What will it take to eliminate pediatric HIV? Reaching WHO target rates of mother-to-child HIV transmission in Zimbabwe: a model-based analysis

• Published in: PLoS medicine 2012-01, Vol.9 (1), p.e1001156-e1001156
• Main Authors: Ciaranello, Andrea L, Perez, Freddy, Keatinge, Jo, Park, Ji-Eun, Engelsmann, Barbara, Maruva, Matthews, Walensky, Rochelle P, Dabis, Francois, Chu, Jennifer, Rusibamayila, Asinath, Mushavi, Angela, Freedberg, Kenneth A
• Format: Article
• Language: English
• Subjects: Acquired immune deficiency syndrome; Adolescent; Adult; AIDS; Antiretroviral drugs; Breast feeding; Child; Child, Preschool; Communicable Disease Control; Communicable Disease Control - legislation & jurisprudence; Communicable Disease Control - statistics & numerical data; Demographic aspects; Disease transmission; Drug therapy; Female; Health aspects; HIV; HIV infection in children; HIV Infections; HIV Infections - epidemiology; HIV Infections - transmission; HIV-1; HIV-1 - physiology; Human health and pathology; Human immunodeficiency virus; Humans; Infant; Infant, Newborn; Infectious Disease Transmission, Vertical; Infectious Disease Transmission, Vertical - prevention & control; Infectious Disease Transmission, Vertical - statistics & numerical data; Infectious diseases; Life Sciences; Medicine; Models, Theoretical; Pediatrics; Pediatrics - methods; Pregnancy; Prevention; Risk factors; Studies; Women; Womens health; World Health Organization; Young Adult; Zimbabwe; Zimbabwe - epidemiology
• ISSN: 1549-1676; 1549-1277; 1549-1676
• DOI: 10.1371/journal.pmed.1001156

The World Health Organization (WHO) has called for the "virtual elimination" of pediatric HIV: a mother-to-child HIV transmission (MTCT) risk of less than 5%. We investigated uptake of prevention of MTCT (PMTCT) services, infant feeding recommendations, and specific drug regimens necessary to achieve this goal in Zimbabwe. We used a computer model to simulate a cohort of HIV-infected, pregnant/breastfeeding women (mean age, 24 y; mean CD4, 451/µl; breastfeeding duration, 12 mo). Three PMTCT regimens were evaluated: (1) single-dose nevirapine (sdNVP), (2) WHO 2010 guidelines' "Option A" (zidovudine in pregnancy, infant nevirapine throughout breastfeeding for women without advanced disease, lifelong combination antiretroviral therapy for women with advanced disease), and (3) WHO "Option B" (pregnancy/breastfeeding-limited combination antiretroviral drug regimens without advanced disease; lifelong antiretroviral therapy with advanced disease). We examined four levels of PMTCT uptake (proportion of pregnant women accessing and adhering to PMTCT services): reported rates in 2008 and 2009 (36% and 56%, respectively) and target goals in 2008 and 2009 (80% and 95%, respectively). The primary model outcome was MTCT risk at weaning. The 2008 sdNVP-based National PMTCT Program led to a projected 12-mo MTCT risk of 20.3%. Improved uptake in 2009 reduced projected risk to 18.0%. If sdNVP were replaced by more effective regimens, with 2009 (56%) uptake, estimated MTCT risk would be 14.4% (Option A) or 13.4% (Option B). Even with 95% uptake of Option A or B, projected transmission risks (6.1%-7.7%) would exceed the WHO goal of less than 5%. Only if the lowest published transmission risks were used for each drug regimen, or breastfeeding duration were shortened, would MTCT risks at 95% uptake fall below 5%. Implementation of the WHO PMTCT guidelines must be accompanied by efforts to improve access to PMTCT services, retain women in care, and support medication adherence throughout pregnancy and breastfeeding, to approach the "virtual elimination" of pediatric HIV in Zimbabwe. Please see later in the article for the Editors' Summary.