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Espinal M, Yee LM, Fisher SA. Advances in HIV Management During Pregnancy and Infant Feeding. Infect Dis Clin North Am 2024; 38:423-452. [PMID: 38969531 DOI: 10.1016/j.idc.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2024]
Abstract
Recent advances in human immunodeficiency virus (HIV) management during pregnancy and infant feeding encompass several key elements: expanded HIV testing guidance; growing evidence of safety, efficacy, and pharmacokinetic data favoring the use of preferred antiretroviral therapy (ART) during pregnancy and breastfeeding; increasing advocacy for the inclusion of pregnant individuals with HIV in clinical trials to expedite access to new ART; and updated guidelines supporting shared decision-making for choice of infant feeding methods in people with HIV.
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Affiliation(s)
- Mariana Espinal
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 East Superior Street, Suite 05-2303, Chicago, IL, USA
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 East Superior Street, Suite 05-2303, Chicago, IL, USA.
| | - Stephanie A Fisher
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 East Superior Street, Suite 05-2303, Chicago, IL, USA
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Powell A, Agwu A. In Support of Breast-/Chestfeeding by People With HIV in High-Income Settings. Clin Infect Dis 2024; 79:202-207. [PMID: 38270916 DOI: 10.1093/cid/ciae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/28/2023] [Accepted: 01/23/2024] [Indexed: 01/26/2024] Open
Abstract
Given that HIV can be transmitted through breastfeeding, historically, breastfeeding among women with HIV in the US and other resource-rich settings was discouraged. Formula feeding was the mandated feeding option out of concern for breast-milk transmission of HIV, which occurred in 16-24% of cases pre-antiretroviral therapy (pre-ART) use. In January 2023, the US Department of Health and Human Services' Perinatal Guidelines were revised to support shared decision-making for infant feeding choices. Updated clinical trials' data from resource-limited settings suggest the actual breastmilk HIV transmission rate in the context of maternal ART or neonatal postexposure prophylaxis is 0.3-1%. High-income countries are reporting more people with HIV breastfeeding their infants without cases of HIV transmission. We present the reasons for fully embracing breast-/chestfeeding as a viable, safe infant feeding option for HIV-exposed infants in high-income settings, while acknowledging unanswered questions and the need to continually craft more nuanced clinical guidance.
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Affiliation(s)
- Anna Powell
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Allison Agwu
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Infectious Diseases, Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Belete NK, Megersa ND, Hebo SH, Animut MD, Tariku EZ. Feeding modalities, HIV transmission and its predictors among HIV-exposed infants visited Gamo and Gofa zones public health facilities, Southern Ethiopia: a retrospective follow up study. BMC Pediatr 2024; 24:410. [PMID: 38926639 PMCID: PMC11202369 DOI: 10.1186/s12887-024-04894-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 06/19/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Despite the highest (88%) Prevention of Mother-To-Child Transmission (PMTCT) of HIV coverage in Eastern Africa, 50% of new HIV infections in children aged 0-14 years occur in the region. OBJECTIVE The aim of this study was to assess the feeding modalities, the rate of HIV transmission and its predictors among HIV exposed infants (HIV-EIs) visited Gamo and Gofa Zones public health facilities, Southern Ethiopia from January 2013 to February 2019. METHOD AND MATERIALS Institution-based retrospective follow up study was employed among 450 HIV-EIs having DNA/PCR test results. All infant-mother pair records in selected health facilities were reviewed using a standard data extraction tool from March to July 2019. HIV transmission probabilities were assessed by Kaplan-Meier time-to-event analysis method and log-rank tests were used to compare the risk among different groups. The Cox-proportional hazards model, adjusted on infant feeding modalities and other co-variants was used to identify predictors of HIV transmission, and statistical significance was declared at a p-value of < 0.05. RESULTS In total, 383 complete records were analyzed. In the study, 85.6% (95%CI: 81.6%, 89.1%) of HIV-EIs were exclusively breastfed in the first six months. The 18 months probability of infant HIV transmission was 64 (16.7%) (95%CI: 13.1%-20.8%). The risk of HIV-transmission was higher among infants who were delivered at the hospital than health centers/health posts (AHR = 3.07; 95%CI: 1.19, 7.95); discontinued Cotrimoxazole prophylaxis in at least one visit (AHR = 6.32; 95%CI: 3.35, 11.94); did not exclusively breastfeed (AHR = 3.07; 95%CI: 1.72, 5.47) and came from urban areas (AHR = 5.90; 95%CI: 1.40, 24.85). CONCLUSIONS The study showed that HIV-EIs had a greater rate of 18 months HIV transmission than the national pooled prevalence. The risk of transmission is higher among infants who do not breastfeed exclusively for the first 6 months, and the risk increases with the number of months spent by breastfeeding. Therefore, strengthening counselling on safer feeding options and Cotrimoxazole prophylaxis use; provision of quality PMTCT service with special focus in hospitals and urban residents were recommended.
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Affiliation(s)
| | | | | | | | - Eshetu Zerihun Tariku
- School of Public Health, Arba Minch University, Arba Minch, Ethiopia
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
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Moseholm E, Fetters MD, Aho I, Mellgren Å, Johansen IS, Katzenstein TL, Pedersen G, Storgaard M, Weis N. Perception and Emotional Experiences of Infant Feeding Among Women Living With HIV in a High-Income Setting: A Longitudinal Mixed Methods Study. J Acquir Immune Defic Syndr 2024; 95:52-64. [PMID: 37797230 DOI: 10.1097/qai.0000000000003314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 09/14/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND The recommendation of breastfeeding avoidance for women living with HIV in high-income settings may be influenced by cultural beliefs and come at an emotional cost. This multicenter, longitudinal, convergent mixed methods study aimed to compare differences in attitudes, concerns, and experiences surrounding breastfeeding in women living with HIV of Nordic and non-Nordic origin. SETTING High-income setting. METHODS Pregnant women living with HIV in the Nordic countries Denmark, Finland, and Sweden were recruited in 2019-2020. Quantitative data on attitudes surrounding infant feeding were assessed using the Positive Attitudes Concerning Infant Feeding questionnaire completed in the third trimester (T1), and 3 (T2) and 6 (T3) months postpartum. Women who completed the survey were also invited to participate in semistructured interviews at T1 and T3. The findings from the quantitative survey and qualitative interviews were brought together through merging to assess for concordance, complementarity, expansion, or discordance between the data sets and to draw metainferences. RESULTS In total, 44 women completed the survey, of whom 31 also participated in qualitative interviews. The merged analyses identified three overarching domains representing commonalities across the quantitative and qualitative data: emotional impact, justifying not breastfeeding, and coping strategies. Not being able to breastfeed was emotionally challenging. Cultural expectations influenced the women's experiences and the strategies they used to justify their infant feeding choice. CONCLUSIONS For women living with HIV in Nordic countries not breastfeeding was a complex, multilayered process substantially influenced by social and cultural expectations.
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Affiliation(s)
- Ellen Moseholm
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Hvidovre, Denmark
- Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Michael D Fetters
- Mixed Methods Program and Department of Family Medicine, University of Michigan, Ann Arbor, MI
| | - Inka Aho
- Department of Infectious Diseases, Helsinki University Hospital, Helsinki, Finland
| | - Åsa Mellgren
- Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Isik S Johansen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Terese L Katzenstein
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Gitte Pedersen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Merete Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark; and
| | - Nina Weis
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Hvidovre, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Pollock L, Levison J. 2023 updated guidelines on infant feeding and HIV in the United States: what are they and why have recommendations changed. TOPICS IN ANTIVIRAL MEDICINE 2023; 31:576-586. [PMID: 38198669 PMCID: PMC10776031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
The US Department of Health and Human Services guidelines on infant feeding among people with HIV have changed in response to (1) evidence of low risk of transmission via breast milk among individuals with consistent viral suppression, (2) considerations of equity and cultural norms, and (3) community desires. The 2023 guidelines recommend patient-centered shared decision-making. Individuals with HIV who are receiving antiretroviral therapy (ART) and have consistent viral suppression should be counseled on the options of for-mula feeding, feeding with banked donor milk, or breast (or chest) feeding, and nonjudgmentally supported in their decision. Individuals who choose to breastfeed should be counseled on and supported in adherence to ART, viral suppression, and engagement in postpartum care for themselves and their babies. Exclusive breastfeeding is recommended, with the understanding that brief periods of replacement feeding may be necessary. Data are lacking on ideal infant prophylaxis regimens.
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Francese R, Peila C, Donalisio M, Lamberti C, Cirrincione S, Colombi N, Tonetto P, Cavallarin L, Bertino E, Moro GE, Coscia A, Lembo D. Viruses and Human Milk: Transmission or Protection? Adv Nutr 2023; 14:1389-1415. [PMID: 37604306 PMCID: PMC10721544 DOI: 10.1016/j.advnut.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 07/14/2023] [Accepted: 08/15/2023] [Indexed: 08/23/2023] Open
Abstract
Human milk (HM) is considered the best source of nutrition for infant growth and health. This nourishment is unique and changes constantly during lactation to adapt to the physiological needs of the developing infant. It is also recognized as a potential route of transmission of some viral pathogens although the presence of a virus in HM rarely leads to a disease in an infant. This intriguing paradox can be explained by considering the intrinsic antiviral properties of HM. In this comprehensive and schematically presented review, we have described what viruses have been detected in HM so far and what their potential transmission risk through breastfeeding is. We have provided a description of all the antiviral compounds of HM, along with an analysis of their demonstrated and hypothesized mechanisms of action. Finally, we have also analyzed the impact of HM pasteurization and storage methods on the detection and transmission of viruses, and on the antiviral compounds of HM. We have highlighted that there is currently a deep knowledge on the potential transmission of viral pathogens through breastfeeding and on the antiviral properties of HM. The current evidence suggests that, in most cases, it is unnecessarily to deprive an infant of this high-quality nourishment and that the continuation of breastfeeding is in the best interest of the infant and the mother.
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Affiliation(s)
- Rachele Francese
- Department of Clinical and Biological Sciences, Laboratory of Molecular Virology and Antiviral Research, University of Turin, Orbassano (TO), Italy
| | - Chiara Peila
- Department of Public Health and Pediatrics, Neonatal Intensive Care Unit, University of Turin, Turin, Italy
| | - Manuela Donalisio
- Department of Clinical and Biological Sciences, Laboratory of Molecular Virology and Antiviral Research, University of Turin, Orbassano (TO), Italy
| | - Cristina Lamberti
- Institute of the Science of Food Production - National Research Council, Grugliasco, TO, Italy
| | - Simona Cirrincione
- Institute of the Science of Food Production - National Research Council, Grugliasco, TO, Italy
| | - Nicoletta Colombi
- Biblioteca Federata di Medicina "Ferdinando Rossi", University of Turin, Turin, Italy
| | - Paola Tonetto
- Department of Public Health and Pediatrics, Neonatal Intensive Care Unit, University of Turin, Turin, Italy
| | - Laura Cavallarin
- Institute of the Science of Food Production - National Research Council, Grugliasco, TO, Italy
| | - Enrico Bertino
- Department of Public Health and Pediatrics, Neonatal Intensive Care Unit, University of Turin, Turin, Italy
| | - Guido E Moro
- Italian Association of Human Milk Banks (AIBLUD), Milan, Italy.
| | - Alessandra Coscia
- Department of Public Health and Pediatrics, Neonatal Intensive Care Unit, University of Turin, Turin, Italy.
| | - David Lembo
- Department of Clinical and Biological Sciences, Laboratory of Molecular Virology and Antiviral Research, University of Turin, Orbassano (TO), Italy.
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Floridia M, Galluzzo CM, Orlando S, Luhanga R, Mphwere R, Kavalo T, Andreotti M, Amici R, Ciccacci F, Marazzi MC, Giuliano M. Micronutrient and Nutritional Status of HIV-Exposed and HIV-Unexposed Malawian Infants in the First Year of Life: Assessment of Ferritin, Vitamin A, and D Status and Its Association with Growth. Nutrients 2023; 15:3282. [PMID: 37513701 PMCID: PMC10386663 DOI: 10.3390/nu15143282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/19/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023] Open
Abstract
Breastfed Malawian infants from Human Immunodeficiency Virus (HIV)-uninfected and HIV-infected women who received antiretroviral therapy were followed until 12 months of age, allowing us to evaluate plasma levels of ferritin, vitamin A (as retinol-binding protein, RBP), and vitamin D (25(OH)D) at six months, as well as nutritional status and growth between six and 12 months. Ferritin and RBP levels were adjusted for inflammation. The study included 88 infants, 63 of whom were part of a recent cohort (2019-2021) that included 49 HIV-exposed but uninfected (HEU) and 14 HIV-unexposed and uninfected (HUU) infants, as well as 25 infants (all HEU) from an earlier cohort (2008-2011). No differences were observed between HEU and HUU infants regarding micronutrient levels, anthropometric indexes, growth, and rates of stunting, being underweight, or wasting. HEU infants from the earlier cohort, when compared to more recent HEU infants, had significantly worse anthropometric measures at six months and inferior growth between six and twelve months. Overall, ferritin deficiency involved 68.6% of infants, while vitamin A and vitamin D deficiency involved 8% and 1.2% of infants, respectively. Micronutrient deficiencies were not associated with HIV exposure, cohort, stunting, being underweight, or wasting. At six months, stunting, being underweight, and wasting involved 25.0%, 2.7% and 2.8% of infants, respectively, with no differences related to HIV exposure. Ferritin deficiency at six months was associated with inferior subsequent growth. In this small observational study conducted in Malawian infants, no major nutritional gap was observed between HIV-exposed and HIV-unexposed infants, though the study highlighted specific nutritional deficiencies that deserve attention. High rates of stunting and ferritin deficiency were observed in the first year of life in Malawian infants, irrespective of maternal HIV status; a significant association between ferritin deficiency and worse subsequent growth was found. Vitamin A and vitamin D deficiencies were much less frequent. Based on the data observed, nutritional interventions should give priority to the correction of ferritin deficiency and chronic undernutrition.
