Orıgınal Article PEDIATRICS

North Clin Istanb 2021;8(3):243–248

doi: 10.14744/nci.2021.59013

Evaluation of infants with HIV-infected mothers and

perinatal transmission in Turkey: A single-center
experience

Nurhayat Yakut, Eda Kepenekli

Division of Pediatric Infectious Diseases, Department of Pediatrics, Marmara University Faculty of Medicine, Istanbul, Turkey

ABSTRACT
OBJECTIVE: The most common route of HIV infection in children is through perinatal transmission. In this study, we aimed
to evaluate the characteristics of infants with HIV-infected mothers and perinatal HIV transmission.
METHODS: We conducted a retrospective, single-center study of HIV-exposed infants in between December 2017 and Oc-
tober 2019 in a Marmara University Pendik Training and Research Hospital.
RESULTS: A total of 18 infants were examined. All babies were born by cesarean section, and none of them were breastfed.
Seventeen mothers were diagnosed with HIV before pregnancy. These mothers had received antiretroviral therapy (ART)
during pregnancy, and their viral loads before delivery were negative. An antiretroviral prophylaxis with oral zidovudine was
started in all infants within their 1st day of birth and continued for at least 6 weeks. All infants were tested for their HIV viral
load within the first 48 h of birth, with negative results, and 12 infants were tested for anti-HIV antibodies at the 18th month,
again with negative results. In this study, we determined that none of the infants had been infected with HIV.
CONCLUSION: Our findings highlight the importance of initiating ART for all HIV-infected pregnant women and the
importance of protection modalities during pregnancy, delivery, and the postnatal period for the prevention of perinatal
transmission of HIV.
Keywords: Children; HIV; infection; perinatal transmission; Turkey.

Cite this article as: Yakut N, Kepenekli E. Evaluation of infants with HIV-infected mothers and perinatal transmission in Turkey: A single-
center experience. North Clin Istanb 2021;8(3):243–248.

A ccording to data from the Joint United Nations

Program on HIV/AIDS (UNAIDS), 36.7 mil-
lion people worldwide are infected with HIV and 1.8
children living with HIV infection worldwide [3].
Pediatric HIV infection can occur during pregnancy,
delivery, or breastfeeding. The rate of transmission
million are newly diagnosed [1]. The first AIDS case without intervention ranges from 15% to 35% [4, 5].
was reported in Turkey in 1985. The Turkish Ministry However, perinatal transmission of HIV can be pre-
of Health reports that in Turkey, there are 21,988 pa- vented by taking precautions in the perinatal period,
tients with a diagnosis of HIV or AIDS and that 718 and the probability of transmission can be reduced
of these people are children or adolescents [2]. Peri- to below 2% with plasma HIV viral load suppression
natal transmission, also known as vertical or mother- [6, 7]. Prevention of perinatal transmission of HIV is
to-child transmission, is the main route of HIV infec- possible using the following measures: Antiretroviral
tion in children. It is estimated that there are 2 million therapy (ART) throughout the pregnancy, cesarean
Received: January 14, 2021 Accepted: February 09, 2021 Online: May 24, 2021
Correspondence: Nurhayat YAKUT, MD. Marmara Universitesi Tip Fakultesi, Cocuk Sagligi ve Hastaliklari Anabilim Dali,
Cocuk Enfeksiyon Hastaliklari Klinigi, Istanbul, Turkey.
Tel: +90 216 657 06 06 e-mail: [email protected]
© Copyright 2021 by Istanbul Provincial Directorate of Health - Available online at www.northclinist.com
244 North Clin Istanb

