A 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
Date
2018-03
Authors
Journal Title
Journal ISSN
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Publisher
Stellenbosch : Stellenbosch University
Abstract
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.
Agtergrond: Kombinasie antiretrovirale terapie (kART) vir alle HIV-geïnfekteerde swanger en lakterende vroue, sowel as post-blootstellingsprofilakse vir HIV-blootgestelde kinders voorkom moeder-na-kind oordrag van HIV. Dit is reeds sedert Mei 2013 die standaard van sorg in Kaapstad, Suid-Afrika. Ongeag hoë opname en goeie dekking, kom oordrag steeds voor. Vroeë identifikasie van HIV infeksie in kinders en toegang tot kART is sleutelkomponente in die vermindering van morbiditeit en mortaliteit in HIV-geïnfekteerde kinders. Redes vir volgehoue oordrag sluit infeksies wat tydens swangerskap en die postpartum periode gemis is, kort moederlike duur op kART en probleme rondom retensie in sorg, in. Daarbenewens is swak gebruikmaak van diagnoseringsgeleenthede en vertraagde toegang tot kART goed gedokumenteer. Die doel van hierdie studie is om, deur die beskrywing van die profiel van jong geïnfekteerde gehospitaliseerde kinders, begrip vir die huidige risikofaktore vir oordrag te verbreed, mislukkings in die diagnostiese en sorg-paaie te identifiseer en die geassosieerde morbiditeit en mortaliteit te beskryf. Dokumentasie van die probleme in die sorg-paaie is ook ondersoek deur die gesondheidsorgwerkers se notas in die “Road-to-Health” boekies (RtHB) te dokumenteer en die opname van roetine sorg te assesseer deur na die vaksinasie rekords in die RtHB te kyk. Materiale en Metodes: Hierdie was ‘n prospektief beskrywende studie vanaf Februarie 2015 tot Januarie 2016 waarin die voorkoming van Moeder-tot-Kind oordrag (pMTCT), diagnosering van kinders en sorgkontinuum van gehospitaliseerde HIV-geïnfekteerde kinders jonger as 18 maande met nuut-gediagnoseerde of voorheen bevestigde HIV, gedokumenteer is. Data van moederlike HIV en swangerskapsgeskiedenis, sowel as kind se HIV geskiedenis en kliniese status is versamel en beskrywend analiseer. Resultate: Drie-en-sestig kinders is gesif en 55 ingesluit (6 wys deelname af; 2 nie beskikbaar vir toestemming). Die gemiddelde ouderdom was 5.7 (IQR 3 – 12.5) maande; 33 (60%) was manlik. Ses-en-veertig is identifiseer as HIV-blootgestel met geboorte. Die meerderheid, 31 (67%), van hulle moeders was bewus van hul HIV-diagnose voor swangerskap. Ten spyte daarvan het slegs 20 (65%) voorgeboortelike sorg bygewoon en 7 (23%, N=31) ook kART wat voor swangerskap iniseer is, onderbreek. Drie-en-twintig vroue (50%) het kART tydens swangerskap begin: 11/31 (35%) se positiewe HIV-status was reeds voor swangerskap bekend en 12/15 (80%) is gedurende swangerskap gediagnoseer (p=0.4). Tien (43%) van hierdie 23 vroue is nie in sorg behou nie: 6/11 (55%) van voorheen gediagnoseerde en 4/12 (33%) van vroue tydens swangerskap met HIV gediagnoseer (p=0.4). Kinders met ‘n onbekende HIV-blootstellingsrisiko was ouer: 9,3 (IQR 5.9 – 12.8) teenoor 4.5 (IQR 2.2 – 12.6) maande vir bekende risiko (p=0.167). Vyftien kinders (27%) is tydens die neonatale periode gediagnoseer, 5/15 (33%) gedurende hospitalisasie by Tygerberg Hospitaal. Kinders met ‘n bekende blootstellingsrisiko is gediagnoseer teen ‘n gemiddelde ouderdom van 1.8 (IQR 0.1 – 3.5) maande teenoor 9.4 (IQR 6.6 – 12.1) maande in onbekende risiko kinders (p=0.001). Kinders met onbekende HIV-blootstellingsrisiko se gemiddelde gewig-vir-ouderdom z-telling was -3.4 (IQR -4.2 tot -2.3) teenoor -2.4 (IQR -4.1 tot -1.8), (p=0.228) en 8 (89%) het WGO (Wêreld Gesondheidsorganisasie) stadium 3 of 4 siekte teenoor 36 kinders (78%) met bekende risiko (p=0.195). Die gemiddelde duur van HIV diagnose tot kART-inisiasie was 8 (IQR 5 – 30) dae in