Eliminating perinatal HIV in the United States

Gnanashanmugam, Devasena; Rakhmanina, Natella; Crawford, Keith W.; Nesheim, Steven; Ruel, Theodore; Birkhead, Guthrie S.; Chakraborty, Rana; Lawrence, Robert M.; Jean‐Philippe, Patrick; Jayashankar, Lakshmi; Hoover, Ashley; Statton, Anne; DʼSouza, Patricia; Fitzgibbon, Joseph E.; Hazra, Rohan; Warren, Barbara L.; Smith, S Abigail; Abrams, Elaine J.

doi:10.1097/qad.0000000000002080

Cited by 11 publications

(5 citation statements)

References 25 publications

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“…The high rates of treatment failure we present here, along with other studies describing the difficulties in treating paediatric HIV infection in sub-Saharan Africa [6,21À23], as well as in highresourced settings [24,25] suggests a prevailing problem across the world. Perinatal HIV transmission, whether in high-or low-resourced settings, is concentrated in the most marginalised populations [26,27] who are often disengaged from conventional health care providers. Indeed, the Mississippi child is a case in point [9], whose remission only came to light following loss to follow up and ART non-adherence.…”

Section: Discussionmentioning

confidence: 99%

HIGH-FREQUENCY failure of combination antiretroviral therapy in paediatric HIV infection is associated with unmet maternal needs causing maternal NON-ADHERENCE

et al. 2020

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Background: Early combination antiretroviral therapy (cART) reduces the size of the viral reservoir in paediatric and adult HIV infection. Very early-treated children may have higher cure/remission potential. Methods: In an observational study of 151 in utero (IU)-infected infants in KwaZulu-Natal, South Africa, whose treatment adhered strictly to national guidelines, 76 infants diagnosed via point-of-care (PoC) testing initiated cART at a median of 26 h (IQR 18À38) and 75 infants diagnosed via standard-of-care (SoC) laboratory-based testing initiated cART at 10 days (IQR 8À13). We analysed mortality, time to suppression of viraemia, and maintenance of aviraemia over the first 2 years of life. Findings: Baseline plasma viral loads were low (median 8000 copies per mL), with 12% of infants having undetectable viraemia pre-cART initiation. However, barely one-third (37%) of children achieved suppression of viraemia by 6 months that was maintained to >12 months. 24% had died or were lost to follow up by 6 months. Infant mortality was 9.3%. The high-frequency virological failure in IU-infected infants was associated not with transmitted or acquired drug-resistant mutations but with cART non-adherence (plasma cART undetectable/subtherapeutic, p<0.0001) and with concurrent maternal cART failure (OR 15.0, 95%CI 5.6À39.6; p<0.0001). High-frequency virological failure was observed in PoC-and SoC-tested groups of children. Interpretation: The success of early infant testing and cART initiation strategies is severely limited by subsequent cART non-adherence in HIV-infected children. Although there are practical challenges to administering paediatric cART formulations, these are overcome by mothers who themselves are cART-adherent. These findings point to the ongoing obligation to address the unmet needs of the mothers. Eliminating the particular barriers preventing adequate treatment for these vulnerable women and infants need to be prioritised in order to achieve durable suppression of viraemia on cART, let alone HIV cure/remission, in HIV-infected children.

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Section: Discussionmentioning

confidence: 99%

HIGH-FREQUENCY failure of combination antiretroviral therapy in paediatric HIV infection is associated with unmet maternal needs causing maternal NON-ADHERENCE

et al. 2020

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“…3–5 While there has been significant progress in reducing perinatal HIV transmission, the United States is yet to meet the proposed elimination goal of less than one infection per 100,000 live births. 6,7 In 2016, 44 infants born in the United States were diagnosed with perinatally acquired HIV, translating to a rate of 1.1 infection per 100,000 live births. 8…”

Section: Introductionmentioning

confidence: 99%

HIV testing among pregnant women with prenatal care in the United States: An analysis of the 2011–2017 National Survey of Family Growth

