m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 2 1 8 e2 2 1
Available online at www.sciencedirect.com
j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / m j a fi
Original Article
Can we prevent pediatric HIV? An experience at a tertiary care hospital Col Rakesh Gupta a,*, Maj R. Praveen b, Brig Mukti Sharma c a
Associate Professor, Dept of Paediatircs, AFMC, Pune-40, India Graded Specialist (Paediatrics), 92 Base Hospital, C/o 56 APO, India c Consultant (Paediatrics), Army Hospital (R&R), Delhi Cantt-10, India b
article info
abstract
Article history:
Background: Parent-to-child transmission (PTCT) is the commonest mode of acquiring HIV
Received 18 October 2011
in more than 90% children. The risk during pregnancy varies from 20 to 45% and with
Accepted 21 November 2012
specific interventions in mother and baby; it can be reduced to less than 2%. This study was
Available online 23 February 2013
conducted to assess the efficacy of comprehensive PPTCT programme. Method: This descriptive study was conducted at a tertiary care hospital, from Jan 2008 till
Keywords:
Jul 2010. 32 HIV-positive pregnant mothers were enrolled in the study. They were
Parent-to-child transmission (PTCT)
evaluated, given triple drug antiretroviral therapy and followed up. Babies were given
HIV exposed babies
single dose nevirapine and zidovudine till 6 weeks of age. DNA-PCR was done for con-
Replacement feeding
firming the HIV status of baby. Results: The yearly period prevalence of pregnant mothers found HIV positive at antenatal clinic showed a downward trend, from 0.39% in 2008 to 0.18% in 2010. Mean CD4 count of mothers at diagnosis was 459.41 [SD e 238.37]. Twenty eight mothers (93.3%) received antiretroviral therapy. 15 (50%) babies were delivered by cesarean section and 26 infants were given replacement feeding. All the babies were singletons, 29 (96.7%) born at term with an average birth weight of 2.60 kg (SD ¼ 0.5) and male to female ratio of 0.87:1. Twenty nine (96.7%) infants were declared HIV-negative and parent-to-child transmission rate at our center was 3.3%. Conclusion: A comprehensive PPTCT programme with administration of antiretroviral therapy to the mother and infant, safe delivery practices, avoidance of breastfeeding, and close follow up, the incidence of PTCT can be reduced to negligible rates as seen in our study. ª 2012, Armed Forces Medical Services (AFMS). All rights reserved.
Background Worldwide, an estimated 430,000 children were newly infected with HIV in 2008, and over 90% of them through motherto-child transmission (MTCT).1e3 The risk of mother-to-child transmission (MTCT) during pregnancy ranges from 20% to
45% and with specific interventions in mother and baby, this risk can be reduced to less than 2%.4e10 With developing concept of pediatric HIV as preventable disease, a descriptive study was conducted to assess the efficacy of comprehensive PPTCT programme and outcome of infants born to HIV positive mothers at a tertiary care hospital.
* Corresponding author. Tel.: þ91 (0) 9850042002. E-mail address: [email protected] (R. Gupta). 0377-1237/$ e see front matter ª 2012, Armed Forces Medical Services (AFMS). All rights reserved. http://dx.doi.org/10.1016/j.mjafi.2012.11.008
219
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 2 1 8 e2 2 1
Material and methods
Total 32 HIV exposed babies
This descriptive study was conducted at a tertiary care hospital in Maharashtra, from Jan 2008 till Jul 2010. The antenatal clinic of our hospital caters to both, families of serving soldiers and civilians. In our study 70% of the pregnant mothers were civilians. All the pregnant mothers at antenatal clinic were screened for HIV after pre-test counseling, and if confirmed, enrolled in the study after informed consent. 32 seropositive parents were enrolled and followed up in the study. Six couples were discordant, where in 5 fathers and one mother was HIV-negative. Mothers were counseled during antenatal period for the mode of delivery, infant feeding choice and followed-up through pregnancy, delivery and babies after birth. CD4 count was done in 29 mothers and given triple drug antiretroviral therapy. Mode of delivery was based on maternal viral load and caesarean section was done, if maternal viral load was >1000 copies/ml. All the babies were given syrup nevirapine @2 mg/kg/single dose within 72 h of birth and syrup zidovudine @8 mg/kg/d till 6 weeks of age. Infant diagnosis for HIV was made by HIV DNA-PCR at 6 weeks and 6 months. If the infant found positive, repeat test was performed immediately and put on highly active antiretroviral therapy (HAART). All the infants were closely followed up for gastro-intestinal or other infections. The data was compiled and analyzed using Epi info 2011.
