Rates of Seroprotection against Vaccine-Preventable Infectious Diseases in HIV-Exposed and -Unexposed Malawian Infants.

BACKGROUND: The evaluation of seroprotection rates against vaccine-preventable infectious diseases allows for the identification of risk populations. HIV-exposed infants, even if not infected with HIV, have higher morbidity and mortality in comparison to unexposed counterparts. The aim of this study was to compare the specific IgG levels against Haemophilus influenzae type-B (HiB), Hepatitis-B (HBV), and Streptococcus pneumoniae (Spn) in two groups of infants (HIV-exposed and HIV-unexposed) living in Malawi. METHODS: Blood samples from 62 infants, 49 HIV-exposed, uninfected (HEU), and born to women living with HIV and 13 HIV-unexposed and uninfected (HUU), were collected at 6 months, and specific IgG levels were determined using ELISA tests. RESULTS: The antibody levels against HiB, HBV, and Spn were similar in the two groups. At six months, all HUU infants and 81.6% of HEU infants showed seroprotective levels against HiB, while a percentage of protection varying from 80.6 to 84.6% was observed for HBV and Spn regardless of HIV exposure. Only 59.2% of HEU and 69.2% of HUU infants showed antibody protection against all three pathogens. CONCLUSIONS: These results indicate similar rates of seroprotection among HEU and HUU infants but also suggest that a consistent fraction of infants received incomplete vaccinations. Strategies to enforce participation in immunization programs in Malawi should be a health priority.

Predictive validity of the Short Functional Geriatric Evaluation for mortality, hospitalization and institutionalization in older adults: A retrospective cohort survey.

Objectives: Bio-psycho-social frailty is related to increased risk of death and utilization of health services. This paper reports the predictive validity of a 10-min multidimensional questionnaire on the risk of death, hospitalization and institutionalization. Methods: A retrospective cohort study was performed based on data from the "Long Live the Elderly!" program, involving 8,561 community-dwelling Italian people >75, followed for an average of 516.6 days (Median = 448, P 25-P 75: 309-692). Mortality, hospitalization, and institutionalization rates according to frailty levels assessed by the Short Functional Geriatric Evaluation (SFGE) have been calculated. Results: Compared with the robust, the pre-frail, frail, and very frail faced a statistically significant increase in the risk of mortality (RR = 1.40, 2.78 and 5.41), hospitalization (OR = 1.31, 1.67, and 2.08) and institutionalization (OR = 3.63, 9.52, and 10.62). Similar results were obtained in the sub-sample of those with only socio-economic issues. Frailty predicted mortality with an area under the ROC curve of 0.70 (95% CI 0.68-0.72) with sensitivity and specificity of 83.2% and 40.4%. Analyses of single determinants of these negative outcomes showed a multivariable pattern of determinants for all the events. Conclusions: The SFGE predicts death, hospitalization and institutionalization by stratifying older people according to the levels of frailty. The short administration time, the socio-economic variables and the characteristics of personnel administering the questionnaire make it suitable for being used in public health as a screening tool for a large population, to put frailty at the core of the care for community-dwelling older adults. The difficulty in capturing the complexity of the frailty is witnessed by the moderate sensitivity and specificity of the questionnaire.

Exploratory Factor Analysis (EFA) of the Short Functional Geriatric Evaluation (SFGE) to Assess the Multidimensionality of Frailty in Community-Dwelling Older Adults.

The Short Functional Geriatric Evaluation (SFGE) is a multidimensional and short questionnaire to assess biopsychosocial frailty in older adults. This paper aims to clarify the latent factors of SFGE. Data were collected from January 2016 to December 2020 from 8800 community-dwelling older adults participating in the "Long Live the Elderly!" program. Social operators administered the questionnaire through phone calls. Exploratory factor analysis (EFA) was carried out to identify the quality of the structure of the SFGE. Principal component analysis was also performed. According to the SFGE score, 37.7% of our sample comprised robust, 24.0% prefrail, 29.3% frail, and 9.0% very frail individuals. Using the EFA, we identified three main factors: psychophysical frailty, the need for social and economic support, and the lack of social relationships. The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.792, and Bartlett's test of sphericity had a statistically significant result (p-value < 0.001). The three constructs that emerged explain the multidimensionality of biopsychosocial frailty. The SFGE score, 40% of which is social questions, underlines the crucial relevance of the social domain in determining the risk of adverse health outcomes in community-dwelling older adults.

