High vertical HIV transmission rate in the Midwest region of Brazil

brazjinfectdis2018;22(3):177–185

w w w . e l s e v i e r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Original

article

High

vertical

HIV

transmission

rate

in

the

Midwest

region

of

Brazil

Vanessa

Terezinha

Gubert

de

Matos

_,

_Fabiani

_de

_Morais

_Batista

_,

Naiara

Valera

Versage

_,

_Clarice

_Souza

_Pinto

_,

_Vanessa

_Marcon

_de

_Oliveira

_,

Érica

Freire

de

Vasconcelos-Pereira

_,

_Roberta

_Barbeta

_dos

_Rios

_de

_Matos

_,

Márcia

Maria

Ferrairo

Janini

Dal

Fabbro

_,

_Ana

_Lúcia

_Lyrio

_de

_Oliveira

b_{UniversidadeFederaldoMatoGrossodoSul,HospitalUniversitárioMariaAparecidaPedrossian,ProgramadeResidência} MultiprofissionalemSaúde,CampoGrande,MS,Brazil

c_{DepartamentodeSaúdedoEstadodoMatoGrossodoSul,CampoGrande,MS,Brazil}

d_{UniversidadeFederaldoMatoGrossodoSul,FaculdadedeFarmácia,CampoGrande,MS,Brazil} e_{UniversidadeFederaldoMatoGrossodoSul,FaculdadedeAdministrac¸ão,CampoGrande,MS,Brazil} f_{DepartamentoMunicipaldeSaúde,CampoGrande,MS,Brazil}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received8February2018 Accepted2April2018 Availableonline9May2018

Keywords: Verticaltransmission HIV Diseaseprevention Antiretroviraltherapy Prenatalfollow-up Healthservices Socialenvironment

a

b

s

t

r

a

c

t

Objectives: ToestimateverticalHIVtransmissionrateinacapitalcityoftheMidwestregion ofBrazilanddescribethefactorsrelatedtotransmission.

Methods:A descriptive epidemiological study based on the analysisof secondary data fromtheNotifiableDiseasesInformationSystem(SINAN).Theanalysisconsideredall HIV-infectedpregnantwomenwithdeliveryinCampoGrande-MSintheyears2007–2013and theirHIV-exposedinfants.

Results:Atotalof218birthsof176HIV-infectedpregnantwomenwereidentifiedduringthe studyperiod,ofwhich187infantswereexposedanduninfected,19seroconverted,and12 werestillinconclusiveinJuly2015.Therefore,theoverallverticalHIVtransmissionratein theperiodwas8.7%.Most(71.6%)ofHIV-infectedpregnantwomenwerelessthan30years atdelivery,housewives(63.6%)andstudieduptoprimarylevel(61.9%).Prenatalinformation wasdescribedin75.3%ofthenotificationformsandapproximately80%ofpregnantwomen receivedantiretroviralprophylaxis.Amonginfants,86.2%receivedprophylaxis,butlittle morethanhalfreceiveditduringthewholeperiodrecommendedbytheBrazilianMinistry ofHealth.Amongtheexposedchildren,11.3%werebreastfed.

Conclusion: TheverticalHIVtransmissionratehasincreasedovertheyearsandthe rec-ommendedinterventionshavenotbeenfullyadopted.HIV-infectedpregnantwomenneed adequateprophylacticmeasuresinprenatal,intrapartumandpostpartum,requiringgreater integrationamonghealthprofessionals.

©2018SociedadeBrasileiradeInfectologia.PublishedbyElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/ by-nc-nd/4.0/).

∗ _{Correspondingauthor.}

E-mailaddress:vanessa.matos@ufms.br(V.T.Matos).

https://doi.org/10.1016/j.bjid.2018.04.002

1413-8670/©2018SociedadeBrasileiradeInfectologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

178

Introduction

ThedynamicsofHumanImmunodeficiencyVirus(HIV) infec-tionhavechangedovertime.Initiallyitsspreadwasidentified amongmenwhohadsexwithmen.Aftersometime,there was a pattern change with increased heterosexual trans-missionofHIVandthusincreasedincidenceofinfectionin women.Still,theidentificationofHIVinsmallcitiesand low-incomepopulationshowstheinfectionisnolongerrestricted toriskgroups,buttothoseunderriskbehavior.1

TheincreasingnumberofHIV-infectedwomen,especially ofchildbearingage,increasestheriskofchildrentobeinfected byverticaltransmission.2,3_{AcquiredImmunodeficiency}

Syn-drome (AIDS)incidencein childrenunderfive years isthe indicatorusedtomonitorverticalHIVtransmission.In1998, the Brazilianincidence rateof AIDSin childrenunder five yearswas 5.9/100,0004 _{and this ratereduced to2.8/100,000}

in2013.5 _{Muchofthisreductionwasduetotheavailability}

ofzidovudine, asitreducesbytwo-thirdsthe possibilityof HIVtransmissionduringpregnancyanddelivery.6_Other

pro-phylactic measures,such asantiretroviral therapy (ART)to theexposedinfant,cesareandelivery,replacementof breast-feedingbyartificialfeedingarepartofthecurrentprotocol recommendedbytheBrazilianMinistryofHealth.7