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Affiliation(s)
- Marco Floridia
- National Center for Global Health, Istituto Superiore di Sanità, 00161 Rome, Italy
| | | | - Stefano Orlando
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Richard Luhanga
- DREAM Program, Community of S. Egidio, Blantyre P.O. Box 30355, Malawi
| | - Robert Mphwere
- DREAM Program, Community of S. Egidio, Blantyre P.O. Box 30355, Malawi
| | - Thom Kavalo
- DREAM Program, Community of S. Egidio, Blantyre P.O. Box 30355, Malawi
| | - Mauro Andreotti
- National Center for Global Health, Istituto Superiore di Sanità, 00161 Rome, Italy
| | - Roberta Amici
- National Center for Global Health, Istituto Superiore di Sanità, 00161 Rome, Italy
| | - Fausto Ciccacci
- UniCamillus, Department of Medicine, Saint Camillus International University of Health Sciences, 00131 Rome, Italy
| | | | - Marina Giuliano
- National Center for Global Health, Istituto Superiore di Sanità, 00161 Rome, Italy
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Baroncelli S, Galluzzo CM, Orlando S, Pirillo MF, Luhanga R, Mphwere R, Kavalo T, Amici R, Floridia M, Andreotti M, Ciccacci F, Scarcella P, Marazzi MC, Giuliano M. Rates of Seroprotection against Vaccine-Preventable Infectious Diseases in HIV-Exposed and -Unexposed Malawian Infants. Pathogens 2023; 12:938. [PMID: 37513785 PMCID: PMC10383556 DOI: 10.3390/pathogens12070938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The evaluation of seroprotection rates against vaccine-preventable infectious diseases allows for the identification of risk populations. HIV-exposed infants, even if not infected with HIV, have higher morbidity and mortality in comparison to unexposed counterparts. The aim of this study was to compare the specific IgG levels against Haemophilus influenzae type-B (HiB), Hepatitis-B (HBV), and Streptococcus pneumoniae (Spn) in two groups of infants (HIV-exposed and HIV-unexposed) living in Malawi. METHODS Blood samples from 62 infants, 49 HIV-exposed, uninfected (HEU), and born to women living with HIV and 13 HIV-unexposed and uninfected (HUU), were collected at 6 months, and specific IgG levels were determined using ELISA tests. RESULTS The antibody levels against HiB, HBV, and Spn were similar in the two groups. At six months, all HUU infants and 81.6% of HEU infants showed seroprotective levels against HiB, while a percentage of protection varying from 80.6 to 84.6% was observed for HBV and Spn regardless of HIV exposure. Only 59.2% of HEU and 69.2% of HUU infants showed antibody protection against all three pathogens. CONCLUSIONS These results indicate similar rates of seroprotection among HEU and HUU infants but also suggest that a consistent fraction of infants received incomplete vaccinations. Strategies to enforce participation in immunization programs in Malawi should be a health priority.
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Affiliation(s)
- Silvia Baroncelli
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Clementina Maria Galluzzo
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Stefano Orlando
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | - Maria Franca Pirillo
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Richard Luhanga
- DREAM Program, Community of S. Egidio, P.O. Box 30355, Blantyre 312200, Malawi
| | - Robert Mphwere
- DREAM Program, Community of S. Egidio, P.O. Box 30355, Blantyre 312200, Malawi
| | - Thom Kavalo
- DREAM Program, Community of S. Egidio, P.O. Box 30355, Blantyre 312200, Malawi
| | - Roberta Amici
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Marco Floridia
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Mauro Andreotti
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Fausto Ciccacci
- UniCamillus, Saint Camillus International University of Health Sciences, Via di Sant'Alessandro 8, 00131 Rome, Italy
| | - Paola Scarcella
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | | | - Marina Giuliano
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
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Bukkems VE, Finkenflügel RN, Grintjes K, Marneef M, de Haan M, Mielitz I, van Hulzen A, Rokx C, van Leeuwen E, Nellen JF, Burger DM, Colbers A. Exploring the Breastfeeding Desires and Decision-Making of Women Living with HIV in the Netherlands: Implications for Perinatal HIV Management in Developed Countries. Breastfeed Med 2023; 18:356-361. [PMID: 37083439 PMCID: PMC10254968 DOI: 10.1089/bfm.2023.0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Introduction: Guidelines in high-income countries recommend women living with human immunodeficiency virus (HIV) to formula feed their newborns, because the possibility of mother-to-child-transmission of HIV during breastfeeding cannot be ruled out. It is an ongoing debate if the possible transmission risk outweighs the medical, cultural, psychological, and social importance of breastfeeding in women stable on current first-line suppressive antiretroviral regimens. The study aim was to explore breastfeeding desires and decision-making of immigrant and nonimmigrant women living with HIV in the Netherlands. Method: A questionnaire was administered orally or online to 82 women living with HIV in the Netherlands. The breastfeeding desires of the participants were collected as categorical data, and breastfeeding decision-making and willingness to adhere to additional monitoring were collected on a 5-point Likert scale. Categorical data were presented as proportions, and Likert scale data were presented in Likert scale bar plots. Results: Seventy-one percent of the participants expressed a desire to breastfeed in the future. The most important factors influencing decision-making to breastfeed were the chance of transmission of HIV to the infant and the advice by the doctor or nurse practitioner. Of the participants, 42% expressed their interest in breastfeeding with a <1/100 transmission risk. More than half of the participants expressed their interest to breastfeed with additional monitoring. Conclusions: A substantial proportion of the women living with HIV in the Netherlands has a desire to breastfeed, of which the majority are willing to adhere to additional monitoring to do so.
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Affiliation(s)
- Vera E. Bukkems
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Karin Grintjes
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Manon Marneef
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Martine de Haan
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Astrid van Hulzen
- Department of Internal Medicine, Isala Hospital, Zwolle, the Netherlands
| | - Casper Rokx
- Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands
| | - Elisabeth van Leeuwen
- Department of Obstetrics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jeannine F. Nellen
- Division of Infectious Diseases, Tropical Medicine and AIDS, Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - David M. Burger
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Angela Colbers
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, the Netherlands
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Baroncelli S, Galluzzo CM, Orlando S, Mphwere R, Kavalo T, Luhanga R, Amici R, Floridia M, Andreotti M, Scarcella P, Marazzi MC, Giuliano M. Dynamics of SARS-CoV-2 exposure in Malawian infants between February 2020 and May 2021. JOURNAL OF CLINICAL VIROLOGY PLUS 2022; 2:100110. [PMID: 36128323 PMCID: PMC9477783 DOI: 10.1016/j.jcvp.2022.100110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/12/2022] [Accepted: 09/15/2022] [Indexed: 11/21/2022] Open
Abstract
Background Very limited information is available on SARS-CoV-2 seroprevalence in infants in sub-Saharan countries. Objective In this study, we aimed to determine the rate and the temporal evolution of SARS CoV-2 seropositivity in breastfed Malawian infants. Study design Blood samples (n = 250) from 158 infants, born to HIV-negative women and women living with HIV, collected from February 2020 to May 2021, were first tested using an Anti-IgG/A/M SARS CoV 2 ELISA assay against trimeric spike protein, and then, if positive, confirmed using a second ELISA assay detecting IgG against Receptor Binding Domain. Results The confirmed prevalence of anti-SARS CoV-2 antibodies was 31.0% (95% CI: 23.7%-38.3%) with no significant difference between HIV-exposed and HIV-unexposed infants (29.3% and 37.1% respectively, P = 0.410). The presence of anti-SARS-CoV-2 IgG was not associated with maternal socioeconomic or demographic indices. Conclusions Our data underline the wide spread of the SARS-CoV-2 infection in the pediatric population in sub-Saharan Africa. Design of more specific serological tests for African samples and improvements in serosurveillance programs are needed for more rigorous monitoring of the dynamics of SARS-CoV-2 infection in Africa.
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Affiliation(s)
- Silvia Baroncelli
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Clementina Maria Galluzzo
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Stefano Orlando
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | - Robert Mphwere
- DREAM Program, Community of S. Egidio, P.O. Box 30355, Blantyre, Malawi
| | - Thom Kavalo
- DREAM Program, Community of S. Egidio, P.O. Box 30355, Blantyre, Malawi
| | - Richard Luhanga
- DREAM Program, Community of S. Egidio, P.O. Box 30355, Blantyre, Malawi
| | - Roberta Amici
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Marco Floridia
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Mauro Andreotti
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Paola Scarcella
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | | | - Marina Giuliano
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
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Adugna Wubneh C, Dessalegn Mekonnen B, Wesenyeleh Delelegn M, Asmare Atalell K. Adherence to option B+ and its association with disclosure status and counseling among HIV-positive pregnant and lactating women in Ethiopia: systematic review and meta-analysis. Public Health 2022; 211:105-113. [PMID: 36058198 DOI: 10.1016/j.puhe.2022.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 05/22/2022] [Accepted: 07/20/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVES This systematic review and meta-analysis aimed to assess the pooled estimate of option B+ level of adherence and its association with disclosure status and counseling among pregnant and lactation women in Ethiopia after option B+ implementation. STUDY DESIGN Systematic review and meta-analysis. METHODS We searched Web of Science, MEDLINE, PUBMED, Scopus, Embase, CINAHL, and Google Scholar databases for studies reporting adherence to option B+ and its association with disclosure status and counseling among pregnant and lactating women in Ethiopia. Heterogeneity was assessed by forest plot, Cochran's Q test, and I2 test. A random effects model was calculated to estimate the pooled prevalence of adherence toward option B+. RESULTS We included eight studies, which gives a total of 1852 pregnant and lactating women in this systematic review and meta-analysis. The overall pooled estimate of good adherence toward option B+ antiretroviral therapy (ART) drug among pregnant and lactating women in Ethiopia was 84.23% (95% confidence interval [CI]: 80.79-87.66). Women who have disclosed their HIV status to their partner (adjusted odds ratio = 4.48, 95% CI: 1.86-10.76) and got counseling during the antenatal period (adjusted odds ratio = 5.02, 95% CI: 2.43-10.34) had a positive association with good adherence to option B+ ART drugs. CONCLUSION Four of five pregnant and lactating women have good adherence to option B+ ART drugs in Ethiopia. Therefore, promoting HIV disclosure status to partners and enhancing counseling services should be strengthened to improve adherence toward option B+ among pregnant and lactating women.
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Affiliation(s)
- Chalachew Adugna Wubneh
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Science, University of Gondar, P.O.BOX: 196, Gondar, Ethiopia.
| | - Birye Dessalegn Mekonnen
- Department of Nursing, Teda Health Science College, Gondar, Ethiopia, P.O.BOX: 790, Gondar, Ethiopia.
| | - Mekdess Wesenyeleh Delelegn
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Science, University of Gondar, P.O.BOX: 196, Gondar, Ethiopia.
| | - Kendalem Asmare Atalell
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Science, University of Gondar, P.O.BOX: 196, Gondar, Ethiopia.
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12
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Malaba TR, Nakatudde I, Kintu K, Colbers A, Chen T, Reynolds H, Read L, Read J, Stemmet LA, Mrubata M, Byrne K, Seden K, Twimukye A, Theunissen H, Hodel EM, Chiong J, Hu NC, Burger D, Wang D, Byamugisha J, Alhassan Y, Bokako S, Waitt C, Taegtmeyer M, Orrell C, Lamorde M, Myer L, Khoo S. 72 weeks post-partum follow-up of dolutegravir versus efavirenz initiated in late pregnancy (DolPHIN-2): an open-label, randomised controlled study. Lancet HIV 2022; 9:e534-e543. [PMID: 35905752 DOI: 10.1016/s2352-3018(22)00173-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/12/2022] [Accepted: 06/08/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Late initiation of antiretrovirals in pregnancy is associated with increased risk of perinatal transmission and higher infant mortality. We report the final 72-week postpartum results for efficacy and safety of dolutegravir-based compared with efavirenz-based regimens in mothers and infants. METHODS DolPHIN-2 was a randomised, open-label trial. Pregnant women in South Africa and Uganda aged at least 18 years, with untreated but confirmed HIV infection and an estimated gestation of at least 28 weeks, initiating antiretroviral therapy in third trimester were eligible for inclusion. Eligible women were randomly assigned (1:1) to receive either dolutegravir-based (50 mg dolutegravir, 300 mg tenofovir disoproxil fumarate, and either 200 mg emtricitabine in South Africa or 300 mg lamivudine in Uganda) or efavirenz-based (fixed dose combination 600 mg tenofovir disoproxil fumarate plus either emtricitabine in South Africa or lamivudine in Uganda) therapy. The primary efficacy outcome was the time to a viral load of less than 50 copies per mL measured at 6, 12, 24, 48, and 72 weeks postpartum with a Cox model adjusting for viral load and CD4 cell count. Safety endpoints were summarised by the number of women and infants with events. This trial is registered with ClinicalTrials.gov, NCT03249181. FINDINGS Between Jan 23 and Aug 15, 2018, 280 women were screened for inclusion, of whom 268 (96%) women were randomly assigned: 133 (50%) to the efavirenz group and 135 (50%) to the dolutegravir group. 250 (93%; 125 [50%] in the efavirenz group and 125 [50%] in the dolutegravir group) women were included in the intention-to-treat analysis of efficacy. Median time to viral load of less than 50 copies per mL was 4·1 weeks (IQR 4·0-5·1) in the dolutegravir group compared with 12·1 weeks (10·7-13·3) in the efavirenz group (adjusted hazard ratio [HR] 1·93 [95% CI 1·5-2·5]). At 72 weeks postpartum, 116 (93%) mothers in the dolutegravir group and 114 (91%) in the efavirenz group had a viral load of less than 50 copies per mL. Of 57 (21%) mothers with a severe adverse event, three (2%) in the dolutegravir group and five (4%) in the efavirenz group were related to the drug (dolutegravir drug-related events were one woman each with suicidal ideation, suicide attempt, herpes zoster meningitis; efavirenz drug-related events were one woman each with suicide attempt and liver cirrhosis, and three people with drug-induced liver injury). Of 136 (56%) infants in whom severe adverse events were recorded, none were related to the study drugs. In addition to the three infant HIV infections detected at birth in the dolutegravir group that have been previously reported, an additional transmission in the efavirenz group occurred during breastfeeding despite optimal maternal viral suppression and serial negative infant tests in the first year of life. INTERPRETATION Dolutegravir was safe and well tolerated, supporting updated WHO treatment recommendations in pregnant and breastfeeding women. Infant HIV transmissions can occur during breastfeeding despite persistently undetectable maternal viral load highlighting the need for continued infant testing. FUNDING Unitaid.