section birth at the 39th week, administration of an an-

Highlight key points
tiretroviral prophylaxis to the newborn, physician care,
and elimination of breastfeeding. This study aimed to • HIV perinatal transmission is an important cause of children
mortality worldwide. In this study, none of the infants hav-
evaluate the characteristics of infants with HIV-infect-
en’t become infected with HIV.
ed mothers and perinatal transmission at a tertiary care
• The number of cases with HIV infection is increasing in Tur-
hospital in Turkey. key.
• There are a little data about HIV exposed infants and peri-
MATERIALS AND METHODS natal transmission in Turkey.
• Antiretroviral therapy for mothers and prevention modalities
Study Design and Data Collection is important to reduce, even eliminate perinatal HIV trans-
This retrospective single-center study examined 18 in- mission.
fants with HIV-infected mothers at a pediatric infec-
tious disease outpatient clinic in a tertiary care hospital in breastfed. There were two preterm, and two low birth
Turkey. The medical records were collected from patients weight infants in our study sample. All infants were giv-
who attended our hospital between December 2017 and en ARV prophylaxis with oral zidovudine (ZDV) for
October 2019. The following demographic and labora- at least 6 weeks. The dosage of ZDV was determined
tory data were collected retrospectively: Gender; birth according to gestational age. ZDV was started 4 mg/
weight; gestational age; type of delivery; obstetric history kg twice daily except two preterm infants. The demo-
(gravida or parity); maternal follow-up period and ART graphic characteristics of the infants and mothers are
regimen; antiretroviral (ARV) prophylaxis; laboratory summarized in Table 1. Seventeen mothers had been
results including leukocyte, lymphocyte, platelet counts, diagnosed with HIV before pregnancy and received
and hemoglobin level within 48 h and after administra- ART during pregnancy. One mother delivered at the
tion of the ARV prophylaxis; HIV RNA levels within another center has received intrapartum prophylax-
the first 48 h, at postnatal 2nd week, 4th week, 4th month, is with intravenous (IV) ZDV. The ART regimen of
and 6th month; and the presence of HIV antibodies at mothers is shown in Table 2.
the 12th month and the 18th month.
HIV RNA analysis for the infants was performed
within the first 48 h of birth, at postnatal 2nd week, 4th
Statistical Analysis week, 4th month, and 6th month. There were 18 infants
Data were entered into Microsoft Office Excel 2010 available for testing within the first 48 h, 14 infants at
(Microsoft; Redmond, WA, USA). The statistical analy- the postnatal 2nd week, 15 infants at the 4th week, 17 in-
sis was performed using SPSS version 21.0 (SPSS Inc.; fants at the 4th month, and 15 infants at the 6th month.
Chicago, IL, USA). Mean, median, minimum, and max- All results came back negative. Anti-HIV analysis was
imum values were used for continuous variables. Fre- performed at the 12th month and the 18th month. There
quencies and percentages were used to summarize cat- were 12 infants tested for anti-HIV antibodies at the
egorical data. 18th month with all results found to be negative. HIV
RNA analysis before delivery produced negative results
Ethical Approval in 17 mothers who received ART during pregnancy.
The Clinical Research Ethics Committee of Marma- The mean white blood cell (WBC) and lymphocyte
ra University Faculty of Medicine approved this study counts within the first 48 h were 12911.11±3059.39
(Date: 04.09.2020 and Decision no: 09.2020.945). (range, 8200–20300)/mm³ and 6038.89±1891.19
(range, 2800–10200)/mm³, respectively. The mean
RESULTS WBC and lymphocyte counts at the 6th week were
10433.33±2758.51 (range, 5700–16000)/mm³ and
A total of 18 infants and their HIV-infected mothers 6700±2574.99 (range, 2500–12000)/mm³, respec-
were examined during the study period. There were 7 tively. The laboratory findings of the infants are sum-
(39%) female and 11 (61%) male infants. The median and marized in Table 3. No adverse effects related to ZDV
mean birth weight were 3045 g and 3011.39±674.726 were observed in any of the infants. All infants tested
(range 1700–4320) g, respectively. None of the infants negative for HIV at their last follow-up.
Yakut et al., Evaluation of infants with HIV-infected mothers and perinatal transmission 245

