Retrospective review of maternal HIV viral load electronic gatekeeping codes in South Africa.

Background: Maternal electronic gatekeeping (eGK) codes for HIV viral load (VL) testing of pregnant and breastfeeding women were developed to permit increased frequency of maternal HIV VL testing without automated gatekeeping cancellation, and to enable virological surveillance. Objectives: This study describes the national uptake of maternal eGK codes and VL suppression (VLS) rates disaggregated by age during antenatal, delivery and postnatal periods in South Africa during 2022. Method: HIV VL tests associated with C#PMTCT (used for antenatal and postnatal testing) and C#DELIVERY (used at delivery) eGK codes between 01 January and 31 December 2022, were extracted from the National Institute for Communicable Diseases Data Warehouse. Uptake of eGK codes was calculated using indicators from the District Health Information System as denominators while HIV VLS rates (< 1000 copies/mL) were calculated as monthly and annual percentages. Results: Overall, national maternal eGK code uptake was 41.8%, 24.5% and 0.12% for the antenatal, delivery and postnatal periods, respectively. The monthly antenatal eGK uptake increased from 27.5% to 58.5% while delivery uptake increased from 17.3% to 30.0%. The overall annual maternal HIV VLS rate was 86.7% antenatally and 87.2% during delivery. The monthly average HIV VLS for adolescent girls and young women (AGYW) was 76.1% antenatally and 79.6% during delivery. Conclusion: Although overall national uptake of maternal HIV VL eGK codes was low, antenatal and delivery uptake improved over time, thereby facilitating use of eGK codes for programmatic monitoring of maternal VLS rates for the first time. Quality of care among pregnant AGYW requires urgent attention.

Effects of the COVID-19 pandemic on early infant diagnosis of HIV in Cape Town, South Africa.

Background: In South Africa, infants who are HIV-exposed are tested for HIV at birth and 10 weeks of age. The COVID-19 pandemic lockdown restrictions resulted in reduced access to healthcare services and uncertain impact on early infant HIV testing. Objectives: To describe the effects of the COVID-19 pandemic lockdown restrictions on early infant HIV testing and diagnosis in Cape Town, South Africa. Method: This retrospective cohort study compares HIV-exposed infants born during the first COVID-19 pandemic lockdown (2020) to those born in the same period the year before (2019). Laboratory and other data were abstracted from the Provincial Health Data Centre. Results: A total of 2888 infants were included: 1474 born in 2020 and 1413 in 2019. Compared to 2019, there was an increase in the 10-week HIV polymerase chain reaction (PCR) uptake in 2020 (71% vs. 60%, P < 0.001). There was also an increase in the proportion of infants who demised without 10-week testing or were lost to follow-up in 2020 compared to 2019 (8% vs. 5%, P = 0.017). Differences detected in birth HIV PCR positivity rates between the two groups (1.1% vs. 0.5%, P = 0.17) did not reach statistical significance; however, a significant increase in vertical transmission of HIV by 10 weeks old was found in the 2020 cohort (1.2% vs. 0.5%. P = 0.046). Conclusion: Vertical transmission of HIV at 10 weeks increased in the Cape Town Metropolitan during the initial COVID-19 lockdown. There was also an increase in the proportion of deaths without testing by 10 weeks in the 2020 group.

Intensification of antiretroviral treatment with raltegravir for pregnant women living with HIV at high risk of vertical transmission.

