Mother-to-child HIV transmission and its correlates in India: systematic review and meta-analysis

Since 1980, in developing countries prevalence of HIV has increased and it has led to plenty of economic demographic, and social significances [1, 2]. Primary way to transmission of HIV among adults is chiefly by insecure sexual intercourse. A large incident of vertical transmissions observed from pregnant woman to her new-born during pregnancy in utero, intrapartum during labour and delivery or postpartum through breast feeding [3, 4]. New-born babies are solely infected due to transmission from mother, here considering the parental investment by the male partner, who transmit the infection to his partner, in India this phenomenon is aptly termed as parent-to-child transmission (PTCT) [5]. Seventy to 75 % HIV transmission occurs in the time of labour and delivery, while 25 to 30 % of transmission of infection occurs in the late stage of pregnancy or antenatally [6]. The third largest HIV infected population; approximately 2.39 million are living in India [7, 8]. India has estimated 145,000 children < 15 years of age who are infected by HIV/AIDS [9]. Children account for 7% of all the new HIV infections [10]. National AIDS Control Organization (NACO) estimated that out of about 30 million annual pregnancies in India, more than 22,000 pregnant women are infected by HIV [11]. In the absence of any intervention more than 10,000 infected babies may be born annually [11]. During 2002 PMTCT interventions initiated in India, through free admittance to HIV diagnosis for each enrolled women with pregnancy in nearby antenatal clinics (ANC), administration of a dose of Nevirapine to pregnant women infected with HIV at the time of labour, subsequently also for their children instantly during birth. Free diagnosis of HIV has been made available through integrated counselling and testing centres (ICTCs) associated with ANCs at most government aided healthcare facilities [12]. From 2016 approximately 21 thousand ICTCs are available to offer free services to pregnant women, across India and most are attached with government aided healthcare facilities [13]. Objective of this PPTCT facilities is to prevent the perinatal transmission from a pregnant woman with HIV to her new-born. Programme involves counselling and testing of pregnant women. NACO in India, adopted the WHO recommendations ‘Option B’ [14] for pregnant women, changing from the a dose of Nevirapine to multi-antiretroviral drug prophylaxis strategy. Similarly, on 2013, in accord through WHO strategies [15] and endorsement obtained form national Technical Resource Group [16], NACO initiated to implement the further efficient “Option B+” PMTCT facility which have different constituents intended to improve the health of pregnant women and simultaneously check vertical HIV transmission. The constituents are: providing lifelong ART to each HIV infected woman with pregnancy to avoid vertical HIV transmission and for other added HIV prevention benefits, administration of nevirapine for 6 to 12 weeks to HIV-infected, breastfed children; with engagement and retention of mother and baby in postpartum care of HIV to enable ‘early infant diagnosis’ [17]. Meta-analysis on prevention of MTCT of HIV is scarce and only a solitary article [18] was reported in India context. To gain insight of the Indian scenario the present work of the systematic review and meta-analysis has been initiated on the MTCT of HIV with its correlates in India using accessible published evidence.

In India, transmission of HIV from mother to new-born, in terms of pooled prevalence is as high as 8.76% (95% CI; 5.76, 12.31). Present findings corroborate with published articles including report of NACO on the prevalence of HIV by MTCT in India [10, 13]. This level of MTCT of HIV is far from what the Indian National AIDS Control Program had planned to accomplish in near future [11]. There is a possibility that these carefully studied cohorts included for analysis are likely to better or worse than all the other hospitals and health centers that have not published their data. It is pretty obvious that the studies presented here are extremely likely to have lower transmission rates than all the unstudied populations.

A recent study in China reported lower prevalence of HIV through MTCT as 3.9% (95% CI; 3.2, 4.6%) [37]. Whereas, another work on South Africa reflects higher prevalence (14%) of parent to child transmission of HIV in children lower than 6 weeks with prevalence of 24% among the babies aged between 3 to 6 months [38]. On the other hand, similar study in Ethiopia showed prevalence of HIV by MTCT as 9.93% (95% CI: 7.29, 12.56), which is much closer to the present findings in India [19]. Major difference in prevalence of HIV through MTCT among advanced and emerging countries might be due to variations in the socio-demographic as well as economic profiles of life, availability of anti-retroviral drugs, coverage for health care system and health-seeking nature of the population [39]. Lower acceptance of PMTCT facilities in those days in India might be the cause of higher prevalence of HIV through MTCT [40]. Poor knowledge of HIV/AIDS or other sexual transmitted diseases (STD) among pregnant women, little knowledge on maternal care, psychological problems and community level issues (social taboo; fear to get identified) might be the common barriers for lower acceptance of PMTCT facilities [41]. Consequently, addressing discrete and public level barriers for lower acceptance of PMTCT facility is vital to decrease the higher frequency of HIV due to MTCT in India [42].

