{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T02:56:32Z","timestamp":1791428192236,"version":"4.3.3"},"reference-count":25,"publisher":"Wiley","issue":"6","license":[{"start":{"date-parts":[[2021,12,30]],"date-time":"2021-12-30T00:00:00Z","timestamp":1640822400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["HIV Medicine"],"published-print":{"date-parts":[[2022,7]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Objectives<\/jats:title><jats:p>Data on long\u2010term HIV\u2010free survival in breastfeeding, HIV\u2010exposed infants (HEIs) are limited. The National Evaluation of Malawi\u2019s Prevention of Mother\u2010to\u2010Child Transmission (PMTCT) Program (NEMAPP), conducted between 2014 and 2018, evaluated mother\u2010to\u2010child transmission (MTCT) and infant outcomes up to 24\u00a0months postpartum.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>We enrolled a nationally representative cohort of HEIs at 54 health facilities across four regional strata in Malawi and used multivariable Cox regression analysis to investigate the risk of adverse outcomes (HIV transmission, infant death and loss to follow\u2010up) to 24\u00a0months postpartum. Models, controlling for survey design, were fitted for the total cohort (<jats:italic>n<\/jats:italic>\u00a0=\u00a03462) and for a subcohort that received maternal viral load (VL) monitoring (<jats:italic>n<\/jats:italic>\u00a0=\u00a01282).<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>By 24\u00a0months, in 3462 HEIs, weighted cumulative MTCT was 4.9% [95% confidence interval (CI) 3.7\u20136.4%], 1.3% (95% CI 0.8\u20132.2%) of HEIs had died, 26.2% (95% CI 24.0\u201328.6%) had been lost to follow\u2010up and 67.5% (95% CI 65.0\u201370.0%) were alive and HIV\u2010free. Primiparity [weighted adjusted hazard ratio (aHR) 1.6; 95% CI 1.1\u20132.2; parity 2\u20133: weighted aHR 1.5; 95% CI 1.2\u20131.9], the mother not disclosing her HIV status to her partner (no disclosure: weighted aHR 1.3; 95% CI 1.1\u20131.6; no partner: weighted aHR 0.7; 95% CI 0.5\u20130.9), unknown maternal ART start (weighted aHR 2.0; 95% CI 1.0\u20133.9) and poor adherence (missed \u2265\u00a02\u00a0days of ART in the last month: weighted aHR 1.7; 95% CI 1.2\u20132.2; not on ART: weighted aHR 1.7; 95% CI 1.0\u20132.7) were associated with adverse outcomes by 24\u00a0months. In the subcohort analysis, risk of HIV transmission or infant death was higher among HEIs whose mothers started ART post\u2010conception (during pregnancy: weighted aHR 3.2; 95% CI 1.3\u20137.7; postpartum: weighted aHR 12.4; 95% CI 1.5\u201399.6) or when maternal viral load at enrolment was &gt;\u00a01000 HIV\u20101 RNA copies\/mL (weighted aHR 15.7; 95% CI 7.8\u201331.3).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Infant positivity and infant mortality at 24\u00a0months were low for a breastfeeding population. Starting ART pre\u2010conception had the greatest impact on HIV\u2010free survival in HEIs. Further population\u2010level reduction in MTCT may require additional intervention during breastfeeding for women new to PMTCT programmes. Pre\u2010partum diagnosis and linkage to ART, followed by continuous engagement in care during breastfeeding can further reduce MTCT but are challenging to implement.<\/jats:p><\/jats:sec>","DOI":"10.1111\/hiv.13209","type":"journal-article","created":{"date-parts":[[2021,12,31]],"date-time":"2021-12-31T05:14:18Z","timestamp":1640927658000},"page":"573-584","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["The National Evaluation of Malawi\u2019s PMTCT Program (NEMAPP) study: 24\u2010month HIV\u2010exposed infant outcomes from a prospective cohort study"],"prefix":"10.1111","volume":"23","author":[{"given":"Monique","family":"van Lettow","sequence":"first","affiliation":[{"name":"Dignitas International  Zomba Malawi"},{"name":"Dalla Lana School of Public Health University of Toronto  Toronto ON Canada"},{"name":"Nyanja Health Research Institute  Salima Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Beth A.","family":"Tippett Barr","sequence":"additional","affiliation":[{"name":"Nyanja Health Research Institute  Salima Malawi"},{"name":"US Centers for Disease Control and Prevention  Lilongwe Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joep J.","family":"van