Socio-economic, clinical and biological risk factors for mother - to - child transmission of HIV-1 in Muhima health centre (Rwanda): a prospective cohort study

Mixed-methods cross-sectional study of the prevention of vertical HIV transmission program users unaware of male partner's HIV status, in six South African districts with a high antenatal HIV burden

BACKGROUND

Elimination of vertical HIV Transmission (VHT) and maternal deaths are global health priorities. Male involvement is one of the most important factors that influences women's decisions, including the uptake of Prevention of vertical HIV transmission (P-VHT). We sought to understand not knowing a male partner's HIV status (MPHIVs) amongst women using services to prevent vertical HIV transmission in six South African districts with high antenatal HIV burden.

METHODS

A mixed-methods cross-sectional study was conducted in six South African districts, and data collected through face-to-face interviews with women and focus group discussions (FGDs) with women or male partners. The quantitative data were analyzed using STATA SE-17.0 and an inductive approach was used for qualitative data analysis.

RESULTS

Overall, 28.7% of women were unaware of their MPHIVs, while 25.3% and 46.0% knew the MPHIVs was positive or negative, respectively. In multivariable logistic regression, single marital status and unplanned pregnancy increased the odds of not knowing a MPHIVs while a woman's disclosure of her HIV status to the male partner reduced the odds. FDGs highlighted complexities around MPHIVs disclosure, e.g., reluctance to test for HIV and potential interventions including healthcare worker (HCW) assisted HIV disclosure.

CONCLUSION

User-informed interventions to address MPHIVs non-disclosure amongst women of child-bearing age, particularly those at risk of unstable sexual partners and unplanned pregnancies, should be strengthened.

Evaluation of Prevention of Mother to Child Transmission Programme at a Tertiary Healthcare Facility in Southwestern Nigeria

Most children acquire human immunodeficiency virus (HIV) infection through mother-to-child transmission (MTCT). The risk of MTCT of HIV is generally 15%-40% without prophylaxis. MTCT has been responsible for approximately 370,000 infant HIV infections worldwide, with Nigeria accounting for 30% of cases. The study evaluated the effectiveness of a prevention program for MTCT of HIV infection by determining the rate of MTCT of HIV in infants who underwent the program by reviewing health records of mother-infant pairs at the Olabisi Onabanjo University Teaching Hospital. This cross-sectional study conducted over 12 years used medical records of 545 mother-infant pairs. The rate of MTCT of HIV infection was 2.9% in this study compared to 7.1% reported by the center earlier. The rate of MTCT of HIV infection was the lowest among mother-infant pairs who received prophylaxis. Ages at recruitment are a strong determinant of the risk of infection. Late usage of the MTCT prevention service is a risk for HIV infection in exposed infants.

Maternal Socio-Demographic Factors and Mother-to-Child Transmission of HIV in the North Region of Cameroon

BACKGROUND AND OBJECTIVE

Socio-demographic factors are important risk factors for HIV infection. Maternal socio-demographic factors associated with HIV transmission from mother to child are not well elucidated to our knowledge. This study aimed to assess the maternal socio-demographic factors associated with HIV vertical transmission.

METHODS

A matched case-control study was conducted among children under 15 years of age born to HIV-infected mothers; using a structured questionnaire. The study was conducted in four health facilities in the North Region of Cameroon from July 2015 to October 2016. HIV- infected children were the cases, and HIV-uninfected children were the controls. One case was matched to nearly 4 controls according to age and sex. A total of 113 HIV-infected mothers of children under 15 years of age were purposively enrolled in the study. A questionnaire was administered to mothers and socio-demographic characteristics were collected. Blood samples were collected from the mother and her child for the determination or confirmation of HIV status. Univariate and multiple logistic regressions were used to assess associations between socio-demographic variables and HIV transmission from mother to child.

