what will it take to eliminate pediatric hiv? reaching who target rates of mother-to-child hiv transmission in zimbabwe: a model-based analysis

PLoS Medicine What Will It Take to Eliminate Pediatric HIV? Reaching WHO Target Rates of Mother-to-Child HIV Transmission in Zimbabwe: A Model-Based Analysis Andrea L. Ciaranello^1*, Freddy Perez^2,3, Jo Keatinge⁴, Ji-Eun Park⁵, Barbara Engelsmann⁶, Matthews Maruva⁴, Rochelle P. Walensky^1,7,10, Francois Dabis², Jennifer Chu⁵, Asinath Rusibamayila⁵, Angela Mushavi⁸, Kenneth A. Freedberg^1,5,9,10 ¹Division of Infectious Disease, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America, ²INSERM U897 Africa Team of the Institut de Santé Publique, d'Epidémiologie et de Développement, Université Bordeaux Segalen, Bordeaux, France, ³HIV/AIDS Unit, Pan American Health Organization, Washington, District of Columbia, United States of America, ⁴Zimbabwe Country Office, Elizabeth Glaser Pediatric AIDS Foundation, Harare, Zimbabwe, ⁵Division of General Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America, ⁶Organization of Public Health Interventions and Development, Harare, Zimbabwe, ⁷Division of Infectious Disease, Brigham and Women's Hospital, Boston, Massachusetts, United States of America, ⁸Ministry of Health and Child Welfare, Harare, Zimbabwe, ⁹Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States of America, ¹⁰Harvard University Center for AIDS Research, Boston, Massachusetts, United States of America PLoS Med 2012 Jan 10; 9(1): e1001156. doi:10.1371/journal.pmed.1001156
January 10, 2012

Background 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. Methods and Findings 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%. Conclusions 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. ^*Corresponding author: aciaranello@partners.org CLICK HERE FOR FULL-TEXT PDF JOURNAL ARTICLE This is an open-access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

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Background

Methods and Findings

Conclusions