Forproperepidemiological surveillance,the reportingof casesofAIDSbeganin1986.8_{In2000,theBrazilianMinistryof}

HealthestablishedcompulsorynotificationofHIVinfectionin pregnantwomen,whosenotificationformalsocontemplated informationabouttheexposedinfants.9_{In2007,thejoint}

noti-ficationofpregnantwomenandnewbornswasdisconnected duetooperationaldifficultiesrelatedtotheplaceofcare.So, itwasestablishedaspecificnotificationtoolforexposed chil-drenandanother instrumentforHIVinfection inpregnant women.10

Despitealltheexistinginterventions,verticalHIV trans-missionisstillareality.Thus,the aimofthisstudy wasto estimateverticalHIVtransmissionrateinacapitalcityofthe MidwestregionofBraziland describethe factorsrelatedto transmission.

Material

and

methods

Studydesignandpopulation

This descriptive epidemiological study was based on the analysis of secondary data from the Notifiable Diseases InformationSystem(SINAN).Theanalysisconsideredall HIV-infectedpregnantwomenwithdeliveryinCampoGrande-MS intheperiodof2007to2013andtheirHIV-exposedinfants.

Allmothers includedinthe study haddocumented HIV infectionbeforeorduringpregnancy,atthetimeofadmission for delivery or while breastfeeding. Infections were docu-mentedbytheresultofpositiveserologyforHIV-1byELISA andconfirmed byindirect immunofluorescenceor Western Blottest.

To be considered infected, the exposed infant should haveapositivescreeningtest(ELISA)confirmedbyindirect immunofluorescenceor WesternBlot. Closing ofcaseswas possibleat12monthsforthoseinfantswhohadtworesultsof

anundetectableviralloadandnegativeresultforanti-HIV,or at18monthsforthosewhohadoneresultofanundetectable viralloadandnegativeanti-HIV.

TheverticalHIVtransmission ratewascalculated using numberofexposedchildrenwhoseroconvertedinthe numer-atorandthetotalnumberofHIV-positivepregnantwomenin theperiodinthedenominator,multipliedby100.

Datacollectionandanalysis

A database was organizedto collect informationregarding HIV-infectedpregnant women(education,race,occupation, ageatdelivery,prenatalcare,antiretroviralprophylaxis dur-ingpregnancyanddelivery,typeofdelivery)andtheirexposed infants(antiretroviralprophylaxis,weeksofprophylaxis,and breastfeeding). These epidemiological data were obtained fromnotificationformsofHIV-positivepregnantwomenand HIVexposedchildren.

Forpurposesofthisstudy,prenatalcarewasconsideredas anynumberofmedicalornursingappointmentsduring preg-nancy.Therecordofanybreastfeedingatanytimeandforany durationwasdefinedas“breastfeedingpresent”.Inaddition, infantanti-HIVpositivityordeathwithin60dayswasusedas criteriatodefinepossibleinfectioninuterus,while identifica-tionofinfectionafter60dayswasconsideredasintrapartum infection.TheidentificationofHIVinfectioninthebabyusing PCRwasnotperformed.

TheunivariateassessmentoftheassociationbetweenHIV infectionandageatdelivery,prenatalcare,antiretroviraluse during pregnancy and delivery, type of delivery, weeks of antiretroviralprophylaxistotheexposedinfant,and breast-feedingwereperformedusingthechi-squaretest.Multivariate logistic regression analysis, using the “Enter”method, was performedtoassesstheassociationbetweenthepresenceor absenceofinfectionandtheothervariablesassessedinthis study.Theresultsofthestatisticalanalysisarepresentedas

p-values,oddsratioand95%confidenceintervaloftheodds ratio.StatisticalanalysiswasperformedusingSPSS,version 22.0,consideringa5%significancelevel.

Ethicalaspects

ThestudywasapprovedbytheResearchEthicsCommitteein HumanBeingsoftheFederalUniversityofMatoGrossodoSul undertheCAAEnumber05705412.0.0000.0021.

Results

Onehundredandseventy-sixHIV-infectedpregnantwomen who delivered inCampo Grande-MSin the period of2007 to2013wereidentified,resultingin218births.Thenumber ofbirthsishigherthanthenumberofpregnanciesbecause somewomenhadmorethanonepregnancyintheperiod.Of totalbirths,187infantswereexposedtoHIVanduninfected, 19seroconvertedand12werestillinconclusivebyJuly2015. Thus,theoverallverticalHIVtransmissionrateintheperiod was8.7%,whilethetransmissionratein2007(0/2)and2008 (0/20)was0%,9.1%(2/22)in2009,10.5%(4/38)in2010,9.1% (4/44)in2011,12.5%(5/40)in2012and10.0%(4/40)in2013.

brazj infect dis.2018;22(3):177–185

179

Fig.1–DiagnosticstatusofHIV-exposedinfantsaccording totheyearofbirthandthenumberofHIV-infected

pregnantwomendiagnosedbeforebirth,from2007to2013.

