Receipt of infant HIV DNA PCR test results is associated with a reduction in retention of HIV-exposed infants in integrated HIV care and healthcare services: a quantitative sub-study nested within a cluster randomised trial in rural Malawi

Abstract

Background: Retention of HIV-infected mothers in integrated HIV and healthcare facilities is effective at reducing mother-to-child-transmission (MTCT) of HIV. In the context of Option B+, we examined maternal and HIV-exposed infant retention across three study arms to 18 months postpartum: mother-and-infant clinics (MIP), MIP with short-messaging service (MIP + SMS) and standard of care (SOC). In particular, we focused on the impact of mothers receiving an infant's HIV PCR test result on maternal and infant study retention.

Methods: A quantitative sub-study nested within a cluster randomised trial undertaken between May 2013 and August 2016 across 30 healthcare facilities in rural Malawi enrolling HIV-infected pregnant mothers and HIV-exposed infants on delivery, was performed. Survival probabilities of maternal and HIV-exposed infant study retention was estimated using Kaplan-Meier curves. Associations between mother's receiving an infant's HIV test result and in particular, an infant's HIV-positive result on maternal and infant study retention were modelled using time-varying multivariate Cox regression.

Results: Four hundred sixty-one, 493, and 396 HIV-infected women and 386, 399, and 300 HIV-exposed infants were enrolled across study arms; MIP, MIP + SMS and SOC, respectively. A total of 47.5% of mothers received their infant's HIV test results < 5 months postpartum. Receiving an infant's HIV result by mothers was associated with a 70% increase in infant non-retention in the study compared with not receiving an infant's result (HR = 1.70; P-value< 0.001). Receiving a HIV-positive result was associated with 3.12 times reduced infant retention compared with a HIV-negative result (P-value< 0.001). Of the infants with a HIV-negative test result, 87% were breastfed at their final study follow-up.

Conclusions: Receiving an infant's HIV test result was a driving factor for reduced infant study retention, especially an infant's HIV-positive test result. As most HIV-negative infants were still breastfed at their last follow-up, this indicates a large proportion of HIV-exposed infants were potentially at future risk of MTCT of HIV via breastfeeding but were unlikely to undergo follow-up HIV testing after breastfeeding cessation. Future studies to identify and address underlying factors associated with infant HIV testing and reduced infant retention could potentially improve infant retention in HIV/healthcare facilities.

Trial registration: Pan African Clinical Trial Registry: PACTR201312000678196 .

Keywords: HIV; HIV PCR test; Malawi; Mother-pair infants; Mother-to-child-transmission; PRIME; Retention.

Fig. 1

Time to mothers receiving HIV PCR blood test results since collection of infant dried blood spot (n = 507 mothers)

Fig. 2

Kaplan Meier curves comparing study non-retention rates of mothers and infants in each study arm

Fig. 3

Kaplan Meier failure curves comparing study non-retention rates of mothers in each study arm by whether a mother received the infant’s HIV PCR test result. Dashed lines represent mothers that received their infant’s HIV PCR test result. Solid lines represent mothers that did not receive their infant’s HIV PCR test result

Fig. 4

Kaplan Meier failure curves comparing study non-retention rates of infants in each study arm by whether a mother received the infant’s HIV PCR test result. Dashed lines represent mothers that received their infant’s HIV PCR test result. Solid lines represent mothers that did not receive their infant’s HIV PCR test result