2020

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Although there has been significant progress in reducing perinatal human immunodeficiency virus (HIV) transmission, the United States is yet to meet the proposed elimination goal of less than one infection per 100,000 live births. Failure to screen all pregnant women for HIV as recommended by the Centers for Disease Control and Prevention can result in missed opportunities for preventing vertical transmission of HIV with antiretroviral drugs. Using the 2011–2017 National Survey of Family Growth, this study examined HIV testing among pregnant women during prenatal care. We estimated the weighted proportion of self-reported HIV testing among women whose last pregnancy ended within 12 months prior to the interview. Logistic regression models were used to determine the factors associated with HIV testing. Of the 1566 women included in the study, 76.4% (95% confidence intervals [CI] = 72.8–80.0) reported receiving an HIV test during prenatal care. In the multivariable regression model, high school diploma (adjusted odds ratio [aOR] = 1.9, 95% CI = 1.1–3.1), two completed pregnancies (aOR = 1.7, 95% CI = 1.1–2.7), health insurance coverage in the last 12 months (aOR = 1.6, 95% CI = 1.0–2.6), Hispanic race/ethnicity (aOR = 2.8, 95% CI = 1.8–4.4), and non-Hispanic black race/ethnicity (aOR = 2.2, 95% CI = 1.3–3.8) were associated with higher odds of reporting being tested for HIV. However, household income of 300% or more of the federal poverty level (aOR = 0.6, 95% CI = 0.3–0.9) and urban residence (aOR = 0.5, 95% CI = 0.3–0.9) were associated with lower odds of reporting HIV testing. These findings suggest that HIV testing among pregnant women during prenatal care is not universal and may affect achieving the goal of elimination of mother-to-child transmission of HIV in the United States.

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“…30 We also report more optimal postnatal ARV administration with a lower proportion of low-risk HEI receiving unnecessarily long durations of postnatal ARV (8.4% vs 38.2%) and a higher proportion of high-risk HEI appropriately receiving 2-3 ARVs (73.6% vs 62.5%) instead of ZDV alone. 12 Improvements to intrapartum and postnatal HIV management reported in our region can be attributed to local health departments collaborating closely with health care facilities, ongoing support by Ryan White funding of maternal and infant HIV services, 31 continued medical education for medical providers who care for pregnant women with HIV and HEI, and development and/or updates of institutional protocols to reflect latest HHS guidelines and standardize care of HEI. We have conducted annual virtual and in-person trainings and regularly participated in forums for pediatric and obstetric staff at major regional referral hospitals to educate and update medical providers on the national guidelines for the care of mothers and infants affected by HIV.…”

Section: Discussionmentioning

confidence: 99%

Progress in Eliminating Perinatal HIV Transmission in the Metropolitan DC Area Between 2018-2022

Unternaher,

Koay,

Mareuil

et al. 2024

JAIDS Journal of Acquired Immune Deficiency Syndromes

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Background: The number of perinatal HIV cases have continued to decline since the United States (US) achieved the goal of perinatal HIV elimination in 2019. We aimed to evaluate dynamics in perinatal HIV transmission in the metropolitan District of Columbia (DC) area during 2018-2022. Setting: Children’s National Hospital’s (CNH) is a major referral site for the metropolitan DC area, including suburban Maryland and Virginia, and evaluates >95% of HIV-exposed infants (HEI) in the region. Methods: A retrospective cohort study of mother-infant pairs with perinatal HIV exposure seen at CNH during 2018-2022. We describe the demographics, intrapartum/postpartum management and outcomes among mothers and HEI. Results: We analyzed 503 HEI; the majority (78.9%) were at low-risk for perinatal HIV. Most mothers were African or African American (87.1%) and had HIV RNA <50 copies/mL around delivery (78.1%). The proportion of HEI at high-risk for perinatal HIV decreased from 28.2% to 15.5% in 2018 and 2020, respectively, but increased to 24.8% in 2022. Most HEI received postnatal antiretroviral drugs for at least 4 weeks (95.3%). Seventy-nine infants (15.7%) were born to mothers diagnosed with HIV during pregnancy. Two infants (0.4%) were diagnosed with perinatally acquired HIV. Conclusion: We report high rates of antiretroviral drugs use among mother-infant pairs and a low rate of perinatal HIV transmission in metropolitan DC. Despite a 1.8-fold decrease in the number of high-risk perinatal HIV exposures since 2018, this rate rebounded in 2022. There remain opportunities to optimize maternal care and reduce the number of high-risk HEI.

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Eliminating perinatal HIV in the United States

Cited by 11 publications

References 25 publications

HIGH-FREQUENCY failure of combination antiretroviral therapy in paediatric HIV infection is associated with unmet maternal needs causing maternal NON-ADHERENCE

HIGH-FREQUENCY failure of combination antiretroviral therapy in paediatric HIV infection is associated with unmet maternal needs causing maternal NON-ADHERENCE

HIV testing among pregnant women with prenatal care in the United States: An analysis of the 2011–2017 National Survey of Family Growth

Progress in Eliminating Perinatal HIV Transmission in the Metropolitan DC Area Between 2018-2022

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