN, Gray GE. Morbidity and mortality among infants born to HIV-infected women in South Africa: implications for child health in resource-limited settings. J Trop Pediatr 2011; 57:109-19. [PMID: 20601692 PMCID: PMC3107462 DOI: 10.1093/tropej/fmq061] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND We examined correlates of infant morbidity and mortality within the first 3 months of life among HIV-exposed infants receiving post-exposure antiretroviral prophylaxis in South Africa. METHODS We conducted a prospective cohort study of 848 mother-child dyads. Multivariable Cox proportional hazards models were used. RESULTS The main causes of infant morbidity were gastrointestinal and respiratory infections. Morbidity was higher with infant HIV infection (HR: 2.61; 95% CI: 1.40-4.85; p = 0.002) and maternal plasma viral load (PVL) >100,000 copies ml⁻¹ (HR: 1.87; 95% CI: 1.01-3.48; p = 0.048), and lower with maternal age < 20 years (HR: 0.25; 95% CI: 0.07-0.88; p = 0.031). Mortality was higher with infant HIV infection (HR: 4.10; 95% CI: 1.18-14.31; p = 0.027) and maternal PVL >100,000 copies ml⁻¹ (HR: 6.93; 95% CI: 1.64-29.26; p = 0.008). Infant feeding status did not influence the risk of morbidity nor mortality. CONCLUSIONS Future interventions that minimize pediatric HIV infection and reduce maternal viremia, which are the main predictors of child health soon after birth, will impact positively on infant health outcomes.
Collapse
Affiliation(s)
- Kartik K. Venkatesh
- Department of Community Health, Alpert Medical School, Brown University, Providence, RI, USA
| | - Guy de Bruyn
- Perinatal HIV Research Unit, University of the Witwatersrand, Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - Edmore Marinda
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Kennedy Otwombe
- Perinatal HIV Research Unit, University of the Witwatersrand, Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - Ronelle van Niekerk
- Perinatal HIV Research Unit, University of the Witwatersrand, Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - Michael Urban
- Coronation Hospital, Department of Pediatrics, Johannesburg, South Africa
| | - Elizabeth W. Triche
- Department of Community Health, Alpert Medical School, Brown University, Providence, RI, USA
| | - Stephen T. McGarvey
- Department of Community Health, Alpert Medical School, Brown University, Providence, RI, USA
| | - Mark N. Lurie
- Department of Community Health, Alpert Medical School, Brown University, Providence, RI, USA
| | - Glenda E. Gray
- Perinatal HIV Research Unit, University of the Witwatersrand, Chris Hani Baragwanath Hospital, Soweto, South Africa
| |
Collapse
|
10
|
Teasdale CA, Marais BJ, Abrams EJ. HIV: prevention of mother-to-child transmission. BMJ CLINICAL EVIDENCE 2011; 2011:0909. [PMID: 21477392 PMCID: PMC3217724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Over 2 million children are thought to be living with HIV/AIDS worldwide, of whom over 80% live in sub-Saharan Africa. Without antiretroviral treatment, the risk of HIV transmission from infected mothers to their children is 15% to 30% during gestation or labour, with an additional transmission risk of 10% to 20% associated with prolonged breastfeeding. HIV-1 infection accounts for most infections; HIV-2 is rarely transmitted from mother to child. Transmission is more likely in mothers with high viral loads, advanced disease, or both, in the presence of other sexually transmitted diseases, and with increased exposure to maternal blood. Mixed feeding practices (breast milk plus other liquids or solids) and prolonged breastfeeding are also associated with increased risk of mother-to-child transmission of HIV. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical question: What are the effects of measures to reduce mother-to-child transmission of HIV? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). We performed a GRADE evaluation of the quality of evidence for interventions. RESULTS We found 53 systematic reviews, RCTs, or observational studies that met our inclusion criteria. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: antiretroviral drugs, different methods of infant feeding, elective caesarean section, immunotherapy, micronutrient supplements, vaginal microbicides, and vitamin supplements.
