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      Effectiveness of Lifelong ART (Option B+) in the Prevention of Mother-to-Child Transmission of HIV Programme in Zambia: Observations Based on Routinely Collected Health Data

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          Background: Mother to child transmission of HIV (MTCT) is a global challenge affecting many countries especially in sub-Saharan Africa. In 2009 about 370,000 infants were infected with HIV mainly through MTCT and most of them in sub-Saharan Africa. We aimed to determine the effectiveness of Option B+ compared to other options in reducing rates of early MTCT of HIV infections in Zambia.

          Methods: This was a retrospective cohort study based on routinely collected data using SmartCare in Zambia. Survival analysis with Cox Proportional Hazard regression was used to determine association between MTCT and regimen type of mothers. Kaplan-Meier (K-M) curves were used to compare MTCT for infants born to mothers option B+ to those on other options, and Wilcoxon (Breslow) test was used to establish statistical significance.

          Results: Overall ( n = 1,444), mother-baby pairs with complete data were included in the analysis, with the median age of mothers being 33 (28–38) years; and 57% of these women were on Option B+. MTCT rate was estimated at 5% (73/1,444) [ P = 0.025]. A Kaplan-Meier estimate showed that HIV Exposed Infants (HEI) of mothers on Option B+ had lower MTCT rate than those who were on other MTCT prevention interventions [Wilcoxon test; chi2 = 4.97; P = 0.025]. Furthermore, The Nelson Aalen cumulative hazard estimates indicated similar evidence of option B+ being more effective than other options with some statistical significance [HR = 0.63, P = 0.068]. HEI of option B+ mothers had 50% reduced risk of having HIV infection compared to option A/B [adjusted HR = 0.4; 95% CI = 0.28–0.84; P = 0.010]. HEI to women who were married had an increased risk 50% of getting infected compared to those not married [adjusted HR = 1.5; 95% CI = 3.43–6.30; P < 0.001]. Exposed infants whose mothers had assisted delivery had 3 times increased risk of getting infected compared to those born through normal vaginal delivery [Adjusted HR = 3.2; 95% CI = 0.98–10.21; P = 0.050].

          Conclusions: The use of Option B+ as PMTCT intervention was found to be more effective in reducing MTCT of HIV compared to other options. Scaling up access to life-long ART and improving retention for women on treatment can potentially reduce further vertical transmission.

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          Most cited references 22

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          Evaluation of a 5-year programme to prevent mother-to-child transmission of HIV infection in Northern Uganda.

          Prevention of mother-to-child transmission (PMTCT) is essential in HIV/AIDS control. We analysed 2000-05 data from mother-infant pairs in our PMTCT programme in rural Uganda, examining programme utilization and outcomes, HIV transmission rates and predictors of death or loss to follow-up (LFU). Out of 19,017 women, 1,037 (5.5%) attending antenatal care services tested HIV positive. Of these, 517 (50%) enrolled in the PMTCT programme and gave birth to 567 infants. Before tracing, 303 (53%) mother-infant pairs were LFU. Reasons for dropout were infant death and lack of understanding of importance of follow-up. Risk of death or LFU was higher among infants with no or incomplete intrapartum prophylaxis (OR = 1.90, 95% CI 1.07-3.36) and of weaning age <6 months (OR 2.55, 95% CI 1.42-4.58), and lower in infants with diagnosed acute illness (OR 0.30, 95% CI 0.16-0.55). Mother-to-child HIV cumulative transmission rate was 8.3%, and 15.5% when HIV-related deaths were considered. Improved tracking of HIV-exposed infants is needed in PMTCT programmes where access to early infant diagnosis is still limited.
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            Risks and benefits of lifelong antiretroviral treatment for pregnant and breastfeeding women: a review of the evidence for the Option B+ approach.

            Considerable debate has emerged on whether Option B+ (B+), initiation of lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women, is the best approach to achieving elimination of mother-to-child-transmission. However, direct evidence and experience with B+ is limited. We review the current evidence informing the proposed benefits and potential risks of the B+ approach, distinguishing individual health concerns for mother and child from program delivery and public health issues. For mothers and infants, B+ may offer significant benefits for transmission prevention and maternal health. However, several studies raise concerns about the safety of ART exposure to fetuses and infants, as well as adherence challenges for pregnant and breastfeeding mothers. For program delivery and public health, B+ presents distinct advantages in terms of transmission prevention to uninfected partners and increased simplicity potentially improving program feasibility, access, uptake, and retention in care. Despite being more costly in the short-term, B+ will likely be cost effective over time. This review provides a detailed analysis of risks and benefits of B+. As national programs adopt this approach, it will be critical to carefully assess both short-term and long-term maternal and infant outcomes.
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              Prevention in neglected subpopulations: prevention of mother-to-child transmission of HIV infection.

              Worldwide, >1000 children are newly infected with human immunodeficiency virus (HIV) each day; the majority of these children are in sub-Saharan Africa. The primary mode of HIV acquisition is through mother-to-child transmission (MTCT) during pregnancy, childbirth, or breastfeeding. In well-resourced health care systems, like those in the United States, universal HIV testing for pregnant women, provision of antiretroviral therapy (when needed for maternal health) or prophylaxis, elective cesarean delivery, and avoidance of breastfeeding has reduced MTCT of HIV infection to 1%-2%. However, in resource-limited countries, the perinatal epidemic continues generally unabated. Clinical trials have identified simple, less expensive, effective antiretroviral prophylaxis regimens that can be implemented in resource-limited settings. However, implementation has been slow, and postnatal transmission of HIV through breastfeeding remains a significant challenge. This article will review the research on prevention of MTCT of HIV infection in resource-limited countries and the challenges to expansion of the benefits of preventive interventions for MTCT throughout the world.

                Author and article information

                Front Public Health
                Front Public Health
                Front. Public Health
                Frontiers in Public Health
                Frontiers Media S.A.
                17 January 2020
                : 7
                1Department of Epidemiology and Biostatistics, The University of Zambia School of Public Health , Lusaka, Zambia
                2Ministry of Health, University Teaching Hospital , Lusaka, Zambia
                3Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine , London, United Kingdom
                Author notes

                Edited by: Mitsunori Ogihara, University of Miami, United States

                Reviewed by: Shihao Yang, Harvard Medical School, United States; Abu Saleh Mohammad Mosa, University of Missouri, United States

                *Correspondence: Brian Muyunda muyundamwinanu@

                This article was submitted to Digital Public Health, a section of the journal Frontiers in Public Health

                †These authors have contributed equally to this work

                Copyright © 2020 Muyunda, Musonda, Mee, Todd and Michelo.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                Page count
                Figures: 3, Tables: 4, Equations: 0, References: 34, Pages: 10, Words: 6437
                Funded by: Bill and Melinda Gates Foundation 10.13039/100000865
                Award ID: OPP1084472
                Public Health
                Original Research

                hei, zambia, option b+, routine data, pmtct, pregnant women


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