Objectives: The rate of vertical HIV transmission for women at high risk of HIV transmission stands at approximately 7.6%. In the present study we describe infant infection rates in women who had received raltegravir (RAL) intensification during pregnancy to a standard three-drug antiretroviral (ART) regimen in Thailand. Methods: This prospective cohort study enrolled HIV-1-positive pregnant women at high risk of vertical transmission, as defined by (1) ART initiation at a gestational age (GA) ≥32 weeks or (2) HIV-1 RNA >1000 copies/mL at GA of 32-38 weeks while on ART. Women received a standard three-drug ART regimen with RAL intensification (400 mg twice daily) until delivery and continued on a three-drug ART regimen after delivery. Plasma HIV-1 RNA testing was performed before intensification and at delivery. Infant HIV-1 status was determined using DNA PCR at birth, and at 1, 2 and 4 months of life. Results: Between February 2016 and November 2017, 154 pregnant women on ART were enrolled into the study with a median CD4 cell count and plasma HIV-1 RNA level of 382 cells/mm3 and 4.0 log10 copies/mL, respectively. The three-drug combination consisted of either a lopinavir/ritonavir- (53%) or efavirenz-based (43%) regimen. Median GA at time of RAL initiation was 34 weeks (interquartile range [IQR] 33-36) and median duration was 21 days (IQR 8-34). The proportion of women who had a plasma HIV-1 RNA <50 and <1000 copies/mL at delivery was 45% and 76%, respectively. There were six infants with HIV infection, three in utero and three peripartum. Overall vertical transmission rate was 3.9% (95% confidence interval [CI] 1.4-8.2). Conclusion: The majority of high-risk pregnant women living with HIV-1 who had received RAL intensification achieved viral suppression at delivery with a relatively low rate of vertical transmission. This intensification strategy represents an option for prevention in HIV-positive women at high risk of vertical transmission.

Caracterización de madres de pacientes con exposición perinatal al Virus de Inmunodeficiencia Humana

La mayor incidencia de la infección por el virus de inmunodeficiencia humana (VIH) en mujeres ha tenido un impacto directo en la transmisión vertical, situación que puede ser evitada con un adecuado control prenatal. Objetivo: Determinar características demográficas, epidemiológicas y obstétricas de madres de pacientes con exposición perinatal al VIH. Métodos: Se realizó un estudio retrospectivo, observacional, transversal y analítico. Se incluyeron madres con infección por VIH de transmisión horizontal, cuyos hijos con exposición perinatal, nacidos entre 2001 y 2020, fueron atendidos en la Unidad VIH del Hospital de Niños "J.M. de los Ríos" (Caracas-Venezuela). La información fue obtenida de la Base de Datos Interna. Las madres fueron agrupadas según la década de nacimiento del hijo (2001-2010 o 2011-2020). El análisis estadístico incluyó la prueba de Chi cuadrado. Resultados: Se estudiaron 805 madres. La edad promedio al nacer fue 26,4 años; el 8,6 % (n=69/803) era adolescente. El control prenatal fue inadecuado o inexistente en 59,7 % (n=463/776). La identificación de la infección materna fue obtenida durante o después del nacimiento en 36,4 % (n=280/769), con diferencias entre décadas: 26,7 % en la primera y 42,5 % en la segunda (p<0,01). En el 90,4 % (n=253/280) de este grupo el diagnóstico se obtuvo posterior al nacimiento. Conclusiones: La edad promedio de las madres fue 26,4 años. Aproximadamente 50 % tuvo control prenatal inadecuado o inexistente. Alrededor de un tercio obtuvo el diagnóstico después del embarazo, con significativo mayor porcentaje en la segunda década. Sólo en 1/10 madres de este grupo, la infección fue identificada al nacimiento.

The higher incidence of human immunodeficiency virus (HIV) infection in women has had a direct impact on vertical transmission, situation that can be avoided with an adequate prenatal control. Objective: To determine demographic, epidemiological, and obstetric characteristics of mothers of children with perinatal exposure to HIV. Methods: A retrospective, observational, cross-sectional and analytical study was carried out. It was included mothers, with horizontally transmitted HIV infection, whose children with perinatal exposure, born between 2001 and 2020, were treated at the HIV Unit of the Children's Hospital "J.M. de los Ríos" (Caracas-Venezuela). The information was obtained from the Unit Internal Database. The mothers were grouped according to the decade of her child's birth (2001-2010 or 2011-2020). Chi square test was performed for statistical analysis. Results: A total of 805 mothers were studied. The average age at birth was 26.4 years; 8.6 % (n=69/803) were adolescents. Prenatal care was inadequate or non-existent in 59.7 % (n=463/776). Identification of maternal infection was obtained during or after birth in 36.4 % (n=280/769), with differences between decades: 26.7 % in the first and 42.5 % in the second (p<0.01). In 90.4 % (n=253/280) of this group, the diagnosis was obtained after birth. Conclusions: The average age of the mothers was 26.4 years. Approximately 50 % had inadequate or nonexistent prenatal care. About a third were diagnosed after pregnancy, with a significantly higher percentage in the second decade. In only 1/10 mothers of this group the infection was identified at birth.

