An audit of mother to child HIV transmission rates and neonatal outcomes at a tertiary hospital in South Africa

Abstract

Background: With nearly half of all HIV infections occurring in women of child bearing age, one of the main challenges surrounding the HIV pandemic is the prevalence of mother to child transmission (MTCT), with the majority of HIV infections in children being as a result of MTCT. Objective: The aim of this study was to explore the prevalence of congenital HIV infection of neonates at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) between 2015 and 2017, as well as compare the HIV PCR positive and HIV PCR negative neonates, using data from the CMJAH neonatal databases. Methods: This was a retrospective, cross sectional descriptive study of all neonates admitted to the neonatal unit, between January 2015 and December 2017, at CMJAH. All HIV exposed neonates were included. All neonates who had no HIV PCR test at birth, or, who had indeterminate HIV PCR results, were excluded. Results: A total number of 1443 HIV exposed neonates was examined for the study period out of a total of 5029 admissions (HIV exposure 25.3%) The study found that the rate of HIV transmission at birth was 2.52%. The majority of infants had low birth weight and were also born prematurely. Conclusion: HIV transmission is high, despite the introduction of the early mother to child transmission (EMTCT) programme. However, there is no difference between the two groups of neonates under study; except for maternal syphilis, as the study shows a higher rate of infection in neonates with positive HIV PCR. Keywords: HIV positive mother, HIV exposed neonate, HIV prophylaxis, ANC visit, HIV transmission. Introduction Human Immunodeficiency Virus (HIV) disease has been, and continues to be, a health challenge to overcome globally. One of the main challenges with HIV is the high prevalence of HIV infections in mothers and children. Nearly half of all HIV-infected adults are women of child bearing age, and as a result of this, the majority of HIV infections in children are a result of MTCT [1] . According to the Foundation for AIDS Research, 91% of the world's HIV positive children live in sub-Saharan Africa [1] . The majority of MTCT of HIV takes place during pregnancy and/or delivery; therefore, interventions to prevent mother-to-child transmission are urgently needed to reduce the future incidence of paediatric HIV [2] . 2 The HIV transmission rate has been shown to be twice as high in Africa as in Europe. This difference is not yet fully understood, but contributory factors include: primary HIV infection occurring during pregnancy [3]; lower maternal CD4 count; differences in use of antiretroviral (ARV) drugs (e.g. less extensive availability, lower adherence rates, higher drug abuse rates); differences in virulence of the virus according to geographical origin; co-existence with other sexually transmitted diseases; concomitant infections in the mother; invasive intra-partum procedures (e.g. foetal scalp electrodes and forceps); chorioamnionitis [3]; vaginal delivery; rupture of membranes (especially if delivery is more than four hours after the membranes ruptured); advanced maternal age; lack of prevention of mother-to-child transmission (PMTCT) services; and mixed feeding regimes [4,5]. This shows that the transmission of HIV from mother to child is a multi-factorial event. A number of these factors cannot be controlled or reduced in a meaningful manner in a resource limited setting, but the availability of ARVs and preventative MTCT services are two areas that can be influenced. The transmission of HIV can be trans-placental during early or late gestation, and the prevalence of trans-placental transmission is high, especially in African countries as compared with global rates [5,6]. A number of researchers have shown a higher mortality rate among babies born to HIV positive mothers, as compared to those born to seronegative mothers [7] . Prematurity, low birth weight, and intrauterine growth retardation, are also higher in HIV exposed infants [7]. HIV Polymerase Chain Reaction (PCR) screening was introduced in South Africa in 2015 as part of the early mother to child transmission (EMTCT) programme. The aim of this study was to review HIV exposed neonates admitted to a tertiary hospital in Johannesburg, South Africa, after the introduction of EMTCT. Method This was a retrospective, cross sectional descriptive study conducted in the neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) from 1 st of January 2015 to the 31st of December 2017. The study population included all neonates admitted to the neonatal unit during the study period. All HIV exposed neonates were included. All neonates with indeterminate or no HIV PCR results, were excluded. All HIV exposed neonates were screened using a HIV PCR test at birth. Background: With nearly half of all HIV infections occurring in women of child bearing age, one of the main challenges surrounding the HIV pandemic is the prevalence of mother to child transmission (MTCT), with the majority of HIV infections in children being as a result of MTCT. Objective: The aim of this study was to explore