Table 1. The demographic characteristics of the infants and mothers

Variable n %

Gender
Female 7 39
Male 11 61
Hospital of birth
Our hospital 10 55
Other hospital 8 45
Type of delivery
Spontaneous vaginal deliver 0 0
Cesarean delivery 18 100
Breastfeeding
No 18 100
Yes 0 0
Antiretroviral prophylaxis
No 0 0
Yes 18 100
Ethnicity of mother
Turkish 15 83
Other 3 17
HIV status at last follow-up
Not infected 18 100
Infected 0 0

Min–Max Mean±SD

Admission age (days) (median) 1–75 65±72.56 (34)

Last follow-up age (months) (median) 7–54 25.39±13.695 (23)
Duration of babies follow-up (months) (median) 6–48 23.2±12.2 (20.5)
Birth weight (g) (median) 1700–4320 3011.39±674.726 (3045)
Gestational age at birth (week) (median) 32–40 37.5±2.176 (38)
Duration of mother’s ARV treatment (years) (median) 0.5–10 4.083±2.7667 (4)
HIV: Human immunodeficiency virus; ARV: Antiretroviral; Min: Minimum; Max: Maximum; SD: Standard deviation.

DISCUSSION
Table 2. Antiretroviral therapy regimen of mothers
Although the number of new HIV infections, as well
as perinatal infections, has fallen in the United States, Drugs %
perinatal transmission is one of the most important
challenges facing developing countries in the HIV ep- Emtricitabine/tenofovir+raltegravir 41
idemic [8, 9]. The majority of children with HIV have Emtricitabine/tenofovir+lopinavir/ritonavir 35
acquired it through perinatal transmission, during Elvitegravir/cobicistat/emtricitabine/tenofovir 23.5
pregnancy, at childbirth, or from breastfeeding [10]. Zidovudine/lamivudine+lopinavir/ritonavir 0.5
Therefore, the prevention modalities of ART during
pregnancy and delivery, cesarean delivery, and postnatal
ARV prophylaxis for the infant are the keys to reduc- limited studies have evaluated the perinatal transmis-
ing new HIV infection in children [11, 12]. In Turkey, sion of HIV and infection outcomes [13, 14]. In this
246 North Clin Istanb

Table 3. The laboratory findings of the infants with HIV-infected mothers

Variables Min-Max Mean±SD

Hemoglobin [in the first 48 h, g/dl (median)] 10.4–19.3 14.48±1.74

WBC [in the first 48 h,/mm3 (median)] 8200–20.300 12911.11±3059.39
Thrombocytes [in the first 48 h/mm (median)] 16.000–496.000 302,611.11±71,229.65
Lymphocytes [in the first 48 h/mm3 (median)] 2800–10.200 6038.89±1891.19
Hemoglobin [at the 6th week, g/dl (median)] 8.2–13.4 11.01±1.50
WBC [at the 6th week,/mm3 (median)] 5700–16.000 10433.33±2758.51
Thrombocytes [at the 6th week, /mm (median)] 210.000–583.000 445,944.44±116,695.44
Lymphocytes [at the 6th week, /mm3 (median)] 2500–12.000 6700±2574.99
Granulocytes [at the 6th week, /mm3 (median)] 1700–3600 2244.4±835.40
SD: Standard deviation; Min: Minimum; Max: Maximum; WBC: White blood cell.