RESULTS

A total of 113 HIV-infected mothers and 113 children under 15 years of age were enrolled in this study. The majority of the mothers were between the age ranges of 25 years to 34 years. Of the 113 HIV-infected mothers, 69 (61%) were Muslims, 33 (32.1%) were not educated, 88 (77.8%) were unemployed, 80 (70.9%) were married, out of which 49 (61.6%) were engaged in a monogamous union. Of the 113 children (49.6%) were female, 25 (22.1%) were HIV-infected and 88 (77.9%) were HIV-exposed uninfected. At the univariate level, mothers who achieved a primary level of education were less likely to transmit HIV to infants compared to uneducated mothers [OR=0.28; CI (0.08-0.95); p=0.04]; and widows had a higher likelihood of HIV transmission to infants compared to married mothers [OR=4.65; CI (1.26-17.20); p=0.02]. Using multiple logistic regression, the maternal primary education level [aOR=0.32; CI (0.08-0.90); p=0.03] and widowerhood [aOR=7.05; CI (1.49-33.24); p=0.01] remained highly associated with the likelihood of HIV transmission to infants.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Uneducated mothers and widows had a higher likelihood of mother-to-child transmission of HIV. Our findings should prompt reinforcement of prevention strategies targeting uneducated women and widows.

Male partner unknown HIV status as a risk factor for HIV incidence and clinical outcomes in prevention of mother-to-child transmission of HIV programmes in 21 WHO priority countries: a systematic review protocol

INTRODUCTION

Research has shown an association between increased disclosure of HIV status by pregnant and breastfeeding women and improved clinical health and that of their infant. Increasing awareness about their male partner's HIV status will no doubt lead to even better outcomes at the population level. Male partner involvement is important for improving outcomes of prevention of mother-to-child transmission of HIV (MTCT) as it improves social support and commitment from both parents of the baby to ensure sustained good health. Although lack of knowledge of the HIV status of a male partner is of great concern, limited research has been done to determine whether it remains one of the barriers to reaching the proposed goals of eliminating MTCT in pregnant or postpartum women. Our aim is to determine if lack of knowledge of a male partner's HIV status is a significant risk factor for HIV incidence and poor HIV clinical outcomes among pregnant women and postpartum women and their infants.

METHODS AND ANALYSIS

A systematic review and meta-analysis of experimental and observational studies will be conducted. The review will focus on knowledge of male partner's HIV status in the 21 priority countries most affected by HIV in Africa. We will search electronic databases such as PubMed/Medline, Scopus, Web of Science and Cochrane library, Science Direct, CINAHL, LILACS and SciELO databases from January 2011 to December 2021. We will also search the Pan African and WHO clinical trial registries and conference archives. We will conduct a quality assessment of eligible studies and evaluate the heterogeneity of the pooled studies using the I ² statistic. The statistical analysis will be performed using STATA statistical software V.16.

ETHICS AND DISSEMINATION

The study will use publicly available data and ethics exemption has been obtained from Human Research Ethics Committees, Faculty of Medicine & Health Sciences, Stellenbosch University. The protocol was registered on Prospective Register of Systematic Reviews, registration number CRD42021247686, in May 2021. Findings of this systematic review will be disseminated in peer-review journals including various media platforms, that is, webinars, symposia, conferences or congresses.

PROSPERO REGISTRATION NUMBER

Registration number CRD42021247686.

HIV viral load non-suppression and associated factors among pregnant and postpartum women in rural northeastern South Africa: a cross-sectional survey

OBJECTIVES

We aimed to measure the prevalence of maternal HIV viral load (VL) non-suppression and assess associated factors, to evaluate progress towards United Nations-AIDS (UNAIDS) targets.

DESIGN

Cross-sectional study.

SETTING

The eight largest community health centres of Ehlanzeni, a rural district in northeast South Africa.

PARTICIPANTS

Pregnant women living with HIV (WLHIV) in their third trimester and postpartum WLHIV and their biological infants, recruited equally across all stages of the first 24 months post partum, were included. A sample of 612 mothers participated from a target of 1000.

PRIMARY OUTCOME MEASURES

The primary outcome was maternal VL (mVL) non-suppression (defined here as mVL >1000 copies/mL). We collected information on antiretroviral use, healthcare visits and sociodemographics through interviews and measured plasma mVL. Descriptive statistics, χ² tests and multivariable logistic regression analysis were conducted.

