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Approximately 130 000 infants acquire HIV annually despite global maternal antiretroviral therapy scale-up. We evaluated the potential clinical impact and cost-effectiveness of offering long-acting, anti-HIV broadly neutralizing antibody (bNAb) prophylaxis to infants in three distinct settings. We simulated infants in Côte d'Ivoire, South Africa, and Zimbabwe using the Cost-Effectiveness of Preventing AIDS Complications-Pediatric (CEPAC-P) model. We modeled strategies offering a three-bNAb combination in addition to WHO-recommended standard-of-care oral prophylaxis to infants: a) with known, WHO-defined high-risk HIV exposure at birth (HR-HIVE); b) with known HIV exposure at birth (HIVE); or c) with or without known HIV exposure (ALL). Modeled infants received 1-dose, 2-doses, or Extended (every 3 months through 18 months) bNAb dosing. Base case model inputs included 70% bNAb efficacy (sensitivity analysis range: 10-100%), 3-month efficacy duration/dosing interval (1-6 months), and $20/dose cost ($5-$100/dose). Outcomes included pediatric HIV infections, life expectancy, lifetime HIV-related costs, and incremental cost-effectiveness ratios (ICERs, in US$/year-of-life-saved [YLS], assuming a ≤ 50% GDP per capita cost-effectiveness threshold). The base case model projects that bNAb strategies targeting HIVE and ALL infants would prevent 7-26% and 10-42% additional pediatric HIV infections, respectively, compared to standard-of-care alone, ranging by dosing approach. HIVE-Extended would be cost-effective (cost-saving compared to standard-of-care) in Côte d'Ivoire and Zimbabwe; ALL-Extended would be cost-effective in South Africa (ICER: $882/YLS). BNAb strategies targeting HR-HIVE infants would result in greater lifetime costs and smaller life expectancy gains than HIVE-Extended. Throughout most bNAb efficacies and costs evaluated in sensitivity analyses, targeting HIVE infants would be cost-effective in Côte d'Ivoire and Zimbabwe, and targeting ALL infants would be cost-effective in South Africa. Adding long-acting bNAbs to current standard-of-care prophylaxis would be cost-effective, assuming plausible efficacies and costs. The cost-effective target population would vary by setting, largely driven by maternal antenatal HIV prevalence and postpartum incidence.

A Man with Redness of the Right EyeA 31-year-old man was evaluated because of redness and pain of the right eye. He was taking tecovirimat for mpox, which had been diagnosed 2 days earlier. A diagnosis was made.

Introduction The Spectrum/AIM model is used by national HIV programs and UNAIDS to prepare annual estimates of key HIV indicators. This article describes key updates to paediatric and adult models for the 2021 round of HIV estimates. Methods Potential updates to Spectrum arise due to newly available data, new analyses of existing data, and the need for new issues to be addressed. Updates are guided by experts through the UNAIDS Reference Group on Estimates, Modelling and Projections. Changes are tested and assessed for impact before being accepted into the final model. Results Spectrum tracks children living with HIV by CD4% for ages 0–4 and CD4 count for ages 5–14. Data from IeDEA treatment sites have been used to map the transition from CD4% to CD4 count at age 5. Breastfeeding patterns in sub‐Saharan Africa have been updated with the latest survey data and estimates of continuation on antiretroviral therapy (ART) with breastfeeding have been revised based on recent studies. Model assumptions about the CD4 counts of people who drop out of ART have been revised to account for CD4 count increases while on treatment. If available, monthly data on numbers on ART can now be used to estimate the effects of COVID‐19‐related disruptions during 2020. Conclusions These changes are intended to provide more accurate estimates of HIV burden. The effects of these changes on paediatric indicators are small except in countries with new surveys that might have updated patterns of breastfeeding. Changes to the adult model have little effect on total new infections. AIDS‐related deaths will be somewhat lower in countries that have data on ART drop out but might be increased by HIV care disruptions due to COVID‐19. The updated model uses newly available data to improve the estimation of paediatric and adult HIV indicators.

