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Background: Children living with HIV remain undiagnosed due to missed opportunities along the prevention of mother-to-child HIV transmission cascade. This study addresses programmatic gaps in the cascade by describing pregnancy and HIV-related services received by mothers of children newly identified as HIV-positive through active case finding., Methods: This was a prospective observational cohort (2017-2018) of HIV-positive children <15 years of age newly diagnosed at study facilities and/or surrounding communities in Kenya and Uganda. At enrollment, caregivers were interviewed about maternal and child health and HIV history. Child medical and laboratory information was abstracted at two months post-diagnosis. Descriptive summary statistics were calculated; associations between selected factors and child age at HIV diagnosis were evaluated using generalized estimating equations., Results: 174 HIV-positive children (median age 2.4 years) were enrolled. Among maternal caregivers, 110/132 (83.3%) attended antenatal care and 60 (45.5%) reported testing HIV-negative in antenatal care. Of 41 and 56 women known to be HIV-positive during pregnancy and breastfeeding respectively, 17 (41.5%) and 15 (26.8%) did not receive antiretroviral drugs. Despite known maternal HIV-positive status during pregnancy, 39% of these children were not diagnosed until after two years of age; children were diagnosed at younger ages in Uganda (p = 0.0074) and if mother was the caregiver (p<0.0001). The most common HIV testing points identifying children were outpatient (44.3%) and maternal/child health departments (29.9%). Nearly all children initiated antiretroviral therapy within two weeks of diagnosis., Conclusions: Multiple missed opportunities for HIV prevention and delays in HIV testing of HIV-exposed children were identified in newly diagnosed children. Findings support critical prevention messaging and retesting of HIV-negative women during pregnancy and breastfeeding, strengthening HIV treatment initiation and follow-up systems and interventions to ensure HIV-positive women receive lifelong antiretroviral therapy throughout the cascade, and broader implementation of community case finding so children not engaged in care receive testing services., Competing Interests: The authors have declared that no competing interests exist.

Lifelong antiretroviral therapy (ART) provision to all pregnant HIV-positive women ("Option B+") has been recommended by the World Health Organization since 2013, but there remain limited data on the effects of Option B+ on long-term HIV-free survival in breastfeeding HIV-exposed infants. The Kigali Antiretroviral and Breastfeeding Assessment for the Elimination of HIV (Kabeho) study enrolled HIV-positive women from the third trimester of pregnancy to 2 weeks postpartum in 14 heath facilities implementing Option B+ in Kigali, Rwanda. Mother-child pairs in the longitudinal observational cohort were followed until 24 months postpartum, with HIV diagnostic testing at 6 weeks, and 9, 18 and 24 months. The Kaplan-Meier method was used to estimate HIV transmission, survival, and HIV-free survival through 24 months. We enrolled 608 HIV-positive women in 2013-2014; birth outcome data were available for 600 women and 597 live-born infants. By 6 weeks, 11 infants had died and 3 infants had confirmed HIV infection (0.5% transmission; 95% confidence interval [CI] 0.2-1.6). At 9 months, there were 9 additional deaths and 2 new infections (cumulative transmission 0.9%, 95% CI 0.4-2.2). At 18 months, there were 6 additional deaths and no new infant infections. At 24 months, there were no additional child deaths and 1 new infection (cumulative 2.2%, 95% CI 0.7-7.0), for an overall 24-month HIV-free survival of 93.2% (95% CI 89.5-95.6). Low transmission rates and high HIV-free survival at 24 months were achieved in breastfeeding infants of HIV-positive mothers receiving universal ART in urban health facilities in Rwanda, though vigilance on maintaining viral suppression for ART-experienced women is needed., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