Efficacy of Post-Exposure Prophylaxis in Infants Born to HBsAg Positive Mothers in Iran; Is It Authentic?

BACKGROUND: Hepatitis B infection is a universal concern. This infection can lead to chronic liver disease and hepatocellular carcinoma. Neonates born to HBsAg-positive mothers are at high risk of chronic hepatitis B virus (HBV) infection, especially for HBeAg-positive mothers or neonates who have not received hepatitis B immunoglobulin (HBIg) and HBV vaccines. OBJECTIVES: The aim of this study was to evaluate the efficacy of post-exposure prophylaxis in these infants to prevent infection. PATIENTS AND METHODS: Thirty-eight infants born to HBsAg-positive mothers between September 2006 and September 2013 were followed. The investigation evaluated whether the standard prevention protocol of neonatal HBV transmission including HBIg at birth and receiving three doses of vaccine at birth and 2 and 6 months of age was performed, followed by post-vaccination tests (evaluation of HBsAg and HBsAb titer at 9 to 18 months of age) to determine subsequent infection. HBsAb titer ≥ 10 was considered as criterion for effectiveness of the prophylaxis procedure. The acquired data were analyzed using SPSS software (Version 18). The results are reported in descriptive tabulations. RESULTS: Ninety seven percent (97%) of infants received HBIg at birth in the hospital. Generally, all of them received the first, second and third doses of vaccine at birth, 2 months, and 6 months after birth, respectively. Information for 35 mothers infected with HBV and 38 infants was available. The mean age of the mothers was 30.3 years. The results indicated that 20% of mothers were HBeAg positive. HBsAg was positive in one (2.6%) infant born to an HBeAg-positive mother. Around 94% of infants' HBsAb titers were ≥ 10, and 5.8% were reported as non-responders. CONCLUSIONS: The vertical transmission prevention program used in the study population in Tehran, which had an appropriate sample size, is effective. Additional doses of the vaccine can be useful in raising the effectiveness of immunoprophylaxis for infants at high risk of HBV infection. Also, emphasis must be set on post-vaccination testing.

Prevention of mother-to-child transmission of HIV-1 in Africa.

PIP: With the prevalence of HIV among pregnant women higher than 35% in some parts of sub-Saharan Africa, the number of HIV-infected children will continue to grow. It is estimated that almost 70% of the approximately 500,000 children who became infected with HIV in 1995 were born in sub-Saharan Africa. An effective intervention to prevent the vertical transmission of HIV is therefore most urgently needed in Africa. Following the release of the results of the AIDS Clinical Trials Group (ACTG) 076 study, the routine use of zidovudine (AZT) among HIV-infected pregnant women in the US and Europe has resulted in a significant reduction in the rate of mother-to-child vertical HIV transmission. However, most women in Africa will not benefit from these advances in the immediate future due to inadequate prenatal health care, the unavailability of prenatal HIV testing, and the high cost and complexity of the recommended regimen. Researchers need to build upon the findings of developed countries to identify feasible, effective, and implementable interventions to reduce the vertical transmission of HIV as well as to prevent HIV infection among women and to protect the health of HIV-infected women in Africa. Rates and timing of vertical HIV transmission, risk factors associated with vertical HIV transmission, and prevention interventions are discussed.^ieng

Conclusions of a round-table that took place during a seminar on the prevention of TB and HIV transmission in health care settings, Douala, Cameroon, January 1995.

