The prevention of mother-to-child HIV transmission programme and infant feeding practices.

Since the first cases of HIV transmission through breast-feeding were documented, a fierce debate has raged on appropriate guidelines for infant feeding in resource-poor settings. A major problem is determining when it is safe and feasible to formula-feed, as breast-milk protects against other diseases. A cross-sectional survey of 113 women attending the programme for the prevention of mother-to-child transmission in Khayelitsha, Cape Town, was conducted. Over 95% of women on the programme formula-fed their infants and did not breast-feed at all. Seventy per cent of women said that their infant had never had diarrhoea, and only 3% of children had had two episodes of diarrhoea. Focus groups identified the main reasons for not breast-feeding given by women to their families and those around them. Formula feeding is safe and feasible in an urban environment where sufficient potable water is available.     

Timing of HIV testing among pregnant and breastfeeding women and risk of mother‐to‐child HIV transmission in Malawi: a sampling‐based cohort study

IntroductionPregnant women living with HIV can achieve viral suppression and prevent HIV mother‐to‐child transmission (MTCT) with timely HIV testing and early ART initiation and maintenance. Although it is recommended that pregnant women undergo HIV testing early in antenatal care in Malawi, many women test positive during breastfeeding because they did not have their HIV status ascertained during pregnancy, or they tested negative during pregnancy but seroconverted postpartum. We sought to estimate the association between the timing of last positive HIV test (during pregnancy vs. breastfeeding) and outcomes of maternal viral suppression and MTCT in Malawi’s PMTCT programme.MethodsWe conducted a two‐stage cohort study among mother–infant pairs in 30 randomly selected high‐volume health facilities across five nationally representative districts of Malawi between 1 July 2016 and 30 June 2017. Log‐binomial regression was used to estimate prevalence ratios (PR) and risk ratios (RR) for associations between timing of last positive HIV test (i.e. breastfeeding vs. pregnancy) and maternal viral suppression and MTCT, controlling for confounding using inverse probability weighting.ResultsOf 822 mother–infant pairs who had available information on the timing of the last positive HIV test, 102 mothers (12.4%) had their last positive test during breastfeeding. Women who lived one to two hours (PR = 2.15; 95% CI: 1.29 to 3.58) or >2 hours (PR = 2.36; 95% CI: 1.37 to 4.10) travel time to the nearest health facility were more likely to have had their last positive HIV test during breastfeeding compared to women living <1 hour travel time to the nearest health facility. The risk of unsuppressed VL did not differ between women who had their last positive HIV test during breastfeeding versus pregnancy (adjusted RR [aRR] = 0.87; 95% CI: 0.48 to 1.57). MTCT risk was higher among women who had their last positive HIV test during breastfeeding compared to women who had it during pregnancy (aRR = 6.57; 95% CI: 3.37 to 12.81).ConclusionsMTCT in Malawi occurred disproportionately among women with a last positive HIV test during breastfeeding. Testing delayed until the postpartum period may lead to higher MTCT. To optimize maternal and child health outcomes, PMTCT programmes should focus on early ART initiation and providing targeted testing, prevention, treatment and support to breastfeeding women.     

An evaluation of the effectiveness of nutrition advisers in three rural areas of northern province.

