Uptake and performance of prevention of mother-to-child transmission and early infant diagnosis in pregnant HIV-infected women and their exposed infants at seven health centres in Addis Ababa, Ethiopia

The progress of mother-to-child transmission of Human Immunodeficiency Virus (HIV) after Dolutegravir (DTG) optimization program: evidence from a multicenter cohort study in Ethiopia

BACKGROUND

Ethiopia aims to eliminate mother-to-child transmission (MTCT) of HIV by 2030. In 2020, Dolutegravir-based antiretroviral treatment (ART) regimen optimization was done for the Prevention of Mother-to-Child Transmission (PMTCT). However, data tracking progress, particularly post-rollout of the Dolutegravir (DTG)-based regimen, and the real-world effectiveness of the new regimen are unavailable.

METHODS

A multicenter retrospective cohort study was conducted among HIV-infected mothers and their HIV-exposed infants visiting the selected hospitals for routine care. Eligible participants were HIV-exposed infants enrolled in the PMTCT care from 2017 to 2022. However, only the 2021 and 2022 birth cohorts were considered post-DTG optimization considering 2020 a year of optimization. The cumulative incidence of perinatal MTCT tested at 6-8 weeks of infant age, and end of care MTCT tested at 18 months of age was assessed. The exposures of the study were the infant birth cohort years and the different ART regimens used for PMTCT of HIV.

RESULTS

Among a total of 2,643 routine care enrolled participants, 2521 (95.4%) HIV-exposed infants were included in the analysis. Of these, 210 were on follow-up and excluded from the breastfeeding MTCT analysis. A total of 30/2521(1.2%) [95% confidence interval (CI): 0.8-1.7%] were positive for HIV at 6-8 weeks. Additionally, 11 /2281 (0.50%) (95% CI: 0.3-0.9%) were positive during breastfeeding. At the end of the care, 41/2311 (1.8%) (95% CI: 1.3-2.4%) infants were HIV-positive. The highest end-of-care MTCT was reported in 2019 and 2022 birth cohorts while the lowest was in 2018 (P-value > 0.3). However, after adjusting for baseline characteristics, the trend showed a decrease in transmission rates following the rollout of DTG-based regimen, although statistical significance was not reached. The adjusted odds ratios (AORs) for perinatal, breastfeeding, and end-of-care transmission rates were 0.34 (95%CI: 0.08-1.39), 0.29(95%CI: 0.03-3.05), and 0.38(95%CI: 0.11-1.26) respectively. Compared with the Efavirenz (EFV)-based regimen, the DTG-based regimen was associated with a lower risk of MTCT in both the perinatal (AOR 0.23, 95% CI: 0.06-0.85) and at the end of care (AOR 0.27, 95% CI: 0.09-0.82). Pregnant women who started ART at late gestation had the highest transmission rate regardless of ART regimens (P-value < 0.001).

CONCLUSIONS

In the studied cohort population, we observed less than 3% MTCT rate at the end of PMTCT care. The findings might suggest the achievement of MTCT elimination at the hospital level. Although the DTG-based regimen demonstrated a lower risk of transmission, other contributing factors, such as late ART initiation, should be urgently addressed. Future research should focus on prospective designs, interventions targeting late ART initiation, and understanding regional disparities to further advance efforts to eliminate MTCT by 2030.

Facilitators and Barriers to Adherence to Anti-Retroviral Treatment Among Pregnant or Breastfeeding Women Living with HIV and Perinatally Infected Infants: A Scoping Review