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Affiliation(s)
- Thokozile R Malaba
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Irene Nakatudde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kenneth Kintu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Angela Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Tao Chen
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Helen Reynolds
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Lucy Read
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jim Read
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Lee-Ann Stemmet
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Megan Mrubata
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly Byrne
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kay Seden
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Adelline Twimukye
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Helene Theunissen
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Eva Maria Hodel
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Justin Chiong
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Nai-Chung Hu
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - David Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Duolao Wang
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Josaphat Byamugisha
- Department of Gynaecology and Obstetrics, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Yussif Alhassan
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sharon Bokako
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Catriona Waitt
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK; Tropical Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Catherine Orrell
- Desmond Tutu Health Foundation, Department of Medicine, Institute of Infectious Diseases & Molecular Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; Centre for Infectious Diseases Epidemiology & Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Saye Khoo
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK; Tropical Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
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13
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Baroncelli S, Tarantino M, Galluzzo CM, Liotta G, Orlando S, Sagno JB, Luhanga R, Andreotti M, Petrucci P, Amici R, Marazzi MC, Adone R, Giuliano M. Seroprevalence of Brucella Infection in a Cohort of HIV-Positive Malawian Pregnant Women Living in Urban Areas. Vector Borne Zoonotic Dis 2022; 22:263-266. [PMID: 35333643 DOI: 10.1089/vbz.2021.0088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The seroprevalence of Brucella infection in sub-Saharan regions is high, and no recent data are available for Malawi, a country in which >60% of the population is involved in agropastoral activity. Aim: To evaluated the seroprevalence of Brucella in a cohort of HIV-positive pregnant women, living in an urban setting in Malawi. Methods: Sera of 201 pregnant women were tested for Brucella IgG. The Rose Bengal Plate Test and Serum Agglutination Tube test were used to determine antibody titer. Results: Five out of 201 (2.48%) women show positivity to Brucella, consistent with a past exposition to the infection. All five women delivered healthy infants, but two of them reported previous abortion/stillbirths, with a higher rate than those of the rest of the cohort (40% vs. 21.5%). Conclusions: This is one of the first reports of exposure of pregnant women to Brucella infection in Malawi, providing evidence of Brucella occurrence in an urban setting. Control programs should be introduced to reduce its impact on animal and human health.
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Affiliation(s)
- Silvia Baroncelli
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Rome, Italy
| | - Michela Tarantino
- Department of Veterinary Public Health and Food Safety, Istituto Superiore di Sanità, Rome, Rome, Italy
| | | | - Giuseppe Liotta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Stefano Orlando
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | | | - Mauro Andreotti
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Rome, Italy
| | - Paola Petrucci
- Department of Veterinary Public Health and Food Safety, Istituto Superiore di Sanità, Rome, Rome, Italy
| | - Roberta Amici
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Rome, Italy
| | | | - Rosanna Adone
- Department of Veterinary Public Health and Food Safety, Istituto Superiore di Sanità, Rome, Rome, Italy
| | - Marina Giuliano
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Rome, Italy
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14
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Cranmer LM, Chung MH, Chahroudi A. Support for Establishing Best Practices for Breastfeeding in the Current HIV/ART Era. J Pediatric Infect Dis Soc 2022; 11:90-91. [PMID: 34939651 DOI: 10.1093/jpids/piab128] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/01/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Lisa M Cranmer
- Department of Pediatrics, Division of Pediatric Infectious Disease, Emory School of Medicine, Atlanta, Georgia, USA.,Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, Georgia, USA.,Children\'s Healthcare of Atlanta, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Michael H Chung
- Grady Memorial Hospital, Atlanta, Georgia, USA.,Department of Medicine, Division of Infectious Disease, Emory School of Medicine, Atlanta, Georgia, USA.,Departments of Epidemiology and Global Health, Emory Rollins School of Public Health, Atlanta, Georgia, USA
| | - Ann Chahroudi
- Department of Pediatrics, Division of Pediatric Infectious Disease, Emory School of Medicine, Atlanta, Georgia, USA.,Children\'s Healthcare of Atlanta, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
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15
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Amin O, Powers J, Bricker KM, Chahroudi A. Understanding Viral and Immune Interplay During Vertical Transmission of HIV: Implications for Cure. Front Immunol 2021; 12:757400. [PMID: 34745130 PMCID: PMC8566974 DOI: 10.3389/fimmu.2021.757400] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022] Open
Abstract
Despite the significant progress that has been made to eliminate vertical HIV infection, more than 150,000 children were infected with HIV in 2019, emphasizing the continued need for sustainable HIV treatment strategies and ideally a cure for children. Mother-to-child-transmission (MTCT) remains the most important route of pediatric HIV acquisition and, in absence of prevention measures, transmission rates range from 15% to 45% via three distinct routes: in utero, intrapartum, and in the postnatal period through breastfeeding. The exact mechanisms and biological basis of these different routes of transmission are not yet fully understood. Some infants escape infection despite significant virus exposure, while others do not, suggesting possible maternal or fetal immune protective factors including the presence of HIV-specific antibodies. Here we summarize the unique aspects of HIV MTCT including the immunopathogenesis of the different routes of transmission, and how transmission in the antenatal or postnatal periods may affect early life immune responses and HIV persistence. A more refined understanding of the complex interaction between viral, maternal, and fetal/infant factors may enhance the pursuit of strategies to achieve an HIV cure for pediatric populations.
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Affiliation(s)
- Omayma Amin
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Jenna Powers
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Katherine M. Bricker
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Ann Chahroudi
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Center for Childhood Infections and Vaccines of Children’s Healthcare of Atlanta and Emory University, Atlanta, GA, United States
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16
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Goga AE, Van de Perre P, Ngandu N, Nagot N, Abrams EJ, Moodley D, King R, Molès JP, Chirinda W, Scarlatti G, Tylleskär T, Sherman GG, Pillay Y, Dabis F, Gray G. Eliminating HIV transmission through breast milk from women taking antiretroviral drugs. BMJ 2021; 374:n1697. [PMID: 34588170 PMCID: PMC8479590 DOI: 10.1136/bmj.n1697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Ameena Goga and colleagues argue that frequent testing of maternal viral load is needed to eliminate HIV transmission through breast milk in low and middle income settings
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Affiliation(s)
- Ameena E Goga
- South African Medical Research Council, Pretoria and Cape Town, South Africa
- University of Pretoria, Pretoria, South Africa
| | - Philippe Van de Perre
- Pathogenesis and Control of Chronic and Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang; CHU Montpellier, Montpellier, France
| | - Nobubelo Ngandu
- South African Medical Research Council, Pretoria and Cape Town, South Africa
| | - Nicolas Nagot
- Pathogenesis and Control of Chronic and Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang; CHU Montpellier, Montpellier, France
| | - Elaine J Abrams
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, USA
| | - Dhayendre Moodley
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
- Centre for AIDS Research in South Africa, Durban, South Africa
| | - Rachel King
- Pathogenesis and Control of Chronic and Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang; CHU Montpellier, Montpellier, France
- UCSF, San Francisco, CA, USA
| | - Jean-Pierre Molès
- Pathogenesis and Control of Chronic and Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang; CHU Montpellier, Montpellier, France
| | - Witness Chirinda
- South African Medical Research Council, Pretoria and Cape Town, South Africa
| | - Gabriella Scarlatti
- Viral Evolution and Transmission Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Gayle G Sherman
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Centre for HIV & STI, National Institute for Communicable Diseases, National Health Laboratory Services, Johannesburg, South Africa
| | | | - François Dabis
- Agence Nationale de Recherche sur le Sida et les Hépatites Virales (ANRS), Paris, France
- Université Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Glenda Gray
- South African Medical Research Council, Pretoria and Cape Town, South Africa
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17
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Baroncelli S, Galluzzo CM, Liotta G, Andreotti M, Orlando S, Ciccacci F, Mphwere R, Luhanga R, Sagno JB, Amici R, Marazzi MC, Giuliano M. HIV-exposed infants with EBV infection have a reduced persistence of the immune response to the HBV vaccine. AIDS Res Ther 2021; 18:48. [PMID: 34348748 PMCID: PMC8336389 DOI: 10.1186/s12981-021-00375-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 07/28/2021] [Indexed: 11/29/2022] Open
Abstract
Background In sub-Saharan African countries Epstein Barr virus (EBV) infection occurs in early childhood. We aim to investigate the factors associated with EBV acquisition and the impact of EBV infection on the humoral response to HBV vaccination in infants born from HIV-positive, antiretroviral-treated mothers in Malawi. Methods A total of 149 HIV-exposed infants were included in this longitudinal study. EBV anti-VCA IgG were measured using an ELISA assay. The EBV seroconversion was correlated with the maternal viro-immunological conditions, with infant growth and immunological vulnerability, and with the humoral response to the HBV vaccine. Results No infant was EBV-positive at 6 months (n. 52 tested). More than a third of infants (49/115 or 42.6 %) on study beyond 6 months seroconverted at 12 months. At 24 months, out of 66 tested infants, only 13 remained EBV-uninfected, while 53 (80.3 %) acquired EBV infection, rising the total proportion of EBV seroconversion to 88.7 % (102/115 infants). EBV seroconversion was significantly associated with a low maternal educational status but had no impact on infant growth or vulnerability to infections. Reduced HBsAb levels and accelerated waning of antibodies were associated with early EBV seroconversion. Conclusions We found a heterogeneous timing of acquisition of EBV with the majority of infants born from HIV + mothers acquiring infection after 6 months. Anti-HBs levels were lower and appeared to wane faster in infants acquiring EBV infection.
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18
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Van de Perre P, Goga A, Ngandu N, Nagot N, Moodley D, King R, Molès JP, Mosqueira B, Chirinda W, Scarlatti G, Tylleskär T, Dabis F, Gray G. Eliminating postnatal HIV transmission in high incidence areas: need for complementary biomedical interventions. Lancet 2021; 397:1316-1324. [PMID: 33812490 DOI: 10.1016/s0140-6736(21)00570-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 06/06/2020] [Accepted: 10/02/2020] [Indexed: 11/24/2022]
Abstract
The rate of mother-to-child transmission (MTCT) of HIV from breastfeeding is increasing relative to other causes of MTCT. Early effective preconception and antenatal antiretroviral therapy (ART) reduces intrauterine and intrapartum MTCT, whereas maternal post-partum HIV acquisition, untreated maternal HIV, and suboptimal postnatal maternal ART adherence increase the risk of MTCT through breastfeeding. Although the absolute number of cases of MTCT acquired through breastfeeding is decreasing, the rate of decrease is less than the decrease in intrauterine and intrapartum MTCT. Unless current strategies are universally applied, they might not be sufficient to eliminate MTCT due to breastfeeding. Urgent action is needed to evaluate and implement additional preventive biomedical strategies in high HIV prevalence and incidence settings to eliminate MTCT from breastfeeding. Preventive strategies include: pre-exposure prophylaxis in breastfeeding women who have an increased risk of acquiring HIV; postnatal reinforcement strategies, such as maternal retesting for HIV, maternal care reinforcement, and prophylaxis in infants exposed to HIV via breastmilk; and active (vaccine) or passive immunoprophylaxis with long-acting broadly neutralising antibodies.
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Affiliation(s)
- Philippe Van de Perre
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France.
| | - Ameena Goga
- South African Medical Research Council, Cape Town, South Africa; Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa
| | - Nobubelo Ngandu
- South African Medical Research Council, Cape Town, South Africa
| | - Nicolas Nagot
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France
| | - Dhayendre Moodley
- Centre for AIDS Research in South Africa, and Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Rachel King
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France; School of Medicine, University of California, San Francisco, CA, USA
| | - Jean-Pierre Molès
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France
| | - Beatriz Mosqueira
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France
| | | | - Gabriella Scarlatti
- Viral Evolution and Transmission Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milano, Italy
| | | | - François Dabis
- Agence Nationale de Recherche sur le Sida et les Hépatites Virales (ANRS), Paris, France; Bordeaux Population Health, INSERM U 1219, ISPED, Université de Bordeaux, Bordeaux, France
| | - Glenda Gray
- South African Medical Research Council, Cape Town, South Africa
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19
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Dried blood spots for the quantitative evaluation of IgG isotypes and correlation with serum samples in HIV-exposed uninfected (HEU) infants. J Immunol Methods 2021; 493:113019. [PMID: 33705735 DOI: 10.1016/j.jim.2021.113019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 02/24/2021] [Accepted: 03/04/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND The determination of IgG levels and their subclasses can provide clinically relevant information on the status of the immune system. Here we determined the sensitivity and reproducibility of the quantification of IgG subclasses from Dried Blood Spots (DBS) in Malawian uninfected infants exposed to HIV (HEU). METHODS Sixty paired samples of serum and DBS from HEU infants were used. Samples were collected from 1, 6, and 24-month old infants. IgGs concentrations from both serum and DBS were analyzed by BN ProSpec Siemens assay, using a different setting for sample dilutions. The reproducibility of the DBS method was tested on 10 samples run twice, starting from the DBS extraction process. To assess the systematic, proportional, and random differences, we computed the Passing-Bablok regression, and the Bland-Altman analysis to estimate the total mean bias between the two tests. RESULTS The IgG isotypes concentrations from serum and DBS showed significant differences in all the comparisons. Generally, the DBS method underestimated IgG subclasses' values showing a recovery range between 51.2% and 77.6%. Passing Bablok regression on age-based groups showed agreement for IgG, IgG1, and IgG2, but not for IgG3 and IgG4. The mean bias obtained with the Bland Altman test varied largely depending on IgG isotypes (-0.02-2.21 g/l) Coefficient of variation <7.0% was found in the repeated tests for IgG, IgG1, IgG3, and IgG4, while it was 12.4% for IgG2. CONCLUSIONS Varying degrees of differences were seen in the IgGs measurement in the two different matrices. In IgGs analysis, the DBS method offers promise for population-based research, but the results should be carefully evaluated and considered as a relative value since they are not equivalent to the serum concentrations.