RESULTS

All mothers (median age: 30 years) were on antiretroviral therapy (ART) and 24.9% were on ART ≤12 months. The prevalence of mVL non-suppression was 14.7% (95% CI: 11.3% to 19.0%), while 13.8% had low-level viraemia (50-1000 copies/mL). Most (68.9%) women had initiated breast feeding and 37.6% were currently breast feeding their infants. Being younger than 25 years (adjusted odds ratio (AOR): 2.6 (95% CI: 1.1 to 6.4)), on first-line ART (AOR: 2.3 (95% CI: 1.1 to 4.6)) and married/cohabiting (AOR: 1.9 (95% CI: 1.0 to 3.7)) were significantly associated with increased odds of mVL non-suppression.

CONCLUSIONS

The prevalence of mVL ≤1000 copies/mL of 85.3% among pregnant and postpartum WLHIV and attending public healthcare centres in this rural district is below the 2020 90-90-90 and 2030 95-95-95 UNAIDS targets. Given that low-level viraemia may also increase the risk of vertical HIV transmission, we recommend strengthened implementation of the new guidelines which include better ART options, improved ART regimen switching and mVL monitoring schedules, and intensified psychosocial support for younger women, while exploring district-level complementary interventions, to sustain VLs below 50 copies/mL among all women.

Mother-to-child transmission of HIV infection and its associated factors in the district of Bilene, Gaza Province-Mozambique

Background

Mother-to-child transmission of HIV infection is a significant problem in Mozambique. This study aims to determine the risk factors associated with mother-to-child transmission of HIV in rural Mozambique.

Methods

Retrospective case-control study in a rural area of Bilene District, on the coast of southern Mozambique, performed from January 2017 to June 2018. The analysis considered the clinical data of HIV exposed children with definitive HIV positive results and their respective infected mothers (cases), and the data of HIV exposed children with definitive HIV negative results and their respective infected mothers (controls) registered in At Risk Child Clinics from 1st January 2017 to 30th June 2018 at the Macia and Praia de Bilene health facilities in Bilene district, Gaza province–Mozambique.

Results

Ninety pregnant women with HIV were involved in the study, including 30 who had transmitted the infection to their children and 60 who had not. Statistical analysis, adjusted for maternal age and gestational age at first antenatal care visit, showed that independent risk factors for transmission were gestational age at first visit (adjusted odds ratio [aOR] 1.19, 95% confidence interval [CI] 1.05–1.36), non-adherence to combination antiretroviral therapy (56.7% vs. 5%; aOR 14.12, 95% CI 3.15–63.41); a viral load of 1000 copies/mL or more (90% vs. 5%; aOR: 156, 95% CI 22.91–1,062) and female sex of the neonate (80% vs. 51.7%; aOR: 4.43, 95% CI 1.33–15.87).

Conclusion

A high viral load and non-adherence to antiretroviral therapy are important predictors of mother-to-child HIV transmission.

Prevention of HIV Transmission from Mother to Child: Challenges to the Successful Program Implementation and Practice in Indonesia

Introduction:

The level of human immunodeficiency virus (HIV) transmission from mother to child in Indonesia ranks first worldwide. Newborn babies in Indonesia are at greater risk of experiencing the burden of HIV infection than babies born in other countries.

Objectives:

To explore the full extent of Prevention of Mother to Child Transmission (PMTCT) in South Sulawesi Province in 2020 and to discuss program and policy implications for PMTCT.

Methods:

This is a health system analysis study with a qualitative approach using focus group discussion, in-depth interviews, and observations in primary health centers and hospitals.

Results:

There is no local policy and guidelines for PMTCT programs and services; the coverage of HIV testing in pregnant women has not achieved 100% according to the target. There are limitations to human resources in public and private services to conduct the program. The assistance’s activities to ensure antiretroviral (ARV) adherence are limited, and HIV-positive women faced stigma and discrimination, not only from the community but also from health workers.

