Mother-to-child Transmission Of HIV Research Articles

Optimizing HIV Retesting During Pregnancy and Postpartum in Four Countries: A Cost-Effectiveness Analysis

Background: HIV retesting during late pregnancy and breastfeeding can help detect new maternal infections and prevent mother-to-child HIV transmission (MTCT), but the optimal timing and cost-effectiveness of maternal retesting is uncertain. Methods: We constructed Markov models to assess the health and economic impact of maternal HIV retesting, following initial testing in pregnancy, on MTCT in four countries: South Africa and Kenya (high/intermediate HIV prevalence), and Colombia and Ukraine (low HIV prevalence). We evaluated six scenarios with varying retesting frequencies from the second antenatal care visit (ANC) through nine months postpartum. We compared strategies using incremental cost-effectiveness ratios (ICERs) over a 20-year time horizon using country-specific thresholds. Findings: Maternal retesting once at second ANC with catch-up testing through six weeks postpartum was cost-effective in Kenya (ICER=$166 per DALY averted) and South Africa (ICER=$289 per DALY averted). This strategy prevented 19% (Kenya) and 12% (South Africa) of infant HIV infections. Adding one or two additional retests postpartum provided smaller benefits (1-2% additional infections averted versus one retest). Adding three retests during the postpartum period averted additional infections (1-3% additional infections averted versus one retest) but ICERs ($7,639 and in Kenya and $11,985 in South Africa) greatly exceeded the cost-effectiveness thresholds. In Colombia and Ukraine, all retesting strategies exceeded the cost-effectiveness threshold and prevented few infant infections (up to 31 and 5 infections, respectively). Interpretation: In high HIV burden settings, HIV retesting once at second ANC, with subsequent intervention, is the most cost-effective strategy for preventing infant HIV infections. In these settings, two HIV retests postpartum marginally reduced MTCT and was less costly than adding three retests. Retesting in Colombia and Ukraine was not cost-effective at any time point due to very low HIV prevalence and limited breastfeeding. Funding: This study was funded by WHO #201742717, WHO #018/CDS/HIV/004, WHO #2018/865307-0, USAID GHA‐G‐ 00‐09‐00003, and the Bill and Melinda Gates Foundation OPP1177903, and supported by NIH/NIAID P30‐ AI027757, NIH/NIAID K01 AI116298 (ALD), NIH/NIMH K01 MH115789 (MS) and NIH/NIEHS T32 ES015459-09 (JM). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: Missing.

Mother-to-Child HIV Transmission among Infants Born to HIV-Positive Women in Amhara National Regional State, Ethiopia

Mother-to-child transmission (MTCT) is the major source of HIV infection among children under the age of 15 years. There were limited studies on the MTCT rate in Amhara Region, Ethiopia. Therefore, this study aimed to measure mother-to-child transmission and to identify factors associated with MTCT. An institutional-based retrospective cohort study was conducted among HIV-exposed infants (HEIs). The HEIs who booked in mother–baby pair cohort register between January 2014 and December 2016 were abstracted and included in the study. A structured pretested questionnaire was used for data abstraction. The collected data were coded and double entered into EPI Info version 3.5.4 and exported to STATA version 14 for analysis. A penalized logistic regression model was used. p-value <0.05 was taken as the significance level. A total of 796 HEIs participated in the study in which 96.9% received nevirapine prophylaxis, 97.5% were exclusively breastfed for 6 months, and 95.2% received HIV test at 6 weeks. About 36.5% of mothers of HEIs received ART (Antiretroviral Treatment) for less than 4 weeks during delivery. Of the mothers of HEIs, 7.6% were in WHO clinical stage I and 64.1% had >350 CD4 count at the first antenatal care visit. Overall, MTCT of HIV was 1.5%, and 59.2% of HEIs were discharged from the PMTCT care at the age of 12-18 months. The vertical transmission of HIV was significantly associated with the duration of ART (AOR 0.16; 95% CI: 0.02, 0.96). The MTCT was 84.0% less likely in mothers who did receive Antiretrovirals (ARVs) >12 months compared with mothers who did receive ARVs <4 weeks during delivery. The study indicated that vertical transmission of HIV was significantly associated with the duration of ART. Even if a considerable low MTCT rate was observed, early identification and treatment among HIV-positive pregnant women should be strengthened.