the prevalence of congenital HIV infection of neonates at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) between 2015 and 2017, as well as compare the HIV PCR positive and HIV PCR negative neonates, using data from the CMJAH neonatal databases. Methods: This was a retrospective, cross sectional descriptive study of all neonates admitted to the neonatal unit, between January 2015 and December 2017, at CMJAH. All HIV exposed neonates were included. All neonates who had no HIV PCR test at birth, or, who had indeterminate HIV PCR results, were excluded. Results: A total number of 1443 HIV exposed neonates was examined for the study period out of a total of 5029 admissions (HIV exposure 25.3%) The study found that the rate of HIV transmission at birth was 2.52%. The majority of infants had low birth weight and were also born prematurely. Conclusion: HIV transmission is high, despite the introduction of the early mother to child transmission (EMTCT) programme. However, there is no difference between the two groups of neonates under study; except for maternal syphilis, as the study shows a higher rate of infection in neonates with positive HIV PCR. Keywords: HIV positive mother, HIV exposed neonate, HIV prophylaxis, ANC visit, HIV transmission. Introduction Human Immunodeficiency Virus (HIV) disease has been, and continues to be, a health challenge to overcome globally. One of the main challenges with HIV is the high prevalence of HIV infections in mothers and children. Nearly half of all HIV-infected adults are women of child bearing age, and as a result of this, the majority of HIV infections in children are a result of MTCT [1] . According to the Foundation for AIDS Research, 91% of the world's HIV positive children live in sub-Saharan Africa [1] . The majority of MTCT of HIV takes place during pregnancy and/or delivery; therefore, interventions to prevent mother-to-child transmission are urgently needed to reduce the future incidence of paediatric HIV [2] . 2 The HIV transmission rate has been shown to be twice as high in Africa as in Europe. This difference is not yet fully understood, but contributory factors include: primary HIV infection occurring during pregnancy [3]; lower maternal CD4 count; differences in use of antiretroviral (ARV) drugs (e.g. less extensive availability, lower adherence rates, higher drug abuse rates); differences in virulence of the virus according to geographical origin; co-existence with other sexually transmitted diseases; concomitant infections in the mother; invasive intra-partum procedures (e.g. foetal scalp electrodes and forceps); chorioamnionitis [3]; vaginal delivery; rupture of membranes (especially if delivery is more than four hours after the membranes ruptured); advanced maternal age; lack of prevention of mother-to-child transmission (PMTCT) services; and mixed feeding regimes [4,5]. This shows that the transmission of HIV from mother to child is a multi-factorial event. A number of these factors cannot be controlled or reduced in a meaningful manner in a resource limited setting, but the availability of ARVs and preventative MTCT services are two areas that can be influenced. The transmission of HIV can be trans-placental during early or late gestation, and the prevalence of trans-placental transmission is high, especially in African countries as compared with global rates [5,6]. A number of researchers have shown a higher mortality rate among babies born to HIV positive mothers, as compared to those born to seronegative mothers [7] . Prematurity, low birth weight, and intrauterine growth retardation, are also higher in HIV exposed infants [7]. HIV Polymerase Chain Reaction (PCR) screening was introduced in South Africa in 2015 as part of the early mother to child transmission (EMTCT) programme. The aim of this study was to review HIV exposed neonates admitted to a tertiary hospital in Johannesburg, South Africa, after the introduction of EMTCT. Method This was a retrospective, cross sectional descriptive study conducted in the neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) from 1 st of January 2015 to the 31st of December 2017. The study population included all neonates admitted to the neonatal unit during the study period. All HIV exposed neonates were included. All neonates with indeterminate or no HIV PCR results, were excluded. All HIV exposed neonates were screened using a HIV PCR test at birth. Background: With nearly half of all HIV infections occurring in women of child bearing age, one of the main challenges surrounding the HIV pandemic is the prevalence of mother to child transmission (MTCT), with the majority of HIV infections in children being as a result of MTCT. Objective: The aim of this study was to explore the prevalence of congenital HIV infection of neonates at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) between 2015 and 2017, as well as compare the HIV PCR positive and HIV PCR negative neonates, using data from the CMJAH neonatal databases. Methods: This was a retrospective, cross sectional descriptive study of all neonates admitted to the neonatal unit, between January 2015 and December 2017, at CMJAH. All HIV exposed neonates were