In settings where pneumonia, diarrhea, and malnutrition are significant causes of infant mortality, breastfeeding for 12 months combined with antiretroviral and cotrimoxazole preventive therapy (CPT) offers infants of HIV-infected mothers the greatest chance for HIV-free survival. Both maternal and infant antiretroviral (ARV) prophylaxis and CPT have been independently associated with reports of neutropenia and anemia, so it is important to evaluate the impact of their concurrent use.
We used data from the Breastfeeding, Antiretrovirals and Nutrition study (conducted 2004-2010) to evaluate the impact of CPT and ARV treatment on hematologic outcomes from 6 to 48 weeks of age for 2,006 HIV-exposed, uninfected infants in Lilongwe, Malawi. Using Cox proportional hazards models, we compared the hazard of severe (grade 3 and higher) anemia and neutropenia (as defined by the NIAID Division of AIDS, 2014) according to time-varying CPT, implemented mid-way through the study, and antiretroviral treatment arm exposure (maternal zidovudine/lamivudine/lopinavir-ritonavir, daily infant nevirapine, or none during six months of breastfeeding) and checked for statistical interaction between the two.
CPT was associated with an increase in severe neutropenia (hazard ratio [95% CI]: 1.97 [1.01, 3.86]) (Figure 1a) and a decrease in severe anemia hazard (HR: 0.65 [0.48, 0.88]) (Figure 1b). The hazard of severe anemia is significantly lower in the infant nevirapine arm compared with the control arm (HR: 0.68 [0.48, 0.96]). The interaction between CPT and ARV treatment arm was not significant for either severe neutropenia (p=0.22) or severe anemia (p=0.32).
In addition to an expected association with increased hazard of severe neutropenia, CPT was associated with a reduced hazard of severe anemia, possibly due to the drugs antimalarial effect. This provides further support for CPT use in HIV-exposed, uninfected infants in malaria-endemic resource-limited settings.
J. Wiener, None
C. Chasela, None
G. Tegha, None
M. Hosseinipour, None
A. Kourtis, None