A 12-month Prospective Study of HIV-infected and HIV-uninfected Women and Their Infants in Malawi: Comparative Analysis of Clinical Events and Infant Growth.

Few studies have compared clinical outcomes in HIV-exposed uninfected (HEU) and HIV-unexposed uninfected (HUU) infants in the current scenario of universal and lifelong maternal antiretroviral therapy (ART). HIV-uninfected and HIV-infected Malawian women receiving ART and their breastfed infants were followed for 12 months postpartum, analyzing the rates of infectious and noninfectious events and assessing infant growth at 6 weeks, 6 months, and 12 months. The cohorts included 227 mothers (70 HIV-negative, 157 HIV-positive) and 235 infants (72 HUU, 163 HEU). No maternal or infant deaths occurred during follow-up. HIV-negative women were less likely to complete follow-up (48.6% versus 91.1%). Mothers with and without HIV had similar rates of both infectious and noninfectious events per person-month. Infants who were HEU, compared with HUU, had higher rates of events of any type, lower respiratory tract infections (LRTI), and noninfectious events. HEU had lower body mass index (BMI) at 6 weeks but did not differ from HUU in all anthropometric measures at 6 and 12 months; in growth between 6 weeks and 12 months; and in occurrence of stunting, underweight, and wasting at 6 weeks, 6 months, and 12 months. During the first year of life, infants who were HEU, compared with HUU, showed a transiently lower BMI and an increased risk of LRTI.

Dynamics of SARS-CoV-2 exposure in Malawian infants between February 2020 and May 2021.

Background: Very limited information is available on SARS-CoV-2 seroprevalence in infants in sub-Saharan countries. Objective: In this study, we aimed to determine the rate and the temporal evolution of SARS CoV-2 seropositivity in breastfed Malawian infants. Study design: Blood samples (n = 250) from 158 infants, born to HIV-negative women and women living with HIV, collected from February 2020 to May 2021, were first tested using an Anti-IgG/A/M SARS CoV 2 ELISA assay against trimeric spike protein, and then, if positive, confirmed using a second ELISA assay detecting IgG against Receptor Binding Domain. Results: The confirmed prevalence of anti-SARS CoV-2 antibodies was 31.0% (95% CI: 23.7%-38.3%) with no significant difference between HIV-exposed and HIV-unexposed infants (29.3% and 37.1% respectively, P = 0.410). The presence of anti-SARS-CoV-2 IgG was not associated with maternal socioeconomic or demographic indices. Conclusions: Our data underline the wide spread of the SARS-CoV-2 infection in the pediatric population in sub-Saharan Africa. Design of more specific serological tests for African samples and improvements in serosurveillance programs are needed for more rigorous monitoring of the dynamics of SARS-CoV-2 infection in Africa.

Admission to the Long-Term Care Facilities and Institutionalization Rate in Community-Dwelling Frail Adults: An Observational Longitudinal Cohort Study.

The worldwide aging and the increase of chronic disease impacted the Health System by generating an increased risk of admission to Long-Term Care (LTC) facilities for older adults. The study aimed to evaluate the admission rate to LTC facilities for community-dwelling older adults and investigate factors associated with these admissions. A secondary data analysis stemming from an observational longitudinal cohort study (from 2014 to 2017) was performed. The sample was made up by 1246 older adults (664 females and 582 males, mean age 76.3, SD ± 7.1). The LTC facilities access rate was 12.5 per 1000 observations/ year. Multivariable Linear Regression identified frailty, cardiovascular disease, and incapacity to take medicine and manage money as predictors of the LTC facilities' access rate. The Multiple Correspondence Analysis identified three clusters: those living at home with comorbidities; those living in LTC facilities who are pre-frail or frail; those very frail but not linked to residential LTC. The results indicate that access to LTC facilities is not determined by severe disability, severe comorbidity, and higher frailty levels. Instead, it is related to moderate disability associated with a lack of social support. Therefore, the care policies need to enhance social interventions to integrate medical, nursing, and rehabilitative care.

