Use of neonatal post-exposure prophylaxis for prevention of mother-to-child HIV transmission in the UK and Ireland, 2001-2008

Objectives

To investigate changing clinical practice with regard to antiretroviral post‐exposure prophylaxis (PEP) and factors associated with the use of combination prophylaxis in infants born to HIV‐infected women in the UK and Ireland.

Methods

Surveillance of obstetric and paediatric HIV infection in the UK and Ireland is conducted through the National Study of HIV in Pregnancy and Childhood. Infants born to HIV‐infected women between 2001 and 2008 were included in the study.

Results

Ninety‐nine per cent of infants (8155 of 8205) received antiretroviral prophylaxis; 86% of those with information on type of prophylaxis (n=8050) received single, 3% dual and 11% triple drug prophylaxis. Among those who received prophylaxis, use of triple prophylaxis increased significantly between 2001–2004 and 2005–2008, from 9% (297 of 3243) to 13% (624 of 4807) overall (P<0.001); from 43% (41 of 95) to 71% (45 of 63) in infants born to untreated women; and from 13% (114 of 883) to 32% (344 of 1088) where mothers were viraemic despite highly active antiretroviral therapy (HAART) in pregnancy. In multivariable analysis, factors associated with receipt of triple prophylaxis included later time period, shorter duration or lack of antenatal antiretroviral therapy, receipt of antiretroviral drugs during labour, detectable maternal viral load, CD4 count<200 cells/μL in pregnancy, preterm delivery (<37 weeks) and unplanned (emergency caesarean or vaginal) delivery.

Conclusion

Between 2001 and 2008, almost all infants born to HIV‐infected women in the UK and Ireland received antiretroviral PEP, mostly with one drug. Use of triple PEP increased over time, particularly for infants whose mothers were untreated or viraemic despite HAART, in line with current guidelines.     

Sentinel hospital surveillance for rotavirus diarrhea in Taiwan, 2001-2003

We examined the epidemiological profile of rotavirus infection among children hospitalized for diarrhea in Taiwan, to assess the burden of this disease. From 1 April 2001 through 31 March 2003, children <5 years old with gastroenteritis admitted to 4 sentinel hospitals were enrolled in a surveillance study and had stool specimens tested for the presence of rotavirus, enteric adenovirus, and the bacterial pathogens for which routine screening is performed. For 52% of patients, a recognized enteric pathogen was identified, including rotavirus (43% of patients), bacteria (11%), enteric adenovirus (2.5%), and a mixture of pathogens (3.9%). Rotavirus was detected year-round, but great month-to-month variability made it difficult to identify a distinct seasonal pattern. Rotavirus disease was most common among children 7-23 months old, but the rate of rotavirus detection varied little between the youngest and oldest age groups. The novel strain P[8]G9 was detected most commonly (37% of strains), followed by strains P[8]G1 (31%), P[4]G2 (10%), P[8]G3 (9.3%), and P[8]G4 (3.7%). Rotavirus infection is the most important cause of diarrhea among hospitalized children in Taiwan, and a rotavirus vaccination program for young children might significantly reduce this problem.     

Maternal viral load and timing of mother-to-child HIV transmission, Bangkok, Thailand. Bangkok Collaborative Perinatal HIV Transmission Study Group

OBJECTIVES: To determine the proportion of HIV-1-infected infants infected in utero and intrapartum, the relationship between transmission risk factors and time of transmission, and the population-attributable fractions for maternal viral load. DESIGN: Prospective cohort study of 218 formula-fed infants of HIV-1-infected untreated mothers with known infection outcome and a birth HIV-1-positive DNA PCR test result. METHODS: Transmission in utero was presumed to have occurred if the birth sample (within 72 h of birth) was HIV-1-positive by PCR; intrapartum transmission was presumed if the birth sample tested negative and a later sample was HIV-1-positive. Two comparisons were carried out for selected risk factors for mother-to-child transmission: infants infected in utero versus all infants with a HIV-1-negative birth PCR test result, and infants infected intrapartum versus uninfected infants. RESULTS: Of 49 infected infants with an HIV-1 birth PCR result, 12 (24.5%) [95% confidence interval (CI), 14 -38] were presumed to have been infected in utero and 37 (75.5%) were presumed to have been infected intrapartum. The estimated absolute overall transmission rate was 22.5%; this comprised 5.5% (95% CI, 3-9) in utero transmission and 18% (95% CI, 13-24) intrapartum transmission. Intrapartum transmission accounted for 75.5% of infections. High maternal HIV-1 viral load (> median) was a strong risk factor for both in utero [adjusted odds ratio (AOR) 5.8 (95% CI, 1.4-38.8] and intrapartum transmission (AOR, 4.4; 95% CI, 1.9-11.2). Low birth-weight was associated with in utero transmission, whereas low maternal natural killer cell and CD4(+) T-lymphocyte percentages were associated with intrapartum transmission. The population-attributable fraction for intrapartum transmission associated with viral load > 10 000 copies/ml was 69%. CONCLUSIONS: Our results provide further evidence that most perinatal HIV-1 transmission occurs during labor and delivery, and that risk factors may differ according to time of transmission. Interventions to reduce maternal viral load should be effective in reducing both in utero and intrapartum transmission.     