PIP: Gynecologists and obstetricians in Africa are at high risk of being exposed to tuberculosis (TB) and HIV during child delivery. To protect themselves against infection, they must wear cuffs which cover gown sleeves and refuse to work with fingerstalls which do not cover the hand. There must be one pair of gloves per woman giving birth and the wearing of glasses and a mask is advised. To reduce the risk of disease transmission from mother to fetus, the uterus should not be punctured in case HIV is present in the amniotic fluid. The lower birth canal should be disinfected using betadinel before delivery. Care must be taken in using electrodes for monitoring, clearing the mouth and nasal passages. Forceps should be used only when clearly indicated and absolutely needed. Furthermore, the highly contaminated placenta should be handled carefully, while traditional midwives must be properly trained and followed up. Retain the BCG vaccination of all children before they leave the maternity hospital or as soon as possible and condom use should be promoted against TB and HIV transmission.^ieng

Short course antiretroviral regimens to reduce maternal transmission of HIV.

PIP: The ACTG076 trial showed that a complex and expensive antiretroviral regimen reduced mother-to-child HIV transmission by 67%. A more recent Bangkok perinatal HIV study found that oral zidovudine (AZT) given during late pregnancy and labor to non-breast-feeding women reduced the rate of vertical HIV transmission by 51%. These latter findings are particularly interesting to countries unable to afford the more expensive and complex 076 regimen. The reaction to the results of the Bangkok trial may, however, threaten the health of Africa's poorest women and children. Within days of the release of the Thai data, investigators studying other regimens closed recruitment to the placebo arms of their trials, and it has recently become clear that the National Institutes for Health will probably fund no more placebo-controlled trials of interventions designed to reduce maternal HIV transmission. The use of antiretroviral drugs in Africa is unlikely to ever significantly reduce maternal HIV transmission and the incidence of pediatric AIDS. While most of Africa's women have no option to breast-feed, breast-feeding is responsible for one-third of maternal HIV transmission cases. The results of the Thai trials only partially address the needs of African women, for the nutritional, immunological, and birth spacing benefits of breast-feeding should be retained if possible, and formula feeding may stigmatize HIV-infected mothers. The short-course regimen is still expensive to developing countries, and the implementation of a costly, vertical program may also draw financial and human resources from other programs. Placebo-controlled trials to develop simple, cheap, and effective potentially non-drug interventions against vertical HIV transmission should be encouraged in settings in which antiretroviral drugs and formula feeding cannot be safely delivered.^ieng

South African minister accused of human rights abuse.

PIP: South African Health Minister Dr. Manto Tshabalala-Msimang was accused of human rights abuse for refusing to supply zidovudine to all HIV-positive pregnant women. The accusations were laid by Dr. Costa Gazi, a South African doctor employed in the state health system with the Human Rights Commission. Dr. Gazi believes that supplying such a drug to pregnant women would be more cost-effective than facing the economic and humanitarian consequences of refusing to supply the drug. Meanwhile, the health minister's refusal was based on his doubt about the safety and efficacy of zidovudine. She said that findings of several trials of the drug used in the prevention of maternal transmission of HIV do not adequately show that zidovudine would be useful for South African pregnant women. Moreover, the toxic effects of the drug, particularly on their children, have not yet been sufficiently examined.^ieng

Prevention of HIV transmission from mother-to-child.

PIP: A technical consultancy meeting was held in Geneva from March 23-24, 1998 to discuss the prevention of vertical transmission of HIV. This paper highlights some of the discussion and recommendations from the meeting. The discussion includes the importance of implementing a national strategy to prevent mother-to-child transmission of HIV; the parameters to implement effectively interventions necessary to reduce vertical transmission of HIV; the key principles to underpin the implementation of all interventions to prevent mother-to-child transmission; unresolved issues such as the efficacy of zidovudine in preventing HIV vertical transmission; and coordinating mechanisms to support efforts for accelerated capacity-strengthening and technical development, and to scale up the implementation of interventions to reduce mother-to-child transmission. It is noted that for effective reduction of HIV vertical transmission, interventions should depend on political will, affordability of the interventions, and the strength of existing human resources and infrastructures.^ieng