Pro-active monitoring and social interventions at community level mitigate the impact of coronavirus (COVID-19) epidemic on older adults' mortality in Italy: A retrospective cohort analysis.

BACKGROUND: The COVID-19 epidemic in Italy has severely affected people aged more than 80, especially socially isolated. Aim of this paper is to assess whether a social and health program reduced mortality associated to the epidemic. METHODS: An observational retrospective cohort analysis of deaths recorded among >80 years in three Italian cities has been carried out to compare death rate of the general population and "Long Live the Elderly!" (LLE) program. Parametric and non-parametric tests have been performed to assess differences of means between the two populations. A multivariable analysis to assess the impact of covariates on weekly mortality has been carried out by setting up a linear mixed model. RESULTS: The total number of services delivered to the LLE population (including phone calls and home visits) was 34,528, 1 every 20 day per person on average, one every 15 days during March and April. From January to April 2019, the same population received one service every 41 days on average, without differences between January-February and March-April. The January-April 2020 cumulative crude death rate was 34.8‰ (9,718 deaths out of 279,249 individuals; CI95%: 34.1-35.5) and 28.9‰ (166 deaths out of 5,727 individuals; CI95%:24.7-33.7) for the general population and the LLE sample respectively. The general population weekly death rate increased after the 11th calendar week that was not the case among the LLE program participants (p<0.001). The Standardized Mortality Ratio was 0.83; (CI95%: 0.71-0.97). Mortality adjusted for age, gender, COVID-19 weekly incidence and prevalence of people living in nursing homes was lower in the LLE program than in the general population (p<0.001). CONCLUSIONS: LLE program is likely to limit mortality associated with COVID-19. Further studies are needed to establish whether it is due to the impact of social care that allows a better clients' adherence to the recommendations of physical distancing or to an improved surveillance of older adults that prevents negative outcomes associated with COVID-19.

Predictors of Emergency Room Access and Not Urgent Emergency Room Access by the Frail Older Adults.

Background: Emergency rooms (ERs) overcrowded by older adults have been the focus of public health policies during the recent COVID-19 outbreak too. This phenomenon needed a change in the nursing care of older frail people. Health policies have tried to mitigate the frequent use of ER by implementing community care to meet the care demands of older adults. The present study aimed to investigate the predictors of emergency room access (ERA) and not-urgent emergency room access (NUERA) of community-dwelling frail older adults in order to provide an indication for out-of-hospital care services. Method: Secondary analysis of an observational longitudinal cohort study was carried out. The cohort consisted of 1,246 community-dwelling frail older adults (over 65 years) in the Latium region in Italy. The ER admission rate was assessed over 3 years from the administration of the functional geriatric evaluation (FGE) questionnaire. The ordinal regression model was used to identify the predictors of ERA and NUERA. Moreover, the ERA and NUERA rate per 100 observations/year was analyzed. Results: The mean age was 73.6 (SD ± 7.1) years, and 53.4% were women. NUERAs were the 39.2% of the ERAs; robust and pre-frail individuals (79.3% of the sample) generated more than two-third of ERAs (68.17%), even if frails and very frails showed the higher ER rates per observation/year. The ordinal logistic regression model highlighted a predictive role on ERAs of comorbidity (OR = 1.13, p < 0.001) and frailty level (OR = 1.29; p < 0.001). Concerning NUERAs, social network (OR 0.54, P = 0.015) and a medium score of pulmo-cardio-vascular function (OR 1.50, P = 0.006) were the predictors. Conclusion: Comorbidity, lack of social support, and functional limitations increase both ERA and NUERA rates generated by the older adult population. Overall, bio-psycho-social frailty represents an indicator of the frequency of ERAs. However, to reduce the number of ERAs, intervention should focus mainly on the robust and pre-frail needs for prevention and care.

Hypercholesterolemia and related risk factors in a cohort of patients with diabetes and hypertension in Maputo, Mozambique.