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20
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Orlando S, Palla I, Ciccacci F, Triulzi I, Thole D, Sangaré HM, Marazzi MC, Nielsen-Saines K, Turchetti G, Palombi L. Improving Treatment Adherence and Retention of HIV-Positive Women Through Behavioral Change Interventions Aimed at Their Male Partners: Protocol for a Prospective, Controlled Before-and-After Study. JMIR Res Protoc 2021; 10:e19384. [PMID: 33492232 PMCID: PMC7870353 DOI: 10.2196/19384] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 10/16/2020] [Accepted: 10/26/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND According to the World Health Organization, in 2018, 37.9 million people were living with HIV globally. More than two-thirds were residing in sub-Saharan Africa, where the HIV prevalence in the adult population (aged 15-49 years) was 3.9%. This population included 1.3 million pregnant women, of whom 82% had received antiretroviral therapy (ART) for the prevention of HIV mother-to-child transmission. In these countries, one challenge is an insufficient level of treatment adherence, particularly in HIV-positive pregnant women. Among the causes, the lack of involvement from a male partner is a significant contributor to the problem. This issue has strongly emerged in Malawi, one of the countries with the highest HIV prevalence in the world: 9.2% of its adult population were living with HIV in 2018. OBJECTIVE This study aims to assess 3 interventions that are aimed at improving ART adherence and retention among HIV-positive women through engagement with their male partners in 4 Malawian health care centers. METHODS The prospective, controlled before-and-after study is conducted in 3 phases (total duration: 24 months): preintervention, intervention, and postintervention analyses. The number of selected clusters (clinical centers) is limited to 4: one for each intervention, plus a cluster where no intervention is performed (control arm). The interventions are as follows: opening the facility on one Saturday per month only for men, defined as a special day; testing peer-to-peer counseling among men, male champions; and providing a noneconomic incentive to all women who are accompanied by their partners to the facility, nudge. The primary outcome of the study is to evaluate the differences in retention in care and adherence to therapeutic protocols among women; the intermediate outcome is the assessment of differences in male involvement. The level of male involvement in the health of their partners (intermediate outcome) will be evaluated through a dedicated questionnaire administered at baseline and in the postintervention phase. Data will be collected at the clinical centers and stored in 2 electronic databases managed using 2 different types of software. RESULTS The analysis of data collected in the 4 centers during the preintervention phase is ongoing, as enrollment ended on March 31, 2020. The total number of patients enrolled was 452 (Namandanje: 133; Kapeni: 78; Kapire: 75; and Balaka: 166). Meanwhile, several meetings have been conducted to organize the intervention phase. CONCLUSIONS The study will identify the best intervention that enhances the involvement of male partners in women's health, using an approach that considers a broad spectrum of behaviors. An important aspect is the use of educational tools focused on messages, thereby initiating a reflective discussion of stereotypes and false beliefs related to the idea of masculinity present in the Malawian culture. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/19384.
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Affiliation(s)
- Stefano Orlando
- Department of Biomedicine, University of Tor Vergata, Rome, Italy
| | - Ilaria Palla
- Institute of Management, Scuola Superiore Sant'Anna, PIsa, Italy
| | - Fausto Ciccacci
- Unicamillus, Saint Camillus International University of Health Sciences, Rome, Italy
| | - Isotta Triulzi
- Institute of Management, Scuola Superiore Sant'Anna, PIsa, Italy
| | | | | | | | - Karin Nielsen-Saines
- David Geffen UCLA School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | | | - Leonardo Palombi
- Department of Biomedicine, University of Tor Vergata, Rome, Italy
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Mekuria AD, Sisay AL, Hailegiorgies KK, Abebe AM. Joint and Separate Analysis for Longitudinal and Survival Data on Mother-to-Child Transmission of HIV Among Infected Mothers on Option B+ at Health Centers in North Shewa Zone, Ethiopia, 2017. J Multidiscip Healthc 2020; 13:1179-1189. [PMID: 33116563 PMCID: PMC7585812 DOI: 10.2147/jmdh.s269558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/24/2020] [Indexed: 11/23/2022] Open
Abstract
Background Prevention of mother-to-child transmission of HIV (PMTCT) is a frequently used word for programs and intervention methods to decrease the risk of mother-to-child transmission of HIV. The aim of this study was to identify determinants of the reduction of CD4 count through time and the maternal transmission of HIV to their child on the PMTCT program at health centers in North Shewa Zone, Ethiopia. Methods The cohort study design was conducted by using secondary data collected from the cohort register of PMTCT starting from September 1, 2014 to November 30, 2017. In this study, a longitudinal study was conducted for two types of result; these were longitudinal response measurements of HIV infected women CD4 count and the time to maternal transmission of HIV taken from 203 patients. Results The prevalence rate of HIV infection among exposed infants was 5.58%. Baseline CD4 count, visiting times, weight, and interaction between visiting time and baseline CD4 count had a statistically significant effect on the longitudinal biomarker. From the Weibull AFT model, ART start, partner test, clinical stage, educational status, place of delivery, and MUAC were statistically significant. Hence, as a measurement unit decreased in square root CD4 cell count by 1.18 elevates the risk of maternal transmission of HIV. Conclusion In this study, the determinant of mother-to-child transmission of HIV including loss of weight, ART start (ANC), place of delivery at home, illiterate and mother with severe malnutrition, had a significant effect. The longitudinal biomarker also had a strong association with baseline CD4 and the risk of maternal transmission of HIV. Health education should be given about balanced diet, weight control, and take medication for HIV positive patients by the responsible bodies.
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Affiliation(s)
- Abinet Dagnaw Mekuria
- Department of Public Health, College of Health Science, Debre Berhan University, Debre Berhan, Ethiopia
| | - Assefa Legesse Sisay
- Department of Epidemiology and Bio-Statistics, Jimma University, Jimma, Ethiopia
| | | | - Ayele Mamo Abebe
- Pediatrics nursing Department, College of Health Science, Debre Berhan University, Debre Berhan, Ethiopia
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Baroncelli S, Galluzzo CM, Liotta G, Andreotti M, Orlando S, Ciccacci F, Jere H, Luhanga R, Sagno JB, Amici R, Marazzi MC, Giuliano M. Dynamics of immunoglobulin G subclasses during the first two years of life in Malawian infants born to HIV-positive mothers. BMC Pediatr 2020; 20:181. [PMID: 32326903 PMCID: PMC7178742 DOI: 10.1186/s12887-020-02091-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/16/2020] [Indexed: 11/24/2022] Open
Abstract
Background Maternal antibodies are key components of the protective responses of infants who are unable to produce their own IgG until 6 months of life. There is evidence that HIV-exposed uninfected children (HEU) have IgG levels abnormalities, that can be partially responsible for the higher vulnerability to infections in the first 2 years of the life of this population. This retrospective study aimed to characterize the dynamics in plasma levels of total IgG and their isotypes during the first 2 years of life in HEU infants exclusively breastfed through 6 months of age. Methods Total IgG, IgG1, IgG2, IgG3 and IgG4 isotypes, and IgM and IgA plasma concentrations were determined by nephelometric methods in 30 Malawian infants born to HIV-positive women at month 1, 6 and 24 of life. Results At 1-month infants had a median concentration of total IgG of 8.48 g/l, (IQR 7.57–9.15), with an overrepresentation of the IgG1 isotype (89.0% of total) and low levels of IgG2 (0.52 g/l, IQR, 0.46–0.65). Total IgG and IgG1 concentrations were lower at 6 months (− 2.1 and − 1.12 g/dl, respectively) reflecting disappearance of maternal antibodies, but at 24 months their levels were higher with respect to the reported reference values for age-matched pairs. Abnormal isotype distribution was still present at 24 months with IgG2 remaining strongly underrepresented (0.87 g/l, 7.5% of total IgG). Conclusion HIV exposure during pregnancy and breastfeeding seems to influence the IgG maturation and isotype distribution that persist in 2-year old infants.
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Affiliation(s)
- Silvia Baroncelli
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy.
| | - Clementina Maria Galluzzo
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy
| | - Giuseppe Liotta
- Department of Biomedicine and Preventio, University of Rome Tor Vergata, Rome, Italy
| | - Mauro Andreotti
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy
| | - Stefano Orlando
- Department of Biomedicine and Preventio, University of Rome Tor Vergata, Rome, Italy
| | - Fausto Ciccacci
- Saint Camillus International University of Health Sciences, Rome, Italy
| | - Haswell Jere
- DREAM Program, Community of S. Egidio, Blantyre, Malawi
| | | | | | - Roberta Amici
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy
| | | | - Marina Giuliano
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy
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Baroncelli S, Galluzzo CM, Liotta G, Andreotti M, Mancinelli S, Mphwere R, Bokola E, Amici R, Marazzi MC, Palombi L, Palmisano L, Giuliano M. Immune Activation and Microbial Translocation Markers in HIV-Exposed Uninfected Malawian Infants in the First Year of Life. J Trop Pediatr 2019; 65:617-625. [PMID: 31006009 DOI: 10.1093/tropej/fmz022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND HIV-exposed uninfected (HEU) infants show a high rate of morbidity. We aimed to investigate on biomarkers of immune activation/microbial translocation in HEU infants, evaluating the impact that infections/malnutrition can have on biomarker levels during the first year of life. METHODS Clinical data of 72 Malawian infants were recorded monthly and correlated with levels of soluble CD14 (sCD14), lipopolysaccharide-binding protein (LBP) and intestinal fatty acid-binding protein (I-FABP), analyzed longitudinally. RESULTS Levels of sCD14 and LBP showed a significant age-related increase. Higher levels of LBP (19.4 vs. 15.2 μg/ml) were associated with stunting, affecting 30% of the infants. The association remained statistically significant after adjusting for cytomegalovirus acquisition, malaria and respiratory infections (p = 0.031). I-FABP levels were significantly increased in infants experiencing gastrointestinal infections (1442.8 vs. 860.0 pg/ml, p = 0.018). CONCLUSION We provide evidence that stunting is associated with an enhanced inflammatory response to microbial products in HEU children, suggesting that malnutrition status should be taken into consideration to better understand the alteration of the immune profile of HEU infants living in poor socioeconomic settings.
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Affiliation(s)
- Silvia Baroncelli
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | | | - Giuseppe Liotta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Mauro Andreotti
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Sandro Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - Enok Bokola
- DREAM Program, Community of S. Egidio, Blantyre, Malawi
| | - Roberta Amici
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | | | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Lucia Palmisano
- National Center for Drug Research and Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Marina Giuliano
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
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Baroncelli S, Maria Galluzzo C, Liotta G, Orlando S, Ciccacci F, Andreotti M, Mpwhere R, Luhanga R, Sagno JB, Amici R, Marazzi MC, Giuliano M. IgG abnormalities in HIV-positive Malawian women initiating antiretroviral therapy during pregnancy persist after 24 months of treatment. Int J Infect Dis 2019; 88:1-7. [PMID: 31499207 DOI: 10.1016/j.ijid.2019.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/27/2019] [Accepted: 09/03/2019] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Hypergammaglobulinemia and anomalies in the IgG subclass distribution are common in HIV-infected individuals and persist even after many years of antiretroviral therapy (ART). The aim of this study was to investigate the IgG profile and dynamics in pregnant HIV-infected Malawian women in the Option B era. METHODS Thirty-seven treatment-naive women received ART from the third trimester of pregnancy to 6 months post delivery (end of the breastfeeding period). ART continuation (group C) or interruption (group I) was then decided on the basis of the CD4+ cell count at enrolment (>350 or ≤350/μl). Total IgG and IgG subclasses were determined in maternal serum using a nephelometric assay at baseline and at 6 and 24 months postpartum. RESULTS At enrolment, 36/37 women had IgG levels >15g/l and there was a predominance of the IgG1 isotype (more than 90%) in parallel with underrepresentation of IgG2 (5.0%). After 6 months of ART, both groups showed a significant median decrease in total IgG (-3.1g/l in group I, -3.5g/l in group C) and in IgG1 (-4.0g/l and -3.6g/l, respectively), but only a modest recovery in IgG2 levels (+0.16 in group I, +0.14g/l in group C). At month 24, hypergammaglobulinemia was still present in 73.7% of women in group C, although a significant reduction was observed in total IgG level and in IgG1 and IgG3 subclasses (p<0.0001 in all cases). IgG2 levels did not show any significant change. In group I at 24 months, total IgG and IgG subclasses had returned to levels comparable to those at baseline. CONCLUSIONS The beneficial effects of 24 months of ART appear to be limited in the B-cell compartment, with an incomplete reduction of total IgG levels and no recovery of IgG2 depletion. A short ART period did not have significant effects on IgG abnormalities in women who interrupted treatment.
