The continuum of care from HIV exposure to early diagnosis, early treatment and sustained viral suppression in infants, in southern Mozambique

Following the Global plan for the elimination of pediatric HIV and the Start Free Stay Free AIDS Free framework, remarkable progress in the prevention of mother-to-child transmission (PMTCT), in treatment access and in reduction of pediatric AIDS related deaths, has been reported. However in 2018, new 160.000 pediatric infection occurred globally, only 52% of infants accessed early diagnosis and only half of the 1.7 million children living with HIV received antiretroviral treatment (ART). Recent data from the Population HIV Impact Assessment in 10 African countries reported 37% viral suppression (VS) among children 0-14 years. In the current global effort to attain elimination of new pediatric HIV infection, ensure early universal access to ART and achieve sustained VS among children, a better understanding of complexities in the PMTCT continuum of care till final infantsâ diagnosis, linkage to ART care for infected ones and VS pattern, is key for a tailored and effective response in this population. In Mozambique, HIV prevalence among women of child bearing age is 15.4% and despite over 95% HIV testing and ART coverage among pregnant women accessing antenatal care, vertical transmission rate is 10%, unacceptably high, 16.000 new pediatric infections occurred in 2018 and VS among children is 46%. Data are scarce on the existing gaps in the PMTCT pathway and evidence on viral response to ART among infected infants who start early treatment is lacking. The main objective of this project is to improve current knowledge on underlying gaps in the infantsâ continuum of care from HIV exposure to early diagnosis, early treatment and viral suppression in southern Mozambique, where HIV prevalence is 22.8%. First, a cross sectional analytical study using data from the national 2015 HIV Survey was conducted to investigate factors associated to the condition of â unknown HIV exposure statusâ and â HIV exposureâ in children under 2 years of age. The study found a high proportion of children with unknown HIV sero-status, 32%, and associated factors were living in the northern and central region of the country, in rural areas, mother with no education and male as head of the household. Second, a retrospective cohort study analyzed the magnitude of HIV Exposed Infants lost to follow-up (LTFU) before definitive diagnosis and related factors, in southern Mozambique. A high rate, 16%, of LTFU was found; underlying factors were age older than 2 months at entry into post-natal care, non-exclusive breastfeeding and poor cotrimoxazole adherence. We also found that less than half of HIV infected infants were diagnosed early, before 2 months of age. Third, a cohort study described viral response up to 18 months follow-up in infants who started ART at one month of age. Viral suppression (<1000 copies/ml) was achieved by 60% of infants, 47% sustained VS throughout the follow-up period; cumulative probability of VS among all infants was 43% at 6 months, 56% at 12 months, 73% at 18 months. The main constraint to achieve VS was adherence to treatment. Finally, a qualitative analysis evaluated whether the standard adherence and psycho-social package (APSS) of care applied to infantsâ caregivers, identified correlates of viral response in infants starting ART at one month of life. Evidence showed that the routine APSS approach did not clearly and timely identified infants who had poor viral response. Overall, this research project increased our understanding of some key gaps in the PMTCT and pediatric HIV program in Mozambique such as sub-optimal access and high drop out of mom-baby pair from the program and some of associated factors. Another important finding was the poor viral response to ART among infants starting early treatment and the need of a tailored psycho-social support package to better address adherenceâ s challenges among caregivers. Findings are important to inform the HIV and PMTCT program for designing differentiated model of care addressing mothers and their infantâ s specific needs. Additional research is needed to study the magnitude of lost to follow-up of HEI in other provinces of the country and underlying socio-economic determinants especially gender dynamics within the family and the male role in contributing to the elimination of pediatric HIV. Moreover, further studies are crucial to evaluate the continuum of APSS care during infancy and childhood to obtain a more robust evidence factors affecting caregiversâ adherence and how they can effectively be addressed.