Correlates of women's knowledge of mother-to-child transmission of HIV and its prevention in Tanzania: a population-based study

Studies that explored women's knowledge on mother-to-child transmission (MTCT) of HIV and its prevention (PMTCT) in the general population are currently lacking. This paper examined factors associated with having adequate knowledge of MTCT of HIV and PMTCT among a nationally representative sample of women in Tanzania. We conducted a cross-sectional analysis including 10,299 women from the 2011–2012 Tanzania HIV/AIDS and Malaria Indicator Survey. The outcome of interest was the presence of adequate knowledge on MTCT and PMTCT of HIV. We used multivariable logistic regression to identify factors associated with having adequate knowledge on MTCT and PMTCT of HIV. Results revealed that the overall prevalence of having adequate knowledge on MTCT and PMTCT of HIV was low (46%). We found a statistically significant difference in the proportions of having adequate knowledge between HIV-negative and HIV-positive women (45% vs. 56%; p?相似文献   

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

HIV infection and mortality rates in African children are astoundingly high. Risk factors for mother-to-child transmission of HIV include maternal plasma viral load and breastfeeding. With regard to the latter, current data indicate that mixed feeding (breastfeeding with other oral foods and liquids) is associated with the greatest risk of transmission. Studies are under way to determine if exclusive breastfeeding with rapid early weaning can reduce transmission rates in the absence of exclusive formula feeding for all infants. Perinatal transmission rates have been dramatically reduced with the use of single-dose nevirapine, but this strategy protects only approximately 50% of infants, and more than 75% of women receiving nevirapine develop a major nevirapine resistance mutation. In developed areas of the world, antiretroviral therapy has reduced perinatal transmission by more than 90% compared with 1993 rates. Improved HIV-related care for HIV-infected women in Africa is needed to reduce rates of HIV infection in children and to prevent maternal mortality. This article summarizes a presentation by Sten H. Vermund, MD, PhD, at the International AIDS Society-USA course in Chicago in May 2004.     

Community approaches to preventing mother-to-child HIV transmission: perspectives from rural Lesotho

This paper examines the cultural and structural difficulties surrounding effective prevention of mother-to-child HIV transmission (PMTCT) in rural Lesotho. We argue for three strategies to improve PMTCT interventions: community-based research and outreach, addressing cultural and structural dynamics, and working with the relevant social groups that impact HIV prevention. These conclusions are based on interviews and participant observation conducted within the rural Mokhotlong district and capital city of Maseru, involving women and men of reproductive age, grandmothers serving as primary caretakers, HIV/AIDS programme staff, and medical professionals. Qualitative analysis focused on rural women's socio-medical experience with the four measures of PMTCT (educational outreach, voluntary counselling and testing, antiretroviral interventions, and safe infant feeding). Based on these results, we conclude that intervention models must move beyond a myopic biomedical 'best-practices' approach to address the social groups and contextual determinants impacting vertical HIV transmission. Given the complexities of effective PMTCT, our results show that it is necessary to consider the biomedical system, women and children, and the community as valuable partners in achieving positive health outcomes.     

Maternal 12-month response to antiretroviral therapy following prevention of mother-to-child transmission of HIV type 1, Ivory Coast, 2003-2006.