ThehighestverticalHIVtransmissionrateandthelargest number of cases occurred both in Campo Grande in 2012 (Fig.1).Thewomen(34/176,19.3%)withmultiplepregnancies hadbothtwo(26/34,76.5%)andthree(8/34,23.5%)deliveries. Most (156/218, 71.6%) of HIV-infected pregnant women werelessthan30yearsoldatdelivery,housewives(112/176, 63.6%),pardo(83/176,47.2%)and white(58/176,33.0%),and studieduptoprimarylevel(109/176,61.9%).Two(1.1%)ofthem wereregistered asilliterateand onlyfive (2.9%)hadhigher education.Theageofmothersatdeliveryrangedfrom14to 43years(Table1).

Prenatalfollow-upwasperformedin185(84.9%) deliver-ies.Mostpregnantwomen(172/218,78.9%)usedantiretroviral therapy(ART), aswell as mostoftheir newborns(175/218, 80.3%).Amongthe38(17.4%)womenwhohadnotusedART duringpregnancy,12 (31.6%)had previousdiagnosis ofHIV infectionanddidnotundergoanyprophylaxis,10(26.3%)were diagnosedduring prenatal consultation, 10 (26.3%)became aware of their HIV positivity shortly before delivery, three (7.9%)deliveredundiagnosedforHIVinfection,andinthree pregnantwomen(7.9%)thereasonfornon-prophylaxisduring pregnancywasunknown.

According to the notification forms, 12 women who receivedARTduringpregnancy(12/172,6.9%)didnotreceive ART atdelivery. Among the mothers who reported having breastfed,tworeportedmixedfeeding(breastandbottle).

No prenatal care (OR 13.92; 95% CI, 3.98–48.73) and no antiretroviral prophylaxis (pregnancy, labor and exposed infant)weresignificantlyassociatedwithahigheroddsratio forHIVtransmission.Inthesameway,exposedinfantswho didnotreceive ART,receivedincompleteantiretroviral pro-phylaxisor werebreastfedwere morelikelytobeinfected. However,inmultivariatelogisticregression,onlytheexposed infantswho received incomplete antiretroviral prophylaxis weremorelikelytobeHIVinfectedthroughvertical transmis-sion.

From2007to2013,19casesofverticalHIVtransmission wereidentifiedinCampoGrande.Table2presentsthe epi-demiologicalandgestational characteristicsofHIV-infected mothers whose pregnancy resulted in transmissionof the

virus.Patient6wasaddictedtococainepasteandpatient13 wasaddictedtoinjectingdrugs.DespiteHIVdiagnosispriorto delivery,pregnantwomen6and17hadnoprenatalcare.

Itseemsthattechnicalandoperationalproblems involv-ingthehealthteamoccurredinthemanagementofpregnant woman7,whoseHIVinfectionhasnotbeenidentifiedbefore deliveryandinthemanagementofpregnantwoman12,who didnotreceiveantiretroviralprophylaxisduringlabor,despite being aware of herpositive serological situation. Pregnant woman 15didnotreceiveantiretroviral prophylaxisduring labor.

Table3presentsthecharacteristicsofHIV-exposedinfants infectedbyverticaltransmissionbetween2007and 2013in CampoGrande-MS.Althoughinfectionininfants3,6,9and 10wereclassifiedaspossiblyintrapartum,itispossiblethat infectionhadoccurredinutero.Likewise,child7hadpossibly intrapartuminfection becauseofthenucleicacid detection date,butasnoprophylacticmeasureforthepregnantwomen andforthechildwasused,theinfectionprobablyoccurredin utero.Furthermore,child9wasexposedtosyphilis.

Discussion

TheverticalHIVtransmissionrateinCampoGrande-MS dur-ing the periodof2007–2013was 8.7%.Itrepresents almost threetimes theBrazilianrateforthe period,whichranged between2.7%and 3.7%4 _{andwas almostfour timeshigher}

thantherateestimatedatCampoGrandebetween1996and 2001.2_{Also,itisfarfromtheMinistryofHealthrecommended}

rateof2%anditisalsohigherthantherateof6.3%identified inItajai,theBraziliancitywiththehighestHIVincidence.11

ThereductionofverticalHIVtransmissioninBrazilwas identifiedinmulticenterstudiessince1997,12–15 _butCampo

Granderesultsare similartothescenariooftheNorth and Northeast region of the country, where local studies have foundtransmissionratesof6.6%16and9.2%.17TheSoutheast rateswhich werecloseto3.0%18,19 _{roseagainand arecent}

studydescribedarateof5.1%.20 _{TheotherregionsofBrazil}

havebeensuccessfulinreducingthisrate,withadecreaseof 51.4%,49.2%,and40.0%,respectively,whencomparing2006 with2016.5_{HIVverticaltransmissionrateislessthanorequal}

to2.0%intheSouth.21,22

Theloweducational level18,23,24 _{andage atdeliveryless}

than30years4,8,20,25_{arecharacteristicsofHIV-infected}

preg-nant women in Campo Grande and other regions of the country.Unawarenessaboutprenatalcare,appropriatetype ofdeliveryandlactation,adequateprophylaxisduring preg-nancy, delivery and to the newborn point to a health surveillancesystemnotintegratedwithprimarycare.26