Results The yearly period prevalence of pregnant mothers found HIV positive at antenatal clinic showed a downward trend, from 0.39% in 2008 to 0.18% in 2010 as shown in Table 1. The follow up was completed for 30 motherebaby pairs as one baby born to HIV negative mother was excluded and one baby lost to follow up. Mean CD4 count was 459.41 [SD e 238.37]. 28 mothers (93.3%) received antiretroviral therapy. Reasons for not taking ART in 2 mothers were, late reporting due to ignorance and fear of stigmatization. 15 (50%) babies were delivered by cesarean section. 26 (86.7%) mothers were agreed to give replacement feeding to their babies and of 4 infants were breast fed for duration 1 month to six months.
Neonatal data
1 baby born to HIV- mother
01 Loss to follow up
30 Babies completed follow up
01 Positive
29 Negative
Fig. 1 e Showing the data of HIV exposed babies.
nine (96.7%) infants were declared HIV negative after 2 negative DNA-PCR tests. One infant was found to be positive and started on HAART. In one infant born to discordant couple (Mother-positive, father negative) 1st DNA-PCR was positive at 2 weeks, second negative at 6 weeks and 3rd DNA-PCR again positive at repeat testing at 6 months, hence started on HAART. On follow up at 2 years of age, child was asymptomatic and did not have any marker, whatsoever for HIV and on thorough evaluation found to be HIV negative on DNA-PCR and ELISA. The reason for her negative status could not be explained. The parent-to-child transmission rate at our center was 3.3%. The outcome of HIV exposed infants is shown in Figs. 1 and 2.
Discussion Mother-to-child transmission (MTCT) of HIV represents the most common means by which children acquire HIV infection in over 90% children. The corner stone of reduction of transmission is an effective PPTCT programme. According to the WHO report 2009, “Towards universal access: scaling up priority HIV/AIDS interventions” in the health sector, significant progress in the area of PMTCT has been made during the past several years, but still lots to be done.1 In India, of the estimated 1.8e2.9 million people living with HIV, 39% are women.11 According to UNICEF ‘National programme targets’ by 2012, 80% of HIV positive pregnant women will be reached by PMTCT services.12 In our study, all the pregnant mothers reported for antenatal checkup were screened and yearly
Of the 30 motherebaby pairs studied, all the babies were singletons, 29 (96.7%) born at term with mean birth weight of 2.60 kg (SD ¼ 0.5 kg) and male to female ratio of 0.87:1. Twenty
Table .1 e Showing the yearly period prevalence of HIV at antenatal clinic. Year
No of ANC cases screened
Mothers found positive
2008 2009 2010
3263 3550 4763
13 (0.39%) 13 (0.36%) 9 (0.18%)
Fig. 2 e Showing the outcome of HIV exposed babies.