Oosterhout","sequence":"additional","affiliation":[{"name":"Dignitas International  Zomba Malawi"},{"name":"Department of Medicine College of Medicine University of Malawi  Blantyre Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erik","family":"Schouten","sequence":"additional","affiliation":[{"name":"Management Sciences for Health  Lilongwe Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreas","family":"Jahn","sequence":"additional","affiliation":[{"name":"Malawi Ministry of Health Department of HIV and AIDS  Lilongwe Malawi"},{"name":"International Training Education and Community Health (ITECH)  Lilongwe Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thokozani","family":"Kalua","sequence":"additional","affiliation":[{"name":"Malawi Ministry of Health Department of HIV and AIDS  Lilongwe Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew","family":"Auld","sequence":"additional","affiliation":[{"name":"US Centers for Disease Control and Prevention  Lilongwe Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rose","family":"Nyirenda","sequence":"additional","affiliation":[{"name":"Malawi Ministry of Health Department of HIV and AIDS  Lilongwe Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nellie","family":"Wadonda","sequence":"additional","affiliation":[{"name":"US Centers for Disease Control and Prevention  Lilongwe Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Evelyn","family":"Kim","sequence":"additional","affiliation":[{"name":"US Centers for Disease Control and Prevention  Lilongwe Malawi"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Megan","family":"Landes","sequence":"additional","affiliation":[{"name":"Dalla Lana School of Public Health University of Toronto  Toronto ON Canada"},{"name":"Nyanja Health Research Institute  Salima Malawi"},{"name":"Department of Family and Community Medicine University of Toronto  Toronto ON Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2021,12,30]]},"reference":[{"issue":"8","key":"e_1_2_9_2_1","first-page":"148","article-title":"Impact of an innovative approach to prevent mother\u2010to\u2010child transmission of HIV\u2014Malawi, July 2011\u2010September 2012","volume":"62","author":"Centers for Disease Control and Prevention","year":"2013","journal-title":"Morbidity and Mortality Weekly Report (MMWR)"},{"key":"e_1_2_9_3_1","doi-asserted-by":"publisher","DOI":"10.2471\/BLT.17.203265"},{"key":"e_1_2_9_4_1","doi-asserted-by":"publisher","DOI":"10.1097\/QAI.0000000000001357"},{"key":"e_1_2_9_5_1","doi-asserted-by":"publisher","DOI":"10.1097\/MD.0000000000008055"},{"key":"e_1_2_9_6_1","doi-asserted-by":"publisher","DOI":"10.7448\/IAS.20.1.21947"},{"key":"e_1_2_9_7_1","doi-asserted-by":"publisher","DOI":"10.1016\/S2352-3018(18)30316-3"},{"key":"e_1_2_9_8_1","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0100741"},{"key":"e_1_2_9_9_1","unstructured":"DinhTH MushaviA BalachandraS et al.Impact of option B+ and maternal HIV RNA viral load on mother to child HIV transmission: findings from an 18 month prospective cohort of a nationally representative sample of mother infant pairs Zimbabwe 2016\u20102017. Poster presented at: AIDS 2018. 22nd International AIDS Conference; 2018 July 23\u201027; Amsterdam the Netherlands"},{"key":"e_1_2_9_10_1","doi-asserted-by":"crossref","first-page":"576","DOI":"10.1093\/cid\/cix820","article-title":"Impact of timing of antiretroviral treatment and birth weight on mother\u2010to\u2010child human immunodeficiency virus transmission: findings from an 18\u2010month prospective cohort of a nationally representative sample of mother\u2010infant pairs during the transition from Option A to Option B+ in Zimbabwe","volume":"66","author":"Dinh T","year":"2018","journal-title":"CID"},{"key":"e_1_2_9_11_1","unstructured":"GogaA.Highest risk of mother\u2010to\u2010child transmission of HIV or death in the first 6 months postpartum: results from 18 month follow\u2010up of an HIV\u2010exposed cohort South Africa. 21st International AIDS Conference; Durban. 2016; abstract TUAE0106"},{"key":"e_1_2_9_12_1","unstructured":"Malawi Ministry of Health Clinical Management of HIV in Children and Adults \u2010 Malawi Integrated Guidelines for Providing HIV Services Department of HIV and AIDS Editor. 2011 Ministry of Health: Lilongwe. 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