Background : In Cameroon, the prevalence of HIV in pregnant women was 7.8% in 2012, and they were 8500 HIV positive newborn s in 2013. Option B+ is the first highly active antiretroviral therapy (HAART) preventive protocol. The objective was to evaluate the rate of HIV transmission on children born from mothers who were on Option B+ during pregnancy, in three university teaching hospitals of the University of Yaoundé I. Methods : It was a retrospective, cross-sectional study over a period of four years (2013-2017). We included HIV positive mothers not on previous antiretroviral treatment and who received a single tablet daily of combined tenofovir (300 mg) + Lamivudine (300 mg) + Efavirenz (600 mg) started at any time during pregnancy. Newborn received nevirapine syrup according to WHO option B+ protocol. Results : 179 women were included. The average age was 33.5 ± 2.92 years, all ages were represented. Blood donation was the most frequent HIV positive screening opportunity, voluntary testing rate was 29% (29/179), and adherence rate was 98.9%. Few male partners were involved (58/179). Premature deliveries and low birth weight were rare (5/179; 10/179)), the indication of mode of delivery was strictly obstetrical, newborn feeding choice didn’t affect the transmission outcome, and the mother to child transmission rate was 2.2% (4/179). Conclusion : Option B+ could achieve the lowest mother to child transmission ever in Cameroon and should be generalized in high endemicity low resources settings.
Mother to child transmission of HIV represents 90% of HIV transmission among children less than 14 years and, globally, it was still the seventh leading cause of death among children aged 10 - 14 years in 2015, and the ninth of death among adolescents (aged 10 - 19 years). AIDS is indeed the leading cause of adolescent death around the world with 328 deaths every day [
This transmission can occur during pregnancy, labor, delivery or breastfeeding and can be eliminated if HIV positive (HIV+) mothers have access to prevention of mother to child transmission (PMTCT) programs [
The objective of our study was to evaluate the rate of HIV transmission on exposed children whose mother took Tenofovir-Lamivudine-Efavirenz once a day during pregnancy, in three university teaching hospitals of the University in the capital of the republic of Cameroon in Central Africa.
It was a retrospective, cross-sectional study over a four years period (2013-2017), conducted from January 1st to 30th of April 2017 in three University major PMTCT implementing and referral centers of the University of Yaoundé I, namely, the University Teaching Hospital, the Central Hospital and the Gynecological Obstetrics and Pediatric Hospital, all in Yaoundé, the capital city of the republic of Cameroon in Central Africa. Altogether, they realize more than 8000 deliveries per year including a few hundred HIV positive pregnant women a year.
We included HIV+ mothers who were not on previous ART and who received a single tablet daily of combined tenofovir (300 mg) + Lamivudine (300 mg) + Efavirenz (600 mg) started at any time during pregnancy and taken at least for four completed weeks on the day of delivery. Newborn received nevirapine syrup for 6 weeks, according to WHO (World Health Organization) option B+ protocol. Non-consenting mothers, lost or incomplete records with missed HAART duration, mode of delivery, child PCR (polymerase chain reaction) early diagnosis result and serology status were excluded. Early detection of HIV infection in exposed children was done by dried blood spot (DBS) DNA PCR of HIV 1, performed at Chantal Biya International Reference Center for Research on Prevention and Management of HIV in Yaoundé, an important HIV research center in Sub-Saharan Africa. Exposed children’s serology was performed by enzyme-linked immunosorbent essay (ELISA) test, performed in the three University affiliated Hospitals of our study. The final diagnosis was made at 18 months of age, if serology was still positive after the first done at 10 months of age.
The data were collected using a pre-tested data sheet after due maternal consent. They concerned, the socio-demographic characteristics, the status of children born from HIV positive mothers. There was no viral load or CD4 assessment before delivery according to WHO’s Option B+ recommendations.
Retention was defined as 100% on time monthly ART intake, confirmed by computerized registers. This study received the ethical clearance of the ethical committee of the University of Yaoundé I. Data were analyzed using CS Pro version 6.3 and Microsoft Office Excel 2013. Statistical analysis was processed using X2, and P ≤ 0.05 was the statistical significance threshold.
