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Acheampong AK, Naab F, Kwashie A. Qualitative exploration of psychological reactions and coping strategies of breastfeeding mothers living with HIV in the Greater Accra Region of Ghana. Int Breastfeed J 2017; 12:28. [PMID: 28652860 PMCID: PMC5483253 DOI: 10.1186/s13006-017-0119-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 06/18/2017] [Indexed: 11/23/2022] Open
Abstract
Background Exploring the psychological reactions of breastfeeding mothers living with Human Immunodeficiency Virus (HIV) is an important step which may improve guidelines for counselling. The purpose of this study was to explore the psychological reactions and coping strategies of breastfeeding mothers living with HIV in the Greater Accra Region of Ghana. Methods Qualitative descriptive exploratory design was used to explore the psychological experiences and coping strategies of 13 breastfeeding mothers living with HIV in a main referral public hospital, at the greater Accra Region of Ghana. An interview guide was designed and piloted before it was used to collect data between November, 2014 and February, 2015. Data was content analyzed for themes and subthemes to emerge. Results The two major themes that emerged included psychological reactions and coping strategies. Some of the subthemes were fear, anxiety, blame, hope, denial, prayer and trust in positive situations of life. Conclusion The women used denial, prayer and hope in ART, among others to cope with their emotions. This highlights the need for HIV counsellors to detect signs of denial since it can lead to non-adherence to ART as well as relapse. Health workers should therefore put the coping strategies in context during counselling of mothers in this category.
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Affiliation(s)
- Angela Kwartemaa Acheampong
- School of Nursing, Wisconsin International University College-Ghana, Taifa-Burkina, P. O. Box TB 105, Accra, Ghana
| | - Florence Naab
- Department of Maternal and Child Health, School of Nursing, College of Health Science, University of Ghana, Legon, P. O. Box LG 43, Accra, Ghana
| | - Adzo Kwashie
- Department of Education, Research & Administration, School of Nursing, College of Health Science, University of Ghana, Legon, P. O. Box LG 43, Accra, Ghana
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Egbe TO, Tazinya RMA, Halle-Ekane GE, Egbe EN, Achidi EA. Estimating HIV Incidence during Pregnancy and Knowledge of Prevention of Mother-to-Child Transmission with an Ad Hoc Analysis of Potential Cofactors. J Pregnancy 2016; 2016:7397695. [PMID: 27127653 PMCID: PMC4830744 DOI: 10.1155/2016/7397695] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 02/07/2016] [Accepted: 02/11/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND We determined the incidence of HIV seroconversion during the second and third trimesters of pregnancy and ad hoc potential cofactors associated with HIV seroconversion after having an HIV-negative result antenatally. We also studied knowledge of PMTCT among pregnant women in seven health facilities in Fako Division, South West Region, Cameroon. METHOD During the period between September 12 and December 4, 2011, we recruited a cohort of 477 HIV-negative pregnant women by cluster sampling. Data collection was with a pretested interviewer-administered questionnaire. Sociodemographic information, knowledge of PMTCT, and methods of HIV prevention were obtained from the study population and we did Voluntary Counselling and Testing (VCT) for HIV. RESULTS The incidence rate of HIV seroconversion during pregnancy was 6.8/100 woman-years. Ninety percent of the participants did not use condoms throughout pregnancy but had a good knowledge of PMTCT of HIV. Only 31.9% of participants knew their HIV status before the booking visit and 33% did not know the HIV status of their partners. CONCLUSION The incidence rate of HIV seroconversion in the Fako Division, Cameroon, was 6.8/100 woman-years. No risk factors associated with HIV seroconversion were identified among the study participants because of lack of power to do so.
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Affiliation(s)
- Thomas Obinchemti Egbe
- Department of Obstetrics and Gynecology, Douala General Hospital, Douala, Cameroon
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | | | - Gregory Edie Halle-Ekane
- Department of Obstetrics and Gynecology, Douala General Hospital, Douala, Cameroon
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
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Nguefack HLN, Gwet H, Desmonde S, Oukem-Boyer OOM, Nkenfou C, Téjiokem M, Tchendjou P, Domkam I, Leroy V, Alioum A. Estimating mother-to-child HIV transmission rates in Cameroon in 2011: a computer simulation approach. BMC Infect Dis 2016; 16:11. [PMID: 26754155 PMCID: PMC4709976 DOI: 10.1186/s12879-016-1336-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 01/06/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Despite the progress in the Prevention of the Mother-to-Child Transmission of HIV (PMTCT), the paediatric HIV epidemic remains worrying in Cameroon. HIV prevalence rate for the population of pregnant women was 7.6% in 2010 in Cameroon. The extent of the paediatric HIV epidemic is needed to inform policymakers. We developed a stochastic simulation model to estimate the number of new paediatric HIV infections through MTCT based on the observed uptake of services during the different steps of the PMTCT cascade in Cameroon in 2011. Different levels of PMTCT uptake was also assessed. METHODS A discrete events computer simulation-based approach with stochastic structure was proposed to generate a cohort of pregnant women followed-up until 6 weeks post-partum, and optionally until complete breastfeeding cessation in both prevalent and incident lactating HIV-infected women. The different parameters of the simulation model were fixed using data sources available from the 2011 national registry surveys, and from external cohorts in Cameroon. Different PMTCT coverages were simulated to assess their impact on MTCT. Available data show a low coverage of PMTCT services in Cameroon in 2011. RESULTS Based on a simulation approach on a population of 995, 533 pregnant women, the overall residual MTCT rate in 2011 was estimated to be 22.1% (95 % CI: 18.6%-25.2%), the 6-week perinatal MTCT rate among prevalent HIV-infected mothers at delivery is estimated at 12.1% (95% CI: 8.1%-15.1%), with an additional postnatal MTCT rate estimated at 13.3% (95% CI: 9.3%-17.8%). The MTCT rate among children whose mothers seroconverted during breastfeeding was estimated at 20.8% (95% CI: 14.1%-26.9%). Overall, we estimated the number of new HIV infections in children in Cameroon to be 10, 403 (95% CI: 9, 054-13, 345) in 2011. When PMTCT uptake have been fixed at 100%, 90% and 80%, global MTCT rate failed to 0.9% (9% CI: 0.5%-1.7%), 2.0% (95% CI: 0.9%-3.2%) and 4.3% (95% CI: 2.4%-6.7%) respectively. CONCLUSIONS This model is helpful to provide MTCT estimates to guide the national HIV policy in Cameroon. Increasing supply and uptake of PMTCT services among prevalent HIV infected pregnant women, as well as HIV-prevention interventions including the offer and acceptance of HIV testing and counselling in lactating women could reduce significantly the residual HIV MTCT in Cameroon. A public health effort should be made to encourage health care workers and pregnant women to use PMTCT services until complete breastfeeding cessation.
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Affiliation(s)
- Hermine L Nguena Nguefack
- National Advanced School of Engineering, The University of Yaoundé I, PO Box 8390, Yaoundé, Cameroon.
| | - Henri Gwet
- National Advanced School of Engineering, The University of Yaoundé I, PO Box 8390, Yaoundé, Cameroon.
| | - Sophie Desmonde
- Inserm, U897, Bordeaux, France.
- Bordeaux School of Public Health, The University of Bordeaux, Bordeaux, France.
| | - Odile Ouwe Missi Oukem-Boyer
- Centre International de Référence Chantal Biya (CIRCB) pour la recherche sur la prévention et la prise en charge du VIH/SIDA, Yaoundé, Cameroun.
- Centre de Recherche Médicale et Sanitaire (CERMES), member of Réseau International des Instituts Pasteur, Niamey, Niger.
| | - Céline Nkenfou
- Centre International de Référence Chantal Biya (CIRCB) pour la recherche sur la prévention et la prise en charge du VIH/SIDA, Yaoundé, Cameroun.
| | - Mathurin Téjiokem
- Centre Pasteur du Cameroun, member of Réseau International des Instituts Pasteur, Yaoundé, Cameroun.
| | - Patrice Tchendjou
- Centre Pasteur du Cameroun, member of Réseau International des Instituts Pasteur, Yaoundé, Cameroun.
| | - Irénée Domkam
- Centre International de Référence Chantal Biya (CIRCB) pour la recherche sur la prévention et la prise en charge du VIH/SIDA, Yaoundé, Cameroun.
| | - Valériane Leroy
- Inserm, U897, Bordeaux, France.