Collapse
Affiliation(s)
- Chloe A Teasdale
- International Center for AIDs Care & Treatment Programs, Columbia University, New York, USA
| | | | | |
Collapse
|
11
|
Abstract
DESIGN the origin and evolution of HIV-1 in breast milk is unclear, despite the continuing significance of this tissue as a transmitting compartment. To elucidate the evolutionary trajectory of viral populations in a transient mucosal compartment, longitudinal sequences of the envelope glycoprotein (gp120) region from plasma and breast milk spanning the first year after delivery were analyzed in six women infected by HIV-1 subtype C. METHODS multiple phylogenetic algorithms were used to elucidate the evolutionary history and spatial structure of virus populations between tissues. RESULTS overall persistent mixing of viral sequences between plasma and breast milk indicated that breast milk is not a distinct genetic viral compartment. Unexpectedly, longitudinal phylogenies showed multiple lineages defined by long branches that included virus from both the breast milk and the plasma. Plasma was unlikely the anatomical origin of the most recent common ancestor (MRCA) in at least three of the patients, although in other women, the temporal origin of the MRCA of the viral populations following delivery occurred well before the onset of breast milk production. CONCLUSIONS these findings suggest that during pregnancy/lactation, a viral variant distinct from the plasma virus initially seeds the breast milk, followed by subsequent gene flow between the plasma and breast milk tissues. This study indicates the potential for reactivation or reintroduction of distinct lineages during major immunological disruptions during the course of natural infection.
Collapse
|
12
|
Chopra M, Doherty T, Goga A, Jackson D, Persson LA. Survival of infants in the context of prevention of mother to child HIV transmission in South Africa. Acta Paediatr 2010; 99:694-698. [PMID: 20096027 DOI: 10.1111/j.1651-2227.2009.01675.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM We sought to study the survival of newborn children according to HIV status of the mother, that of the child and the timing of infection. METHODS This is a prospective cohort study of 883 mothers (665 HIV-positive and 218 HIV-negative) and their infants. Data were collected using semi-structured questionnaires during home visits between the antenatal period and 36 weeks post-delivery. Infant HIV status was determined at 3, 24 and 36 weeks by HIV DNA PCR. RESULTS The majority (81.3%) of infected infants who died were infected by 3 weeks of age. Of the HIV-exposed infants who died, 19 (28.4%) died before 6 weeks and 38 (56.7%) died by 12 weeks. The hazard ratio (HR) of mortality at 36 weeks of age in HIV-infected infants compared with exposed but negative infants was 8.9 (95% CI: 6.7-11.8). There was no significant difference in 36 week survival rates between HIV-non-exposed and HIV-exposed but negative infants (HR: 0.7; 95% CI: 0.3-1.5). The infant being HIV-positive at age 3 weeks (HR: 32 95% CI: 14.0-73.1) and rural site (HR: 4.4 95% CI: 1.2-23.4) were the two independent risk factors for infant death amongst HIV-exposed infants. CONCLUSION The prognosis for infants with early HIV infection was very poor in this cohort. A greater focus on prevention of early infection, earlier screening for HIV infection and access to antiretrovirals for eligible infants is recommended.
Collapse
Affiliation(s)
- M Chopra
- .Health Systems Research Unit, Medical Research Council, Tygerberg, Western Cape, South Africa.Department of International Maternal & Child Health Uppsala University, Uppsala, Sweden.School of Public Health, University of the Western Cape, Western Cape, South Africa.Department of Paediatrics and Child Health, University of Limpopo, MEDUNSA Campus, South Africa
| | - T Doherty
- .Health Systems Research Unit, Medical Research Council, Tygerberg, Western Cape, South Africa.Department of International Maternal & Child Health Uppsala University, Uppsala, Sweden.School of Public Health, University of the Western Cape, Western Cape, South Africa.Department of Paediatrics and Child Health, University of Limpopo, MEDUNSA Campus, South Africa
| | - A Goga
- .Health Systems Research Unit, Medical Research Council, Tygerberg, Western Cape, South Africa.Department of International Maternal & Child Health Uppsala University, Uppsala, Sweden.School of Public Health, University of the Western Cape, Western Cape, South Africa.Department of Paediatrics and Child Health, University of Limpopo, MEDUNSA Campus, South Africa
| | - D Jackson
- .Health Systems Research Unit, Medical Research Council, Tygerberg, Western Cape, South Africa.Department of International Maternal & Child Health Uppsala University, Uppsala, Sweden.School of Public Health, University of the Western Cape, Western Cape, South Africa.Department of Paediatrics and Child Health, University of Limpopo, MEDUNSA Campus, South Africa
| | - L A Persson
- .Health Systems Research Unit, Medical Research Council, Tygerberg, Western Cape, South Africa.Department of International Maternal & Child Health Uppsala University, Uppsala, Sweden.School of Public Health, University of the Western Cape, Western Cape, South Africa.Department of Paediatrics and Child Health, University of Limpopo, MEDUNSA Campus, South Africa
| |
Collapse
|
13
|
Tornatore M, Gonçalves CV, Mendoza-Sassi RA, Silveira JM, D'ávila NE, Maas CG, Bianchi MS, Pinheiro EM, Machado ES, Soares MA, Martinez AMB. HIV-1 vertical transmission in Rio Grande, Southern Brazil. Int J STD AIDS 2010; 21:351-5. [DOI: 10.1258/ijsa.2009.009033] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to determine the rate and risk factors of HIV-1 mother-to-child transmission (MTCT), the timing of transmission and the transmitted subtype in a population where subtypes B and C co-circulate. One hundred and forty-four babies born to HIV-1-infected mothers were studied. Subtype and timing of transmission were determined by a nested polymerase chain reaction of the gp41 gene. Seven children were infected (4.9%): four were infected intrautero and one intrapartum. The higher frequency of intrautero transmission was statistically significant ( P = 0.001). Use of antiretrovirals (ARVs) in the three stages of gestation was a protective risk factor for MTCT (PR = 0.42; CI: 0.21–0.83; P = 0.013). A higher HIV viral load at delivery was the only independent risk factor for MTCT. Early and universal access to ARVs during pregnancy are the most important measures to decrease vertical HIV-1 transmission even in areas where HIV clade distribution differs.