OBJECTIVE: To evaluate the efficacy of a nutrition education intervention programme undertaken by trained local women (nutrition advisers) in rural villages in Northern Province. The programme was aimed at the caregivers of infants living in those villages. STUDY DESIGN: A cross-sectional survey design undertaken in 1989 and again in 1992. STUDY POPULATION: Female caregivers of infants living in three study villages (study area (SA)) and three control villages (control area (CA)) in Northern Province. Households were randomly selected. The response rate of households in the SA and CA was 70% (N = 1,040) at baseline and 84% (N = 1,263) after intervention. METHODS: A baseline study was undertaken in the SA and CA in 1989. A questionnaire eliciting sociodemographic data and information on dietary practices and nutritional knowledge was developed and used in the baseline study and after intervention. A nutrition education programme was undertaken by 6 trained local women (nutrition advisers) in the SA. After 2 years the survey was repeated using the same questionnaire in both the SA and CA. The SA and CA were compared with regard to breast-feeding and infant feeding practices; use of milk, brown bread, legumes and nuts; and use of school lunch boxes by older children. RESULTS: The percentage of women who initiated breast-feeding on the day of birth improved significantly in the SA from 60% to 90%. The frequency of feeding infants at 6 months improved significantly in the SA (P < 0.01). The introduction of solid foods to infants on the first day of life decreased from 26.5% to 6.3% in the SA. There were no significant differences in the SA only with regard to use of milk, brown bread, legumes, nuts, and school lunch boxes. However, some positive findings were a greater increase in the use of these items in the SA compared with the CA. CONCLUSION: A nutrition education programme undertaken by trained local women can significantly improve breast-feeding and infant feeding practices in rural areas.     

Informed choice--the timing of postpartum contraceptive initiation.

BACKGROUND: In South Africa injectable progestogen-only contraceptives (IPC) are typically administered to women immediately after delivery. Several guidelines advise that breast-feeding women should not commence IPC until 6 weeks postpartum on the basis of theoretical risks to the infant. OBJECTIVE: We examined women's preferences regarding timing of postpartum IPC initiation, as well as women's contraceptive and breast-feeding behaviours and pregnancy risk in the early postpartum period. DESIGN AND DATA COLLECTION: A cross-sectional study was conducted among 200 antenatal clinic (ANC) attendees and 180 mothers attending a child health clinic (CHC). At the ANC, women were given information on the theoretical risks of IPC and re-interviewed about their postpartum contraceptive intentions. RESULTS: Most ANC women planned to use IPCs (92%) and to breast-feed (98%) after delivery. Most CHC mothers had used IPCs (91%) and had breast-fed (83%) after delivery. When women at the ANC were provided with appropriate information they made decisions about when to initiate IPC by balancing the theoretical risks of IPC to their infant against their personal risk of pregnancy and ability to return to a clinic in the early postpartum period. CONCLUSION: It is important to include informed choice in postpartum IPC initiation guidelines.     

Breast-feeding problems after epidural analgesia for labour: a retrospective cohort study of pain, obstetrical procedures and breast-feeding practices

Various clinical practices have been found to be associated with breast-feeding problems. However, little is known about the effect of pain, obstetrical procedures and analgesia on breast-feeding behaviour. We designed a retrospective study with a questionnaire concerning pain, obstetrical procedures and breast-feeding practices mailed to 164 primiparae in Lapland. Altogether 99 mothers (60%) returned completed questionnaires that could be included in the analysis, which was carried out in two steps. Firstly, all accepted questionnaires were grouped according to the success or failure to breast-feed fully during the first 12 weeks of life. Secondly, an ad hoc cohort study was performed on the sub-sample of 64 mothers delivered vaginally. As many as 44% of the 99 mothers reported partial breast feeding or formula feeding during the first 12 weeks. Older age of the mother, use of epidural analgesia and the problem of "not having enough milk" were associated with the failure to breast-feed fully. Caesarean section, other methods of labour analgesia and other breast-feeding problems were not associated with partial breast feeding or formula feeding. In the sub-sample, 67% of the mothers who had laboured with epidural analgesia and 29% of the mothers who laboured without epidural analgesia reported partial breast feeding or formula feeding (P = 0.003). The problem of "not having enough milk" was more often reported by those who had had epidural analgesia. Further studies conducted prospectively are needed to establish whether a causal relationship exists between epidural analgesia and breast-feeding problems.     

