Suchergebnisse

It is remarkable that we find ourselves at a point in history where we can seriously consider the possibility of virtual elimination of mother-to-child HIV transmission (MTCT). Effective antiretroviral strategies, carefully honed through randomized clinical trials, provide the means to almost entirely prevent the transmission of HIV from an HIV-infected woman to her infant during pregnancy, delivery and breastfeeding - if started timeously and sustained through the full period of risk. Massive mobilization of governments, policy-makers, health service managers, clinicians, researchers and communities have led to implementation of Prevention of Mother To Child Transmission (PMTCT) interventions on an impressive scale. South Africa, which faces the world's highest adult HIV prevalence, has risen to the challenge, also implementing the one of the world's largest antiretroviral drug treatment program. In so doing, South Africa has made impressive gains in mitigating the tragedy of its generalized and substantial HIV epidemic. ; The South African Medical Research Council ; https://bmcinfectdis.biomedcentral.com ; am2020 ; Paediatrics and Child Health

AbstractIntroduction: Timely diagnosis is necessary to avert early death in HIV‐infected neonates. Birth PCR testing may improve early identification and facilitate access to care. We implemented a birth HIV diagnosis programme in Johannesburg, South Africa and present successes and challenges of the first two and a half years of operation.Methods: Between June 2014 and December 2016, we sought to identify all HIV‐exposed births and offer newborn HIV PCR testing before discharge after delivery. The programme identified newly delivered women who had tested positive during pregnancy and provided post‐partum HIV antibody testing for women without recent negative results. HIV‐positive women were required to consent for neonatal birth testing and asked to return a week later to obtain their results. Neonatal venous blood was sampled and tested at the national laboratory using Roche COBAS® TaqMan® HIV‐1 Qualitative Test (Version 2.0). Non‐negative results triggered active follow‐up for confirmatory testing and appropriate treatment.Results: Of 30,591 women with live births, 6864 (22.4%) were known to be HIV positive and an additional 221 women (1.4% of those tested) were identified during maternal postnatal testing. Of 7085 HIV‐positive women, 6372 (89.9%) were interviewed and agreed to data collection, 6358 (99.8%) consented to birth testing for 6467 neonates and a blood sample was collected for 6377 (98.6%). If tested, 6210 (97.4%) tested negative, 91 (1.4%) positive, 57 (0.9%) revealed errors and 19 (0.3%) were indeterminate . Seven of the 19 neonates with indeterminate results and one with initial error result were found to be infected on subsequent testing yielding an intrauterine transmission rate of 1.6% (95% CI: 1.3–1.9). Sixteen (16%) of 99 infected infants were born to women (n = 221) identified during postnatal testing. With active outreach, 95/99 (96%) infected infants were initiated on antiretroviral therapy. Of 6261 neonates with negative results, 3251 (52%) returned to receive their test results.Conclusion: Our programme successfully achieved high coverage and uptake of birth PCR testing and was able, with active tracking, to start almost all identified HIV‐infected neonates on antiretroviral therapy. Implementation required additional staff for counselling, quality control and outreach. Return for negative results was low and neonates with indeterminate results required multiple repeat tests.

Clinical and epidemiologic research has identified increasingly effective interventions to reduce mother to child HIV transmission in resource‐limited settings These scientific breakthroughs have been implemented in some programmes, although much remains to be done to improve coverage and quality of these programmes. But prevention of HIV transmission is not enough. It is necessary also to consider ways to improve maternal health and protect child survival.A win‐win approach is to ensure that all pregnant and lactating women with CD4 counts of <350 cells/mm3 have access to antiretroviral therapy. On its own, this approach will substantially improve maternal health and markedly reduce mother to child HIV transmission during pregnancy and delivery and through breastfeeding. This approach can be combined with additional interventions for women with higher CD4 counts, either extended prophylaxis to infants or extended regimens of antiretroviral drugs to women, to reduce transmission even further.Attempts to encourage women to abstain from all breastfeeding or to shorten the optimal duration of breastfeeding have led to increases in mortality among both uninfected and infected children. A better approach is to support breastfeeding while strengthening programmes to provide antiretroviral therapy for pregnant and lactating women who need it and offering antiretroviral drug interventions through the duration of breastfeeding. This will lead to reduced HIV transmission and will protect the health of women without compromising the health and well‐being of infants and young children.