In 2022, 54% of 1.5 million children (age 0-14) living with HIV had access to anti-retroviral medication (ART). Adherence to ART for pregnant or breastfeeding HIV + women is critical for maintaining their personal health and to prevent mother-to-child-transmission (MTCT). For HIV + infants, adherence is essential to establish early viremic control and is contingent on caregiver administration. We conducted a scoping review to systematically identify and categorize the influences on ART adherence for pregnant or breastfeeding HIV + women and their HIV + infants. We searched databases in June 2023 and employed the Social-Ecological Model (SEM) to organize facilitators and barriers to adherence referenced in published articles. All articles published before 2016 were excluded due to updated guidelines from WHO on MTCT and ART. Our analysis included 52 articles. 50/52 took place in Africa and used cross-sectional and mixed-methods design. Barriers to adherence for pregnant or breastfeeding HIV + women included maternal education, self-efficacy, social support, and social/economic context. Barriers to infant adherence included development, nutrition, age of treatment initiation, disclosure, and ART side effects. Additional facilitators and barriers to adherence are presented at family, extra-familial, and socio-cultural SEM levels. Stigma was the most salient barrier referenced across the entire continuum of HIV care and all SEM levels. This review revealed a dearth of literature focusing on HIV + infants who are dependent on their caregivers for ART adherence and lack of a standard adherence measure. We identified multi-leveled influences on adherence impacting both the mother and infant and are amenable to public health intervention.

An assessment of turnaround times of infant Deoxyribonucleic acid-Polymerase Chain Reaction testing and the associated factors in Western Kenya: A mixed methods study

INTRODUCTION

The HIV/AIDS continues being a significant global public health priority in the 21st century with social and economic consequences Mother-to-child transmission (MTCT) occurs when an HIV-infected woman passes the virus to her infant and about 90% of these MTCT infections occurs in Africa where children and infants are still dying of HIV. Early definitive diagnosis using Deoxyribonucleic acid reaction of HIV infection in infants is critical to ensuring that HIV-infected infants receive appropriate and timely care and treatment to reduce HIV related morbidity and mortality.

OBJECTIVE

To assess the Infant Deoxyribonucleic acid-Polymerase Chain Reaction (DNA-PCR) Turnaround Time (TAT) of dry blood spots and associated factors in Vihiga, Bungoma, Kakamega and Busia counties, in Kenya.

METHOD

A mixed methods study using a) retrospectively collected data from Ministry of Health Laboratory registers, Early Infant Diagnosis (EID) database from 28 health facilities and b) 9 key informant interviews with laboratory in-charges were conducted. A total of 2,879 HIV exposed babies' data were abstracted from January 2012 to June 2013.

RESULTS

The mean TAT from specimen collection and results received back at the facilities was 46.90 days, Vihiga county having the shortest mean duration at 33.7days and Kakamega county having the longest duration at 51.7days (p = 0.001). In addition, the mean transport time from specimen collection and receipt at Alupe Kenya Medical Research Institute (KEMRI) reference Laboratory was 16.50 days. Vihiga County had the shortest transport time at 13.01 days while Busia had the longest at 18.99 days (p = 0.001). Longer TAT was due to the batching of specimens at the peripheral health facilities and hubbing to the nearest referral hospitals.

CONCLUSION

The TAT for DNA-PCR specimen was 46.90 days with Vihiga County having the shortest TAT due to lack of specimen batching and hubbing.

RECOMMENDATION

Discourage specimen batching/hubbing and support point-of-care early infant diagnosis (EID) tests.

Evaluation of the prevention of mother-to-child transmission of HIV programs at the second immunization visit in Burkina Faso and Zambia

OBJECTIVE

Our study aimed to assess the PMTCT indicators in Burkina Faso and Zambia using a patient-orientated innovative strategy based on the second visit in the Expanded Program on Immunization (EPI-2) visit at 6-8 weeks.

DESIGN

This was a cross sectional study.

METHODS

We assessed women attending EPI-2 at primary healthcare facilities in Burkina Faso and Zambia with their children about their exposure to PMTCT interventions. For women living with HIV (WLHIV), viral load was measured and their children were tested for HIV DNA using point of care devices.