OBJECTIVE: Our aim was to study the response to antiretroviral treatment among women exposed to single-dose nevirapine (NVP) and/or short-course zidovudine (ZDV; with or without lamivudine [3TC]) for the prevention of mother-to-child transmission of human immunodeficiency virus (HIV) infection. METHODS: All HIV type 1-infected women who initiated antiretroviral treatment with stavudine or ZDV, 3TC, and NVP or efavirenz were eligible for the MTCT-Plus program in Abidjan, Ivory Coast. Exposed women had received either single-dose NVP alone or short-course ZDV (with or without 3TC) plus single-dose NVP during previous pregnancy. Genotypic resistance testing was performed at week 4 after delivery. Virologic failure was defined as a plasma HIV RNA level >500 copies/mL 12 months after initiation of antiretroviral treatment. RESULTS: Among 247 women who received antiretroviral treatment, 109 (44%) were unexposed; 81 had received short-course ZDV with 3TC, as well as single-dose NVP; 5 had received short-course ZDV plus 3TC; 50 had received short-course ZDV plus single-dose NVP; and 2 had received single-dose NVP alone. No ZDV mutation was detected in the 115 women whose specimens were available for genotypic testing; 11 (15.1%) of 73 women with 3TC exposure who were tested after delivery had 3TC resistance mutations. Three (4.3%) of 69 women exposed to short-course ZDV and 3TC plus single-dose NVP and 16 (38.1%) of 42 women exposed to short-course ZDV plus single-dose NVP had NVP resistance mutations. Antiretroviral treatment was initiated a median of 21 months after the intervention to prevent mother-to-child HIV transmission (median CD4(+) T lymphocyte count, 188 cells/mm(3)). Month 12 virologic failure was identified in 42 (19.2%) of 219 women for whom data were available, and multivariate analysis revealed that it was associated with poor adherence to treatment (adjusted odds ratio [aOR], 12.7; 95% confidence interval [CI], 3.0-53.9), postpartum 3TC resistance mutations (aOR, 6.9; 95% CI, 1.1-42.9), and a baseline CD4(+) T lymphocyte count <200 cells/mm(3) (aOR, 0.3; 95% CI, 0.2-0.8). NVP resistance was not associated with virological failure (aOR, 1.8; 95% CI, 0.5-6.5). CONCLUSIONS: Our study found that poor adherence and 3TC resistance acquired after the intervention to prevent mother-to-child transmission of HIV infection were associated with virologic failure in women who initiated antiretroviral treatment.     

Patterns of HIV and syphilis infection in Northern Thailand 1998-2001

Northern Thailand has been the epicentre of a largely heterosexually transmitted HIV epidemic that has recently involved married women. In preparation for HIV-prevention trials, we investigated patterns of HIV and syphilis risk through annually measured HIV and syphilis prevalence among northern Thai, peri-urban, community-dwelling men (n=2564) and women (n=3907) aged 18-35 years between 1998 and 2001. Crude HIV and syphilis prevalence were 3.3% and 2.7% for men and 2.3% and 2.1% for women, respectively. In logistic regression models of HIV and syphilis, compared with married men/women, widowers and widows were at increased risk (odds ratio; 95% confidence interval) of syphilis (7.86; 1.56-39.6 and 3.3; 1.14-9.61, respectively) and HIV (12.68; 3.23-49.8 and 41.3; 24.3-70.3, respectively). The oldest women were at lower risk of HIV (0.43; 0.22-0.85). For men and women, those with syphilis were approximately three times more likely to have HIV. These unique population data illustrate evolving sex parity of HIV burden in northern Thailand.     

Factors affecting attitudes towards mother-to-child transmission of HIV among pregnant women in a maternal and child hospital in Thailand

This study determines the factors which correlate with attitudes towards mother-to-child transmission of HIV in pregnant women. Using a structured questionnaire, 527 pregnant women who visited a hospital to have prenatal checkups were interviewed. The survey items were: sociodemographic characteristics, experiences of pre-test counselling, knowledge of mother-to-child transmission, and attitude towards termination of pregnancy. Results showed that many pregnant women (80%) did not have proper knowledge of the possibility of mother-to-child transmission. Logistic regression analysis also indicates that age and knowledge of the possibility of mother-to-child transmission were the significant determinants of attitudes towards termination of pregnancy. Older women who believe that all the babies of pregnant women with HIV will be infected are most likely to terminate their pregnancy when they are diagnosed as HIV positive. Considering the importance of informed decisions regarding pregnancy, this study must have important implications for future support programmes for HIV-positive pregnant women.     