included. All neonates who had no HIV PCR test at birth, or, who had indeterminate HIV PCR results, were excluded. Results: A total number of 1443 HIV exposed neonates was examined for the study period out of a total of 5029 admissions (HIV exposure 25.3%) The study found that the rate of HIV transmission at birth was 2.52%. The majority of infants had low birth weight and were also born prematurely. Conclusion: HIV transmission is high, despite the introduction of the early mother to child transmission (EMTCT) programme. However, there is no difference between the two groups of neonates under study; except for maternal syphilis, as the study shows a higher rate of infection in neonates with positive HIV PCR. Keywords: HIV positive mother, HIV exposed neonate, HIV prophylaxis, ANC visit, HIV transmission. Introduction Human Immunodeficiency Virus (HIV) disease has been, and continues to be, a health challenge to overcome globally. One of the main challenges with HIV is the high prevalence of HIV infections in mothers and children. Nearly half of all HIV-infected adults are women of child bearing age, and as a result of this, the majority of HIV infections in children are a result of MTCT [1] . According to the Foundation for AIDS Research, 91% of the world's HIV positive children live in sub-Saharan Africa [1] . The majority of MTCT of HIV takes place during pregnancy and/or delivery; therefore, interventions to prevent mother-to-child transmission are urgently needed to reduce the future incidence of paediatric HIV [2] . 2 The HIV transmission rate has been shown to be twice as high in Africa as in Europe. This difference is not yet fully understood, but contributory factors include: primary HIV infection occurring during pregnancy [3]; lower maternal CD4 count; differences in use of antiretroviral (ARV) drugs (e.g. less extensive availability, lower adherence rates, higher drug abuse rates); differences in virulence of the virus according to geographical origin; co-existence with other sexually transmitted diseases; concomitant infections in the mother; invasive intra-partum procedures (e.g. foetal scalp electrodes and forceps); chorioamnionitis [3]; vaginal delivery; rupture of membranes (especially if delivery is more than four hours after the membranes ruptured); advanced maternal age; lack of prevention of mother-to-child transmission (PMTCT) services; and mixed feeding regimes [4,5]. This shows that the transmission of HIV from mother to child is a multi-factorial event. A number of these factors cannot be controlled or reduced in a meaningful manner in a resource limited setting, but the availability of ARVs and preventative MTCT services are two areas that can be influenced. The transmission of HIV can be trans-placental during early or late gestation, and the prevalence of trans-placental transmission is high, especially in African countries as compared with global rates [5,6]. A number of researchers have shown a higher mortality rate among babies born to HIV positive mothers, as compared to those born to seronegative mothers [7] . Prematurity, low birth weight, and intrauterine growth retardation, are also higher in HIV exposed infants [7]. HIV Polymerase Chain Reaction (PCR) screening was introduced in South Africa in 2015 as part of the early mother to child transmission (EMTCT) programme. The aim of this study was to review HIV exposed neonates admitted to a tertiary hospital in Johannesburg, South Africa, after the introduction of EMTCT. Method This was a retrospective, cross sectional descriptive study conducted in the neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) from 1 st of January 2015 to the 31st of December 2017. The study population included all neonates admitted to the neonatal unit during the study period. All HIV exposed neonates were included. All neonates with indeterminate or no HIV PCR results, were excluded. All HIV exposed neonates were screened using a HIV PCR test at birth. Data Collection This was a secondary analysis of an existing database. The data of all patients was entered into the neonatal computer database for the purpose of quality control. Data was managed using the Research Electronic Data Capture (REDCap) database [8] and was exported into Excel for data cleaning. Statistical Analysis Neonates were divided on the basis of the PCR test into birth HIV positive and negative. Outcome, clinical and demographic data was compared between the two groups. Data was analysed using IBM SPSS 25. Missing values were excluded in the analysis of each variable. Continuous variables, such as birth weight and gestational age, were described using mean and standard deviation, depending on the distribution of the data. On the other hand, categorical variables, such as gender and mode of delivery, were described using percentages. Categorical variables were compared using Chi Square. Continuous variables were compared using an independent sample t test, as the data was normally distributed. A P value ≤0.05 was considered statistically significant. Results There were 1 443 HIV exposed neonates who were admitted during the study period. The results were broken down as shown in Figure 1.