- Bordeaux School of Public Health, The University of Bordeaux, Bordeaux, France.
- Inserm U1027 Epidémiologie et analyses en santé publique : risques, maladies chroniques et handicaps, Université Paul Sabatier Toulouse 3, Toulouse, France.
| | - Ahmadou Alioum
- Inserm, U897, Bordeaux, France.
- Bordeaux School of Public Health, The University of Bordeaux, Bordeaux, France.
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Kumela K, Amenu D, Chelkeba L. Comparison of anti-retroviral therapy treatment strategies in prevention of mother-to-child transmission in a teaching hospital in Ethiopia. Pharm Pract (Granada) 2015; 13:539. [PMID: 26131041 PMCID: PMC4482841 DOI: 10.18549/pharmpract.2015.02.539] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 04/12/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND More than 90% of Human immunodeficiency virus (HIV) infection in children is acquired due to mother-to-child transmission, which is spreading during pregnancy, delivery or breastfeeding. OBJECTIVE To determine the effectiveness of highly active antiretroviral and short course antiretroviral regimens in prevention of mother-to-child transmission of HIV and associated factors Jimma University Specialized Hospital (JUSH). METHOD A hospital based retrospective cohort study was conducted on HIV infected pregnant mothers who gave birth and had follow up at anti-retroviral therapy (ART) clinic for at least 6 months during a time period paired with their infants. The primary and secondary outcomes were rate of infant infection by HIV at 6 weeks and 6 months respectively. The Chi-square was used for the comparison of categorical data multivariate logistic regression model was used to identify the determinants of early mother-to-child transmission of HIV at 6 weeks. Cox proportional hazard model was used to analyze factors that affect the 6 month HIV free survival of infants born to HIV infected mothers. RESULTS A total of 180 mother infant pairs were considered for the final analysis, 90(50%) mothers received single dose nevirapine (sdNVP) designated as regimen-3, 67 (37.2%) mothers were on different types of ARV regimens commonly AZT + 3TC + NVP (regimen-1), while the rest 23 (12.8%) mothers were on short course dual regimen AZT + 3TC + sdNVP (regimen-2). Early mother-to-child transmission rate at 6 weeks for regimens 1, 2 and 3 were 5.9% (4/67), 8.6% (2/23), and 15.5% (14/90) respectively. The late cumulative mother-to-child transmission rate of HIV at 6 months regardless of regimen type was 15.5% (28/180). Postnatal transmission at 6 months was 28.5% (8/28) of infected children. Factors that were found to be associated with high risk of early mother-to-child transmission of HIV include duration of ARV regimen shorter than 2 months during pregnancy (OR=4.3, 95%CI =1.38-13.46), base line CD4 less than 350 cells/cubic mm (OR=6.98, 95%CI=0.91-53.76), early infant infection (OR=5.4, 95%CI=2.04-14.4), infants delivered home (OR=13.1, 95%CI=2.69-63.7), infant with birth weight less than 2500 g (OR=6.41, 95%CI=2.21-18.61), and mixed infant feeding (OR=6.7, 95%CI=2.2-20.4). Antiretroviral regimen duration less than 2 months, maternal base line CD4 less than 350 cells/cubic mm and mixed infant feeding were also important risk factors for late infant infection or death. CONCLUSION The effectiveness of multiple antiretroviral drugs in prevention of early mother-to-child transmission of HIV was found to be more effective than that of single dose nevirapine, although, the difference was not statistically significant. But in late transmission, a significant difference was observed in which infants born to mother who received multiple antiretroviral drugs were less likely to progress to infection or death than infants born to mothers who received single dose nevirapine.
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Affiliation(s)
- Kabaye Kumela
- Department of Clinical Pharmacy, School of Pharmacy, College of Public health and Medical Sciences, Jimma University . Jimma ( Ethiopia ).
| | - Demisew Amenu
- Department of Gynecology and Obstetrician, College of Public health and Medical Sciences, Jimma University . Jimma ( Ethiopia ).
| | - Legese Chelkeba
- Department of Clinical pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences . Tehran ( Iran ).
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Boerma RS, Wit FWNM, Orock SO, Schonenberg-Meinema D, Hartdorff CM, Bakia A, van Hensbroek MB. Mortality risk factors among HIV-exposed infants in rural and urban Cameroon. Trop Med Int Health 2014; 20:170-6. [PMID: 25345882 DOI: 10.1111/tmi.12424] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES HIV-exposed infants, including those who do not become infected, have higher morbidity and mortality rates than HIV unexposed infants. The underlying mechanisms of this difference are largely unknown. The objective of this study was to identify the risk factors for mortality among HIV-exposed (infected as well as uninfected) infants in a prevention of mother-to-child transmission (PMTCT) programme in Cameroon. METHODS We analysed the data from 319 mother-infant pairs included in a PMTCT programme at a rural and an urban hospital between 2004 and 2012. The programme offered free formula feeding, monthly follow-up visits and antiretroviral therapy (ART) according to national PMTCT guidelines. Mother-infant pairs were divided in three study groups, based on year of recruitment and study site: (I) rural hospital, 2004-07; (II) rural hospital, 2008-12; (III) urban hospital, 2008-12. RESULTS Two hundred and eighty-five medical records were included in the final analysis. Infant mortality rates were 23.9%, 20.0% and 5.3% in group I, II and III, respectively (P = 0.02). Hazard ratios of infant mortality were 6.4 (P < 0.001) for prematurity, 4.6 (P = 0.04) for no maternal use of ARTs, 5.6 (P = 0.025) for mixed feeding, 2.7 for home deliveries (P = 0.087) and 0.4 (P = 0.138) for urban study group. CONCLUSIONS In this programme, prematurity, no ART use, and the practice of mixed feeding were independent predictors of infant mortality. Mixed feeding and not using ART increased the hazard of death, probably through its increased risk of HIV infection. Although mortality rates were significantly higher in the rural area, rural setting was not a risk factor for infant mortality. These findings may contribute to the development of tailor-made programmes to reduce infant mortality rates among HIV-exposed infants.
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Affiliation(s)
- Ragna S Boerma
- Global Child Health Group, Academic Medical Center, Emma Children's Hospital, Amsterdam, The Netherlands
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Derebe G, Biadgilign S, Trivelli M, Hundessa G, Robi ZD, Gebre-Mariam M, Makonnen M. Determinant and outcome of early diagnosis of HIV infection among HIV-exposed infants in southwest Ethiopia. BMC Res Notes 2014; 7:309. [PMID: 24885260 PMCID: PMC4045956 DOI: 10.1186/1756-0500-7-309] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 05/19/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Preventing mother-to-child transmission (PMTCT) of human immunodeficiency virus infection (HIV) has been a fundamental advancement in the acquired immunodeficiency syndrome (AIDS) response for the past decade. Several countries have made great strides in the efforts to prevent HIV through mother-to-child transmission. The objective of this study is to assess the determinant and outcome of early diagnosis of HIV infection among HIV-exposed infants in southwest Ethiopia. METHODS An institutional based retrospective cohort study was conducted in a hospital. Medical records of HIV-exposed infants and their mothers enrolled into the program were reviewed. Data entry and analysis was carried out using SPSS version 20 for Windows. RESULTS A total of 426 HIV exposed infant-mother pairs where both mother and infants received a minimum ARV intervention for PMTCT were included in the study. Two hundred fifty-four (59.6%) of mothers had attended antenatal care (ANC). Of all participants, 234(54.9%) mothers did not receive any PMTCT prophylaxis during ANC, while only 104(24.4) received antiretroviral (ART) as PMTCT prophylaxis and 163(38.3%) claimed that did not observe any infant PMTCT interventions while 135(31.7%) of the infants received single-dose NVP + AZT. About 385(90.4%) infants were not infected at their final infection status. Those mothers who did not attended ANC follow-up, infants on mixed and complementary feeding and infants weaned off and mothers who were in WHO clinical stage III and IV were more likely to have HIV sero positive infant. CONCLUSION This study showed that 385(90.4%) of the infants were not infected at their final infection status. Therefore, encouraging pregnant women to visit health facilities during their course of pregnancy, focusing on exclusive breast feeding counseling and promotion, and early initiation of antiretroviral treatment to HIV infected pregnant women are recommend.