Ingeneral,theperiodbetween2007and2013was charac-terizedbylowprophylacticcoverageandlackofretentionof HIV-infectedwomeninhealthservices,withpregnantwomen whowereawareofbeingHIV-infectedandneverused prophy-laxis,pregnantwomenwhousedARTduringpregnancybut notatdelivery,exposedchildrenwhodidnotreceiveARTor receivedforaperiodshorterthanrecommendedbythe Min-istryofHealth.Thesefailuresareholdingbehindthegoalof achieving90.0%coverageateachstepofpreventionof

mother-180

Table1–PrenatalandpostnatalvariablesofHIV-infectedpregnantwomenwhogavebirthinCampoGrande-MSfrom2007to2013.

Variables Total(n=218) (%) Inconclusive cases(n=12) n(%) Infected infants (n=19)n(%) Non-infected infants (n=187)n(%) Univariate analysisORb (95%CIc₎ Multivariate analysisaORd (95%CI) Ageatdelivery 0.907 0.275 <30 156(71.6) 8(70.8) 14(9.5) 134(90.5) 1.07(0.37–3.11) 2.74(0.45–16.76) ≥30 60(27.5) 4(29.2) 5(8.9) 51(91.1) Ignored 2(0.9) 0(0.0) – 2 Prenatalcare <0.001 0.084 No 16(7.3) 1(8.3) 6(40.0) 9(60.0) 13.92(3.98–48.73) 11.91(0.72–197.84) Yes 185(84.9) 10(83.4) 8(4.9) 167(95.4) Ignored 17(7.8) 1(8.3) 5 11

ARTa_{duringpregnancy <0.001 0.699}

No 38(17.4) 4(33.3) 9(26.5) 25(73.5) 7.02(2.48–19.90) 0.60(0.05–7.89)

Yes 172(78.9) 8(66.7) 8(4.9) 156(95.1)

Ignored 8(3.7) 0(0.0) 2 6

ARTduringlabor <0.001 0.288

No 29(13.3) 1(8.3) 9(32.1) 19(67.9) 9.30(3.21–26.96) 2.67(0.44–16.26) Yes 175(80.3) 10(83.4) 8(4.8) 157(95.2) Ignored 14(6.4) 1(8.3) 2 11 Typeofdelivery 0.129 0.838 Vaginal 52(23.9) 3(25.0) 7(14.3) 42(85.7) 2.15(0.79–5.90) 0.81(0.10–6.25) Cesarean 162(74.3) 9(75.0) 11(7.2) 142(92.8) Ignored 4(1.8) 0(0.0) 1 3

ARTforexposedinfant <0.001 0.381

No 15(6.9) 1(8.3) 6(42.9) 8(57.1) 12.53(3.64–43.11) 2.99(0.26–34.74)

Yes 188(86.2) 11(91.7) 10(5.6) 167(94.4)

Ignored 15(6.9) 0(0.0) 3 12

DurationofARTforexposedinfant <0.001 0.019

Incompletetreatment 55(25.2) 3(25.0) 12(23.1) 40(76.9) 7.88(2.40–25.85) 8.92(1.43–55.55) Completetreatment 113(51.8) 4(33.3) 4(3.7) 105(96.3) Ignored 50(22.9) 5(41.7) 3 42 Breastfeeding 0.001 0.437 Yes 10(4.6) 0(0) 4(40.0) 6(60.0) 8.00(2.00–31.99) 0.21(0.00–10.47) No 192(88.1) 12(100) 13(7.2) 167(92.8) Ignored 16(7.3) 0(0.0) 2 14 a _{ART,antirretroviral.} b _{OR,oddsratio.} c _{CI,confidenceinterval.} d _{aOR,adjustedoddsratio.}

b r a z j i n f e c t d i s . 2 0 1 8; 2 2(3) :177–185

181

Table2–CharacteristicsofepidemiologicalandgestationalHIV-infectedmotherswhosepregnancyresultedintransmissionofthevirus,CampoGrande-MS,from2007 to2013.