INTRODUCTION: some studies reported that 25.5% of African population presents hypercholesterolemia; however, epidemiology of hypercholesterolemia in Africa is poorly described. Mozambique is experiencing a constant growth of non-communicable diseases, but scarce data are available about hypercholesterolemia. Our study aims at describing the prevalence of hypercholesterolemia in patients with diabetes and hypertension in Mozambique and investigate possible risk factors. METHODS: we conducted a cross-sectional study involving all the patients diagnosed with hypertension and/or diabetes from June 2018 to November 2020 in the Zimpeto DREAM Centre (Maputo, Mozambique). For each patient, anthropometric, clinical and laboratory data were collected. Hypercholesterolemia was defined as total blood cholesterol >200 mg/dL. Univariable and multivariable analysis were perfumed. RESULTS: a total of 885 patients were included, 76.2% (n=674) female. Hypertension alone was diagnosed in 670 (75.7%) patients, diabetes in 109 (12.3%) patients and 106 (11.9%) both diseases. Hypercholesterolemia was present in 410 (46.3%) patients and it was more prevalent in patients diagnosed with both diabetes and hypertension (52.8%), as compared to the patients diagnosed with hypertension (46.9%) or diabetes alone (36.7%). In the multivariable analysis, the only factors independently associated with hypercholesterolemia were female sex (aOR 1.77, 95% CI 1.26-2.48, p=0.001) and a body mass index >25kg/m2 (aOR 1.50, 95% CI 1.11-2.04, p=0.008). CONCLUSION: our results highlight the need for a specific focus on female and obese/overweight patients, especially if diagnosed with both hypertension and diabetes, to promptly detect metabolic disorders and establish temporary preventive measures for cardiovascular events.

Early assessment of weight velocity can support frontline health workers in predicting malnutrition in HIV-exposed infants: preliminary results from a DREAM cohort in Malawi.

BACKGROUND: Children born to HIV-positive mothers are particularly susceptible to malnutrition. Currently, monitoring programs rely on punctual anthropometric measurements to assess child growth. Growth velocities could be an additional tool in identifying critical time windows for prevention and implementation of early intervention for malnutrition. METHODS: A retrospective analysis was conducted using data from 817 HIV exposed but uninfected children extracted from DREAM program database. By using the WHO reference for growth standards, patterns of weight velocity for different intervals of assessment from one to 18 months of age were explored. Odds ratios and multinomial logistic regressions between selected weight velocity Z-scores thresholds and successive malnutrition indices (at 6, 12, 18 months of age) were calculated. RESULTS: Weight velocity was above the standard mean in the first 3 months, then progressively declined over time. In children with normal nutritional status, significant risks of becoming malnourished (mild malnutrition - underweight [OR 10.8; 95% CI: 4.5-26], chronic malnutrition - stunting [OR 8.3; 95% CI: 2-34.9] and acute malnutrition - wasting [OR 11.7; 95% CI: 1.5-90.5]) started when weight velocity Z-scores <0, at all interval ages. Multinomial regression showed that in the first 6 months, the weight velocity decrements strongly impacted on underweight (OR 17.9; 95% CI: 4-80.7), while the risk of Stunting occurred later at 18 months (OR 8.7; 95% CI: 4.3-17.6), with highest impact at the lowest thresholds. CONCLUSIONS: The assessment of weight velocity Z-scores, coupled with the already validated malnutrition indices, can support frontline health workers in early prediction of child malnutrition and performing nutritional counselling in the context of HIV/AIDS and food insecurity.

Cost of hospital care for the older adults according to their level of frailty. A cohort study in the Lazio region, Italy.

BACKGROUND: The increasing burden of chronic diseases associated with the ageing of the European population constitutes one of the main challenges for the welfare systems in developed western countries, especially through its impact on the use of hospital services and the cost of care. This study aims at evaluating the cost of hospital care for older adults living in the Lazio Region, Italy, according to their level of frailty. METHODS: Since 2014 a longitudinal randomized cohort study has been carried out on a sample consisting of 1280 older adults aged over 64 years resident in the Lazio region (Italy), with their being evaluated for multidimensional frailty. Accesses to Hospital Services (acute care and Day Hospital care admissions and Emergency Room accesses) during the first year after enrolment, as well as the related costs have been recorded through a regional database. Costs have been stratified on the basis of the state of frailty. RESULTS: The analysis of hospital services and costs highlights the role played by pre-frail individuals who generated 49.3% of the hospital care cumulative costs. Hospital Admission (HA) costs arising from robust and pre-frail subjects are 70% of the total HA costs. Pre-frail individuals also showed the highest average HA cost per person/year (7062.89 Euros). The main determinant of the highest HA costs was given by the number of HAs during the follow-up (multivariate linear regression, ß coefficient = 0.319; p<0.001), which was higher among pre-frail individuals than in any other group of patients. CONCLUSIONS: Pre-frail individuals generated the highest cost for hospital care in a sample of representative subjects living in an Italian Region with a low rate of community care services, as is the case in the Lazio region. Assessment of the multidimensional frailty of older adults permits a better definition of the important target of the pre-frail population as the main category within which interventions to prevent or mitigate frailty should be carried out.