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Affiliation(s)
| | - Sibhatu Biadgilign
- Ethiopian Catholic Church, Health and HIV/AIDS Department, Addis Ababa, Ethiopia.
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Maredza M, Bertram MY, Saloojee H, Chersich MF, Tollman SM, Hofman KJ. Cost-effectiveness analysis of infant feeding strategies to prevent mother-to-child transmission of HIV in South Africa. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2013; 12:151-60. [DOI: 10.2989/16085906.2013.863215] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Fonjungo PN, Girma M, Melaku Z, Mekonen T, Tanuri A, Hailegiorgis B, Tegbaru B, Mengistu Y, Ashenafi A, Mamo W, Abreha T, Tibesso G, Ramos A, Ayana G, Freeman R, Nkengasong JN, Zewdu S, Kebede Y, Abebe A, Kenyon TA, Messele T. Field expansion of DNA polymerase chain reaction for early infant diagnosis of HIV-1: The Ethiopian experience. Afr J Lab Med 2013; 2:31. [PMID: 26855901 PMCID: PMC4740918 DOI: 10.4102/ajlm.v2i1.31] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Early diagnosis of infants infected with HIV (EID) and early initiation of treatment significantly reduces the rate of disease progression and mortality. One of the challenges to identification of HIV-1-infected infants is availability and/or access to quality molecular laboratory facilities which perform molecular virologic assays suitable for accurate identification of the HIV status of infants. Method We conducted a joint site assessment and designed laboratories for the expansion of DNA polymerase chain reaction (PCR) testing based on dried blood spot (DBS) for EID in six regions of Ethiopia. Training of appropriate laboratory technologists and development of required documentation including standard operating procedures (SOPs) was carried out. The impact of the expansion of EID laboratories was assessed by the number of tests performed as well as the turn-around time. Results DNA PCR for EID was introduced in 2008 in six regions. From April 2006 to April 2008, a total of 2848 infants had been tested centrally at the Ethiopian Health and Nutrition Research Institute (EHNRI) in Addis Ababa, and which was then the only laboratory with the capability to perform EID; 546 (19.2%) of the samples were positive. By November 2010, EHNRI and the six laboratories had tested an additional 16 985 HIV-exposed infants, of which 1915 (11.3%) were positive. The median turn-around time for test results was 14 days (range 14–21 days). Conclusion Expansion of HIV DNA PCR testing facilities that can provide quality and reliable results is feasible in resource-limited settings. Regular supervision and monitoring for quality assurance of these laboratories is essential to maintain accuracy of testing.
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Affiliation(s)
- Peter N Fonjungo
- Center for Disease Control and Prevention (CDC), Addis Ababa, Ethiopia
| | - Mulu Girma
- Ethiopian Health and Nutrition Research Institute (EHNRI), Addis Ababa, Ethiopia
| | | | - Teferi Mekonen
- Center for Disease Control and Prevention (CDC), Addis Ababa, Ethiopia
| | | | | | - Belete Tegbaru
- Ethiopian Health and Nutrition Research Institute (EHNRI), Addis Ababa, Ethiopia
| | - Yohannes Mengistu
- Center for Disease Control and Prevention (CDC), Addis Ababa, Ethiopia
| | | | - Wubshet Mamo
- University of Washington, ITECH Program, Addis Ababa, Ethiopia
| | | | - Gudetta Tibesso
- Ethiopian Health and Nutrition Research Institute (EHNRI), Addis Ababa, Ethiopia
| | - Artur Ramos
- Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, USA
| | - Gonfa Ayana
- Ethiopian Health and Nutrition Research Institute (EHNRI), Addis Ababa, Ethiopia
| | - Richard Freeman
- Clinton HIV/AIDS Access Initiative (CHAI), Addis Ababa, Ethiopia
| | - John N Nkengasong
- Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, USA
| | - Solomon Zewdu
- John Hopkins University, TSEHAI program, Addis Ababa, Ethiopia
| | - Yenew Kebede
- Center for Disease Control and Prevention (CDC), Addis Ababa, Ethiopia
| | - Almaz Abebe
- Ethiopian Health and Nutrition Research Institute (EHNRI), Addis Ababa, Ethiopia
| | - Thomas A Kenyon
- Center for Disease Control and Prevention (CDC), Addis Ababa, Ethiopia
| | - Tsehaynesh Messele
- Ethiopian Health and Nutrition Research Institute (EHNRI), Addis Ababa, Ethiopia
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Ijumba P, Doherty T, Jackson D, Tomlinson M, Sanders D, Persson LÅ. Free formula milk in the prevention of mother-to-child transmission programme: voices of a peri-urban community in South Africa on policy change. Health Policy Plan 2012; 28:761-8. [PMID: 23144227 DOI: 10.1093/heapol/czs114] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In 2001, South Africa began implementing the Prevention of Mother-to-Child Transmission of HIV (PMTCT) programme. This programme included distribution of free formula milk for infants up to 6 months of age at all public health facilities. Effective from 1 January 2011, KwaZulu-Natal became the first province to phase out free formula milk from its PMTCT programme. On 23 August 2011, the South African National Department of Health adopted promotion of exclusive breastfeeding as the national infant feeding strategy and made a decision to withdraw free formula milk from the PMTCT programme. OBJECTIVE To explore the perceptions and understanding of households at community level on the policy decision to phase out free formula milk from the PMTCT programme in South Africa. METHODS An exploratory qualitative study was conducted amongst women enrolled in a community randomized trial known as Good Start III. Focus group discussions were held with grandmothers, fathers and teenage mothers; and in-depth interviews were performed with HIV-positive and HIV-negative mothers. Data were analysed using thematic analysis. RESULTS Identified themes included: (1) variations in awareness and lack of understanding of the basis for the policy change, (2) abuse of and dysfunctional policy as perceived reasons for policy change and (3) proposed strategies for communicating the policy change. CONCLUSION There is an urgent need to develop a multifaceted communication strategy clearly articulating the reasons for the infant feeding policy change and promoting the new breastfeeding strategy. The communication strategy should take into account inputs from the community. With a supportive environment and one national infant feeding strategy, South Africa has an opportunity to reverse years of poor infant feeding practices and to improve the health of all children in the country.
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Affiliation(s)
- Petrida Ijumba
- Health Systems Research Unit, Medical Research Council, 460 Ridge Road, PO Box 70380, Overport 4067, South Africa. E-mail:
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Duff P, Rubaale T, Kipp W. Married men's perceptions of barriers for HIV-positive pregnant women accessing highly active antiretroviral therapy in rural Uganda. Int J Womens Health 2012; 4:227-33. [PMID: 22675268 PMCID: PMC3367405 DOI: 10.2147/ijwh.s31807] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The aim of this study was to describe the perceptions of married men about barriers to accessing and accepting highly active antiretroviral therapy (HAART) by pregnant/postnatal women positive for human immunodeficiency virus (HIV) and registered in Kabarole District's Program for the Prevention of HIV from Mother to Child (PMTCT-Plus). MATERIALS AND METHODS Our study was a qualitative descriptive exploratory study using thematic analysis. Four focus group discussions were held with a convenience sample of 40 married men. RESULTS Lack of disclosure of a positive HIV diagnosis to the partner and stigmatization of persons with HIV were two major obstacles for women in accessing HAART. In addition, men felt that their low knowledge of HAART and their low HIV testing rate also constituted important barriers to these women taking treatment. Men complained that they were not sufficiently involved in the reproductive care of women and that couples' counseling could be a step towards addressing this problem. CONCLUSION Barriers to HAART experienced by pregnant/postnatal women need to be addressed in order to improve their uptake of treatment, increase their low treatment coverage, improve their survival, and at the same time dramatically reduce HIV transmission from mother to child.