Mothers and babies: widening the HIV safety net

A national health policy of exclusive breastfeeding is finally imminent while routine re-testing of initially HIV-negative pregnant women at 32 weeks could soon become standard practice. These two simple measures would boost the already impressive gains in prevention of HIV transmission from mothers to infants (PMTCT) -- a major highlight of the fifth South African AIDS conference in Durban from 7 to 10 June this year. National surveys presented at the conference showed that the MTCT rate among babies 4 - 6 weeks old has dropped to 3.5%, potentially saving some 67 000 infants from HIV infection. This is a dramatic acceleration from the 8.8% MTCT rate under the previous regime of a single dose of nevirapine to mothers and their newborns. The impressive gains are almost exclusively due to a much-awaited policy change last April when all HIV-positive pregnant women began receiving AZT from 14 weeks of pregnancy (instead of at 28 weeks) and triple therapy (nevirapine, tenofovir and 3TC) during labour (when most infections take place). Those women with CD4 cell counts below 350 were also put onto triple therapy within 2 weeks of getting their CD4 cell results and all HIV-positive newborns were given nevirapine syrup for as long as their mothers were breastfeeding them (or for 6 weeks if not breastfed), regardless of CD4 cell count. Together these measures have put South Africa on track to meet this part of its 2007 - 2011 National Strategic Plan on HIV/AIDS (i.e. reducing MTCT to less than 5%), with the latest policy changes likely to edge the country even closer towards European and United States MTCT rates, where paediatric HIV infections are 1% or less.     

National and provincial estimated costs and cost effectiveness of a programme to reduce mother-to-child HIV transmission in South Africa.

OBJECTIVE: To estimate the cost and cost effectiveness nationally and for each province of a programme to reduce mother-to-child transmission (MTCT) of HIV in South Africa. METHODS: A model developed to estimate cost and cost effectiveness of interventions in Hlabisa, KwaZulu-Natal, was modified and applied to each province. This model predicts a 37% reduction in paediatric HIV infections if short-course oral zidovudine (ZDV) plus infant formula feed for 4 months is provided within a strengthened health system. Estimates of the number of pregnancies and HIV prevalence among pregnant women per province in 1997 were combined with an estimated 30% MTCT rate. Costs were calculated from a health system perspective, and effectiveness was estimated as cost per infection averted and cost per disability-adjusted life year (DALY) gained. RESULTS: In 1997, 63,397 paediatric HIV infections were estimated to have occurred in South Africa, mainly in KwaZulu-Natal (18,513, 29%) and Gauteng (10,417, 16%). The cost of a national programme is estimated at R155.9 million (1997 rand costs, 0.94% of the national health budget). Major cost items are drugs (R46.4 m, 30%), staff salaries (R45.8 m, 29%), and formula feed (R37.1 m, 24%). Most money would need to be spent in KwaZulu-Natal (R37.6 m, 24% of national cost), Gauteng (R25.2 m, 16%) and the Eastern Cape (R24 m, 15%). National cost per infection averted is R6,724, and R213 per DALY gained. Provincial DALY costs range from R176 to R369. CONCLUSIONS: A national programme preventing 37% of expected paediatric HIV infections would cost a small fraction of the national health budget, at a cost equivalent to R3.89 per capita total population. The cost per DALY gained compares well with established public health and clinical interventions in middle-income countries, even without factoring in the care costs that would be saved through a successful programme. Cost effectiveness is greatest where HIV prevalence is highest.     

Public health lessons from a pilot programme to reduce mother-to-child transmission of HIV-1 in Khayelitsha.

OBJECTIVE: Short-course antiretroviral therapy (ART) has been shown to be effective in reducing mother-to-child transmission (MTCT) of HIV-1. This article details the public health lessons learnt from a district-based pilot programme where a short-course zidovudine (ZDV) regimen has been used in a typical South African peri-urban setting. METHODS: The pilot programme was initiated at two midwife obstetric units in January 1999. Lay counsellors conducted pre- and post-test counselling and nurses took blood for HIV enzyme-linked immunosorbent assay (ELISA) testing. Short-course ZDV was administered antenatally (from 36 weeks' gestation) and during labour. Mother-infant pairs were followed up at eight child health clinics where free formula feed was dispensed weekly. Infants received co-trimoxazole prophylaxis and were ELISA tested for HIV at 9 and 18 months. After 17 months protocol changes aimed at eliminating weaknesses included initiation of ZDV at 34 weeks, self-administration of the first dose of ZDV with the onset of labour, and rapid HIV testing for both mothers and infants. RESULTS: Voluntary counselling and testing was shown to be highly acceptable, with individual counselling more effective than group counselling. Based on less than optimal availability of records, ZDV utilisation was encouraging with up to 59% of subjects initiating treatment, 3 weeks' median duration of ZDV use, and up to 88% receiving at least one intrapartum ZDV dose. Self-administration of the intrapartum dose reached 41%. CONCLUSIONS: Short-course antenatal and intrapartum ART to prevent MTCT of HIV1 was shown to be feasible.     