RESULTS

Overall, 25 093 were enrolled from Burkina Faso and 8961 women from Zambia. Almost, all women attended at least one antenatal care visit. Among those aware of their HIV-positive status, 95.8 and 99.2% were on antiretroviral therapy (ART) in Burkina Faso and Zambia, respectively. Among WLHIV on ART, 75 and 79.2% achieved a viral load suppression (viral load <1000 copies/ml) in Burkina Faso and Zambia, respectively. Infant postnatal prophylaxis was administered from birth until EPI-2 to 60.9 and 89.7% of HIV-exposed children in Burkina Faso and Zambia, respectively. In Burkina Faso, only 60 of 192 (31.3%) of HIV-exposed children were sampled at day 42 for early infant diagnosis (EID) and 3 (1.6%) received a result by EPI-2. In Zambia, these figures were 879 of 1465 (64.0%) and 9.9% (145/1465), respectively for HIV-exposed children sampled at birth.

CONCLUSION

This evaluation strategy at EPI-2 visit could strengthen program monitoring and help identifying gaps to be addressed on the last mile towards elimination of MTCT of HIV.

Determinants of Turn-Around-Time for Early Infant Diagnosis of HIV Testing: Retrospective Analysis of National Level PCR Testing Data

India has been implementing one of the biggest Early Infant Diagnosis (EID) of HIV intervention globally. The turn-around-time (TAT) for EID test is one of the major factors for success of the program. This study was to assess the turnaround time and its determinants. It is a mixed methods study with quantitative analysis of retrospective data (2013-2016) collected from all the 7 Early Infant Diagnosis testing laboratories (called as regional reference laboratories or RRLs) in India and qualitative component that can help explain the determinants of turn-around-time. The retrospective national level data available from the RRLs was analyzed to measure the turn-around-time from the receipt of samples to the dispatch of results and to understand the determinants for the same. The 3 components transport time, testing time, and dispatch time were also calculated. Transport time was analyzed state-wise and the testing time RRL wise to understand disparities, if any. Qualitative interviews with the RRL officials were conducted to understand the underlying determinants of TAT. The Median turn-around-time ranged between 29 and 53 days over the 4 years. Transport time was significantly higher for states without RRL (42 days) than those with RRL (27 days). Testing time varied from RRL to RRL and was associated with incomplete forms, inadequate samples, kits logistics, staff turnover, staff training, and instrument related issues. The TAT is high and can be potentially reduced with interventions, such as decentralization of RRLs; courier systems for sample transport; and ensuring adequate resources at the RRL level.

Interventions to improve antiretroviral adherence in HIV-infected pregnant women: A systematic review and meta-analysis

Background

Medication adherence in HIV-infected pregnant women remains suboptimal. This systematic review and meta-analysis aimed to evaluate the effectiveness of interventions on improving antiretroviral adherence targeting among HIV-infected pregnant women.

Methods

Five databases were screened to identify quasi-experimental studies and randomized controlled trials. The risk ratios (RR) and confidential intervals (CI) were extracted to estimate the improvement in antiretroviral adherence after interventions compared with control conditions. This study was registered with PROSPERO, number CRD42021256317.

Results

Nine studies were included in the review, totaling 2,900 participants. Three interventions had significance: enhanced standard of care (eSOC, RR 1.14, 95%CI 1.07-1.22, Z = 3.79, P < 0.01), eSOC with supporter (RR 1.12, 95%CI 1.04-1.20, Z = 2.97, P < 0.01) and device reminder (RR 1.33, 95%CI 1.04-1.72, Z = 2.23, P = 0.03).

Discussion

The study supported the eSOC and the device reminder as effective intervention strategies for improving HIV medication adherence. Based on the current findings, the study called for more efforts to improve antiretroviral care for pregnant women through involving multicenter, large-sample, and high-quality research and combining the device reminder with other intervention methods.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021256317, identifier CRD42021256317.

Interventions to increase early infant diagnosis of HIV infection: A systematic review and meta-analysis

Objectives

Early infant diagnosis (EID) of HIV infection increases antiretroviral therapy initiation, which reduces pediatric HIV-related morbidity and mortality. This review aims to critically appraise the effects of interventions to increase uptake of early infant diagnosis.

