Retrospective analysis of risk factors and gaps in prevention strategies for mother-to-child HIV transmission in Rio de Janeiro, Brazil

Abstract

BackgroundDespite great progress made in methods to prevent mother-to-child transmission of HIV (MTCT), delivery and uptake of these measures remains a challenge in many countries. Although the Brazilian Ministry of Health aimed to eliminate MTCT by 2015, infection still occured in 15–24% of infants born to HIV-infected mothers. We sought to identify remaining factors that constrain MTCT elimination.MethodsWe conducted a retrospective, matched case-control study by reviewing hospital charts of infants born to HIV-infected mothers between 1997 and 2014 at three MTCT reference hospitals in the Rio de Janeiro metropolitan area. Cases were defined as HIV-exposed children with two positive HIV tests before 18 months of age; controls were defined as HIV-exposed children with two negative HIV tests before 18 months of age. We performed bivariate and MTCT cascade analyses to identify risk factors for MTCT and gaps in prevention services.ResultsWe included 435 infants and their mothers (145 cases, 290 controls). Bivariate analyses of MTCT preventative care (PMTCT) indicated that cases were less likely to complete all individual measures in the antenatal, delivery, and postnatal period (p < 0.05). Assessing completion of the PMTCT cascade, the sequential steps of PMTCT interventions, we found inadequate retention in care among both cases and controls, and cases were significantly less likely than controls to continue receiving care throughout the cascade (p < 0.05). Motives for incompletion of PMTCT measures included infrastructural issues, such as HIV test results not being returned, but were most often due to lack of care-seeking. Over the course of the study period, PMTCT completion improved, although it remained below the 95% target for antenatal care, HIV testing, and antenatal ART set by the WHO. Adding concern, evaluation of co-infections indicated that case infants were also more likely to have congenital syphilis (OR: 4.29; 95% CI: 1.66 to 11.11).ConclusionsWhile PMTCT coverage has improved over the years, completion of services remains insufficient. Along with interventions to promote care-seeking behaviour, increased infrastructural support for PMTCT services is needed to meet the HIV MTCT elimination goal in Brazil as well as address rising national rates of congenital syphilis.

Review of the missed opportunities for the prevention of vertical transmission of HIV in Brazil

“…Similar results were identified in a study of HIV-infected pregnant women from Rio de Janeiro between 1997 and 2014, in which 11.5% (50/435) did not receive an HIV diagnosis until after delivery. Additionally, while this study found an increase in prenatal HIV diagnosis across the study period, just 83% of mothers were diagnosed before or during the prenatal period in 2014 40.…”

“…A study of 1364 HIV-infected pregnant women between 2000 and 2009 across the northeast state of Ceará found an increase in prenatal attendance over the study period, although just 84.5% of women had attended any prenatal care in the final study year 37. In the Rio de Janeiro cohort of HIV-infected pregnant women from 1997 to 2014, prenatal care attendance increased over the study period, although again just 83.3% of HIV-infected pregnant women had at least one prenatal visit in 2014 40.…”

“…Of these women, 30% did not attend prenatal care, 50% had 1 to 5 consultations, and 20% had 6 or more consultations 39. Another study in Rio de Janeiro, evaluating a cohort of HIV-infected pregnant women between 1997 and 2014, found that 14% of these women did not attend any prenatal care 40. Two studies we identified evaluated prenatal care attendance over the years and observed a modest increase in attendance rates.…”

“…In the northeast region, Cruz Gouveia et al 16 demonstrated that, of the pregnancies with a maternal diagnosis made before or during gestation between 2000 and 2009, the rate of infected children was 4.7%; when the diagnosis was made during or after delivery, this rate increased to 25.8%. In the southeast region, Lovero et al 40 found that, in a cohort of HIV-infected pregnant women from Rio de Janeiro between 1997 and 2014, a postpartum diagnosis was associated with an eleven-fold increase in the likelihood of MTCT.…”

“…Additionally, in the northern region, the number of women receiving prenatal ARVs increased from 70.8% in 1999-2000 to 79.4% in 2011 13. In Rio de Janeiro, the use of prenatal ART also increased between 1997 and 2014, although 16.7% of HIV-infected pregnant women did not use ART in 2014 40.…”