Retrospective analysis of risk factors and gaps in prevention strategies for mother-to-child HIV transmission in Rio de Janeiro, Brazil

Evaluating elimination of mother-to-child transmission of HIV in Suriname: a mixed method study

Objectives

To evaluate the cascade of care for the elimination of mother-to-child-transmission of human immunodeficiency virus (HIV) in Suriname and identify sociodemographic and clinical factors preventing transmission to exposed infants.

Methods

A mixed-methods study design was used. Antenatal care data from the 2018 cross-sectional multi-indicator cluster survey on 1 026 women aged 15-49 years who had had a live birth in the previous 2 years were used. Furthermore, national data on a cohort of 279 mothers with HIV and their 317 infants born from 2016 to 2018 were evaluated. Additionally, 13 cases of mother-to-child-transmission of HIV were reviewed.

Results

In 89.3% of cases, no mother-to-child HIV transmission occurred. Early cascade steps show that 28.4% of women had unmet family planning needs, 15% had no antenatal visits, 8% delivered outside a health facility, and 71.5% received an HIV test during antenatal care. Of the pregnant women with HIV, 84.2% received antiretroviral therapy, while 95.5% of their infants received HIV prophylactic treatment. Receiving antiretroviral therapy for the mother (odds ratio (OR) 45.4, 95% confidence interval (CI) 9.6-215.3) and the child (OR 145.7, 95% CI 14.4-1477.4) significantly increased the odds of a negative HIV test result in infants. Conversely, living in the interior decreased the odds (OR 0.2, 95% CI 0.4-0.7) compared with urban living.

Conclusions

HIV medication for mothers with HIV and their infants remains key in the prevention of mother-to-child-transmission of HIV. Early prenatal care with follow-up should be strengthened in Suriname.

Pregnancy incidence, outcomes and associated factors in a cohort of women living with HIV/AIDS in Rio de Janeiro, Brazil, 1996-2016

The aim of this research was to analyze pregnancy incidence and associated factors in a cohort of 753 women living with HIV/AIDS (WLWHA) in Rio de Janeiro, Brazil, from 1996 to 2016. Women aged 18-49 years who were not on menopause (surgical or natural) and did not have a tubal ligation were eligible for the study. Data were collected by medical professionals during initial and follow-up visits. Person-time pregnancy incidence rates were calculated throughout the follow-up period. Pregnancy incidence-associated factors were investigated by univariate and multiple analyzes, using an extension of the Cox survival model. Follow-up visits recorded 194 pregnancies, with an incidence rate of 4.01/100 person-years (95% CI: 3.47; 4.60). A higher pregnancy incidence was associated with CD4 nadir ≥ 350 cells/mm³, use of an antiretroviral regimen not containing Efavirenz, and prior teenage pregnancy. In turn, women with a viral load ≥ 50 copies/mL, age ≥ 35 years old, with two or more children and using a highly effective contraceptive method showed a lower incidence. Results showed a significant reduction in pregnancy incidence after 2006, a significant reduction in female sterilization from 1996 to 2016, and a high rate of cesarean sections. The association found between pregnancy incidence and the use of contraceptive methods and virological control markers suggests a good integration between HIV/AIDS and reproductive health services. The high rate of cesarean section delivery indicates the need to improve childbirth care.

Spatial variability of mother-to-child human immunodeficiency virus transmission in a province in the Brazilian Rainforest: An ecological study

The mother-to-child transmission (MTCT) of the human immunodeficiency virus (HIV) remains a serious public health problem in the Brazilian Rainforest. This study aimed to spatially analyze this type of infection between 2007 and 2018 in Pará, which is the second-largest Brazilian state in the Brazilian Rainforest and also has the highest MTCT of HIV in Brazil. We analyzed the incidence rates of HIV (including the acquired immunodeficiency syndrome (AIDS) by MTCT as the main route of infection in children younger than 13 years old and whose mothers live in Pará. We employed spatial autocorrelation, spatial scanning, and geographic-weighted spatial regression techniques. In the period of this study, 389 new HIV/AIDS were noted, with territorial expansion of the incidence rates in the municipalities in northern and southern Pará having the highest rates. São Francisco do Pará had high spatial risk and high-spatiotemporal risk clusters comprising municipalities in western and south-western Pará between 2013 and 2016. The spatial variability of HIV/AIDS incidence rates was found to be common in the number of men and women with formal jobs; unemployed ≥18 years old people; elementary school pupils; and families enrolled in the "Single Registry for Social Programs". The social equity approach in Pará guarantee pregnant women access to preventive, diagnostic and treatment health services and their children should be supported to eliminate the MTCT of HIV in Pará.