Design

This is a systematic review and meta-analysis of interventions to increase the EID of HIV infection. We searched PubMed, EMBASE, CINAHL, and PsycINFO to identify eligible studies from inception of these databases to June 18, 2020. EID Uptake at 4–8 weeks of age was primary outcome assessed by the review. We conducted meta-analysis, using data from reports of included studies. The measure of the effect of dichotomous data was odds ratios (OR), with a 95% confidence interval. The grading of recommendations assessment, development, and evaluation (GRADE) approach was used to assess quality of evidence.

Settings

The review was not limited by time of publication or setting in which the studies conducted.

Participants

HIV-exposed infants were participants.

Results

Database search and review of reference lists yielded 923 unique titles, out of which 16 studies involving 13,822 HIV exposed infants (HEI) were eligible for inclusion in the review. Included studies were published between 2014 and 2019 from Kenya, Nigeria, Uganda, South Africa, Zambia, and India. Of the 16 included studies, nine (experimental) and seven (observational) studies included had low to moderate risk of bias. The studies evaluated eHealth services (n = 6), service improvement (n = 4), service integration (n = 2), behavioral interventions (n = 3), and male partner involvement (n = 1). Overall, there was no evidence that any of the evaluated interventions, including eHealth, health systems improvements, integration of EID, conditional cash transfer, mother-to-mother support, or partner (male) involvement, was effective in increasing uptake of EID at 4–8 weeks of age. There was also no evidence that any intervention was effective in increasing HIV-infected infants’ identification at 4–8 weeks of age.

Conclusions

There is limited evidence to support the hypothesis that interventions implemented to increase uptake of EID were effective at 4–8 weeks of life. Further research is required to identify effective interventions that increase early infant diagnosis of HIV at 4–8 weeks of age.

Prospero number

(CRD42020191738).

Retention-in-care in the PMTCT cascade: definitions matter! Analyses from the INSPIRE projects in Malawi, Nigeria and Zimbabwe

Introduction

Definitions of retention‐in‐care in Prevention of Mother‐to‐Child Transmission of HIV (PMTCT) vary substantially between studies and programmes. Some definitions are based on visits missed/made, others on a minimum total number of visits, or attendance at a final clinic visit at a specific time. An agreed definition could contribute to developing evidence‐based interventions for improving retention‐in‐care. In this paper, we estimated retention‐in‐care rates according to different definitions, and we quantified and visualized the degree of agreement between definitions.

Methods

We calculated retention in care rates using nine definitions in the six INSPIRE PMTCT intervention studies, conducted in three sub‐Saharan African countries between 2013 and 2017. With data from one of the studies (E4E), we estimated the agreement between definitions using Gwet’s agreement coefficient (AC1) and concordance. We calculated positive predictive values (PPV) and negative predictive values (NPV) for all definitions considering successively each definition as the reference standard. Finally, we used a Multiple Correspondence Analysis (MCA) to examine clustering of the way different definitions handle retention‐in‐care.

Results

Retention‐in‐care rates among 5107 women ranged from 30% to 76% in the complete dataset with Gwet’s AC1 being 0.56 [0.53; 0.59] indicating a moderate agreement between all definitions together. Two pairs of definitions with high inner concordance and agreement had either very high PPV or very high NPV, and appeared distinct from the other five definitions on the MCA figures. These pairs of definitions were also the ones resulting in the lowest and highest estimates of retention‐in‐care. The simplest definition, that only required a final clinic visit to classify women as retained in care, and classified 55% of women as retained in care, had a PPV ranging from 0.7 to 1 and a NPV ranging from 0.69 to 0.98 when excluding the two pairs afore‐mentioned; it resulted in a moderate to substantial agreement and a 70% to 90% concordance with all other definitions.

Conclusions

Our study highlights the variability of definitions in estimating retention‐in‐care. Some definitions are very stringent which may be required in some instances. A simple indicator such as attendance at a single time point may be sufficient for programme planning and evaluation.