220
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 2 1 8 e2 2 1
period prevalence of HIV positive among pregnant mothers showed a downward trend from 0.39% in 2008 to 0.18% in 2010, as against 0.27% reported by NACO in 2011.12 All the mothers found HIV positive were enrolled under PPTCT programme, given triple drug antiretroviral therapy and all the infants were started on ARV prophylaxis, and closely followed up. As a result of this comprehensive PPTCT programme, among 30 HIV exposed babies, only one infant found to be HIV positive and rate of perinatal transmission at our center was 3.3%, which is comparable with similar studies in the developed countries.4e8 Twenty eight mothers (93.3%) in our study were started on ARV and all infants were given single dose of nevirapine and zidovudine for 6 weeks. In India 68% of HIVþ motherebaby pairs received single dose nevirapine ARV in 2010.12 American Academy of Pediatrics recommends routine HIV screening for all pregnant women, if found positive ARV instituted as soon as possible and counseled not to breastfeed their babies in order to minimize the risk of perinatal transmission.7 Study conducted by Kouanda et al and Chama et al confirms that HAART for mothers effectively reduces the risk of infant HIV infection while preserving the breastfeeding option of mothers.4,8 The role of mode of delivery in the management of HIVinfected women should be considered in the light of risks as well as benefits. Cesarean delivery is an efficacious intervention for the prevention of MTCT among HIV-1-infected women having advanced disease or low CD4 count or not taking ARVs, however associated with higher postpartum morbidities.9 American College of Obstetrics and Gynecology recommends cesarean section to mothers with viral load more than 1000 copies/ml. Although the benefit of elective cesarean delivery (ECD) in preventing MTCT of HIV is substantial, some questions remain, specifically in women with very low viral loads or women on HAART.13 Indian data in this regard reveals HIV transmission probabilities, 0.04e0.14 for vaginal delivery and 0.00e0.02 for caesarian delivery and suggest that pregnant HIV-infected women receiving nevirapine should consider the benefits of a cheaper and safer vaginal delivery.14 In our study, 15 (50%) mothers underwent caesarean delivery with no significant postpartum morbidities. All the babies were singletons, 29 (96.7%) born at term with an average birth weight of 2.60 kg (SD ¼ 0.5) and comparable with similar study done by Mukhtar-Yola in Nigeria.6 Post-natal transmission of HIV via breastfeeding reverses gains achieved by perinatal antiretroviral interventions. There is 14% extra risk of HIV transmission by breastfeeding. Colostrum has higher viral load and increases the risk of infection, hence not to be given. With the implementation of new WHO guidelines on infant feeding practices in HIV positive mothers, mother-to-child HIV transmission risk can be reduced to 5% or lower in a breastfeeding population, from a background transmission risk of 35% in the absence of any interventions and with continued breastfeeding.15 In our study group of 30 infants, 4 (13.3%) opted for breastfeeding probably, due to poor literacy, not enough motivation and non-affordability of top feeds by the mother. On follow up, mothers were advised to continue infant ARV prophylaxis and switch over to complementary feeding. On follow up screening, three infants were
found to be negative. One mother continued breastfeeding till one year and on screening, child was found HIV positive and initiated HAART. Complete avoidance of breastfeeding is efficacious in preventing MTCT, but this intervention has significant associated morbidity (e.g., diarrheal morbidity if formula is prepared without clean water).5 In our study, there was no significant infective morbidity or stigmata of nutritional deficiencies. For infant diagnosis, serologic tests are not useful because of persistence of maternal antibodies and DNA-PCR can reliably detect the presence of HIV infection in infants up to 18 months.10
Conclusion With the administration of antiretroviral therapy to the mother and infant, safe delivery practices, complete avoidance of breastfeeding and close follow up, the incidence of PTCT can be reduced to negligible rates of below 5% as seen in our study. Counseling of mother regarding measures for prevention of perinatal transmission and infant feeding choice should be done during pregnancy, as mother is most receptive during this period and maximum yield of success can be achieved. HIV-DNA PCR is highly specific and sensitive test for infant diagnosis. PPTCT remains the best way of preventing pediatric HIV infection.
Conflicts of interest All authors have none to declare.