24‐Month HIV‐free survival among HIV‐exposed Infants in Lesotho: the PEAWIL cohort study

IntroductionFollowing the implementation of the provision of lifelong antiretroviral therapy to all HIV‐positive pregnant or breastfeeding women for prevention of mother‐to‐child transmission (PMTCT) of HIV by the Kingdom of Lesotho in 2013, we assessed the effectiveness of this approach by evaluating 24‐month HIV‐free survival among HIV‐exposed infants (HEIs).MethodsWe conducted a prospective observational cohort study that enrolled HIV‐positive and HIV‐negative pregnant women, with follow‐up of women and their infants for 24 months after delivery. Participant recruitment started in June 2014 and follow‐up ended in September 2018. Trained nurses collected study information through patient interviews and chart abstraction at enrolment and every three to six months thereafter. Maternal HIV testing, infant mortality, HIV transmission and HIV‐free survival rates were computed using Kaplan–Meier estimation. Cox regression hazard models were used to identify factors associated with infant HIV infection and death.ResultsBetween June 2014 and February 2016, we enrolled 653 HIV‐positive and 941 HIV‐negative pregnant women. Twenty‐seven HIV‐negative women acquired HIV during follow‐up. Ultimately, 634 liveborn HEI (382 (52%) male, 303 (48%) female, 3 missing) and 839 who remained HIV‐unexposed (HUIs) (409 (49.0%) male, 426 (51.0%) female, 4 missing) were followed; 550 HEIs and 701 HUIs completed the 24‐month follow‐up period. Of 607 (95.7%) HEIs who were tested for HIV at least once during follow‐up, 17 were found to be HIV‐positive. Two (9.5%) of 21 infants born to mothers who acquired HIV infection during follow‐up were HIV‐positive compared to 15 (2.4%) of 613 HEI born to women with known HIV infection. The risk of HIV transmission from HIV‐positive mothers to their infants by 24 months of age was 2.9% (95% CI: 1.8 to 4.7). The estimated 24‐month mortality rate among HEIs was 6.0% (95% CI: 4.4 to 8.2) compared to 3.8% (95% CI: 2.6 to 5.3) among HUIs (Log‐rank p = 0.065). HIV‐free survival at 24 months was 91.8% (95% CI: 89.2 to 93.7). Lower maternal age and birth weight were independently associated with increased HIV infection or death of infants.ConclusionsThe implementation of lifelong ART for PMTCT in the Lesotho public health system resulted in low HIV transmission, but survival of HEI remains lower than their HIV uninfected counterparts.     

Perinatal health in the peri-urban township of Khayelitsha, Cape Town. Part I. Mothers and their newborn infants