Eliminated mother to child transmission (MTCT) of HIV and syphilis in Sri Lanka; WHO confirms

Sri Lanka has been declared as a country that eliminated mother to child transmission of HIV and syphilis by the World Health Organisation (WHO), Geneva on 13th November 2019. National STD AIDS Control Programme (NSACP) of Sri Lanka In 1954, commenced a programme for the prevention of congenital syphilis. In 2002, started the programme for the prevention of mother to child transmission of HIV. In 2013, these two programmes were combined for the “Elimination of mother to child transmission (EMTCT) of HIV and syphilis.” Overall target was to achieve and maintain the impact indicators for one year and process indicators for two years and then maintain these achievements to be eligible for the application of the validation process. The programme was designed on a multi-disciplinary, multi-partnered, and multi-level approach with strong links between maternal and child health services and sexually transmitted infections and HIV services in both government and private sectors. By end 2018, the country had achieved the set targets to be eligible to apply for the WHO validation of EMTCT of HIV and syphilis. In July 2019, the ministry of health made a formal request to the WHO to validate the EMTCT of HIV and syphilis programme. After a thorough assessment of the country situation, the regional validation team recommended certification of Sri Lanka. This was further assessed by the Global validation team at WHO Geneva. On 13th November 2019, the WHO formally announced that Sri Lanka has eliminated MTCT of HIV and syphilis

Comparison of 6-week PMTCT outcomes for HIV-exposed and HIV-unexposed infants in the era of lifelong ART: Results from an observational prospective cohort study.

Lifelong antiretroviral therapy (ART) reduces mother-to-child HIV transmission (MTCT) and improves maternal health. Data on the outcomes of HIV-exposed infants (HEI) compared to their unexposed counterparts in the era of universal ART is limited. We compared birth and 6-week outcomes among infants born to HIV-positive and HIV-negative women in Lesotho. 941 HIV-negative and 653 HIV-positive pregnant women were enrolled in an observational cohort to evaluate the effectiveness of prevention of mother-to-child HIV transmission (PMTCT) program after implementation of universal maternal ART in 14 health facilities. Pregnancy, delivery, birth, and 6-week data were collected through participant interviews and medical record review. DNA PCR testing for HEI was conducted within 2 weeks of birth and at around 6 weeks of age. Data were analysed to estimate the distribution of birth outcomes, mortality, HIV transmission and HIV-free survival at 6 weeks. HIV-positive women were older (mean age of 28.7 vs. 24.4 years) and presented for antenatal care earlier (mean gestational age of 23.0 weeks vs 25.3 weeks) than HIV-negative women. Prematurity was more frequent among HEI, 7.8% vs. 3.6%. There was no difference in rates of congenital anomalies between HEI (1.0%) and HIV-unexposed infants (HUI) (0.6%). Cumulative HIV transmission was 0.9% (N = 4/431) (95% CI:0.25-2.36) at birth and 1.0% (N = 6/583) (95% CI:0.38-2.23) at 6 weeks. Overall mortality, including stillbirths, was 5.2% and 6.0% by 6 weeks for HUI and HEI respectively. Among liveborn infants, 6-week HIV-free survival for HEI was 95.6% (95% CI:93.7-97.1) compared to 96.8% (95% CI:95.4-97.9) survival for HUI. Implementation of universal maternal ART lowers MTCT at 6 weeks of age with no differences in congenital anomalies or early mortality between HIV exposed Infants and HIV unexposed infants. However, HIV exposed infants continue to have high rates of prematurity despite improved maternal health on ART.

Outcome of Prevention of Mother to Child Transmission (PMTCT) of HIV Services at the University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria

Background: Mother to Child Transmission (MTCT) of HIV causes over 90% of Paediatric HIV and its prevention must be targeted to curb this scourge.
 Objective: To determine the associated risk factors and outcome (HIV status) of HIV-exposed babies at the University of Port Harcourt Teaching Hospital (UPTH).
 Methodology: This was a prospective study carried out at the Paediatric HIV clinic of UPTH. Information on sociodemographic data of the babies, age at referral, when the mother’s HIV status was diagnosed, HAART use status of the mother, place of ANC and delivery, method of delivery, feeding option, duration of breast feeding and HIV status of the babies were obtained. Obtained data was analysed and a p- value of < 0.05 was considered significant at 95% confidence interval.
 Result: A total of two hundred and sixty HIV exposed children were seen over the study period, with a male: female ratio of 1.4:1. The overall MTCT rate was 6.2%. Among the mothers that had the complete PMTCT intervention, an MTCT rate of 1.1% was observed, while it was 28.6% among mothers who had no form of PMTCT. Identified statistically significant risk factors to MTCT include; lack of use of HAART (χ2 =116.2, p=0.0001); No infant ARV prophylaxis (p=0.0001); Mixed feeding (p=0.0001); Prolonged breast feeding (χ 2 = 7.09, P= 0.0287); TBA supervised pregnancy (χ2 =31.9, P= 0.0001) and delivery (χ2 =61.47, P= 0.0001).
 Conclusion: PMTCT interventions in the control of MTCT of HIV is effective. To eliminate MTCT of HIV, promoting PMTCT services must be encouraged.

HIV infections and HIV testing during pregnancy, Germany, 1993 to 2016.