Recommendations:

Some recommendations are to improve the HIV test coverage to 100% in pregnant women as well as the coverage and quality of ARV treatment.

Impact of maternal ART on mother-to-child transmission (MTCT) of HIV at six weeks postpartum in Rwanda

BACKGROUND

In 2010, Rwanda adopted ART for prevention of mother to child transmission of HIV from pregnant women living with HIV during pregnancy and breasfeeding period. This study examines rates of mother-to-child-transmission of HIV at 6-10 weeks postpartum and risk factors for mother-to-child transmission of HIV (MTCT) among HIV infected women on ART during pregnancy and breastfeeding.

METHODS

A cross-sectional survey study was conducted between July 2011-June 2012 among HIV-exposed infants aged 6-10 weeks and their mothers/caregivers. Stratified multi-stage, probability proportional to size and systematic sampling to select a national representative sample of clients. Consenting mothers/caregivers were interviewed on demographic and program interventions. Dry blood spots from HIV-exposed infants were collected for HIV testing using DNA PCR technique. Results are weighted for sample realization. Univariable analysis of socio-demographic and programmatic determinants of early mother-to-child transmission of HIV was conducted. Variables were retained for final multivariable models if they were either at least of marginal significance (p-value < 0.10) or played a confounding role (the variable had a noticeable impact > 10% change on the effect estimate).

RESULTS

The study sample was 1639 infants with HIV test results. Twenty-six infants were diagnosed HIV-positive translating to a weighted MTCT estimate of 1.58% (95% CI 1.05-2.37%). Coverage of most elimination of MTCT (EMTCT) program interventions, was above 80, and 90.4% of mother-infant pairs received antiretroviral treatment or prophylaxis. Maternal ART and infant antiretroviral prophylaxis (OR 0.01; 95%CI 0.001-0.17) and maternal age older than 25 years were significantly protective (OR 0.33; 95%CI 0.14-0.78). No disclosure of HIV status, not testing for syphilis during pregnancy and preterm birth were significant risk factors for MTCT. Factors suggesting higher socio-demographic status (flush toilet, mother self-employed) were borderline risk factors for MTCT.

CONCLUSION

ART for all women during pregnancy and breastfeeding was associated with the estimated low MTCT rate of 1.58%. Mothers who did not receive a full package of anti-retroviral therapy according to the Rwanda EMTCT protocol, and young and single mothers were at higher risk of MTCT and should be targeted for support in preventing HIV infection.

Why is mother to child transmission (MTCT) of HIV a continual threat to new-borns in sub-Saharan Africa (SSA)

Sub-Saharan Africa (SSA) accounts for more than two thirds of the world's HIV infection. Despite scaled-up prevention of mother-to-child transmission of HIV (PMTCT) programmes, mother to child transmission of HIV (MTCT) continues to escalate. We describe the challenges faced by PMTCT in MTCT in SSA. The study reviewed articles and reports published online. The most common barriers and challenges were non-disclosure of HIV status, late initiation of ARVs treatment/adherence, STIs screening, long clinics waiting time, non-involvement of men in ANC/PMTCT, infant feeding methods and sensitization of community members on ANC/PMTCT programmes. The study highlights the need to expand PMTCT coverage and the implementation of the 90-90-90 programme toward MTCT elimination in SSA. That is " ≥90% of pregnant and breast-feeding mothers must know their HIV status; ≥90% of those that are positive are enrolled on ARVs treatment and care; ≥90% of those on ARVs treatment and care are virally suppressed.

Non-disclosure of HIV-positive status to a partner and mother-to-child transmission of HIV: Evidence from a case-control study conducted in a rural county in Kenya

BACKGROUND

Many factors contribute to an enhanced risk of infant HIV acquisition, two of which may include failure of a mother to disclose her HIV-positive status to her partner and exclusion of male partners in preventing mother-to-child transmission of HIV (PMTCT) interventions. To justify why HIV programmes need to integrate male partner involvement and partner disclosure, we need to establish an association between the two factors and infant HIV acquisition.

