Survival and HIV-Free Survival Among Children Aged ≤3 Years — Eight Sub-Saharan African Countries, 2015–2017
Weekly / May 15, 2020 / 69(19);582–586
Sasi Jonnalagadda, PhD1; Katharine Yuengling, MPH2; Elaine Abrams, MD2; Paul Stupp, PhD1; Andrew Voetsch, PhD1; Monita Patel, PhD1; Zandi Minisi, MSc3; Michael Eliya4; Ndapewa Hamunime, MD5; Anath Rwebembera6; Wilford Kirungi, MBChB7; Lloyd Mulenga8; Angela Mushavi, MBChB 9; Caroline Ryan, MD10; Mamorapeli Ts’oeu11; Evelyn Kim, PhD12; Eric J. Dziuban, MD13; Kathy Hageman, PhD14; Jennifer Galbraith, PhD15; Keith Mweebo, MBChB 16; Annie Mwila, MBChB16; Elizabeth Gonese, PhD17; Hetal Patel, MSc1; Surbhi Modi, MD1; Suzue Saito, PhD2 (View author affiliations)View suggested citation
What is already known about this topic?
Mother-to-child transmission of human immunodeficiency virus (HIV) is preventable through antiretroviral treatment (ART) during pregnancy and postpartum.
What is added by this report?
Among children born to mothers with HIV infection in eight sub-Saharan African countries, HIV-free survival was highest among children whose mothers received ART before pregnancy, compared with those who initiated ART during pregnancy or those who did not receive ART during pregnancy.
What are the implications for public health practice?
In addition to prevention of HIV acquisition, national programs should prioritize early diagnosis of HIV infection and ART initiation among women of reproductive age before pregnancy to reduce mother-to-child transmission of HIV and improve child survival rates.
Views equals page views plus PDF downloads
Although mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) is preventable through antiretroviral treatment (ART) during pregnancy and postpartum, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that 160,000 new HIV infections occurred among children in 2018 (1). Child survival and HIV-free survival rates* are standard measures of progress toward eliminating MTCT† (2). Nationally representative Population-based HIV Impact Assessment (PHIA)§ survey data, pooled from eight sub-Saharan African countries¶ were used to calculate survival probability among children aged ≤3 years by maternal HIV status during pregnancy and HIV-free survival probability among children aged ≤3 years born to women with HIV infection, stratified by maternal ART** status during pregnancy. Survival probability was significantly lower among children born to women with HIV infection (94.7%) than among those born to women without HIV infection (97.6%). HIV-free survival probability of children born to women with HIV infection differed significantly by the timing of initiation of maternal ART: 93.0% among children whose mothers received ART before pregnancy, 87.8% among those whose mothers initiated ART during pregnancy, and 53.4% among children whose mothers did not receive ART during pregnancy. Focusing on prevention of HIV acquisition and, among women of reproductive age with HIV infection, on early diagnosis of HIV infection and ART initiation when applicable, especially before pregnancy, can improve child survival and HIV-free survival.
Females aged ≥15 years who provided consent†† to survey participation answered questions about the most recent pregnancy that resulted in a live birth in the 3 years preceding the interview (i.e., births occurring during 2012–2017, depending on the date of the survey). Questions asked whether any antenatal care was received, timing of HIV testing and HIV status (HIV diagnosis before pregnancy; during pregnancy, labor, or delivery; or did not have a diagnosis of HIV infection), and ART use among mothers with HIV infection (initiated ART before pregnancy; initiated ART during pregnancy, labor, or delivery; or did not receive ART). All mothers provided the child’s date of birth; whether the child was living or deceased, and if deceased, the date of death or age at death; and HIV status of living children. All mothers and a random subsample of children underwent HIV testing in the household using country-specific HIV rapid testing algorithms. Positive rapid test results were confirmed using Geenius HIV-1/2 confirmatory assay (Bio-Rad) (for children aged ≥18 months).§§ Infants aged <18 months were screened for HIV exposure using rapid tests; a positive rapid test result was confirmed using total nucleic acid polymerase chain reaction. HIV test results were provided to the participants along with referral to HIV treatment services. Survey protocols for each of the eight countries were reviewed by the CDC Institutional Review Board (IRB), the Columbia University Medical Center IRB, and the IRB in each country.
Children were classified according to maternal report of HIV status during pregnancy to determine survival by maternal HIV status. For the HIV-free survival analysis, children born to mothers with HIV infection were classified according to maternal self-reported ART use during pregnancy. Mothers whose response to HIV status during pregnancy was missing but who had positive test results for HIV (0.8%), were classified as having HIV infection during pregnancy. Mothers with HIV infection who were missing information on ART use during pregnancy (5%) were classified as not having received ART during pregnancy.