BackgroundElimination of mother-to-child transmission (MTCT) of HIV by 2020 is a goal of the World Health Organization (WHO) action plan for the European Region. However, data to monitor progress towards MTCT elimination are not readily available in Germany.AimWe aimed to estimate the number of pregnant women with HIV and MTCT rates in Germany.MethodsWe triangulated retrospectively obtained data from: (i) healthcare reimbursement for HIV screening tests, (ii) a statutory health insurance subsample of prevalent and incident HIV diagnoses among pregnant women, (iii) a mathematical model of the German HIV epidemic with number, region of origin and risk factors for women of childbearing age, and (iv) the statutory anonymous HIV registry on children infected through HIV MTCT.ResultsThe number of women aged 15–49 years with HIV increased from ca 6,000 in 1993 to ca 11,000 in 2016. Risk of injecting drug use (IDU) declined from 65% in 1993 to 16% in 2016. The annual proportion of women living with HIV giving live birth increased from a mean of 1.9% during 1993 to 1998 to 4.9% in 2011 to 2015. HIV screening rates during pregnancy increased from ca 50% in 2001 to ca 90% in 2016. The HIV MTCT rate dropped from 6.8% in 2001 to 1.1% in 2016.ConclusionsThe population of women living with HIV in Germany shifted from predominantly IDU-associated infections to predominantly sexually acquired infections, while fertility rates more than doubled. MTCT rates dropped, mainly because of improved detection and management of HIV in pregnancy.

Combination antiretroviral treatment use in prevention of mother-to-child transmission programmes: 6-week HIV prevalence and relationship to time of antiretroviral treatment initiation and mixed feeding.

BackgroundIn Zimbabwe, 16% of pregnant women aged 15–49 years are infected with HIV. More than 90% of HIV infection in children is through mother-to-child transmission (MTCT). We investigated the effectiveness of the Option B+ in reducing HIV infection and factors associated with HIV transmission among infants born to mothers enrolled in the prevention of mother-to-child transmission (PMTCT) programme.MethodsWe randomly selected 1204 early infant HIV diagnosis test results for HIV-exposed infants and linked these results to maternal clinical records at primary healthcare clinics in Harare to estimate the prevalence of MTCT and to determine the clinical factors associated with MTCT of HIV at 6 weeks.ResultsOf the 1204 infants in the study, 2.5% (95% confidence interval [CI], 1.7–3.5) were infected with HIV at 6 weeks post-delivery. Antiretroviral adherence reduced the odds of HIV infection by about 99% (odds ratio [OR] 0.01 [95% CI, 0.00–0.06]). Both mixed feeding (OR 3.89 [95% CI, 0.92–16.50]) and late initiation of antiretroviral treatment (ART) (after delivery) (OR 3.18 [95% CI, 0.42–23.94]) increased the odds of HIV infection.ConclusionEarly initiation of combination ART reduces 6-week MTCT of HIV in PMTCT programmes to levels similar to those found in controlled trial settings. Exclusive breastfeeding remains important even in the presence of ART.

The unexposed world of the (HIV‐negative) exposed

Dear Editor, As recently discussed by Di Biagio et al. 1, the number of missed opportunities to prevent mother-to-child transmission (MTCT) is unacceptable in Italy. Only women with missed diagnoses of HIV infection that caused newborn infection were included in Di Biagio et al.'s study; the number of women who do not receive a diagnosis during pregnancy and do not transmit the infection to the newborn is even higher. In this Letter, we report the findings of a study of exposed children born to HIV-positive mothers and observed in a paediatric hospital in an Italian setting. We included mothers who came to our centre for assessment of the HIV status of the child. Eighty-eight mothers were observed between 2006 and 2017 at the Bambino Gesù Hospital, Rome, an HIV reference centre for central and southern Italy (Table 1). Fifty-four (51%) were aware of their HIV status before pregnancy and were taking antiretroviral therapy. Thirty-four mothers (39%) were diagnosed during (76%) or after (24%) after delivery. We decided to better characterize this group as they have the highest risk of MTCT. Of the mothers of these 34 HIV-exposed children (56% born to European mothers, 29% born to African mothers and 15% born to mothers from South America), 76% received highly active antiretroviral therapy (HAART) during pregnancy, 65% underwent a caesarean section and only five breastfed their children (they discovered their status after delivery). Maternal risk factors for HIV infection were risky sexual behaviour in 88% of women and injecting drug use in 12%. Regarding knowledge of the Italian language, 47% of mothers were able to communicate fully in Italian, 29% had poor or no knowledge of the language and 21% were able to comprehend basic information. Exposed children had a median birth weight of 2910 g (range 830–3980 g), the Apgar score was ≤ 7 in 8% of cases and they were born at a median of 38 weeks (range 25–42 weeks) of gestation. Of the 26 mothers who were diagnosed during pregnancy, nine (26%) were diagnosed at delivery. Three of these mothers had an earlier negative HIV test during pregnancy (two in the first trimester and one during the third trimester) and were never re-tested. Low-quality antenatal care and delays in HIV testing during pregnancy are matters of concern in Italy, where HIV testing is recommended as part of preconception and prenatal care 2. A survey carried out in 2011 in a sample of 1568 women delivering children at 36 maternity hospitals in the Lazio region found that 88.2% of pregnant women underwent the test but only 33.6% received it as part of preconception care 3. Women who missed the test tended to be younger, with a lower education level, a lower HIV knowledge score and fewer visits during pregnancy 3. Thus, despite the enormous progress made in recent years in the prevention of MTCT of HIV, we continue to observe in European countries late diagnosis in HIV-positive mothers. It is important to put in place health policies that are not limited to increasing awareness of HIV in the general population but that also aim to achieve increased awareness in health personnel (gynaecologists, obstetricians and all those who work with pregnant women) of the importance of careful diagnostic monitoring of all sexually transmitted diseases throughout pregnancy. Furthermore, it is desirable that women should have equitable access to periconceptional counselling and screening for congenital infections.