bekende-risiko kinders; 15/46(27%) het kART suksesvol inisieer voor toelating en het in sorg gebly. Teen die tyd van hospitalisering het 5 (9%) kinders voorheen inisieerde kART gestaak. Sewe kinders (13%) is in die hospitaal dood, met 14/55 (25%) (13 met bekende risiko) wat opname in intensiewe sorg benodig het. Die gemiddelde hospitalisasieduur was 17 dae, ooreenstemmend in die met bekende (23 [IQR 12 – 30.5] dae) teenoor onbekende risiko (15.5 [IQR 10 – 32.3] dae) (p=0.67). Ses-en-veertig (96%) RtHBs van die kohort was beskikbaar vir ondersoek gedurende toelating. Sewe van 55 kinders (12.7%) was nog in die neonatale diens opgeneem en dus nog nie in besit van ‘n RtHB. Van die 39 (98%, N=40) kinders wie se moeders antenataal identifiseer is, het 7 (18%) ‘n ouderdomstoepaslik voltooide HIV-verwante bladsy gehad. Van die 31 kinders ouer as 6 weke, was HIV PKR toetsing gedokumenteer in 19 (61%), maar resultate slegs aangedui in 15 (79%). Inisiëring van co-trimoxazole op 6 weke was gedokumenteer in 15 (52%). Van die 8 kinders wie postpartum en buite die pMTCT diens geïdentifiseer is, was 7 (88%) se RtBHs beskikbaar, met dokumentasie rakende antenatale of postpartum toetse slegs by 1 kind (14%) aangedui. Ouderdomstoepaslike vaksinasies was by 24 van die 39 (62%) antenataal gediagnoseerde kinders en 5 van die 7, postpartum geïdentifiseer, gedokumenteer. Gevolgtrekking: Hierdie studie identifiseer swak voorgeboortelike kliniekbywoning en onderbreking van kART-behandeling by vroue bewus van hul HIV-status voor swangeskap as die dryfveer van nuut-geïnfekteerde kinders. Ten spyte daarvan dat HIV relatief vroeg gediagnoseer is, was mobiditeit en mortaliteit hoog. Dokumentasie van HIV in die RtHB is swak voltooi deur gesondheidsorg werkers, met ‘n moontlike impak op die sorg-kontinuum. Lae voltooiing van die kindervaksinasies was ‘n ernstige bekommernis en verdere aanduiding van die gesondheidsorg-soekende gedrag van die moeders.
Agtergrond: Kombinasie antiretrovirale terapie (kART) vir alle HIV-geïnfekteerde swanger en lakterende vroue, sowel as post-blootstellingsprofilakse vir HIV-blootgestelde kinders voorkom moeder-na-kind oordrag van HIV. Dit is reeds sedert Mei 2013 die standaard van sorg in Kaapstad, Suid-Afrika. Ongeag hoë opname en goeie dekking, kom oordrag steeds voor. Vroeë identifikasie van HIV infeksie in kinders en toegang tot kART is sleutelkomponente in die vermindering van morbiditeit en mortaliteit in HIV-geïnfekteerde kinders. Redes vir volgehoue oordrag sluit infeksies wat tydens swangerskap en die postpartum periode gemis is, kort moederlike duur op kART en probleme rondom retensie in sorg, in. Daarbenewens is swak gebruikmaak van diagnoseringsgeleenthede en vertraagde toegang tot kART goed gedokumenteer. Die doel van hierdie studie is om, deur die beskrywing van die profiel van jong geïnfekteerde gehospitaliseerde kinders, begrip vir die huidige risikofaktore vir oordrag te verbreed, mislukkings in die diagnostiese en sorg-paaie te identifiseer en die geassosieerde morbiditeit en mortaliteit te beskryf. Dokumentasie van die probleme in die sorg-paaie is ook ondersoek deur die gesondheidsorgwerkers se notas in die “Road-to-Health” boekies (RtHB) te dokumenteer en die opname van roetine sorg te assesseer deur na die vaksinasie rekords in die RtHB te kyk. Materiale en Metodes: Hierdie was ‘n prospektief beskrywende studie vanaf Februarie 2015 tot Januarie 2016 waarin die voorkoming van Moeder-tot-Kind oordrag (pMTCT), diagnosering van kinders en sorgkontinuum van gehospitaliseerde HIV-geïnfekteerde kinders jonger as 18 maande met nuut-gediagnoseerde of voorheen bevestigde HIV, gedokumenteer is. Data van moederlike HIV en swangerskapsgeskiedenis, sowel as kind se HIV geskiedenis en kliniese status is versamel en beskrywend analiseer. Resultate: Drie-en-sestig