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Original Articles • Braz J Infect Dis 18 (03) • May-June 2014 • https://doi.org/10.1016/j.bjid.2013.11.002 copy

Cascade of access to interventions to prevent HIV mother to child transmission in the metropolitan area of Rio de Janeiro, Brazil^☆ ☆ This study was supported by Brazilian Ministry of Health, PN-DST/AIDS . SVS/Ministerio da Saude/BIRD/UNODC. ProjetoAD/BRA/03/H34. Acordo de Emprestimo BIRD 4713-BR. TC 292/07.

Authorship SCIMAGO INSTITUTIONS RANKINGS

OBJECTIVES:

To describe the access to the interventions for the prevention of Human Immunodeficiency Virus (HIV) mother to child transmission and mother to child transmission rates in the outskirts of Rio de Janeiro, from 1999 to 2009.

METHODS:

This is a retrospective cohort study. Prevention of HIV mother to child transmission interventions were accessed and mother to child transmission rates were calculated.

RESULTS:

The study population is young (median: 26 years; interquartile range: 22.0-31.0), with low monthly family income (40.4% up to one Brazilian minimum wage) and schooling (62.1% less than 8 years). Only 47.1% (n = 469) knew the HIV status of their partner; of these women, 39.9% had an HIV-seronegative partner. Among the 1259 newborns evaluated, access to the antenatal, intrapartum and postpartum prevention of HIV mother to child transmission components occurred in 59.2%, 74.2%, and 97.5% respectively; 91.0% of the newborns were not breastfed. Overall 52.7% of the newborns have benefited from all the recommended interventions. In subsequent pregnancies (n = 289), 67.8% of the newborns received the full package of interventions. The overall rate of HIV vertical transmission was 4.7% and the highest annual rate occurred in 2005 (7.4%), with no definite trend in the period.

CONCLUSIONS:

Access to the full package of interventions for the prevention of HIV vertical transmission was low, with no significant trend of improvement over the years. The vertical transmission rates observed were higher than those found in reference services in the municipality of Rio de Janeiro and in the richest regions of the country.

HIV; HIV vertical transmission; Antiretroviral chemoprophylaxis; Cohort studies; Brazil

Variables	n	%
Characteristics of pregnant women ( n = 997) ^a
Age (years)
<18	43	4.3
18–24	346	34.7
25–35	515	51.7
>35	93	9.3

Skin color
White	270	27.1
Non white	727	72.9

Schooling (years)
<8	619	62.1
=8	352	35.3
Data not available	26	2.6

Sexual partner HIV serostatus
No sexual partner	24	2.4
Positive	282	28.3
Negative	187	18.8
Unknown	429	43.0
Data not available	75	7.5

Number of previous pregnancies
None	178	17.9
1	174	17.5
2	212	21.3
=3	369	37.0
Data not available	64	6.4

Time of HIV testing ^b
Before pregnancy	199	20.0
During pregnancy	449	45.0
Intrapartum	177	17.8
Postpartum	171	17.2
Data not available	1	0.1

AIDS-CDC 1993
Yes	312	31.3
No	657	65.9
Data not available	28	2.8

CD4+ lymphocyte count at enrolment (cells/mm ³ )
<200	75	7.5
200–350	191	19.2
>350	511	51.3
Data not available	220	22.0

Characteristics of prenatal and delivery ( n = 1269) ^a
Gestational age at the beginning of prenatal (weeks)
No prenatal visits	127	10.0
<14	227	17.9
14–28	507	40.0
>28	138	10.9
Data not available	270	21.3

Number of prenatal visits
None	127	10.0
1–3	241	19.0
4–6	526	41.4
=7	311	24.5
Unknown	64	5.0

Maternity of delivery
HGNI	960	75.7
Other institution	275	21.7
Delivery outside the maternity	22	1.7
Data not available	12	0.9

Mode of delivery
Elective cesarean	531	41.8
Vaginal	514	40.5
Emergency cesarean	203	16.0
Data not available	21	1.7