HIV status of children in this analysis was determined by HIV testing during the survey (74%) or maternal report for nonsampled children (26%). Date of the child’s HIV diagnosis was based on the survey test date for sampled children and on mothers’ report of first HIV test date with positive results for nonsampled children. Mothers reported the date of death or age at death for children who had died. HIV status of deceased children was not recorded uniformly across surveys and was therefore not included in the analysis. Children without a survey-confirmed HIV status and without mothers’ report were excluded.
Kaplan-Meier survival analyses were used to estimate overall survival and HIV-free survival probability (3). Interview data about mothers’ last pregnancy were used to determine the outcomes of children using the age of the child at the time of events of interest. To estimate survival, children were censored at the age at death or age at time of survey. To estimate HIV-free survival, children of mothers with HIV infection were censored at their age at death, their age at HIV diagnosis, or their age at the time of survey. A sensitivity analysis was conducted to estimate HIV-free survival rates after excluding children currently breastfeeding who were still at risk for HIV infection through breast milk transmission. The analyses were unweighted. Analyses were performed using SAS (version 9.4; SAS Institute) and Stata (version 14.2; StataCorp) statistical software.
Among 36,278 live births, data for the survival analysis were available for 33,863 (93%), including 30,703 (91.0%) children born to mothers without HIV infection, 3,020 (9.0%) born to mothers with HIV infection, and 140 (0.4%) children whose mothers’ HIV status was unknown (Table 1). Among children born to mothers with HIV infection, 108 (3.6%) died; 552 (1.8%) mothers without HIV infection and five (3.6%) mothers with unknown HIV status also died. Cumulative probability of survival up to 3 years among children born to mothers with HIV infection was 94.7% and among children born to mothers without HIV infection was 97.6% (p<0.001) (Figure) (Table 2).
Among the 3,020 children born to mothers with HIV infection, 2,373 (78.6%) had complete HIV data (HIV status and diagnosis date) and death data available and were included in the HIV-free survival analysis. Among these 2,373 children, mothers of 1,252 (52.8%) received ART before pregnancy; 842 (35.5%) initiated ART during pregnancy, labor, or delivery; and 276 (11.6%) did not receive ART during pregnancy, labor, or delivery (Table 1). Overall, 127 (5.4%) of these children had HIV infection, 2,138 (90.1%) did not, and 108 (4.6%) had died.
HIV-free survival probability in children born to mothers with HIV infection was 85.3%. HIV-free survival rates among children whose mothers initiated ART before pregnancy, during pregnancy, and who did not receive ART during pregnancy were 93.0%, 87.8%, and 53.4%, respectively (log-rank p-value <0.001) (Figure). Excluding children who were currently breastfeeding did not alter the HIV-free survival estimates.
The PHIA surveys provide population-level estimates of child survival and HIV-free survival in eight sub-Saharan African countries among children born during 2012–2017, allowing population-level assessment of progress toward elimination of MTCT. The estimated probability of survival of children born to mothers with HIV infection was lower than that of children born to mothers without HIV infection, as has been previously reported (4). Previous studies on child mortality by maternal HIV status were conducted before the widespread scale–up of Option B+ (lifelong ART for all pregnant and breastfeeding mothers living with HIV infection regardless of CD4 cell count or clinical stage)¶¶ that occurred during 2011–2014 and the 2016 “treat-all” guidance for all persons living with HIV infection (5,6). Most children included in this analysis were conceived or born before or during the early efforts to scale up adult*** and pediatric††† ART (6). The difference in survival probability of children born to mothers with HIV infection and those without HIV infection in the recent birth cohorts§§§ appears to be narrowing, which could be the early sign of progress in reducing AIDS-specific morbidity and mortality among adults, potentially conferring survival benefits to children (7).