As lifelong antiretroviral therapy (ART) for pregnant women is implemented, it is important to understand the attitudes and norms affecting women's postpartum ART adherence. This is a qualitative cross-sectional study of HIV-positive postpartum women (n = 112) enrolled in a 2-year observational prospective cohort in Rwanda. Informed by the Theory of Reasoned Action (TRA), we conducted in-depth interviews with women whose children were 0-6, 7-12, 13-18, or 21-24 months of age to describe factors contributing to adherence and changes over time. Positive ART attitudes reported by women included mothers' health promotion, prevention of infant HIV infection, higher CD4 count, and improved physical appearance. Negative attitudes were few, but included side effects and the lifelong nature of treatment. Learning from people living with HIV (PLHIV) was identified as a norm facilitating adherence; ART adherence was inhibited by fear of disclosure or stigmatization in communities and clinics. Poor adherence behaviors were common immediately after HIV diagnosis, not necessarily during prevention of mother-to-child transmission (PMTCT). Women with older children, most of whom stopped breastfeeding by 13-18 months, reported more barriers and missed doses than women with younger children. The TRA was useful in identifying the collective influence of attitudes, norms, and intentions on behavior. Findings suggest that HIV-positive women are vulnerable to poor adherence following HIV diagnosis and around the time of breastfeeding cessation. Lifelong treatment adherence can be supported through PLHIV exemplifying long-term ART use, fewer and less stigmatizing clinic visits, and counseling messages highlighting the benefits of drugs on appearance and illness prevention and incorporating biological feedback.

There are limited viral load (VL) data available from programs implementing "Option B+," lifelong antiretroviral treatment (ART) to all HIV-positive pregnant and postpartum women, in resource-limited settings. Extent of viral suppression from a prevention of mother-to-child transmission of HIV program in Rwanda was assessed among women enrolled in the Kigali Antiretroviral and Breastfeeding Assessment for the Elimination of HIV (Kabeho) Study. ARV drug resistance testing was conducted on women with VL>2000 copies/ml. In April 2013-January 2014, 608 pregnant or early postpartum HIV-positive women were enrolled in 14 facilities. Factors associated with detectable enrollment VL (>20 copies/ml) were examined using generalized estimating equations. The most common antiretroviral regimen (56.7%, 344/607) was tenofovir/lamivudine/efavirenz. Median ART duration was 13.5 months (IQR 3.0-48.8); 76.1% of women were on ART at first antenatal visit. Half of women (315/603) had undetectable RNA-PCR VL and 84.6% (510) had <1,000 copies/ml. Detectable VL increased among those on ART > 36 months compared to those on ART 4-36 months (72/191, 37.7% versus 56/187, 29.9%), though the difference was not significant. The odds of having detectable enrollment VL decreased significantly as duration on ART at enrollment increased (AOR = 0.99, 95% CI: 0.9857, 0.9998, p = 0.043). There was a higher likelihood of detectable VL for women with lower gravidity (AOR = 0.90, 95% CI: 0.84, 0.97, p = 0.0039), no education (AOR = 2.25, (95% CI: 1.37, 3.70, p = 0.0004), nondisclosure to partner (AOR = 1.97, 95% CI: 1.21, 3.21, p = 0.0063) and side effects (AOR = 2.63, 95% CI: 1.72, 4.03, p<0.0001). ARV drug resistance mutations were detected in all of the eleven women on ART > 36 months with genotyping available. Most women were receiving ART at first antenatal visit, with relatively high viral suppression rates. Shorter ART duration was associated with higher VL, with a concerning increasing trend for higher viremia and drug resistance among women on ART for >3 years., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Investigate levels of retention at specified time periods along the prevention of mother-to-child transmission (PMTCT) cascade among mother-infant pairs as well as individual- and facility-level factors associated with retention., Methods: A retrospective cohort of HIV-positive pregnant women and their infants attending five health centres from November 2010 to February 2012 in the Option B programme in Rwanda was established. Data were collected from several health registers and patient follow-up files. Additionally, informant interviews were conducted to ascertain health facility characteristics. Generalized estimating equation methods and modelling were utilized to estimate the number of mothers attending each antenatal care visit and assess factors associated with retention., Results: Data from 457 pregnant women and 462 infants were collected at five different health centres (three urban and two rural facilities). Retention at 30 days after registration and retention at 6 weeks, 3, 6, 9 and 12 months post-delivery were analyzed. Based on an analytical sample of 348, we found that 58% of women and 81% of infants were retained in care within the same health facility at 12 months post-delivery, respectively. However, for mother-infant paired mothers, retention at 12 months was 74% and 79% for their infants. Loss to facility occurred early, with 26% to 33% being lost within 30 days post-registration. In a multivariable model retention was associated with being married, adjusted relative risk (ARR): 1.26, (95% confidence intervals: 1.11, 1.43); antiretroviral therapy eligible, ARR: 1.39, (1.12, 1.73) and CD4 count per 50 mm(3), ARR: 1.02, (1.01, 1.03)., Conclusions: These findings demonstrate varying retention levels among mother-infant pairs along the PMTCT cascade in addition to potential determinants of retention to such programmes. Unmarried, apparently healthy, HIV-positive pregnant women need additional support for programme retention. With the significantly increased workload resulting from lifelong antiretroviral treatment for all HIV-positive pregnant women, strategies need to be developed to identify, provide support and trace these women at risk of loss to follow-up. This study provides further evidence for the need for such a targeted supportive approach.