Factors associated with the timely uptake of initial HIV virologic test among HIV-exposed infants attending clinics within a faith-based HIV program in Kenya; a cross-sectional study

BACKGROUND

Early infant diagnosis (EID) of HIV, followed by effective care including antiretroviral therapy (ART), reduces infant mortality by 76% and HIV progression by 75%. In 2015, 50% of 1.2 million HIV-exposed infants (HEI) in 21 priority countries received a virologic test within the recommended 2 months of birth. We sought to identify factors associated with timely uptake of virologic EID among HEI and gain insight into missed opportunities.

METHODS

This was a cross-sectional study that used de-identified data from electronic medical records of 54 health facilities within the Christian Health Association of Kenya (CHAK) HIV Project database. All HEI who had their first HIV virologic test done between January 2015 and December 2017 were included in the study and categorized as either having the test within or after 8 weeks of birth. Multivariate linear mixed effects regression model was used to determine factors associated with uptake of the first HIV EID polymerase chain reaction (PCR). Predictor variables studied include sex, birth weight, the entry point into care, provision of ART prophylaxis for the infant, maternal ART at time of EID, mode of delivery, and place of delivery.

RESULTS

We included 2020 HEI of whom 1018 (50.4%) were female. A majority, 1596 (79.0%) had their first HIV PCR within 2 months of birth at a median age of 6.4 weeks (interquartile range 6-7.4). Overall, HIV positivity rate at initial test among this cohort was 1.2%. Delayed HIV PCR testing for EID was more likely to yield a positive result [adjusted odds ratio (aOR) = 1.29 (95% confidence interval (CI) 1.09-1.52) p = 0.003]. Infants of mothers not on ART at the time of HIV PCR test and infants who had not received prophylaxis to prevent vertical HIV transmission had significant increased odds of a delayed initial test [aOR = 1.27 (95% CI = 1.18-1.37) p = < 0.0001] and [aOR = 1.43 (95% CI 1.27-1.61) p = < 0.001] respectively.

CONCLUSION

An initial HIV PCR test done after 8 weeks of birth is likely to yield a positive result. Barriers to accessing ART for treatment among HIV-infected pregnant and breastfeeding women, and prophylaxis for the HEI were associated with delayed EID. In order to ensure timely EID, programs need to incorporate both facility and community strategy interventions to ensure all pregnant women seek antenatal care and deliver within health facilities.

Retention in Care and Health Outcomes of HIV-Exposed Infants in a Prevention of Mother-to-Child Transmission of HIV (PMTCT) Cohort in Addis Ababa, Ethiopia

PURPOSE

Currently, a high number of mother-infant cohorts do not complete the full cascade of prevention of mother-to-child transmission of HIV (PMTCT) services in Ethiopia. This study examined the level of HIV-exposed infants discharged negative and rate of loss to follow-up (LTFU) in a mother-infant cohort in Addis Ababa, Ethiopia.

METHODS

A retrospective cohort study was conducted in selected public health facilities of Addis Ababa. Data were abstracted from infant and mother registration cards and mother-infant cohort follow-up charts. The proportion of HIV-exposed infants discharged negative was examined. LTFU was then analyzed and a Kaplan-Meier survival curve was used to estimate Cumulative probability of LTFU among the different groups. Cox proportional hazard model was used to determine significant factors associated with LTFU.

RESULTS

Three hundred fifty six mother-infant pairs were included in this study. The LTFU rate at the end of follow-up period was of 13.2% (95% CI= 9.83-17.6%) and an overall HIV transmission rate of 0.61% was observed. Younger women (AHR=0.90, 95% CI = 0.83-0.97) and those who were newly diagnosed at the time of entry to PMTCT (AHR=0.35, 95% CI = 0.18-0.68) were less likely to complete PMTCT.

CONCLUSION

High retention to PMTCT services and low mother-to-child HIV transmission rate was observed. To successfully achieve the PMTCT program outcomes, more emphasis should be given to younger women and to those newly enrolled in the PMTCT program.