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Affiliation(s)
- Putu Duff
- School of Public Health, University of Alberta, Edmonton, Canada
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Peters PJ, Polle N, Zeh C, Masaba R, Borkowf CB, Oyaro B, Omolo P, Ogindo P, Ndivo R, Angira F, Lando R, Fowler MG, Weidle PJ, Thomas TK. Nevirapine-associated hepatotoxicity and rash among HIV-infected pregnant women in Kenya. ACTA ACUST UNITED AC 2011; 11:142-9. [PMID: 22020069 DOI: 10.1177/1545109711423445] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Few studies have evaluated the risk of nevirapine (NVP)-associated hepatotoxicity among HIV-infected pregnant women with a CD4 count ≥250 cells/mm(3). METHODS We enrolled HIV-infected pregnant Kenyan women who initiated triple antiretroviral therapy (ART) at 34 weeks gestation. We compared the rates of severe hepatotoxicity (grades 3-4 hepatotoxicity) and rash-associated hepatotoxicity (rash with ≥grade 2 hepatotoxicity) with NVP and nelfinavir (NFV), respectively. RESULTS We initiated triple ART in 522 pregnant women; severe hepatotoxicity and rash-associated hepatotoxicity occurred in 14 (3%) and 9 (2%) women, respectively. Women who initiated NVP had higher rates of severe hepatotoxicity (5% vs 1%; P = .03) and rash-associated hepatotoxicity (4% vs 0%; P = .003) when compared with NFV. Among women who initiated NVP (n = 254), a baseline CD4 count ≥250 cells/mm(3) was not associated with severe hepatotoxicity (5% vs 3%; P = .52) or rash-associated hepatotoxicity (4% vs 3%; P = .69). CONCLUSION Nevirapine use but not CD4 count ≥250 cells/mm(3) was associated with hepatotoxicity.
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Affiliation(s)
- Philip J Peters
- 1Centers for Disease Control and Prevention, Atlanta, GA, USA
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Kipp W, Heys J, Jhangri GS, Alibhai A, Rubaale T. Impact of antiretroviral therapy on fertility desires among HIV-infected persons in rural Uganda. Reprod Health 2011; 8:27. [PMID: 21975089 PMCID: PMC3214790 DOI: 10.1186/1742-4755-8-27] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 10/06/2011] [Indexed: 11/10/2022] Open
Abstract
Background Little is known about the fertility desires of HIV infected individuals on highly active antiretroviral therapy (HAART). In order to contribute more knowledge to this topic we conducted a study to determine if HIV-infected persons on HAART have different fertility desires compared to persons not on HAART, and if the knowledge about HIV transmission from mother-to-child is different in the two groups. Methods The study was a cross-sectional survey comparing two groups of HIV-positive participants: those who were on HAART and those who were not. Semi-structured interviews were conducted with 199 HIV patients living in a rural area of western Uganda. The desire for future children was measured by the question in the questionnaire "Do you want more children in future." The respondents' HAART status was derived from the interviews and verified using health records. Descriptive, bivariate and multivariate methods were used to analyze the relationship between HAART treatment status and the desire for future children. Results Results from the multivariate logistic regression model indicated an adjusted odds ratio (OR) of 1.08 (95% CI 0.40-2.90) for those on HAART wanting more children (crude OR 1.86, 95% CI 0.82-4.21). Statistically significant predictors for desiring more children were younger age, having a higher number of living children and male sex. Knowledge of the risks for mother-to-child-transmission of HIV was similar in both groups. Conclusions The conclusions from this study are that the HAART treatment status of HIV patients did not influence the desire for children. The non-significant association between the desire for more children and the HAART treatment status could be caused by a lack of knowledge in HIV-infected persons/couples about the positive impact of HAART in reducing HIV transmission from mother-to-child. We recommend that the health care system ensures proper training of staff and appropriate communication to those living with HIV as well as to the general community.
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Affiliation(s)
- Walter Kipp
- Department of Public Health Sciences, School of Public Health, University of Alberta, Edmonton, Alberta, Canada.
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Granich R, Lo YR, Suthar AB, Vitoria M, Baggaley R, Obermeyer CM, McClure C, Souteyrand Y, Perriens J, Kahn JG, Bennett R, Smyth C, Williams B, Montaner J, Hirnschall G. Harnessing the prevention benefits of antiretroviral therapy to address HIV and tuberculosis. Curr HIV Res 2011; 9:355-66. [PMID: 21999771 PMCID: PMC3528009 DOI: 10.2174/157016211798038551] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 07/04/2011] [Accepted: 08/02/2011] [Indexed: 02/02/2023]
Abstract
After 30 years we are still struggling to address a devastating HIV pandemic in which over 25 million people have died. In 2010, an estimated 34 million people were living with HIV, around 70% of whom live in sub-Saharan Africa. Furthermore, in 2009 there were an estimated 1.2 million new HIV-associated TB cases, and tuberculosis (TB) accounted for 24% of HIV-related deaths. By the end of 2010, 6.6 million people were taking antiretroviral therapy (ART), around 42% of those in need as defined by the 2010 World Health Organization (WHO) guidelines. Despite this achievement, around 9 million people were eligible and still in need of treatment, and new infections (approximately 2.6 million in 2010 alone) continue to add to the future caseload. This combined with the international fiscal crisis has led to a growing concern regarding weakening of the international commitment to universal access and delivery of the Millennium Development Goals by 2015. The recently launched UNAIDS/WHO Treatment 2.0 platform calls for accelerated simplification of ART, in line with a public health approach, to achieve and sustain universal access to ART, including maximizing the HIV and TB preventive benefit of ART by treating people earlier, in line with WHO 2010 normative guidance. The potential individual and public health prevention benefits of using treatment in the prevention of HIV and TB enhance the value of the universal access pledge from a life-saving initiative, to a strategic investment aimed at ending the HIV epidemic. This review analyzes the gaps and summarizes the evidence regarding ART in the prevention of HIV and TB.
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Affiliation(s)
- Reuben Granich
- Antiretroviral Treatment and HIV Care Unit, Department of HIV/AIDS, World Health Organization, Avenue Appia 20, CH-1211, Geneva 27, Switzerland.
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Thomas TK, Masaba R, Borkowf CB, Ndivo R, Zeh C, Misore A, Otieno J, Jamieson D, Thigpen MC, Bulterys M, Slutsker L, De Cock KM, Amornkul PN, Greenberg AE, Fowler MG. Triple-antiretroviral prophylaxis to prevent mother-to-child HIV transmission through breastfeeding--the Kisumu Breastfeeding Study, Kenya: a clinical trial. PLoS Med 2011; 8:e1001015. [PMID: 21468300 PMCID: PMC3066129 DOI: 10.1371/journal.pmed.1001015] [Citation(s) in RCA: 145] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 02/17/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Effective strategies are needed for the prevention of mother-to-child HIV transmission (PMTCT) in resource-limited settings. The Kisumu Breastfeeding Study was a single-arm open label trial conducted between July 2003 and February 2009. The overall aim was to investigate whether a maternal triple-antiretroviral regimen that was designed to maximally suppress viral load in late pregnancy and the first 6 mo of lactation was a safe, well-tolerated, and effective PMTCT intervention. METHODS AND FINDINGS HIV-infected pregnant women took zidovudine, lamivudine, and either nevirapine or nelfinavir from 34-36 weeks' gestation to 6 mo post partum. Infants received single-dose nevirapine at birth. Women were advised to breastfeed exclusively and wean rapidly just before 6 mo. Using Kaplan-Meier methods we estimated HIV-transmission and death rates from delivery to 24 mo. We compared HIV-transmission rates among subgroups defined by maternal risk factors, including baseline CD4 cell count and viral load. Among 487 live-born, singleton, or first-born infants, cumulative HIV-transmission rates at birth, 6 weeks, and 6, 12, and 24 mo were 2.5%, 4.2%, 5.0%, 5.7%, and 7.0%, respectively. The 24-mo HIV-transmission rates stratified by baseline maternal CD4 cell count <500 and ≥500 cells/mm(3) were 8.4% (95% confidence interval [CI] 5.8%-12.0%) and 4.1% (1.8%-8.8%), respectively (p = 0.06); the corresponding rates stratified by baseline maternal viral load <10,000 and ≥10,000 copies/ml were 3.0% (1.1%-7.8%) and 8.7% (6.1%-12.3%), respectively (p = 0.01). None of the 12 maternal and 51 infant deaths (including two second-born infants) were attributed to antiretrovirals. The cumulative HIV-transmission or death rate at 24 mo was 15.7% (95% CI 12.7%-19.4%). CONCLUSIONS This trial shows that a maternal triple-antiretroviral regimen from late pregnancy through 6 months of breastfeeding for PMTCT is safe and feasible in a resource-limited setting. These findings are consistent with those from other trials using maternal triple-antiretroviral regimens during breastfeeding in comparable settings.
