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Child mortality according to maternal and infant HIV status in Zimbabwe

Child mortality according to maternal and infant HIV status in Zimbabwe. E Marinda, J Humphrey , P Iliff, K Mutusa, E Piwoz, L Moulton, K Nathoo, P Salama, B Ward For the ZVITAMBO Study Group. Paediatric HIV. Every year: 600,000 new cases 500,000 deaths.

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Child mortality according to maternal and infant HIV status in Zimbabwe

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  1. Child mortality according to maternal and infant HIV status in Zimbabwe E Marinda, J Humphrey, P Iliff, K Mutusa, E Piwoz, L Moulton, K Nathoo, P Salama, B Ward For the ZVITAMBO Study Group

  2. Paediatric HIV Every year: 600,000 new cases 500,000 deaths

  3. ZVITAMBO trial (1997-2000) • RCT of postpartum vitamin A supplementation • No effect of vitamin A on overall infant mortality • (Humphrey, et al, JID 2006, 93:860-871)

  4. Contributions of these data • Large sample • Defined timing of infection • Concurrent negative cohort • Cause of death

  5. Recruitment • 14,110 mother-infant pairs • < 96 h postpartum, • 14 health centers in Harare • PMTCT programming • WHO recommendations cotrimoxazole prophylaxis of HIV-exposed infants Preceded

  6. Follow up • 6 week, 3 months, 3 monthly

  7. Mothers • Tested for HIV at baseline • CD4 counts for HIV-positive mothers

  8. Infants Babies of HIV+ mothers: -Blood collected at every time point - Cell pellets prepared and archived for DNA-PCR Tested last available sample first, then worked backwards to detect timing of infection

  9. Throughout the trial • Medical care • drug treatment of acute infections • referral of suspected tuberculosis • Group Health Education • HIV prevention • MTCT • Individual Counseling • Pre and post test • Psychosocial support • Infant feeding

  10. Cause of Death • Assigned by paediatrician masked to treatment group, maternal and child HIV status • Primary source: record of hospital admission near time of death • Secondary source: verbal autopsy

  11. Current Analysis:5 groups of infants Infected IU: In-Utero: PCR-pos < 96 h IP: Intra-Partum: PCR-neg <96 h and PCR-pos at 6 wk PN: PostNatally: PCR-neg at 6 wk and HIV-pos >3 mo Uninfected NI: HIV-positive mother, Not Infected NE: HIV-negative mother, Not Exposed

  12. Objectives of this analysis: to compare Mortality among the 5 groups Duration of survival following infection among the 3 infected groups Cause of death between the 5 groups

  13. 14,110 Mothers 53 Indeterminate 4495HIV-positive 9562HIV-negative Infants 381 IU 353 seroconverted during follow-up 508 IP 1336 258 PN 189 infected with uncertain timing 3135 NI 9210 NE

  14. Mortality from birth to 24 months Negative mother 2.9% 1.00 Positive mother 23.3% 0.75 Survival probability 0.50 0.25 0.00 0 60 120 180 240 300 360 420 480 540 600 660 720 780 analysis time Age in days HIV_status = Positive HIV_status = Negative

  15. Mortality from birth to 24 months Negative mother 2.9% 1.00 Positive mother /Negative infant 9.2% 0.75 Survival probability 0.50 66.6% IU+IP+PN 0.25 0.00 0 60 120 180 240 300 360 420 480 540 600 660 720 780 analysis time Age in days Age in days HIV_group = IU+IP+PN HIV_group = NI HIV_group = NE

  16. Mortality from birth to 24 months NE 1.00 7% NI 19% 0.75 PN 33% 33% 45% 47% Survival probability 0.50 59% IP IU 67% 0.25 0.00 0 60 120 180 240 300 360 420 480 540 600 660 720 780 analysis time Age in days

  17. 3 groups whose mortality can be defined from birth: IU, NI, NE For all, ~80% of all infant mortality occurred in the first six months of life

  18. Infant mortality by maternal and infant HIV status

  19. Uninfected infants of HIV-positive mothers are vulnerable

  20. The earlier infants are infected, the shorter their duration of survival.

  21. Cause of death

  22. Maternal factors associated with child mortality (Cox models) Adjusted for timing of infection, birth weight, sex, household income, marital status

  23. 4 Programmatic Implications

  24. Finding Mortality of perinatally infected babies (IU+IP) is extraordinarily high between ~6 weeks and 6 months due primarily to PCP Program Implication-1 Provide HIV-exposed infants with cotrimoxazole particularly targeting the 6 week to 6 month period

  25. Finding The younger infants are infected, the shorter their duration of survival. Of IU and IP infants: 40% die by 6 months 50% by one year 67% by 2 years Program Implication-2 Expand and improve PMTCT Provide early diagnosis and HAART to young infants

  26. Finding Uninfected infants of HIV-positive mothers are 4 times more likely to die during infancy than infants of HIV-negative mothers. Program Implication-3 Target all HIV-exposed infants with child survival interventions and strengthen the capacity of extended family members and other alternative infant care-givers.

  27. Finding HIV-exposed infants whose mothers had advanced compared to less advanced HIV disease, were not only more likely to become infected, but were also more likely to die - whether infected or not. Program Implication-4 Treating HAART-eligible pregnant and breastfeeding women will increase both survival of mothers and infection-free survival of their children.

  28. Acknowledgements Donors CIDA, USAID, Rockefeller Foundation, BASF Collaborating Institutions Harare City Health Department, Harare Central Hospital,University of Zimbabwe Mothers and children who participated in ZVITAMBO

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