study, we examined the characteristics of infants with nant women [23]. Many previous studies have shown
HIV-infected mothers and perinatal transmission at a that ART is effective in reducing the risk of perinatal
tertiary care hospital in Turkey. transmission of HIV [24–27]. A cross-sectional survey
As reported by the Turkish Ministry of Health study of HIV-exposed infants demonstrated that ART
in 2019, the rate of perinatal transmission was 0.47% used during their mothers’ pregnancy was associated
(n=18) from January 2018 to December 2018 [2]. with a low perinatal transmission rate of 1.58% [26].
A study by Gülümser and Erbaydar investigated epi- In the present study, almost all the mothers (94.5%) re-
demiologic characteristics for HIV/AIDS in Turkey ceived ART during pregnancy. In addition, all infants
between 1985 and 2013 and reported that the rate of in our study sample were given an ARV prophylaxis
perinatal transmission has increased proportionally over with oral ZDV for at least 6 weeks following birth as
time with 0.37% increase in the past 2-year period [15]. giving an ARV prophylaxis to the newborn immediately
In two studies conducted in our country, Sutcu et al. after birth reduces the risk of perinatal HIV transmis-
[13] and Inkaya et al. [14] demonstrated that the rate of sion. The protection afforded by the prophylaxis against
perinatal transmission was 6.2% and 8.3%, respectively. the virus is due to its access to the infant’s bloodstream
In this study, we did not observe any cases of perinatal and the unintegrated virus that helps to prevent peri-
transmission over the period of the study. Worldwide, natal transmission [28, 29]. In a cross-sectional study
developing countries with a high prevalence of HIV in- conducted on HIV-exposed infants, Yitayew et al. [30]
fection have developed policies, prevention modalities, reported that ARV drugs given to the mother during
and created follow-up organizations to reduce the inci- pregnancy and the administration of an ARV prophy-
dence of perinatal transmission. Despite the efficacious laxis to the infant was the two most significant factors
interventions and the significant reduction of perinatal in avoiding perinatal HIV transmission. In a systematic
transmission of HIV in many of these countries, it con- review, Lumaca et al. [31] reported that an optimal ART
tinues to be a problem. In contrast, studies conducted regimen and the use of intrapartum ZDV for pregnant
in developed countries report a low perinatal transmis- women are recommended to reduce perinatal HIV
sion rate of 1.2–1.4% [16–18]. Furthermore, the rate transmission. One mother in this study who gave birth
of transmission is increasing in developing countries. at another hospital received an intrapartum prophylaxis
In large cohort studies with HIV-exposed infants, the with IV ZDV.
rate of perinatal transmission was reported to be 7.8% The other important preventive methods against
by Potty et al., 8.2% by Okoko et al., 5.9% by Read et perinatal HIV transmission are elective cesarean section
al., and 8.9% by Mintsa-Ndong et al. [19–22]. One of and not breastfeeding if safety formula feeding can be ac-
the most important interventions for avoiding perinatal cessed [32]. In this study, all infants were born by cesare-
transmission of HIV is ART for all HIV-positive preg- an section, and none of them were breastfed.
Yakut et al., Evaluation of infants with HIV-infected mothers and perinatal transmission 247

The important limitations of this study were its retro- 2006;55:592–7.

