Abstract
In Rwanda the prevalence of mother-to-child HIV transmission is 1.5%, the prevalence was found to be higher in rural area. The purpose of this study was to determine the Prevalence and Risk Factors of HIV Infection among Children born from HIV Positive Women in Musanze District. The study findings help to decrease the rate of HIV infection among children born from mother HIV positive to zero. This study was conducted in Musanze District, Northern Province in Rwanda. The study targeted 420 HIV positive mothers who delivery in different health facilities located in Musanze district form January 2019 to December 2020 and their children. SPSS version 22 was used for analysis. Of 420 children born from HIV positive mothers 91.7% were aged between 18-24 months, 55.2% were female. The majority of HIV positive mothers 80.2% who participated in the study were married. The prevalence of HIV infection among children born from HIV positive women was 2.9%. Children whose mother had poor adherence to ART were 1.5 times more likely to get HIV at birth compared to those whose mother had good adherence (AOR = 1.5; 95% CI: (1.12-2.21)). Children born from mothers in WHO stage II were more likely to get HIV from their mother (AOR = 1.24; 95% CI: (1.32-2.207)). Children born from HIV positive mother with one ANC visit were 2.5 times more likely to get HIV from their mothers (AOR = 1.56; 95% CI: (2.31-5.17)).
Author Contributions
Academic Editor: Sasho Stoleski, Institute of Occupational Health of R. Macedonia, WHO CC and Ga2len CC, Macedonia.
Checked for plagiarism: Yes
Review by: Single-blind
Copyright © 2021 Olivier Nderelimana, et al.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Competing interests
The authors have declared that no competing interests exist.
Citation:
Background
The transmission of HIV from a HIV-positive mother to her child during pregnancy, labour, delivery or breastfeeding is called mother-to-child transmission. In the absence of any intervention, transmission rates range from 15% to 45%. This rate can be reduced to below 5% with effective interventions during the periods of pregnancy, labour, delivery and breastfeeding 1.
Worldwide, Acquired Immunodeficiency Syndrome (AIDS) accounts for three per cent of deaths in children under five years of age, and six per cent of those in sub-Saharan Africa, where AIDS has become one of the major killers of young children. At least 1600 infants are infected with Human Immunodeficiency Virus (HIV) everyday and more than 600,000 infants are infected by the virus annually. About 90% of these infections occur in developing countries, mainly Sub-Saharan Africa 2.
The primary intervention to reduce MTCT of HIV is antiretroviral treatment for the mother and a short course of antiretroviral drugs for the baby. They also include measures to prevent HIV acquisition in the pregnant woman and appropriate breastfeeding practices. The new Sustainable Development Goals place heightened emphasis on prevention of mother-to-child transmission (PMTCT) in the context of better health for mothers and their children 1.
Most of HIV infected children were from sub-Saharan Africa and mother-to-child transmission during pregnancy, on delivery and during breastfeeding were the major route of infection. It is believed that about two thirds are infected during pregnancy and around the time of delivery, and about one third are infected through breastfeeding. Interventions have reduced MTCT of HIV to less than 2% in high income countries but this rate remains high in resource poor countries ranging between 20% and 45% 3.
In Rwanda, according to the data from Rwanda Biomedical Center, the prevalence of HIV transmission from mother to child is 1.56%. The child is infected during in utero (Trans placenta route) 5-10% due to free virus, infected cell or micro transfusion. Is also infected during delivery 10-20% by ingestion of vaginal secretion and contact with maternal blood. Then the child is infected during breastfeeding on 5-20% 4.
From 2014 up to 2017 the health facilities of Musanze District received 698 pregnant women HIV positive. Among these women, 14 children were infected with HIV infection 5. The use of Antiretroviral (ARV) drugs is one of the interventions available to prevent transmission of HIV from mother to child during pregnancy, labor and delivery and breastfeeding. ARV prophylaxis, elective caesarean section (CS) and avoidance of breastfeeding reduced risk of MTCT to less than 2 % 6.
The international recommendations on infant and young child feeding in the context of HIV had been last revised by the World Health Organization 7. Rwanda national protocol of HIV prevention when an HIV pregnant woman is well followed and was shown a good adherence on HIV treatment with Viral Lord suppression, she is supposed at 100% to have a child free from HIV infection 8.
It is recommended that when the pregnant women have been tested HIV positive, she should immediately start the ART. However some women still resisting on starting ART or poor adherence to HIV drugs due to different factors such negative health seeking behavior, lower education level, socio economic condition and cultural aspects 8. Therefore, there was a need to assess prevalence and risk factors of HIV infection among children born from HIV positive women in Musanze district of Rwanda.