The satellite 'city' of Khayelitsha lies some 40 km south-east of the centre of metropolitan Cape Town. The first phase of the development, Town 1, including a large 'squatter' area, accommodates approximately 150,000 people at present. It is envisaged that ultimately the entire 3,200 ha site will house between 250,000 and 350,000 people. In order to obtain useful planning information for future community obstetric and neonatal health care services, a survey of all births within the Peninsula Maternal and Neonatal Service (PMNS) during 1986 was undertaken. Of a total of 2,113 mothers from Khayelitsha, 2,000 (94.7%) gave birth to a live singleton infant. The mean maternal age was 26.2 years, 15.1% of mothers being under 20 years of age. The mean parity was 3.03, and 18.3% of mothers were having their first baby. Only 3.1% of mothers booked early (in the first trimester); however, 91.9% were booked before delivery. The average number of prenatal visits was 3. The largest proportion of mothers (43.1%) delivered at the Heideveld midwife obstetric unit (MOU). There was an overall pre-term rate of 7.6%, while 8.8% of infants were of low birth weight (LBW) (less than 2,500 g). In addition, 51.4% of the LBW infants were born at term. The mean birth weight was 3,160 g. The largest proportion of mothers (53.6%) were residents of the 'squatter' area. No statistically significant differences in obstetric features, maternal characteristics and pregnancy outcome were discernible between the squatter, site-and-service, and core housing areas of Khayelitsha, with the exception of higher maternal weight, earlier booking and more antenatal visits in the group from the core housing area.     

Do BRCA1 mutations affect the ability to breast-feed? Significantly shorter length of breast-feeding among BRCA1 mutation carriers compared with their unaffected relatives

The difference in length of breast feeding between women with a BRCA 1 mutation and their unaffected relatives was investigated. Fifty women belonging to a family with a known BRCA1 mutation had themselves undergone testing and each had given birth to at least one child. Women with BRCA1 mutation breast-fed their first infant for a significantly shorter period (P = 0.048) and the second and third infants for a non-significantly shorter time than their unaffected relatives. Computing a mean breast-feeding time per child based on the first three infants and also taking birth year of the mother and smoking into account, having a BRCA1 mutation was associated with a significantly shorter time of breast-feeding (P = 0.034), and so was smoking (P = 0.001), but birth year of the woman did not significantly influence length of breast-feeding. Seventy-five per cent of the assessable women with a BRCA1 mutation stopped breast-feeding owing to little or no milk production compared with 36% of the non-carriers OR = 5.3 (CI 95% 1.1–22.1) and (P = 0.02). Our finding may reflect a disturbed differentiation of the breast tissue in women with BRCA1 mutations.     

Factors influencing breast-feeding in an urban community

In an attempt to answer the question of what influences mothers' decisions on how to feed their babies, a questionnaire was administered to 200 mothers when their babies were approximately 1 year of age. The questions covered a wide variety of factors, including socio-economic, educational, housing and family details, employment, ante- and perinatal experiences, maternal beliefs, support systems and actual feeding practices. Those mothers who had breast-fed their babies for longer than 36 weeks were compared with those who had stopped before 12 weeks. The most important factors distinguishing the two groups, as decided by stepwise regression analysis, were the beliefs that breast-feeding helps teething and does not make the baby irritable; also female babies were more likely to be breast-fed and the postnatal income of the mother was important. It is believed that these factors, together with the other, less statistically significant differences, should be used when formulating breast-feeding promotion strategies. The importance of income, and therefore of employment, underlines the necessity for legislation requiring large-scale employers of women to provide crèches and breast-feeding breaks for female staff.     

Breast feeding after breast reduction]

Few authors have addressed the feasibility of breast-feeding after a reduction mammaplasty. Nowadays, the majority of plastic surgeons perform breast reductions with techniques preserving the continuity of the nipple-areola complex with the retained breast tissue. These pedicle techniques should permit lactation as opposed to the free nipple grafting technique used earlier. To find out how many women nurse their children after a reduction mammaplasty, we reviewed 806 charts to identify 243 women having had a pedicle technique breast reduction, between 1967-1987, at the age of 15 to 35 years. These women were contacted and 98 of them were reached. Eighteen women had become pregnant after their surgery. They agreed to answer a questionnaire regarding their decision to nurse their children, the duration of breast-feeding and the difficulties encountered. Eight of eighteen mothers (45%) nursed their children up to 32 weeks (mean 11 weeks). Among them, 3 nursed for less than 3 weeks and 5 nursed from 3 to 32 weeks (mean 20 weeks). Only one mother had to supplement nursing with formula. Two mothers used mixed formula and breast-feeding when they returned to work. Ten of eighteen mothers (55%) did not breast-feed for the following reasons: 6 by personal choice, 2 due to premature delivery, one was advised that nursing was not feasible and one had no lactation. We believe that the nursing capacity of the breast is preserved after a breast reduction and that women should be encouraged to nurse their children.     