spective, single-center design, and small sample size. 8. Esber A, Cohen S, Dempsey A, Cheever LW. Using systems of care and
a public health approach to achieve zero perinatal HIV transmissions.
JAMA Pediatr 2017;171:421–2.
Conclusion 9. Evans C, Jones CE, Prendergast AJ. HIV-exposed, uninfected infants:
new global challenges in the era of paediatric HIV elimination. Lancet
It is possible to reduce, even eliminate, perinatal HIV Infect Dis 2016;16:e92–107.
transmission with preventive modalities. In this study, 10. Newell ML, Brahmbhatt H, Ghys PD. Child mortality and HIV infec-
we determined that none of the infants in the study be- tion in Africa: a review. AIDS 2004;18 Suppl 2:S27–34.
came infected with HIV during the study period. Our 11. Chukwuemeka IK, Fatima MI, Ovavi ZK, Olukayode O. The impact of
results reaffirm the benefits of ART for mothers, ARV a HIV prevention of mother to child transmission program in a nigeri-
an early infant diagnosis centre. Niger Med J 2014;55:204–8.
prophylaxis for infants, birth by cesarean section, and
12. Mandelbrot L, Tubiana R, Le Chenadec J, Dollfus C, Faye A, Pannier
avoidance of breastfeeding. Further multicenter studies E, et al; ANRS-EPF Study Group. No perinatal HIV-1 transmission
with a larger number of patients are needed to provide from women with effective antiretroviral therapy starting before con-
more reliable results. ception. Clin Infect Dis 2015;61:1715–25.
13. Sütçü M, Aktürk H, Somer A, Hançerli Törün S, İnce Z, Çoban A,
et al. Mother-to-child transmisson of HIV: an eight-year experience.
Ethics Committee Approval: The Marmara University Clinical Mikrobiyol Bul 2015;49:542–53.
Research Ethics Committee granted approval for this study (date:
14. İnkaya AÇ, Örgül G, Halis N, Alp Ş, Kara A, Özyüncü Ö, et al. Peri-
04.09.2020, number: 09.2020.945).
natal outcomes of twenty-five human immunodeficiency virus-infected
Conflict of Interest: No conflict of interest was declared by the pregnant women: Hacettepe University experience. J Turk Ger Gynecol
authors. Assoc 2020;21:180–6.
Financial Disclosure: The authors declared that this study has re- 15. Gülümser Ç, Erbaydar T. HIV/AIDS epidemic in Turkey and use of
ceived no financial support. antiretroviral drugs for treating pregnant women and preventing HIV
infection in infants. Turk J Obstet Gynecol 2015;12:192–8.
Authorship Contributions: Concept – NY, EK; Design – NY, EK;
16. Fernández-Ibieta M, Ramos Amador JT, Guillén Martín S, González-
Supervision – EK; Materials – NY, EK; Data collection and/or process-
Tomé MI, Navarro Gómez M, Iglesias González-Nicolás E, et al. Why
ing – NY; Analysis and/or interpretation – NY, EK; Literature review
are HIV-infected infants still being born in Spain? [Article in Spanish].
– NY, EK; Writing – NY, EK; Critical review – EK.
An Pediatr (Barc) 2007;67:109–15.
17. Townsend CL, Cortina-Borja M, Peckham CS, de Ruiter A, Lyall H,
REFERENCES Tookey PA. Low rates of mother-to-child transmission of HIV follow-
ing effective pregnancy interventions in the United Kingdom and Ire-
1. Joint United Nations Programme on HIV/AIDS (UNAIDS). (2017). land, 2000-2006. AIDS 2008;22:973–81.
UNAIDS data 2017. Available at: https://www.unaids.org/sites/ 18. Warszawski J, Tubiana R, Le Chenadec J, Blanche S, Teglas JP, Dollfus
default/files/media_asset/20170720_Data_book_2017_en.pdf. Ac- C, et al; ANRS French Perinatal Cohort. Mother-to-child HIV trans-
cessed Apr 21, 2021. mission despite antiretroviral therapy in the ANRS French Perinatal
2. T.C. Sağlık Bakanlığı Halk Sağlığı Genel Müdürlüğü Bulaşıcı Cohort. AIDS 2008;22:289–99.
Hastalıklar Dairesi Başkanlığı. HIV-AIDS İstatistikleri. Available at: 19. Potty RS, Sinha A, Sethumadhavan R, Isac S, Washington R. Inci-
https://hsgm.saglik.gov.tr/tr/bulasici-hastaliklar/hiv-aids/hiv-aids- dence, prevalence and associated factors of mother-to-child transmis-
liste/hiv-aids-istatislik.html. Accessed Apr 21, 2021. sion of HIV, among children exposed to maternal HIV, in Belgaum
3. Volmink J, Marais B. HIV: mother-to-child transmission. BMJ Clin district, Karnataka, India. BMC Public Health 2019;19:386.
Evid 2008;2008:0909. 20. Okoko NA, Owuor KO, Kulzer JL, Owino GO, Ogolla IA, Wandera
4. World Health Organization, Unicef. Guidance on global scale-up of the RW, et al. Factors associated with mother to child transmission of HIV
prevention of mother to child transmission of HIV: towards univer- despite overall low transmission rates in HIV-exposed infants in rural
sal access for women, infants and young children and eliminating HIV Kenya. Int J STD AIDS 2017;28:1215–23.
and AIDS among children / Inter-Agency Task Team on Prevention 21. Read JS, Samuel NM, Srijayanth P, Dharmarajan S, Van Hook HM,
of HIV Infection in Pregnant Women, Mothers and their Children. Jacob M, et al; PMTCT Project. Infants of human immunodeficien-
WHO, 2007, Switzerland. Available at: https://www.who.int/hiv/ cy virus type 1-infected women in rural south India: feeding pat-
pub/toolkits/PMTCT9789241596015_eng.pdf. Accessed Apr 21, terns and risk of mother-to-child transmission. Pediatr Infect Dis J
2021. 2010;29:14–7.
5. Campos Coelho AV, Campos Coelho HF, Arraes LC, Crovella S. HIV- 22. Mintsa-Ndong A, Ndong-Ella C, Boussougou RK, Busugu LM, Mba
1 mother-to-child transmission in Brazil (1994-2016): a time series A, Agwambouet FA, et al. Mother-to-child HIV-transmission preven-
modeling. Braz J Infect Dis 2019;23:218–23. tion programs in a sub-Saharan African setting: The Gabonese experi-
6. Luzuriaga K. Mother-to-child transmission of HIV: a global perspec- ence. Int J STD AIDS 2018;29:221–6.
tive. Curr Infect Dis Rep 2007;9:511–7. 23. World Health Organization. Antiretroviral drugs for treating preg-
7. Centers for Disease Control and Prevention (CDC). Achievements nant women and preventing HIV infection in infants: recommenda-
in public health. Reduction in perinatal transmission of HIV infec- tions for a public health approach– 2010 version. Geneva, Switzerland:
tion-United States, 1985-2005. MMWR Morb Mortal Wkly Rep WHO; 2010. Available at: https://www.who.int/hiv/pub/mtct/an-
248 North Clin Istanb