references
1. PMTCT Strategic Vision 2010e2015: Preventing Mother-to-child Transmission of HIV to Reach the UNGASS and Millennium Development Goals. WHO; 2010. 2. UNAIDS. AIDS Epidemic Update 2007. Geneva: UNAIDS and WHO. Available at: www.unaids.org; 2007. 3. NACO. HIV Sentinel Surveillance and HIV Estimation. New Delhi: National AIDS Control Organization 2007. Also available at: www.nacoonline.org; 2006. Accessed 19.12.2007. 4. Kouanda S, Tougri H, Cisse M, et al. Impact of maternal HAART on the prevention of mother-to-child transmission of HIV: results of an 18-month follow-up study in Ouagadougou, Burkina Faso. AIDS Care. 2010 Jul;22(7):843e850. 5. Horvath T, Madi BC, Iuppa IM, Kennedy GE, Rutherford G, Read JS. Interventions for preventing late postnatal mother-to-child transmission of HIV. Cochrane Database Syst Rev. 2010;Jan 21(1):CD006734. 6. Mukhtar-Yola M, Gwarzo GD, Galadanci HS, et al. HIV exposed infants: a preliminary report of the Aminu Kano Teaching Hospital Experience Niger. Postgrad Med J. 2009 Jun;16(2):143e148. 7. Havens PL, Chakraborty R, Cooper E. HIV testing and prophylaxis to prevent mother-to-child transmission in the United States. Pediatrics. 2008;Nov; 122(5):1127e1134. 8. Chama CM, Bello M, Ajayi BA, Zarma S, Gashau W. The use of highly active antiretroviral therapy for the prevention of mother-to-child transmission of the human
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 2 1 8 e2 2 1
immunodeficiency virus in Nigeria. J Obstet Gynaecol. 2010 May;30(4):362e366. 9. Read JS, Newell MK. Efficacy and safety of cesarean delivery for prevention of mother to child transmission of HIV-1. Cochrane Database Syst Rev. 2005 Oct;19(4):CD005479. 10. Read JS. Diagnosis of HIV-1 infection in children younger than 18 months in the United States. Pediatrics. 2007 Dec;120(6):e1547ee1562. 11. Damania K, Parikshit T, Mamatha L. Recent trends in mother to child transmission of HIV in pregnancy. J Obstet Gynaecol India. 2010;60(5):395e402.
221
12. National AIDS Control Organization [NACO]. Annual report 2010e11. 13. Legardy-Williams Jennifer K, Denise JJ, Jennifer SR. Prevention of mother-to-child transmission of HIV: the role of cesarean delivery. Clin Perinatol. 2010;37(4):777e785. 14. Mukherjee K. Cost-effectiveness of childbirth strategies for prevention of mother-to-child transmission of HIV among mothers receiving nevirapine in India. Indian J Community Med. 2010;35(1):29e33. 15. WHO Guidelines. HIV and Infant Feeding: Revised Principles and Recommendations. Rapid Advice; Nov 2009.
Available online at www.sciencedirect.com
j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / m j a fi
Original Article
Can we prevent pediatric HIV? An experience at a tertiary care hospital Col Rakesh Gupta a,*, Maj R. Praveen b, Brig Mukti Sharma c a
Associate Professor, Dept of Paediatircs, AFMC, Pune-40, India Graded Specialist (Paediatrics), 92 Base Hospital, C/o 56 APO, India c Consultant (Paediatrics), Army Hospital (R&R), Delhi Cantt-10, India b
article info
abstract
Article history:
Background: Parent-to-child transmission (PTCT) is the commonest mode of acquiring HIV
Received 18 October 2011
in more than 90% children. The risk during pregnancy varies from 20 to 45% and with
Accepted 21 November 2012
specific interventions in mother and baby; it can be reduced to less than 2%. This study was
Available online 23 February 2013
conducted to assess the efficacy of comprehensive PPTCT programme. Method: This descriptive study was conducted at a tertiary care hospital, from Jan 2008 till
Keywords:
Jul 2010. 32 HIV-positive pregnant mothers were enrolled in the study. They were
Parent-to-child transmission (PTCT)
evaluated, given triple drug antiretroviral therapy and followed up. Babies were given
HIV exposed babies
single dose nevirapine and zidovudine till 6 weeks of age. DNA-PCR was done for con-
Replacement feeding
firming the HIV status of baby. Results: The yearly period prevalence of pregnant mothers found HIV positive at antenatal clinic showed a downward trend, from 0.39% in 2008 to 0.18% in 2010. Mean CD4 count of mothers at diagnosis was 459.41 [SD e 238.37]. Twenty eight mothers (93.3%) received antiretroviral therapy. 15 (50%) babies were delivered by cesarean section and 26 infants were given replacement feeding. All the babies were singletons, 29 (96.7%) born at term with an average birth weight of 2.60 kg (SD ¼ 0.5) and male to female ratio of 0.87:1. Twenty nine (96.7%) infants were declared HIV-negative and parent-to-child transmission rate at our center was 3.3%. Conclusion: A comprehensive PPTCT programme with administration of antiretroviral therapy to the mother and infant, safe delivery practices, avoidance of breastfeeding, and close follow up, the incidence of PTCT can be reduced to negligible rates as seen in our study. ª 2012, Armed Forces Medical Services (AFMS). All rights reserved.