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Affiliation(s)
- Timothy K Thomas
- Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA.
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Coutsoudis A, Kwaan L, Thomson M. Prevention of vertical transmission of HIV-1 in resource-limited settings. Expert Rev Anti Infect Ther 2011; 8:1163-75. [PMID: 20954881 DOI: 10.1586/eri.10.94] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
One of the most exciting areas of HIV research is that of prevention of vertical transmission from mother to child, since it accounts for 90% of childhood HIV infections, and therefore prevention in this context has an enormous potential impact on the spread of HIV among children. Focused research has yielded highly successful strategies for reducing infant infection rates, particularly in the developed world, and much work is underway to implement appropriate strategies in resource-limited settings, although this is not without challenges. Although transmission rates in some settings have been reduced to approximately 1%, scale-up and widespread implementation and application of strategic interventions for prevention of mother-to-child transmission of HIV during pregnancy, delivery and breastfeeding are needed in the developing world.
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Affiliation(s)
- Anna Coutsoudis
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, Private Bag 7, Congella 4013, South Africa.
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CD4+ cell count testing more effective than HIV disease clinical staging in identifying pregnant and postpartum women eligible for antiretroviral therapy in resource-limited settings. J Acquir Immune Defic Syndr 2010; 55:404-10. [PMID: 20595905 DOI: 10.1097/qai.0b013e3181e73f4b] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Identifying antiretroviral therapy (ART) eligible HIV-infected (HIV+) pregnant women and rapidly initiating treatment preserves maternal health and prevents mother-to-child transmission. However, there have been few investigations of the performance of ART eligibility criteria in pregnant and postpartum women in resource-limited settings. METHODS Pregnant and recently postpartum HIV+ women received CD4+ cell count and World Health Organization (WHO) clinical staging at enrollment into the mother-to-child transmission Plus Initiative. We compared immunologic and clinical criteria based on 2009 WHO ART treatment guidelines (WHO stage 3/4 or CD4+ cell count ≤350 cells/mm³) in identifying ART eligible women. RESULTS Among 6036 women (62% antepartum, 38% postpartum), 2915 (48%) were ART eligible. Only 23% had WHO stage 3 or 4 disease, whereas 94% met CD4+ cell count criterion. Among 5356 women with WHO stage 1 or 2 disease, 2235 (42%) had CD4+ ≤350 cells per cubic millimeter. Change of CD4+ cell count ART eligibility threshold from ≤200 to ≤350 cells per cubic millimeter increased the proportion of ART eligible women from 21% to 45%. CONCLUSIONS Use of CD4+ cell count criterion is superior to clinical staging in identifying pregnant and postpartum HIV+ women eligible for ART. Improving access to CD4+ testing is essential to identify and treat eligible women, optimizing maternal and child health outcomes.
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Eighteen-month follow-up of HIV-1-infected mothers and their children enrolled in the Kesho Bora study observational cohorts. J Acquir Immune Defic Syndr 2010; 54:533-41. [PMID: 20543706 DOI: 10.1097/qai.0b013e3181e36634] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the effectiveness and safety of antiretrovirals (ARVs) used for treatment or prophylaxis in a breastfeeding population of HIV-1-infected women (Burkina-Faso, Kenya, South Africa). METHODS HIV-1-infected pregnant women with <200 CD4 cells per cubic millimeter or with World Health Organization stage 4 disease (cohort A) and asymptomatic women with >500 CD4 cells per cubic millimeter (cohort B) were enrolled into 2 prospective cohorts. Women with 200-500 CD4 cells per cubic millimeter were enrolled in a parallel randomized trial. Women in cohort A initiated antiretroviral therapy. Women in cohort B received zidovudine from 34 to 36 weeks gestation until delivery, with single-dose nevirapine in labor (cohort B). All children received single-dose nevirapine. RESULTS Of 248 women enrolled, 111 (cohort A) and 125 (cohort B) infants alive at 24 hours after birth were analyzed. Sixty-nine percent and 42% of women had undetectable viral load at delivery, respectively. Ten children in each cohort died. The 18-month cumulative incidences of HIV-1 infection were 7.5% (95% confidence interval: 3.8% to 14.5%) (cohort A) and 5.8% (2.8% to 11.8%) (cohort B). Sixty-one percent (cohort A) and 78% (cohort B) were breastfed for a median duration of 20 weeks. Four children in cohort A and only 1 in cohort B became HIV-1 infected after 6 weeks of age. CONCLUSIONS Antiretroviral therapy initiated a median of 7 weeks before delivery in women with advanced HIV-1 disease was associated with a significant residual risk of HIV-1 transmission due to insufficient decrease in viral load by the time of delivery. Among women with >500 CD4 cells per cubic millimeter, the risk of breast-milk transmission was very low despite lack of postnatal prophylaxis.
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Shapiro RL, Hughes MD, Ogwu A, Kitch D, Lockman S, Moffat C, Makhema J, Moyo S, Thior I, McIntosh K, van Widenfelt E, Leidner J, Powis K, Asmelash A, Tumbare E, Zwerski S, Sharma U, Handelsman E, Mburu K, Jayeoba O, Moko E, Souda S, Lubega E, Akhtar M, Wester C, Tuomola R, Snowden W, Martinez-Tristani M, Mazhani L, Essex M. Antiretroviral regimens in pregnancy and breast-feeding in Botswana. N Engl J Med 2010; 362:2282-94. [PMID: 20554983 PMCID: PMC2999916 DOI: 10.1056/nejmoa0907736] [Citation(s) in RCA: 372] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The most effective highly active antiretroviral therapy (HAART) to prevent mother-to-child transmission of human immunodeficiency virus type 1 (HIV-1) in pregnancy and its efficacy during breast-feeding are unknown. METHODS We randomly assigned 560 HIV-1-infected pregnant women (CD4+ count, > or = 200 cells per cubic millimeter) to receive coformulated abacavir, zidovudine, and lamivudine (the nucleoside reverse-transcriptase inhibitor [NRTI] group) or lopinavir-ritonavir plus zidovudine-lamivudine (the protease-inhibitor group) from 26 to 34 weeks' gestation through planned weaning by 6 months post partum. A total of 170 women with CD4+ counts of less than 200 cells per cubic millimeter received nevirapine plus zidovudine-lamivudine (the observational group). Infants received single-dose nevirapine and 4 weeks of zidovudine. RESULTS The rate of virologic suppression to less than 400 copies per milliliter was high and did not differ significantly among the three groups at delivery (96% in the NRTI group, 93% in the protease-inhibitor group, and 94% in the observational group) or throughout the breast-feeding period (92% in the NRTI group, 93% in the protease-inhibitor group, and 95% in the observational group). By 6 months of age, 8 of 709 live-born infants (1.1%) were infected (95% confidence interval [CI], 0.5 to 2.2): 6 were infected in utero (4 in the NRTI group, 1 in the protease-inhibitor group, and 1 in the observational group), and 2 were infected during the breast-feeding period (in the NRTI group). Treatment-limiting adverse events occurred in 2% of women in the NRTI group, 2% of women in the protease-inhibitor group, and 11% of women in the observational group. CONCLUSIONS All regimens of HAART from pregnancy through 6 months post partum resulted in high rates of virologic suppression, with an overall rate of mother-to-child transmission of 1.1%. (ClinicalTrials.gov number, NCT00270296.)