The effects of placental malaria on mother-to-child HIV transmission in Rakai, Uganda

We examined the association of placental malaria and mother-to-child transmission (MTCT) of HIV in a prospective community-randomized trial in Rakai District, Uganda. In the 746 HIV-positive mother-infant pairs, the MTCT rate was 20.4%. Placental malaria was more common in HIV-positive than HIV-negative women. After multivariate adjustment for HIV viral load, the risk of MTCT associated with placental malaria was 2.89 and with HIV viral load the risk was 2.85. Interventions to prevent malaria during pregnancy could potentially reduce MTCT.     

Syphilis surveillance in France, 2000-2003

This article describes syphilis trends, characteristics of patients from 2000 to 2003 in France and trends of the benzylpenicillin benzathine 2.4 million UI sales from 2001 to 2003. The ongoing surveillance system for syphilis case reporting since 2001 has been set up in volunteer settings, mostly public settings where STI treatment is offered. Clinical case reporting is complemented by sexual behavioural data based on a self-administered questionnaire. From 2000 to 2003, 1089 syphilis cases were reported in France, increasing from 37 cases in 2000 to 428 in 2003. Overall, 96% of syphilis cases were in men with a mean age of 36.5 years and 70% of whom were born in France. The proportion of syphilis cases with HIV co-infection decreased over time from 60% in 2000 to 33% in 2003. The most affected area by the syphilis epidemic is the Ile-de-France region, mainly the city of Paris. The greatest proportion of syphilis cases diagnosed in men who have sex with men (MSM) were in the Ile-de-France region, where they made up 87% of cases, compared with 75% in other regions. Among the patients who completed the self-administered questionnaire on sexual behaviour, 83% reported having casual sex partners in the 3 months prior to their syphilis diagnosis. Trends in the sales of benzylpenicillin benzathine 2.4 million UI in private pharmacies are similar to those observed in the surveillance system, and increased between 2001 and 2003. In conclusion, syphilis transmission is still ongoing in France in 2003 and the role of unprotected oral sex in the transmission of syphilis should be emphasised.     

Effectiveness of a city-wide program to prevent mother-to-child HIV transmission in Lusaka, Zambia

OBJECTIVE: To determine the population effectiveness of a city-wide perinatal HIV prevention program. DESIGN: An anonymous surveillance of newborn cord blood for HIV serology and nevirapine (NVP). METHODS: All 10 public-sector delivery centers in Lusaka, Zambia participated. All mother-infant pairs delivering during the 12-week surveillance period at the participating centers and who received antenatal care at a public-sector facility in Lusaka were included in the study. The main outcome measure was population NVP coverage, defined as the proportion of HIV-infected women and HIV-exposed infants in the population that ingested NVP. RESULTS: Of 8787 women in the surveillance population, 7204 (82%) had been offered antenatal HIV testing, of which 5149 (71%) had accepted, and of which 5129 (99%) had received a result. Overall, 2257 of 8787 (26%) were cord seropositive. Of the 1246 (55%) cord blood seropositive women who received an antenatal HIV test result, 1112 (89%) received a positive result; the other 134 comprise seroconverters and clerical errors. Only 751 of 1112 (68%) women who received a positive antenatal test result and a NVP tablet for ingestion at labor onset had NVP detected in the cord blood (i.e., maternal non-adherence rate was 32%). A total of 675 infants born to 751 adherent mothers (90%) received NVP before discharge. Thus, only 675 of 2257 (30%) seropositive mother-infant pairs in the surveillance population received both a maternal and infant dose of NVP. CONCLUSIONS: Successful perinatal HIV prevention requires each mother-infant pair to negotiate a cascade of events that begins with offering HIV testing and continues through adherence to the prescribed regimen. This novel surveillance demonstrates that failures occur at each step, resulting in reduced coverage and diminished program effectiveness.     

Nocardiosis in Srinagarind Hospital, Thailand: review of 70 cases from 1996-2001.