kinders is gesif en 55 ingesluit (6 wys deelname af; 2 nie beskikbaar vir toestemming). Die gemiddelde ouderdom was 5.7 (IQR 3 – 12.5) maande; 33 (60%) was manlik. Ses-en-veertig is identifiseer as HIV-blootgestel met geboorte. Die meerderheid, 31 (67%), van hulle moeders was bewus van hul HIV-diagnose voor swangerskap. Ten spyte daarvan het slegs 20 (65%) voorgeboortelike sorg bygewoon en 7 (23%, N=31) ook kART wat voor swangerskap iniseer is, onderbreek. Drie-en-twintig vroue (50%) het kART tydens swangerskap begin: 11/31 (35%) se positiewe HIV-status was reeds voor swangerskap bekend en 12/15 (80%) is gedurende swangerskap gediagnoseer (p=0.4). Tien (43%) van hierdie 23 vroue is nie in sorg behou nie: 6/11 (55%) van voorheen gediagnoseerde en 4/12 (33%) van vroue tydens swangerskap met HIV gediagnoseer (p=0.4). Kinders met ‘n onbekende HIV-blootstellingsrisiko was ouer: 9,3 (IQR 5.9 – 12.8) teenoor 4.5 (IQR 2.2 – 12.6) maande vir bekende risiko (p=0.167). Vyftien kinders (27%) is tydens die neonatale periode gediagnoseer, 5/15 (33%) gedurende hospitalisasie by Tygerberg Hospitaal. Kinders met ‘n bekende blootstellingsrisiko is gediagnoseer teen ‘n gemiddelde ouderdom van 1.8 (IQR 0.1 – 3.5) maande teenoor 9.4 (IQR 6.6 – 12.1) maande in onbekende risiko kinders (p=0.001). Kinders met onbekende HIV-blootstellingsrisiko se gemiddelde gewig-vir-ouderdom z-telling was -3.4 (IQR -4.2 tot -2.3) teenoor -2.4 (IQR -4.1 tot -1.8), (p=0.228) en 8 (89%) het WGO (Wêreld Gesondheidsorganisasie) stadium 3 of 4 siekte teenoor 36 kinders (78%) met bekende risiko (p=0.195). Die gemiddelde duur van HIV diagnose tot kART-inisiasie was 8 (IQR 5 – 30) dae in bekende-risiko kinders; 15/46(27%) het kART suksesvol inisieer voor toelating en het in sorg gebly. Teen die tyd van hospitalisering het 5 (9%) kinders voorheen inisieerde kART gestaak. Sewe kinders (13%) is in die hospitaal dood, met 14/55 (25%) (13 met bekende risiko) wat opname in intensiewe sorg benodig het. Die gemiddelde hospitalisasieduur was 17 dae, ooreenstemmend in die met bekende (23 [IQR 12 – 30.5] dae) teenoor onbekende risiko (15.5 [IQR 10 – 32.3] dae) (p=0.67). Ses-en-veertig (96%) RtHBs van die kohort was beskikbaar vir ondersoek gedurende toelating. Sewe van 55 kinders (12.7%) was nog in die neonatale diens opgeneem en dus nog nie in besit van ‘n RtHB. Van die 39 (98%, N=40) kinders wie se moeders antenataal identifiseer is, het 7 (18%) ‘n ouderdomstoepaslik voltooide HIV-verwante bladsy gehad. Van die 31 kinders ouer as 6 weke, was HIV PKR toetsing gedokumenteer in 19 (61%), maar resultate slegs aangedui in 15 (79%). Inisiëring van co-trimoxazole op 6 weke was gedokumenteer in 15 (52%). Van die 8 kinders wie postpartum en buite die pMTCT diens geïdentifiseer is, was 7 (88%) se RtBHs beskikbaar, met dokumentasie rakende antenatale of postpartum toetse slegs by 1 kind (14%) aangedui. Ouderdomstoepaslike vaksinasies was by 24 van die 39 (62%) antenataal gediagnoseerde kinders en 5 van die 7, postpartum geïdentifiseer, gedokumenteer. Gevolgtrekking: Hierdie studie identifiseer swak voorgeboortelike kliniekbywoning en onderbreking van kART-behandeling by vroue bewus van hul HIV-status voor swangeskap as die dryfveer van nuut-geïnfekteerde kinders. Ten spyte daarvan dat HIV relatief vroeg gediagnoseer is, was mobiditeit en mortaliteit hoog. Dokumentasie van HIV in die RtHB is swak voltooi deur gesondheidsorg werkers, met ‘n moontlike impak op die sorg-kontinuum. Lae voltooiing van die kindervaksinasies was ‘n ernstige bekommernis en verdere aanduiding van die gesondheidsorg-soekende gedrag van die moeders.
Description
Thesis (MMed)--Stellenbosch University, 2018.
Keywords
HIV infections -- Prevention, Mother-to-child transmission (pMTCT), HIV-infected children, Tygerberg Hospital, HIV (Viruses) -- Transmission