Preventing HIV-1 transmission in breastfed infants in low resource settings: early HIV infection and late postnatal transmission in a routine prevention of mother-to-child transmission program in Yaounde, Cameroon.

OBJECTIVE: To report on overall HIV-transmission rates [early and late postnatal transmission (LPNT)] in breastfed infants born to HIV-positive women. METHODS: Mother-baby pairs in a routine prevention of mother-to-child transmission program. Promotion of exclusive breastfeeding (EBF) coupled with access to antiretroviral treatment (ART) or prevention using antiretroviral (pARV). Early infant diagnosis using HIV-RNA/PCR or HIV-DNA/PCR >6 weeks. LPNT assessed 6 weeks after weaning in infant earlier tested negative. MAIN MEASUREMENT: early HIV infection and LPNT. RESULTS: We included 285 infants for analysis; 89.5 % of mothers were receiving ART or pARV; 86% babies took daily pARV (median duration, 6 weeks). Exclusive breastfeeding (EBF) rate: 96% (median duration, 4 months). The cumulative transmission of HIV-1 was 2.8% at 8 weeks (95% confidence interval: 1.9-3.7). After weaning (abrupt 44%), 3 of 212 infants were HIV infected (1.4%). Nine-month cumulative HIV-transmission rate was 4.2% (1.5-6.9). Incidence of late postnatal HIV infection stood at 1.5/100 child-years of breastfeeding (BF). Cumulative risk of HIV transmission (8 weeks-9 months) was 1%. CONCLUSION: Both promotion of EBF and access to antiretroviral therapy contribute to lower HIV transmission in breastfed infants in low resource settings.

Early outcomes of HIV exposed children in the first district-wide programme using extended regimens for the prevention of mother-to-child transmission of HIV, in Yaounde, Cameroon.

OBJECTIVE: Report on the early outcomes achieved in the prevention of mother-to-child transmission (PMTCT) programme in the Djoungolo Health District using more effective antiretroviral PMTCT regimens. METHODS: Observational cohort of HIV exposed infants. MAIN OUTCOME MEASURE: early infant HIV status and 3-month mortality rate. RESULTS: From March 2008 to March 2010, 587 HIV-positive mother-baby pairs were enrolled and classified according to the following maternal antiretroviral regimen: Group 1: highly active antiretroviral therapy (HAART), Group 2: dual therapy, Group 3: no treatment. 484/587 (82%) underwent HIV-early infant diagnosis at a median age of 7 weeks; 4.5% (95% CI 2.65-6.34) were HIV-infected. HIV transmission rate differed by maternal prophylaxis: 1.7% for HAART, 2.7% for dual therapy and 15.7% for Group 3 (p < 0.001), but not by feeding method (2.74%)-exclusive breastfeeding vs. 5.34% formula (NS). The 3-month mortality rate stands at 1%. CONCLUSIONS: The 4.5% MTCT-rate of HIV-1 reported, confirms the feasibility and effectiveness of a district wide PMTCT programme using HAART in low-income settings.

Virological profile of pregnant HIV positive women with high levels of CD4 count in low income settings: can viral load help as eligibility criteria for maternal triple ARV prophylaxis (WHO 2010 option B)?

INTRODUCTION: The objective of the study was to determine HIV-1 RNA load profile during pregnancy and assess the eligibility for the maternal triple antiretroviral prophylaxis. It was an observational cohort of pregnant HIV positive women ignorant of antiretroviral therapy with CD4 cell count of > 350/mm(3) METHODS: Routine CD4 cell count assessment in HIV positive pregnant women completed by non exclusive measurement of the viral load by PCR /ARN in those with CD4 cell count > 350/mm(3). EXCLUSION CRITERIA: highly active antiretroviral therapy prior to pregnancy. RESULTS: Between January and December 2010, CD4 cell count was systematically performed in all pregnant women diagnosed as HIV-infected (n=266) in a referral center of 25 antenatal clinics. 63% (N=170) had CD4 cell count > 350/mm(3), median: 528 (IQR: 421-625). 145 underwent measurement of viral load by PCR/RNA at a median gestational of 23 weeks of pregnancy (IQR: 19-28). Median viral load 4.4 log(10)/ml, IQR (3.5-4.9).19/145(13%) had an undetectable viral load of = 1.8 log(10)/ml. 89/145(61%) had a viral load of = 4 log(10)/ml and were eligible for maternal triple ARV prophylaxis. CONCLUSION: More than 6 in 10 pregnant HIV positive women with CD4 cell count of > 350/mm(3) may require triple antiretroviral for prophylaxis of MTCT. Regardless of cost, such results are conclusive and may be considered in HIV high burden countries for universal access to triple antiretroviral prophylaxis in order to move towards virtual elimination of HIV MTCT.