Mother-to-Child HIV Transmission among Pregnant Women in a City with the Highest Rates of HIV in Brazil

OBJECTIVE

Most of the HIV pediatric infections are acquired through mother-to-child transmission (MTCT). Porto Alegre is a state capital of Brazil that had a HIV MTCT rate of 4.1% in 2013 and the highest rate of HIV-infected pregnant women in the country during 2018. Zidovudine and nevirapine have been used in Brazil for high-risk newborns since 2012. The aim of the study was to investigate HIV MTCT rate and the factors associated with HIV transmission at a hospital that is a reference center for HIV-infected mothers in Porto Alegre, after the introduction of this policy.

STUDY DESIGN

This retrospective cohort study included all HIV-exposed infants born between February 2013 and December 2016 at the Hospital de Clínicas de Porto Alegre. Student's t-test or Fisher's exact test was used to compare variables between HIV-infected and uninfected groups of newborns. Poisson's regression with robust variance was used to determine the factors associated with HIV MTCT.

RESULTS

A total of 375 newborns were exposed to HIV, with an outpatient loss of 14.4% (n = 54). The HIV MTCT rate was 2.18% (n = 7), with four infected during the intrauterine period. The risk factors for MTCT were no prenatal care (relative risk [RR] = 9.4; 95% confidence interval [CI]: 2.0-44.3), late maternal HIV diagnosis in the peripartum period (RR = 16.3; 95% CI: 3.6-73.0), syphilis infection during pregnancy (RR = 9.3; 95% CI: 2.1-40.3), maternal viral load >1,000 copies/mL in the third trimester or peripartum period (RR = 9.5; 95% CI: 1.7-50.5), and lack of or inappropriate antiretroviral therapy during pregnancy (RR = 8.2; 95% CI: 1.6-41.4).

CONCLUSION

MTCT rate was 2.18%. With the institution of two-drug prophylaxis for high-risk newborns, persistent cases HIV MTCT were predominantly found among women with absence of antenatal care, late HIV diagnosis, syphilis coinfection, high viral load, and inadequate ARV therapy during pregnancy. Although zidovudine and nevirapine were administered postnatally to high-risk newborns, this regimen could not prevent transplacental transmission.

KEY POINTS

· Most of the HIV pediatric infections are acquired through mother-to-child transmission.. · The study investigated HIV MTCT rate and the factors associated with HIV transmission in Brazil.. · HIV MTCT rate was 2.18% and most of them were infected during the intrauterine period..

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

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

Review of the missed opportunities for the prevention of vertical transmission of HIV in Brazil

OBJECTIVE

The present literature review aims to highlight gaps in the treatment of preventative mother-to-child HIV transmission and the risk factors in Brazil.

METHODS

Among the 425 articles identified in SciELO and PubMed searches, 59 articles published between 1994 and 2016 were selected for reading and data extraction, and 33 articles were included in the present review.

RESULTS

The rates of vertical HIV transmission described in the studies varied widely, from 1.8% to 27.8%, with a significant reduction over the years. However, recent rates were also found to be variable in different regions of Brazil, and despite the significant reduction in mother-to-child transmission, many gaps remain in prevention services. A failure to attend prenatal care is the main factor associated with the increased risk of vertical transmission of HIV, hindering early maternal diagnosis and the completion of preventative measures during the prenatal period and, often, the peripartum and postnatal periods. A small number of studies discussed the sociodemographic factors, including a low level of education for pregnant women and the inadequacies of health services, such as difficulties scheduling appointments and undertrained staff, associated with vertical transmission. As such, the current challenge is to better define the sociodemographic and infrastructural factors that increase the risk of mother-to-child transmission of HIV to provide the necessary investments to promote an earlier inclusion of these populations in prevention services.

CONCLUSIONS

This review may serve as a guide for future programs to focus efforts on the prevention of vertical HIV transmission.