Clinical and programmatic outcomes of HIV-exposed infants enrolled in care at geographically diverse clinics, 1997–2021: A cohort study

Abstract

Background Although 1·3 million women with HIV give birth annually, care and outcomes for HIV-exposed infants remain incompletely understood. We analyzed programmatic and health indicators in a large, multidecade global dataset of linked mother–infant records from clinics and programs associated with the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. Methods and findings HIV-exposed infants were eligible for this retrospective cohort analysis if enrolled at Conclusions While there was marked regional and temporal heterogeneity in clinical and programmatic outcomes, infant LTFU was high across all regions and time periods. Further efforts are needed to keep HIV-exposed infants in care to receive essential services to reduce HIV infection and mortality. Author summary Why was this study done? Clinical and programmatic outcomes among HIV-exposed infants are poorly documented, with gaps in information on receipt of antiretrovirals by infants and their mothers, early infant diagnosis and definitive diagnostic testing, anthropometric and developmental measures, and susceptibilities to mortality and loss to follow-up (LTFU). Previous evidence from both observational studies and clinical trials is largely limited to single-program or single-country reports with small sample sizes, lack of mother–infant linkages, or restricted geographical or temporal breadth. What did the researchers do and find? Pooling data from the International epidemiology Databases to Evaluate AIDS consortium (sub-Saharan Africa and Brazil) and the Umoyo+ project (Malawi) to create the largest global dataset of HIV-exposed infants to date, our study features >82,000 HIV-exposed infants, with >90% linked to maternal records, born over a 25-year period at 198 clinics providing routine HIV services in 10 countries—including 6 UNAIDS high HIV burden focus countries. Results from this retrospective cohort analysis provide robust, geographically broad insights on key clinical and programmatic outcomes across 5 regions, including the cumulative incidences of DNA PCR testing, LTFU, HIV diagnosis, and death through 24 months of age, accounting for relevant competing risks, while also utilizing mother–infant linkages to examine associations between these outcomes and maternal and infant characteristics. Notably, we found that while mortality and HIV diagnosis decreased over time globally, infant retention at 2 years did not exceed 60% in any period in any region. What do these findings mean? Although real-world service delivery data limitations include potential misclassification of outcomes and nonrepresentativeness of contributing sites, this study generated novel information on clinical characteristics and programmatic outcomes among HIV-exposed infants. While elucidating deficiencies in care that must be mitigated to deliver the package of medications and support necessary to assure that all such children remain uninfected, survive, and thrive, our analysis corroborated prior studies in highlighting unacceptably poor retention among those initially engaged in care. Our finding of widespread and persistent LTFU across disparate settings should motivate changes in policy and practice to improve patient retention, as maintaining infants in care will facilitate not only HIV testing and prevention, but also the provision of other services (primary care, nutrition, immunizations, etc.) essential for the achievement of long-term health.