IntroductionAdolescents account for over 40% of new HIV infections in Haiti. This analysis compares outcomes among HIV‐positive adolescents before and after implementation of an adolescent HIV clinic in Port‐au‐Prince, Haiti.MethodsWe conducted a cohort study using programmatic data among HIV‐positive adolescents aged 13 to 19. Data from 41,218 adolescents who were HIV tested from January 2003 to December 2012 were included. Outcomes across the HIV care cascade were assessed before and after implementation of an adolescent clinic (2009), including HIV testing, enrolment in care, assessment for antiretroviral therapy (ART) eligibility, ART initiation and 12‐month retention. Pre‐ART outcomes were assessed 12 months after HIV testing. Factors associated with pre‐ART and ART attrition were identified through multivariable competing risk and Cox proportional hazards regression modelling.ResultsCumulatively, 1672 (4.1%) adolescents tested HIV positive (80% female, median age 16 years). Retention by cascade step comparing pre‐ and post‐clinic included the following: 86% versus 87% of patients enrolled in care, 61% versus 79% were assessed for ART eligibility, 85% versus 92% initiated ART and 68% versus 66% were retained 12 months after ART initiation. Pre‐ART attrition decreased from 61% pre‐clinic to 50% post‐clinic (p<0.001). Pre‐ART attrition was associated with being female (sub‐distributional hazard ratio (sHR): 1.59; CI: 1.31–1.93), syphilis diagnosis (sHR: 1.47; CI: 1.16–1.85) and slum residence (sHR: 0.84; CI: 0.72–0.97). ART attrition was associated with syphilis diagnosis (hazard ratio (HR): 2.23; CI: 1.35–3.68) and CD4 <50 cells/µL (HR: 1.88; CI: 1.15–3.06).ConclusionsImplementation of a youth‐friendly adolescent clinic improved retention in HIV care among adolescents, particularly in the assessment of ART eligibility and ART initiation. Additional interventions are needed to improve retention among pre‐ART patients and support long‐term retention among ART patients.

AbstractIntroduction: HIV‐1 polymerase chain reaction (PCR) testing at birth aims to facilitate earlier initiation of antiretroviral therapy (ART) for HIV‐infected neonates. Data from two years of universal birth testing implementation in a high‐burden South African urban setting are presented to demonstrate the prevalence and outcomes of diagnostic challenges in this context.Methods: HIV‐exposed neonates born at Rahima Moosa Mother and Child Hospital between 5 June 2014 and 31 August 2016 were routinely screened at birth for HIV‐1 on whole blood samples using the COBAS® AmpliPrep/COBAS® TaqMan (CAP/CTM) HIV‐1 Qualitative Test, version 2.0 (Roche Molecular Systems, Inc., Branchburg, NJ, USA). Virological results were interpreted according to standard operating procedures with the South African National Health Laboratory Service. All neonates with non‐negative results were actively followed‐up and categorized according to HIV infection status as positive, negative, uncertain and lost to follow‐up (LTFU).Results: 104 (1.8%) of 5743 HIV‐exposed neonates received a non‐negative birth PCR result, for which laboratory data were available for 102 (98%) cases – 78 (76%) tested positive and 24 (24%) indeterminate. HIV infection status was confirmed positive in 83 (81%) infants, negative in 8 (8%), uncertain in 5 (5%) and LTFU in 6 (6%) cases. The positive predictive value (excluding cases of uncertain diagnosis and inadequate testing) following a non‐negative HIV‐1 PCR screening test at birth was 0.91 (83/91; 95% confidence interval: 0.85–0.96). Neonates testing positive at birth had significantly higher viral load (VL) results than those testing indeterminate at birth of 4.5 and 3.0 log copies/ml (p = 0.0007), respectively. Similarly, mothers of neonates with positive as compared to indeterminate birth test results had higher VLs of 4.5 and 2.7 log copies/ml (p = 0.0013), respectively. Half of neonates with an indeterminate birth test were shown to be HIV‐infected on subsequent confirmatory testing, with time to final diagnosis 30 days longer for these neonates (p < 0.0001).Conclusion: Indeterminate HIV‐1 PCR results accounted for a quarter of non‐negative results at birth and were associated with a high risk of infection in comparison to the risk of in utero transmission. Indeterminate birth results with positive HIV PCR results on repeat testing were associated with later final diagnosis. The HIV‐1 status remains uncertain in a minority of cases because of repeatedly indeterminate results, highlighting the need for more sensitive and specific virological tests.