Page 337 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 6 of 7 Original Research

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rMOM. The VLBW infants in our study received prMOM before 7 days of life (32/39) and are likely to have been
and its additional nutritional and immunological advantages immaturity related. However, the possibility of peripartum
with seemingly no increased risk of MTCT. This finding HIV infection in the late deaths (7/39) cannot be excluded.
lends support for the contention that exclusive breastfeeding
of HIV-exposed infants and their VLBW counterparts is safe Other confounding factors include the possibility of false-
3
in the context of antiretroviral prophylaxis. negative HIV-PCR tests by 4–6 weeks of age as a result of
incomplete viral suppression caused by maternal ART
As previously documented, 690 of the 3774 infants (18.28%) exposure and/or infant prophylaxis. 30
admitted to the Neonatal Unit at Kalafong Provincial Tertiary
Hospital were VLBW, 219 being HIV-exposed. Their risk of Conclusion and recommendations
being already HIV-infected at the time of birth (in utero HIV
acquisition) or acquiring the infection during the peripartum Viral suppression by antenatal ART followed by infant
period could be minimised by timeous antenatal as well as prophylaxis decreases the risk of MTCT in preterm infants in
postnatal maternal ART. Providing the infant with additional the presence of rMOM and is likely to protect from life-
ART prophylaxis after birth should further reduce the risk of threatening infection in this group of special – ‘key
peripartum HIV transmission, particularly via breast milk. population’ – patients. Additional personal and public health
This directive was mandated by the National PMTCT consequences of breastfeeding such as bonding and long-
programme of 2010, 19,22 at the time of this study, however was term successful lactation are of importance to HIV-positive
not reliably applied especially during the antenatal period. mothers and their children.
At least 15/72 women received no ART during pregnancy,
which increased the risk of in utero and peripartum infection Addendum
in 16 infants in the study population (one mother had twins). 24
Only two of these 16 infants acquired HIV infection, while The latest National PMTCT programme (2017) differs
19,22
none of the infants exposed to antenatal ART acquired HIV from the 2010 programme (Table 2) as follows: Maternal
infection, although receiving prMOM in the presence of lifelong cART is initiated immediately at HIV diagnosis,
postnatal NVP prophylaxis (Figure 2). These results suggest irrespective of the CD4 count or HIV staging. Infant
that NVP prophylaxis may be effective in preventing early PMTCT prophylaxis (drugs and duration) is dependent on
transmission of HIV in VLBW infants receiving prMOM; maternal factors, with risk classified as low or high. ‘Low-
however, as this is the first study reporting on the safety of risk’ infants (maternal cART since conception; cART >
prMOM in VLBW infants, this observation should be 4 weeks prior to delivery with a viral load < 1000 copies/mL)
confirmed by larger studies. receive NVP for 6 weeks, and ‘high-risk’ infants (newly
diagnosed maternal HIV; cART < 4 weeks; viral load >
Limitations 1000 copies/mL) receive dual therapy (NVP plus AZT) for
12 weeks. Breastfeeding is recommended for all HIV-
Although all infants received prophylaxis, it was carried out exposed infants (‘low risk’ and ‘high risk’), except for
inconsistently. Some infants did not receive the first NVP dose those whose mothers are failing second-line or third-line
immediately after delivery, and in almost half, the weight-based ART regimens.
NVP regimen was not adhered to. Notably, only 2/42 infants
with suboptimal or no antenatal ART exposure acquired HIV Acknowledgements
infection in the presence of prMOM. The inconsistencies in the
practical implementation of the National PMTCT programme The authors thank Prof. P.J. Becker, Research Office,
of 2010 19,22 at clinic and hospital level demonstrate the importance University of Pretoria, South Africa, for his assistance with
of correct emphasis when training healthcare workers. data analysis and reporting. They also thank the Department
of Research Innovation at the University of Pretoria for their
Lack of maternal ART may have contributed to HIV assistance.
transmission in the two HIV-infected infants in this study
because neither of the mothers received antenatal or postnatal Competing interests
ART before the infants were diagnosed with HIV infection.
The authors declare that they have no financial or personal
By virtue of the retrospective nature of this study, limitations relationship(s) that may have inappropriately influenced
exist. Reduced infant numbers (n = 80) resulting from various them in writing this article.
exclusions (Figure 1) was the predominant limitation. The
largest number of exclusions was for undocumented Authors’ contributions
maternal HIV status (67/690), and no traceable infant HIV-
PCR result at ≥ 4 weeks of age (54/219). No long-term follow- Both authors conceptualised and designed the research
up HIV results were available for the 80 included infants, so project, interpreted the data after statistical analysis and
the overall HIV transmission rate is unknown. drafted the article. M.C. collected and managed the data.
S.D.D. revised the article critically for important scientific
Although the results may be confounded by the 39 deaths content. Both authors approved the final version to be
prior to 4 weeks of age, the majority of these deaths occurred published.

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