Uptake of early infant diagnosis in Thailand’s national program for preventing mother-to-child HIV transmission and linkage to care, 2008–2011

Introduction

Early infant diagnosis (EID) has been a component of Thailand''s prevention of mother-to-child HIV transmission (PMTCT) programme since 2007. This study assessed the uptake, EID coverage, proportion of HIV-exposed infants receiving a definitive HIV diagnosis, mother-to-child transmission (MTCT) rates and linkage to HIV care and treatment.

Methods

Infant polymerase chain reaction (PCR) testing data from the National AIDS Program database were analyzed. EID coverage was calculated as the percentage of number of HIV-exposed infants receiving ≥1 HIV PCR test divided by the number of HIV-exposed infants estimated from HIV prevalence and live-birth registry data. Definitive HIV diagnosis was defined as having two concordant PCR results. MTCT rates were calculated based on infants tested with PCR and applied as a best-case scenario, and a sensitivity analysis was used to adjust these rates in average and worst scenarios. We defined linkage to HIV care as infants with at least one PCR-positive test who were registered with Thailand''s National AIDS Program. Chi-squared tests for linear trend were used to analyze changes in programme coverage.

Results

For 2008 to 2011, the average EID coverage rate increased from 54 to 76% (p<0.001), with 65% coverage (13,761/21,099) overall. The number of hospitals submitting EID samples increased from 458 to 645, and the percentage of community hospitals submitting samples increased from 75 to 78% (p=0.044). A definitive HIV diagnosis was made for 10,854 (79%) infants during this period. The adjusted MTCT rates had significantly decreasing trends in all scenarios. Overall, an estimated 53% (429/804) of HIV-infected infants were identified through the EID programme, and 80% (341/429) of infants testing positive were linked to care. The overall rate of antiretroviral treatment (ART) initiation within one year of age was 37% (157/429), with an increasing trend from 28 to 52% (p<0.001).

Conclusions

EID coverage increased and MTCT rates decreased during 2008 to 2011; however, about half of HIV-infected infants still did not receive EID. Most HIV-infected infants were linked to care but less than half initiated ART within one year of age. Active follow-up of HIV-exposed infants to increase early detection of HIV infection and early initiation of ART should be more widely implemented.     

Optimizing HIV retesting during pregnancy and postpartum in four countries: a cost‐effectiveness analysis

IntroductionHIV retesting during late pregnancy and breastfeeding can help detect new maternal infections and prevent mother‐to‐child HIV transmission (MTCT), but the optimal timing and cost‐effectiveness of maternal retesting remain uncertain.MethodsWe constructed deterministic models to assess the health and economic impact of maternal HIV retesting on a hypothetical population of pregnant women, following initial testing in pregnancy, on MTCT in four countries: South Africa and Kenya (high/intermediate HIV prevalence), and Colombia and Ukraine (low HIV prevalence). We evaluated six scenarios with varying retesting frequencies from late in antenatal care (ANC) through nine months postpartum. We compared strategies using incremental cost‐effectiveness ratios (ICERs) over a 20‐year time horizon using country‐specific thresholds.ResultsWe found maternal retesting once in late ANC with catch‐up testing through six weeks postpartum was cost‐effective in Kenya (ICER = $166 per DALY averted) and South Africa (ICER=$289 per DALY averted). This strategy prevented 19% (Kenya) and 12% (South Africa) of infant HIV infections. Adding one or two additional retests postpartum provided smaller benefits (1 to 2 percentage point increase in infections averted versus one retest). Adding three retests during the postpartum period averted additional infections (1 to 3 percentage point increase in infections averted versus one retest) but ICERs ($7639 and in Kenya and $11 985 in South Africa) greatly exceeded the cost‐effectiveness thresholds. In Colombia and Ukraine, all retesting strategies exceeded the cost‐effectiveness threshold and prevented few infant infections (up to 31 and 5 infections, respectively).ConclusionsIn high HIV burden settings with MTCT rates similar to those seen in Kenya and South Africa, HIV retesting once in late ANC, with subsequent intervention, is the most cost‐effective strategy for preventing infant HIV infections. In these settings, two HIV retests postpartum marginally reduced MTCT and were less costly than adding three retests. Retesting in low‐burden settings with MTCT rates similar to Colombia and Ukraine was not cost‐effective at any time point due to very low HIV prevalence and limited breastfeeding.     

