Risk Factors Associated with Mother-to-Child Transmission of HIV-1, Spontaneous Abortion and Infant Mortality in HIV-1 Infected Women in Burkina Faso: A Prospective Study

Background: Despite efforts to fight, HIV/AIDS mother-to-child transmission of HIV-1 (MTCT), as well as abortion and infant mortality, remains a problem in sub-Saharan Africa. Indeed, a low level of CD4 and a high viral load can be associated with these situations. The aim of this study was to determine the risk factors associated with the occurrence of MTCT, spontaneous abortion and infant mortality in HIV-1 infected women in Ouagadougou, Burkina Faso. This was a prospective study conducted from May 2014 to September 2017 and involved 423 HIV-1 infected women followed at Saint Camille Hospital in Ouagadougou, Burkina Faso. Sociodemographic data were collected through a questionnaire. The CD4 count and HIV-1 viral load were determined using respectively BD FACSCount and Abbott m2000rt instruments. Bivariate analysis and multinomial logistic regression were performed for associations with a significance threshold for p < 0.05. Results: The average age of women was 38.75 ± 7.98 years. Rates of MTCT, abortion and infant mortality were 16.31%, 30.49% and 34.75%, respectively. The number of pregnancies was associated with the number of infant deaths (p = 0.002). A correlation between the number of pregnancies and infant mortality was observed (p = 0.002) with a relatively high rate (28.6%) among women who had three pregnancies. In addition, marital status was associated with HIV-1 infection in infants (p = 0.042) and spontaneous abortion (p = 0.033). HIV-1 infected women with low CD4 counts (less than 350 cells/μL) and How to cite this paper: Soubeiga, S.T., Yonli, A.T., Compaore, T.R., Ouattara, A.K., Diarra, B., Obiri-Yeboah, D., Douamba, Z., Traore, L., Djigma, W.F. and Simpore, J. (2018) Risk Factors Associated with Mother-to-Child Transmission of HIV-1, Spontaneous Abortion and Infant Mortality in HIV-1 Infected Women in Burkina Faso: A Prospective Study. Journal of Biosciences and Medicines, 6, 12-21. https://doi.org/10.4236/jbm.2018.610003 Received: August 16, 2018 Accepted: October 8, 2018 Published: October 11, 2018 Copyright © 2018 by authors and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access S. T. Soubeiga et al. DOI: 10.4236/jbm.2018.610003 13 Journal of Biosciences and Medicines those with viral load more than 1000 copies/mL were about twice as likely to have an spontaneous abortion [OR (IC 95%): 2.50 (1.085 5.760); p = 0.03] and [OR (95% CI): 2.16 (1.043 4.505); p = 0.04]. Conclusions: The results of this study show the need to improve the treatment of HIV-1 infected women in order to restore CD4 levels and make viral load of HIV-1 undetectable.


Introduction
Human immunodeficiency virus type 1 (HIV-1) continues to affect many people worldwide despite prevention and antiretroviral therapy (ART). In 2016, 36.7 million (30.8 million -42.9 million) people was living with HIV/AIDS [1] in the world. In the same year, the number of women (15 years and older) and children (<15 years) infected with HIV-1 was estimated at 17.8 million (15.4 million -20.3 million) and 2.1 million (1.7 million -2.6 million) respectively [1].
In Burkina Faso, the rate of adherence of pregnant women to the prevention of mother-to-child transmission of HIV-1 (PMTCT) was 86.14% in 2015, still below the national target of 90%. In addition, the residual rate of MTCT decreased from 5.30% in 2014 to 4.95% in 2015 [2]. The MTCT of HIV-1 is always real because most of serodiscordant couples or those living with HIV-1 are sexually active and express the desire to have children [3] [4]. A combination of ARVs, elective cesarean, and abstinence from breastfeeding can significantly reduce MTCT [5]. When the HIV status of the pregnant woman is known, midwives can take precautions to avoid possible complications that may lead to transmission of the virus to the baby during delivery. Despite these preventive measures, some children may be infected either during pregnancy, childbirth or breastfeeding [6] [7] [8]. Several studies have shown that age, undetectable viral load, and high CD4 T-cell counts were associated with reproductive desire in couples living with HIV-1 [9] [10]. It should be noted that there are cases of spontaneous abortions and stillbirths due to complications that can be caused by HIV-1 infection [11] [12].
However, other studies have found that high viral load is a high risk factor for the loss of the baby in HIV-1 infected pregnant women [13]. In Burkina Faso, no study has yet been conducted about the association of risk factors related to desire for children, MTCT and infant mortality. Therefore, the objective of this study was to identify the risk factors for these complications in order to strengthen the prevention and treatment strategies in HIV-1 infected pregnant women and their children in Burkina Faso.

1) Type and period of study Journal of Biosciences and Medicines
It was a prospective study that took place from May 2014 to September 2017 at Saint Camille Hospital in Ouagadougou, Burkina Faso.