Methods
Research Design
The study was retrospective quantitative method was used because this study determined prevalence of HIV infection among children born from mother HIV positive. Retrospective assessed subjects' histories of exposures and outcomes over a specified time period. The study was examined the medical files of both children and women HIV positive in PMTCT period. 15 health centers of Musanze District were included in this study.
Target Population
The study population composed by the HIV positive pregnant women from conception to 24 months after delivery and their children followed in PMTCT service from birth to 24 months with their final HIV test result. The said populations was from 15 health centers of Musanze District and were 420 children who were in follow up in December 2019 5.
Sample Size
The sample size was 420 children from 15 health centers in Musanze District followed from conception to 24 months after delivery with their final HIV test result. Depending on the objective of this study, all study population was enrolled in the research to better estimate the prevalence.
Data Collection Procedures and Tools
In collaboration with Nurse working in PMTCT service, medical files of both children in follow up and women HIV positive were founded in service. After finding those files, data collectors were sat together and examined the files both children and mother.
Age of the mother, Gestation, marital status, Education, Profession, ART during pregnant period, VL suppression, Adherence, breast abscess, sexual transmitted infections, malnutrition, WHO stage and Antenatal Care were recorded from medical file
From infant there is age and sex, delivery model, place of delivery, ART prophylaxis, type of nutrition and HIV testing.
Data Analysis Procedures
Raw data from the instrument tool were entered into SPSS version 22 for analysis. Descriptive statistics was used to tabulate and describe data and bivariate analysis to assess the association between independent and dependent variables were carried out using P-value. The strengths of the associations were determined with multivariate logistic regression. Crude and adjusted odd ratios were estimated with 95% confidence interval. Variables with P-value <0.05 were considered statistically significant.
Ethical Consideration
The introduction letter from Mont Kenya University was deposited to Ruhengeri Referral Hospital for approval of data collection in Health Centers in its catchment area. The Hospital and Health Centers staffs were explained about the benefits of the present study. On the data collection sheet was not provided the patient name. The Health Centers have been guaranteed that the data presentation will not point the name of health facility and the data will be stored confidentially.
Results
Demographic Characteristic of Mother and their Babies
As shown in the Table 1, the majority of the mother with HIV infection (52,1%) were aged 30 - 39 years. Of 420 children born from HIV positive mothers 91.7% were aged between 18-24 months, 55.2% were female. The majority of HIV positive mothers 80.2% who participated in the study were married, 85.5% had only primary education, and 86.5% had informal work. Table 2.
Table 1. Socio-demographic characteristics of the mothers and babies| Variable | N=420 | % |
|---|---|---|
| Age of the mother | ||
| 15-19 | 1 | 0.2 |
| 20-24 | 35 | 8.3 |
| 25-29 | 86 | 20.5 |
| 30-39 | 219 | 52.1 |
| 40-49 | 79 | 18.8 |
| Age of the Infant | ||
| <6 weeks | 9 | 2.1 |
| 6 weeks -9 months | 15 | 3.6 |
| 9-18 months | 11 | 2.6 |
| 18 months- 24 months | 385 | 91.7 |
| Sex of the infant | ||
| Male | 188 | 44.8 |
| Female | 232 | 55.2 |
| Marital status of the mother | ||
| Single | 45 | 10.7 |
| Married | 337 | 80.2 |
| Widower | 18 | 4.3 |
| Separate | 20 | 4.8 |
| Education of the mother | ||
| Non education | 27 | 6.4 |
| Primary | 359 | 85.5 |
| Secondary | 30 | 7.1 |
| University | 4 | 1 |
| Profession of the mother | ||
| Informal work | 364 | 86.5 |
| Private institution | 52 | 12.4 |
| Public institution | 4 | 1 |
| Gestation of the of the mother | ||
| Primigravida | 85 | 20.2 |
| Multigravida | 335 | 79.8 |
| Variable | N=420 | % |
| ART during pregnancy period | ||
| Yes | 410 | 97.6 |
| Non | 10 | 2.4 |
| Viral Load Suppression for the mother | ||
| Yes | 408 | 97.1 |
| Non | 12 | 2.9 |
| Adherence of the mother on ART | ||
| Good | 378 | 90 |
| Bad | 42 | 10 |
| Breast abscess for the mother | ||
| Yes | 6 | 1.4 |
| Non | 414 | 98.6 |
| Sexual transmitted infection | ||
| Yes | 4 | 1 |
| Non | 416 | 99 |
| Malnutrition for the mother | ||
| Yes | 8 | 1.9 |
| Non | 412 | 98.1 |
| WHO stage of the mother | ||
| Stage I | 360 | 85.7 |
| Stage II | 40 | 9.5 |
| Stage III | 20 | 4.8 |
| The quarter the mother started ANC | ||
| Quarter I | 363 | 86.4 |
| Quarter II | 25 | 6 |
| Quarter III | 11 | 2.6 |
| Quarter IV | 21 | 5 |
The majority of HIV Positive mother were ART during pregnancy period 410 (97.6%), 408 (97.1%) were suppressed their viral load, 420 (90.0%) demonstrated good adherence to ART medication, (85.7%) of mothers which correspond to 360 mothers were in WHO stage I. Table 3.