Reaching the Hard to Reach in Thailand: Eliminating Mother-To-Child HIV Transmission

ABSTRACT Thailand is the first country in the Asia-Pacific region to be validated by the World Health Organization as having eliminated mother-to-child transmission (MTCT) of HIV. The Thai government made health—and specifically addressing the HIV/AIDS crisis—a political priority. The Thailand experience, from the emergence of the HIV/AIDS epidemic in the 1980s through the present, provides an important case study of successful MTCT elimination. To eliminate MTCT requires that health interventions reach those who are hardest to reach: the poorest of the poor, geographically distant and rural, and marginalized. This policy report highlights key factors for successfully reaching the hard to reach in Thailand, including the importance of national public policy as well as investments in health care infrastructure, such as access to antenatal care, the creation of effective monitoring and surveillance systems, and strengthening local health capacity. Increased availability and affordability of antiretroviral therapies was also critical to Thailand’s success in addressing MTCT. The Thailand case offers important policy lessons for achieving universal health. This policy report draws on secondary research and key informant interviews in Thailand to highlight factors for success in eliminating MTCT of HIV.

Longitudinal adherence to maternal antiretroviral therapy and infant Nevirapine prophylaxis from 6\u2009weeks to 18\u2009months postpartum amongst a cohort of mothers and infants in South Africa

BackgroundDespite improved policies to prevent mother-to-child HIV transmission (MTCT), adherence to maternal antiretroviral therapy (ART) and infant Nevirapine prophylaxis (NVP) is low in South Africa. We describe ART adherence amongst a cohort of HIV-positive mothers and HIV-exposed but uninfected infants from 6 weeks until 18 months post-delivery and identify risk factors for nonadherence.MethodsData were collected in 2012–2014 through a nationally representative survey of PMTCT effectiveness. Mother-infant pairs were enrolled during the infant’s first immunization visit at 6 weeks. Mothers and HIV-exposed infants (2811 pairs) were followed to 18 months at 3-month intervals. Mothers who self-reported being on ART at 6 weeks postpartum (N = 1572 (55.9%)) and infants on NVP at 6 weeks (N = 2370 (84.3%)) were eligible for this analysis and information about their adherence was captured at each interview they attended thereafter. We defined nonadherence within each 3-month interval as self-report of missing > 5% of daily ART/NVP doses, estimated adherence using a Cox survival curve with Andersen & Gill setup for recurring events, and identified risk factors for nonadherence with an extended Cox regression model (separately for mothers and infants) in Stata 13. Results are not nationally representative as this is a subgroup analysis of the follow-up cohort.ResultsAmongst mothers on ART at 6 weeks postpartum, cumulative adherence to maternal ART until 18 months was 63.4%. Among infants on NPV at 6 weeks postpartum, adherence to NVP was 74.5%.. Risk factors for nonadherence to maternal ART, controlling for other factors, included mother’s age (16–24 years vs. ≥34 years, adjusted Hazard Ratio (aHR): 1.9, 95% CI: 1.4–2.5), nondisclosure of HIV status to anyone (nondisclosure vs. disclosure: aHR: 1.7, 95% CI: 1.3–2.1), and timing of ART initiation (initiated ART after delivery vs. initiated ART before delivery: aHR: 1.6, 95% CI: 1.3–2.0). Provincial variation was seen in nonadherence to infant NVP, controlling for other factors.ConclusionMaintaining ART adherence until 18 months postpartum remains a crucial challenge, with maternal ART adherence among the six week maternal ART cohort below 65% and infant NVP adherence among breastfeeding infants in this cohort below 75%.This is gravely concerning, given the global policy shift to lifelong ART amongst pregnant and lactating women, and the need for extended infant prophylaxis amongst mothers who are not virally suppressed. Our findings suggest that young mothers and mothers who do not disclose their status should be targeted with messages to improve adherence, and that late maternal ART initiation (after delivery) increases the risk of maternal nonadherence.