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Affiliation(s)
- Silvia Baroncelli
- National Centre for Global Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161 Rome, Italy.
| | - Clementina Maria Galluzzo
- National Centre for Global Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161 Rome, Italy
| | - Giuseppe Liotta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier, 1, 00133 Rome, Italy
| | - Stefano Orlando
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier, 1, 00133 Rome, Italy
| | - Fausto Ciccacci
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier, 1, 00133 Rome, Italy
| | - Mauro Andreotti
- National Centre for Global Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161 Rome, Italy
| | - Robert Mpwhere
- DREAM Program, Community of S. Egidio, PO Box 30355, Blantyre, Malawi
| | - Richard Luhanga
- DREAM Program, Community of S. Egidio, PO Box 30355, Blantyre, Malawi
| | | | - Roberta Amici
- National Centre for Global Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161 Rome, Italy
| | | | - Marina Giuliano
- National Centre for Global Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161 Rome, Italy
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A Systematic Review and Meta-analysis of Antiretroviral Therapy (ART) Adherence Interventions for Women Living with HIV. AIDS Behav 2019; 23:1998-2013. [PMID: 30443806 DOI: 10.1007/s10461-018-2341-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
A systematic review and meta-analysis was conducted to determine the efficacy of women-focused ART adherence interventions. Included studies (a) reported on a behavioral ART adherence intervention for cis-women living with HIV, (b) measured ART adherence as an outcome, and (c) employed a randomized controlled trial design. Thirteen studies were included in the meta-analysis. Overall, interventions significantly improved ART adherence compared to control conditions (random-effects d = 0.82, 95% CI [0.18, 1.45], p = 0.01), however, this was largely driven by two studies that had effect sizes greater than 3 standard errors above the mean effect size. Key moderators were location, recruitment method, group-based intervention, and alteration of the healthcare system. Innovative behavioral interventions that focus on young women and adolescents, target the critical periods of pregnancy and postpartum and test the integration of multiple levels of intervention to create lasting effects on ART adherence are needed.
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Buonomo E, Germano P, Moramarco S, Rossi R, Malizia A, Scarcella P, Orlando S, Guidotti G, Nielsen-Saines K, Tembo D, Marazzi MC, Palombi L. Early assessment of weight velocity can support frontline health workers in predicting malnutrition in HIV-exposed infants: preliminary results from a DREAM cohort in Malawi. Minerva Pediatr 2019; 72:14-21. [PMID: 30916516 DOI: 10.23736/s0026-4946.19.05417-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Children born to HIV-positive mothers are particularly susceptible to malnutrition. Currently, monitoring programs rely on punctual anthropometric measurements to assess child growth. Growth velocities could be an additional tool in identifying critical time windows for prevention and implementation of early intervention for malnutrition. METHODS A retrospective analysis was conducted using data from 817 HIV exposed but uninfected children extracted from DREAM program database. By using the WHO reference for growth standards, patterns of weight velocity for different intervals of assessment from one to 18 months of age were explored. Odds ratios and multinomial logistic regressions between selected weight velocity Z-scores thresholds and successive malnutrition indices (at 6, 12, 18 months of age) were calculated. RESULTS Weight velocity was above the standard mean in the first 3 months, then progressively declined over time. In children with normal nutritional status, significant risks of becoming malnourished (mild malnutrition - underweight [OR 10.8; 95% CI: 4.5-26], chronic malnutrition - stunting [OR 8.3; 95% CI: 2-34.9] and acute malnutrition - wasting [OR 11.7; 95% CI: 1.5-90.5]) started when weight velocity Z-scores <0, at all interval ages. Multinomial regression showed that in the first 6 months, the weight velocity decrements strongly impacted on underweight (OR 17.9; 95% CI: 4-80.7), while the risk of Stunting occurred later at 18 months (OR 8.7; 95% CI: 4.3-17.6), with highest impact at the lowest thresholds. CONCLUSIONS The assessment of weight velocity Z-scores, coupled with the already validated malnutrition indices, can support frontline health workers in early prediction of child malnutrition and performing nutritional counselling in the context of HIV/AIDS and food insecurity.
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Affiliation(s)
- Ersilia Buonomo
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy -
| | - Paola Germano
- DREAM Program, Community of Sant'Egidio Catholic Association, Rome, Italy
| | - Stefania Moramarco
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Riccardo Rossi
- Department of Engineering, University of Rome Tor Vergata, Rome, Italy
| | - Andrea Malizia
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Paola Scarcella
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Stefano Orlando
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - Karin Nielsen-Saines
- Department of Pediatrics, David Geffen UCLA School of Medicine, Los Angeles, CA, USA
| | - Dyna Tembo
- DREAM Program, Community of Sant'Egidio Catholic Association, Blantyre, Malawi
| | | | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
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Waitt C, Low N, Van de Perre P, Lyons F, Loutfy M, Aebi-Popp K. Does U=U for breastfeeding mothers and infants? Breastfeeding by mothers on effective treatment for HIV infection in high-income settings. Lancet HIV 2018; 5:e531-e536. [PMID: 29960731 DOI: 10.1016/s2352-3018(18)30098-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 04/30/2018] [Accepted: 05/02/2018] [Indexed: 12/01/2022]
Abstract
Can the campaign Undetectable=Untransmittable (U=U), established for the sexual transmission of HIV, be applied to the transmission of HIV through breastfeeding? European AIDS Clinical Society and, to some extent, American guidelines now state that mothers with HIV who wish to breastfeed should be supported, with increased clinical and virological monitoring. This Viewpoint summarises existing evidence on transmission of HIV through breastfeeding, differences in HIV dynamics and viral load between breastmilk and plasma, and the effects of antiretroviral therapy on infants. At present, insufficient evidence exists to make clear recommendations for the required frequency of clinical and virological monitoring for mother and infant in a breastfeeding relationship or for the action to be taken in the event of viral rebound. We propose a roadmap for collaborative research to provide the missing evidence required to enable mothers who wish to breastfeed to make a fully informed choice.
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Affiliation(s)
- Catriona Waitt
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK; Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda; Royal Liverpool University Hospital, Liverpool, UK.
| | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Philippe Van de Perre
- Pathogenesis and Control of Chronic Infections, INSERM, University of Montpellier, Etablissement Français du Sang, CHU Montpellier, Montpellier, France
| | - Fiona Lyons
- Department of Genitourinary Medicine and Infectious Diseases, St James's Hospital, Dublin, Ireland
| | - Mona Loutfy
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Karoline Aebi-Popp
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
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Baroncelli S, Galluzzo CM, Liotta G, Andreotti M, Mancinelli S, Mphwere R, Bokola E, Amici R, Marazzi MC, Palombi L, Lucaroni F, Giuliano M. Deficit of IgG2 in HIV-positive pregnant women is responsible of inadequate IgG2 levels in their HIV-uninfected children in Malawi. Med Microbiol Immunol 2018; 207:175-182. [PMID: 29488063 DOI: 10.1007/s00430-018-0537-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 02/17/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transplacental passage of IgGs is impaired in HIV + pregnant women, possibly determining an inadequate immunological protection in their children. We aimed to determine the impact of maternal immunological IgG profile and immunoactivation status on the efficiency of transplacental passage of IgG subclasses in HIV + mothers. METHODS 16 mother/infants pairs were studied in Malawi. Mothers received antiretroviral therapy (ART) from the third trimester of pregnancy. Determinations of pre-ART levels of maternal sCD14, of IgG subclasses in mothers at delivery and in their 1-month-old infants, were performed using commercial ELISA kits. RESULTS At delivery, after a median of 10 weeks of ART, 12/16 mothers were hypergammaglobulinemic, with IgG levels (20.5 mg/ml, 95% CI:18.8-26.8) directly correlated to the plasmatic levels of sCD14 (r = 0.640, p = 0.014). IgG1 levels (17.9 mg/ml) accounted for 82% of IgG, IgG3 and IgG4 levels were in the normal range. A profound deficit of IgG2 was observed both in mothers (0.60 mg/ml) and in infants (0.14 mg/ml). Placental transfer ratio (range 0.16-0.42) did not show a selective impairment between the different IgG subclasses. The transplacental passage of all IgG subclasses was decreased in the presence of maternal IgG over 16 mg/ml (significantly for IgG1, p = 0.031) and of high levels of sCD14 (p = 0.063). CONCLUSIONS Transplacental passage was reduced for all IgG subclasses and inversely correlated to high levels of maternal IgGs and to the degree of immunoactivation. The profound depression of IgG2 in mothers suggests that IgG2 neonatal levels mostly reflect the maternal deficit rather than a selective impairment of IgG2 transfer.
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Affiliation(s)
- Silvia Baroncelli
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161, Rome, Italy.
| | - Clementina Maria Galluzzo
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161, Rome, Italy
| | - Giuseppe Liotta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier, 1 00133, Rome, Italy
| | - Mauro Andreotti
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161, Rome, Italy
| | - Sandro Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier, 1 00133, Rome, Italy
| | - Robert Mphwere
- DREAM Program, Community of S. Egidio, P.O. Box 30355, Blantyre, Malawi
| | - Enok Bokola
- DREAM Program, Community of S. Egidio, P.O. Box 30355, Blantyre, Malawi
| | - Roberta Amici
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161, Rome, Italy
| | | | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier, 1 00133, Rome, Italy
| | - Francesca Lucaroni
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier, 1 00133, Rome, Italy
| | - Marina Giuliano
- National Center for Global Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161, Rome, Italy
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Mancinelli S, Pirillo MF, Liotta G, Andreotti M, Mphwere R, Amici R, Marazzi MC, Vella S, Palombi L, Giuliano M. Antibody response to hepatitis B vaccine in HIV-exposed infants in Malawi and correlation with HBV infection acquisition. J Med Virol 2018; 90:1172-1176. [PMID: 29427444 DOI: 10.1002/jmv.25049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/18/2017] [Indexed: 11/06/2022]
Abstract
The aim of this study was to assess the immune response to HBV vaccine in HIV-exposed infants and to correlate it to HBV infection acquisition. Protective anti-HBs levels (>10 mIU/mL) were found in 54/58 (93.2%) infants at 6 months, 126/144 (87.5%) at 12 months and 141/176 (80.1%) children at 24 months. HBV infection (seven children were HBsAg + at Month 24) occurred also in the presence of levels above 10 mIU/mL. Our findings indicate limited impact of HIV exposure on anti-HBV immune response, but suggest that levels >10 mIU/mL may be required to confer protection in this context.
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Affiliation(s)
- Sandro Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Maria F Pirillo
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Giuseppe Liotta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Mauro Andreotti
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | | | - Roberta Amici
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | | | - Stefano Vella
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Marina Giuliano
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
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Baroncelli S, Galluzzo CM, Liotta G, Andreotti M, Ciccacci F, Mancinelli S, Tolno VT, Gondwe J, Amici R, Marazzi MC, Vella S, Giuliano M, Palombi L, Palmisano L. Soluble CD14 levels in plasma and breastmilk of Malawian HIV+ women: Lack of association with morbidity and mortality in their exposed infants. Am J Reprod Immunol 2018; 79. [PMID: 29323435 DOI: 10.1111/aji.12812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 12/14/2017] [Indexed: 12/22/2022] Open
Abstract
PROBLEM Data on soluble CD14 (sCD14) during pregnancy and lactation are scarce. We assessed the levels of sCD14 in plasma and breastmilk of Malawian HIV-positive women and evaluated the possible association with morbidity and mortality in the HIV-exposed children. METHOD OF STUDY One hundred and forty-nine mother/child pairs were studied. Women received antiretroviral therapy from 26 weeks of gestation to at least 6 months of exclusive breastfeeding. sCD14 concentrations were determined using an enzyme-linked immunosorbent assay. RESULTS sCD14 levels measured at 26 weeks of pregnancy (median: 1418 ng/mL, IQR: 1086-1757) were inversely correlated to maternal CD4+ cell count (r = -.283, P = .001) and to neonatal birthweight (r = -.233, P = .008). At 6 months, sCD14 plasma levels were significantly higher compared to baseline (1993 ng/mL, IQR: 1482-2604, P < .001), and breastmilk sCD14 levels (7668 ng/mL, IQR: 5495-10207) were 4-fold higher than in plasma (although the concentrations in the two compartments were not correlated). No association was found between sCD14 levels in plasma or breastmilk and morbidity or mortality in children. CONCLUSION Higher sCD14 levels in HIV-positive women were associated with a more compromised maternal immunological status and to a lower neonatal birthweight, but not to poorer clinical outcomes in the HIV-exposed children.
