Treatment failure among HIV-positive newborns linked to mother’s non-adherence

10 June 2020

South African study finds that treatment fails in two-thirds of HIV-positive infants, and that failure is linked to concurrent maternal treatment failure.

Mother and child hold hands

A South African study comparing the health of HIV-positive infants who started antiretroviral treatment (ART) within 26 hours of life, with those who started ART within 10 days, has found high-levels of treatment failure in both groups.

Non-adherence to treatment was thought to be the deciding factor in whether an infant’s treatment was successful or not – and that this is closely linked to their mother’s ability to adhere to her treatment.

Researchers followed 150 babies born to HIV-positive women in KwaZulu-Natal, South Africa between 2015 and 2019. Each baby was given post-exposure prophylaxis (PEP) within minutes of birth. Within 26 hours, half were diagnosed HIV positive through point-of-care testing and began ART. The other half were diagnosed HIV positive at 10 days using standard laboratory testing, before beginning ART.

After one month of life, any difference in the viral load and CD4 counts between the two groups had disappeared.

Overall, only one-third (37%) of all the infants studied that were virally suppressed at six months remained virally suppressed by the time they were one. Of these, 18% were no longer virally suppressed by the age of two.

Despite being born healthy, 7% of infants died within the first six months of life, most within 3.5 months. A further 16% of infants stopped attending appointments by six months.

The high level of virological failure in both groups was found to be strongly associated with both an infant and their mother’s non-adherence to ART, rather than with drug-resistant HIV. Non-adherence was defined as missing three or more consecutive ART doses.

Around 25% of women did not start taking ART until giving birth, mainly due to receiving poor antenatal care or becoming HIV positive at a late stage of pregnancy. For the 75% of women who were on ART during pregnancy, 55% had poor ART adherence, and 8% had not taken any ART doses.

The findings indicate that adherence is the single biggest factor in whether ART is successful among infants. If the treatment-support needs of a mother can be successfully addressed they are more likely to meet the practical challenges of administering ART to their infants, which is often seen as a key reason for treatment failure.

The findings also suggest that, in countries such as South Africa where HIV testing at birth is universally implemented and where ART is reaching the majority of HIV-positive infants through the placenta and at birth via PEP, the advantages of point-of-care testing over standard laboratory testing may be minimal.

It is important to note that some differences between the two groups were observed, such as the proportion of infants that exclusively breastfed (91% in the group that started treatment within 26 hours, compared to 68% in the group that started ART at 10 days). Although the clinical significance of these differences is unclear, making a direct comparison between the two groups should be done with caution.

Regardless of this limitation, the findings suggest that, in the absence of long-acting ART solutions that can be given to infants very soon after birth, effective support for mothers who are vulnerable to treatment failure must be prioritised. Unless and until these women’s adherence needs are met, HIV-related illness and AIDS-related deaths among both them and their infants will continue.

Written by Hester Phillips