Race Schooling Occupationat delivery

Ageat delivery

Yearof delivery

Prenatalcare HIVdiagnosis inrelationto

delivery

ARTa

pregnancy

ARTdelivery Typeof delivery

1 White Completeprimaryeducation Housewife 22 2009 Yes Prior Yes Yes Vaginal

2 White 5thto8thgradeincomplete Housewife 29 2009 Yes Prior No No Ign

3 Pardo CompleteHighSchool Freelancer 24 2010 Ignb _{Prior Ign Ign Vaginal}

4 Pardo CompleteHighSchool Technicalassistant 22 2010 Yes Prenatalcare Yes No Vaginal

5 Pardo Completeprimaryeducation Housewife 23 2010 Yes Prenatalcare Yes Yes Cesarean

6 Black 5thto8thgradeincomplete Prisoner 37 2010 No Prior No Yes Vaginal

7 Pardo Completeprimaryeducation Housewife 36 2011 Ign After No No Cesarean

8 White 5thto8thgradeincomplete Housekeeper 31 2011 Yes Prenatalcare Ign Ign Cesarean

9 White 5thto8thgradeincomplete Housewife 14 2011 Ign Prior No Yes Cesarean

10 Pardo 5thto8thgradeincomplete Housewife 29 2011 Yes Prior Irregular No Cesarean

11 White 5thto8thgradeincomplete Housewife 28 2012 No Delivery No Yes Cesarean

12 Pardo Completeprimaryeducation Saleswoman 28 2012 Yes Prior Yes No Vaginal

13 White CompleteHighSchool Housewife 30 2012 No Ign No No Cesarean

14 Black 5thto8thgradeincomplete Housewife 25 2012 Yes Prior Irregular Yes Cesarean

15 Pardo Complete4thgradefromPE Housewife 29 2012 No Delivery No No Vaginal

16 White Ign Ign 21 2013 No Delivery No No Cesarean

17 Black 5thto8thgradeincomplete Housewife 40 2013 No Prior No No Vaginal

18c _{Black Complete4thgradefromPE Housewife 24 2013 Yes Prior No Yes Cesarean}

19d _{Black Complete4thgradefromPE Housewife 24 2013 Yes Prior No Yes Cesarean}

a _{ART,antiretroviral.} b _Ign,Ignored. c _TwinI. d _TwinII.

182

Table3–CharacteristicsofHIV-infectedchildrenbyverticaltransmissionbetween2007and2013inCampoGrande-MS.

Sex Received ARTa Durationof ART(weeks) Breastfed 1sttest nucleicacid detection 2ndtest nucleicacid detection Probable momentof vertical transmission Death

1 Fb _{No Nouse N Notperformed Notperformed Intra-uterine At16days}

2 F No Nouse Y Detected Detected Intrapartum/breastfeeding No

3 Mc _Ignd _{Ign Ign Detected Detected Intrapartum No}

4 M No Nouse N Notperformed Notperformed Intra-uterine At6days

5 M Yes Lessthan3 N Notperformed Notperformed Intra-uterine At20days

6 M No Nouse N Detected Detected Intrapartum No

7 M No Nouse Y Detectede _Detectedf _{Intrapartum/breastfeeding At11months}

8 M Ign Ign Ign Notperformed Notperformed Intra-uterine At26days

9 M Yes 6 N Detected Detected Intrapartum No

10 M Yes 3to5 N Detected Detected Intrapartum No

11 F Yes Irregular N Detected Detected Intrapartum No

12 M Yes Lessthan3 N Detected Detected Intra-uterine No

13 F No Nouse Y Detected Detected Intra-uterine No

14 M Yes Lessthan3 N Detected Detected Intrapartum No

15 M Yes Lessthan3 N Detected Detected Intra-uterine No

16 M Ign Ign Y Detected Detected Intra-uterine No

17 M No Nouse N Notdetected Detected Intrapartum No

18 F Yes 6 N Detected Detected Intra-uterine No

19 M Yes 6 N Detectedg _Notperformedh _{Intra-uterine At3months}

a _{ART,antiretroviraltherapy.} b _F,female.

c _M,male. d _Ign,ignored.

e _{Testconductedat8months.} f _{Testconductedat10months.} g _{Testconductedat2months.}

brazj infect dis.2018;22(3):177–185

183

to-childtransmissioncascadetoward reducingverticalHIV transmission.27

Despitethe awarenessofHIV seropositivitysome barri-erslimitandleadtonon-useorinterruptionofprophylaxis. Suchbarriersinvolve the HIV-infectedpregnant women as theyareunwillingand/orunabletocomplywithmedical rec-ommendations, drug-drug interactions,dosages, history of psychiatrictreatmentand/ordruguse.28_{Therelationshipof}

thehealthprofessionalwiththeHIV-infectedpatientshould seekthe developmentofagood liaison,accompaniedbya welcomingposturetomeetspecificdemandsandthus encour-agepatient’sresponsibilityandparticipationinplanningand decidingabouttheirowntreatment.29,30_{Ontheotherhand,no}

self-careandlackofinterestoftheHIV-infectedmotherabout theirownhealthconditioncanbeextendedtohernewborn.31

TheBrazilianguidelinesfortheuseofARTinpregnancy indicatevaginaldeliveryonlyformotherswithviralloadlower than1000copies after34weeks.7,32 _{However,inpracticeit}

seemsdifficulttoensurethesafeperformanceofvaginal deliv-eries.Duetothisreason,itwasexpectedthatatleastthesame numberofpregnantwomenwhousedARTduringpregnancy wouldhavecesareandelivery.