Background Worldwide, an estimated 430,000 children were newly infected with HIV in 2008, and over 90% of them through motherto-child transmission (MTCT).1e3 The risk of mother-to-child transmission (MTCT) during pregnancy ranges from 20% to
45% and with specific interventions in mother and baby, this risk can be reduced to less than 2%.4e10 With developing concept of pediatric HIV as preventable disease, a descriptive study was conducted to assess the efficacy of comprehensive PPTCT programme and outcome of infants born to HIV positive mothers at a tertiary care hospital.
* Corresponding author. Tel.: þ91 (0) 9850042002. E-mail address: [email protected] (R. Gupta). 0377-1237/$ e see front matter ª 2012, Armed Forces Medical Services (AFMS). All rights reserved. http://dx.doi.org/10.1016/j.mjafi.2012.11.008
219
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 2 1 8 e2 2 1
Material and methods
Total 32 HIV exposed babies
This descriptive study was conducted at a tertiary care hospital in Maharashtra, from Jan 2008 till Jul 2010. The antenatal clinic of our hospital caters to both, families of serving soldiers and civilians. In our study 70% of the pregnant mothers were civilians. All the pregnant mothers at antenatal clinic were screened for HIV after pre-test counseling, and if confirmed, enrolled in the study after informed consent. 32 seropositive parents were enrolled and followed up in the study. Six couples were discordant, where in 5 fathers and one mother was HIV-negative. Mothers were counseled during antenatal period for the mode of delivery, infant feeding choice and followed-up through pregnancy, delivery and babies after birth. CD4 count was done in 29 mothers and given triple drug antiretroviral therapy. Mode of delivery was based on maternal viral load and caesarean section was done, if maternal viral load was >1000 copies/ml. All the babies were given syrup nevirapine @2 mg/kg/single dose within 72 h of birth and syrup zidovudine @8 mg/kg/d till 6 weeks of age. Infant diagnosis for HIV was made by HIV DNA-PCR at 6 weeks and 6 months. If the infant found positive, repeat test was performed immediately and put on highly active antiretroviral therapy (HAART). All the infants were closely followed up for gastro-intestinal or other infections. The data was compiled and analyzed using Epi info 2011.
Results The yearly period prevalence of pregnant mothers found HIV positive at antenatal clinic showed a downward trend, from 0.39% in 2008 to 0.18% in 2010 as shown in Table 1. The follow up was completed for 30 motherebaby pairs as one baby born to HIV negative mother was excluded and one baby lost to follow up. Mean CD4 count was 459.41 [SD e 238.37]. 28 mothers (93.3%) received antiretroviral therapy. Reasons for not taking ART in 2 mothers were, late reporting due to ignorance and fear of stigmatization. 15 (50%) babies were delivered by cesarean section. 26 (86.7%) mothers were agreed to give replacement feeding to their babies and of 4 infants were breast fed for duration 1 month to six months.
Neonatal data
1 baby born to HIV- mother
01 Loss to follow up
30 Babies completed follow up
01 Positive
29 Negative
Fig. 1 e Showing the data of HIV exposed babies.
nine (96.7%) infants were declared HIV negative after 2 negative DNA-PCR tests. One infant was found to be positive and started on HAART. In one infant born to discordant couple (Mother-positive, father negative) 1st DNA-PCR was positive at 2 weeks, second negative at 6 weeks and 3rd DNA-PCR again positive at repeat testing at 6 months, hence started on HAART. On follow up at 2 years of age, child was asymptomatic and did not have any marker, whatsoever for HIV and on thorough evaluation found to be HIV negative on DNA-PCR and ELISA. The reason for her negative status could not be explained. The parent-to-child transmission rate at our center was 3.3%. The outcome of HIV exposed infants is shown in Figs. 1 and 2.