Introduction: Acute infection with HIV in the postpartum period results in a high risk of vertical transmission through breastfeeding. A study was done to determine the HIV incidence rate and associated risk factors among postpartum women in Southern Mozambique, where HIV prevalence among pregnant women is 21%., Methods: A prospective cohort study was conducted in six rural health facilities in Gaza and Maputo provinces from March 2008 to July 2011. A total of 1221 women who were HIV-negative on testing at delivery or within two months postpartum were recruited and followed until 18 months postpartum. HIV testing, collection of dried blood spot samples and administration of a structured questionnaire to women were performed every three months. Infant testing by DNA-PCR was done as soon as possible after identification of a new infection in women. HIV incidence was estimated, and potential risk factors at baseline were compared using Poisson regression., Results: Data from 957 women were analyzed with follow-up after the enrolment visit, with a median follow-up of 18.2 months. The HIV incidence in postpartum women is estimated at 3.20/100 women-years (95% CI: 2.30-4.46), with the highest rate among 18- to 19-year-olds (4.92 per 100 women-years; 95% CI: 2.65-9.15). Of the new infections, 14 (34%) were identified during the first six months postpartum, 11 (27%) between 6 and 12 months and 16 (39%) between 12 and 18 months postpartum. Risk factors for incident HIV infection include young age, low number of children, higher education level of the woman's partner and having had sex with someone other than one's partner. The vertical transmission was 21% (95% CI: 5-36) among newly infected women., Conclusions: Incidence of HIV is high among breastfeeding women in Southern Mozambique, contributing to increasing numbers of HIV-infected infants. Comprehensive primary prevention strategies targeting women of reproductive age, particularly pregnant and postpartum women and their partners, will be crucial for the elimination of paediatric AIDS in Africa.

Background: Given that integration of syphilis testing into prevention of mother-to-child transmission of HIV (PMTCT) programs can prevent adverse pregnancy outcomes, this study assessed feasibility and acceptability of introducing rapid syphilis testing (RST) into PMTCT services., Methods: RST was introduced into PMTCT programs in Zambia and Uganda. Using a pre-post intervention design, HIV and syphilis testing and treatment rates during the intervention were compared with baseline., Results: In Zambia, comparing baseline and intervention, 12,761 of 15,967 (79.9%) and 11,460 of 11,985 (95.6%) first-time antenatal care (ANC) attendees were tested for syphilis (P < 0.0001), 523 of 12,761 (4.1%) and 1050 of 11,460 (9.2%) women tested positive (P < 0.0001); and 267 of 523 (51.1%) and 1000 of 1050 (95.2%) syphilis-positive women were treated (P < 0.0001), respectively. Comparing baseline and intervention, 7479 of 7830 (95.5%) and 11,151 of 11,409 (97.7%) of ANC attendees were tested for HIV (P < 0.0001) and 1303 of 1326 (98.3%) and 2036 of 2034 (100.1%) of those testing positive received combination antiretroviral drugs or single-dose nevirapine prophylaxis (P < 0.0001). In Uganda, 13,131 of 14,540 (90.3%) women were tested for syphilis during intervention, with 690 of 13,131 (5.3%) positive and 715 of 690 (103.6%) treated. Syphilis baseline data were collected, but not included in analysis, as ANC syphilis testing before the study was not consistently practiced. Comparing baseline and intervention, 6479 of 6776 (95.6%) and 11,192 of 11,610 (96.4%) ANC attendees were tested for HIV (P = 0.0009) and 570 of 726 (78.5%) and 964 of 1153 (83.6%) received combination or single-dose prophylaxis (P = 0.007). In Zambia, 254 of 1050 (24.2%) syphilis-positive pregnant women were HIV-positive and 99 of 690 (14.3%) in Uganda., Conclusions: Integrating RST in PMTCT programs increases screening and treatment for syphilis among HIV-positive pregnant women and does not compromise HIV services.

