In sub-Saharan Africa, most women who test HIV negative at the first antenatal care encounter are rarely tested again during pregnancy and postpartum, yet data suggests that pregnancy is associated with increased risk of HIV acquisition compared to non-pregnant women. We describe HIV incidence during pregnancy and postpartum in Lesotho, a high prevalence setting, and factors associated with HIV seroconversion. We enrolled a cohort of HIV negative women presenting at health facilities for antenatal care and followed them through delivery up to 24 months postpartum. Women were repeatedly tested for HIV according to the Lesotho Ministry of Health routine rapid HIV testing guidelines and responded to risk behavior questionnaire every three months. We estimated HIV incidence and associated 95% confidence intervals. We used mixed effects Cox regression models to identify independent factors associated with seroconversion accounting for repeated assessment. The estimated overall HIV incidence rate was 1.58 (95% CI: 1.05–2.28) per 100 person- years. The estimated HIV incidence rate during pregnancy (2.61 per 100 person-years, 95% CI: 1.12–5.14) was almost double the estimated HIV incidence during postpartum (1.36 per 100 person-years, 95% CI: 0.83–2.10). Women’s age (14–24 years compared to 25–45 years), multiple sexual partnerships, urethral discharge and no condoms nor pre-exposure prophylaxis were independently associated with HIV infection. There is an increased need for counseling and support of HIV-uninfected pregnant and breastfeeding women to stay HIV-negative, including provision of pre-exposure prophylaxis during this high-risk period, particularly among adolescent and young women.

Very early infant diagnosis (VEID) (testing within two weeks of life), combined with rapid treatment initiation, could reduce early infant mortality. Our study evaluated turnaround time (TAT) to receipt of infants' HIV test results and ART initiation if HIV-infected, with and without birth testing availability. Data from facility records and national databases were collected for 12 facilities offering VEID, as part of an observational prospective cohort study, and 10 noncohort facilities. HIV-exposed infants born in January–June 2016 and any cohort infant diagnosed as HIV-infected at birth or six weeks were included. The median TAT from blood draw to caregiver result receipt was 76.5 days at birth and 63 and 70 days at six weeks at cohort and noncohort facilities, respectively. HIV-exposed infants tested at birth were approximately one month younger when their caregivers received results versus those tested at six weeks. Infants diagnosed at birth initiated ART about two months earlier (median 6.4 weeks old) than those identified at six weeks (median 14.8 weeks). However, the long TAT for testing at both birth and six weeks illustrates the prolonged process for specimen transport and result return that could compromise the effectiveness of adding VEID to existing overburdened EID systems.

Background: Without treatment, HIV infection in pregnant women is associated with adverse pregnancy outcomes. We compared adverse pregnancy outcomes among HIV-positive women on antiretroviral therapy (ART) and HIV-negative women who enrolled for antenatal care in selected health facilities in Maseru district, Lesotho. Methods: We enrolled a cohort of HIV-positive and HIV-negative women at their first antenatal visit and followed them through delivery. Study data on miscarriage, stillbirth, preterm birth, low birth weight and birth defects were collected through participant interviews and medical record abstraction. We used the Rao-Scott χ 2 test and the t test to assess differences in characteristics and outcomes between HIV-positive and HIV-negative women and generalized estimating equations for multivariable analysis. Results: A total of 614 HIV-positive and 390 HIV-negative pregnant women were enrolled in the study with delivery information on 571 (93.1%) and 352 (90.3%) respectively. In the delivery cohort, the median age at enrolment was 28 years for HIV-positive women and 23 years for HIV-negative women with median gestational ages of 20 and 21 weeks, respectively. A total of 149 singleton pregnancies had documented adverse pregnancy outcomes; 33 (9.6%) HIV-negative pregnancies and 116 (20.6%) HIV-positive pregnancies. Compared with their HIV-negative counterparts, HIV-positive women were more likely to experience an adverse pregnancy outcome, adjusted odds ratio (AOR) 2.6 [95% confidence interval (CI): 1.71–3.97]; an intrauterine death (miscarriage or stillbirth), AOR 2.64 [95% CI: 1.25–5.49]; or a low birth weight delivery, AOR 1.89 [95% CI: 1.16–3.09]. Conclusion: Adverse pregnancy outcomes remained 2–3 times higher among HIV-positive women compared with HIV-negative women despite universal ART.

BackgroundInfants with HIV infection, particularly those infected in utero, who do not receive antiretroviral therapy (ART) have high mortality in the first year of life. Virologic diagnostic testing is recommended by the World Health Organization between ages 4 and 6 weeks after birth. However, adding very early infant diagnosis (VEID) testing at birth has been suggested to enable earlier diagnosis and rapid treatment of in utero infection. We assessed the costs of adding VEID to the standard 6-week testing in Lesotho where coverage of PMTCT services is nearly universal.MethodsRetrospective cost data were collected at eight health-care facilities in three districts participating in an observational prospective study that included birth testing as well as at the National Reference Laboratory in Lesotho, to investigate the cost-per-infection identified. Extrapolating to the national level, it was possible to estimate the impact of VEID on the identification of HIV-infected infants.ResultsThe unit cost-per-VEID test in Lesotho in 2015 was $40.50. Major cost drivers were supplies/commodities (46%) and clinical labor (22%). In 2015, 66.3% of cohort study infants born at study facilities underwent VEID; one out of 199 infants had a positive HIV DNA PCR test at birth (0.5% potential in utero infection), yielding a cost of $8,060 per HIV-positive infant identified. Sensitivity analysis showed costs based on Lesotho costing data ranged from $810 to $16,194 per-infected child with varying in utero infection rates from 5% and 0.25%, respectively. With 11,157 HIV-exposed births nationally from pregnant women on PMTCT, 66.3% VEID coverage, and 0.5% in utero infection, 37 infants infected with HIV could have been identified at birth in 2015 and 8 early infant deaths potentially averted with immediate ART compared with waiting for 6-week testing.ConclusionIf Lesotho costing data from this pilot study were applied to different epidemic circumstances, the cost-per-infected child identified by adding VEID birth testing to standard 6-week testing was lowest when in utero infection rates were high (when HIV prevalence is high and PMTCT coverage is low).

Implementation of ACF and IPT is feasible within the MCH setting. Uptake of IPT during pregnancy among HIV-positive women was high, but with a high rate of loss to follow-up.