tiretroviral2010/en/. Accessed Apr 21, 2021. and challenges. Int Health 2019;11:240–9.
24. De Cock KM, Fowler MG, Mercier E, de Vincenzi I, Saba J, Hoff E, et 28. Hurst SA, Appelgren KE, Kourtis AP. Prevention of mother-to-child
al. Prevention of mother-to-child HIV transmission in resource-poor transmission of HIV type 1: the role of neonatal and infant prophylax-
countries: translating research into policy and practice. JAMA is. Expert Rev Anti Infect Ther 2015;13:169–81.
2000;283:1175–82. 29. Chappell CA, Cohn SE. Prevention of perinatal transmission of human
25. Siegfried N, van der Merwe L, Brocklehurst P, Sint TT. Antiretrovirals immunodeficiency virus. Infect Dis Clin North Am 2014;28:529–47.
for reducing the risk of mother-to-child transmission of HIV infection. 30. Yitayew YA, Bekele DM, Demissie BW, Menji ZA. Mother to child
Cochrane Database Syst Rev 2011:CD003510. transmission of HIV and associated factors among HIV exposed ıin-
26. Mugwaneza P, Lyambabaje A, Umubyeyi A, Humuza J, Tsague L, fants at public health facilities, Dessie Town, Ethiopia. HIV AIDS
Mwanyumba F, et al. Impact of maternal ART on mother-to-child (Auckl) 2019;11:343–50.
transmission (MTCT) of HIV at six weeks postpartum in Rwanda. 31. Lumaca A, Galli L, de Martino M, Chiappini E. Paediatric HIV-1 in-
BMC Public Health 2018;18:1248. fection: updated strategies of prevention mother-to-child transmission.
27. Olakunde BO, Adeyinka DA, Olawepo JO, Pharr JR, Ozigbu CE, J Chemother 2018;30:193–202.
Wakdok S, et al. Towards the elimination of mother-to-child transmis- 32. Teasdale CA, Marais BJ, Abrams EJ. HIV: prevention of mother-to-
sion of HIV in Nigeria: a health system perspective of the achievements child transmission. BMJ Clin Evid 2011;2011:0909.