Objective: Prevention of Mother-to-Child Transmission of HIV programs require follow-up of HIV-exposed infants (HEI) for infant feeding support, prophylactic medicines, and HIV diagnosis for at least 18 months. Retention in care and receipt of HIV services are challenging in resource-limited settings. This study compared infant follow-up results when HEI services were provided within Maternal and Child Health (MCH) clinics or in specialized HIV Comprehensive Care Clinics (CCCs) in Kenya., Methods: This observational prospective cohort study enrolled HEI at 6-8 weeks of age in 2 purposively selected hospitals with similar characteristics but different models of service delivery. In the CCC model, HEI received immunization and growth monitoring in MCH but cotrimoxazole prophylaxis and infant HIV testing in the CCC. In the MCH model, all services were provided in the MCH. Data were collected at enrollment, 14 weeks, and 6, 9, and 12 months., Results: From April 2008 to April 2009, 184 HEI were enrolled in the CCC cohort and 179 in the MCH cohort. Infants in MCH were 1.14, 1.42, 1.95, and 1.29 times more likely to attend 14-week, 6-, 9-, and 12-month postnatal visits, respectively, and 2.24 times (95% confidence interval: 1.57 to 3.18) more likely to attend all 4 visits. Although infants in MCH were 1.33 times (95% confidence interval: 1.10 to 1.62) more likely to have HIV antibody testing at 1 year than CCC, there were no differences for polymerase chain reaction test or cotrimoxazole initiation at 6-8 weeks., Conclusions: HIV services integrated in MCH yield better follow-up of HEI than CCC.

Objective: To maximize prevention of mother-to-child transmission of HIV (PMTCT) effectiveness and increase identification of HIV status in maternity units in Swaziland., Design: With a quasi-experimental design, 3 maternity units were randomly assigned to the training intervention and 3 units were controls., Methods: Targeted on-site training was provided to nurse-midwives in intervention sites. HIV status was recorded with testing offered to women presenting with unknown and distant negative status. Cord blood was obtained and tested for HIV antibodies and presence of nevirapine as a marker of PMTCT intervention coverage. Contingency tables and χ² tests were used to test for associations between frequencies of events., Results: Of the 2444 enrolled women, 215 (9%) arrived in maternity with unknown status and 1398 (58%) had tested HIV negative in antenatal clinic. Significantly more HIV-negative women (45%) and women with unknown status (96%) in intervention sites were tested compared with similar women in control sites, 14% and 65%, respectively (P < 0.0001 for both). Nevirapine coverage in HIV-positive cord blood was significantly higher in intervention sites (80%) than in control sites (69%, P < 0.0001). Cumulative HIV incidence was 4% with an incidence rate of 16.8 per 100 person-years. Antiretroviral prophylaxis coverage in seroconverters was significantly higher in intervention sites 54% (13 of 24) than the control group [26% (9 of 34), P = 0.03]., Conclusions: In high HIV prevalence settings, such as Swaziland, the incidence of HIV during pregnancy is high. An on-site training intervention for maternity nurses significantly increases the identification of HIV infection and maximizes the provision of PMTCT interventions.