We included 179 mother and child couples. They had an average age of 33.5 ± 2.92 years. The youngest and the oldest age were 15 and 43 respectively, all the ages were represented, 93% had at least middle school education level (
1) Maternal HIV data
Blood donation and antenatal care were the main circumstances of discovery of HIV+ status (71.5%; 128/179), retention rate was very high (99%; 177/179), 68% (121/179) of current sexual partner HIV status was unknown (
2) Maternal pregnancy follows up data
Ninety-seven per cent point two percent (174/179) attended at least 4 antenatal care (ANC), premature delivery rate was 2.8% (5/179), 77.7% (139/179) of children were born vaginally, 21.2% delivered by emergency caesarean section not indicated for viral load which was never taken into consideration at the moment of delivery. None of these parameters was related to child HIV status (P > 0.05) (
Artificial milk and breast milk feeding were equally adopted in post-natal feeding option and were not related to new born HIV status (
Post-natal HIV-exposed children HIV status assessment moment.
By 3 months post natally, 89% of HIV-exposed children had done their DBS DNA PCR screening, all the results were confirmed by serology (ELISA) at 18 months of age (
Variables | (n) | Frequency (%) |
---|---|---|
Ages of HIV+ mothers (in years) [15 - 19[ [19 - 24[ [24 - 29[ [29 - 34[ [34 - 39[ ≥39 Highest educational achievement level Never attended school Primary school Secondary education University education Marital status Married Single Cohabitation with partner Divorced Widow | 12 18 29 76 38 6 11 2 88 78 82 70 22 3 2 | 6,7 10 16.2 42.5 21.2 3.3 6.2 1.1 49.2 43.6 45.8 39.1 12.3 1.7 1.1 |
Variables | n | Frequency (%) |
---|---|---|
Circumstances of HIV+ discovery During blood donation During current pregnancy Voluntary testing Testing during disease management Duration of known HIV+ status <4 years ≥4 years Retention/adherence Yes No Viral load unknown Yes No Current sexual partner HIV status Unknown Positive Negative HAART to HIV+ partner Yes No | 87 41 29 22 169 10 177 2 0 179 121 43 15 40 3 | 48.6 22.9 16.2 12.3 94.4 5.6 98.9 1.1 0 100 67.6 24 8.4 93 7 |
The overall mother to child transmission rate of HIV was 2.2% (
This study as multicentric studies had limitations due to the different medical environment of the concerning PMTCT centers, the quality of male partners data due to confidentiality and those concerning HIV-exposed children feeding mode collected through mother’s declaration, with corresponding bias.
Variables | n | Frequency (%) |
---|---|---|
ANC* <4 4 to 8 >8 Gestational age on delivery (W)* <37 [37 - 40[ [40 - 42[ >42 Mode of delivery* Vaginal delivery Emergency caesarean section Instrumental delivery Birth weight (g)* <2500 ≥2500 | 5 48 126 5 122 52 0 139 38 2 10 169 | 2.8 26.8 70.4 2.8 68.2 29 0 77.7 21.2 1.1 5.6 94.4 |
*P > 0.05; ANC: ante natal care; W: weeks.
Post-natal feeding** | |||||||
---|---|---|---|---|---|---|---|
<6 months | ≥6 months | Total | |||||
n | % | n | % | ||||
Post-natal new-born feeding | Artificial Milk feeding | 39 | 51.31% | 98 | 95.10% | 137 | |
