Transmission of HIV from mother to child can occur in utero, during labor or after delivery via breast feeding. Data on the fate of babies born with HIV in India are scarce. We present details of 25 infants with perinatally acquired HIV infection (virologically confirmed) to highlight the observed high rate of morbidity and mortality within the first 18 months of life. Our findings of rapid disease progression among perinatally infected HIV positive children underline the importance of early diagnosis and treatment.

Keywords: HIV, India, Infant, Progression, Transmission.

This was a prospective, observational study conducted in Tuberculosis Research Centre (TRC) Clinics of Madurai and Chennai between March 2004 and June 2007. Infants born to HIV-1 positive women at Chennai and Madurai were referred to TRC for confirmation of diagnosis by DNA-PCR. 19 infants were referred to TRC Madurai unit while 6 were referrals from hospitals in Chennai. The study had Institutional Ethics approval and informed consent was obtained from a parent/guardian. Clinical examination including anthropometry was done and blood drawn for DNA-PCR and CD4/CD8 counts. CD4 and CD8 counts were measured on a Coulter Epics flow cytometer (Beckman Coulter, USA) using a standard 4-colour protocol. DNA-PCR was done using the Roche AMPLICOR HIV-1 DNA Test Version 1.5.

Detailed counseling was provided including the feeding options; however the choice was left to the mother. Babies were followed every 3 months, till 18 months of age. All babies were given cotrimoxazole 5mg/kg orally daily and opportunistic infections were managed appropriately. Diagnoses of opportunistic infections were based on clinical and disease specific criteria. Patients were referred to government ART centres in Madurai and Chennai but pediatric formulations became available only in November 2006 and most of these infants could not access ART, at the time of this study.

The baseline immunological profile and age at the time of presentation, sex, type of feeding, CD4 counts and CD4/CD8 ratio, status at the time of writing the report (October 2007) and cause of death are shown in Table I. The mean age at presentation was 154 days (SD 68). DNA-PCR was found positive in 21 infants at presentation. Four infants whose test was negative and CD4% was high at baseline, had a fall in CD4% along with a positive PCR at 6 months of age. All infants were delivered vaginally except one. Fourteen mother-infant pairs received nevirapine prophylaxis as per the prevention of mother to child transmission guidelines of National AIDS Control Organization. Eleven infants were breast-fed, 3 were artificially fed while nine were given mixed feeds. Feeding details for 2 infants were not known. All four infants who showed a later conversion of DNA-PCR to positive result were given mixed feeds.

TABLE I

Clinical and Immunological Features of 25 HIV Infected Infants

*CD4 at the time of registration (DNA-PCR found to be negative); 

** CD4 at the time of HIV suspicion (Repeat DNA-PCR found to be positive); NA–Not available; 

# LSCS; $ soon after ART initiation; FTT: Failure to thrive.

Twelve children died before 18 months of age. Five children received antiretroviral treatment, of whom 2 died and 3 are surviving. Of 20 children who did not receive ART, 10 died and 10 are under follow up. The most common diagnoses during the course of the disease are shown in Table I.

Of the 25 HIV-1 infected infants enrolled in this study, 10 died before antiretroviral treatment could be initiated and 2 died shortly after initiation of ART. This suggests that a substantial proportion of HIV-1 positive children infected perinatally in India are rapid progressors and will die in infancy unless diagnosed and treated early.

We observed that four children who initially had a CD4/CD8 ratio >1.0 and were later found to have a ratio <1.0 had become HIV positive. These infections are likely to have occurred due to breastfeeding. The practice of breastfeeding has been shown to diminish the long-term efficacy of perinatal prophylactic antiretroviral therapy(8). Two African studies have found that infants assigned to be formula fed or breastfed had similar mortality rates and incidence of diarrhea and pneumonia during the first 2 years of life. However, HIV-1-free survival at 2 years was significantly higher in the formula arm(9,10). Replacement feeding with animal milk or formula should be encouraged whenever it is acceptable, feasible, affordable, sustainable and safe. Our preliminary observation that the CD4/CD8 ratio can be used as a supporting diagnostic test for HIV-1 needs confirmation in controlled trials.

Contributors: NPGD and SS conceived and coordinated the study and drafted the manuscript. RS and SNR were involved in patient recruitment and follow-up and KR performed the laboratory investigations.

Funding: Indian Council of Medical Research.

Competing interests: None Stated.