With the efforts toward elimination of mother to child transmission (EMTCT), the number of infants with HIV has declined sharply. However, EMTCT programs need to be monitored to identify gaps and design interventions to further reduce MTCT. This study determined MTCT at 6 weeks, 9 and 18 months, and cofactors for MTCT in a multi-year, nationwide registry-based survey in Kenya.
We conducted a retrospective chart review of HIV Exposed Infants (HEI) enrolled in 62 randomly selected facilities in Kenya between 2011-2013. MTCT was defined as infant positive DNA PCR test. Cohort analysis included infants with PCR result at <3 months of age followed to last known visit. Cox regression determined correlates of MTCT. Estimates were weighted to account for survey design.
Overall, 8773 HEI were identified of whom 6034 (87.5%) had PCR results at <3 months and were included in the analysis. At 9 months, 75.4% of HEI remained in care and 57.1% at 18 months. By 18 months, 39.5% were lost, 0.9% reported dead, and 2.5% had transferred care. Overall MTCT was 2.7% at 6 weeks, 3.8% at 9 months, and 5.5% at 18 months (Table 1). From 2011 to 2013, 6 week MTCT declined from 3.5% to 2.8%; 9 month MTCT from 4.8% to 3.8%; and 18 month MTCT from 7.4% to 5.2%. Overall, 73.1% of HEI-mother pairs received maternal and infant ARVs, 10.6% maternal ARVs only, 8.7% infant ARVs only, and 7.7% no ARVs. Most women (68.6%) received HAART, 13.5% received short course prophylaxis (AZT+NVP+3TC), 1.5% single dose NVP (sdNVP) and 16.4% no ARVs. Among infants, 72.3% received NVP for 6 weeks during breastfeeding, 4.1% NVP+AZT+3TC for 7 days, 5.3% sdNVP only, and 18.3% no ARVs. MTCT was associated with older infant age (months) at enrollment (HR=1.02, 95% CI 1.00-1.04). Compared to complete PMTCT (maternal and infant ARVs), no maternal or infant ARVs, maternal ARVs only, and infant ARVs only were associated with increased MTCT [HR=7.4 (4.6-11.9), HR=2.3 (1.4-3.9), HR=2.0 (1.2-3.2), respectively]. MTCT was highest in women receiving short course prophylaxis and sdNVP compared to HAART [HR=2.5 (1.7-3.7) and HR=2.6 (1.0-6.5), respectively].
Despite decreases from 2011-2013, MTCT remains high underscoring the benefit of early HEI enrollment and need for rapid expansion of HAART to all HIV-infected women irrespective of immune status. The high loss to follow-up at 18 months underscores the need for better strategies to improve retention and the implementation of interventions to track and retain HEI in care.