Correlates and determinants of Early Infant Diagnosis outcomes in North-Central Nigeria

Reduced mother-to-child transmission rates of HIV between 2017 and 2020 in Kenya. What changed?

Background

In 205 health facilities, mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) rates were reduced from 7.4% to 2.1% between 2017 and 2020, respectively.

Aim

To determine characteristics that potentially correlate to the change in MTCT rates between two time points.

Setting

Study was conducted in Kenya, semi-urban and rural areas.

Methods

A retrospective, cross-sectional, exploratory analysis of programme implementation at two points in time (2017 and 2020). Between 2017 and 2020, we compared over 170 mother-infant pairs where MTCT occurred to over 6000 mother-infant pairs where MTCT did not occur through the following factors: (1) location of health facilities, (2) mother and infant characteristics, (3) access to antiretroviral therapy (ART), and (4) viral load suppression. Bivariate and multivariable logistic regression models were used to identify factors associated with MTCT.

Results

Factors significantly associated with reduced MTCT rates were time points, mother's age, infant age at first test, proportions of mothers receiving ART, and maternal viral load. When restricting the analysis to the sub-counties contributing data at both time points, the results were similar; however, counties' location became significant in the updated model, as did the interaction term for mother and infant receipt of antiretrovirals (odds ratio [OR]: 0.228; p = 0.04).

Conclusion

What changed between 2017 and 2020 is a higher proportion of pregnant women living with HIV received ART. Also, unlike in 2017, in 2020, tenofovir disoproxil fumarate was the backbone of the ART regimen for the prevention of MTCT.

Contribution

The findings can potentially inform efforts on elimination of mother-to-child transmission of HIV.

Rapid antiretroviral therapy initiation following rollout of point-of-care early infant diagnosis testing, Uganda, 2018-2021

BACKGROUND

Uganda Ministry of Health (MOH) recommends a first HIV DNA-PCR test at 4-6 weeks for early infant diagnosis (EID) of HIV-exposed infants (HEI) and immediate return of results. WHO recommends initiating antiretroviral therapy (ART) ≤ 7 days from HIV diagnosis. In 2019, MOH introduced point-of-care (POC) whole-blood EID testing in 33 health facilities and scaled up to 130 facilities in 2020. We assessed results turnaround time and ART linkage pre-POC and during POC testing.

METHODS

We evaluated EID register data for HEI at 10 health facilities with POC and EID testing volume of ≥ 12 infants/month from 2018 to 2021. We abstracted data for 12 months before and after POC testing rollout and compared time to sample collection, results receipt, and ART initiation between periods using medians, Wilcoxon, and log-rank tests.

RESULTS

Data for 4.004 HEI were abstracted, of which 1.685 (42%) were from the pre-POC period and 2.319 (58%) were from the period during POC; 3.773 (94%) had a first EID test (pre-POC: 1.649 [44%]; during POC: 2.124 [56%]). Median age at sample collection was 44 (IQR 38-51) days pre-POC and 42 (IQR 33-50) days during POC (p < 0.001). Among 3.773 HEI tested, 3.678 (97%) had test results. HIV-positive infants' (n = 69) median age at sample collection was 94 (IQR 43-124) days pre-POC and 125 (IQR 74-206) days during POC (p = 0.04). HIV positivity rate was 1.6% (27/1.617) pre-POC and 2.0% (42/2.061) during POC (p = 0.43). For all infants, median days from sample collection to results receipt by infants' caregivers was 28 (IQR 14-52) pre-POC and 1 (IQR 0-25) during POC (p < 0.001); among HIV-positive infants, median days were 23 (IQR 7-30) pre-POC and 0 (0-3) during POC (p < 0.001). Pre-POC, 4% (1/23) HIV-positive infants started ART on the sample collection day compared to 33% (12/37) during POC (p < 0.001); ART linkage ≤ 7 days from HIV diagnosis was 74% (17/23) pre-POC and 95% (35/37) during POC (p < 0.001).

CONCLUSION

POC testing improved EID results turnaround time and ART initiation for HIV-positive infants. While POC testing expansion could further improve ART linkage and loss to follow-up, there is need to explore barriers around same-day ART initiation for infants receiving POC testing.