Efficacy of WHO recommendation for continued breastfeeding and maternal cART for prevention of perinatal and postnatal HIV transmission in Zambia

Introduction

To prevent mother-to-child transmission (MTCT) of HIV in developing countries, new World Health Organization (WHO) guidelines recommend maternal combination antiretroviral therapy (cART) during pregnancy, throughout breastfeeding for 1 year and then cessation of breastfeeding (COB). The efficacy of this approach during the first six months of exclusive breastfeeding has been demonstrated, but the efficacy of this approach beyond six months is not well documented.

Methods

A prospective observational cohort study of 279 HIV-positive mothers was started on zidovudine/3TC and lopinavir/ritonavir tablets between 14 and 30 weeks gestation and continued indefinitely thereafter. Women were encouraged to exclusively breastfeed for six months, complementary feed for the next six months and then cease breastfeeding between 12 and 13 months. Infants were followed for transmission to 18 months and for survival to 24 months. Text message reminders and stipends for food and transport were utilized to encourage adherence and follow-up.

Results

Total MTCT was 9 of 219 live born infants (4.1%; confidence interval (CI) 2.2–7.6%). All breastfeeding transmissions that could be timed (5/5) occurred after six months of age. All mothers who transmitted after six months had a six-month plasma viral load >1,000 copies/ml (p<0.001). Poor adherence to cART as noted by missed dispensary visits was associated with transmission (p=0.04). Infant mortality was lower after six months of age than during the first six months of life (p=0.02). The cumulative rate of infant HIV infection or death at 18 months was 29/226 (12.8% 95 CI: 7.5–20.8%).

Conclusions

Maternal cART may limit MTCT of HIV to the UNAIDS target of <5% for eradication of paediatric HIV within the context of a clinical study, but poor adherence to cART and follow-up can limit the benefit. Continued breastfeeding can prevent the rise in infant mortality after six months seen in previous studies, which encouraged early COB.     

Vaginal microbicides for preventing mother-to-child transmission of HIV infection--no evidence of an effect or evidence of no effect?

BACKGROUND: Vaginal disinfection is a simple, potentially effective strategy for reducing mother-to-child transmission (MTCT) of HIV that can be implemented in combination with antiretroviral therapy or even in the absence of prenatal HIV testing. We systematically reviewed currently available randomised controlled trials to estimate the benefits and risks of this intervention. METHODS: We conducted an exhaustive search for published and unpublished trials assessing the effect of vaginal microbicides on MTCT of HIV, extracted data in triplicate, assessed statistical heterogeneity between trial results, and conducted meta-analysis using Mantel-Haenszel's method. FINDINGS: Five potentially eligible studies were identified, two of which met eligibility criteria. Pooling the data shows that the effect of vaginal disinfection on the risk of MTCT of HIV (relative risk (RR) 0.94, 95% confidence interval (CI) 0.71 - 1.25) and neonatal death (RR 1.36, 95% CI 0.32 - 5.79) is uncertain. The combined data (two trials with 708 participants) had less than 80% power to detect a 30% reduction in the risk of MTCT of HIV from a baseline risk of 30%, and are compatible with a wide range of effects; from a 29% reduction to a 25% increase in risk. One trial, with 108 participants, showed no evidence that adverse effects increased in mothers (RR 1.02, 95% CI 0.87 - 1.20) and found that adverse effects decreased in neonates (RR 0.45, 95% CI 0.32 - 0.64). INTERPRETATION: At present there is insufficient and inconclusive evidence on the effect of vaginal microbicides on the risk of MTCT of HIV. This review identifies the need and provides the impetus for an adequately powered randomised controlled trial to assess the effect(s) of this inexpensive intervention.     