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Affiliation(s)
- Silvia Baroncelli
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | | | - Giuseppe Liotta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Mauro Andreotti
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | | | - Sandro Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - Jane Gondwe
- DREAM Program, Community of S. Egidio, Blantyre, Malawi
| | - Roberta Amici
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | | | - Stefano Vella
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Marina Giuliano
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Lucia Palmisano
- National Center for Drug Research and Evaluation, Istituto Superiore di Sanità, Rome, Italy
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Nguyen TTV, Sabin K, Ho TQT, Le AKA, Hayashi C, Kato M. Monitoring Prevention Impact of Mother-to-Child Transmission of HIV in Concentrated Epidemics With Program and Survey Data. JMIR Public Health Surveill 2017; 3:e76. [PMID: 29263016 PMCID: PMC5757733 DOI: 10.2196/publichealth.7701] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 07/11/2017] [Accepted: 08/23/2017] [Indexed: 11/17/2022] Open
Abstract
Background The prevention of mother-to-child transmission (PMTCT) of HIV program was introduced in Vietnam in 2005. Despite the scaling up of PMTCT programs, the rate of mother-to-child HIV transmission in Vietnam was estimated as high as 20% in 2013. Objective The objective of this study was to assess the outcomes of PMTCT and identified factors associated with mother-to-child transmission and infant survival using survey and program data in a high HIV burden province in Vietnam. Methods This community-based retrospective cohort study observed pregnant women diagnosed with HIV infection in Thai Nguyen province from October 2008 to December 2012. Data were collected through interviews using a structured questionnaire and through reviews of log books and medical charts in antenatal care and HIV clinics. Logistic regression and survival analysis were used to analyze data using Stata (StataCorp). Results A total of 172 pregnant women living with HIV were identified between 2008 and 2012. Most of these women had acquired the HIV infection from their husband (77/119, 64.7%). Significant improvement in the PMTCT program was documented, including reduction in late diagnosis of HIV for pregnant women from 62.5% in 2008 to 30% in 2012. Access to antiretrovirals (ARVs) improved, increasing from a rate of 18.2% (2008) to 70.0% (2011) for mothers and from 36.4% (2008) to 93.3% (2012) for infants. For infants, early diagnosis within 2 months of birth reached 66.7% in 2012 compared with 16.7% in 2009. Transmission rate reduced from 27.3% in 2008 to 6.7% in 2012. Late diagnosis was associated with increased risk for HIV transmission (odds ratio [OR] 14.7, 95% CI 1.8-121.4, P=.01), whereas ARV therapy for mother and infant in combination with infant formula feeding were associated with reduced risk for HIV transmission (OR 0.01, 95% CI 0.001-0.1; P<.001). Overall survival rate for HIV-exposed infants at 12 months was 97.7%. Conclusions A combination of program and survey data measured the impact of prevention of HIV transmission from mother-to-child interventions. Significant improvement in access to the interventions was documented in Thai Nguyen province. However, factors that increased the risk of HIV transmission, such as late diagnosis, remain to be addressed.
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Affiliation(s)
| | - Keith Sabin
- World Health Organization Country Office, Hanoi, Viet Nam
| | | | - Ai Kim Anh Le
- Thai Nguyen Provincial AIDS Centre, Thai Nguyen, Viet Nam
| | - Chika Hayashi
- World Health Organization, HIV/AIDS, Geneva, Switzerland
| | - Masaya Kato
- World Health Organization Country Office, Hanoi, Viet Nam
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Gill MM, Hoffman HJ, Ndatimana D, Mugwaneza P, Guay L, Ndayisaba GF, Bobrow EA, Asiimwe A, Mofenson LM. 24-month HIV-free survival among infants born to HIV-positive women enrolled in Option B+ program in Kigali, Rwanda: The Kabeho Study. Medicine (Baltimore) 2017; 96:e9445. [PMID: 29390577 PMCID: PMC5758279 DOI: 10.1097/md.0000000000009445] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Lifelong antiretroviral therapy (ART) provision to all pregnant HIV-positive women ("Option B+") has been recommended by the World Health Organization since 2013, but there remain limited data on the effects of Option B+ on long-term HIV-free survival in breastfeeding HIV-exposed infants. The Kigali Antiretroviral and Breastfeeding Assessment for the Elimination of HIV (Kabeho) study enrolled HIV-positive women from the third trimester of pregnancy to 2 weeks postpartum in 14 heath facilities implementing Option B+ in Kigali, Rwanda. Mother-child pairs in the longitudinal observational cohort were followed until 24 months postpartum, with HIV diagnostic testing at 6 weeks, and 9, 18 and 24 months. The Kaplan-Meier method was used to estimate HIV transmission, survival, and HIV-free survival through 24 months. We enrolled 608 HIV-positive women in 2013-2014; birth outcome data were available for 600 women and 597 live-born infants. By 6 weeks, 11 infants had died and 3 infants had confirmed HIV infection (0.5% transmission; 95% confidence interval [CI] 0.2-1.6). At 9 months, there were 9 additional deaths and 2 new infections (cumulative transmission 0.9%, 95% CI 0.4-2.2). At 18 months, there were 6 additional deaths and no new infant infections. At 24 months, there were no additional child deaths and 1 new infection (cumulative 2.2%, 95% CI 0.7-7.0), for an overall 24-month HIV-free survival of 93.2% (95% CI 89.5-95.6). Low transmission rates and high HIV-free survival at 24 months were achieved in breastfeeding infants of HIV-positive mothers receiving universal ART in urban health facilities in Rwanda, though vigilance on maintaining viral suppression for ART-experienced women is needed.
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Affiliation(s)
| | - Heather J. Hoffman
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | | | | | - Laura Guay
- Elizabeth Glaser Pediatric AIDS Foundation
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | | | | | - Anita Asiimwe
- Rwanda University Teaching Hospitals (CHU), Kigali, Rwanda
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Low mother-to-child HIV transmission rate but high loss-to-follow-up among mothers and babies in Mandalay, Myanmar; a cohort study. PLoS One 2017; 12:e0184426. [PMID: 28886165 PMCID: PMC5590939 DOI: 10.1371/journal.pone.0184426] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 08/23/2017] [Indexed: 11/19/2022] Open
Abstract
Introduction Loss-to-follow-up (LTFU) throughout the Prevention of Mother-To-Child Transmission (PMTCT) cascade remains one of the major threats to the success of PMTCT programs. In this study, we aimed to determine the mother-to-child transmission rate in a programmatic setting and to determine factors associated with LTFU among enrolled mothers and unfavorable outcomes among HIV-exposed babies which includes being HIV positive, death and LTFU. Methods A retrospective cohort study reviewing routinely collected data in an Integrated HIV care program, Mandalay, Myanmar in June 2016.LTFU means mother/infant missing appointed visit for more than three months. Results Of 678 pregnant women enrolled in PMTCT program between March 2011 and June 2014, one stillbirth and 607 live births were recorded in this cohort. Of 457 HIV-exposed babies with HIV-test recorded at the end of the intervention, nine (2%) were HIV-positive. Pregnant women’s and exposed-babies’ LTFU rate was 7 per 1000 person-years, and 10 per 1000 person-years respectively. PMTCT option B protocol was found to be significantly associate with maternal LTFU [adjusted Hazard Ratio (aHR) 95% CI: 3.52 (1.38–8.96)] when compare to mothers receiving option B+/lifelong antiretroviral therapy (ART). Weight <2.5 Kg at enrolment, receiving mixed-feeding, vaginal delivery and option B PMTCT protocol were significantly associated with unfavorable outcomes among exposed babies [aHR(95% CI): 5.40 (1.66–17.53), 5.91(1.68–20.84), 2.27 (1.22–4.22) and 2.33 (1.16–4.69) respectively]. Conclusion Mother-to-child HIV transmission rate in this public hospital-based program was lower than the 5% national target, which indicates a successful PMTCT intervention. However, a high proportion of HIV-infected mothers and exposed babies LTFU was recorded. Lifelong ART provision to HIV-positive pregnant women was shown to reduce exposed babies’ LTFU, death and transmission rate (unfavorable outcomes) in this setting. Lessons learned from this program could be used to inform policy and practice in the country, while the programmatic challenge of LTFU should be urgently addressed.
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Giuliano M, Pirillo MF, Liotta G, Andreotti M, Jere H, Sagno JB, Ciccacci F, Amici R, Marazzi MC, Vella S, Palombi L, Mancinelli S. High CMV IgG antibody levels are associated to a lower CD4+ RESPONSE to antiretroviral therapy in HIV-infected women. J Clin Virol 2017; 96:17-19. [PMID: 28918126 DOI: 10.1016/j.jcv.2017.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 08/28/2017] [Accepted: 08/31/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND Virtually all HIV-infected women in sub-Saharan Africa have evidence of Cytomegalovirus (CMV) infection and levels of specific anti-CMV IgG have been suggested to represent more intense reactivation of subclinical infection. Studies have also shown direct influence of CMV on lymphocytes. OBJECTIVE The aim of this study was to determine if levels of anti-CMV specific antibodies could impact on the immunological response to antiretroviral treatment (ART) in HIV-infected pregnant women. STUDY DESIGN CMV-specific IgG were measured in HIV-infected pregnant women at 26 weeks of gestation (before ART initiation). Women received ART until 6 months postpartum or indefinitely according to local guidelines at the time of the study. Immunological and virological responses were assessed 6 months and 24 months after delivery. RESULTS A total of 81 women were studied. At baseline high levels (above the median) of specific IgG were associated to a low CD4+ cell count (P<0.001), a high viral load (P=0.003), and to an older age (P=0.051). In a multivariate model adjusting for baseline CD4+ count, baseline viral load and age, the presence of low levels of CMV IgG was the only independent predictor of a a CD4+ count above 500/mm3 24 months after delivery among women on continuous therapy. CONCLUSIONS In this cohort, levels of CVM IgG had a significant influence on the immunological response to ART, adding information to the known impact of CMV infection in the HIV-positive population, and underlining the need of new strategies to contain the infection.
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Affiliation(s)
- Marina Giuliano
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy.
| | | | - Giuseppe Liotta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy
| | - Mauro Andreotti
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Haswell Jere
- DREAM Program, Community of S. Egidio, Blantyre, Malawi
| | | | | | - Roberta Amici
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | | | - Stefano Vella
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy
| | - Sandro Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy
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Postnatal HIV transmission in breastfed infants of HIV-infected women on ART: a systematic review and meta-analysis. J Int AIDS Soc 2017; 20:21251. [PMID: 28362072 PMCID: PMC5467610 DOI: 10.7448/ias.20.1.21251] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction: To systematically review the literature on mother-to-child transmission in breastfed infants whose mothers received antiretroviral therapy and support the process of updating the World Health Organization infant feeding guidelines in the context of HIV and ART. Methods: We reviewed experimental and observational studies; exposure was maternal HIV antiretroviral therapy (and duration) and infant feeding modality; outcomes were overall and postnatal HIV transmission rates in the infant at 6, 9, 12 and 18 months. English literature from 2005 to 2015 was systematically searched in multiple electronic databases. Papers were analysed by narrative synthesis; data were pooled in random effects meta-analyses. Postnatal transmission was assessed from four to six weeks of life. Study quality was assessed using a modified Newcastle-Ottawa Scale (NOS) and GRADE. Results and discussion: Eleven studies were identified, from 1439 citations and review of 72 abstracts. Heterogeneity in study methodology and pooled estimates was considerable. Overall pooled transmission rates at 6 months for breastfed infants with mothers on antiretroviral treatment (ART) was 3.54% (95% CI: 1.15–5.93%) and at 12 months 4.23% (95% CI: 2.97–5.49%). Postnatal transmission rates were 1.08 (95% CI: 0.32–1.85) at six and 2.93 (95% CI: 0.68–5.18) at 12 months. ART was mostly provided for PMTCT only and did not continue beyond six months postpartum. No study provided data on mixed feeding and transmission risk. Conclusions: There is evidence of substantially reduced postnatal HIV transmission risk under the cover of maternal ART. However, transmission risk increased once PMTCT ART stopped at six months, which supports the current World Health Organization recommendations of life-long ART for all.
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Chevalier MS, King CC, Ellington S, Wiener J, Kayira D, Chasela CS, Jamieson DJ, Kourtis AP. Maternal and neonatal outcomes among women with HIV infection and their infants in Malawi. Int J Gynaecol Obstet 2017; 137:282-289. [PMID: 28258582 PMCID: PMC5419872 DOI: 10.1002/ijgo.12136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 01/11/2017] [Accepted: 02/28/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe maternal and neonatal morbidity and mortality among women with HIV infection and their infants. METHODS A secondary analysis was undertaken of data obtained in the BAN Study, a trial of postnatal antiretrovirals among pregnant women with HIV infection enrolled in 2004-2010. Mothers and infants had 13 scheduled visits through 48 weeks of follow-up. Serious maternal morbidity and mortality were examined at delivery (n=2791), from delivery to 6 weeks later (n=2369) and from 7 to 48 weeks (n=1980). Neonatal morbidity and mortality were examined (n=2685). RESULTS Of 2791 deliveries, 169 (6.1%) were by cesarean (153 emergency). Compared with women with vaginal delivery, those with cesarean delivery had lower prenatal HIV viral loads (P=0.016) and increased odds of pre-eclampsia/eclampsia (odds ratio [OR] 10.8, 95% CI 4.4-26.8). Women with cesarean delivery also had increased odds of serious infection with 14 days of delivery (OR 3.0, 95% CI 1.3-7.4) and severe anemia (grade 3 or 4) by 6 weeks (OR 6.7, 95% CI 2.3-19.1). Infants born by cesarean had increased odds of a low 5-minute Apgar score (OR 8.1, 95% CI 3.5-18.6) and admission to an intensive care unit (OR 5.4, 95% CI 3.7-7.8). CONCLUSION Odds of serious maternal and neonatal morbidity were higher after cesarean than vaginal delivery, despite lower maternal viral loads.