Table 3. Children characteristics factors of HIV infection among children born from HIV positive women| Variable | N=420 | % |
| Delivery mode of the infant | ||
| Spontaneous Vaginal Delivery | 383 | 91.2 |
| Caesarian Section | 37 | 8.8 |
| Place of delivery of the infant | ||
| Home | 17 | 4 |
| Health facility | 403 | 96 |
| ART prophylaxis in first 4 hours for the baby | ||
| Yes | 404 | 96.2 |
| Non | 16 | 4.8 |
| Complete prophylaxis for 6 weeks after delivery | ||
| Yes | 403 | 96 |
| Non | 17 | 4 |
| Type of nutrition of the baby | ||
| Exclusive breastfeeding | 420 | 100 |
| Mixed breastfeeding | 0 | 0 |
| Cotrimaxazol at 6 weeks after delivery | ||
| Yes | 407 | 96.9 |
| Non | 13 | 3.1 |
| Weaning at 18 month of the baby | ||
| Yes | 387 | 92.1 |
| Non | 33 | 7.9 |
The majority (91.2%) of children under the study were delivered by Spontaneous Delivery Vaginal, 96% were delivered at health facilities. The majority of children (96.2%) received ART Prophylaxis in the First 4 hours after birth, 96% were given cotrimaxazol prophylaxis at 6 weeks post-delivery
Prevalence of HIV Infection Among Children Born from HIV Positive Mother. Figure 1.
Figure 1.Prevalence of HIV infection among children born from HIV positive mother
As can be seen in the table above, in 420 infants, (97.1%) tested negative on final HIV test and (2.9%) infants tested positive on final HIV test positive.Factors associated with HIV Infection among children born from HIV Positive women Musanze district, Rwanda.
The findings of the factors associated with HIV infection among children born from HIV positive mothers are presented in table 4. The results shows that children born from mother who works in private sector had higher risk of HIV infection compared to those born from unemployed mother (AOR = 1.97; 95% CI: (1.13-3.25)).
Table 4. Factors associated with HIV infection| Variables | Crude OR (95% CI) | Adjusted OR (95% CI) |
| Mothers occupation | ||
| Informal work | 1 | 1 |
| Working in Private institution | 1.00(0.3-1.45) | 1.97(1.13-3.25)* |
| Public servant | 0.8(0.45-1.32) | 1.56(0.45-2.20) |
| Age of the infant | ||
| < 6 weeks | 1 | 1 |
| 6 weeks – 9 months | 1.3(0.78-2.32) | 1.02(0.45-1.26) |
| 9 -18 months | 0.98(0.52-1.40) | 0.63(0.43-1.32) |
| 18 – 24 months | 0.13(0.03-0.62) | 0.45(0.34-0.82) |
| Sex of the infant | ||
| Male | 1 | 1 |
| Female | 0.68(0.13-0.97) | 0.42(0.60-0.78) |
| Adherence to the ART | ||
| Good (Ref) | 1 | 1 |
| Poor | 1.5(1.34-3.21)* | 1.5(1.12-2.21)* |
| HIV WHO states | ||
| Stage I (Ref) | 1 | 1 |
| Stage II | 1.96(1.47-2.56)* | 1.54(1.23-2.32)* |
| Stage III | 1.54(1.23-1.87)* | 1.24(1.32-2.07)* |
| Number of ANC visit | ||
| One visit | 2.78(2.11-5.91)* | 2.56(2.31-5.17)* |
| Two visits | 1.7(1.12-2.75)* | 1.62(1.10-2.63)* |
| Three visits | 0.40(0.21-1.43) | 0.12(0.10-1.43) |
| Four visits (Ref) | 1 | 1 |
| Cotrimoxazol prophylaxis at 6 week | ||
| Yes (Ref) | 1 | 1 |
| No | 0.5(0.10-1.23) | 0.32(0.14-1.17) |
| Weaning at 18 months | ||
| Yes (Ref) | 1 | 1 |
| No | 1.2(1.08-2.34)* | 1.14(0.98-1.78) |
Children whose mother had poor adherence to ART were 1.5 times more likely to get HIV at birth compared to those whose mother had good adherence (AOR = 1.5; 95% CI: (1.12-2.21)). Children born from mothers in WHO stage I and II were more likely to get HIV from their mother with odd ratios of (AOR = 1.54; 95% CI: (1.12-2.32)), (AOR = 1.24; 95% CI: (1.32-2.207)) respectively.