Although a growing body of evidence supports zero risk of sexual HIV transmission from a person with sustained virological suppression, known as U=U (undetectable equals untransmittable), data have been insufficient to determine whether this is also true for vertical HIV transmission. We conducted a systematic review and meta-analysis to quantify vertical transmission risk by maternal HIV viral load (mHVL) and to evaluate the applicability of U=U to perinatal and postnatal HIV transmission. In this systematic review and meta-analysis, we searched PubMed, Embase, Web of Science, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature, the WHO Global Health Library, and abstracts from the International AIDS Society Conference and the Conference on Retroviruses and Opportunistic Infections (2016–24) for studies published from Jan 1, 1989, to Dec 31, 2024, reporting the relationship between mHVL near birth (to estimate perinatal transmission risk by 6 weeks) or during breastfeeding (to estimate monthly postnatal transmission risk by mHVL within the past 6 months) and vertical transmission. We pooled risks of perinatal and postnatal transmission across prespecified mHVL categories. We also conducted comparative analyses to determine the adjusted relative risk (aRR) of transmission by mHVL using Poisson meta-regression. The protocol for this analysis is registered on the International Prospective Register of Systematic Reviews (PROSPERO; CRD42019146768). 147 studies were included in the analysis; 138 studies contributed to perinatal analyses and 13 studies contributed to postnatal analyses. Data on 82 723 mother–child pairs were included across all analyses. Pooled perinatal transmission risks were 0·2% (95% CI 0·2–0·3) with a mHVL of <50 copies per mL, 1·3% (1·0–1·7) with 50–999 copies per mL, and 5·1% (2·6–7·9) with ≥1000 copies per mL. aRRs of perinatal transmission were 6·3 (3·9–10·3) with a mHVL of 50–999 copies per mL and 22·5 (13·9–36·5) with ≥1000 copies per mL versus <50 copies per mL. In subgroup analyses, in five studies reporting on 4675 women receiving pre-conception antiretroviral therapy (ART) with a mHVL of <50 copies per mL near birth, there were zero (0%, 0·0–0·1) perinatal transmissions. Monthly postnatal transmission risks were 0·1% (0·0–0·4) with recent mHVL <50 copies per mL and 0·5% (0·1–1·8) with a mHVL of ≥50 copies per mL. Perinatal transmission with a mHVL of <50 copies per mL is ≤0·2% overall. Zero transmissions were observed among women receiving ART before pregnancy with a mHVL of <50 copies per mL near birth, supporting U=U in pregnancy and birth. Postnatal transmission was very low—but not zero—among women with a recent mHVL of <50 copies per mL. Current data, largely from studies lacking frequent mHVL monitoring or modern first-line ART regimens, are insufficient to assess U=U during breastfeeding. National Institutes of Health, WHO, and Massachusetts General Hospital.

Poor engagement in postpartum maternal HIV care is a challenge worldwide and contributes to adverse maternal outcomes and vertical transmission. Our objective was to project the clinical and economic impact of integrated postpartum maternal antiretroviral therapy (ART) and pediatric care in South Africa. Using the CEPAC computer simulation models, parameterized with data from the Maternal and Child Health-Antiretroviral Therapy (MCH-ART) randomized controlled trial, we evaluated the cost-effectiveness of integrated postpartum care for women initiating ART in pregnancy and their children. We compared two strategies: 1) standard of care (SOC) referral to local clinics after delivery for separate standard ART services for women and pediatric care for infants, and 2) the MCH-ART intervention (MCH-ART) of co-located maternal/pediatric care integrated in Maternal and Child Health (MCH) services throughout breastfeeding. Trial-derived inputs included: 12-month maternal retention in care and virologic suppression (SOC: 49%, MCH-ART: 67%), breastfeeding duration (SOC: 6 months, MCH-ART: 8 months), and postpartum healthcare costs for mother-infant pairs (SOC: $50, MCH-ART: $69). Outcomes included pediatric HIV infections, maternal and infant life expectancy (LE), lifetime HIV-related per-person costs, and incremental cost-effectiveness ratios (ICERs; ICER

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