Time for Option B+? Prevalence and Characteristics of HIV Infection among Attendees of 2 Antenatal Clinics in Buea,Cameroon

Abstract

As countries consider a wider use of triple antiretroviral therapy (ART) in pregnancy, which in recent World Health Organization guidelines is called Option B+, this study sought to explore the potential implications of adopting Option B+ by characterizing HIV infection in pregnant women attending 2 semiurban antenatal clinics in Cameroon. In a descriptive cross-sectional study, consenting women were screened for HIV; positive samples were confirmed using an enzyme-linked immunosorbent assay test, and CD4 levels and HIV viral loads were determined using flow cytometry and reverse transcription–polymerase chain reaction, respectively. The seroprevalence of HIV in the 407 pregnant women screened was 8.4% (95% confidence interval: 5.9%-11.5%). The majority (82.4%) of HIV-positive women had CD4 counts >350 cells/mm³. A quarter (25%) had undetectable viral levels (<80 copies/mL). Adopting Option B+ in this setting would result in a 5-fold increase in the number of HIV-infected pregnant women being placed on lifelong triple ART.

Keywords

HIV pregnancy CD4 viral load Cameroon

Introduction

In 2010, the World Health Organization (WHO) published revised guidelines on the management of HIV in adults (including pregnant women) and adolescents,¹ as well as on the prevention of mother-to-child transmission (PMTCT) of HIV infection.² The 2010 revised guidelines for PMTCT of HIV infection recommended 2 options for antiretroviral (ARV) prophylaxis in pregnant women: Option A (ARV prophylaxis for HIV-infected pregnant women with CD4 counts >350 cells/mm³) and Option B (antiretroviral therapy [ART] for those with CD4 counts ≤350 cells/mm³).

Despite significant efforts that the international community has made toward reducing the cost of ARVs, a recent update published in 2012 by the WHO estimated that Option B was about 2 to 5 times more costly than Option A,³ explaining why Option A has been adopted by many resource-limited countries. Recent developments in the field of PMTCT have led to the advent of a new third option (Option B+) that advocates the maternal administration of ART for life irrespective of the CD4 counts.^3,4 There is now a global advocacy and trend toward the universal adoption of Option B+ to meet the changes in the context and expectations of PMTCT programs such as the goals to eliminate pediatric HIV infections,⁵ new evidence to support ARV treatment as HIV prevention,⁶ and the decreasing cost of ARV drugs,⁷ among others.

Although the prevalence of HIV in Cameroon has significantly decreased over the years,⁸ by the end of 2012 HIV still remained a major public health problem with current prevalence rates of 4.3% and 7.9% in the general population and in pregnant women, respectively.⁹ With the constantly changing epidemiology of the HIV infection and with Option B+ being considered for adoption in Cameroon, we conducted this study to understand the prevalence and characteristics of maternal HIV infection, which are crucial in supplying adequate information with respect to the shift to Option B+ in our context. Since many pregnant women in our context are likely to have been infected around the period of conception or during the course of the current pregnancy, we hypothesized that the CD4 counts in this group of pregnant women would be greater than 350 cells/mm³.

Methods

Ethical Considerations

Conducted as part of a larger project aimed at studying mother-to-child transmission of HIV in Buea, Tiko, and Limbe, Cameroon, this study received ethical and administrative approval from the Cameroon National Ethics Committee and the South West Regional Delegation for Public Health, respectively. Participation was strictly based on providing written consent. Participants faced no added risk from participating in the study, and relevant results were handed over to the participants’ care providers for appropriate management.

This article was written following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for the reporting of observational studies.¹⁰

Study Design and Setting

Buea, the capital of the southwest region of Cameroon, is a semiurban community that comprises about 200 000 inhabitants of multiple ethnicities. Following the founding of the University of Buea in 1992, the town experienced an increase in its population, which is now comprised essentially of adolescents and young adults who come for higher education. The town was reputed for having one of the highest prevalences of HIV infection among pregnant women attending antenatal care (ANC) clinics in Cameroon between 2000 and 2002.¹¹

The population of the town of Buea is served by the Buea Regional Hospital (BRH) and a number of integrated health centers that, respectively, occupy the intermediate and peripheral levels on the pyramid of organization of the health care delivery system in Cameroon. We conducted an observational descriptive cross-sectional study among pregnant women receiving ANC services in 2 ANC clinics in the town. The choice of these 2 health facilities was driven by convenience as they had the highest attendance by pregnant women in the study area.