Retrospective stuclies on lactation mastitis distribution in breast

Objective To find out the factors which would be likely to affect the occurrence of lactation mastitis.Methods 216 patients with lactation mastitis,who met our grouping criteria,were chosen for survey and clinical data collection.Their age,time of onset,mode of delivery,post-partum colostrum time,mastering of breast-feeding skills,feeding habits,occurring site of their mastitis and other data were input into SPSS 17.0 software,respectively,to perform retrospective analysis.Results Patients' average age and their age of first breast-feeding were all 30 years old ; the average age of their first pregnancy were 27 years old.Their initial post-natal breast-feeding was about 2 to 4 days.The onset of incidence of mastitis was about 28 days post-natal.First,second and third pregnancy patients represented 1/3 of the total patients respectively.63.4％ patients had cesarean delivery and only 36.6％ patients had vaginal delivery; 91.7％ were outpatients and 8.3％ patients were inpatients.10.6％ patients had abscess and 89.4％ patients hadn't.The distribution ratio of inflammation in the upper outer,lower outer,lower inner and upper inner quadrants of the breast was 30.6％,48.1％,19％,2.3％ respectively.If the mode of delivery is considered as a factor to investigate incidence time of mastitis and postpartum colostrums time,no significant difference between the two groups was found (P ＞ 0.05).Our survey indicated that 79.2％ patients did not have any knowledge of breastfeeding,8.8％ patients got the breast-feeding knowledge from their mothers,11.6％ patients got the breastfeeding knowledge from books or web resources,only 0.5％ of the patients participated in the training of breast-feeding.76.9％ patients never had breast massage,19％ of patients had a few times of massage,2.8％ of patients had occasional massage,and only 1.4％ of patients had regular breast massage with the help of their family.85.6％ patients didn't have their breasts emptied from breast-feeding to incidence of mastitis,11.6％ patients occasionally emptied their breasts,and only 2.8％ of patients can ensure one side of the breasts emptied daily.56.5％ patients used lying position with the lower breast as the most common breastfeeding posture,37％ patients used sitting position,only 6.5％ of patients used lying position with the upper breast.The correlation analysis of breeding posture and occurring site of lactation mastitis revealed that the Spearman coefficient was-0.14,P value was 0.04,which is statistically significant,suggesting there is correlation between occurring sites of lactation mastitis and breeding posture.Conclusions Mothers need to master breast-feeding skills including breast massage,breast milk emptying and breast-feeding postures to prevent the occurrence of mastitis.Furthermore,gravity probably affects the occurring sites of mastitis through its impact on patients' preferred breast-feeding postures.     

Urbanisation and women's health in Khayelitsha. Part II. Health status and use of health services

A study was conducted among women in Khayelitsha to determine the relationship between urbanisation, health status and use of health services; 722 households were visited, and 659 female respondents provided information on acute and chronic illness for the 3,229 individuals who were members of their households. In addition, they provided information concerning their reproductive health, AIDS awareness, knowledge of cervical smears and use and knowledge of health services. Acute illness was reported for 4.3% of the study population, the commonest complaints being diarrhoea, abdominal pain and upper respiratory infections; 4.4% reported chronic illness, the commonest complaints being hypertension and tuberculosis; 16.2% of women reported gynaecological illness; 86% had of heard of AIDS (although their knowledge of transmission and prevention was poor); and 45% had heard of cervical smears. Patterns of illness and knowledge and use of health services vary in the different areas of residence of Khayelitsha. This appears to be related to urbanisation, age, and environmental and socio-economic factors.