HIV prevalence and risk factors in infants born to HIV positive mothers, measured by dried blood spot real-time PCR assay in Tigray, Northern Ethiopia

BackgroundInfants infected during pregnancy or while breastfeeding requires early HIV diagnosis at 6 weeks after birth to identify HIV infection and timely treatment. The objective of this work was to determine the prevalence and associated risk factors of HIV among HIV exposed infants in the Tigray regional state, Northern Ethiopia.MethodsA cross-sectional study was conducted on 350 exposed infants born to HIV seropositive mothers from September 01 to December 30, 2016. Convenient consecutive sampling technique was employed to enroll HIV exposed infants from age 6 weeks to 18 months attending prevention of mother to child transmission (PMCT) clinic at Anti Retroviral Therapy (ART) site facility in Tigray, Ethiopia. Sociodemographic data and associated risk factors were collected using a structured questionnaire. Dried Blood Spot (DBS) samples were collected from each infant and transported by post to Tigray Health Research Institute to detect HIV infection using real-time Polymerase Chain Reaction (PCR). Data were entered into EPI Info version 7, exported and analyzed using Statistical Package for Social Sciences (SPSS) version 22. p-value less than 0.05 was deemed to be statistically significant by Fisher’s exact test.ResultsThree hundred forty infants (175 males, 165 females) met the criteria for selection during the completion of the study and the overall HIV prevalence was found to be 2.1% (n = 7). The majority of infants were from urban areas (n = 246, 72.4%). 45.5% (5/11, p = 0.001) infants were without ARV prophylaxis, 60% (3/5, p = 0.001) infants born to mothers who did not take maternal PMTCT intervention, 43% (3/7, p = 0.001) infants born to mothers who were not enrolled to ART care, and 6.1% (4/66, p = 0.029) infants of unmarried mothers showed statistically significant difference.ConclusionsThe overall prevalence of HIV among exposed infants was high but lower than the Millennium Development Goal targets. In order to eliminate the mother to child HIV transmission (MTCT) ARV prophylaxis in infants must be strengthened, and enrollment of HIV positive pregnant women to PMTCT and ART care and treatment is needed.

Peripartum HIV infection in very low birth weight infants fed 'raw' mother's own milk.

BackgroundHIV-exposed very low birth weight (VLBW) infants (≤ 1500 g) are considered at high risk of peripartum mother-to-child HIV transmission (MTCT). In the past, they received formula to prevent breast milk related HIV transmission. This denied them the benefits of breast milk, thus exposing the infant to the risk of necrotising enterocolitis (NEC). From 2010, ‘raw’ mother’s own milk (rMOM) has been recommended for term infants whose mothers’ received antenatal antiretroviral therapy (ART). At the same time, the infant received antiretroviral (ARV) prophylaxis as per the National Prevention of MTCT programme.ObjectivesTo determine the cumulative incidence of peripartum HIV infection by 4–6 weeks of age in HIV-exposed VLBW infants, who received rMOM and infant ARV prophylaxis.MethodA retrospective, observational audit over 3 years at a single institution was undertaken. The study population comprised HIV-exposed VLBW infants who received both nevirapine prophylaxis and rMOM from birth until discharge. A positive HIV-PCR by 4–6 weeks of life was used to confirm maternal to infant HIV transmission.ResultsOf the 80 eligible infants admitted between 2010 and 2013, 63 (79%) were exposed to antenatal ART. Seventy-eight (97.5%) tested HIV-PCR negative at 4–6 weeks. Of the two infants who tested positive, both presented with features of an acute HIV infection. The absence of MTCT in the remaining 78 infants given ARV prophylaxis and rMOM suggests that rMOM is an unlikely source of infection in the two infected infants.ConclusionrMOM, in the presence of infant prophylaxis, was a safe feeding option for HIV-exposed VLBW infants. It should be strongly considered for these infants, as rMOM likely provides additional maternal and child benefits.