Participants and Sampling

Study participants were recruited from the ANC clinics of the BRH and the Buea Road Health Center simultaneously from July 19 to September 14, 2010. To be eligible, participants must have been at least 20 years old, pregnant, and voluntarily given written informed consent. Exclusion was based on an indeterminate HIV serology or the expressed wish to withdraw from the study. Participants were selected by convenience and consecutive sampling. Recruitment was pursued until a sample size of 407 was achieved. We used a sample size of 407 as it was required by the larger project on baseline studies of HIV in pregnancy.

Data Collection, Variables, and Measurements

Data collection was done using a structured questionnaire that was investigator administered. Information about the demographic and obstetrical characteristics as well as HIV serology, CD4 count, and HIV viral load was recorded.

After obtaining informed consent, 6 mL of venous blood was drawn for HIV serology testing and for determining the CD4 count and HIV viral load. Following the respective manufacturers’ instructions, HIV serology testing was done using Determine HIV 1/2 (Abbott GmbH Diagnostika, Wiesbaden, Germany) and SD Bioline HIV 1/2 3.0 (Standard Diagnostics Inc, Kyonggi-do, Korea) rapid immunodiagnostic assays, and positive samples confirmed with the Murex HIV Ag-Ab Combination (Abbott GmbH Diagnostika) enzyme-linked immunosorbent assay. CD4 count was determined by flow cytometry using the PartecCyflow Counter (Partec GmbH, Gorlitz, Germany), and HIV viral load was determined by polymerase chain reaction (PCR) using the automated Abbott Real Time HIV-1 m2000rt and m2000sp Assay (Abbott Molecular, Wiesbaden, Germany).

Data Management and Statistical Analysis

The collected data were entered into an electronic database using the statistical software package EpiInfo 3.5.3 (US Centers for Disease Control and Prevention [CDC], Atlanta, Georgia). Data analysis was done using EpiInfo 3.5.3 (CDC), MedCalc 12.3.0 (MedCalc Software, Mariakerke, Belgium), and Microsoft Excel 2010 (Microsoft Corporation, Redmond, Washington). Data organization was done by means of distribution tables and bar charts. Data were summarized using means, medians, and ranges for continuous variables and proportions and frequencies for categorical variables.

Results

Demographic and Obstetrical Characteristics

The demographic characteristics of the participants are summarized in Table 1. The majority (35.9%) of the participants were in the 25- to 29-year age-group, and more than half (63.1%) were married. The sample was fairly educated, as close to half (43.2%) of the participants had completed secondary school education. More than half (64.4%) of the participants had some form of employment (either self-employed or working for an employer).

Table 1.

Demographic Characteristics of 407 Pregnant Women Who Responded to a Survey on HIV Infection in Buea, Cameroon.^a

Category	Study Sample, N = 407
Category	Frequency	Percentage
Age, y
<20	29	7.1
20-24	125	30.7
25-29	146	35.9
30-34	79	19.4
35-39	24	5.9
≥40	3	0.7
Marital status
Married	257	63.1
Unmarried	144	35.4
Other^b	2	0.5
Level of education^c
None	2	0.5
Primary	117	28.7
Secondary	176	43.2
Tertiary	107	26.3
Employment status
Unemployed^d	143	35.2
Employed^e	262	64.4

Abbreviation: GCE, General Certificate of Education.

^a Some totals may not sum up to 407 because of missing data resulting from nonresponse.

^b Widow, divorced, or cohabiting.

^c Primary education = first school leaving certificate; secondary education = GCE O′- and/or A′-level certificate; tertiary education = university certificate or equivalent.

^d Includes housewives and students.

^e Includes those self-employed or working for an employer.

The obstetrical characteristics of participants are summarized in Table 2. Less than half (41.3%) of the participants were attending ANC visits for the first time in the current pregnancy. Most (59.7%) of the study population had a maximum of 2 pregnancies, and close to half (47.2%) of them were nulliparous. About half (47.4%) of them were in the third trimester.

Table 2.

Obstetrical Characteristics of 407 Pregnant Women Who Responded to a Survey on HIV Infection, in Buea, Cameroon.^a

Category	Study Population, N = 407
Category	Frequency	Percentage
First consultation
Yes	168	41.3
No	239	58.7
Gravidity
1-2	243	59.7
3-4	129	31.7
≥5	33	8.1
Parity
0	192	47.2
1-2	155	38.1
3-4	50	12.3
≥5	2	0.5
Gestational period
First trimester	11	2.7
Second trimester	180	44.2
Third trimester	193	47.4

^a Some totals may not sum up to 407 because of missing data resulting from nonresponse.