Among the exposed children, 13.8% have not received antiretroviralprophylaxisorthisinformationwasunknown. Also,amongthosewhoreceivedprophylacticmedication,just over half receivedthe complete regimenrecommended by theBrazilianMinistryofHealth.Itisnecessarytoconsider thattheinfantisdependentonothersforanycare, includ-ing medication.Usually the mother isthe main person in chargeofadministeringtheART,buttheyreportthatthe non-acceptanceoftheirhealthcondition, feelingofguiltand/or fearofprejudice,preventsthemfromcorrectlyadministerART medicationtotheirexposedinfant.33

Fewaddictedtoillegaldrugswereidentifiedinthisstudy, but it is known that legal and sociocultural barriers pre-ventordiscourageaccesstoanduseofhealthservices.The removalofpunitivemeasuresinsuchcasesandthecreationof environmentsthatreducestigmaanddiscriminationand pro-tecthumanrightscouldcontributetoHIV-infectedpregnant womenandtheirexposedinfantstoreceiveprophylaxis.34

Exposure to syphilis, identified in the child who sero-converted,increasestheriskofHIVinfection,oncesexually transmittedinfectionsbreakthemucosalbarrierprotection andrecruitsensitiveimmunecellstothelocalinfection, facil-itatingHIVtransmission.23,35

Oncethechildhasbeenverticallyinfected,early identi-ficationisessential fortheinitiationofART,prophylaxisof opportunisticinfections,andmanagementofinfectious com-plications and nutritional disorders. Therefore, due to the monitoringofchildrenexposedtoHIVortheintentioninearly detectionofinfection,itisimportanttoperformthefirstviral loadcollectionbetweenfourtosixweeksoflife.Symptomatic infantscanhaveviralloadmeasuredatanytime.36_Despite

therecommendationsoftheBrazilianMinistryofHealth,most viralloadcountswereperformedorweredocumentedfrom thefourthmonthon.

Manymedicalandnon-medicaltechnologiesareavailable, includingfourHIVtestingduringpregnancy,butthesearenot properlyusedcausingpartialornoneprophylaxisforvertical transmission.7_{Inaddition,betterhealthsurveillanceservices}

articulatedwithprimarycarecouldovercomethesebarriers. By 2013, the STD/AIDSProgram ofCampoGrande and the CoordinationofPrimaryCarewereundertheresponsibility ofthesameMunicipalBoard.Eventhough,itwasnotpossible toobserveareductionofverticalHIVtransmission.

Thisstudy hadlimitationsasthequality ofinformation containedinthenotificationformsofHIV-infectedpregnant womenandtheHIV-exposedinfant,reflectedinthenumber ofignoreditems.Overloadingofnurseactivitiesatthe facil-itywheretheexposedinfantswerefollowedwasadifficulty totheclosureofthecases,alongwiththeabandonmentof monitoring.Theinvolvementofthepharmacistfromthe Spe-cializedCareService(SAE)inthereturnofmotherandexposed childrencouldcontributetosolvethisproblem.Further,the nucleicaciddetectionperformedatdifferenttimesmadeit hardertoidentifythetimeofinfection,disfavoringthe analy-sisofthisresult.

On the other hand, the lack of understanding of HIV-infectedpregnantwomenregardingtheconsequencesofHIV infection,thelackofcommitmentofthehealthteamtothe healthofthepopulationandtotheirprofessionitself,andthe deficiencyinthemonitoringofdrugusersandadolescentsby MentalHealthServicewerelimitationsinpreventingvertical HIVtransmissioninthatperiod.

TheverticalHIVtransmissionrateinCampoGrande-MS isincreasing overthe years.Theannual ratesofthe years 2007to2013representalmostthreetimestheBrazilianrate for the periodand was almost four times higherthan the rateestimatedbetween1996and2001.Itwasalsoobserved theinadequateprenatalfollow-upandlackofantiretroviral therapywhichsuggestthatrecommendationsoftheBrazilian STD/AIDSProgramtoreduceverticalHIVtransmissionarenot beingimplementedproperly.

Theevaluationofhealthservicesintegration,thequality ofbiomedicalinterventions aswell asthe impact of inter-ventionsonthesocialenvironmentshouldbeinvestigatedto try toreduceverticaltransmissionrate andeveneliminate mother-to-childtransmissionofHIV.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

r

e

f

e

r

e

n

c

e

s

1.BritoAM,CastilhoAC,SzwarcwaldCL.AIDSeinfecc¸ãopelo HIVnoBrasil:umaepidemiamultifacetada.RevSocBrasMed Trop.2000;34:207–17.

2.DalFabbroMMFJ,CunhaRV,PaniagoAMM,etal.Prospective studyonthepreventionofverticaltransmissionofHIVin CampoGrande,MatoGrossodoSul,Brazil,from1996to2001. BrazJInfectDis.2005;9:20–7.

3.RodriguesST,VazMJR,BarrosSMO.Transmissãoverticaldo HIVempopulac¸ãoatendidanoservic¸odereferência.ActPaul Enferm.2013;26:158–64.

4.BRASIL,MinistériodaSaúde,SecretariadeVigilânciaem Saúde,DepartamentodeDST,AidseHepatitesVirais.Boletim EpidemiológicoAIDSeDST,Brasília,anoIII,n.1,27aà52a semanasepidemiológicas–julhoadezembrode2013a01aà 26asemanasepidemiológicas–janeiroajunhode2014;2014.

184

Availablefrom:

http://www.aids.gov.br/system/tdf/pub/2014/73/boletim epidemiologicohivaids-2014.pdf?file=1&type=node&id= 73&force=1[accessed04.12.17].

