Division of Global HIV & Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Lilongwe, Malawi; Center for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya.
Dignitas International, Zomba, Malawi.
Lancet HIV. 2018 Dec;5(12):e688-e695. doi: 10.1016/S2352-3018(18)30316-3. Epub 2018 Nov 19.
Routine data from Malawi's prevention of mother-to-child transmission (MTCT) option B+ programme suggest high uptake of antiretroviral therapy (ART) among pregnant women. Malawi's Ministry of Health led the National Evaluation of Malawi's PMTCT Program to obtain nationally representative data on maternal ART coverage and prevention of MTCT effectiveness. Here, we present the early transmission data for infants aged 4-12 weeks.
We used a multistage cluster design to recruit a nationally representative sample of HIV-exposed infants and their mothers in Malawi. Between October 16, 2014, and May 17, 2016, we screened for HIV in all mothers attending an under-5 vaccination or outpatient sick-child clinic with infants aged 4-26 weeks at 54 health facilities selected across ten districts and four regional sampling zones. Infants with mothers identified as HIV-infected were enrolled in the cohort. We calculated weighted MTCT rates for only the subset of infants aged 4-12 weeks at screening, thereby capturing MTCT from early pregnancy, to delivery, and early breastfeeding. We collected data on maternal and infant demographics and self-reported use of HIV services, ART, and antenatal clinics. We tested HIV-exposed infants for the virus and assessed associations of certain variables with infant HIV status.
We confirmed HIV exposure in 3542 (10·4%) of 33 980 mother (guardian)-infant pairs with infants aged 4-26 weeks. Of those, 2530 (2514 mothers and 16 guardians) had infants aged 4-12 weeks at the time of screening (2498 singlets and 32 twins). We excluded 25 infants from the analysis because no information was available about their HIV status. 91·3% (95% CI 85·6-96·9) of mothers were on ART during pregnancy. The MTCT rate was 3·7% (2·3-6·0) overall and ranged from 1·4% (0·4-4·4) in women who initiated ART before pregnancy to 19·9% (13·4-28·6) in women not on ART. In multivariable logistic regression analysis, the odds of early MTCT were higher in mothers starting ART post partum (adjusted odds ratio 16·7, 95% CI 1·6-171·5; p=0·022) and in those not on ART with an unknown HIV status during pregnancy (19·1, 8·5-43·0; p<0·0001) than in mothers on ART before pregnancy. Among HIV-exposed infants, 98·0% (95% CI 96·9-99·1) were reported by the mother to have received infant nevirapine prophylaxis, and only 45·6% (34·8-56·4) were already enrolled in an exposed infant HIV care clinic at the time of study screening.
These data suggest that Malawi's decentralisation of ART services has resulted in higher ART coverage and lower early MTCT. However, the uptake of services for HIV-exposed infants remains suboptimal.
President's Emergency Plan for AIDS Relief.
马拉维预防母婴传播（PMTCT）选项 B+ 方案的常规数据表明，孕妇中抗逆转录病毒治疗（ART）的使用率很高。马拉维卫生部主导了全国性的马拉维 PMTCT 项目评估，以获取全国范围内孕产妇接受抗逆转录病毒治疗的覆盖范围和预防母婴传播的有效性数据。在此，我们报告了婴儿 4-12 周时的早期传播数据。
我们采用多阶段聚类设计，在马拉维招募了一个具有代表性的 HIV 暴露婴儿及其母亲的样本。2014 年 10 月 16 日至 2016 年 5 月 17 日，我们在十个区和四个区域抽样区的 54 个卫生设施中，对所有在 4-26 周龄时在五岁以下儿童疫苗接种或门诊儿童就诊的母亲进行 HIV 筛查。在筛查时，我们对母亲被确认为 HIV 感染者的婴儿进行了入组。我们仅对筛查时年龄在 4-12 周的婴儿进行了 MTCT 率的计算，从而捕获了从早期妊娠到分娩和早期母乳喂养的母婴传播。我们收集了母婴人口统计学和自我报告的 HIV 服务、ART 和产前检查的数据。我们对 HIV 暴露婴儿进行了病毒检测，并评估了某些变量与婴儿 HIV 状况的相关性。
我们在 33980 名 4-26 周龄母婴对中确认了 3542 名（10.4%）婴儿的 HIV 暴露情况。其中，2530 名（2514 名母亲和 16 名监护人）在筛查时年龄在 4-12 周（2498 名单胎和 32 名双胞胎）。我们排除了 25 名婴儿的分析，因为他们的 HIV 状况没有信息。91.3%（95%CI 85.6-96.9）的母亲在怀孕期间接受了 ART。总的 MTCT 率为 3.7%（2.3-6.0），范围从妊娠前开始接受 ART 的妇女的 1.4%（0.4-4.4）到未接受 ART 的妇女的 19.9%（13.4-28.6）。在多变量逻辑回归分析中，产后开始接受 ART 的母亲（调整后的比值比 16.7，95%CI 1.6-171.5；p=0.022）和未接受 ART 且在怀孕期间 HIV 状态未知的母亲（19.1，8.5-43.0；p<0.0001）发生早期 MTCT 的可能性更高。在 HIV 暴露婴儿中，母亲报告 98.0%（95%CI 96.9-99.1）接受了婴儿奈韦拉平预防，而在研究筛查时，只有 45.6%（34.8-56.4）已经入组了暴露婴儿 HIV 护理诊所。
这些数据表明，马拉维将 ART 服务去中心化的措施已经提高了 ART 的覆盖率，降低了早期母婴传播的风险。然而，HIV 暴露婴儿接受服务的情况仍然不理想。
总统艾滋病紧急救援计划。