Membranes at delivery
No rupture	865	68.2
Rupture less than 3 h	88	6.9
Rupture between 3–6 h	81	6.4
Rupture more than 6 h	97	7.6
Rupture not knowing time	81	6.4
Data not available	57	4.5

Gestational age at delivery (weeks)
<37	185	14.6
=37	1010	79.6
Data not available	74	5.8

Interventions received by newborns, n (%)	Timing of HIV testing				Total	Subsequent pregnancies
	Before pregnancy	During pregnancy	Labor	Postpartum	(n = 1259) ^f	(n = 289) ^and
	(n = 482) ^{e, g}	(n = 435) ^h	(n = 172) ⁱ	(n = 170) ^j
ARV prophylaxis ^a + (IV) ZDV^b + formula^c + ARV syrup^d	339 (70.3)	324 (74.5)	–	–	663 (52.7)	196 (67.8)
ARV prophylaxis ^a + (IV) ZDV^b + ARV syrup^d	8 (1.7)	5 (1.1)	–	–	13 (1.0)	4 (1.4)
ARV prophylaxis^a + formula^c + ARV syrup^d	44 (9.1)	21 (4.8)	–	–	65 (5.2)	33 (11.4)
ARV prophylaxis^a + ARV syrup^d	2 (0.4)	3 (0.7)	–		5 (0.4)	1 (0.3)
(IV) ZDV^b + Formula^c + ARV syrup^d	41 (8.5)	63 (14.5)	125 (72.7)		229 (18.2)	23 (8.0)
(IV) ZDV^b + Formula^c	–	1 (0.2)	–	–	1 (0.1)	–
(IV) ZDV^b + ARV syrup^d	1 (0.2)	2 (0.5)	5 (2.9)		8 (0.6)	–
Formula^c + ARV syrup^d	14 (2.9)	1 (0.2)	23 (13.4)	116 (68.2)	154 (12.2)	8 (2.8)
Only formula^c	1 (0.2)	–	–	–	1 (0.1)	1 (0.3)
Only ARV syrup^d	2 (0.4)	1 (0.2)	9 (5.2)	49 (28.8)	61 (4.8)	1 (0.3)
None of the interventions	1 (0.2)	–	–	2 (1.2)	3 (0.2)	1 (0.3)

^a
ARV prophylaxis - ARV use during pregnancy.
^b
(IV) ZDV - intravenous zidovudine.
^c
Formula - newborns who were not breastfed and received infant formula.
^d
ARV syrup - ARV syrup administered to newborns.
^e
Among 482 newborns who were born to women diagnosed with HIV before pregnancy, 289 were born from subsequent pregnancies during the study period.
^f
Of the 1260 newborns, data on timing of HIV testing of the women were available for 1259. Of the 1260 newborns, 53 had missing data in at least one intervention and they do not appear in the table, as we could not define which set of interventions they received.
^g
Of the 482 newborns who were born to women diagnosed with HIV before pregnancy, 29 had missing data in at least one intervention and we could not define which set of interventions they received. Among these 29, at least 8 received (IV) ZDV, 14 received formula and at least 17 received ARV syrup.
^h
Of the 435 newborns who were born to women diagnosed with HIV during pregnancy, 14 had missing data in at least one intervention and we could not define which set of interventions they received. Among these 14, all of them received ARV prophylaxis, 8 received (IV) ZDV, 11 received formula and 6 received ARV syrup.
ⁱ
Of the 172 newborns who were born to women diagnosed with HIV during delivery, 10 had missing data in at least one intervention and we could not define which set of interventions they received. Among these 10, at least 4 received (IV) ZDV, 5 received formula and 6 received ARV syrup.
^j
Of the 170 newborns who were born to women diagnosed with HIV during the postpartum period, 3 had missing data in at least one intervention and we could not define which set of interventions they received. Among these 3, 2 received formula and all 3 received ARV syrup.
^k
Of the 289 newborns from subsequent pregnancies in the cohort, 21 had missing data in at least one intervention and we could not define which set of interventions they received. ^lOne newborn died and did not receive ARV syrup. The death was related to prematurity and hepatomegaly.

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