OBJECTIVE: Nocardiosis is a common opportunistic infection found in both immunocompromised and immunocompetent patients. The clinical manifestations, underlying diseases, radiologic findings, antimicrobial susceptibility and treatment of nocardial infection are presented here. METHOD: A retrospective study at Srinagarind Hospital, Khon Kaen in Thailand was performed. Medical records from 1996-2001 were reviewed. RESULTS: There were 81 cases of nocardiosis during the study period but data of only 70 cases were available. 80% of cases were male. The mean age was 39.7+/-14.9 years. Underlying diseases were found in 80%, of which HIV infection was the most common (34.3%). The common clinical findings were fever, cough, and cutaneous abscess. The most common clinical syndrome was pleuropulmonary infection (44.3%), followed by skin and soft tissue infection (22.8%). Multiorgan dissemination was found in 11.4% of cases. The chest X-rays were abnormal in 46 cases (65.7%); alveolar and reticulonodular infiltration was common. Only 70% had positive cultures for Nocardia spp. The resistance rate of Nocardia isolates to trimethoprim-sulfamethoxazole (TMP-SMX) was very high (57.9%) in this study. Most of the patients (85.7%) were treated with antimicrobials, of which TMP-SMX was commonly used. In-hospital mortality was 20%. Most of the cases who died had dissemination, brain abscesses or infection with TMP-SMX-resistant strains. The long-term prognosis was good, with a treatment success rate of 93.75%. CONCLUSION: Nocardiosis is a common opportunistic infection in many immunocompromised conditions. It can present with various clinical syndromes, especially pleuropulmonary infection. Culture may not yield the organism but modified acid-fast staining is very helpful in diagnosis. Drug susceptibility testing should be performed due to increasing resistance to TMP-SMX.     

乌鲁木齐市2000～2003年AIDS/STD监测情况分析

目的为了解乌鲁木齐市艾滋病／5传播疾病(AIDS／STD)在各类人群中的分布及其发生频率、现状和估计流行趋势，为乌鲁木齐市防治AIDS／STD策略提供依据。方法按照全国AIDS／STD检测工作规范要求，在2000～2003年对各类人群进行了监测。结果对吸毒、性乱人群、孕产妇、婚前体检者、公共场所服务人员、长途卡车司机及供血员的监测共计111337人，结果查出艾滋病病毒(HIV)感染者829例，梅毒914例，淋病323例，非淋菌性尿道(宫颈)炎1066例，尖锐湿疣221例，生殖器疱疹78例。结论HIV感染者在乌鲁木齐市仍主要集中在静脉吸毒人群中，近年来有从吸毒人群向一般人群发展的趋势，且供血员中检出率较高。应加大宣传力度，特别是用少数民族语言文字的宣传教育，增强民众的自我保护意识，通过干预改变和减少高危行为，并扩大检测范围，推广使用安全套，规范STD诊治，是乌鲁木齐地区预防控制AIDS／STD传播的有力措施。     

Progress in prevention of mother-to-child transmission of HIV infection in Ukraine: results from a birth cohort study

Background  

Ukraine was the epicentre of the HIV epidemic in Eastern Europe, which has the most rapidly accelerating HIV epidemic world-wide today; national HIV prevalence is currently estimated at 1.6%. Our objective was to evaluate the uptake and effectiveness of interventions for prevention of mother-to-child transmission (PMTCT) over an eight year period within operational settings in Ukraine, within the context of an ongoing birth cohort study.     

Declining HIV prevalence and risk behaviours in Zambia: evidence from surveillance and population-based surveys

OBJECTIVE: To examine trends in HIV prevalence and behaviours in Zambia during the 1990s. METHODS: The core Zambian system for epidemiological surveillance and research has two major components: (i) HIV sentinel surveillance at selected antenatal clinics (ANC) in all provinces; and (ii) population-based HIV surveys in selected sentinel populations (1996 and 1999). The former was refined in 1994 to improve the monitoring of prevalence trends, whereas the latter was designed to validate ANC-based data, to study change in prevalence and behaviour concomitantly and to assess demographic impacts. RESULTS: The ANC-based data showed a dominant trend of significant declines in HIV prevalence in the 15--19 years age-group, and for urban sites also in age-group 20--24 years and overall when rates were adjusted for over-representation of women with low education. In the general population prevalence declined significantly in urban women aged 15--29 years whereas it showed a tendency to decline among rural women aged 15-24 years. Prominent decline in prevalence was associated with higher education, stable or rising prevalence with low education. There was evidence in urban populations of increased condom use, decline in multiple sexual partners and, among younger women, delayed age at first birth. CONCLUSIONS: The results suggested a dominant declining trend in HIV prevalence that corresponds to declines in incidence since the early 1990s attributable to behavioural changes. Efforts to sustain the ongoing process of change in the well-educated segments of the population should not be undervalued, but the modest change in behaviour identified among the most deprived groups represents the major preventive challenge.