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Affiliation(s)
- Michelle S. Chevalier
- Division of Global HIV and Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Caroline C. King
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sascha Ellington
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jeffrey Wiener
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Dumbani Kayira
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Charles S. Chasela
- Epidemiology and Strategic Information, Human Sciences Research Council, Pretoria, South Africa
| | - Denise J. Jamieson
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Athena P. Kourtis
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Pirillo MF, Liotta G, Andreotti M, Jere H, Sagno JB, Scarcella P, Mancinelli S, Buonomo E, Amici R, Marazzi MC, Vella S, Palombi L, Giuliano M. CMV infection in a cohort of HIV-exposed infants born to mothers receiving antiretroviral therapy during pregnancy and breastfeeding. Med Microbiol Immunol 2016; 206:23-29. [PMID: 27629556 DOI: 10.1007/s00430-016-0478-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 09/07/2016] [Indexed: 01/25/2023]
Abstract
Antiretroviral therapy has been shown to reduce rates of congenital CMV infection. Little information is available on the possible impact of antiretroviral therapy on postnatal breastfeeding-associated CMV infection acquisition. A cohort of 89 HIV-infected mothers and their children was studied. Women received antiretroviral therapy from week 25 of gestation until 6 months postpartum or indefinitely if meeting the criteria for treatment. All women were evaluated for CMV IgG presence and CMV DNA in breast milk. Children were tested for CMV infection by either the presence of IgM or the presence of CMV DNA in plasma at 1, 6 and 12 months and by the presence of IgG at 24 months. All mothers had high titers of CMV DNA in breast milk (5.7 log at Month 1 and 5.1 log at Month 6). Cumulative CMV infection rates were 60.3 % at Month 6, 69 % at Month 12 and 96.4 % at Month 24. There was a significant negative correlation between the duration of antiretroviral treatment during pregnancy and levels of CMV DNA in breast milk at Month 1 (P = 0.033). There was a trend for a correlation between high titers of CMV DNA in breast milk at 6 months and CMV infection at 6 months (P = 0.069). In this cohort, more than 95 % of the children had acquired CMV infection by 2 years of age. Besides breastfeeding, which played a major role, also horizontal transmission between 1 and 2 years was certainly relevant in determining CMV infection acquisition.
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Affiliation(s)
- Maria Franca Pirillo
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Vaile Regina Elena 299, 00161, Rome, Italy
| | - Giuseppe Liotta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Mauro Andreotti
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Vaile Regina Elena 299, 00161, Rome, Italy
| | - Haswel Jere
- DREAM Program, Community of S. Egidio, Blantyre, Malawi
| | | | - Paola Scarcella
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Sandro Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Ersilia Buonomo
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Roberta Amici
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Vaile Regina Elena 299, 00161, Rome, Italy
| | | | - Stefano Vella
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Vaile Regina Elena 299, 00161, Rome, Italy
| | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Marina Giuliano
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Vaile Regina Elena 299, 00161, Rome, Italy.
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Mancinelli S, Galluzzo CM, Andreotti M, Liotta G, Jere H, Sagno JB, Amici R, Pirillo MF, Scarcella P, Marazzi MC, Vella S, Palombi L, Giuliano M. Virological Response and Drug Resistance 1 and 2 Years Post-Partum in HIV-Infected Women Initiated on Life-Long Antiretroviral Therapy in Malawi. AIDS Res Hum Retroviruses 2016; 32:737-42. [PMID: 27067142 DOI: 10.1089/aid.2015.0366] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The objective of this study was to determine the virological response and the possible emergence of drug resistance at 1 and 2 years postpartum in HIV-positive pregnant women enrolled under the Option B approach and meeting the criteria for treatment. In the study, women with baseline CD4(+) <350/mm(3) received a combination of stavudine, lamivudine, and nevirapine during pregnancy (from week 25 of gestation) and continued it indefinitely after delivery. HIV-RNA was measured at 12 and 24 months postpartum. Drug resistance mutations were assessed in those with HIV-RNA >50 copies/ml. Baseline resistance mutations were assessed in the entire cohort. A total of 107 women were studied. At baseline, resistance mutations were seen in 6.6% of the women. At 12 months, 26.7% of the women had >50 copies/ml and among them 12.9% had virological failure (HIV-RNA >1,000 copies/ml). At 24 months, detectable HIV-RNA was seen in 28.3% of the women and virological failure in 10.1% of the women. Resistance mutations (mainly non-nucleoside reverse transcriptase inhibitors mutations) were seen in 40% of the women with detectable HIV-RNA. Baseline mutations did not correlate with virological failure or the emergence of resistance at later time points. Virological failure 2 years postpartum and emergence of resistance were rare in this cohort of HIV-infected women. These findings are reassuring in the light of the new strategies for the prevention of mother-to-child HIV transmission, recommending life-long antiretroviral therapy administration.
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Affiliation(s)
- Sandro Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Clementina Maria Galluzzo
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Mauro Andreotti
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Giuseppe Liotta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Haswel Jere
- DREAM Program, Community of S. Egidio, Blantyre, Malawi
| | | | - Roberta Amici
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Maria Franca Pirillo
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Paola Scarcella
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - Stefano Vella
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Marina Giuliano
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
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Floridia M, Liotta G, Andreotti M, Galluzzo CM, Amici R, Jere H, Sagno JB, Marazzi MC, Buonomo E, Scarcella P, Mancinelli S, Vella S, Giuliano M, Palombi L. Levels of bone markers in a population of infants exposedin uteroand during breastfeeding to tenofovir within an Option B+ programme in Malawi. J Antimicrob Chemother 2016; 71:3206-3211. [DOI: 10.1093/jac/dkw268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/04/2016] [Accepted: 06/02/2016] [Indexed: 01/11/2023] Open
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Chikhungu LC, Bispo S, Rollins N, Siegfried N, Newell ML. HIV-free survival at 12-24 months in breastfed infants of HIV-infected women on antiretroviral treatment. Trop Med Int Health 2016; 21:820-8. [PMID: 27120500 PMCID: PMC5096069 DOI: 10.1111/tmi.12710] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Objective To provide estimates of HIV‐free survival at 12–24 months in breastfed children by maternal ART (6 months or lifelong) to inform WHO HIV and Infant Feeding guidelines. Methods Eighteen studies published 2005–2015 were included in a systematic literature review (1295 papers identified, 156 abstracts screened, 55 full texts); papers were analysed by narrative synthesis and meta‐analysis of HIV‐free survival by maternal ART regimen in a random effects model. We also grouped studies by feeding modality. Study quality was assessed using a modified Newcastle–Ottawa Scale (NOS) and GRADE. Results The pooled estimates for 12‐month HIV‐free survival were 89.8% (95% confidence interval, CI: 86.5%, 93.2%) for infants of mothers on ART for 6 months post‐natally (six studies) and 91.4% (95% CI 87.5%, 95.4%) for infants of mothers on lifelong ART (three studies). Eighteen‐month HIV‐free survival estimates were 89.0% (95% CI 83.9%, 94.2%) with 6 months ART (five studies) and 96.1% (95% CI 92.8%, 99.0%) with lifelong ART (three studies). Twenty‐four‐month HIV‐free survival for infants whose mothers were on ART to 6 months post‐natally (two studies) was 89.2% (95% CI 79.9%, 98.5%). Heterogeneity was considerable throughout. In four studies, HIV‐free survival in breastfed infants ranged from 87% (95% CI 78%, 92%) to 96% (95% CI 91%, 98%) and in formula‐fed infants from 67% (95% CI 35.5%, 87.9%) to 97.6% (95% CI 93.0%, 98.2%). Conclusion Our results highlight the importance of breastfeeding for infant survival and of ART in reducing the risk of mother‐to‐child HIV transmission and support the WHO recommendation to initiate ART for life immediately after HIV diagnosis.
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Affiliation(s)
| | - Stephanie Bispo
- Department of Social Statistics and Demography, University of Southampton, Southampton, UK
| | - Nigel Rollins
- Department of Maternal, New-born, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | | | - Marie-Louise Newell
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
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Altan AMD, Taafo F, Fopa F, Buonomo E, Marazzi MC, Nielsen-Saines K, Orlando S, Scarcella P, Ciccacci F, Mancinelli S, Lio MMS, Palombi L. An assessment of option B implementation for the prevention of mother to child transmission in Dschang, Cameroon: results from the DREAM (Drug Resource Enhancement against AIDS and Malnutrition) cohort. Pan Afr Med J 2016; 23:72. [PMID: 27217896 PMCID: PMC4862786 DOI: 10.11604/pamj.2016.23.72.7958] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 02/27/2016] [Indexed: 11/12/2022] Open
Abstract
Introduction Scaling up of antiretroviral therapy (ART) to HIV+ pregnant women is crucial for the elimination of HIV infection in children. The aim of this study was to evaluate the feasibility and effectiveness of triple ART for Prevention of Mother-to Child Transmission (PMTCT) in Cameroon. Methods HIV-positive pregnant women attending the DREAM Centre of Dschang, Cameroon for prenatal care were enrolled in a prospective cohort study, and received ART until the end of breastfeeding or indefinitely if their CD4 count was <350mm3. Infants were evaluated for HIV infection at 1, 6 and 12 months of age. Results A total of 298 women were enrolled. Among them, 152 were already on established ART. Women were followed until 6 months after delivery with a retention rate of 92.6%. Eight women died. Those with a CD4 count <350 cells/mm3 during pregnancy had the highest mortality risk (RR 2.53; 95% CL= 1.86-3.44). The HIV transmission rate was 1.2% at 12 months with an HIV free survival of 91%. In the proportional Cox regression analysis, the following factors were positively associated with infant mortality: maternal CD4< 350 cells/mm3, no breastfeeding in the first 6 months of life, weight-for-age z score<-2. Conclusion Results confirm the feasibility and effectiveness of the implementation of Option B, with very low rates of HIV MTC transmission, and potential benefits to the health of mothers and infants with earlier initiation of ART. Breastfeeding again demonstrates to be highly beneficial for the growth and survival of HIV exposed children.
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Affiliation(s)
| | | | | | - Ersilia Buonomo
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy
| | | | - Karin Nielsen-Saines
- Department of Pediatrics, David Geffen UCLA School of Medicine, Los Angeles, California
| | | | - Paola Scarcella
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy
| | | | - Sandro Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy
| | | | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy
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Growth indices in breastfed infants pre and postnatally exposed to tenofovir compared with tenofovir-unexposed infants. AIDS 2016; 30:525-7. [PMID: 26765942 DOI: 10.1097/qad.0000000000000944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We evaluated growth indices in two cohorts of Malawian infants exposed to tenofovir, lamivudine and efavirenz in utero and during 12 months of breastfeeding, and to stavudine/zidovudine, lamivudine and nevirapine in utero and during 6 months of breastfeeding. Growth indices were similar in the two cohorts at one and 6 months but were significantly better in the first group at 12 months, suggesting no negative effect of tenofovir and a significant benefit of extended breastfeeding.
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Baroncelli S, Galluzzo CM, Mancinelli S, Andreotti M, Jere H, Amici R, Marazzi MC, Vella S, Palombi L, Giuliano M. Antibodies against pneumococcal capsular polysaccharide in Malawian HIV-positive mothers and their HIV-exposed uninfected children. Infect Dis (Lond) 2015; 48:317-321. [PMID: 26609569 DOI: 10.3109/23744235.2015.1115895] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background HIV-exposed uninfected children have a higher risk of infection and mortality compared to HIV-unexposed children and the reasons for this vulnerability are still under investigation. AIM This study aimed to evaluate the influence of maternal HIV parameters on the passive transfer of anti-pneumococcal capsular polysaccharide (PCP) IgG and to determine whether the concentrations of specific IgG might be related to the morbidity and mortality in HIV-exposed uninfected children. Methods One hundred and twenty-six Malawian HIV-infected pregnant women and their uninfected children were studied. Antiretroviral treatment-naive women started a nevirapine-based triple combination regimen from the third trimester of pregnancy until at least 6 months of exclusive breastfeeding. Mother/child pairs were followed until 2 years after delivery. Plasma anti-PCP IgG titers (in mothers at 26 weeks of gestation and in infants at 1 and 6 months) were determined by an enzyme-linked immunosorbent assay. None of these women and children had received any vaccination against pneumococcal polysaccharides. Results Maternal anti-PCP IgG concentration was independent from viral load (p = 0.848), CD4 count (p = 0.740) and WHO stage (p = 0.450). However, the child/mother ratio of anti-PCP IgG measured at 1 month among infants was significantly reduced in pairs whose mothers had HIV-RNA > 10 000 copies/ml (p = 0.043) and CD4 < 350 cells/μl (p = 0.090) before antiretroviral therapy (ART). No clear associations between anti-PCP IgG and respiratory-related deaths were found, but respiratory infection episodes were more frequent among children with lower anti-PCP IgG ratio (p = 0.046). Conclusion This study indicates that HIV pre-ART conditions in mothers may influence the rate of specific immunoglobulins transfer, increasing infants vulnerability to respiratory infections.
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Affiliation(s)
- Silvia Baroncelli
- a Department of Therapeutic Research and Medicines Evaluation , Istituto Superiore di Sanità , Rome , Italy
| | - Clementina Maria Galluzzo
- a Department of Therapeutic Research and Medicines Evaluation , Istituto Superiore di Sanità , Rome , Italy
| | - Sandro Mancinelli
- b Department of Biomedicine and Prevention , University of Rome Tor Vergata , Rome , Italy
| | - Mauro Andreotti
- a Department of Therapeutic Research and Medicines Evaluation , Istituto Superiore di Sanità , Rome , Italy
| | - Haswell Jere
- c DREAM Program , Community of S. Egidio , Blantyre , Malawi
| | - Roberta Amici
- a Department of Therapeutic Research and Medicines Evaluation , Istituto Superiore di Sanità , Rome , Italy
| | | | - Stefano Vella
- a Department of Therapeutic Research and Medicines Evaluation , Istituto Superiore di Sanità , Rome , Italy
| | - Leonardo Palombi
- b Department of Biomedicine and Prevention , University of Rome Tor Vergata , Rome , Italy
| | - Marina Giuliano
- a Department of Therapeutic Research and Medicines Evaluation , Istituto Superiore di Sanità , Rome , Italy
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Thorne C, Idele P, Chamla D, Romano S, Luo C, Newell ML. Morbidity and mortality in HIV-exposed uninfected children. Future Virol 2015. [DOI: 10.2217/fvl.15.70] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Approximately 1.5 million HIV-positive women become pregnant annually. Antiretroviral therapy (ART) is central to prevention of mother-to-child transmission and maternal ART continued postpartum allows breastfeeding for at least 1 year of life, with important benefits for the child. In the pre-ART era, it was suggested that HIV-exposed uninfected (HEU) children may be at higher morbidity and mortality risk than children of HIV-negative mothers, associated with maternal illness and death and the lack, or limited duration, of breastfeeding as recommended for preventing mother-to-child transmission at that time. This review summarizes the evidence on morbidity and mortality risk in HEU children compared with HIV-unexposed children, and assesses the likely impact of roll-out of ART, which prolongs maternal survival and allows breastfeeding.
