Mother-to-Child Transmission of HIV Through Breastfeeding Improving Awareness and Education: A Short Narrative Review

Adherence, perceptions and knowledge of an HIV PMTCT programme: A mother-baby pair study

Background

Prevention of mother-to-child transmission (PMTCT) programmes are designed to prevent HIV transmission to infants and children. Despite efforts to achieve this goal, several factors continue to pose challenges.

Objectives

To investigate the level of adherence, perceptions, knowledge, and factors associated with adherence to the PMTCT programme in primary healthcare facilities.

Method

A descriptive cross-sectional study design and quantitative research approach was used, and clinical records were reviewed to determine the prevalence of seroconverted babies of mothers enrolled in a PMTCT programme for the past 2 years in the community healthcare centres. Bivariate and multivariate logistic regression analyses were performed.

Results

A total of 341 mother-baby pairs were recruited and took part in the study. Most women (263; 77%), perceived that a pregnant woman living with HIV can transmit the virus to her unborn baby. The following factors were independently associated with non-adherence: being unmarried, the period of maternal HIV diagnosis and initiation on antiretroviral therapy, unsuppressed viral load results, missed clinic appointments, side effects, and getting tired of taking HIV medication.

Conclusion

This study investigated adherence to and perceptions of all components of the PMTCT programme by pregnant and breastfeeding women in primary healthcare facilities. Despite the significant progress made, maternal and paediatric HIV pandemic pose a challenge to the PMTCT services. There is a need for follow-up research to monitor the ongoing adherence to the PMTCT programme and its long-term impact in reducing the rate of transmission of HIV in mothers.

HIV retesting uptake and incidence during pregnancy and breastfeeding period among women in sub-Saharan Africa

To prevent and reduce mother-to-child transmission of HIV and maternal morbidity and mortality, the World Health Organization currently requires retesting for HIV during pregnancy and postpartum. This was a systematic review and meta-analysis in which PubMed, Cochrane Library, Embase, and clinicaltrials.gov were searched for articles published between January 2005 and February 2024. Retesting uptake was defined as the number of women who tested for HIV during pregnancy/breastfeeding periods following an initial HIV-negative test during these periods. Using random-effects models, we computed the pooled prevalence of HIV retesting uptake, incidence rates (IRs), and 95% confidence intervals (CIs). A sensitivity analysis was done by excluding studies that tested women during labor and reported 100% retesting uptake. A total of 37 studies with 1,999,621 women were analyzed. Overall, the pooled prevalence of HIV retesting uptake was 89.1% (95%CI, 81.0-95.2). Retesting uptake was significantly higher during breastfeeding compared to pregnancy (93.3% vs. 89.9%; P < 0.001). A sensitivity analysis showed that overall retesting uptake was 73.9% (95%CI, 60.1-83.8). A total of 1302 (0.2%) women acquired HIV. Twenty-two studies reported an IR; the overall pooled IR was 4.3/100 person-year (PY; 95%CI, 3.4-5.2/100 PY). The HIV incidence rate was significantly higher during pregnancy compared to breastfeeding (5.9/100 vs. 3.4/100 PY; P < 0.001). One to three in 10 women in sub-Saharan Africa do not retest for HIV following a negative test during pregnancy or breastfeeding periods. Emphasizing HIV retesting during these periods is critical to eliminate pediatric HIV given that the overall IR is beyond the WHO threshold (3.0/100 PY) for a substantial risk of HIV transmission.

IAPSM Position Paper on Vertical Transmission of HIV from Mother to Child

Human immunodeficiency virus (HIV) can be transmitted through vertical route from the mother to her child during the period of pregnancy, process of childbirth, or through the breastfeeding. This is still a worldwide health issue, especially in environments with low resources. Without intervention, the transmission rate ranges from 15 to 45%, influenced by breastfeeding practices. Effective interventions, including antiretroviral therapy (ART), can reduce the transmission likelihood to about 2% with breastfeeding and 1% without breastfeeding. A further expansion of access to prevention of mother-to-child transmission of HIV (PMTCT) services was made possible by the year 2011 through the Global Plan toward the Elimination of New HIV Infections among Children and Keeping their Mothers Alive. By 2022, there were 130,000 new HIV infections in children under five, down from 310,000 in 2010. Nevertheless, the Joint United Nations Programme on HIV/AIDS (UNAIDS) Global Strategy to End AIDS's 2025 targets cannot be met with the current level of progress. To prevent new infections in children, pregnant and breastfeeding women with HIV must receive faster medical attention. This position paper discusses the primary prevention of HIV and the healthcare system's role in providing comprehensive care to HIV-positive women and their families. The continuum of care includes antenatal, intrapartum, post-delivery, and pediatric services, addressing the unique needs of each woman and her family. Individual-level interventions highlight the importance of partner selection, consistent condom use, avoiding needle sharing, and reducing risky sexual behaviors. Overcoming barriers to medication adherence, such as stigma and discrimination, is crucial for effective prevention and treatment. Community-level interventions are equally important in reducing stigma and discrimination and fostering healthcare-seeking behavior. The paper emphasizes a multi-faceted approach, involving healthcare systems, individuals, and communities, to accomplish the objective of an HIV-free generation by stopping HIV from spreading through the vertical route. Collaboration across these levels is essential to realizing this vision and ensuring optimal health outcomes for HIV-infected individuals, their children, and families.