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

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

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

Mother-child separation among women living with HIV and their children in the first four years postpartum in South Africa

OBJECTIVES

Mother-child pairs may separate during early life, yet the health impacts thereof are unclear. We explored the patterns and impact of separation among women living with HIV (WLHIV) and their children in South Africa.

METHODS

WLHIV who had initiated antiretroviral therapy (ART) during pregnancy received HIV viral load (VL) testing and completed a timeline questionnaire of mother-child separation since delivery at 3-5 years post-partum. Health care usage was abstracted from routine medical records. We examined associations between separation and (a) maternal health outcomes (engagement in HIV care and HIV viral suppression, [VS]) and (b) child health outcomes (post-breastfeeding HIV testing and immunisation completion), using logistic regression.

RESULTS

Of 346 mother-child pairs (median maternal age at antenatal ART initiation, 28 years), 24% were ever separated (median time to first separation 20 months, interquartile range [IQR] 9, 31). Most separated children were living with their grandmothers (65/83, 78%). Mothers who ever separated were younger, and more likely to be employed, and to reside in informal housing than those who never separated. Any separation reduced the odds of VS ≤ 50 copies/mL at four years post-partum (odds ratio 0.57; 95% CI 0.34-0.93); associations were similar for VL ≤ 1000 copies/mL and maternal engagement in care. No association was found between separation and child confirmatory HIV testing or immunisation completion.

CONCLUSIONS

In this setting, mother-child separation is common in the first four years of life and appears associated with suboptimal maternal outcomes. Further research is required to understand the drivers and implications of mother-child separation.

Acceptability and feasibility of testing for HIV infection at birth and linkage to care in rural and urban Zambia: a cross-sectional study

BACKGROUND

Early infant diagnosis is important for timely identification of HIV-infected infants and linkage to care. Testing at birth has been implemented to facilitate earlier diagnosis of HIV infection but may present new challenges. This study was conducted to understand the acceptability and feasibility of birth testing in urban and rural settings in southern Zambia.

METHODS

This cross-sectional study was conducted at 11 hospitals and clinics in Livingstone, Choma, and Macha in Southern Province, Zambia from 2016 to 2018. Infants born to pregnant women living with HIV at the sites were eligible for enrollment. After enrollment, a questionnaire was administered to the mother and a dried blood spot card was collected from infants for testing at a central laboratory. When results were available, mothers were notified to return to the clinic. Acceptability of birth testing was evaluated based on the proportion of women who agreed to participate and the reasons for non-participation among women who declined. Feasibility of testing at birth was evaluated using turnaround times for returning results, the proportion of women receiving results, and linkage to care for infants testing positive.

RESULTS

One thousand four hundred three women were approached for the study. A small proportion declined due to refusal of birth testing (0 to 8.2% across sites). One thousand two hundred ninety women agreed to have their infants tested. The proportion of mothers receiving results ranged from 51.6 to 92.1%, and was significantly lower at the hospital than clinics in Livingstone (51.6% vs. 69.8%; p < 0.0001) and Macha (69.5% vs. 85.7%; p < 0.0001) but not Choma (85.7% vs. 92.1%; p = 0.34). For mothers who received test results, the median turnaround time from sample collection was 67 days in Livingstone and 53 days in Macha and Choma. Overall, 23 (1.8%) infants tested positive for HIV but only 8 (34.8%) were linked to care a median of 68 days (range: 29, 784) after sample collection.

CONCLUSIONS

While testing at birth was acceptable, this study highlights the operational challenges under a centralized laboratory testing system. Point-of-care platforms are needed for rapid testing and return of results so HIV-infected children can be identified, linked to care, and treated as early as possible.

High turnaround times and low viral resuppression rates after reinforced adherence counselling following a confirmed virological failure diagnostic algorithm in HIV-infected patients on first-line antiretroviral therapy from Tanzania

OBJECTIVE

Early identification of confirmed virological failure is paramount to avoid accumulation of drug resistance in patients on antiretroviral therapy (ART). Scale-up of HIV-RNA monitoring in Africa and timely switch to second-line regimens are challenged.