OBJECTIVE

To determine whether failure to disclose an HIV-positive status to a male partner is associated with increased risk of infant HIV acquisition, and whether part of the association is explained by exclusion of male partner in PMTCT programmes.

METHODS

Using a case-control study design, we identified a total of 180 mother-baby pairs with HIV-exposed infants. Thirty-six pairs with HIV-positive babies (cases) were compared to 144 pairs with HIV-negative babies (controls) on whether the mothers had disclosed their HIV status to their partner in order to determine whether a disclosure or lack of it contributed to increased risk of mother-to-child transmission of HIV (MTCT). Each case pair was matched to four control pairs from the same facility.

RESULTS

Overall, 16.7% of mothers had not disclosed their HIV status to their partners, the proportion being significantly more among cases (52.8% vs. 7.6%, p < 0.001). Non-disclosure was significantly associated with infant HIV acquisition (aOR 9.8 (3.0-26.3); p < 0.001) and male partner involvement partially mediated the effect of non-disclosure on infant HIV acquisition (indirect coefficient = 0.17, p < 0.005).

CONCLUSIONS

Failure of an HIV-positive woman to disclose her status to her male partner and exclusion of male partners in PMTCT programmes are two social factors that may curtail success of interventions towards the goal of eliminating MTCT.

Epidemiology of children with acquired immune deficiency syndrome (stage 3): A referral hospital-based study in Iran

Lack of recognition of human immunodeficiency virus (HIV) infection especially in children and delayed implementation of effective control programs makes HIV infection as a major cause for concern. Information on HIV epidemiology in Iran as well as other Islamic countries is limited. The aim of our study was to describe the clinical manifestation and laboratory finding of HIV infected children who were admitted to a referral Children Medical Center (CMC) in Tehran, Iran, during 11 years from January 2002 to January 2013. This was a retrospective study carried out over a period of 11 years. The records of all patients attending to the CMC with confirmed acquired immunodeficiency syndrome (AIDS) were screened. The patients were evaluated for social circumstance, family history, age, gender, clinical, and laboratory features. Clinical data including fever, respiratory distress, diarrhea, rash, etc. as well as laboratory tests including complete blood count, serum glucose level, electrolytes, liver function test, cultures, CD4 lymphocyte count were evaluated. During the study period, 32 HIV positive children were enrolled. The majority of patients were presented with weight loss, prolonged fever, respiratory infection and chronic diarrhea. In this study, salmonella infections as well as streptococcal pneumonia and candida infections followed by, tuberculosis and Pseudomonas aeruginosa infections were the predominant opportunistic infections. Since the number of HIV-positive children has been alarmingly increasing in recent years and perinatal transmission is the most common route of HIV infection in children, essential recommendations for prenatal HIV testing as well as appropriate antiretroviral therapy by HIV infected mothers are needed.

Obstetrical, maternal characteristics and outcome of HIV-infected rapid progressor infants at Yaounde: a retrospective study

BACKGROUND

Rapid progressors are exposed to HIV infection at an early stage of life, and the prognosis is poor without treatment. Reducing the proportion of infants who are rapid progressors, require strengthening strategies to achieve the highest level of performance for the PMTCT program.

METHODS

This was a retrospective study carried out on HIV infected infants aged less than 12 months, clinically classified stage 4 (WHO) or having CD4 count <25%. We described maternal and obstetrical characteristics of HIV-infected rapid progressors using univariate and bivariate analysis. Patients' survival was monitored from the inclusion time to the end of the study. We then estimated their probability of survival with or without anti-retroviral (ARV) treatment from birth using the Kaplan-Meier method.

RESULTS

The characteristics of the mothers of the 150 rapid progressors infants we included were: low level of education (OR=3.87; P=0.016), CD4 count less than 200/mm(3) (OR=43.3; P=0.000), absence of ARV prophylaxis (OR=6.02; P=0.043), or treatment with HAART (OR=5.74; P=0.000) during pregnancy. In the children, the most important findings were lack of co-trimoxazole prophylaxis (OR=11.61; P=0.000) and antiretroviral prophylaxis (OR=2.70; P=0.0344). The survival rate was 84.3% in infants who were receiving HAART as opposed to 43.3% in those who were not (P<0.05).