Using PBPK modeling to supplement clinical data and support the safe and effective use of dolutegravir in pregnant and lactating women

Optimal dosing in pregnant and lactating women requires an understanding of the pharmacokinetics in the mother, fetus, and breastfed infant. Physiologically-based pharmacokinetic (PBPK) modeling can be used to simulate untested scenarios and hence supplement clinical data to support dosing decisions. A PBPK model for the antiretroviral dolutegravir (mainly metabolized by UGT1A1) was verified using reported exposures in non-pregnant healthy volunteers, pregnant women, and the umbilical cord, lactating mothers, and breastfed neonates. The model was then applied to predict the impact of UGT1A1 phenotypes in extensive (EM), poor (PM), and ultra-rapid metabolizers (UM). The predicted dolutegravir maternal plasma and umbilical cord AUC in UGT1A1 PMs was 1.6-fold higher than in EMs. The predicted dolutegravir maternal plasma and umbilical cord AUC in UGT1A1 UMs mothers was 1.3-fold lower than in EMs. The predicted mean systemic and umbilical vein concentrations were in excess of the dolutegravir IC90 at 17, 28, and 40 gestational weeks, regardless of UGT1A1 phenotype, indicating that the standard dose of dolutegravir (50 mg q.d., fed state) is generally appropriate in late pregnancy, across UGT1A1 phenotypes. Applying the model in breastfed infants, a 1.5-, 1.7-, and 2.2-fold higher exposure in 2-day-old neonates, 10-day-old neonates, and infants who were UGT1A1 PMs, respectively, compared with EMs of the same age. However, it should be noted that the exposure in breastfed infants who were UGT1A1 PMs was still an order of magnitude lower than maternal exposure with a relative infant daily dose of <2%, suggesting safe use of dolutegravir in breastfeeding women.

Protecting maternal health: Strategies against HIV and malaria in pregnancy

Maternal health remains a global priority, with particular emphasis on combating infectious diseases such as HIV and malaria during pregnancy. Despite significant progress in prevention and treatment efforts, both HIV and malaria continue to pose significant risks to maternal and fetal well-being, particularly in resource-limited settings. The prevention of mother-to-child transmission (PMTCT) programs for HIV and intermittent preventive treatment (IPTp) for malaria represent cornerstone strategies in mitigating the impact of these infections on pregnancy outcomes. PMTCT programs focus on early HIV diagnosis, antiretroviral therapy initiation, and promoting safe infant feeding practices to reduce the risk of mother-to-child transmission. Similarly, IPTp involves the administration of antimalarial medication to pregnant women in malaria-endemic regions to prevent maternal and fetal complications associated with malaria infection. Integration of HIV and malaria prevention and treatment services within existing maternal and child health programs is crucial for maximizing impact and minimizing healthcare system strain. Strengthening health systems, improving access to antenatal care services, and enhancing community engagement are essential components of comprehensive maternal health strategies. Furthermore, promoting awareness, education, and empowerment of pregnant women and communities are vital in fostering health-seeking behaviors and adherence to preventive measures against HIV and malaria. In conclusion, protecting maternal health from the dual threat of HIV and malaria requires a multifaceted approach that encompasses prevention, screening, treatment, and community engagement.

Advances in HIV Management During Pregnancy and Infant Feeding

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.

