International AIDS Society

High Infant Attrition From Discrete HIV Programs in Lilongwe, Malawi

Author: Mark Mascolini

14 April 2011

Separate HIV diagnosis and care programs for pregnant women and their neonates resulted in high infant attrition from one program to the next, according to findings of a retrospective cohort study in Lilongwe, Malawi.

Early infant diagnosis, referral to care, initiation of antiretroviral therapy (ART), and retention in care are critical interrelated goals in any program for HIV-exposed and infected infants. To see how well these goals are met, researchers in Malawi collected, merged, and analyzed data from the prevention of mother-to-child transmission, early infant diagnosis, and pediatric HIV treatment programs between 2004 and 2008.

Only 7875 infants of 14,699 HIV-positive mothers (54%) received HIV DNA PCR testing to see if they had HIV. Of the 7875 infants, 1084 (14%) had a positive test.

Among infants with a positive test, 320 (29.5%) entered pediatric care, 202 of them at the Baylor Center of Excellence. Of the 202 infants enrolled in the Baylor program, 110 (54.5%) started antiretroviral therapy. (World Health Organization guidelines now call for immediate antiretroviral therapy in newly diagnosed infants.)

Among infants who began treatment, median age was 9.1 months (interquartile range [IQR] 5.4 to 13.8), and a median of 2.5 months (IQR 1.4 to 5.2) elapsed between clinic registration and the start of therapy.

Through the end of follow-up, 69 of the 202 infants (34%) in care at the Baylor program had died or stopped returning to the clinic for care. Starting antiretroviral therapy raised chances of survival 7 times (odds ratio 7.1, 95% confidence interval 3.68 to 13.70).

The researchers conclude that “separate programs for maternal and infant HIV prevention and care services demonstrated high attrition rates of HIV-exposed and HIV-infected infants, elevated levels of mother-to-child transmission, late infant diagnosis, delayed pediatric antiretroviral therapy initiation, and high HIV-infected infant mortality.”

The authors see an “urgent need for improved service coordination and strategies that increase access to infant HIV diagnosis, improve patient retention, and reduce antiretroviral therapy initiation delays.”

The Lilongwe team makes the following recommendations, which are detailed in the full text, available at the link below.

Recommendation 1. ART initiation in infants should be treated as medically urgent, given the rapid disease progression and high mortality observed within this age group in the absence of ART.

Recommendation 2. In lieu of restructuring the delivery of maternal and infant HIV services into 1 facility, we recommend that a universal patient identification system be nationally implemented to allow tracing of mother-infant pairs between prevention of mother-to-child transmission, early infant diagnosis, and pediatric HIV facilities.

Recommendation 3. We recommend routine provider-initiated infant HIV antibody testing at all immunization visits, starting at the sixth week of life in settings where HIV exposure documentation does not exist or tracking mother-infant pairs is not feasible.

Recommendation 4. Routine inpatient pediatric HIV testing provides another critical avenue for the identification of HIV-exposed and HIV-infected children who may have been missed in the early postnatal period or who acquired HIV later in infancy via breastfeeding.

Recommendation 5. Infant HIV DNA PCR test results should be reported in 2 weeks or less if ART initiation hinges on the result to prevent excessive infant mortality.

Source: Maureen Braun, Mark M. Kabue, Eric D. McCollum, Saeed Ahmed, Maria Kim, Leela Aertker, Marko Chirwa, Michael Eliya, Innocent Mofolo, Irving Hoffman, Peter N. Kazembe, Charles van der Horst, Mark W. Kline, Mina C. Hosseinipour. Inadequate coordination of maternal and infant HIV services detrimentally affects early infant diagnosis outcomes in Lilongwe, Malawi. JAIDS. 2011; 56: e122-e128.

For the complete article