CONCLUSIONS

HIV infected women who are eligible should start antiretroviral treatment prior to a pregnancy, in order to improve their immunological status. This measure associated to cotrimoxazole prophylaxis and ART could improve their survival.

Eliminating mother-to-child transmission of the human immunodeficiency virus in sub-Saharan Africa: The journey so far and what remains to be done

This review was carried out to provide a comprehensive overview of efforts toward elimination of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) with respect to progress, challenges, and recommendations in 21 sub-Saharan African priority countries. We reviewed literature published from 2011 to April 2015 using 3 databases; PubMed, Scopus, and Web of Science, as well as the 2014 Global Plan Progress Report. A total of 39 studies were included. Between 2009 and 2013, there was a 43% reduction in new HIV infections, the final MTCT rate was reduced from 28% to 18%, and antiretroviral therapy (ART) coverage increased from 11% to 24%. Challenges included poor adherence to antiretroviral therapy, poor linkage between mother-child pairs and post-natal healthcare services low early infant diagnosis coverage, low pediatric ART coverage, and high unmet needs for contraceptive services. Future recommendations include identification of key barriers, health system strengthening, strengthening community involvement, and international collaboration. There has been significant progress toward eliminating MTCT of HIV, but more effort is still needed.

Implementing primary health care-based PMTCT interventions: operational perspectives from Muhima cohort analysis (Rwanda)

INTRODUCTION

In countries with high burden of HIV, major programmatic challenges have been identified to preventing new infections among children and scaling up of treatment for pregnant mothers. We initiated this study to examine operational approaches that were used to enhance implementation of PMTCT interventions in Muhima health Centre (Kigali/Rwanda) from 2007 to 2010.

METHODS

The prospective cohort study was conducted at Muhima health centre. A sample size of 656 was the minimum number required for the study. The main outcome was cumulative incidence of mother - to - child transmission of HIV-1 measured at 6 weeks of life among live born children.

RESULTS

Among the 679 live born babies and followed up in this study, the overall cumulative rate of HIV-1 mother - to - child transmission observed was 3.2% at 6 weeks of age after birth. Disclosure of HIV status to partner was significantly associated with HIV-1 status of infants at 6 weeks of age (non-disclosure of HIV status adjusted odds ratio [AOR] 4.68, CI 1.39 to 15.77, p.

CONCLUSION

The Muhima type of decentralized health facility offered an appropriate platform for implementation of PMTCT interventions, with the following operational features: family - centered approach; integrated service delivery for PMTCT/MCH interventions, task shifting; subsidized membership fees for people living with HIV, allowing for access to the community-based health insurance benefits.

Double disclosure bind: complexities of communicating an HIV diagnosis in the context of unintended pregnancy in Durban, South Africa

Disclosure of HIV status is widely promoted in the prevention of mother-to-child transmission (PMTCT), but a number of context-specific factors may mediate disclosure outcomes. To better understand HIV-disclosure dynamics, we conducted in-depth interviews among 62 HIV-positive pregnant women accessing PMTCT services in Durban, South Africa. Transcripts were coded for emergent themes and categories. Thirty-nine women (63 %) had been recently diagnosed with HIV; most (n = 37; 95 %) were diagnosed following routine antenatal HIV testing. Forty-two women (68 %) reported unplanned pregnancies. Overall, 37 women (60 %) reported an unintended pregnancy and recent HIV diagnosis. For them, 2 life-changing diagnoses had resulted in a double-disclosure bind. The timing and stigma surrounding these events strongly influenced disclosure of pregnancy and/or HIV. PMTCT-related counseling must be responsive to the complex personal implications of contemporaneous, life-changing events, especially their effect on HIV-disclosure dynamics and, ultimately, on achieving better maternal mental-health outcomes.