5. Brasil,MinistériodaSaúde,SecretariadeVigilânciaem Saúde,DepartamentodeDST,AidseHepatitesVirais.Boletim EpidemiológicoAids–DST;2017.Availablefrom:

http://www.aids.gov.br/system/tdf/pub/2017/65093/boletim aids internet 0.pdf?file=1&type=node&id=65093&force=1

[accessed04.12.17].

6. ConnorEM,SperlingRS,GelberR,etal.Reductionof maternal-infanttransmissionofhumanimmunodeficiency virustype1withzidovudinetreatment.PediatricAIDS ClinicalTrialsGroupProtocol076StudyGroup.NEnglJMed. 1994;331:1173–80.

7. Brasil,MinistériodaSaúde,SecretariadeVigilânciaem Saúde.Protocoloclínicoediretrizesterapêuticaspara prevenc¸ãodatransmissãoverticaldeHIV,sífilise hep-atitesvirais.Brasília:MinistériodaSaúde;2017.Availablefrom:

http://www.aids.gov.br/system/tdf/pub/2015/57801/pcdttv02 2018web.pdf?file=1&type=node&id=57801&force=1[accessed 04.12.17].

8. Brasil,MinistériodaSaúde.Portarian◦542de22dedezembro de1986.Inclusãonarelac¸ãodedoenc¸asdenotificac¸ão compulsórianoterritórionacional(PortariaMinisterialn◦

608,de28deoutubrode1979)asífiliscongênitaeaaids. Brasília:Diário

OficialdaUnião,p.19827,Sec¸ão1,24dez;1986.Availablefrom:

http://www3.crt.saude.sp.gov.br/arquivos/arquivosbiblioteca crt/Portarian542de22dez86.pdf[accessed04.12.17].

9. Brasil,MinistériodaSaúde,GabinetedoMinistro.Portarian◦ 993de4desetembrode2000–AlteraaListadeDoenc¸asde Notificac¸ãoCompulsória.Brasília:DiárioOficialdaUnião,p. 28,Sec¸ão1,5set;2000.Availablefrom:

http://bvsms.saude.gov.br/bvs/saudelegis/gm/2000/prt0993 04092000.html[accessed04.12.17].

10.Brasil,MinistériodaSaúde,SecretariadeVigilânciaem Saúde,ProgramaNacionaldeDST/AIDS.NotaTécnican◦ 62/2007/GAB/UIV/PN-DST-AIDS/SVS/MS–Vigilância epidemiológicadascrianc¸asexpostasaoHIV.Brasília: MinistériodaSaúde;2007.Availablefrom:

http://www.aids.gov.br/system/tdf/legislacao/2007/-vigilancia epidemiologica/notatecnicandeg6207pdf20712.pdf?file= 1&type=node&id=50999&force=1[accessed04.12.17]. 11.DominguesRMSM,SzwarcwaldCL,SouzaPRB,LealMC.

PrenataltestingandprevalenceofHIVinfectionduring pregnancy:datafromthe“BirthinBrazil”study,anational hospital-basedstudy.BMCInfectDis.2015;15:1–11.

12.TessBH,RodriguesLC,NewellML,DunnDT,LagoTD. Breastfeeding,genetic,obstetricandotherriskfactors associatedwithmother-to-childtransmissionofHIV-1inSao PauloState,Brazil.SãoPauloCollaborativeStudyforVertical TransmissionofHIV-1.AIDS.1998;12:513–20.

13.VasconcelosALR,HamannEM.PorqueoBrasilaindaregistra elevadoscoeficientesdetransmissãoverticaldoHIV?Uma avaliac¸ãodaqualidadedaassistênciaprestadaa

gestantes/parturientesinfectadaspeloHIVeseus

recém-nascidos.RevBrasSaudeMaternInfant.2005;5:483–92.

14.BritoAM,deSousaJL,LunaCF,DouradoI.Trendsin maternal-infanttransmissionofAIDSafterantiretroviral therapyinBrazil.RevSaúdePublica.2006;40:18–22.

15.Menezes-SucciRC.Mother-to-childtransmissionofHIVin Brazilduringtheyears2000and2001:resultsofa multi-centricstudy.CadSaúdePublica.2007;23:S379.

16.deAndradeSD,SabidóM,MarceloMonteiroW,etal. Mother-to-childtransmissionofHIVfrom1999to2011inthe Amazonas,Brazil:riskfactorsandremaininggapsin preventionstrategies.PediatrInfectDisJ.2016;35:189–95.

17.GouveiaPAC,daSilvaGAP,AlbuquerqueMFPM.Factors associatedwithmother-to-childtransmissionofthehuman immunodeficiencyvirusinPernambuco,Brazil,2000–2009. TropMedIntHealth.2013;18:276–85.

18.MatidaLH,SantosNJS,RamosNA,etal.EliminatingVertical TransmissionofHIVinSãoPaulo,Brazil:progressand challenges.JAcquirImmuneDeficSyndr.2011;57:S164–70.

19.DelicioAM,MilanezH,AmaralE,etal.Mother-to-child transmissionofhumanimmunodeficiencyvirusinaten yearsperiod.ReprodHealth.2011;8:35.

