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Prevention
of mother-to-child transmission of HIV (PMTCT) in Central Haiti: HIV-free
survival at 18 months of age in a cohort of HIV-exposed infants enrolled in the partners In health / Zanmi Lasante (PIH/ZL) program
L. Ivers1, S. Appleton1, K. Cullen1, G. Jerome2, B. Wang3, M. Smith Fawzi1,4
1Partners In Health, Boston, United States, 2Zanmi Lasante Sociomedical Complex, Cange, Haiti, 3Massachusetts General Hospital, Boston, United States, 4Harvard Medical School, Department of Global Health and Social Medicine, Boston, United States
Background: PIH/ZL has one of the longest track
records of providing care for PMTCT in the developing world, initiating
services in 1995 after AZT was known to reduce vertical transmission of HIV.
PIH/ZL offers comprehensive care, including ART during pregnancy, AZT and
co-trimoxazole for the infant after birth, and free infant formula accompanied
with community health worker support to ensure safe feeding practices.
Methods: An
observational study was performed, examining HIV transmission, death, and
HIV-free survival at 18 months among infants enrolled in the PIH/ZL PMTCT
program. Among 351 pregnant women/infants who came to receive care at PIH/ZL,
91 presented after delivery and 260 presented during or prior to delivery.
Twins were excluded from the analysis resulting in an effective sample size of
n=254.
Results: Among
HIV-exposed infants in the PIH/ZL program, 91% of infants at 18 months survived
and were free from HIV infection, 3.5% were HIV-positive, and 6.7% had died at
18 months. For those mothers who had exclusively bottle fed, transmission of
HIV was 3.2%. Protective factors for HIV-free survival included exclusive
bottle feeding and longer duration of ART during pregnancy (starting at 4 weeks
before delivery or earlier).
Conclusions:
Although this population was in a severe resource-poor setting, with only 52%
having an improved water source and 41% having an improved latrine, the rate of
mortality at 18 months was much lower than Haiti overall. This finding may be
related to the additional support that women received through the community
health worker (accompagnateur) program at PIH/ZL, which offered support for directly
observed therapy of ART during pregnancy and safe bottle feeding after delivery.
The results also demonstrate that a key bottleneck to program success is the
problem of identifying HIV-positive pregnant women before delivery and earlier
in their pregnancy to prevent HIV transmission among their infants.
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