2) Study population
This study involved a cohort of 423 HIV-1 infected women followed at Saint Camille Hospital in Ouagadougou as part of the PMTCT strategy. Patients are selected according to HIV-1 status and availability of sociodemographic and clinical data. Data such as age, profession, marital status, number of infants HIV-1 positive, number of spontaneous abortions, number of children who died, and adherence to ART were collected through a questionnaire.
3) Determination of CD4 T cell count and HIV-1 plasma viral load Whole blood samples were taken in two EDTA tubes. The first tube was used for determination of CD4 T cell count using BD FACSCount (BD Dickinson, CA, USA) while the second tube was centrifuged at 5000 rpm for 5 minutes, to collect plasma that was used to quantify the HIV-1 plasma viral load on the Abbott m2000rt instrument (Abbott Laboratories, USA) according manufacturer's instructions.

4) Statistical data analysis
The data was analyzed using IBM SPSS software version 21.0. The Chi square test was used for comparisons. Bivariate analysis and multinomial logistic regression were used for the associations. The difference was considered statistically significant for p < 0.05.

5) Ethical considerations
This study has been approved by the Ethics Committee for Health Research in Burkina Faso (deliberation N˚2014-7-084). All participants gave their free and informed consent. Anonymity and confidentiality have been respected.

1) Sociodemographic and biological characteristics
In this study, the age of women was between 19 to 64 years with a mean age of 38.75 ± 7.98 years. Of them, 68.1% (288/423) were married and 52.5% (222/423) were illiterate.
The mean CD4 count was 449.98 ± 240.98 cell/μL. In this study, 40.4% of women had a CD4 count less than 350 cell/ µL while 44.7% had a plasma viral load more than 1000 copies/mL. Also, there was no association between the age of women and MTCT, spontaneous abortion and infant mortality ( Table 1).

Discussion
This study, conducted for the first time in Burkina Faso, showed a high rate of MTCT of 16.31%. This rate was significantly higher than the national rate of 4.95% reported in 2015 [2]. It also reported a spontaneous abortion rate of 30.49% and 34.75% of infant mortality rate for infant born from HIV-1 infected mothers.
In addition, the number of spontaneous abortions was significantly associated with the number of pregnancies. Indeed, the study showed that women who had at least four pregnancies had more than two spontaneous abortions. This means that as the number of pregnancies increases, the risk of spontaneous abortion is high. The high number of pregnancies is explained by the strong desire for reproduction in HIV-1 infected women [10]. A significant relationship was also found between marital status and number of abortions and number of children is quite high among women in general, including HIV-1 infected women [14].
The spontaneous abortion rate found in our study is very high, even   though these women are on highly active antiretroviral therapy (HAART). Indeed, some authors have reported that miscarriages, ectopic pregnancies and stillbirths are common among HIV-infected women (some of whom are on ART) compared to HIV-1-negative women [15] [16]. This is supported by other authors who have shown that HIV-1 infection in women is associated with an increased risk of adverse birth outcomes, even if they are on ART [17] [18] [19]. It Journal of Biosciences and Medicines should be noted that most HIV-infected women have been infected during their youth because of their active sex life and may have an unwanted pregnancy and decide to end it [20]. Studies have shown that HIV-1 infected pregnant women were four times more likely to lose their pregnancies than those who were not infected [21]. In this study, married women were about eleven times more likely to have a spontaneous abortion and had the highest number of spontaneous abortions. This could be explained by factors such as psychological weight when they are declared HIV-1 positive during pregnancy, discrimination, fear of giving birth to an infected child and lack of support from the husband. Moreover, our results showed that HIV-1 infected women with low CD4 counts (<350 cells/μL) and a viral load more than 1000 copies/mL are twice as likely to have a spontaneous abortion. Indeed, these two factors can influence the course of pregnancy. In Brazil, a study showed that the risks of complications was very high for the mother and the foetus, when the mother develops an opportunistic disease related to HIV-1 and when the CD4 T lymphocyte counts are less than 200 cell/μL [22]. A higher plasma viral load is a marker of disease severity in the mother, and has been associated with adverse birth outcomes [13] [19] [23]. That is why it is important to achieve the third objective 90 of UNAIDS in 2020 about the suppression of viral load because this will avoid certain risks of complications during pregnancy such as spontaneous abortion. The illiterate women in our study were about 14 times more likely to transmit HIV-1 infection to their baby. This could be explained by ignorance of ways of PMTCT and contraceptive methods. Our study showed a correlation between the number of pregnancies and the occurrence of death of children born from HIV-1 infected mothers. Indeed, those who had 3 pregnancies had the most two deaths of children. We did not find an association between the number of infant who died with age, the CD4 T cell count, and the viral load of mothers. In contrast, in the United States, one study reported that age, CD4 T-cell count, race/ethnicity of HIV-1-infected mothers were associated with childhood death [24]. In the same study, some children died from opportunistic infections (cytomegalovirus, liver disease, pneumonia, sepsis). But, it is important to note that since 2010, there has been a 33% decrease in new HIV-1 infections among children in West and Central Africa [1]. It can be expected that the recent ART guidelines of WHO, which recommend treatment for all HIV-infected persons, will be an important structural intervention for the elimination of mother-to-child transmission, and therefore zero HIV-1 infected children and zero death [25].
One of the limitations of our study is that we could not have information on whether or not the deceased children were on treatment, whether they had opportunistic infections or not, their age at death, which could have allowed us to deepen our analysis. Also, all women were on ART and most of them had good compliance.

Conclusion
This study identified risk factors associated with MTCT, spontaneous abortion