Abstract
ObjectiveTo assess the 18-month field effectiveness on severe events of a pediatric package combining early HIV-diagnosis and targeted cotrimoxazole prophylaxis in HIV-infected children from age six-week before the antiretroviral era, in Abidjan, Côte d'Ivoire.MethodsData from two consecutive prevention of HIV mother-to-child transmission programs were compared: the ANRS 1201/1202 Ditrame-Plus cohort (2001–2005) and the pooled data of the ANRS 049a Ditrame randomized trial and its following open-labeled cohort (1995–2000), used as a reference group. HIV-infected pregnant women ≥ 32–36 weeks of gestation were offered a short-course peri-partum antiretroviral prophylaxis (ZDV in Ditrame, and ZDV ± 3TC+single-dose (sd) NVP in Ditrame-Plus). Neonatal prophylaxis was provided in Ditrame-Plus only: 7-day ZDV and sdNVP 48–72 h after birth. A 6-week pediatric HIV-RNA diagnosis was provided on-line in the Ditrame-Plus while it was only oriented on clinical symptoms in Ditrame. Six-week HIV-infected children received a daily cotrimoxazole prophylaxis in Ditrame-Plus while no prophylaxis was provided in Ditrame. The determinants of severe events (death or hospitalization > 1 day) were assessed in a Cox regression model.ResultsBetween 1995 and 2003, 98 out of the 1121 live-births were diagnosed as HIV-infected in peri-partum: 45 from Ditrame-Plus and 53 from Ditrame. The 18-month Kaplan-Meier cumulative probability of presenting a severe event was 66% in Ditrame-Plus (95% confidence interval [95%CI]: 50%–81%) and 77% in Ditrame (95%CI: 65%–89%), Log Rank test: p = 0.47. After adjustment on maternal WHO clinical stage, maternal death, 6-week pediatric viral load, birth-weight, and breastfeeding exposure, the 18-month risk of severe event was lower in Ditrame-Plus than in Ditrame (adjusted Hazard Ratio (aHR): 0.55, 95%CI: 0.3–1.1), although the difference was not statistically significant; p = 0.07). Maternal death was the only variable determinant of the occurrence of severe events in children (aHR: 3.73; CI: 2.2–11.2; p = 0.01).ConclusionEarly cotrimoxazole from 6 weeks of age in HIV-infected infants seemed to reduce probability of severe events but the study lacked statistical power to prove this. Even with systematic cotrimoxazole prophylaxis, infant morbidity and mortality remained high pointing towards a need for early pediatric HIV-diagnosis and antiretroviral treatment in Africa.
Highlights
Randomized clinical trials have shown the efficacy of short antiretroviral regimens in preventing mother to child transmission of HIV (PMTCT) in Africa [1,2]
In 2005, 750,000 children died of AIDS-related diseases of whom 87% were living in sub-Saharan Africa and most had been infected by mother-to-child transmission (MTCT) [4]
Within the Agence Nationale de Recherches sur le Sida (ANRS) 1201/1202 Ditrame-Plus cohort conducted in Abidjan, Côte d'Ivoire, infants born to HIVinfected mothers who received an PMTCT intervention [18,19] were offered a paediatric package including a routine and early diagnosis of HIV infection from age 6-week by real-time PCR [20,21] and a cotrimoxazole prophylaxis targeted on HIV-infected infants from
Summary
Randomized clinical trials have shown the efficacy of short antiretroviral regimens in preventing mother to child transmission of HIV (PMTCT) in Africa [1,2]. Despite these encouraging findings, less than 11% of HIVinfected pregnant women had received one of these PMTCT interventions in low-income countries in 2005 [3]. In 2005, 750,000 children died of AIDS-related diseases of whom 87% were living in sub-Saharan Africa and most had been infected by mother-to-child transmission (MTCT) [4]. Within the ANRS 1201/1202 Ditrame-Plus cohort conducted in Abidjan, Côte d'Ivoire, infants born to HIVinfected mothers who received an PMTCT intervention [18,19] were offered a paediatric package including a routine and early diagnosis of HIV infection from age 6-week by real-time PCR [20,21] and a cotrimoxazole prophylaxis targeted on HIV-infected infants from
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