Effectiveness of multidrug antiretroviral regimens to prevent mother-to-child transmission of HIV-1 in routine public health services in Cameroon.

BACKGROUND: Multidrug antiretroviral (ARV) regimens including HAART and short-course dual antiretroviral (sc-dARV) regimens were introduced in 2004 to improve Prevention of Mother-to-Child Transmission (PMTCT) in Cameroon. We assessed the effectiveness of these regimens from 6-10 weeks and 12 months of age, respectively. METHODOLOGY/FINDINGS: We conducted a retrospective cohort study covering the period from October 2004 to March 2008 in a reference hospital in Cameroon. HIV-positive pregnant women with CD4 < or = 350 cells/mm(3) received first-line HAART [regimen 1] while the others received ARV prophylaxis including sc-dARV or single dose nevirapine (sd-NVP). Sc-dARV included at least two drugs according to different gestational ages: zidovudine (ZDV) from 28-32 weeks plus sd-NVP [regimen 2], ZDV and lamuvidine (3TC) from 33-36 weeks plus sd-NVP [regimen 3]. When gestational age was > or = 37 weeks, women received sd-NVP during labour [regimen 4]. Infants received sd-NVP plus ZDV and 3TC for 7 days or 30 days. Early diagnosis (6-10 weeks) was done, using b-DNA and subsequently RT-PCR. We determined early MTCT rate and associated risk factors using logistic regression. The 12-month HIV-free survival was assessed using Cox regression. Among 418 mothers, 335 (80%) received multidrug ARV regimens (1, 2, and 3) and MTCT rate with multidrug regimens was 6.6% [95%CI: 4.3-9.6] at 6 weeks, without any significant difference between regimens. Duration of mother's ARV regimen < 4 weeks [OR = 4.7, 95%CI: 1.3-17.6], mother's CD4 < 350 cells/mm(3) [OR = 6.4, 95%CI: 1.8-22.5] and low birth weight [OR = 4.0, 95%CI: 1.4-11.3] were associated with early MTCT. By 12 months, mixed feeding [HR = 8.7, 95%CI: 3.6-20.6], prematurity [HR = 2.3, 95%CI: 1.2-4.3] and low birth weight were associated with children's risk of progressing to infection or death. CONCLUSIONS: Multidrug ARV regimens for PMTCT are feasible and effective in routine reference hospital. Early initiation of ARV during pregnancy and proper obstetrical care are essential to improve PMTCT.

Is exclusive artificial feeding feasible at 6 months post partum in Cameroon urban areas for HIV-exposed infants?

UNLABELLED: The aim of the study was to evaluate the feasibility of infant feeding options of HIV positive mothers in urban areas (especially compliance to artificial feeding choices), before the implementation of the infant feeding interventions and procurement of breastmilksubstitutes. We conducted a survey among seropositive women diagnosed during pregnancy and counselled for infant feeding options. At 6 months post delivery an interview was done. 47 mothers were included. Bromocriptine was prescribed to all the mothers who opted for artificial feeding from birth. FINDINGS: After counselling 85% of women opted for exclusive artificial feeding of whom 83% mothers practised this option since birth. For those who opted for replacement feeding The main given reason for infant feeding choice was related to medical or nurses advices. Overall 36% [CI 95%, 22-50] of the mothers who opted for artificial milk faced difficulties to afford supplies during the 6 months, leading into an early introduction of paps. Clinical mastitis were mentioned by all those mothers who breastfed. Infant feeding choices were related to the level of education (X2 = 24.10, P = 0.002). CONCLUSION: Artificial feeding under recovery of cost seems feasible in urban areas in Cameroon and can be facilitate by the administration of antilacteal drugs. More adequate support must be provided for the mother who breastfeed in order to prevent and to treat mastitis. Additional training for counselling in HIV and infant feeding options is recommended for health workers.