HIV Seroprevalence

The proportion of HIV-infected participants was 8.4% (95% confidence interval: 5.9%-11.5%); the majority (70.6%) were HIV-1 infected. None of the participants was infected with both HIV-1 and HIV-2. Of the HIV-sero-positive participants, the majority (32.4%) were in the 25- to 29-year age-group, half (50%) were married, about two-thirds (61.8%) were employed, and more than half (52.9%) were in the third trimester of the gestation period (see Table 3). Furthermore, the majority (41.2%) were attending antenatal consultation for the very first time in the current pregnancy, and most (35.3%) were nulliparous. Of the 407 participants, 5.3% (n = 20) disclosed their serostatus as positive, of which 10% were on combinational ART before enrollment in this study.

Table 3.

Demographic and Obstetrical Characteristics of 34 HIV-Infected Pregnant Women Who Responded to a Survey in Buea, Cameroon.^a

	Study Population, N = 34
	Number HIV Positive	Percentage HIV Positive
Age, y
<20	1	2.9
20-24	7	20.6
25-29	11	32.4
30-34	10	29.4
35-39	5	14.7
≥40	0	0
Educational level^e
None	1	2.9
Primary	11	32.4
Secondary	16	47.1
Tertiary	6	17.6
Marital status
Unmarried	16	47.1
Married	17	50
Other^b	1	2.9
Employment status
Unemployed^c	7	20.6
Student	6	17.6
Employed^d	21	61.8
Gestational period
First trimester	1	2.9
Second trimester	13	38.2
Third trimester	18	52.9
Number of pregnancies
1-2	16	47.1
3-4	13	38.2
≥5	5	14.7
Number of children born alive
None	12	35.3
One	9	26.5
Two	5	14.7
Three	7	20.6
≥Four	0	0.0
First antenatal consultation
Yes	14	41.2
No	20	58.8

Abbreviation: GCE, General Certificate of Education.

^a Some totals may not sum up to 34 because of missing data resulting from nonresponse.

^b Widow, divorced, or cohabiting.

^c Includes housewives.

^d Includes those self-employed or working for an employer.

^e Primary education = first school leaving certificate; secondary education = GCE O′- and/or A′-level certificate; tertiary education = university certificate or equivalent.

CD4 Enumeration

The CD4 counts ranged from 249 to 988 cells/mm³. The mean CD4 count was 546 (±179) cells/mm³. The vast majority (82.40%) of the participants had CD4 counts >350 cells/mm³ (Figure 1).

Figure 1.

Distribution of CD4 count of 34 pregnant women sero-positive for HIV, in Buea, Cameroon.

HIV Viral Load Determination

The viral load determination had a success rate of 82.4%. The viral load ranged from 2.71 log₁₀ to 5.95 log₁₀ copies/mL (508-891 004 copies/mL) with a mean viral load of 4.93 log₁₀ copies/mL (85 979 copies/mL). A quarter (25%) of the samples had undetectable viral load levels (<80 copies/mL). Most (27.3%) of the sero-positive participants had viral load levels ranging between 3.50 log₁₀ and 3.99 log₁₀ copies/mL (3162-9772 copies/mL). Of the participants who were on ARV drugs before enrollment, 72.7% had viral load levels >5000 copies/mL.

Discussion

In this study, we find that the prevalence of HIV in pregnancy remains high in antenatal clinics in Buea, Cameroon. Furthermore, although a vast majority had CD4 counts >350 cells/mm³, the viral load levels remained high, suggesting a considerable risk of transmission to their infants if these women did not receive ARV regimens. Our findings were similar to other reports from sub-Saharan countries, which showed that the prevalence of HIV among pregnant women is still high despite the efforts that are being made to prevent new infections.^12–14 Pregnant women who were married, employed, or had completed at least secondary school education were most likely to be HIV positive. However, our findings indicated that the prevalence of HIV among pregnant women in Buea has shown a significant drop since the last estimate in 2002.¹¹ Our findings also revealed that the majority of the sero-positive participants were infected with HIV-1, a similar finding from other reports in Cameroon, which demonstrated that HIV-1 is the predominant type in the country.^15,16

The mean CD4 count of 546 (±179) cells/mm³ was similar to those obtained from studies in Yaoundé, Cameroon,¹⁷ and North-Rift, Kenya.¹² The relatively high mean CD4 count in the majority of the sero-positive participants may be indicative of recent HIV infection. Most of the HIV-infected participants had CD4 counts >350 cells/mm³, which confirmed our hypothesis. According to the WHO 2010 guidelines for ARV prophylaxis in pregnancy, these sero-positive participants would be eligible for ARV prophylaxis with either Option A or B. However, with Option B+, all HIV-sero-positive pregnant women would be placed on lifelong ART. If this is true, this will certainly demand a significant increase in financial resources for the provision of combinational ART, especially in a resource-limited country like Cameroon, where over 60% of all the funding for the fight against HIV was from international donors.⁹

The mean viral load (at log₁₀ 4.4 copies/mL) was similar to that reported by Njom Nlend in 2011 in Yaoundé.¹⁷ We found that 7 of 10 sero-positive pregnant women who were on ARVs before enrollment were experiencing virological failure. This finding poses a significant obstacle in the management of sero-positive pregnant women, especially as viral load testing still remains a scarce and expensive laboratory examination in this part of the world.