Maternal feeding | 34 | 44.74% | 5 | 4.90% | 39 | ||
Mixed feeding | 3 | 3.95% | 0 | 3.90% | 3 | ||
Total | 76 | 100.00% | 103 | 100.00% | 179 |
**P > 0.05.
Mother to child transmission of HIV has been a public health focus in high prevalence countries like Cameroon for almost two decades. Since the HIVNET 012, first randomized trial assessing the prevention of mother to child transmission of HIV in 1999 in Uganda [
tried, looking for a better reduction of the vertical transmission rate. Option B+ is the latest recommendation concerning the PMTCT, issued by WHO [
Pregnant women of all ages were represented in our sample, showing the magnitude of the epidemy in this country. Women aged 29 - 34 years represented almost half of the study population. Those aged 15 - 24 counted for 16.7% (20/179). The frequency of HIV + pregnant women aged 15 - 24 years in Cameroon is unknown. That age group is more at risk than the others. In sub-Saharan Africa, women aged 15 - 24 made up 66% of new infections among young people, the highest in the world, the proportion of women aged 15 - 24 years in new infections varying from 29% in Western and Central Europe and North America to 48% in the Middle East and North Africa [
The paradigm of antiretroviral prevention of mother to child transmission of HIV has changed, from short course antiretroviral preventive therapies to lifelong HAART treatment, thanks to the lessons learnt from the publication of Cohen et al., showing the advantages of early treatment of HIV regardless of CD4 count [
Circumstances of discovery of HIV status in our study revealed the difficulties of voluntary self-screening behavior in Africa, although living in a high prevalence Sub-Saharan Africa, regardless of national and multisectoral strategies in the fight against HIV, with voluntary HIV free of charge screening campaign. Less than one fifth did it through voluntary testing indeed, whereas the 2014 Cameroon Multiple Indicators Cluster Survey (MICS) has shown that 83.4% of women aged 15 - 49 years knew how and where to do HIV test [
The fear of HIV positive result, stigma, misconception of HIV testing and the fear of negative consequences are among major obstacles for using the testing services [
This study has also shown the enrolment power of antenatal care, in a context of low HIV self-screening behavior. It also permitted the initiation of lifelong HAART treatment on all the 179 women for the very first time. One of the methods to promote HIV testing among pregnant women is the “opt out” approach recommended by the CDC since 2006 [
One of the main problems of the new strategy is the adherence, which is the proportion of patients taking ART without missing any single day of prescription over the whole pregnancy period. With this test and treat attitude, more and more HIV+ patients are bound to take a lifelong compelling treatment, without symptoms which, if there, might have strengthen the will of abiding by drug prescription, in order to avoid falling seek again. Our adherence rate was surprisingly very high (99%). A study conducted in 2015 in the University Teaching Hospital, a PMTCT center also involved in this study, identified the bad perception of HIV infection, poverty, stigmatization, low involvement of the partners, and misunderstanding of the PMTCT as factors reducing the adherence rate, but it was a patient recorded data and they randomly included 61 women attending ANC without any consideration of their real ART adherence status in a six months period [
The involvement of male partner is important for HIV test uptake and case finding [
The majority of our study population delivered vaginally, there was no single case of elective caesarian section indicated for HIV status, nor need of viral load considerations, another advantage in resource-limited settings like Cameroon. Elective cesarean section has been proven to reduce the rate of mother to child transmission of HIV [
Although antenatal viral load was not taken into consideration for the mode of delivery in this study, the rate of mother to child transmission of HIV was very low 2.2% (4/179) as compared the 22% got from a survey in the same country [
One of the advantages of the option B+ in low resources environment is that it can be implemented in any health facility level. It only needs routine confirmatory HIV testing, antiretroviral drugs given by any medical personnel in a task shifting strategy [
HAART reduces milk HIV-1 mRNA which was the most frequent HIV type in our study more than zidovudine/nevirapine [
The issue of obstetrical, early and long term postnatal complications due to fetal exposure to HAART is still debated. In India, it has been shown that women on HAART without protease inhibitors as it’s the case in option B+ increased the risk of adverse pregnancy outcomes like preterm births and low birth weight children compared to AZT regimen [
HIV during pregnancy concerned pregnant women of all ages, blood donation and ANC HIV screening remained the main HIV screening opportunity, self-decided spontaneous HIV screening behavior was rare and yet to be a routine, but once screened positive, the ART compliance was very good. The HIV status of the male partner was unknown. The mother to child transmission of HIV was very low and was not related to the number of antenatal visits, gestational age of delivery, mode of delivery, birth weight or post-natal feeding. Antenatal viral load assessment in case of HAART taken for at least 4 weeks or elective caesarian section in a context of option B+ are probably outdated strategies for PMTCT of HIV.
This work was not sponsored by any organization and the authors declare no conflict of interest.
Valère, M.K., Nelly, K., Mefo, N. and Pascal, F. (2018) Mother to Child Transmission of HIV after Option B+ in Low Income Environment. Open Journal of Obstetrics and Gynecology, 8, 1163-1175. https://doi.org/10.4236/ojog.2018.812118