The HIV-free survival rate of 85.3% suggests that substantial gaps remain in improving child survival and eliminating MTCT. HIV-free child survival probability was highest when mothers received ART before pregnancy, compared with survival probability of children whose mothers initiated ART during pregnancy or who did not receive ART during pregnancy, as has been reported in another impact assessment of the prevention of mother-to-child transmission (PMTCT) (8). Initiation of ART before pregnancy reduces in utero MTCT of HIV and is associated with postpartum ART retention, which, in turn, reduces the risk for HIV transmission through breastfeeding (8,9). In this analysis, >90% of mothers with HIV infection received ART during pregnancy, but only approximately 50% initiated ART before pregnancy. These results suggest that achieving MTCT elimination targets will require earlier diagnosis of HIV infection and earlier initiation of ART among women of reproductive age with HIV infection, along with prevention of HIV acquisition among women, prevention of unintended pregnancies, and safe conception planning for mothers living with HIV infection so that they can receive ART and be virally suppressed before pregnancy.¶¶¶ The difference in HIV-free survival in children determined by maternal ART status during pregnancy was least pronounced in the most recent birth cohort (i.e., children aged ≤1 year at the time of the survey); these children likely benefited most from Option B+ and adult treat-all programs.****
The findings in this report are subject to at least three limitations. First, children in the sample were born during 2012–2017 and received different care depending on HIV treatment standards at the time, which could limit comparability over time. Second, the cross-sectional nature of the data precludes attribution of results to different HIV program effects. Some of the favorable outcomes in children aged ≤1 year could be the consequence of exposure to more effective programs and the shorter duration of observation; however, given that past studies have shown most diagnoses of HIV infection and HIV-associated deaths occurring in the first year of life (10), it is more likely to be related to better programs than to shorter observation periods. Finally, mortality was estimated from the most recent live birth during the preceding 3 years; therefore, these mortality estimates are lower than are those from Demographic and Health Surveys, which estimate infant mortality using all deaths during the preceding 5 years.††††
Despite considerable scale-up of ART and other PMTCT interventions in sub-Saharan Africa, children born to mothers with HIV infection are still at substantial risk for MTCT of HIV and have lower survival rates than do children born to mothers without HIV infection. In addition to prevention of HIV acquisition among women, HIV programs should focus efforts on early diagnosis of HIV infection and initiation of ART among women of reproductive age with HIV infection, especially before pregnancy, to have the greatest impact in reducing MTCT and reaching child survival goals. Ongoing assessments of survival and HIV-free survival will be needed to determine longer-term effects of improving HIV programs on child health outcomes.
Corresponding author: Sasi Jonnalagadda, firstname.lastname@example.org, 404-639-2249.
1CDC; 2ICAP at Columbia University, New York, New York; 3Eswatini Ministry of Health; 4Malawi Ministry of Health; 5Namibia Ministry of Health; 6Tanzania National AIDS Control Program; 7Uganda Ministry of Health; 8Zambia Ministry of Health; 9Zimbabwe Ministry of Health; 10CDC-Eswatini; 11CDC-Lesotho; 12CDC-Malawi; 13CDC-Namibia; 14CDC-Tanzania; 15CDC-Uganda; 16CDC-Zambia; 17CDC-Zimbabwe.
All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.
* For this analysis, HIV-free survival was defined as the child being alive and HIV-negative at the time of the survey, as determined by either the HIV testing conducted during the survey or the maternal report of the child’s HIV status.
† Elimination of new HIV infections among children.
¶ Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia, and Zimbabwe (PHIA surveys in these countries were conducted during 2015–2017).
** Information on HIV treatment regimen was not collected in the PHIA questionnaire, and some mothers might not have been on lifelong ART.
†† Method of consent was either oral or written depending on each country’s PHIA survey protocol.
§§ In Uganda, Geenius confirmation was not used. All specimens collected by venous blood draw were retested at the central laboratory using the national rapid testing algorithm used in the field.
¶¶ Option B+ was first introduced in Malawi in 2011 and expanded globally since 2013. “Treat-all” refers to ART initiation among all adults with HIV regardless of clinical stage and at any CD4 cell count. https://apps.who.int/iris/bitstream/handle/10665/186275/9789241509565_eng.pdf;jsessionid = 1461B0D372ABEF56426E1D7CD95CD354?sequence = 1external icon.
*** Births included in this analysis occurred during 2012–2017. National HIV programs scaled up Option B+ in 2011, and adult treat-all approach was initiated in 2016.
††† The Accelerated Childen’s HIV/AIDS Treatment initiative was a 2-year program to double the number of children receiving ART in sub-Saharan Africa. https://journals.lww.com/jaids/Fulltext/2018/08152/Sustainability_and_Accelerating_Children_s.12.aspxexternal icon.
§§§ Corresponding to children who were aged <1 year at the time of the survey.
¶¶¶ The first two pillars of the World Health Organization’s comprehensive approach to PMTCT are preventing HIV infection and preventing unintended pregnancies. https://www.who.int/hiv/pub/mtct/strategic/en/external icon.
**** In the pooled data, percentages of children born to mothers who were treated with ART before pregnancy and delivered in the 1, 2 and 3 years preceding the survey were 55.3%, 51.9% and 51.3%, respectively, indicating a modest increase in the proportion of mothers treated with ART before pregnancy over time.