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Affiliation(s)
- R L Shapiro
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, 110 Francis St., Suite GB, Boston, MA 02215, USA.
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Tchendjou P, Same-Ekobo C, Nga A, Tejiokem M, Kfutwah A, Nlend AN, Tsague L, Bissek AC, Ekoa D, Orne-Gliemann J, Rousset D, Pouillot R, Dabis F. Effectiveness of multidrug antiretroviral regimens to prevent mother-to-child transmission of HIV-1 in routine public health services in Cameroon. PLoS One 2010; 5:e10411. [PMID: 20454459 PMCID: PMC2861601 DOI: 10.1371/journal.pone.0010411] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Accepted: 04/02/2010] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Multidrug antiretroviral (ARV) regimens including HAART and short-course dual antiretroviral (sc-dARV) regimens were introduced in 2004 to improve Prevention of Mother-to-Child Transmission (PMTCT) in Cameroon. We assessed the effectiveness of these regimens from 6-10 weeks and 12 months of age, respectively. METHODOLOGY/FINDINGS We conducted a retrospective cohort study covering the period from October 2004 to March 2008 in a reference hospital in Cameroon. HIV-positive pregnant women with CD4 < or = 350 cells/mm(3) received first-line HAART [regimen 1] while the others received ARV prophylaxis including sc-dARV or single dose nevirapine (sd-NVP). Sc-dARV included at least two drugs according to different gestational ages: zidovudine (ZDV) from 28-32 weeks plus sd-NVP [regimen 2], ZDV and lamuvidine (3TC) from 33-36 weeks plus sd-NVP [regimen 3]. When gestational age was > or = 37 weeks, women received sd-NVP during labour [regimen 4]. Infants received sd-NVP plus ZDV and 3TC for 7 days or 30 days. Early diagnosis (6-10 weeks) was done, using b-DNA and subsequently RT-PCR. We determined early MTCT rate and associated risk factors using logistic regression. The 12-month HIV-free survival was assessed using Cox regression. Among 418 mothers, 335 (80%) received multidrug ARV regimens (1, 2, and 3) and MTCT rate with multidrug regimens was 6.6% [95%CI: 4.3-9.6] at 6 weeks, without any significant difference between regimens. Duration of mother's ARV regimen < 4 weeks [OR = 4.7, 95%CI: 1.3-17.6], mother's CD4 < 350 cells/mm(3) [OR = 6.4, 95%CI: 1.8-22.5] and low birth weight [OR = 4.0, 95%CI: 1.4-11.3] were associated with early MTCT. By 12 months, mixed feeding [HR = 8.7, 95%CI: 3.6-20.6], prematurity [HR = 2.3, 95%CI: 1.2-4.3] and low birth weight were associated with children's risk of progressing to infection or death. CONCLUSIONS Multidrug ARV regimens for PMTCT are feasible and effective in routine reference hospital. Early initiation of ARV during pregnancy and proper obstetrical care are essential to improve PMTCT.
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Affiliation(s)
- Patrice Tchendjou
- Laboratoire Epidémiologie, Centre Pasteur du Cameroun, Yaoundé, Cameroon.
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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.
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Becquet R, Ekouevi DK, Arrive E, Stringer JSA, Meda N, Chaix ML, Treluyer JM, Leroy V, Rouzioux C, Blanche S, Dabis F. Universal antiretroviral therapy for pregnant and breast-feeding HIV-1-infected women: towards the elimination of mother-to-child transmission of HIV-1 in resource-limited settings. Clin Infect Dis 2010; 49:1936-45. [PMID: 19916796 DOI: 10.1086/648446] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Prevention of mother-to-child transmission (MTCT) of human immunodeficiency virus type 1 (HIV-1) remains a challenge in most resource-limited settings, particularly in Africa. Single-dose and short-course antiretroviral (ARV) regimens are only partially effective and have failed to achieve wide coverage despite their apparent simplicity. More potent ARV combinations are restricted to pregnant women who need treatment for themselves and are also infrequently used. Furthermore, postnatal transmission via breast-feeding is a serious additional threat. Modifications of infant feeding practices aim to reduce HIV-1 transmission through breast milk; replacement feeding is neither affordable nor safe for the majority of African women, and early breast-feeding cessation (eg, prior to 6 months of life) requires substantial care and nutritional counseling to be practiced safely. The recent roll out of ARV treatment has changed the paradigm of prevention of MTCT. To date, postnatal ARV interventions that have been evaluated target either maternal ARV treatment to selected breast-feeding women, with good efficacy, or single-drug postexposure prophylaxis for short periods of time to their neonates, with a partial efficacy and at the expense of acquisition of drug-related viral resistance. We hypothesize that a viable solution to eliminate pediatric AIDS lies in the universal provision of fully suppressive ARV regimens to all HIV-1-infected women through pregnancy, delivery, and the entire breast-feeding period. On the basis of available evidence, we suggest translating into practice the recently available evidence on this matter without any further delay.
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Affiliation(s)
- Renaud Becquet
- INSERM, Unité 897, Centre de Recherche Epidémiologie et Biostatistique, Bordeaux, France
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Is there a gender gap in the HIV response? Evaluating national HIV responses from the United Nations General Assembly Special Session on HIV/AIDS country reports. J Acquir Immune Defic Syndr 2009; 52 Suppl 2:S111-8. [PMID: 19901623 DOI: 10.1097/qai.0b013e3181baeec2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Declaration of Commitment of the United Nations General Assembly Special Session on HIV/AIDS (UNGASS), in 2001, sets out several policy and programmatic commitments that pertain to women and the gender aspects of the HIV epidemic. Some of them are general, whereas others are more specific and include time-bounded targets. This article summarizes data on policies and strategies affecting women and men equity in access to antiretroviral treatment and other HIV services, as reported by countries but do not address other issues of gender, such as men having sex with men. METHODS The analysis includes data from the National Composite Policy Index as reported by 130 countries in response to 14 questions relating to progress in creating an enabling policy environment for women. Additional data on gender equity in knowledge of HIV and access to HIV testing and antiretroviral treatment is obtained with other core UNGASS indicators. The review aggregates countries according to regions. RESULTS A total of 147 countries provided national reports in which 78% of relevant UNGASS indicators were either completely or partially disaggregated by sex. However, 16% of countries did not report any HIV indicators by sex (with a range of 0%-29% across regions). A total of 82% (108 of 130) of countries report having policies in place to ensure that women have equal access to HIV-related services, but 14% of reporting countries also had laws and policies in place that hinder their ability to deliver effective HIV programs for women. About 80% of countries report having included women as a specific "sector" in their multisectoral AIDS strategies or action frameworks. However, only slightly more than half (53%) of those countries report having a budget attached to programs addressing women issues. As of the end of 2007, antiretroviral therapy reached 33% of people in need, and women represent a slight majority of those on treatment. The gender gap on HIV knowledge has narrowed, but overall levels of knowledge on how to prevent HIV remains at low levels, with only about 40% of young men (aged 15-24 years) and 36% of young women with correct comprehensive knowledge about HIV prevention. CONCLUSIONS Since 2001, a large majority of countries have integrated women-related issues into their national HIV policies and strategic plans. However, countries and regions with low-level or concentrated HIV epidemics lag behind countries with generalized epidemics in integrating women-focused policies into national frameworks. The lack of budget support for women-focused programs in half of the countries indicates that those policies have not been sufficiently translated into multisectoral activities. The engagement of development ministries in women's social and economic empowerment is largely still lacking, which raises the concern that strategies to reduce gender inequality may also be lacking in broader development plans. The apparent attainment of gender equity in HIV testing and the delivery of antiretroviral treatment is an important achievement. There has also been a significant increase in countries' abilities to collect and report data disaggregated by sex and age. The monitoring of women's progress in HIV responses via the UNGASS reporting system provides important insights but should be complemented with data that strengthen understandings of the actual implementation of strategies, as well.