Discussion Mother-to-child transmission (MTCT) of HIV represents the most common means by which children acquire HIV infection in over 90% children. The corner stone of reduction of transmission is an effective PPTCT programme. According to the WHO report 2009, “Towards universal access: scaling up priority HIV/AIDS interventions” in the health sector, significant progress in the area of PMTCT has been made during the past several years, but still lots to be done.1 In India, of the estimated 1.8e2.9 million people living with HIV, 39% are women.11 According to UNICEF ‘National programme targets’ by 2012, 80% of HIV positive pregnant women will be reached by PMTCT services.12 In our study, all the pregnant mothers reported for antenatal checkup were screened and yearly
Of the 30 motherebaby pairs studied, all the babies were singletons, 29 (96.7%) born at term with mean birth weight of 2.60 kg (SD ¼ 0.5 kg) and male to female ratio of 0.87:1. Twenty
Table .1 e Showing the yearly period prevalence of HIV at antenatal clinic. Year
No of ANC cases screened
Mothers found positive
2008 2009 2010
3263 3550 4763
13 (0.39%) 13 (0.36%) 9 (0.18%)
Fig. 2 e Showing the outcome of HIV exposed babies.
220
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 2 1 8 e2 2 1
period prevalence of HIV positive among pregnant mothers showed a downward trend from 0.39% in 2008 to 0.18% in 2010, as against 0.27% reported by NACO in 2011.12 All the mothers found HIV positive were enrolled under PPTCT programme, given triple drug antiretroviral therapy and all the infants were started on ARV prophylaxis, and closely followed up. As a result of this comprehensive PPTCT programme, among 30 HIV exposed babies, only one infant found to be HIV positive and rate of perinatal transmission at our center was 3.3%, which is comparable with similar studies in the developed countries.4e8 Twenty eight mothers (93.3%) in our study were started on ARV and all infants were given single dose of nevirapine and zidovudine for 6 weeks. In India 68% of HIVþ motherebaby pairs received single dose nevirapine ARV in 2010.12 American Academy of Pediatrics recommends routine HIV screening for all pregnant women, if found positive ARV instituted as soon as possible and counseled not to breastfeed their babies in order to minimize the risk of perinatal transmission.7 Study conducted by Kouanda et al and Chama et al confirms that HAART for mothers effectively reduces the risk of infant HIV infection while preserving the breastfeeding option of mothers.4,8 The role of mode of delivery in the management of HIVinfected women should be considered in the light of risks as well as benefits. Cesarean delivery is an efficacious intervention for the prevention of MTCT among HIV-1-infected women having advanced disease or low CD4 count or not taking ARVs, however associated with higher postpartum morbidities.9 American College of Obstetrics and Gynecology recommends cesarean section to mothers with viral load more than 1000 copies/ml. Although the benefit of elective cesarean delivery (ECD) in preventing MTCT of HIV is substantial, some questions remain, specifically in women with very low viral loads or women on HAART.13 Indian data in this regard reveals HIV transmission probabilities, 0.04e0.14 for vaginal delivery and 0.00e0.02 for caesarian delivery and suggest that pregnant HIV-infected women receiving nevirapine should consider the benefits of a cheaper and safer vaginal delivery.14 In our study, 15 (50%) mothers underwent caesarean delivery with no significant postpartum morbidities. All the babies were singletons, 29 (96.7%) born at term with an average birth weight of 2.60 kg (SD ¼ 0.5) and comparable with similar study done by Mukhtar-Yola in Nigeria.6 Post-natal transmission of HIV via breastfeeding reverses gains achieved by perinatal antiretroviral interventions. There is 14% extra risk of HIV transmission by breastfeeding. Colostrum has higher viral load and increases the risk of infection, hence not to be given. With the implementation of new WHO guidelines on infant feeding practices in HIV positive mothers, mother-to-child HIV transmission risk can be reduced to 5% or lower in a breastfeeding population, from a background transmission risk of 35% in the absence of any interventions and with continued breastfeeding.15 In our study group of 30 infants, 4 (13.3%) opted for breastfeeding probably, due to poor literacy, not enough motivation and non-affordability of top feeds by the mother. On follow up, mothers were advised to continue infant ARV prophylaxis and switch over to complementary feeding. On follow up screening, three infants were
found to be negative. One mother continued breastfeeding till one year and on screening, child was found HIV positive and initiated HAART. Complete avoidance of breastfeeding is efficacious in preventing MTCT, but this intervention has significant associated morbidity (e.g., diarrheal morbidity if formula is prepared without clean water).5 In our study, there was no significant infective morbidity or stigmata of nutritional deficiencies. For infant diagnosis, serologic tests are not useful because of persistence of maternal antibodies and DNA-PCR can reliably detect the presence of HIV infection in infants up to 18 months.10
Conclusion With the administration of antiretroviral therapy to the mother and infant, safe delivery practices, complete avoidance of breastfeeding and close follow up, the incidence of PTCT can be reduced to negligible rates of below 5% as seen in our study. Counseling of mother regarding measures for prevention of perinatal transmission and infant feeding choice should be done during pregnancy, as mother is most receptive during this period and maximum yield of success can be achieved. HIV-DNA PCR is highly specific and sensitive test for infant diagnosis. PPTCT remains the best way of preventing pediatric HIV infection.