METHODS

A WHO adapted confirmed virological treatment screening algorithm (HIV-RNA screening, enhanced adherence counselling, confirmatory HIV-RNA testing) was evaluated in HIV-infected patients on first-line ART from Tanzania. The main endpoints included viral resuppression and virological failure rates, retention and turnaround time of the screening algorithm until second-line ART initiation. Secondary endpoints included risk factors for virological treatment failure and patterns of genotypic drug resistance.

RESULTS

HIV-RNA >1000 copies/ml at first screening was detected in 58/356 (16.3%) patients (median time-on-treatment 6.3 years, 25% immunological treatment failure). Adjusted risk factors for virological failure were age <30 years (RR 5.2 [95% CI: 2.5-10.8]), years on ART ≥3 years (RR 3.0 [1.0-8.9]), CD4-counts <200 cells/µl (RR 9.3 [4.0-21.8]) and poor self-reported treatment adherence (RR 2.0 [1.2-3.4]). Resuppression of HIV-RNA <1000 copies/ml was observed in 5/50 (10%) cases after enhanced adherence counselling. Confirmatory testing within 3 months was performed in only 46.6% and switch to second-line ART within 6 months in 60.4% of patients. Major NNRTI-mutation were detected in all of 30 patients, NRTI mutations in 96.7% and ≥3 thymidine-analogue mutations in 40%. No remaining NRTI options were predicted in 57% and limited susceptibility in 23% of patients.

CONCLUSION

We observed low levels of viral resuppression following adherence counselling, associated with high levels of accumulated drug resistance. High visit burden and turnaround times for confirmed virological failure diagnosis further delayed switching to second-line treatment which could be improved using novel point-of-care viral load monitoring systems.

Missed opportunities for early infant diagnosis of HIV in rural North-Central Nigeria: A cascade analysis from the INSPIRE MoMent study

Background

Early identification of HIV-infected infants for treatment is critical for survival. Efficient uptake of early infant diagnosis (EID) requires timely presentation of HIV-exposed infants, same-day sample collection, and prompt release of results. The MoMent (Mother Mentor) Nigeria study investigated the impact of structured peer support on EID presentation and maternal retention. This cascade analysis highlights missed opportunities for EID and infant treatment initiation during the study.

Methods

HIV-infected pregnant women and their infants were recruited at 20 rural Primary Healthcare Centers. Routine infant HIV DNA PCR testing was performed at centralized laboratories using dried blood spot (DBS) samples ideally collected by age two months. EID outcomes data were abstracted from study case report forms and facility registers. Descriptive statistics summarized gaps and missed opportunities in the EID cascade.

Results

Out of 497 women enrolled, delivery data was available for 445 (90.8%), to whom 415 of 455 (91.2%) infants were live-born. Out of 408 live-born infants with available data, 341 (83.6%) presented for DBS sampling at least once. Only 75.4% (257/341) were sampled, with 81.7% (210/257) sampled at first presentation. Only 199/257 (77.4%) sampled infants had results available up to 28 months post-collection. Two (1.0%) of the 199 infants tested HIV-positive; one infant died before treatment initiation and the other was lost to follow-up.

Conclusions

While nearly 85% of infants presented for sampling, there were multiple missed opportunities, largely due to health system and not necessarily patient-level failures. These included infants presenting without being sampled, presenting multiple times before samples were collected, and getting sampled but results not forthcoming. Finally, neither of the two HIV-positive infants were linked to treatment within the follow-up period, which may have led to the death of one. To facilitate patient compliance and HIV-free infant survival, quality improvement approaches should be optimized for EID commodity availability, consistent DBS sample collection, efficient processing/result release, and prompt infant treatment initiation.

Point-of-care HIV testing best practice for early infant diagnosis: an implementation study

Background

With Universal Health Coverage and Integrated People-centred Health Care, streamlined health-systems and respectful care are necessary. South Africa has made great strides in prevention of mother-to-child transmission (PMTCT) but with the great burden of HIV, a minimum of birth and 10-week HIV-PCR testing are required for the estimated 360,000 HIV-exposed infants born annually which presents many challenges including delayed results and loss to follow-up. Point-of-care (POC) HIV testing of infants addresses these challenges well and facilitates initiation of HIV-infected infants rapidly after diagnosis for best clinical outcomes.

