University of North Carolina Project/Malawi, Lilongwe, Malawi.
Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
J Int AIDS Soc. 2021 Mar;24(3):e25687. doi: 10.1002/jia2.25687.
Pregnant women living with HIV can achieve viral suppression and prevent HIV mother-to-child transmission (MTCT) with timely HIV testing and early ART initiation and maintenance. Although it is recommended that pregnant women undergo HIV testing early in antenatal care in Malawi, many women test positive during breastfeeding because they did not have their HIV status ascertained during pregnancy, or they tested negative during pregnancy but seroconverted postpartum. We sought to estimate the association between the timing of last positive HIV test (during pregnancy vs. breastfeeding) and outcomes of maternal viral suppression and MTCT in Malawi's PMTCT programme.
We conducted a two-stage cohort study among mother-infant pairs in 30 randomly selected high-volume health facilities across five nationally representative districts of Malawi between 1 July 2016 and 30 June 2017. Log-binomial regression was used to estimate prevalence ratios (PR) and risk ratios (RR) for associations between timing of last positive HIV test (i.e. breastfeeding vs. pregnancy) and maternal viral suppression and MTCT, controlling for confounding using inverse probability weighting.
Of 822 mother-infant pairs who had available information on the timing of the last positive HIV test, 102 mothers (12.4%) had their last positive test during breastfeeding. Women who lived one to two hours (PR = 2.15; 95% CI: 1.29 to 3.58) or >2 hours (PR = 2.36; 95% CI: 1.37 to 4.10) travel time to the nearest health facility were more likely to have had their last positive HIV test during breastfeeding compared to women living <1 hour travel time to the nearest health facility. The risk of unsuppressed VL did not differ between women who had their last positive HIV test during breastfeeding versus pregnancy (adjusted RR [aRR] = 0.87; 95% CI: 0.48 to 1.57). MTCT risk was higher among women who had their last positive HIV test during breastfeeding compared to women who had it during pregnancy (aRR = 6.57; 95% CI: 3.37 to 12.81).
MTCT in Malawi occurred disproportionately among women with a last positive HIV test during breastfeeding. Testing delayed until the postpartum period may lead to higher MTCT. To optimize maternal and child health outcomes, PMTCT programmes should focus on early ART initiation and providing targeted testing, prevention, treatment and support to breastfeeding women.
感染艾滋病毒的孕妇通过及时的艾滋病毒检测和早期抗逆转录病毒治疗的启动和维持，可以实现病毒抑制并预防艾滋病毒母婴传播（MTCT）。尽管马拉维的孕产妇艾滋病毒预防母婴传播规划建议孕妇在产前保健中尽早进行艾滋病毒检测，但许多妇女在哺乳期检测呈阳性，因为她们在怀孕期间没有确定其艾滋病毒状况，或者她们在怀孕期间检测呈阴性但产后血清转换。我们旨在评估最后一次阳性艾滋病毒检测（怀孕期间与哺乳期）的时间与马拉维 PMTCT 规划中母婴病毒抑制和 MTCT 结局之间的关联。
我们在 2016 年 7 月 1 日至 2017 年 6 月 30 日期间，在马拉维五个具有代表性的地区的 30 个随机选定的高容量卫生设施中，对母婴对进行了两阶段队列研究。使用对数二项式回归来估计最后一次阳性艾滋病毒检测时间（即哺乳期与孕期）与母婴病毒抑制和 MTCT 之间的关联的患病率比（PR）和风险比（RR），通过逆概率加权来控制混杂因素。
在 822 对母婴中，有 102 名母亲（12.4%）在哺乳期时最后一次检测呈阳性。与居住在离最近卫生设施不到 1 小时行程时间的女性相比，居住在距离最近卫生设施 1 至 2 小时（PR = 2.15；95%CI：1.29 至 3.58）或>2 小时（PR = 2.36；95%CI：1.37 至 4.10）的女性更有可能在哺乳期时最后一次检测呈阳性。与孕期相比，在哺乳期最后一次检测呈阳性的女性未抑制的 VL 风险没有差异（调整后的 RR [aRR] = 0.87；95%CI：0.48 至 1.57）。与孕期相比，在哺乳期最后一次检测呈阳性的女性 MTCT 风险更高（aRR = 6.57；95%CI：3.37 至 12.81）。
马拉维 MTCT 不成比例地发生在最后一次阳性 HIV 检测在哺乳期的女性中。检测延迟到产后可能会导致更高的 MTCT。为了优化母婴健康结局，PMTCT 规划应侧重于早期抗逆转录病毒治疗的启动，并为哺乳期妇女提供有针对性的检测、预防、治疗和支持。