Children born from HIV positive mother with one ANC visit were 2.5 times more likely to get HIV from their mothers (AOR = 1.56; 95% CI: (2.31-5.17)). Similarly, children born from HIV positive mother who attended only two ANC were 1.6 times more likely to get HIV from their mothers (AOR = 1.62; 95% CI: (1.10-2.63)).
Discussion
The main objective of this study was to determine the Prevalence and Risk Factors of HIV Infection among Children born from HIV Positive Women in Musanze District. Mother to child transmission of HIV infection occurs when HIV positive women passes the virus to her baby during pregnancy, delivery and breastfeeding period. Of 420 children born from HIV positive mother 12 (2.9%) were HIV positive. The prevalence of HIV infections among children born from HIV positive mother in Musanze District was 2.9%.
In the research conducted by UNAID in 2017 in worldwide founded that the route of HIV infection from mother to child is during pregnancy period, delivery period and breastfeeding period. It is believed that about 2/3 are infected during pregnancy and around the time of delivery, and about 1/3 are infected through breastfeeding period.
A lower HIV prevalence among children born from HIV mother was observed in Musanze District. In contrast the higher prevalence was reported in the study conducted in Ethiopia. The study conducted in Amhara region, Ethiopia showed that the prevalence of HIV infection among HIV exposed infants was 10.1% 10. In Ethiopia an estimated 1.2 % of pregnant women are living with HIV. Consequently, one of every 3 (33.3%) children born to these women is being infected with HIV 11.
The higher prevalence as also reported in the study conducted in Zimbabwe where mother-to-child HIV transmission is between 15–25%. In Zimbabwe like any other country in sub-Saharan Africa, breastfeeding is the norm with 97% of children reported as ever breastfed 12. In Tanzania, a study showed that, the overall rate of transmission can go up to 20% if an HIV infected mother breastfeeds for 18–24 months 13. Similarly to these findings, a research conduct by Rwanda Biomedical Center in 2018 revealed that the prevalence of HIV transmission from mother to child is 1.56% 8. From 2012, the Government of Rwanda has opted for the WHO option in which all HIV positive pregnant women got engaged in ART regardless of the CD4 count. The process excluded breast feeding protected by ART and women continuing ART as a lifelong treatment. Implementation of WHO option resulted in the reduction of MTCT rate at 18 months. Recent data concluded that MTCT rate dropped to 1.8% in a cohort of exposed infants 9.
Factors such as working in private sector, maternal poor adherence to ART, advanced stage of HIV, poor ANC visits were associated with HIV infection among mothers born from HIV positive mothers.
Rwanda Government continue to work together with partners to ensure full implementation of national standards for HIV prevention, care and treatment for pregnant women, mothers and their children; and to develop evidence-based strategies and define baselines and indicators that promote the integration of PMTCT into maternal, newborn and child health services, thus strengthening Rwanda health systems.
Conclusion
The prevalence of HIV infection among children born from HIV positive women in Musanze District was 2.9% this is higher compared to national prevalence (1.5%). Factors such as working in private sector, maternal poor adherence to ART, unsuppressed viral load, and lack of ART drug during PMTCT period, lack of ART prophylaxis for the infant, advanced stage of HIV, poor ANC visits were associated with HIV infection among children born from HIV positive mothers. Effective strategies to promote safe infant feeding practices such as, avoidance of mixed feeding beyond 26 weeks among HIV infected mothers are recommended. This study releases some recommendations such as; early introduction of ART for all HIV positive pregnant women; to provide ARVs prophylaxis for all children born from HIV positive women; enhance cancelling on ART treatment in term of increasing good adherence and encourage HIV positive pregnant women to follow antenatal care program.
References
- 3.UNAIDS. (2017) (12 12).Paediatric HIV infection and AIDS: UNAIDS point of view. UNAIDS best practice collection. 2002. 1-2.
- 4.NISR. (2018) Rwanda Population and Housing. Census2018. Retrieved August 12, 2020, from National Institute of Statistics of , Rwanda: .
- 6.Beyene. (2018) BMC Infectious Diseases.Determinants of HIV infection among children born to mothers on prevention of mother to child transmission program of HIV in Addis Ababa, Ethiopia: a case control study. 1-2.
- 7. (2016) World Health Organization. Guideline: updates on HIV and infant feeding: the duration of breastfeeding,. Geneva: World Health Organization.
- 8.RBC.. (2016). National Guidelines for Prevention and Management of HIV and STIs.Kigali: Ministry of Health .
- 9.RBC. (2015) A question and answer guide on the National guidelines on PMTCT and infant feeding in the context of HIV. Kigali: Ministry of Health.
- 10.Zelalem. (2019) Risk of HIV and associated factors among infants born to HIV positive women in Amhara region, Ethiopia: a facility based retrospective study. BMC. 1-2.