WHO recommended for the PMTCT interventions to afford ARV prophylaxis to the infants’ immediately after birth to 6–12 weeks of continuation [19, 43]. The duration of the administration of ARV to the new-borns depends on the status of ART to the HIV infected mothers [44]. The Nevirapine (NVP) prophylaxis was suggested for early 6 weeks duration for breast feeding infants and for 4 to 6 weeks of same ART prophylaxis for non-breastfeeding infants [45]. Meta-analysis of this review showed that children who didn’t obtain ARV prophylaxis at or after birth are more prone to be HIV-infected than a child who received ARV prophylaxis in time. Several studies also revealed importance of infant ARV prophylaxis to prevent HIV transmission from infected mother to her new-born babies [19, 46, 47]. Antiretroviral prophylaxis administrated to children can serve as both pre and post-exposure prophylaxis against HIV infection and it has a major role to protect new born baby from HIV infection [19, 48, 49]. Present analysis also revealed that pregnant women with HIV infection, who gave birth without proper medical care were more likely to have HIV positive child than pregnant women with HIV infection who were attended by competent medical technicians at any healthcare facilities. This is probably due to absence of proper PMTCT interventions simultaneously during labour and delivery for pregnant women who gave birth at home. It is known that children who were delivered without minimum healthcare facility are prone to HIV-infection from mother due to many harmful outdated practices, such as using common blade to amputating umbilical cord, placental blood adulteration, excision of the uvula, unintended practice of circumcision [10]. In contrast, interventions readily accessible at any health care facility includes the following of any normal contamination prevention procedure, following the progress of labour by partograph, application of ARV prophylaxis to make practices of harmless delivery for the HIV positive women who attended any public health care facility [49]. In India, generally women with HIV are advised for cesarean delivery, which can be carried out only through organized healthcare facility. For an elective cesarean operation, a three to 4 hours window is required to deliver interferences and also permit ART drugs to attain highest tighter in the maternal circulation. This time window may be varying according to the patient’s current health condition and the period of labour. For child birth, however, ART drugs are administered in established labour in the initial stage [50]. Studies performed in Africa and Europe similarly exhibit that a baby born through elective cesarean delivery can strongly prevent HIV transmission from mother [19, 38, 51, 52, 53].

For reduction in the prevalence HIV-positive child, application of PMTCT intervention (providing ART) at the time of pregnancy, during labour, child birth, and breastfeeding period is vital [53, 54]. Findings of this analysis highlighting that pregnant women with HIV infection and devoid of antiretroviral treatment are more prone to give birth of a child with HIV. It is estimated that without administration of antiretroviral treatment, 20 to 45% of new-borns may be affected with HIV globally [11, 13, 14, 19]. In contrast, antiretroviral drugs could reduce the viral load in mother, and hence lower the chance of HIV transmission [12, 13]. According to the WHO, ART interventions to the pregnant woman including her new-born could lower the chance of mother to child transmission of HIV less than 2% [16]. However, very young maternal age [31], HIV infected women, who didn’t avail antenatal care service [33], late admission or without admission of HIV infected infant for follow up in public health care system [34], small period of ART [26], lower maternal CD4 count [32], and low child birth weight (less than 2.0 kg in India) [32], inappropriate family planning (FP) [18, 19] may be the associate factors for MTCT of HIV in India, which warrants further research and surveillance. Also, the resulting attributes might be affected by other lurking variables, which are not stated in the present work [54, 55].

Indian AIDS control program has made progress in reducing HIV transmission from infected pregnant woman to her new-born babies though country is far away to achieve total elimination of MTCT of HIV. Intervention program strengthening early maternal ART, initiation of ARV prophylaxis of babies born to HIV infected mothers simultaneously institutional caesarian delivery might help in reducing MTCT HIV risk. However, at present more surveillance data are crucial to follow the development of PMTCT program.