南非约翰内斯堡一个产科地点出生时即确诊的 HIV 感染婴儿的 12 个月结局：一项观察性队列研究。
12-month outcomes of HIV-infected infants identified at birth at one maternity site in Johannesburg, South Africa: an observational cohort study.
机构信息
Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa.
Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa; Centre for HIV and Sexually Transmitted Infections, National Institute for Communicable Diseases, Johannesburg, South Africa.
出版信息
Lancet HIV. 2018 Dec;5(12):e706-e714. doi: 10.1016/S2352-3018(18)30251-0. Epub 2018 Nov 8.
BACKGROUND
Initiation of antiretroviral therapy (ART) following diagnosis of HIV infection at birth is an emerging area of paediatric HIV care. We present outcomes of HIV-infected infants identified at birth at Rahima Moosa Mother and Child Hospital in Johannesburg, South Africa.
METHODS
From September, 2013 (era 1), only high-risk HIV-exposed infants were offered diagnostic HIV PCR tests at birth. From June, 2014 (era 2), all HIV-exposed infants were offered laboratory-based diagnostic PCR tests. From October, 2014 (era 3), point of care (POC) diagnostic PCR tests were also done if staff availability allowed. We describe time to ART initiation, mortality, retention in care, and viral suppression among the HIV-infected infants identified across these eras.
FINDINGS
We tested 5449 HIV-exposed infants who were born between Sept 1, 2013, and June 30, 2016. 88 neonates with confirmed HIV infection were identified and included in the study, of which 86 (98%) started ART. Median age at ART initiation decreased from 9 days (IQR 6-25) in eras 1 and 2 to 2 days (1-8) in era 3. In era 3, more neonates who were co-tested with POC testing started ART within 48 h of birth (29 [83%] of 35; median 1 day [IQR 1-2]) than infants who were not co-tested (one [4%] of 29; median 6 days [5-10]). The probability of mortality by 12 months across the eras was 14% (95% CI 8-24) and did not differ by era. Of the 72 infants who survived and initiated ART at the site, 56 (78%) were retained at 12 months. Of the 56 infants retained in care, 40 (71%) had a viral load less than 400 copies per mL at 12 months, with no differences between eras (p=0·23).
INTERPRETATION
HIV-infected infants can be identified at birth and ART can be initiated within hours to days. Although most infants in our cohort started ART, mortality remained unacceptably high with suboptimal retention and viral suppression. Reducing mortality and improving retention and viral suppression remain urgent priorities.
FUNDING
Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institute of Allergy and Infectious Disease, National Institutes of Health, USAID/PEPfAR, and the South African National HIV Programme.
背景
在出生时诊断出 HIV 感染后开始抗逆转录病毒治疗（ART）是儿科 HIV 护理的一个新兴领域。我们介绍了在南非约翰内斯堡 Rahima Moosa 母婴医院出生时发现的 HIV 感染婴儿的结果。
方法
从 2013 年 9 月（时代 1）开始，只有高风险的 HIV 暴露婴儿在出生时才提供 HIV PCR 诊断测试。从 2014 年 6 月（时代 2）开始，所有 HIV 暴露婴儿都提供实验室基础诊断 PCR 测试。从 2014 年 10 月（时代 3）开始，如果工作人员允许，还可以进行即时护理（POC）诊断 PCR 测试。我们描述了在这些时代中发现的 HIV 感染婴儿的 ART 起始时间、死亡率、保留在护理中以及病毒抑制情况。
结果
我们测试了 5449 名 HIV 暴露婴儿，他们出生于 2013 年 9 月 1 日至 2016 年 6 月 30 日之间。确定了 88 名确诊 HIV 感染的新生儿，并纳入了研究，其中 86 名（98%）开始接受 ART。ART 起始年龄中位数从时代 1 和 2 的 9 天（IQR 6-25）下降到时代 3 的 2 天（1-8）。在时代 3 中，更多接受 POC 测试联合检测的新生儿在出生后 48 小时内开始 ART（35 例中有 29 例[83%]；中位数为 1 天[IQR 1-2]），而未接受联合检测的新生儿只有 1 例（29 例中有 1 例[4%]；中位数为 6 天[5-10]）。三个时代中 12 个月的死亡率为 14%（95%CI 8-24），且不受时代影响。在幸存并在现场开始 ART 的 72 名婴儿中，56 名（78%）在 12 个月时仍在接受护理。在 56 名接受护理的婴儿中，40 名（71%）在 12 个月时的病毒载量小于 400 拷贝/ml，各时代之间无差异（p=0.23）。
结论
可以在出生时识别出 HIV 感染的婴儿，并且可以在数小时至数天内开始 ART。尽管我们队列中的大多数婴儿都开始接受 ART，但死亡率仍然高得不可接受，保留和病毒抑制情况不佳。减少死亡率并改善保留和病毒抑制仍然是当务之急。
资金
美国国立卫生研究院国家儿童健康与人类发展研究所/国家过敏和传染病研究所、美国国际开发署/PEPfAR 以及南非国家艾滋病毒规划，提供资金支持。
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