Frailty as the Future Core Business of Public Health: Report of the Activities of the A3 Action Group of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA).

Background: The prevalence of frailty at population-level is expected to increase in Europe, changing the focus of Public Health. Here, we report on the activities of the A3 Action Group, focusing on managing frailty and supporting healthy ageing at community level. Methods: A three-phased search strategy was used to select papers published between January 2016 and May 2018. In the third phase, the first manuscript draft was sent to all A3-Action Group members who were invited to suggest additional contributions to be included in the narrative review process. Results: A total of 56 papers were included in this report. The A3 Action Group developed three multidimensional tools predicting short⁻medium term adverse outcomes. Multiple factors were highlighted by the group as useful for healthcare planning: malnutrition, polypharmacy, impairment of physical function and social isolation were targeted to mitigate frailty and its consequences. Studies focused on the management of frailty highlighted that tailored interventions can improve physical performance and reduce adverse outcomes. Conclusions: This review shows the importance of taking a multifaceted approach when addressing frailty at community level. From a Public Health perspective, it is vital to identify factors that contribute to successful health and social care interventions and to the health systems sustainability.

Social Interventions to Prevent Heat-Related Mortality in the Older Adult in Rome, Italy: A Quasi-Experimental Study.

This study focuses on the impact of a program aimed at reducing heat-related mortality among older adults residing in central Rome by counteracting social isolation. The mortality of citizens over the age of 75 living in three Urban Areas (UAs) located in central Rome is compared with that of the residents of four adjacent UAs during the summer of 2015. The data, broken down by UA, were provided by the Statistical Office of the Municipality of Rome, which gathers them on a routine basis. During the summer of 2015, 167 deaths were recorded in those UAs in which the Long Live the Elderly (LLE) program was active and 169 in those in which it was not, implying cumulative mortality rates of 25‰ (SD ± 1.4; Cl 95%: 23-29) and 29‰ (SD ± 6.7; Cl 95%: 17-43), respectively. Relative to the summer of 2014, the increase of deaths during the summer of 2015 was greater in UAs in which the LLE program had not been implemented (+97.3% vs. +48.8%). In conclusion, the paper shows the impact of a community-based active monitoring program, focused on strengthening individual relationship networks and the social capital of the community, on mortality in those over 75 during heat waves.

Frailty as a predictor of mortality and hospital services use in older adults: a cluster analysis in a cohort study.

Background: Lowering mortality and hospitalization of older adults is one of the main goals of public health to improve both health systems' sustainability and older adults' quality of life. The aim of this study is to identify the determinants associated with mortality and the use of hospital services in the population older than 64 years of age. Methods: A randomized sample from the population of the Lazio region (Italy) above the age of 64 was enrolled in 2014 by the administration of a questionnaire to assess frailty; the rates of use of hospital services and mortality in the year following the enrolment have been retrieved by the regional database. Univariable and multivariable analyses addressed the association of health status, social and economic variables with health outcomes. Results: One thousand two hundred and eighty persons were recruited; 52 deaths were reported at 1 year of follow-up (robust 1.8%, frail 10.1% and very frail 19.1%, P < 0.001). The mean rate of use of hospital services was 692.2 per 1000 observation/year (robust 589.5, frail 1191.1 and very frail 848.4, P < 0.001). In the multivariate analysis, the higher rate of use of hospital services was independently associated with functional status, social support, psychological/psychiatric discomfort, availability of home care services and physical health. Conclusions: Frailty, as a multidimensional issue, is also a strong predictor of survival in the short term. The use of the hospital services by older adults is associated mainly with functional status, social resources, psycho-physical status and health service organization factors.

