Background
Young women in sub-Sahara Africa face a high risk of acquiring HIV. Antiretroviral therapy (ART) is prioritized for pregnant women with HIV to treat the infection and prevent transmission to newborns. Assessing recency of infection in women who initiated ART during pregnancy and the associated social determinants are pivotal to monitor the epidemic in this vulnerable population.
Methods
ART-naïve participants were enrolled through an antenatal clinic in Lilongwe, Malawi, between 2015-2019. We used a multiplexed Primer ID next generation sequencing based recency assay to predict recent HIV infection on entry plasma specimens by measuring intra-host diversity on pol (RT) and env (V1V3). Both the qualitative recency using a 9-month cutoff and the quantitative days post infection (DPI) were reported for each participant. Demographics characteristics, clinical characteristics and social determinants were collected at study entry.
Results
A total of 203 participants were successfully analyzed by the recency assay; 8.9% were considered recent infection by 9-month cutoff, 15.3% were considered as borderline recent infection, and 75.9% were considered as chronic infection. In the quantitative assessment of DPI, 5% were within 6 months of infection at study enrollment, 18% within one year of infection, and 45% within two years of infection. A majority (76%) of the participants were in their 2nd trimester of pregnancy at enrollment. Recent and borderline recent infections were combined for the following analyses. Participants with recent infection were younger (median age 23 y/o vs. 27 y/o in chronic group, p<0.01), had higher CD4+ T cell counts (median 482 cells/uL vs. 307 cells/uL in the chronic group, p<0.01), had lower income (p=0.04), were more likely to be in their first pregnancy (p=0.002), and more likely to have a partner with confirmed HIV positive status (p=0.03). In the multivariant analysis, participant’s age (OR: 0.9 per year, 95%CI: 0.83-0.97) and partner with HIV (OR: 3.3, 95%CI: 1.24-8.79) were associated with recent infection at ART initiation. We also identified a significant association between self-reported domestic violence and recent HIV infection (p=0.01).
Conclusions
A majority of study participants acquired HIV before the current pregnancy and did not initiate ART until second trimester. Our data suggest that increasing access to HIV testing for the women and their partners, and initiating ART early in the pregnant women are pivotal in this study population.
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