These findings are confined to a sample of semiurban pregnant women who attended ANC clinics in 2 health facilities, thus limiting their generalizability to the whole of Cameroon. Moreover, participants who could have been in seroconversion may have been missed out because only sero-positive samples were tested for the presence of viral RNA by the PCR technique for viral load determination.

Conclusion

Generally, our findings indicate that HIV is still prevalent among pregnant women attending ANC clinics in the town of Buea. Most of the sero-positive pregnant women, as for now, are not receiving ART with respect to the 2010 WHO guidelines (as directed by their CD4 counts) for managing HIV infection in pregnant women in order to prevent transmission of the virus from mother to infant. Also, about 7 of 10 sero-positive pregnant women receiving ARVs in Buea are likely to be experiencing virological failure with the current medications. Further studies would be necessary to appreciate the feasibility of adopting Option B+ for PMTCT in Cameroon.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was part of a project on baseline studies of mother-to-child transmission of HIV in Buea, Limbe, and Tiko, supported by a grant from the European and Developing Countries Trial Partnership (EDCTP) to the Central African Network against Tuberculosis, AIDS and Malaria (CANTAM).

References

WHO. Antiretroviral Therapy for HIV Infection in Adults and Adolescents: Reccommendations for a Public Health Approach. Geneva, Switzerland: WHO Press; 2010.

WHO. Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants: Recommendations for a Public Health Approach. Geneva, Switzerland: WHO Press; 2010.

WHO. Programmatic Update: Use of Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infections in Infants. Geneva, Switzerland: WHO Press; 2012.

Coutsoudis

Goga

Desmond

Barron

Black

Coovadia

. Is Option B+ the best choice? Lancet. 2013;381(9863):269–271.

UNAIDS. Count Down to Zero: Global Plan for the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive, 2011-2015. Geneva: UNAIDS; 2011.

Cohen

Chen

McCauley

. Prevention of HIV-1 with early antiretroviral therapy. NEJM. 2011;365(6):493–505.

WHO. Transaction Prices for Antiretroviral Medicines and HIV Diagnostics From 2008 to July 2011: Global Price Reporting Mechanism, GPRM, October 2011. Geneva, Switzerland: WHO Press; 2011.

Mbanya

Sama

Tchounwou

. Current status of HIV/AIDS in Cameroon: how effective are control strategies? Int J Environ Res Public Health. 2008;5(5):378–383.

NACC/CTG. Rapport national de suivi de la declaration politique sur le VIH/SIDA Cameroun. Yaounde, Cameroon: Ministry of Public Health; 2012.

10.

Vandenbroucke

von Elm

Altman

. Strengthening the reporting of observational studies in epidemiology (STROBE): explanation and elaboration. PLoS Med. 2007;4(10):1628–1654.

11.

WHO. Epidemiological Fact Sheet on HIV and AIDS: Core Data on Epidemiology and Response, Cameroon: 2008 Update. Geneva, Switzerland: World Health Organization ; 2008.

12.

Kiptoo

Mpoke

Ng'ang'a

Mueke

Okoth

Songok

Survey on prevalence and risk factors of HIV-1 among pregnant women in North-Rift, Kenya: a hospital-based cross-sectional study conducted between 2005 and 2006. Int Health Hum Rights. 2009;9(10):1–6.

13.

Msuya

Mbizwo

Hussain

Uriyo

Sam

Stray-Pedersen

. HIV among pregnant women in Moshi Tanzania: the role of sexual behaviour, male partner characteristics and sexually transmitted infections. AIDS Res Ther. 2006;3(27):1–10.

14.

Etukumana

Thacher

Sagay

. HIV risk factors among pregnant women in a rural Nigerian hospital. West Indian Med J. 20 10;59(4):424–428.

15.

Vallari

Bodelle

Ngansop

. Four new HIV-1 group N isolates from Cameroon: prevalence continues to be low. AIDS Res Hum Retroviruses. 2010;26(1):109–115.

16.

Ndembi

Takehisa

Zekeng

. Genetic diversity of HIV type 1 in rural eastern Cameroon. J Acquir Immune Defic Syndr. 2004;37(5):1641–1650.

17.

Njom Nlend

Ekobo

Ndiang Moyo

. Virological profile of pregnant HIV positive women with high levels of CD4 count in low income settings: can viral load help as eligibility criteria for maternal triple ARV prophylaxis (WHO Option B)? Pan Afr Med J. 2011;10(27):1–4.