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Rossenkhan R, Ndung'u T, Sebunya TK, Hagan JE, Shapiro R, Novitsky V, Moyo SM, Thior I, Lockman S, Mitchell R, Kim S, Musonda R, van Widenfelt E, Makhema J, Essex M. Temporal reduction of HIV type 1 viral load in breast milk by single-dose nevirapine during prevention of MTCT. AIDS Res Hum Retroviruses 2009; 25:1261-4. [PMID: 20001515 DOI: 10.1089/aid.2009.0037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Short-course zidovudine (ZDV) with or without a single dose of nevirapine (sdNVP) is widely used to prevent mother-to-child HIV transmission (PMTCT). However, more data on viral load in breast milk following pMTCT regimens are needed. In a randomized PMTCT study in Botswana, in which half of the women received sdNVP in labor, stored samples from mothers assigned to breastfeed were analyzed for HIV-1 RNA in breast milk supernatant. A total of 527 samples from 282 women, collected at delivery, 2 weeks, 2 months, and 5 months postpartum were available for testing. Cell-free breast milk HIV-1 RNA was detectable (>40 copies/ml) in 44.8% (236/527) of samples analyzed. Women randomized to sdNVP + ZDV were more likely to have undetectable breast milk viral loads at 2 weeks postpartum compared with those who received ZDV alone (67.8% vs. 38.5%, p = 0.002). By 2 months postpartum the difference between study arms disappeared, and 43.8% of women who received sdNVP + ZDV had undetectable HIV-1 RNA compared to 53.8% of the ZDV alone group (p = 0.19) and 60.5% vs. 64.5%, respectively, at month 5 (p = 0.61.) The addition of sdNVP to antenatal short-course AZT resulted in significantly reduced breast milk viral loads at 2 weeks postpartum suggesting a reduced risk of MTCT during the early postpartum period. However, viral loads in both study arms were comparable at 2 and 5 months postpartum, suggesting that the receipt of sdNVP in labor may defer rather than blunt the postpartum viral load rebound seen in breast milk after the discontinuation of ZDV.
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Affiliation(s)
- Raabya Rossenkhan
- Department of Biological Sciences, University of Botswana, Gaborone, Botswana
- Botswana–Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education, Gaborone, Botswana
| | - Thumbi Ndung'u
- Botswana–Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts 02115
| | - Teresa K. Sebunya
- Department of Biological Sciences, University of Botswana, Gaborone, Botswana
| | - Jose E. Hagan
- Botswana–Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education, Gaborone, Botswana
| | - Roger Shapiro
- Botswana–Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts 02115
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215
| | - Vladimir Novitsky
- Botswana–Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts 02115
| | - Sikhulile M. Moyo
- Botswana–Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education, Gaborone, Botswana
| | - Ibou Thior
- Botswana–Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts 02115
| | - Shahin Lockman
- Botswana–Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts 02115
| | - Rebecca Mitchell
- Botswana–Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education, Gaborone, Botswana
| | - Soyeon Kim
- Botswana–Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education, Gaborone, Botswana
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts 02115
| | - Rosemary Musonda
- Botswana–Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts 02115
| | - Erik van Widenfelt
- Botswana–Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts 02115
| | - Joseph Makhema
- Botswana–Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts 02115
| | - M. Essex
- Botswana–Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts 02115
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Peltier CA, Ndayisaba GF, Lepage P, van Griensven J, Leroy V, Pharm CO, Ndimubanzi PC, Courteille O, Arendt V. Breastfeeding with maternal antiretroviral therapy or formula feeding to prevent HIV postnatal mother-to-child transmission in Rwanda. AIDS 2009; 23:2415-23. [PMID: 19730349 PMCID: PMC3305463 DOI: 10.1097/qad.0b013e32832ec20d] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the 9-month HIV-free survival of children with two strategies to prevent HIV mother-to-child transmission. DESIGN Nonrandomized interventional cohort study. SETTING Four public health centres in Rwanda. PARTICIPANTS Between May 2005 and January 2007, all consenting HIV-infected pregnant women were included. INTERVENTION Women could choose the mode of feeding for their infant: breastfeeding with maternal HAART for 6 months or formula feeding. All received HAART from 28 weeks of gestation. Nine-month cumulative probabilities of HIV transmission and HIV-free survival were determined using the Kaplan-Meier method and compared using the log-rank test. Determinants were analysed using a Cox model analysis. RESULTS Of the 532 first-liveborn infants, 227 (43%) were breastfeeding and 305 (57%) were formula feeding. Overall, seven (1.3%) children were HIV-infected of whom six were infected in utero. Only one child in the breastfeeding group became infected between months 3 and 7, corresponding to a 9-month cumulative risk of postnatal infection of 0.5% [95% confidence interval (CI) 0.1-3.4%; P = 0.24] with breastfeeding. Nine-month cumulative mortality was 3.3% (95% CI 1.6-6.9%) in the breastfeeding arm group and 5.7% (95% CI 3.6-9.2%) for the formula feeding group (P = 0.20). HIV-free survival by 9 months was 95% (95% CI 91-97%) in the breastfeeding group and 94% (95% CI 91-96%) for the formula feeding group (P = 0.66), with no significant difference in the adjusted analysis (adjusted hazard ratio for breastfeeding: 1.2 (95% CI 0.5-2.9%). CONCLUSION : Maternal HAART while breastfeeding could be a promising alternative strategy in resource-limited countries.
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Mandala J, Torpey K, Kasonde P, Kabaso M, Dirks R, Suzuki C, Thompson C, Sangiwa G, Mukadi YD. Prevention of mother-to-child transmission of HIV in Zambia: implementing efficacious ARV regimens in primary health centers. BMC Public Health 2009; 9:314. [PMID: 19712454 PMCID: PMC2739530 DOI: 10.1186/1471-2458-9-314] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Accepted: 08/27/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Safety and effectiveness of efficacious antiretroviral (ARV) regimens beyond single-dose nevirapine (sdNVP) for prevention of mother-to-child transmission (PMTCT) have been demonstrated in well-controlled clinical studies or in secondary- and tertiary-level facilities in developing countries. This paper reports on implementation of and factors associated with efficacious ARV regimens among HIV-positive pregnant women attending antenatal clinics in primary health centers (PHCs) in Zambia. METHODS Blood sample taken for CD4 cell count, availability of CD4 count results, type of ARV prophylaxis for mothers, and additional PMTCT service data were collected for HIV-positive pregnant women and newborns who attended 60 PHCs between April 2007 and March 2008. RESULTS Of 14,815 HIV-positive pregnant women registered in the 60 PHCs, 2,528 (17.1%) had their CD4 cells counted; of those, 1,680 (66.5%) had CD4 count results available at PHCs; of those, 796 (47.4%) had CD4 count<or=350 cells/mm3 and thus were eligible for combination antiretroviral treatment (cART); and of those, 581 (73.0%) were initiated on cART. The proportion of HIV-positive pregnant women whose blood sample was collected for CD4 cell count was positively associated with (1) blood-draw for CD4 count occurring on the same day as determination of HIV-positive status; (2) CD4 results sent back to the health facilities within seven days; (3) facilities without providers trained to offer ART; and (4) urban location of PHC. Initiation of cART among HIV-positive pregnant women was associated with the PHC's capacity to provide care and antiretroviral treatment services. Overall, of the 14,815 HIV-positive pregnant women registered, 10,015 were initiated on any type of ARV regimen: 581 on cART, 3,041 on short course double ARV regimen, and 6,393 on sdNVP. CONCLUSION Efficacious ARV regimens beyond sdNVP can be implemented in resource-constrained PHCs. The majority (73.0%) of women identified eligible for ART were initiated on cART; however, a minority (11.3%) of HIV-positive pregnant women were assessed for CD4 count and had their test results available. Factors associated with implementation of more efficacious ARV regimens include timing of blood-draw for CD4 count and capacity to initiate cART onsite where PMTCT services were being offered.