Early infant diagnosis testing for HIV in a hard-to-reach fishing community in Uganda

BACKGROUND

Infants born to HIV-infected mothers are at a high risk of acquiring the infection. The World Health Organization recommends early diagnosis of HIV-exposed infants (HEIs) through deoxyribonucleic acid polymerase chain reaction (DNA PCR) and rapid HIV testing. Early detection of paediatric HIV is critical for access to antiretroviral therapy (ART) and child survival. However, there is limited evidence of the factors associated with receiving early infant diagnosis (EID) tests of the HIV testing protocol among HEIs in fishing communities in Uganda. This study established the factors associated with receiving EID tests of the HIV testing protocol among HEIs in a hard-to-reach fishing community in Uganda.

METHODS

A cross-sectional study was conducted among HEIs in selected healthcare facilities in Buvuma islands, Buvuma district. We obtained secondary data from mother-infant pair files enrolled in the EID program using a data extraction tool. Data were analysed using STATA Version 14. A modified Poisson regression analysis was used to determine the factors associated with not receiving the 1st DNA PCR test among HEIs enrolled in care.

RESULTS

None of the HEIs had received all the EID tests prescribed by the HIV testing protocol within the recommended time frame for the period of January 2014-December 2016. The proportion of infants that had received the 1st and 2nd DNA PCR, and rapid HIV tests was 39.5%, 6.1%, and 81.0% respectively. Being under the care of a single mother (PR = 1.11, 95% CI: 1.01-1.23, p = 0.023) and cessation of breastfeeding (PR = 0.90, 95% CI: 0.83-0.98, p = 0.025) were significantly associated with not receiving the 1st DNA PCR.

CONCLUSION

Our study revealed that none of the HEIs had received all the EID tests of the HIV diagnosis testing protocol. Receiving the 1st DNA PCR was positively associated with being an infant born to a single mother, and exclusive breastfeeding. Our findings highlight the need for the creation of an enabling environment for mothers and caregivers in order to increase the uptake of early diagnosis services for HEIs. Awareness-raising on the importance of EID should be scaled up in fishing communities. Demographic characteristics such as marital and breastfeeding status should be used as an entry point to increase the proportion of HEIs who receive EID tests.

Association between service readiness and PMTCT cascade effectiveness: a 2018 cross-sectional analysis from Manica province, Mozambique

BACKGROUND

Despite high coverage of maternal and child  health services in Mozambique, prevention of mother-to-child transmission of HIV (PMTCT) cascade outcomes remain sub-optimal. Delivery effectiveness is modified by health system preparedness. Identifying modifiable factors that impact quality of care and service uptake can inform strategies to improve the effectiveness of PMTCT programs. We estimated associations between facility-level modifiable health system readiness measures and three PMTCT outcomes: Early infant diagnosis (polymerase chain reaction (PCR) before 8 weeks of life), PCR ever (before or after 8 weeks), and positive PCR test result.

METHODS

A 2018 cross-sectional, facility-level survey was conducted in a sample of 36 health facilities covering all 12 districts in Manica province, central Mozambique, as part of a baseline assessment for the SAIA-SCALE trial (NCT03425136). Data on HIV testing outcomes among 3,427 exposed infants were abstracted from at-risk child service registries. Nine health system readiness measures were included in the analysis. Logistic regressions were used to estimate associations between readiness measures and pediatric HIV testing outcomes. Odds ratios (OR) and 95% confidence intervals (95%CI) are reported.

RESULTS

Forty-eight percent of HIV-exposed infants had a PCR test within 8 weeks of life, 69% had a PCR test ever, and 6% tested positive. Staffing levels, glove stockouts, and distance to the reference laboratory were positively associated with early PCR (OR = 1.02 [95%CI: 1.01-1.02], OR = 1.73 [95%CI: 1.24-2.40] and OR = 1.01 [95%CI: 1.00-1.01], respectively) and ever PCR (OR = 1.02 [95%CI: 1.01-1.02], OR = 1.80 [95%CI: 1.26-2.58] and OR = 1.01 [95%CI: 1.00-1.01], respectively). Catchment area size and multiple NGOs supporting PMTCT services were associated with early PCR testing OR = 1.02 [95%CI: 1.01-1.03] and OR = 0.54 [95%CI: 0.30-0.97], respectively). Facility type, stockout of prophylactic antiretrovirals, the presence of quality improvement programs and mothers' support groups in the health facility were not associated with PCR testing. No significant associations with positive HIV diagnosis were found.

