Abstract:
BACKGROUND : Eliminating mother–to–child transmission of HIV (EMTCT),
defined as ≤50 infant HIV infections per 100 000 live births, is a global
priority. Since 2011 policies to prevent mother–to–child transmission of
HIV (PMTCT) shifted from maternal antiretroviral (ARV) treatment or
prophylaxis contingent on CD4 cell count to lifelong maternal ARV treatment
(cART). We sought to measure progress with early (4–8 weeks postpartum)
MTCT prevention and elimination, 2011–2013, at national and
sub–national levels in South Africa, a high antenatal HIV prevalence setting
( ≈ 29%), where early MTCT was 3.5% in 2010.
METHODS : Two surveys were conducted (August 2011–March 2012 and
October 2012–May 2013), in 580 health facilities, randomly selected after
two–stage probability proportional to size sampling of facilities (the
primary sampling unit), to provide valid national and sub–national–(provincial)–
level estimates. Data collectors interviewed caregivers of eligible
infants, reviewed patient–held charts, and collected infant dried blood
spots (iDBS). Confirmed positive HIV enzyme immunoassay (EIA) and
positive total HIV nucleic acid polymerase chain reaction (PCR) indicated
infant HIV exposure or infection, respectively. Weighted survey analysis
was conducted for each survey and for the pooled data.
FINDINGS : National data from 10 106 and 9120 participants were analyzed
(2011–12 and 2012–13 surveys respectively). Infant HIV exposure was
32.2% (95% confidence interval (CI) 30.7–33.6%), in 2011–12 and
33.1% (95% CI 31.8–34.4%), provincial range of 22.1–43.6% in 2012–
13. MTCT was 2.7% (95% CI 2.1%–3.2%) in 2011–12 and 2.6% (95%
CI 2.0–3.2%), provincial range of 1.9–5.4% in 2012–13. HIV–infected
ARV–exposed mothers had significantly lower unadjusted early MTCT
(2.0% [2011–12: 1.6–2.5%; 2012–13:1.5–2.6%]) compared to HIV–infected
ARV–naive mothers [10.2% in 2011–12 (6.5–13.8%); 9.2% in
2012–13 (5.6–12.7%)]. Pooled analyses demonstrated significantly lower
early MTCT among exclusive breastfeeding (EBF) mothers receiving
>10 weeks ARV prophylaxis or cART compared with EBF and no ARVs:
(2.2% [95% CI 1.25–3.09%] vs 12.2% [95% CI 4.7–19.6%], respectively);
among HIV–infected ARV–exposed mothers, 24.9% (95% CI 23.5–
26.3%) initiated cART during or before the first trimester, and their early
MTCT was 1.2% (95% CI 0.6–1.7%). Extrapolating these data, assuming
32% EIA positivity and 2.6% or 1.2% MTCT, 832 and 384 infants
per 100 000 live births were HIV infected, respectively.
CONCLUSIONS : Although we demonstrate sustained national–level PMTCT
impact in a high HIV prevalence setting, results are far–removed from
EMTCT targets. Reducing maternal HIV prevalence and treating all maternal
HIV infection early are critical for further progress.