Interventions to prevent mother-to-child transmission in breastfeeding mothers with HIV: a systematic review and meta-analysis of randomized controlled trials

This study aimed to systematically review interventions to prevent mother-to-child transmission of HIV during breastfeeding. We conducted a systematic review and meta-analysis using specific criteria to identify randomized controlled trials that focused on pregnant and breastfeeding women living with HIV and their children from birth to 2 years of age. We extensively searched electronic databases, including Web of Science, Scopus, PubMed, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Google Scholar up to October 24, 2023. After screening 3,110 titles and abstracts, we reviewed 306 full texts. Of these, we assessed the quality and risk of bias of fifty-five articles, ultimately identifying seven studies. Four of these studies, which focused on antiretroviral therapy (ART), were included in the meta-analysis. There was little heterogeneity in study methodology and pooled estimates. The postnatal HIV transmission rate was found to be 0.01 (95%CI: 0.00 - 0.02). Therefore, the risk of mother-to-child transmission among breastfeeding mothers with HIV was significantly lower in the intervention groups than in the placebo groups. Analysis of funnel plots and Egger's test (p = 0.589) showed no evidence of publication bias. In addition to the four articles, two studies compared different ART regimens and one study compared the administration of high-dose vitamin A to the mother or the child. The results suggest that the use of ART significantly reduces the risk of postnatal HIV transmission compared with placebo. However, the effectiveness of different ART regimens or other therapies, including high-dose vitamin A, is unclear.

Womandla Health: development and rationale of a behavioral intervention to support HIV treatment adherence among postpartum women in South Africa

BACKGROUND

While Option B + has made great strides in eliminating vertical transmission of HIV and improving access to lifelong antiretroviral therapy (ART) for women, the postpartum period remains a risk period for disengagement from HIV care and non-adherence.

METHODS

Longitudinal qualitative data was collected from 30 women living with HIV in Cape Town, South Africa from pregnancy through 1 year postpartum to examine key barriers and facilitators to HIV treatment adherence across this transition. Participants were also asked about their preferences for behavioral intervention content, format, and scope. The intervention development process was guided by Fernandez et al.'s Intervention Mapping process and was informed by the qualitative data, the wider literature on ART adherence, and Transition Theory.

RESULTS

The Womandla Health Intervention is a multicomponent intervention consisting of four individual sessions with a lay health worker and four peer group sessions, which span late pregnancy and early postpartum. These sessions are guided by Transition Theory and utilize motivational interviewing techniques to empower women to ascertain their own individual barriers to HIV care and identify solutions and strategies to overcome these barriers.

CONCLUSIONS

This intervention will be tested in a small scale RCT. If successful, findings will provide an innovative approach to HIV treatment by capitalizing on the transition into motherhood to bolster self-care behaviors, focusing on ART adherence and also women's overall postpartum health and psychosocial needs.

Factors associated with retention of mother-baby pairs in the elimination of mother-to-child transmission of HIV program in Kaberamaido district: A longitudinal analysis

BACKGROUND

Retention along the elimination of Mother to Child Transmission (eMTCT) cascade in Uganda remains poor as only 62.7%-69.5% are followed up to 18months. The objective of this study was to determine the rates of retention of mother-baby pairs at two levels of the eMTCT cascade (12 and 18 months) and associated factors.

METHODS

This was a longitudinal analysis of 368 mother-baby pairs who were enrolled into the eMTCT program in Kaberamaido district from January 2013 to December 2018. Data was extracted from early infant diagnosis (EID) and mothers' ART registers, entered into Microsoft Excel and then exported to Stata statistical software package version 14.0 for management and analysis. Descriptive statistics such as mean and frequencies were computed at univariate level. At the bivariate level, Cox proportional hazard regression was performed to assess the level of association between the primary outcome and each independent variable, while Cox proportional hazard regression model was built at multivariate level to determine the factors independently associated with retention of mother-baby pairs in the eMTCT program.

RESULTS

Of the 368 mothers enrolled into the study, their average age was 29.7years (SD = 6.6). Nearly two-thirds of the mothers were married/cohabiting, (n = 232, 63.0%). The 368 mother baby pairs were observed for a total time of 6340 person months, with majority, 349 (94.8%, 95%CI = 92.0-96.7) still active in eMTCT care, while 19(5.2%, 95%CI = 3.3-8.0) were lost to follow up at 12months. At 18 months, 323 (87.8%, 95%CI = 84.0-90.8) were active in eMTCT program while 45(12.2%, 95 CI = 9.2-16.0) were lost to follow up. At bivariate level, marital status, health facility level of enrolment, mothers' ART treatment supporter, and mothers' ART enrolment time were significantly associated with survival/lost to follow up (LTFU) of mother-baby pairs along the eMTCT cascade. At multivariable level, the mothers' time of ART initiation was significantly associated with survival/lost to follow up (LTFU) of mother-baby pairs at along the eMTCT cascade, with mothers-baby pairs who were initiated during the antenatal/post-natal periods having higher hazards of LTFU compared to those who initiated ART before Antenatal period (before pregnancy), aHR = 4.37(95%CI, 1.62-11.76, P = 0.003). Mother-baby pairs who were enrolled into the eMTCT program after the implementation of HIV test and treat policy (year 2017 and 2018) had higher hazards of LTFU as compared to those enrolled before the implementation of test and treat policy in Uganda (year 2013-2016), aHR = 2.22(95% CI, 1.15-4.30, P = 0.017). All the other factors had no significant association with lost to follow up and cascade completion at multivariate level.