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Affiliation(s)
- Claire Thorne
- Population, Policy & Practice Programme, UCL Institute of Child Health, University College London, London, WC1E 6BT, UK
| | - Priscilla Idele
- Data & Analytics Section, UNICEF New York, New York, NY, USA
| | - Dick Chamla
- Health Section, UNICEF New York, New York, NY, USA
| | | | - Chewe Luo
- HIV/AIDS Section, UNICEF New York, New York, NY, USA
| | - Marie-Louise Newell
- Faculty of Medicine/Faculty of Social & Human Sciences, University of Southampton, Southampton, SO17 1BJ, UK
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Palombi L, Galluzzo CM, Andreotti M, Liotta G, Jere H, Sagno JB, Luhanga R, Mancinelli S, Amici R, Marazzi MC, Vella S, Giuliano M. Drug resistance mutations 18 months after discontinuation of nevirapine-based ART for prevention of mother-to-child transmission of HIV in Malawi. J Antimicrob Chemother 2015; 70:2881-4. [PMID: 26111981 DOI: 10.1093/jac/dkv171] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 05/31/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The objective of this study was to determine the prevalence of drug resistance mutations among HIV-positive women in Malawi 18 months after discontinuing nevirapine-based ART for the prevention of mother-to-child transmission. PATIENTS AND METHODS HIV-infected antiretroviral-naive (except for single-dose nevirapine) pregnant Malawian women receiving a nevirapine-based triple antiretroviral regimen from Week 25 of gestation until 6 months of breastfeeding were included in this analysis. Drug resistance was assessed in HIV-DNA 24 months post-partum and at baseline (before the initiation of treatment). In patients with resistance, the presence of mutations was also evaluated in the corresponding plasma samples. RESULTS Seven out of 42 (16.7%) women studied had archived drug resistance at Month 24 [six cases had NNRTI-associated mutations and two cases the M184I mutation]. In four cases, resistance mutations were already present at baseline (all NNRTI mutations). In three cases, there was an emergence of 'new' resistance (also present in the plasma in one case). Of the 35 women without resistance mutations at Month 24, only one subject had resistance mutations at baseline. Baseline resistance was significantly more common among women with mutations at 24 months compared with those harbouring a WT virus (4/7 versus 1/35, P < 0.001). CONCLUSIONS Among women who had discontinued drugs 6 months post-partum, only 3/42 (7.1%) had accumulated new resistance mutations in HIV-DNA 2 years after delivery. These findings are reassuring in terms of the safety of the Option B strategy for the prevention of HIV mother-to-child transmission.
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Affiliation(s)
- Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | - Clementina Maria Galluzzo
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Mauro Andreotti
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Giuseppe Liotta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | - Haswel Jere
- DREAM Program, Community of S. Egidio, PO Box 30355, Blantyre, Malawi
| | | | - Richard Luhanga
- DREAM Program, Community of S. Egidio, PO Box 30355, Blantyre, Malawi
| | - Sandro Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | - Roberta Amici
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | | | - Stefano Vella
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - Marina Giuliano
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
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Giuliano M, Galluzzo CM, Mancinelli S, Andreotti M, Jere H, Sagno JB, Maulidi M, Erba F, Amici R, Buonomo E, Scarcella P, Marazzi MC, Vella S, Palombi L. Laboratory confirmation of clinically diagnosed malaria in a cohort of HIV-infected mothers and their children in Malawi. J Trop Pediatr 2015; 61:222-5. [PMID: 25797059 DOI: 10.1093/tropej/fmv011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
To avoid overdiagnosis, accuracy in the identification of true malaria cases is of critical importance. Samples (either whole blood, dried blood spots or plasma/serum) collected at the time of clinically diagnosed malaria episodes in a cohort of Malawian HIV-infected mothers and their children were retrospectively tested with the enzyme-linked immunosorbent assay (ELISA) for HRP-2 (histidine-rich protein 2) detection. There were 55 and 56 clinically diagnosed cases of malaria in mothers and children, respectively, with samples available for testing. Rates of laboratory-confirmed episodes were 20% (11 of 55) in mothers and 16.1% (9 of 56) in children. Hemoglobin was lower in children with confirmed malaria compared to those with clinical malaria diagnosis. The results of our study support the widespread use of rapid diagnostic tests.
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Affiliation(s)
- Marina Giuliano
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy, DREAM Program, Community of S. Egidio, Blantyre, Malawi and LUMSA University, Rome, Italy
| | - Clementina Maria Galluzzo
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy, DREAM Program, Community of S. Egidio, Blantyre, Malawi and LUMSA University, Rome, Italy
| | - Sandro Mancinelli
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy, DREAM Program, Community of S. Egidio, Blantyre, Malawi and LUMSA University, Rome, Italy
| | - Mauro Andreotti
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy, DREAM Program, Community of S. Egidio, Blantyre, Malawi and LUMSA University, Rome, Italy
| | - Haswel Jere
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy, DREAM Program, Community of S. Egidio, Blantyre, Malawi and LUMSA University, Rome, Italy
| | - Jean-Baptiste Sagno
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy, DREAM Program, Community of S. Egidio, Blantyre, Malawi and LUMSA University, Rome, Italy
| | - Martin Maulidi
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy, DREAM Program, Community of S. Egidio, Blantyre, Malawi and LUMSA University, Rome, Italy
| | - Fulvio Erba
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy, DREAM Program, Community of S. Egidio, Blantyre, Malawi and LUMSA University, Rome, Italy
| | - Roberta Amici
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy, DREAM Program, Community of S. Egidio, Blantyre, Malawi and LUMSA University, Rome, Italy
| | - Ersilia Buonomo
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy, DREAM Program, Community of S. Egidio, Blantyre, Malawi and LUMSA University, Rome, Italy
| | - Paola Scarcella
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy, DREAM Program, Community of S. Egidio, Blantyre, Malawi and LUMSA University, Rome, Italy
| | - Maria Cristina Marazzi
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy, DREAM Program, Community of S. Egidio, Blantyre, Malawi and LUMSA University, Rome, Italy
| | - Stefano Vella
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy, DREAM Program, Community of S. Egidio, Blantyre, Malawi and LUMSA University, Rome, Italy
| | - Leonardo Palombi
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy, DREAM Program, Community of S. Egidio, Blantyre, Malawi and LUMSA University, Rome, Italy
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Baroncelli S, Galluzzo CM, Liotta G, Andreotti M, Jere H, Erba F, Sagno JB, Amici R, Mancinelli S, Marazzi MC, Vella S, Palombi L, Giuliano M. Anti-Streptococcus pneumoniae and rotavirus IgG levels in HIV-positive women do not correlate with maternal status and infant morbidity and mortality. J Med Microbiol 2015; 64:795-797. [PMID: 25976002 DOI: 10.1099/jmm.0.000087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Silvia Baroncelli
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Regina Elena, 299, 00161 Rome, Italy
| | - Clementina Maria Galluzzo
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Regina Elena, 299, 00161 Rome, Italy
| | - Giuseppe Liotta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | - Mauro Andreotti
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Regina Elena, 299, 00161 Rome, Italy
| | - Haswell Jere
- DREAM Program, Community of S. Egidio, P.O. Box 30355, Blantyre, Malawi
| | - Fulvio Erba
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | | | - Roberta Amici
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Regina Elena, 299, 00161 Rome, Italy
| | - Sandro Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | | | - Stefano Vella
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Regina Elena, 299, 00161 Rome, Italy
| | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | - Marina Giuliano
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Regina Elena, 299, 00161 Rome, Italy
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Giuliano M, Liotta G, Andreotti M, Mancinelli S, Buonomo E, Scarcella P, Amici R, Jere H, Sagno JB, Di Gregorio M, Marazzi MC, Vella S, Palombi L. Retention, transfer out and loss to follow-up two years after delivery in a cohort of HIV+ pregnant women in Malawi. Int J STD AIDS 2015; 27:462-8. [PMID: 25953961 DOI: 10.1177/0956462415585450] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 04/13/2015] [Indexed: 11/15/2022]
Abstract
In this study, we analysed in a cohort of pregnant women followed for two years the proportion of women remaining at the same clinic, those who transferred to other clinics, and those lost to follow-up. The possible determinants of the loss to follow-up were also assessed in a setting of postpartum discontinuation based on CD4+ count. A total of 311 pregnant women received antiretroviral therapy from week 25 of gestational age until six months postpartum (end of breastfeeding period), or indefinitely if meeting the criteria for treatment (baseline CD4+ <350 cells/mm(3)). Twenty-four months after delivery, six women had died, 247 were in active follow-up, 21 had transferred to another antiretroviral therapy clinic and 37 were lost to follow-up (rate of loss to follow-up 13%, 95% CI 9.1-16.9%). The presence of a baseline CD4+ count above 350 cells/mm(3) was associated with a ten-fold higher risk of loss to follow-up after six months of delivery (hazard ratio: 9.8, 95% CI 2.2-42.7, for baseline CD4 >350 cells/mm(3) versus baseline CD4+ count below 350 cells/mm(3), p = 0.002). This finding suggests that discontinuation of drugs when the risk of transmission has ceased can have a negative impact on the retention in care of these women.
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Affiliation(s)
- Marina Giuliano
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Giuseppe Liotta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Mauro Andreotti
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Sandro Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Ersilia Buonomo
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Paola Scarcella
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Roberta Amici
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Haswel Jere
- DREAM Program, Community of S. Egidio, Blantyre, Malawi
| | | | - Massimiliano Di Gregorio
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | | | - Stefano Vella
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
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Pirillo MF, Scarcella P, Andreotti M, Jere H, Buonomo E, Sagno JB, Amici R, Mancini MG, Leone P, Ceffa S, Mancinelli S, Marazzi MC, Vella S, Palombi L, Giuliano M. Hepatitis B virus mother-to-child transmission among HIV-infected women receiving lamivudine-containing antiretroviral regimens during pregnancy and breastfeeding. J Viral Hepat 2015; 22:289-96. [PMID: 25174900 DOI: 10.1111/jvh.12301] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The study included 309 HIV-infected pregnant women receiving a lamivudine-containing antiretroviral regimen from week 25 of gestational age until 6 months postpartum, during breastfeeding. Twenty-seven of them (8.7%) were hepatitis B virus surface antigen (HBsAg) positive; at baseline, hepatitis B virus (HBV) DNA levels >3 log(10) IU/mL (with a median level of 6.2 log(10) IU/mL) were found in 10 women, who at one, three and six months postpartum had median levels of 5.2 log(10) IU/mL, 4.5 log(10) IU/mL and 2.8 log(10) IU/mL, respectively. Twenty-four of the 30 breast milk samples evaluated had undetectable HBV DNA and the other six had values between 15 and 155 IU/mL. Median lamivudine concentrations were 1070 ng/mL in serum and 684 ng/mL in breast milk. Among the 24 HBV-exposed children with available samples, 16 always tested negative, four had a transient infection, one had an undetermined status and three (12.5%) first tested positive at Month 12 or Month 24. Among the children born to the HBV-uninfected mothers of the same cohort, the rate of HBsAg positivity at 12-24 months was 2% (4/196). Our finding of the absence of significative levels of HBV DNA in the breast milk of co-infected mothers supports the present recommendations for breastfeeding in HBV-infected women. Horizontal transmission can be hypothesized for the infections detected in children at 12-24 months. Children born to HBV-positive mothers remained at higher risk of postnatal HBV acquisition compared to those born to HBV-negative women.
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Affiliation(s)
- M F Pirillo
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
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Early infant feeding patterns and HIV-free survival: findings from the Kesho-Bora trial (Burkina Faso, Kenya, South Africa). Pediatr Infect Dis J 2015; 34:168-74. [PMID: 25741969 DOI: 10.1097/inf.0000000000000512] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the association between feeding patterns and HIV-free survival in children born to HIV-infected mothers and to clarify whether antiretroviral (ARV) prophylaxis modifies the association. METHODS From June 2005 to August 2008, HIV-infected pregnant women were counseled regarding infant feeding options, and randomly assigned to triple-ARV prophylaxis (triple ARV) until breastfeeding cessation (BFC) before age 6 months or antenatal zidovudine with single-dose nevirapine (short-course ARV). Eighteen-month HIV-free survival of infants HIV-negative at 2 weeks of age was assessed by feeding patterns (replacement feeding from birth, BFC <3 months, BFC ≥3 months). RESULTS Of the 753 infants alive and HIV-negative at 2 weeks, 28 acquired infection and 47 died by 18 months. Overall HIV-free survival at 18 months was 0.91 [95% confidence interval (CI): 0.88-0.93]. In the short-course ARV arm, HIV-free survival (0.88; CI: 0.84-0.91) did not differ by feeding patterns. In the triple ARV arm, overall HIV-free survival was 0.93 (CI: 0.90-0.95) and BFC <3 months was associated with lower HIV-free survival than BFC ≥3 months (adjusted hazard ratio: 0.36; CI: 0.15-0.83) and replacement feeding (adjusted hazard ratio: 0.20; CI: 0.04-0.94). In the triple ARV arm, 4 of 9 transmissions occurred after reported BFC (and 5 of 19 in the short-course arm), indicating that some women continued breastfeeding after interruption of ARV prophylaxis. CONCLUSIONS In resource-constrained settings, early weaning has previously been associated with higher infant mortality. We show that, even with maternal triple-ARV prophylaxis during breastfeeding, early weaning remains associated with lower HIV-free survival, driven in particular by increased mortality.
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