Maternal Combination Antiretroviral Therapy Is Associated with Improved Retention of HIV-Exposed Infants in Kinshasa, Democratic Republic of Congo

  • Journal of Acquired Immune Deficiency Syndromes, Volume 69, No. 3, Year 2015

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Study Justification:
– The study aimed to assess whether providing combination antiretroviral therapy (cART) to HIV-infected mothers would reduce loss to follow-up (LTFU) of their HIV-exposed infants in Kinshasa, DR Congo.
– Programs to prevent mother-to-child HIV transmission often face challenges with LTFU of HIV-exposed infants, which hinders the effectiveness of interventions.
– Understanding the impact of maternal cART on infant retention is crucial for improving the clinical and population-level outcomes of prevention of mother-to-child HIV transmission interventions.
Study Highlights:
– A cohort of mother-infant pairs was constructed using routinely collected clinical data.
– Maternal cART eligibility was determined based on national guidelines.
– Infants were considered LTFU if they had 3 failed tracking attempts after a missed visit or if more than 6 months had passed since their last clinic visit.
– Statistical methods accounted for competing risks, such as death.
– A total of 1318 infants were enrolled at a median age of 2.6 weeks, with 24% of mothers receiving cART at that time.
– Overall, 5% of infants never returned to care after enrollment, and 18% were LTFU by 18 months.
– Infants whose mothers initiated cART by infant enrollment had an 18-month cumulative incidence of LTFU of 8%, compared to 20% among infants whose mothers were not yet on cART.
– Adjusted for baseline factors, infants whose mothers were not on cART were over twice as likely to be LTFU, with a subdistribution hazard ratio of 2.75.
– The association between maternal cART and reduced LTFU remained strong regardless of maternal CD4 count at infant enrollment.
Recommendations for Lay Reader and Policy Maker:
– Increasing access to cART for pregnant women could improve the retention of HIV-exposed infants.
– This would enhance the effectiveness of prevention of mother-to-child HIV transmission interventions and early access to cART for HIV-infected infants.
– Policy makers should prioritize efforts to expand access to cART for pregnant women, ensuring that national guidelines are followed and that resources are allocated accordingly.
– Lay readers should be aware of the importance of maternal cART in improving the long-term health outcomes of HIV-exposed infants and the overall impact on reducing mother-to-child HIV transmission.
Key Role Players:
– Ministry of Health: Responsible for implementing policies and guidelines related to HIV prevention and treatment, including access to cART for pregnant women.
– Healthcare Providers: Involved in the identification, counseling, and provision of cART to HIV-infected pregnant women.
– Community Health Workers: Play a crucial role in tracking and following up with HIV-exposed infants to ensure their retention in care.
– Non-Governmental Organizations (NGOs): Provide support and resources for HIV prevention and treatment programs, including initiatives targeting pregnant women and infants.
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare providers on cART administration and monitoring.
– Procurement and distribution of antiretroviral drugs for pregnant women.
– Development and implementation of tracking systems for HIV-exposed infants.
– Community outreach and engagement activities to improve awareness and adherence to cART among pregnant women.
– Monitoring and evaluation of the program’s impact on infant retention and mother-to-child HIV transmission rates.

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Background: Programs to prevent mother-to-child HIV transmission are plagued by loss to follow-up (LTFU) of HIV-exposed infants. We assessed if providing combination antiretroviral therapy (cART) to HIV-infected mothers was associated with reduced LTFU of their HIV-exposed infants in Kinshasa, DR Congo. Methods: We constructed a cohort of mother-infant pairs using routinely collected clinical data. Maternal cART eligibility was based on national guidelines in effect at the time. Infants were considered LTFU after 3 failed tracking attempts after a missed visit or if more than 6 months passed since they were last seen in clinic. Statistical methods accounted for competing risks (eg, death). Results: A total of 1318 infants enrolled at a median age of 2.6 weeks (interquartile range: 2.1-6.9), at which point 24% of mothers were receiving cART. Overall, 5% of infants never returned to care after enrollment and 18% were LTFU by 18 months. The 18-month cumulative incidence of LTFU was 8% among infants whose mothers initiated cART by infant enrollment and 20% among infants whose mothers were not yet on cART. Adjusted for baseline factors, infants whose mothers were not on cART were over twice as likely to be LTFU, with a subdistribution hazard ratio of 2.75 (95% confidence limit: 1.81 to 4.16). The association remained strong regardless of maternal CD4 count at infant enrollment. Conclusions: Increasing access to cART for pregnant women could improve retention of HIV-exposed infants, thereby increasing the clinical and population-level impacts of prevention of mother-tochild HIV transmission interventions and access to early cART for HIV-infected infants.