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Affiliation(s)
- Justin Mandala
- Family Health International (FHI), Public Health Programs, 4401 Wilson Blvd, Suite 700, Arlington, VA 22203, USA.
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Abstract
PURPOSE OF REVIEW There is an unprecedented global commitment to reverse the pediatric HIV epidemic by making prevention of mother-to-child transmission (PMTCT) services accessible in all countries. This review outlines the successes made and the challenges that remain. RECENT FINDINGS In resource-rich countries, mother-to-child transmission rates of HIV as low as 1% have been achieved. The efficacy of short-course antiretrovirals for PMTCT in Africa is estimated at 50%. Coinfections with herpes simplex virus type 2, other sexually transmitted infections resulting in genital ulcers, and endemic infectious diseases (e.g., malaria) may increase the risk of mother-to-child transmission of HIV. Vertical transmission of drug-resistant viruses has been reported; the prevalence and effect of transmitted resistant virus on treatment outcomes are under investigation. Obstacles facing PMTCT in resource-limited countries include the lack of healthcare infrastructure, limited manpower, and competing public health priorities with the limited healthcare budget. SUMMARY Although the birth of an HIV-infected child in a resource-rich country is now a sentinel health event, in most resource-limited countries the birth of an HIV-infected child continues to be the status quo. Comprehensive PMTCT, including antiretroviral treatment for HIV-infected women and children, should be paramount in resource-limited countries.
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Saloojee H. HIV and exclusive breastfeeding: Just how exclusive and when to stop? Prev Med 2008; 47:36-7. [PMID: 18502493 DOI: 10.1016/j.ypmed.2008.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Revised: 04/05/2008] [Accepted: 04/13/2008] [Indexed: 11/26/2022]
Affiliation(s)
- Haroon Saloojee
- Division of Community Paediatrics, Department of Paediatrics and Child Health, University of the Witwatersrand, Private Bag 3, PO Wits, 2050, South Africa.
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Harambat J, Fassinou P, Becquet R, Touré P, Rouet F, Dabis F, Msellati P, Blanche S, Timité-Konan M, Salamon R, Leroy V. 18-month occurrence of severe events among early diagnosed HIV-infected children before antiretroviral therapy in Abidjan, Côte d'Ivoire: a cohort study. BMC Public Health 2008; 8:169. [PMID: 18492259 PMCID: PMC2416449 DOI: 10.1186/1471-2458-8-169] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Accepted: 05/20/2008] [Indexed: 11/21/2022] Open
Abstract
Objective To assess the 18-month field effectiveness on severe events of a pediatric package combining early HIV-diagnosis and targeted cotrimoxazole prophylaxis in HIV-infected children from age six-week before the antiretroviral era, in Abidjan, Côte d'Ivoire. Methods Data from two consecutive prevention of HIV mother-to-child transmission programs were compared: the ANRS 1201/1202 Ditrame-Plus cohort (2001–2005) and the pooled data of the ANRS 049a Ditrame randomized trial and its following open-labeled cohort (1995–2000), used as a reference group. HIV-infected pregnant women ≥ 32–36 weeks of gestation were offered a short-course peri-partum antiretroviral prophylaxis (ZDV in Ditrame, and ZDV ± 3TC+single-dose (sd) NVP in Ditrame-Plus). Neonatal prophylaxis was provided in Ditrame-Plus only: 7-day ZDV and sdNVP 48–72 h after birth. A 6-week pediatric HIV-RNA diagnosis was provided on-line in the Ditrame-Plus while it was only oriented on clinical symptoms in Ditrame. Six-week HIV-infected children received a daily cotrimoxazole prophylaxis in Ditrame-Plus while no prophylaxis was provided in Ditrame. The determinants of severe events (death or hospitalization > 1 day) were assessed in a Cox regression model. Results Between 1995 and 2003, 98 out of the 1121 live-births were diagnosed as HIV-infected in peri-partum: 45 from Ditrame-Plus and 53 from Ditrame. The 18-month Kaplan-Meier cumulative probability of presenting a severe event was 66% in Ditrame-Plus (95% confidence interval [95%CI]: 50%–81%) and 77% in Ditrame (95%CI: 65%–89%), Log Rank test: p = 0.47. After adjustment on maternal WHO clinical stage, maternal death, 6-week pediatric viral load, birth-weight, and breastfeeding exposure, the 18-month risk of severe event was lower in Ditrame-Plus than in Ditrame (adjusted Hazard Ratio (aHR): 0.55, 95%CI: 0.3–1.1), although the difference was not statistically significant; p = 0.07). Maternal death was the only variable determinant of the occurrence of severe events in children (aHR: 3.73; CI: 2.2–11.2; p = 0.01). Conclusion Early cotrimoxazole from 6 weeks of age in HIV-infected infants seemed to reduce probability of severe events but the study lacked statistical power to prove this. Even with systematic cotrimoxazole prophylaxis, infant morbidity and mortality remained high pointing towards a need for early pediatric HIV-diagnosis and antiretroviral treatment in Africa.
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Becquet R, Bequet L, Ekouevi DK, Viho I, Sakarovitch C, Fassinou P, Bedikou G, Timite-Konan M, Dabis F, Leroy V. Two-year morbidity-mortality and alternatives to prolonged breast-feeding among children born to HIV-infected mothers in Côte d'Ivoire. PLoS Med 2007; 4:e17. [PMID: 17227132 PMCID: PMC1769413 DOI: 10.1371/journal.pmed.0040017] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Accepted: 10/31/2006] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Little is known about the long-term safety of infant feeding interventions aimed at reducing breast milk HIV transmission in Africa. METHODS AND FINDINGS In 2001-2005, HIV-infected pregnant women having received in Abidjan, Côte d'Ivoire, a peripartum antiretroviral prophylaxis were presented antenatally with infant feeding interventions: either artificial feeding, or exclusive breast-feeding and then early cessation from 4 mo of age. Nutritional counseling and clinical management were provided for 2 y. Breast-milk substitutes were provided for free. The primary outcome was the occurrence of adverse health outcomes in children, defined as validated morbid events (diarrhea, acute respiratory infections, or malnutrition) or severe events (hospitalization or death). Hazards ratios to compare formula-fed versus short-term breast-fed (reference) children were adjusted for confounders (baseline covariates and pediatric HIV status as a time-dependant covariate). The 18-mo mortality rates were also compared to those observed in the Ditrame historical trial, which was conducted at the same sites in 1995-1998, and in which long-term breast-feeding was practiced in the absence of any specific infant feeding intervention. Of the 557 live-born children, 262 (47%) were breast-fed for a median of 4 mo, whereas 295 were formula-fed. Over the 2-y follow-up period, 37% of the formula-fed and 34% of the short-term breast-fed children remained free from any adverse health outcome (adjusted hazard ratio [HR]: 1.10; 95% confidence interval [CI], 0.87-1.38; p = 0.43). The 2-y probability of presenting with a severe event was the same among formula-fed (14%) and short-term breast-fed children (15%) (adjusted HR, 1.19; 95% CI, 0.75-1.91; p = 0.44). An overall 18-mo probability of survival of 96% was observed among both HIV-uninfected short-term and formula-fed children, which was similar to the 95% probability observed in the long-term breast-fed ones of the Ditrame trial. CONCLUSIONS The 2-y rates of adverse health outcomes were similar among short-term breast-fed and formula-fed children. Mortality rates did not differ significantly between these two groups and, after adjustment for pediatric HIV status, were similar to those observed among long-term breast-fed children. Given appropriate nutritional counseling and care, access to clean water, and a supply of breast-milk substitutes, these alternatives to prolonged breast-feeding can be safe interventions to prevent mother-to-child transmission of HIV in urban African settings.
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Affiliation(s)
- Renaud Becquet
- Institut National de la Santé et de la Recherche Médicale Unité 593, Université Victor Segalen, Bordeaux, France.
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