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Infant Human Immunodeficiency Virus–free Survival in the Era of Universal Antiretroviral Therapy for Pregnant and Breastfeeding Women

A Community-based Cohort Study From Rural Zambia

Chi, Benjamin H., MD, MSc*; Mutale, Wilbroad, MBChB, PhD; Winston, Jennifer, PhD*; Phiri, Winifreda, RN*; Price, Joan T., MD, MPH*; Mwiche, Angel, MBChB, MMed, MPH; Ayles, Helen, MBBS, PhD§,¶; Stringer, Jeffrey S. A., MD*

The Pediatric Infectious Disease Journal: November 2018 - Volume 37 - Issue 11 - p 1137–1141
doi: 10.1097/INF.0000000000001997
HIV Reports

Background: Lifelong antiretroviral therapy (ART) is now recommended for all human immunodeficiency virus (HIV)-infected pregnant and breastfeeding women; however, few have described overall infant outcomes in this new era for the prevention of mother-to-child HIV transmission (PMTCT).

Methods: As part of an assessment of PMTCT program impact, we enrolled a prospective cohort study in 4 predominantly rural districts in Zambia. HIV-infected mothers and their newborns (≤30 days old) were recruited and followed at 6 weeks, 6 months and 12 months postpartum; infant specimens were tested via HIV DNA polymerase chain reaction. In Kaplan–Meier analyses, we estimated overall infant HIV-free survival and then stratified by district, community and maternal ART use. We investigated the relationship between community-level 12-month, self-reported maternal ART use and infant HIV-free survival via linear regression.

Results: From June 2014 to November 2015, we enrolled 827 mother–infant pairs in 33 communities. At 12 months, small proportions of infants had died (2.8%), were HIV-infected (3.0%) or were lost to follow-up (4.3%). Overall, infant HIV-free survival was 99.0% [95% confidence interval (CI): 98.0%–99.5%] at 6 weeks, 97.5% (95% CI: 96.1%–98.4%) at 6 months and 96.3% (95% CI: 94.8%–97.4%) at 12 months. Women reporting ART use at enrollment had higher infant HIV-free survival than those who did not (97.4% vs. 89.0%, P = 0.01). Differences were noted at the district and site levels (P = 0.01). In community-level analysis, no relationship was observed between 12-month infant HIV-free survival and self-reported maternal ART use (P = 0.65).

Conclusion: Although encouraging, these findings highlight the need for rigorous monitoring and evaluation of PMTCT services at the population level.

From the *School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

School of Public Health, University of Zambia, Lusaka, Zambia

Zambian Ministry of Health, Lusaka, Zambia

§Zambart, Lusaka, Zambia

London School of Hygiene and Tropical Medicine, London, United Kingdom.

Accepted for publication February 28, 2018.

The authors have no funding or conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Address for correspondence: Benjamin H. Chi, MD, MSc, University of North Carolina at Chapel Hill, Campus Box 7577, MBRB 4300C, Chapel Hill, NC 27599. E-mail:

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