†††† Infant mortality rates (deaths in children aged <1 year per 1,000 live births), irrespective of maternal HIV status, from the PHIA surveys and Demographic and Health Surveys (DHS), respectively, in the eight countries are as follows: Eswatini (0.9% and 8.5%), Lesotho (2.6% and 5.9%), Malawi (1.8% and 4.2%), Namibia (1.1% and 3.9%), Tanzania (1.6% and 4.3%), Uganda (1.5% and 6.4%), Zambia (1.7% and 4.5%), and Zimbabwe (1.5% and 5.0%). DHS methods for estimating child mortality are available at https://dhsprogram.com/Data/Guide-to-DHS-Statistics/Early_Childhood_Mortality.htmexternal icon.
- Joint United Nations Programme on HIV/AIDS. Start free stay free AIDS free. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS; 2019. https://www.unaids.org/sites/default/files/media_asset/20190722_UNAIDS_SFSFAF_2019_en.pdfpdf iconexternal icon
- World Health Organization. A short guide on methods: measuring the impact of national PMTCT programmes: towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive. Geneva, Switzerland: World Health Organization; 2012. https://apps.who.int/iris/bitstream/handle/10665/75478/9789241504362_eng.pdf;jsessionid=1BED4F90DB3F3B8ED99E16101F91863B?sequence=1external icon
- Stalpers LJA, Kaplan EL. Edward L. Kaplan and the Kaplan-Meier survival curve. BSHM Bulletin 2018;33:109–35. CrossRefexternal icon
- Brennan AT, Bonawitz R, Gill CJ, et al. A meta-analysis assessing all-cause mortality in HIV-exposed uninfected compared with HIV-unexposed uninfected infants and children. AIDS 2016;30:2351–60. CrossRefexternal icon PubMedexternal icon
- Kieffer MP, Mattingly M, Giphart A, et al.; EGPAF Technical Directors Forum. Lessons learned from early implementation of option B+: the Elizabeth Glaser Pediatric AIDS Foundation experience in 11 African countries. J Acquir Immune Defic Syndr 2014;67(Suppl 4):S188–94. CrossRefexternal icon PubMedexternal icon
- World Health Organization. Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV. Geneva, Switzerland: World Health Organization; 2015. https://apps.who.int/iris/bitstream/handle/10665/186275/9789241509565_eng.pdf;jsessionid=1461B0D372ABEF56426E1D7CD95CD354?sequence=1external icon
- Wang H, Wolock TM, Carter A, et al.; GBD 2015 HIV Collaborators. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: the Global Burden of Disease Study 2015. Lancet HIV 2016;3:e361–87. CrossRefexternal icon PubMedexternal icon
- Dinh TH, Mushavi A, Shiraishi RW, et al. Impact of timing of antiretroviral treatment and birth weight on mother-to-child human immunodeficiency virus transmission: findings from an 18-month prospective cohort of a nationally representative sample of mother-infant pairs during the transition from Option A to Option B+ in Zimbabwe. Clin Infect Dis 2018;66:576–85. CrossRefexternal icon PubMedexternal icon
- Knettel BA, Cichowitz C, Ngocho JS, et al. Retention in HIV care during pregnancy and the postpartum period in the Option B+ era: systematic review and meta-analysis of studies in Africa. J Acquir Immune Defic Syndr 2018;77:427–38. CrossRefexternal icon PubMedexternal icon
- De Cock KM, Fowler MG, Mercier E, et al. Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice. JAMA 2000;283:1175–82. CrossRefexternal icon PubMedexternal icon
FIGURE. Probability of survival (A)*,† and HIV-free survival (B)§ among children aged ≤3 years at the time of the Population-based HIV Impact Assessment (PHIA) survey — eight sub-Saharan African countries,¶ 2015–2017
Abbreviations: ANC = antenatal care; ART = antiretroviral therapy; CI = confidence interval; HIV = human immunodeficiency virus.
* Excludes 140 children out of 33,863 whose mothers had unknown HIV status.
† Excludes 11 deaths among children not exposed to HIV that took place after 3 years.
§ Out of 2,373 children born to mothers with HIV infection, three were born to mothers with missing ART use data.
¶ Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia, and Zimbabwe.
Suggested citation for this article: Jonnalagadda S, Yuengling K, Abrams E, et al. Survival and HIV-Free Survival Among Children Aged ≤3 Years — Eight Sub-Saharan African Countries, 2015–2017. MMWR Morb Mortal Wkly Rep 2020;69:582–586. DOI: http://dx.doi.org/10.15585/mmwr.mm6919a3external icon.
MMWR and Morbidity and Mortality Weekly Report are service marks of the U.S. Department of Health and Human Services.
Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.
All HTML versions of MMWR articles are generated from final proofs through an automated process. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version (https://www.cdc.gov/mmwr) and/or the original MMWR paper copy for printable versions of official text, figures, and tables.
Questions or messages regarding errors in formatting should be addressed to email@example.com.