20.BarbieriMM,vonLinsingenR,SbalqueiroRL,TristãoEG. Verticalmother-to-childHIVtransmissioninbabiesbornina tertiaryhospitalinsouthernBrazil.JMaternFetalNeonatal Med.2017;6:1–7.

21.HoffmannIC,SantosWM,PadoinSMM,BarrosSMO.A five-yearreviewofverticalHIVtransmissioninaspecialized service:cross-sectionalstudy.SaoPauloMedJ.

2016;134:508–12.

22.daRosaMC,LobatoRC,GoncalvesCV,etal.Evaluationof factorsassociatedwithverticalHIV-1transmission.JPediatr (RioJ).2015;91:523–8.

23.AcostaLMW,Gonc¸alvesTR,BarcellosNT.HIVandsyphilis coinfectioninpregnancyandverticalHIVtransmission:a studybasedonepidemiologicalsurveillancedata.RevPanam SaludPublica.2016;40:435–42.

24.AyalaALM,MoreiraA,FrancelinoG.Características socioeconômicasefatoresassociadosàpositividadeparao HIVemgestantesdeumacidadedosuldoBrasil.RevAPS. 2016;19:210–20.

25.PereiraGF,SabidóM,CarusoA,etal.HIVprevalenceamong pregnantwomeninBrazil:anationalsurvey.RevBrasGinecol Obstet.2016;38:391–8.

26.MirandaAE,PereiraGFM,AraujoMAL,etal.Avaliac¸ãoda cascatadecuidadonaprevenc¸ãodatransmissãoverticaldo HIVnoBrasil.CadSaúdePública.2016;32:e00118215.

27.MeloVH,MaiaMMM,CorreaJúniorMD,etal.Vertical transmissionofHIV-1inthemetropolitanareaofBelo Horizonte,Brazil:2006–2014.RevBrasGinecolObstet. 2018;40:59–65.

28.BritoAM,SzwarcwaldCL,CastilhoE.Fatoresassociadosà interrupc¸ãodetratamentoantirretroviralemadultoscom AIDS.RioGrandedoNorte,Brasil,1999–2002.RevAssocMed Bras.2006;52:86–92.

29.PaivaV,LemeB,NigroR,CaracioloJ.Lidandocomaadesão– aexperiênciadeprofissionaiseativistasnacidadedeSão Paulo.In:TeixeiraP,PaivaV,ShimmaE,organizadores.Tá difícildeengolir?Experiênciasdeadesãoaotratamento antirretroviralemSãoPaulo.SãoPaulo:NúcleodeEstudos paraPrevenc¸ãodaAIDS,UniversidadedeSãoPaulo.2000. Availablefrom:

http://nepaids.vitis.uspnet.usp.br/wp-content/uploads/2010/ 04/tadificil.pdf[accessed04.12.17].

30.GavinLA,WamboldrMZ,SorokinN,LevySY,WamboldtFS. Treatmentallianceanditsassociationwithfamily

functioning,adherence,andmedicaloutcomeinadolescents withseverechronicasthma.JPediatrPsychol.1999;24:355–65.

31.BarrosoLMM,GalvãoMTG.Avaliac¸ãodeatendimento prestadoporprofissionaisdesaúdeapuérperascom HIV/AIDS.TextoContextoEnferm.2007;16:463–9.

32.GarciaPM,KalishLA,PittJ,etal.Maternallevelsofplasma humanimmunodeficiencyvirustype1RNAandtheriskof perinataltransmission.WomenandInfantsTransmission StudyGroup.NEnglJMed.1999;341:394–402.

33.LevandowskiDC,CanavarroMC,PereiraMD,etal.

MaternidadeeHIV:revisãodaliteraturabrasileira(2000–2014). ArqBrasPsicol[Internet].2017;69:34–51.Availablefrom:

http://pepsic.bvsalud.org/scielo.php?script=sciarttext&pid= S1809-52672017000200004&lng=pt[accessed04.12.17].

brazj infect dis.2018;22(3):177–185

185

34.WHO.WorldHealthOrganization,UNAIDSandUNICEF. Towardsuniversalaccess:scalinguppriorityHIV/AIDS interventionsinthehealthsector:progressreport,2010. Availablefrom:

http://www.who.int/entity/hiv/pub/2010progressreport/ summaryen.pdf?ua=1[accessed04.12.17].

35.AdachiK,XuJ,YeganehN,etal.Combinedevaluationof sexuallytransmittedinfectionsinHIV-infectedpregnant womenandinfantHIVtransmission.PLOSONE. 2018;13:e0189851.

36.Brasil.MinistériodaSaúde.SecretariadeVigilânciaem Saúde.DepartamentodeDST,AidseHepatitesVirais. Protocoloclínicoediretrizesterapêuticasparamanejoda infecc¸ãopeloHIVemcrianc¸aseadolescentes.Brasília: MinistériodaSaúde,2017.Availablefrom:

http://www.aids.gov.br/system/tdf/pub/2017/64833/pcdt infantil 270917.pdf?file=1&type=node&id=64833&force=1