Temporal changes in the outcomes of HIV-exposed infants in Kinshasa, Democratic Republic of Congo during a period of rapidly evolving guidelines for care (2007-2013)

Abstract

Objective: Guidelines for prevention of mother-to-child transmission of HIV have developed rapidly, yet little is known about how outcomes of HIV-exposed infants have changed over time. We describe HIV-exposed infant outcomes in Kinshasa, Democratic Republic of Congo, between 2007 and 2013.

Design: Cohort study of mother-infant pairs enrolled in family-centered comprehensive HIV care.

Methods: Accounting for competing risks, we estimated the cumulative incidences of early infant diagnosis, HIV transmission, death, loss to follow-up, and combination antiretroviral therapy (cART) initiation for infants enrolled in three periods (2007-2008, 2009-2010, and 2011-2012).

Results: 1707 HIV-exposed infants enrolled at a median age of 2.6 weeks. Among infants whose mothers had recently enrolled into HIV care (N = 1411), access to EID by age two months increased from 28% (95% confidence limits [CL]: 24,34%) among infants enrolled in 2007-2008 to 63% (95% CL: 59,68%) among infants enrolled in 2011-2012 (Gray's p-value <0.01). The 18-month cumulative incidence of HIV declined from 16% (95% CL: 11,22%) for infants enrolled in 2007-2008 to 11% (95% CL: 8,16%) for infants enrolled in 2011-2012 (Gray's p-value = 0.19). The 18-month cumulative incidence of death also declined, from 8% (95% CL: 5,12%) to 3% (95% CL: 2,5%) (Gray's p-value = 0.02). LTFU did not improve, with 18-month cumulative incidences of 19% (95% CL: 15,23%) for infants enrolled in 2007-2008 and 22% (95% CL: 18,26%) for infants enrolled in 2011-2012 (Gray's p-value = 0.06). Among HIV-infected infants, the 24-month cumulative incidence of cART increased from 61% (95% CL: 43,75%) to 97% (95% CL: 82,100%) (Gray's p-value <0.01); the median age at cART decreased from 17.9 to 9.3 months. Outcomes were better for infants whose mothers enrolled before pregnancy.

Conclusions: We observed encouraging improvements, but continued efforts are needed.

Fig. 1. Evolution of WHO guidelines for prevention of mother-to-child transmission of HIV

3TC, lamivudine; AZT, zidovudine; cART, combination antiretroviral therapy; NVP, nevirapine; PMTCT, prevention of mother-to-child HIV transmission; sdNVP, single dose of nevirapine.

Fig. 2. Eighteen-month cumulative incidence functions of confirmed HIV infection, death, and loss to follow-up among HIV-exposed infants in Kinshasa, Democratic Republic of Congo

Cumulative incidence functions are plotted by calendar period at infant enrollment into care and enrollment status of the mother (newly enrolled during pregnancy or previously enrolled). P-values are for Gray's test for equality of the cumulative incidence functions. LTFU, loss to follow-up.

Fig. 3. Twenty-four-month cumulative incidence function of combination antiretroviral therapy initiation among HIV-infected infants in Kinshasa, Democratic Republic of Congo

Cumulative incidence functions are plotted by calendar period at infant enrollment into care. The P-value is for Gray's test for equality of the cumulative incidence functions.