Conflicts of interest All authors have none to declare.
references
1. PMTCT Strategic Vision 2010e2015: Preventing Mother-to-child Transmission of HIV to Reach the UNGASS and Millennium Development Goals. WHO; 2010. 2. UNAIDS. AIDS Epidemic Update 2007. Geneva: UNAIDS and WHO. Available at: www.unaids.org; 2007. 3. NACO. HIV Sentinel Surveillance and HIV Estimation. New Delhi: National AIDS Control Organization 2007. Also available at: www.nacoonline.org; 2006. Accessed 19.12.2007. 4. Kouanda S, Tougri H, Cisse M, et al. Impact of maternal HAART on the prevention of mother-to-child transmission of HIV: results of an 18-month follow-up study in Ouagadougou, Burkina Faso. AIDS Care. 2010 Jul;22(7):843e850. 5. Horvath T, Madi BC, Iuppa IM, Kennedy GE, Rutherford G, Read JS. Interventions for preventing late postnatal mother-to-child transmission of HIV. Cochrane Database Syst Rev. 2010;Jan 21(1):CD006734. 6. Mukhtar-Yola M, Gwarzo GD, Galadanci HS, et al. HIV exposed infants: a preliminary report of the Aminu Kano Teaching Hospital Experience Niger. Postgrad Med J. 2009 Jun;16(2):143e148. 7. Havens PL, Chakraborty R, Cooper E. HIV testing and prophylaxis to prevent mother-to-child transmission in the United States. Pediatrics. 2008;Nov; 122(5):1127e1134. 8. Chama CM, Bello M, Ajayi BA, Zarma S, Gashau W. The use of highly active antiretroviral therapy for the prevention of mother-to-child transmission of the human
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 2 1 8 e2 2 1
immunodeficiency virus in Nigeria. J Obstet Gynaecol. 2010 May;30(4):362e366. 9. Read JS, Newell MK. Efficacy and safety of cesarean delivery for prevention of mother to child transmission of HIV-1. Cochrane Database Syst Rev. 2005 Oct;19(4):CD005479. 10. Read JS. Diagnosis of HIV-1 infection in children younger than 18 months in the United States. Pediatrics. 2007 Dec;120(6):e1547ee1562. 11. Damania K, Parikshit T, Mamatha L. Recent trends in mother to child transmission of HIV in pregnancy. J Obstet Gynaecol India. 2010;60(5):395e402.
221
12. National AIDS Control Organization [NACO]. Annual report 2010e11. 13. Legardy-Williams Jennifer K, Denise JJ, Jennifer SR. Prevention of mother-to-child transmission of HIV: the role of cesarean delivery. Clin Perinatol. 2010;37(4):777e785. 14. Mukherjee K. Cost-effectiveness of childbirth strategies for prevention of mother-to-child transmission of HIV among mothers receiving nevirapine in India. Indian J Community Med. 2010;35(1):29e33. 15. WHO Guidelines. HIV and Infant Feeding: Revised Principles and Recommendations. Rapid Advice; Nov 2009.