Knowledge and attitude of pregnant women regarding HIV transmission, prevention and associated factors in Karachi, Pakistan – A cross-sectional study

ObjectivesThis study aimed to assess the misconceptions and attitude regarding HIV transmission and prevention among antenatal mothers, with regards to mother-to-child-transmission (MTCT) in three tertiary care hospitals of Karachi. MethodsA cross-sectional study comprising 350 pregnant females was conducted at three tertiary care hospitals in Karachi for 4 months, in 2018. A structured questionnaire covering knowledge about MTCT, prevention of mother-to-child-transmission (PMTCT) and attitudes about HIV transmission was used and all collected data entered and analyzed via SPSS (Statistical Package for the Social Sciences) software version 25, owned by the IBM Company. Principle ResultsOf the 350 pregnant females participating, around 66.7% (N = 232) were urban residents, lying in their mid-twenties and over 86% (N = 303) were Muslims. Over 14.3% (N = 52) of the participants had full knowledge regarding MTCT of HIV, with only 6% of the respondents having full knowledge related to PMTCT of HIV. Significant associations were found between knowledge about MTCT and residence (p = 0.001), education level (p = 0.001) and expected response from the partner (p = 0.001). While only 17% (60 out of 350) women agreed to invite their partner for testing, 84% showed an interest in looking after an HIV infected family member and 49% believed that all pregnant females should be tested for HIV. ConclusionsThis study shows that majority of the pregnant women in Karachi are unaware of MTCT and PMTCT and they are reluctant towards routine HIV testing. Thus, we see the need for collective and focused efforts for educational programs and further research.

12-months efficacy of option B+ for prevention of mother-to-child transmission of HIV in Yaoundé, Cameroon

Cameroon has adopted the option B+ for the prevention of mother-to-child transmission (MTCT) program of HIV in August 2014 in order to eradicate MTCT of HIV. To analyze in routine life settings, efficacy of option B+ for PMTCT and associate factors. We conducted a cross-sectional study over a 6-month period in the ESSOS hospital center. Study population comprised HIV-positive mothers and their infants aged 0-24 months. Variables included were: moment of HIV maternal testing, timing of commencement of maternal antiretroviral therapy (ART) and self-reported adherence to ART. Efficacy was measured through early and late MTCT rate and associated factors. We included 200 mothers and 124 infants. Under option B+, the rate of transmission was at 4.20% at 6 weeks and 5.83% at 12 months. The rate of HIV transmission in breastfed infants stood at 3.7%. In unadjusted analysis, bottle-feeding, term at birth, early screening and management during pregnancy were associated with lower risk of HIV transmission. After adjustment, term at delivery after 37 weeks adjusted odds ratio (AOR) [0.059; (0.0061; 0.56)] was protective; while lack of prophylaxis was among HIV-exposed infants emerged as the main factor associated with residual transmission of HIV [AOR 117.23; (3.55; 3874.9)]. In this setting of Yaoundé, routine option B+ posted laudable results at 12 months even amongst breastfed children and should therefore be made sustainable.

Pediatric HIV-1 Acquisition and Lifelong Consequences of Infant Infection.

Increased availability of antiretroviral therapy to pregnant and breastfeeding women in resource-limited areas has proven remarkably successful at reducing HIV vertical transmission rates over the past several decades. Yet, still more than 170,000 children are infected annually due to failures in therapy implementation, monitoring, and adherence. Mother-to-child transmission (MTCT) of HIV-1 can occur at one of several distinct stages of infant development - intrauterine, intrapartum, and postpartum. The heterogeneity of the maternal-fetal interface at each of these modes of transmission poses a challenge for the implementation of immune interventions to prevent all modes of HIV MTCT. However, using mother-infant human cohorts and nonhuman primate models of infant simian immunodeficiency virus (SIV) acquisition, investigators have made important observation about the biology of pediatric HIV infection and have identified unique protective immune factors for each mode of transmission. Knowledge of immune factors protective against HIV MTCT will be critical to the development of targeted immune therapies to prevent infant HIV acquisition and to bring an end to the pediatric AIDS epidemic.

Retest and treat: a review of national HIV retesting guidelines to inform elimination of mother-to-child HIV transmission (EMTCT) efforts.