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The recommendation from the study titled “Maternal Combination Antiretroviral Therapy Is Associated with Improved Retention of HIV-Exposed Infants in Kinshasa, Democratic Republic of Congo” is to increase access to combination antiretroviral therapy (cART) for pregnant women. This recommendation is based on the finding that providing cART to HIV-infected mothers was associated with reduced loss to follow-up (LTFU) of their HIV-exposed infants.

To implement this recommendation, several innovations can be considered:

1. Expanding HIV testing and counseling services for pregnant women: This can help identify HIV-infected pregnant women early in their pregnancy and ensure they receive appropriate care and treatment, including access to cART.

2. Strengthening healthcare infrastructure: Improving the availability and accessibility of healthcare facilities, particularly in rural areas, can help pregnant women access antenatal care services and receive cART.

3. Integrating HIV services into maternal and child health programs: By integrating HIV services into existing maternal and child health programs, pregnant women can receive comprehensive care, including HIV testing, counseling, and access to cART, in a more streamlined and efficient manner.

4. Task-shifting and training healthcare providers: Expanding the capacity of healthcare providers, such as nurses and midwives, to provide HIV testing, counseling, and cART services can help increase access to these interventions for pregnant women.

5. Community-based interventions: Engaging community health workers and community-based organizations can help raise awareness about the importance of HIV testing and treatment during pregnancy, and provide support and follow-up for HIV-infected pregnant women to ensure they stay on cART.

These innovations can contribute to increasing access to cART for pregnant women, leading to improved retention of HIV-exposed infants in care and better outcomes for both mothers and infants.
AI Innovations Description
The recommendation from the study titled “Maternal Combination Antiretroviral Therapy Is Associated with Improved Retention of HIV-Exposed Infants in Kinshasa, Democratic Republic of Congo” is to increase access to combination antiretroviral therapy (cART) for pregnant women. This recommendation is based on the finding that providing cART to HIV-infected mothers was associated with reduced loss to follow-up (LTFU) of their HIV-exposed infants.

The study found that infants whose mothers initiated cART by the time of infant enrollment had a lower risk of being LTFU compared to infants whose mothers were not yet on cART. The association remained strong regardless of the maternal CD4 count at infant enrollment.

By increasing access to cART for pregnant women, it is expected that the retention of HIV-exposed infants in care will improve. This can have significant clinical and population-level impacts on the prevention of mother-to-child HIV transmission interventions and access to early cART for HIV-infected infants.

The study was published in the Journal of Acquired Immune Deficiency Syndromes in 2015.
AI Innovations Methodology
To simulate the impact of the main recommendations from this study on improving access to maternal health, you could consider the following methodology:

1. Identify the target population: Determine the population of pregnant women living with HIV in the specific region or country of interest. This could be done using existing data sources such as national HIV surveillance programs or health facility records.

2. Assess current access to combination antiretroviral therapy (cART): Collect data on the proportion of pregnant women living with HIV who currently have access to cART. This can be obtained from health facility records, national treatment programs, or surveys.

3. Estimate the potential impact of increased access to cART: Using the findings from the study, calculate the potential reduction in loss to follow-up (LTFU) of HIV-exposed infants if more pregnant women had access to cART. Apply the reported subdistribution hazard ratio (2.75) to estimate the relative reduction in LTFU among infants whose mothers are not on cART.

4. Model the impact on retention of HIV-exposed infants: Develop a mathematical model or simulation to project the impact of increased access to cART on the retention of HIV-exposed infants in care. This model should consider factors such as the current LTFU rate, the proportion of pregnant women currently on cART, and the estimated reduction in LTFU based on increased access to cART.

5. Sensitivity analysis: Conduct sensitivity analyses to explore the potential impact of different scenarios, such as varying levels of cART coverage or different assumptions about the reduction in LTFU. This will help assess the robustness of the findings and provide a range of potential outcomes.

6. Policy implications: Based on the results of the simulation, provide recommendations for policymakers and program managers on strategies to increase access to cART for pregnant women. Consider factors such as scaling up HIV testing and counseling services, improving linkage to care, and strengthening health systems to support the delivery of cART to pregnant women.

It is important to note that this methodology is a general outline and may need to be adapted based on the specific context and available data. Additionally, collaboration with local stakeholders and experts in the field is crucial to ensure the accuracy and relevance of the simulation.

Statistics:
Citations: 14
Authors: 10
Identifiers:
DOI: 10.1097/QAI.0000000000000644
ISSN: 15254135
Research Areas:
Community Interventions, Environmental, Health System and Policy, Infectious Diseases, Maternal and Child Health, Quality of Care
Study Countries:
Congo
Study Design:
Cohort Study, Cross Sectional Study
Participants Gender:
Female
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