2009 Articles

Impact of Maternal Human Immunodeficiency Virus Infection on Birth Outcomes and Infant Survival in Rural Mozambique

Naniche, Denise; Bardaji, Azucena; Lahuerta Sanau, Maria; Berenguera, Anna; Mandomando, Inacio; Sanz, Sergi; Aponte, John J.; Sigauque, Betuel; Alonso, Pedro L.; Menendez, Clara

Sub-Saharan Africa harbors more than two-thirds of the world’s 33.2 million persons infected with human immunodeficiency virus (HIV) and 80% of the world’s HIV-infected women. In parts of southern Africa, more than 30% of pregnant women attending antenatal clinics are infected with HIV, thus making HIV infection one of the most common complications of pregnancy in sub-Saharan Africa. With successful interventions, mother-to-child transmission (MTCT) of HIV has been reduced to less than 2% in developed countries. However, in untreated populations, MTCT of HIV during pregnancy, delivery, and breastfeeding still occurs at an approximate overall rate of 25–40%, and accounts for almost 420,000 new HIV infections in children and 270,000–320,000 pediatric deaths annually. Until 2004, single-dose intrapartum and neonatal nevirapine (sd-NVP) was the recommended regimen by the World Health Organization to prevent MTCT of HIV among women without access to antiretroviral therapy. Preventive MTCT programs with an sd-NVP have been shown to decrease perinatal HIV transmission to 8% in controlled clinical trial settings. However, there is great concern about the rapid development of resistance. In addition, in predominantly breastfeeding populations of sub- Saharan Africa, most MTCT of HIV still occurs during the postnatal period. Currently, MTCT prevention programs in sub-Saharan African countries include zidovudine and lamivudine during the final weeks of pregnancy and sd-NVP at delivery. In addition, the newborn receives sd-NVP at birth and zidovudine for seven days. Nevertheless, effectiveness of these strategies relies on the great challenge of availability of the drugs and compliance with them, given that these preventive regimens are prolonged and unsupervised. Several studies from the Africa have reported that HIVinfected pregnant women are at increased risk of adverse pregnancy outcomes such as spontaneous abortion, stillbirths, and preterm labor. However, this analysis is complicated by many factors associated with HIV infection and poor pregnancy outcomes such as malnutrition, anemia, and other frequent infections such as syphilis or malaria. These factors may contribute to the observation that the association between HIV infection and adverse pregnancy outcomes is stronger in women from developing countries. Maternal HIV infection has also been associated with an increased risk of infant death. It is well documented that up to 35% of HIV-infected infants may die before the first year of age, but HIV-negative children born to HIV-infected mothers are also at high risk of mortality. There have been few studies characterizing the impact of HIV infection during pregnancy on the mother and her infant and even fewer from rural African settings. The main aim of this study was to assess the impact of HIV infection on birth outcomes and infant survival in a rural area of southern Mozambique. Furthermore, the study also evaluated the effect of unsupervised sd-NVP administration for prevention of MTCT of HIV on HIV RNA viral load at delivery and the prevalence of NVP resistance mutations.