IntroductionHigh maternal HIV incidence contributes substantially to mother‐to‐child HIV transmission (MTCT) in some settings. Since 2006, HIV retesting during the third trimester and breastfeeding has been recommended by the World Health Organization in higher prevalence (≥5%) settings to reduce MTCT. However, many countries lack clarity on when and how often to retest pregnant and postpartum women to optimize resources and service delivery. We reviewed and characterized national guidelines on maternal retesting based on timing and frequency.MethodsWe identified 52 countries to represent variations in HIV prevalence, geography, and MTCT priority and searched available national MTCT, HIV testing and HIV treatment policies published between 2007 and 2017 for recommendations on retesting during pregnancy, labour/delivery and postpartum. Recommended retesting frequency and timing was extracted. Country HIV prevalence was classified as: very low (<1%), low (1% to 5%), intermediate (>5 to <15%) and high (≥15%). Women with unknown HIV status at delivery/postpartum were included in retesting guidelines.Results and discussionOverall, policies from 49 countries were identified; 51% from 2015 or later and most (n = 25) were from Africa. Four countries were high HIV prevalence, seven intermediate, sixteen low and twenty‐two very low. Most (n = 31) had guidance on universal voluntary opt‐out HIV testing at the first antenatal care (ANC) visit. Beyond the first ANC visit, the majority (78%, n = 38) had guidance on retesting; 22 recommended retesting all women with unknown/negative status, five only if unknown HIV status, three in pregnancy based on risk and eight combining these approaches. Retesting was universally recommended during pregnancy, labour/delivery, and postpartum for all high prevalence settings and four of seven intermediate prevalence settings. Five UNAIDS priority countries for EMTCT with low/very low HIV prevalence, but high/intermediate MTCT, had no guidance on retesting.ConclusionsRetesting guidelines for pregnant and postpartum women were ubiquitous in high prevalence countries and defined in some intermediate prevalence countries, but absent in some low HIV prevalence countries with high MTCT. Countries may require additional guidance on how to optimize maternal HIV testing and whether to prioritize retesting efforts or discontinue universal retesting based on HIV incidence. Research is needed to assess country‐level guideline implementation and impact.

I-106 Early treatment initiation in children with vertical HIV infection influences HIV specific immune responses

Background: Despite successes in prevention of mother to child HIV transmission (MTCT), issues related to early diagnosis, ART initiation and adherence play a role in the disease course of HIV infected children. Early ART initiation in HIV infected infants leads to reduced size of HIV reservoirs and curtails clinical progression but role of the immune system in this process is not well understood. With early initiation of ART, HIV infected infants preserve their CD4+ T cells and in some instances remain seronegative for HIV due to limited exposure of B cells to HIV antigen. We are performing immunologic assessments in the HIV Exposed Pediatric Patients (HEPP) Project and discuss a group of children from Rome, Italy. The goal of the present study is to evaluate HIV-specific immunity of vertically HIV infected children in relation to timing of ART initiation. Methods: The study group consists of older vertically infected HIV+ children and adolescents who initiated ART at different ages after birth and have maintained durable viral control (plasma HIV-RNA &lt;50 cp/mL). Immunologic studies were performed in 27 children (at ages 2.1–15.7 yrs) of whom 22 had started ART early, at age &lt;6 mo [early treated (ET)] and 5 who started ART later, at age &gt;2 yrs [late treated (LT)] with ET experiencing longer duration of ART (P &lt; 0.05) at the time of study. ET children were also evaluated by HIV serology (Abbott Architect HIV Ag/Ab Combo Assay) to establish if they were seropositive (SP) or seronegative (SN) to HIV. Flow cytometry was performed using BD LSRFortessa for T cells and BD FACS Aria II for B cells. HIV-gag specific CD4+ and CD8+ T cells were investigated by flow cytometry in cryopreserved PBMC for the induction of intracellular cytokines (IL-2, IFN-g, TNF, IL-21) in CD40L+ CD4+ T cells and intracellular cytokines (IL-2, IFN-g, TNF) as well as Perforin, Granzyme B and CD107a in CD69+ CD8+ T cells following 12 hours stimulation with HIV gag PTE peptides. In addition, Env-specific CD4+ T cells were evaluated following 12 hours stimulation of PBMC with Env peptides. IgD+ and IgM+ B cell subsets were determined in gp140+ B cells. Moreover, env-specific and non-specific B cells were sorted to perform transcriptomic analysis with Fluidigm (Biomark). Differences between groups were determined by unpaired or Mann-Whitney t tests if the data were normally distributed or not, respectively. Results: In this group of HIV+ children, frequencies of HIV gag-specific CD4+ T cells and CD8+ T cells were similar between ET and LT but differed qualitatively. Gag stimulated CD4+ T cells of ET exhibited higher proportions of IL-21 and IFNg with enrichment of polyfunctional T cells defined by the simultaneous presence of 3 or more cytokines. Gag stimulated CD8+ T cells of ET exhibited higher frequencies of cytotoxic cells (CD107a+Perf+GrzB+). In ET, serologic evaluation of HIV Ab revealed 6/22 (27.3%) to be SN. The gp140-specific CD4+ T cell frequencies were similar in SN and SP but intracellular IL-21 expression was higher in SP. Frequencies of gp140+ CD19+ B cells were similar between SN and SP, but HIV-specific CD27+ memory B cells were predominantly IgM+ in SN while in SP, the gp140+CD27+ memory B cells were enriched in IgD-cells. Gene expression signatures in gp140+IgM+ cells revealed upregulation of genes involved in both plasma cell differentiation (PRDM1) and GC reaction (BCL6) only in SP after in-vitro stimulation. Conclusions: Time of ART initiation after birth has a long-term impact on the quality of the host HIV-specific immune responses in vertically infected HIV+ children with durable virus suppression. Earlier ART initiation is associated with preserved HIV gag-specific CD4+ and CD8+ T cells. Moreover, even in those who become seronegative for HIV, the HIV Env-specific CD4+ T cells and B cells persist, the latter demonstrating a blunted differentiation with enrichment of IgM+ B cells. ET children with consistent viral control are prime candidates for therapeutic approaches aimed at permanent remission of HIV. These studies are supported by ViiV Health Care grant to EPIICAL and NIH grant AI127347 to SP.