CONCLUSION

There was high level of retention of mother-baby pairs in the eMTCT program in Kaberamaido at 12 months, but it was suboptimal at 18months. ART initiation during the antenatal and/or post-natal period was significantly associated with suboptimal retention of mother-baby pairs along the eMTCT cascade.

Breast Milk: A Potential Route of Tick-Borne Encephalitis Virus Transmission from Mother to Infant

Tick-borne encephalitis virus (TBEV) is a global public health concern, and understanding its transmission routes is crucial for effective prevention and control. While tick bites are the primary mode of TBEV transmission, emerging evidence suggests the potential for TBEV transmission through breast milk from infected mothers to their infants. This review article provides an overview of the current knowledge regarding TBEV transmission through breast milk and its clinical implications. It explores the presence and persistence of TBEV in breast milk, potential mechanisms of transmission, and the role of immune factors in facilitating or inhibiting viral transmission. The clinical outcomes and complications in infants infected with TBEV through breast milk are discussed, along with the epidemiological patterns and geographical considerations of this transmission mode. Preventive and management strategies are also addressed, including public health measures, risk assessment, and potential interventions. Future research directions are highlighted, emphasizing the need for further epidemiological studies, investigations into viral load dynamics, immune responses, and the development of preventive measures targeting TBEV transmission through breast milk. By expanding our knowledge in these areas, we can improve strategies to reduce the risk of TBEV transmission from mothers to infants and protect vulnerable populations.

Knowledge Gaps and Current Evidence Regarding Breastfeeding Issues in Mothers with Chronic Diseases

The prevalence of chronic maternal disease is rising in the last decades in the developed world. Recent evidence indicated that the incidence of chronic maternal disease ranges from 10 to 30% of pregnancies worldwide. Several epidemiological studies in mothers with chronic diseases have mainly focused on the risk for adverse obstetric outcomes. Evidence from these studies supports a correlation between maternal chronic conditions and adverse perinatal outcomes, including increased risk for preeclampsia, cesarean section, preterm birth, and admission in the Neonatal Intensive Care Unit (NICU). However, there is a knowledge gap pertaining to the management of these women during lactation. This review aimed at summarizing the available research literature regarding breastfeeding in mothers with chronic diseases. Adjusted and evidence-based support may be required to promote breastfeeding in women with chronic diseases; however, our comprehension of breastfeeding in this subpopulation is still unclear. The literature related to breastfeeding extends in various scientific areas and multidisciplinary effort is necessary to compile an overview of current evidence and knowledge regarding breastfeeding issues in mothers with chronic diseases.

Eliminating mother-to-child transmission of HIV in Tanzania calls for efforts to address factors associated with a low confirmatory test

Option B+ approach for prevention of mother-to-child transmission (PMTCT) has demonstrated the potential to eliminate pediatric HIV infections. Its success depends on early infant diagnosis (EID) of HIV among the exposed infants within the first 6 weeks, and a subsequent confirmatory HIV test within 18 months. However, most mothers enrolling in option B+ in Tanzania do not come for such confirmatory tests. We examined factors associated with the turning-up of mother-baby pairs on the PMTCT program for a confirmatory HIV testing 18 months post-delivery in Tanzania. This study utilized longitudinal data collected between 2015 and 2017, from 751 mother-baby pairs enrolled in the PMTCT-option B+ approach in 79 health facilities from the 12 regions of Tanzania-mainland. Only 44.2% of 751 mother-baby records observed received the HIV confirmatory test by the 18th month. Mothers aged 25 years or above (adults' mothers) were 1.44 more likely to turn up for confirmatory HIV testing than young mothers; mothers with partners tested for HIV were 1.74 more likely to have confirmatory HIV testing compared with partners not tested for HIV. Newly diagnosed HIV-positive mothers were 28% less likely to bring their babies for a confirmatory HIV-testing compared to known HIV-positive mothers. Mothers with treatment supporters were 1.58 more likely to receive confirmatory HIV-testing compared to mothers without one. Mother-baby pairs who collected DBS-PCR-1 were 3.61 more likely to have confirmatory HIV-testing than those who didn't collect DBS-PCR-1. In conclusion, the confirmatory HIV testing within 18 months among mother-baby pairs enrolled in the Option B+ approach is still low in Tanzania. This is associated with low maternal age, having a male partner not tested for HIV, lack of experience with HIV services, lack of treatment supporters, and failure to take the DBS-PCR-1 HIV test within the first two months post-delivery.