Methods

Objectives were to determine accuracy, feasibility and acceptability of POC testing compared to standard-of-care (SOC) central-laboratory testing. HIV-exposed infants for birth PCR testing in hospital (n = 323) and follow-up at a primary health care clinic (n = 117) in Durban, South Africa were included. A baseline situational-analysis reviewed registers and phoned mothers of HIV-exposed infants prior to the intervention. An effectiveness-implementation study of the Alere™q HIV-1/2 Detect POC test (heel-prick specimen processed in 50 min) was compared with SOC with questionnaires to mothers and staff. Stata 14 was used for analysis.

Results

At baseline 2% of birth HIV tests were missed; only 40% of mothers could be contacted; 17% did not receive birth test result; 19% did not have a 10-week test; 39% had not received the 10-week results. There were 5(1.5%) HIV-infected and 318(98.5%) HIV-negative infants detected in hospital with all clinic babies negative. All positive infants commenced ART before discharge. Ultimately POC and SOC had perfect concordance but for 10 SOC tests researchers actively tracked-down results or repeated tests. Turn around times for SOC tests were on average 8-days (IQR 6-10  days) and for POC testing was 0-days. The POC error-rate was 9,6% with all giving a result when repeated. The majority of mothers (92%) preferred POC testing with 7% having no preference. No staff preferred SOC testing with 79% preferring POC and 21% having no preference.

Conclusions

Point-of-care HIV testing for EID is accurate, feasible and acceptable, with benefits of early ART for all positive infants at birth facilities. We recommend that it be considered best practice for EID.

Trial registration

ISRCTN38911104 registered 9 January 2018 – retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6990-z) contains supplementary material, which is available to authorized users.

A systematic review and meta-analysis of vertical transmission route of HIV in Ethiopia

BACKGROUND

The burden of mother-to-child transmission rate of HIV is high and risk factors are common in Ethiopia. This systematic review and meta-analysis intended to provide the pooled estimation of mother-to-child transmission rate and its risk factors in Ethiopia.

METHODS

We searched PubMed, Google Scholar, EMBASE and Web of Science electronic databases for all available references. We included observational studies including case-control, cohort, and cross-sectional studies. The search was further limited to studies conducted in Ethiopia and publish in English. Heterogeneity was checked using the I² statistic. Egger's test and the funnel plot were used to assess publication bias. A meta-analysis using a weighted inverse variance random-effects model was performed.

RESULTS

A total of 18 studies with 6253 individuals were included in this systematic review and meta-analysis. Of these, 14 studies with 4624 individuals were used to estimate the prevalence. The estimated pooled prevalence of mother-to-child transmission of HIV was 11.4% (95% CI = 9.1-13.7). The pooled adjusted odds ratio (AOR) of mother-to-child transmission of HIV for the infants from rural area was 3.8 (95% CI = 1.4 to 6.3), infants delivered at home was 3.2 (95% CI = 1.2 to 5.2), infant didn't take antiretroviral prophylaxis was 5.8 (95% CI = 1.5 to 10.3), mother didn't take antiretroviral prophylaxis was 6.1 (95% CI = 2.5 to 9.6), mothers didn't receive PMTCT intervention was 5.1 (95% CI = 1.6, 8.6), and on mixed feeding was 4.3 (95% CI = 1.8 to 6.7).

CONCLUSIONS

This systematic review and meta-analysis showed that mother-to-child transmission rate of HIV was high in Ethiopia. Being from the rural residence, home delivery, not taking antiretroviral prophylaxis, the absence of PMTCT intervention, and mixed infant feeding practices increased the risk of HIV transmission.

TRIAL REGISTRATION

It is registered in the Prospero database: (PROSPERO 2017: CRD42017078232 ).