CMV infection in a cohort of HIV-exposed infants born to mothers receiving antiretroviral therapy during pregnancy and breastfeeding.

Antiretroviral therapy has been shown to reduce rates of congenital CMV infection. Little information is available on the possible impact of antiretroviral therapy on postnatal breastfeeding-associated CMV infection acquisition. A cohort of 89 HIV-infected mothers and their children was studied. Women received antiretroviral therapy from week 25 of gestation until 6 months postpartum or indefinitely if meeting the criteria for treatment. All women were evaluated for CMV IgG presence and CMV DNA in breast milk. Children were tested for CMV infection by either the presence of IgM or the presence of CMV DNA in plasma at 1, 6 and 12 months and by the presence of IgG at 24 months. All mothers had high titers of CMV DNA in breast milk (5.7 log at Month 1 and 5.1 log at Month 6). Cumulative CMV infection rates were 60.3 % at Month 6, 69 % at Month 12 and 96.4 % at Month 24. There was a significant negative correlation between the duration of antiretroviral treatment during pregnancy and levels of CMV DNA in breast milk at Month 1 (P = 0.033). There was a trend for a correlation between high titers of CMV DNA in breast milk at 6 months and CMV infection at 6 months (P = 0.069). In this cohort, more than 95 % of the children had acquired CMV infection by 2 years of age. Besides breastfeeding, which played a major role, also horizontal transmission between 1 and 2 years was certainly relevant in determining CMV infection acquisition.

Assessment of frailty in community-dwelling older adults residents in the Lazio region (Italy): A model to plan regional community-based services.

PURPOSE OF THE STUDY: The prevalence of frailty is expected to increase worldwide in parallel with demographic ageing. Despite this, little is known about the prevalence in different populations particularly community-based samples. This cross-sectional study evaluates the prevalence of frailty in a community-dwelling older adult population and describes a methodology to plan community-based interventions. METHODOLOGY: A random sample of 1331 older adults, resident in the Lazio-Region of Italy, were screened by trained public health nurses (PHNs) by administering a validated questionnaire (the Functional Geriatric Evaluation questionnaire). Prevalence of frailty was calculated using the Final Synthetic Score derived from the questionnaire's Final Score. Variables associated with frailty were selected through univariate and multivariate statistical analysis. RESULTS: Prevalence of frail (FS≥10,≤50) and very frail (FS<10) individuals was 13.9% and 7.6% respectively. Variables associated with frailty were age (older than 85 years), disability, living alone or the presence of a paid carer, lower education and neurological disorders like stroke, dementia, Parkinson disease and other neuropsychiatric diseases; Anaemia or cancer were also associated with a higher prevalence of frailty. DISCUSSION: The study provide a comprehensive picture of the prevalence of frailty and factors associated to this condition in community-dwelling older adults. On the basis of the study results, a plan of community-based services could address the needs of care of the elderly population. A trained team of PHNs may be the most appropriate personnel to carry out multidimensional frailty assessment in this setting.

Levels of bone markers in a population of infants exposed in utero and during breastfeeding to tenofovir within an Option B+ programme in Malawi.

OBJECTIVES: No data are available on bone metabolism in infants exposed to tenofovir during breastfeeding. We investigated bone metabolism markers in the first year of life in infants from mothers who received tenofovir, lamivudine and efavirenz during pregnancy and 12 months of breastfeeding in a national Option B+ programme in Malawi. METHODS: Serum samples collected at 6 and 12 months in tenofovir-exposed infants and in a small sample of tenofovir-unexposed infants from the same clinical centre were analysed in batches for levels of bone-specific alkaline phosphatase (BAP; marker of bone formation) and of C-terminal telopeptide of type I collagen (CTX; marker of bone resorption). RESULTS: Overall, 136 tenofovir-exposed infants were evaluated. No infant had at either timepoint CTX values above the upper normal limit, while most of them had at 6 and 12 months levels of BAP above the upper normal limit for the age range. Levels of bone markers showed no differences by gender and no association with growth parameters. Tenofovir-unexposed and -exposed children had similar mean levels of bone markers at 6 months (CTX: 0.62 versus 0.55 ng/mL, P = 0.122; BAP: 384 versus 362 U/L, P = 0.631). CONCLUSIONS: No significant association between treatment with tenofovir and CTX or BAP levels was found. The high levels of BAP, coupled to the normal levels observed for CTX, might reflect primarily skeletal growth. Potential negative effects of prolonged exposure to tenofovir through breastfeeding cannot however be excluded and longitudinal studies that evaluate bone mineralization status in children enrolled in Option B+ programmes are warranted.

