Masters Degrees (Paediatrics and Child Health)
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Browsing Masters Degrees (Paediatrics and Child Health) by Author "Du Plooy, Elri"
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- ItemA profile of the prevention of mother-to-child transmission (pMTCT) and clinical status of HIV-infected children younger than 18 months admitted to Tygerberg Hospital over a one-year period(Stellenbosch : Stellenbosch University, 2018-03) Du Plooy, Elri; Rabie, Helena; Frigati, Lisa; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.Background: Combination antiretroviral therapy (cART) for all Human Immunodeficiency Virus (HIV) infected pregnant and lactating women and post-exposure prophylaxis for HIV-exposed infants prevents mother-to-child transmission of HIV and has been the standard of care in Cape Town, South Africa since May 2013. Despite high uptake and good coverage, transmission still occurs. Early identification of HIV infection in infants and access to cART are key components in reduction of morbidity and mortality in HIV- infected infants. Reasons for ongoing transmission include missed diagnosis of infection during pregnancy and the postpartum period, short maternal duration on cART and issues around retention in care. In addition, poor uptake of the early infant diagnosis opportunities and delayed access to cART for infants is well documented. This study aimed to describe the antenatal and postnatal prevention of Mother-to-Child transmission (pMTCT) history and current medical condition of HIV-infected children younger than 18 months of age admitted to Tygerberg Hospital over a 12-month period, as well as document the availability of clinical information for these patients through an assessment of the Road-to-Health booklet (RtHB), medical records and the National Health Laboratory Service (NHLS). Materials & Methods: This was a prospectively enrolled descriptive study from February 2015 to January 2016 that documented the pMTCT , infant diagnosis and care cascade of hospitalized HIV infected children younger than 18 months with newly diagnosed or previously confirmed HIV. Data on maternal HIV and pregnancy history, as well as child HIV-history and clinical status were collected and descriptive analysis performed. Results: Sixty-three children were screened and 55 enrolled (6 declined; 2 unavailable for consent). The median age was 5.7 (IQR 3 - 12.5) months; 33 (60%) were male. Forty-six children (83%) were identified as HIV-exposed at birth. The majority, 31 (67%), of their mothers were aware of their HIV diagnosis prior to pregnancy. However, only 20 (65%) attended antenatal care, with 7 (23%) interrupting cART initiated prior to pregnancy. Twenty-three women (50%) began cART during pregnancy: 11/31 (35%) were known to be HIV-infected prior to pregnancy and 12/15 (80%) were diagnosed during pregnancy (p=0.4). Of these 23 women, 10 (43%) were not retained in care: 6/11 (55%) of previously diagnosed and 4/12 (33%) of women diagnosed with HIV in pregnancy (p=0.4). Children with unknown HIV-exposure risk were older: 9.3 (IQR 5.9 – 12.8) vs 4.5 (IQR 2.2 – 12.6) months (p=0.167) for known risk. Fifteen children (27%) were diagnosed in the neonatal period, 5/15 (33%) during hospitalization at Tygerberg Hospital. Children with known exposure risk were diagnosed at a median age of 1.8 (IQR 0.1 – 3.5) months versus 9.4 (IQR 6.6 -12.1) months in unknown risk children (p=0.001). Children with unknown HIV-exposure risk had a median weight-for-age z-score of -3.4 (IQR -4.2 - -2.3) vs -2.4 (IQR -4.1 - -1.8), (p=0.228) and 8 (89%) had WHO stage 3 or 4 disease versus 36 children (78%) with known risk (p=0.195). The median duration from HIV diagnosis to cART initiation was 8 (IQR 5 – 30) days in known-risk children; 15/46 (27%) successfully initiated cART prior to admission and remained in care. At time of hospitalization 5 children (9%) had discontinued previously initiated cART. Seven Seven children (13%) died in hospital, with 14/55 (25%) (13 with known risk) requiring intensive care admission. The median hospitalization duration was 17 days, similar in those with known (23 [IQR 12 – 30.5] days) vs unknown risk (15.5 [IQR 10 – 32.3] days) (p=0.67). Forty-six (96%) of the RtHBs of our cohort were available for review during their admission. Seven of 55 children (12.7%) were still in the neonatal service and had not yet been issued a RtHB. Of the 39 (98%, N=40) children whose mothers were identified antenatally, 7 (18%) had an age-appropriately completed HIV-related page. Of the 31 children older than 6 weeks, HIV polymerase chain reaction (PCR) testing was documented in 19 (61%), but the result was only noted in 15 (79%). Initiation of co-trimoxazole at 6 weeks was documented in 15 (52%). Of the 8 children identified after delivery and outside the pMTCT service, 7 (88%) had RtBHs available, with only 1 child (14%) having any documentation of antenatal or postpartum tests noted. Age appropriate vaccinations were documented in 24 of 39 (62%) of antenatally diagnosed children and 5 of the 7 children identified postpartum. Conclusion: We identified poor antenatal clinic attendance and cART-treatment interruption in women aware of their status prior to pregnancy as the driver of newly infected infants. Despite HIV being diagnosed relatively early, mortality and morbidity were high. Documentation of HIV in the RtHB was poorly completed by healthcare workers, with a possible impact on the care cascade. Of significant concern was the low completion of infant vaccination, a further pointer to the health seeking behaviour of mothers. Identifying women at risk of transmitting HIV to their infants will be challenging as they often do not engage with the health care system. Further research exploring the reasons for this is needed. When these women do attend routine services, they should be identified and more effort made to retain them, not only in the pMTCT cascade of care but also into the well child follow-up system.