Most new HIV infections, vertical transmissions and AIDS-related deaths occur in lower-prevalence countries

ObjectivesThe Joint United Nations Programme on HIV/AIDS (UNAIDS) targets aim to reduce new HIV infections below 500,000 per year by 2020. Despite targeted prevention programmes, total new infections remained in 2016 and 2017 at 1,800,000 cases. We have aimed to analyse data from 2017 and to compare HIV incidence, AIDS-related deaths and provision of antiretroviral therapy (ART) to adults, pregnant women and children living with HIV in lower- and higher-prevalence countries. Vertical or mother-to-child transmission (MTCT) and early infant diagnosis (EID) rates were also investigated. MethodsUNAIDSinfo data use the Spectrum model to represent country-level HIV data. Countries with epidemics over 40,000 HIV cases were separated into higher prevalence (≥4.5%) and lower prevalence (<4.5%). Least squares linear regression, weighted by epidemic size and controlled for gross domestic product/capita, was used to compare HIV prevalence with estimated ART coverage in adults (≥15 years), children (0–14 years), pregnant women, and EID rates and MTCT rates. Data were then compared between higher- and lower-prevalence groups, including numbers of new HIV infections and AIDS-related deaths. ResultsData were available for 56 countries. Twelve higher-prevalence countries accounted for 16.7 million and 44 lower-prevalence ones for 15.1 million people living with HIV, altogether making up 87.5% of the global estimate. Lower-prevalence countries had less ART coverage for adults, pregnant women and children, lower EID rates and higher AIDS-related death levels. There were more new HIV infections in adults and children in lower- than higher-prevalence countries. ConclusionsMost new HIV infections, MTCTs and AIDS-related deaths occurred in countries with an HIV prevalence rate below 4.5%. Many of these countries are not targeted by access programmes, such as the President’ Emergency Plan for AIDS Relief. More intensive programmes of diagnosis and treatment are needed in these countries in the effort to reduce global new HIV infections below 500,000 per year by 2020.

CURRENT STATE OF PREVENTION OF MOTHER-TO-CHILD HIV TRANSMISSION IN SAINT-PETERSBURG

Saint-Petersburg is among the leaders in medical treatment of HIV-positive pregnant women and their children. The joint efforts of AIDS Center, women’s consultation clinics, and maternity hospitals ensure the low rate of mother-tochild HIV transmission (1.3 % in 2007). The article reviews some advances as well as problems related to the medical treatment of HIV-positive pregnant women. The analysis of those issues will contribute to creation of a better healthcare system for pregnant women, will raise the awarness of how important medical monitroting and preventive care are and will favour further reduction of mother-to child transmission.

Implications of Mother to Child Transmission of HIV among Infected Pregnant Women and their Infants attending a PMTCT ARV Clinic in Ibadan, Nigeria

Background: Mother-to-child transmission (MTCT) is a major means through which HIV infected pregnant mothers pass the virus to their infants. This study aimed to assess the implications of MTCT of HIV among infected Pregnant Women and their Infants.Methods:60 consenting HIV infected pregnant women attending a PMTCT ARV clinic in Ibadan, were followed up for eighteen months. Data were captured using structured questionnaire and analyzed to identify associations. Results: The mother’s age range was 24-41 years with a mean of 32.9 years, while the infant’s median age was 35 days. 32 (72.7%) of them were females with mean birth weight of 3.10 Kg. MTCT of HIV was 4.5% (2/44). Majority of the respondents were of parity 1 (22.7%) and parity 2 (27.3%) and are in monogamous marriage (81.8%), while predominant religion and occupation were Christianity (59.1%) and Trading (56.8%). Viral load was negatively correlated with hemoglobin (r=-0.334), lymphocyte (r=-0.188), and neutrophil (- 0.151) but positively correlated with WBC count (r=0.141). However, between pregnancy and birth CD4 count increased from 503 to 716 (p<0.001). Viral load at birth was higher in positive babies (Mean=4.13, SD=0.06) than negative (mean=1.18, SD=0.71) with p=0.001. Conclusions: This study identified high risk as predictors of MTCT of HIV among exposed infants on follow up with severe implicating consequences. Therefore, testing for pregnant women for HIV should be a national priority, hence the need for more sensitization on the utilization of PMTCT program in Nigeria.