An assessment of option B implementation for the prevention of mother to child transmission in Dschang, Cameroon: results from the DREAM (Drug Resource Enhancement against AIDS and Malnutrition) cohort.

INTRODUCTION: Scaling up of antiretroviral therapy (ART) to HIV+ pregnant women is crucial for the elimination of HIV infection in children. The aim of this study was to evaluate the feasibility and effectiveness of triple ART for Prevention of Mother-to Child Transmission (PMTCT) in Cameroon. METHODS: HIV-positive pregnant women attending the DREAM Centre of Dschang, Cameroon for prenatal care were enrolled in a prospective cohort study, and received ART until the end of breastfeeding or indefinitely if their CD4 count was <350mm(3). Infants were evaluated for HIV infection at 1, 6 and 12 months of age. RESULTS: A total of 298 women were enrolled. Among them, 152 were already on established ART. Women were followed until 6 months after delivery with a retention rate of 92.6%. Eight women died. Those with a CD4 count <350 cells/mm(3) during pregnancy had the highest mortality risk (RR 2.53; 95% CL= 1.86-3.44). The HIV transmission rate was 1.2% at 12 months with an HIV free survival of 91%. In the proportional Cox regression analysis, the following factors were positively associated with infant mortality: maternal CD4< 350 cells/mm(3), no breastfeeding in the first 6 months of life, weight-for-age z score<-2. CONCLUSION: Results confirm the feasibility and effectiveness of the implementation of Option B, with very low rates of HIV MTC transmission, and potential benefits to the health of mothers and infants with earlier initiation of ART. Breastfeeding again demonstrates to be highly beneficial for the growth and survival of HIV exposed children.

Virological Response and Drug Resistance 1 and 2 Years Post-Partum in HIV-Infected Women Initiated on Life-Long Antiretroviral Therapy in Malawi.

The objective of this study was to determine the virological response and the possible emergence of drug resistance at 1 and 2 years postpartum in HIV-positive pregnant women enrolled under the Option B approach and meeting the criteria for treatment. In the study, women with baseline CD4(+) <350/mm(3) received a combination of stavudine, lamivudine, and nevirapine during pregnancy (from week 25 of gestation) and continued it indefinitely after delivery. HIV-RNA was measured at 12 and 24 months postpartum. Drug resistance mutations were assessed in those with HIV-RNA >50 copies/ml. Baseline resistance mutations were assessed in the entire cohort. A total of 107 women were studied. At baseline, resistance mutations were seen in 6.6% of the women. At 12 months, 26.7% of the women had >50 copies/ml and among them 12.9% had virological failure (HIV-RNA >1,000 copies/ml). At 24 months, detectable HIV-RNA was seen in 28.3% of the women and virological failure in 10.1% of the women. Resistance mutations (mainly non-nucleoside reverse transcriptase inhibitors mutations) were seen in 40% of the women with detectable HIV-RNA. Baseline mutations did not correlate with virological failure or the emergence of resistance at later time points. Virological failure 2 years postpartum and emergence of resistance were rare in this cohort of HIV-infected women. These findings are reassuring in the light of the new strategies for the prevention of mother-to-child HIV transmission, recommending life-long antiretroviral therapy administration.

Growth indices in breastfed infants pre and postnatally exposed to tenofovir compared with tenofovir-unexposed infants.

We evaluated growth indices in two cohorts of Malawian infants exposed to tenofovir, lamivudine and efavirenz in utero and during 12 months of breastfeeding, and to stavudine/zidovudine, lamivudine and nevirapine in utero and during 6 months of breastfeeding. Growth indices were similar in the two cohorts at one and 6 months but were significantly better in the first group at 12 months, suggesting no negative effect of tenofovir and a significant benefit of extended breastfeeding.