Collapse
Affiliation(s)
- M Tornatore
- Universidade Federal do Rio Grande, Rio Grande do Sul
| | - C V Gonçalves
- Universidade Federal do Rio Grande, Rio Grande do Sul
| | | | - J M Silveira
- Universidade Federal do Rio Grande, Rio Grande do Sul
| | - N E D'ávila
- Universidade Federal do Rio Grande, Rio Grande do Sul
| | - C G Maas
- Universidade Federal do Rio Grande, Rio Grande do Sul
| | - M S Bianchi
- Universidade Federal do Rio Grande, Rio Grande do Sul
| | - E M Pinheiro
- Universidade Federal do Rio Grande, Rio Grande do Sul
| | - E S Machado
- Departamento de Genética, Universidade Federal do Rio de Janeiro
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro
| | - M A Soares
- Departamento de Genética, Universidade Federal do Rio de Janeiro
- Divisão de Genética, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
| | | |
Collapse
|
14
|
Størdal K. [HIV transmission from mother to child--can the epidemic be stopped?]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2010; 130:480-2. [PMID: 20224613 DOI: 10.4045/tidsskr.08.0594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND HIV (human immunodeficiency virus) may be transmitted from mother to child during pregnancy, delivery and breast-feeding. Transmission can be prevented, and efficient methods have caused vertical transmission to become rare in Europe and the USA. The article discusses the global HIV epidemic among children and challenges in reducing transmission from HIV-positive mothers. MATERIAL AND METHODS The article is based on literature retrieved through a non-systematic search in Medline and experience from working as a paediatrician in Botswana. RESULTS HIV transmission from mother to child can be reduced from about 30 % to 4 % with relatively simple measures. In many high-endemic areas in Sub-Saharan Africa, little is done to prevent HIV transmission to neonates. Major challenges exist in identifying pregnant women with HIV, especially in areas which lack pregnancy surveillance programmes. INTERPRETATION To prevent neonatal transmission, safe feeding practices should be encouraged and retroviral drugs should be available. The increasing focus and investments in HIV prevention are possible explanations for the decline of the epidemic.
Collapse
|
15
|
Use of antiretrovirals during pregnancy and breastfeeding in low-income and middle-income countries. Curr Opin HIV AIDS 2010; 5:48-53. [PMID: 20046147 DOI: 10.1097/coh.0b013e328333b8ab] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of the study was to review recent evidence on the use of antiretrovirals during pregnancy and breastfeeding in low-income and middle-income settings. RECENT FINDINGS Access to antiretroviral prophylaxis strategies for HIV-infected pregnant women has increased globally, but two-thirds of women in need still do not receive even the simplest regimen for the prevention of mother-to-child transmission of HIV, and most pregnant women in need of antiretroviral treatment do not receive it. The use of combination antiretroviral treatment in pregnancy in low-resource settings is safe and effective, and increasing evidence supports starting ongoing antiretroviral treatment at a CD4 cell count below 350/microl in pregnant women. The use of appropriate short-course antiretroviral prophylactic regimens is effective for prevention of mother-to-child transmission of HIV in women with higher CD4 cell counts. New data on the use of antiretroviral prophylaxis to prevent transmission through breastfeeding demonstrate that both maternal antiretroviral treatment and extended infant prophylaxis are effective. SUMMARY Antiretroviral use in pregnancy can benefit mothers in need of treatment and reduce the risk of mother-to-child transmission. Emerging evidence of the effectiveness of antiretroviral prophylaxis in preventing transmission through breastfeeding is encouraging and likely to influence practice in the future.
Collapse
|