CONCLUSION

Salient modifiable factors associated with HIV testing for exposed infants include staffing levels, NGO support, stockout of essential commodities and accessibility of reference laboratories. Our study provides insights into modifiable factors that could be targeted to improve PMTCT performance, particularly at small and rural facilities.

The impact of Option B+ on mother-to-child transmission of HIV in Africa: A systematic review

OBJECTIVE

In 2015, the WHO released new guidelines to reduce mother-to-child transmission (MTCT) of HIV. The recommendations, known as Option B+, included initiation of lifelong highly active antiretroviral therapy regardless of CD4 count for all HIV-positive pregnant and breastfeeding mothers. For infants, exclusive breastfeeding for 6 months and antiviral therapy were sanctioned. Targets of <5% transmission in breastfeeding populations and <2% in non-breastfeeding populations were set. This review evaluated the impact of Option B+ on MTCT in African countries.

METHODS

Using the PRISMA guidelines, a systematic search of PubMed and Google Scholar databases was conducted to identify relevant studies published between 2015 and 2021. All studies meeting inclusion criteria were evaluated.

RESULTS

Of the 687 references screened, 22 studies from 11 countries (Cameroon, Ethiopia, Lesotho, Malawi, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe) met inclusion criteria. Six studies reported MTCT rates of <2%, 16 studies reported rates of 2-5% and two studies (Uganda and Zambia) reported 6% or more. Rates varied within the same study at different time points postpartum and amongst studies from the same country. Overall, reported MTCT rates appear to be close to WHO targets. However, diverse study designs, selection bias, extensive loss to follow-up and undocumented adherence rates to Option B+ protocols may significantly underestimate MTCT rates of HIV in Africa.

CONCLUSIONS

Standardised protocols for impact evaluation must be established to provide evidenced-based data on the efficacy of Option B+ in Africa.

A Review and Analysis of Outcomes from Prevention of Mother-to-Child Transmission of HIV Infant Follow-up Services at a Pediatric Infectious Diseases Unit of a Major Tertiary Hospital in Nigeria: 2007-2020

BACKGROUND AND OBJECTIVE

Above 90% of childhood HIV infections result from mother-to-child transmission (MTCT). This study examined the MTCT rates of HIV-exposed infants enrolled in the infant follow-up arm of the prevention of mother-to-child transmission (PMTCT) program in a teaching hospital in Southeast Nigeria.

METHODS

This was a 14-year review of outcomes of infants enrolled in the infant follow-up arm of the PMTCT program of Nnamdi Azikiwe University Teaching Hospital Nnewi, Nigeria. The majority of subjects were enrolled within 72 hours of birth and were followed up until 18 months of age according to the National Guidelines on HIV prevention and treatment. At enrollment, relevant data were collected prospectively, and each scheduled follow-up visit was recorded both electronically and in physical copy in the client's folders. Data were analyzed using SPSS version 20. The major outcome variable was final MTCT status.

RESULTS

Out of 3,784 mother-infant dyads studied 3,049 (80.6%) received both maternal and infant Antiretroviral (ARV) prophylaxis while 447 (11.8%) received none. The MTCT rates were 1.4%, 9.3%, 24.1%, and 52.1% for both mother and infant, mother only, infant only, and none received ARV prophylaxis respectively. There was no gender-based difference in outcomes. The MTCT rate was significantly higher among mixed-fed infants (p<0.001) and among those who did not receive any form of ARVs (p<0.001). Among dyads who received no ARVs, breastfed infants significantly had a higher MTCT rate compared to never-breastfed infants (57.9% vs. 34.8%; p<0.001). The MTCT rate was comparable among breastfed (2.5%) and never-breastfed (2.1%) dyads who had received ARVs. After logistic regression, maternal (p<0.001, OR: 7.00) and infant (p<0.001, OR: 4.00) ARV prophylaxis for PMTCT remained significantly associated with being HIV-negative.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Appropriate use of ARVs and avoidance of mixed feeding in the first six months of life are vital to the success of PMTCT programs in developing countries. PMTCT promotes exclusive breastfeeding and reduces the burden of pediatric HIV infection, thereby enhancing child survival.