BACKGROUND: The elimination of mother-to-child-transmission (MTCT) of HIV is defined by the Center for Disease Control and Prevention as a transmission rate of less than 1% of exposed infants and less than 1 case per 100,000 live births. New York State (NYS) achieved the elimination of MTCT in 2013 (2 infected infants) and 2015 (0 infected infants). In NYS, the majority of HIV-exposed/infected infants have Medicaid health insurance coverage, and each prevented infection saves Medicaid an estimated $357,498 (2013 dollars) in averted lifetime treatment costs.
METHODS: New York State Department of Health (NYSDOH) monitors and comprehensively evaluates HIV exposed births. In addition to universal voluntary prenatal HIV testing of pregnant women, all newborns are screened for HIV at birth by the Newborn Screening Program (NBS) and exposed infants undergo follow-up testing to determine final infection status. Using data from the NBS, diagnostic testing of exposed infants, and maternal and infant medical record review, NYSDOH assesses: 1) prenatal HIV testing of women giving birth; 2) HIV prevalence in women giving birth; 3) MTCT; 4) quality of care in pregnant/delivering HIV-positive women and their infants; and, 5) identification of missed opportunities to prevent MTCT.
RESULTS: Between 2004 and 2014, 5,836 HIV- positive mothers gave birth to 5,951 live-born infants. Of these infants, 81 were confirmed infected. Most infected infants (75/81; 93%) were born to mothers who seroconverted during pregnancy or whose diagnosis was missed. A majority (57/75; 76%) of infected infants were identified solely through NBS, whereas most non-infected infants’ exposure status is known prenatally. Half of the NBS identified HIV infected infants (27/57) were breastfed. Six (11%) infants whose exposure was identified by NBS were infected compared to 40% (8/20) of infants whose HIV exposure status was identified after NBS.
CONCLUSIONS: NYS’ comprehensive MTCT prevention initiatives fueled the decline in MTCT in NYS; despite this, missed opportunities occur. NBS plays a key safety-net role in those situations. Additionally, with greater emphasis on breastfeeding and the likelihood of transmission via breastfeeding (14%-30%), early identification by the NBS program of HIV-exposed infants whose exposure was not known prior to NBS is critical in preventing infection. Prevention of MTCT, inclusive of NBS, is cost effective in reducing the financial burden on NYS as well eliminating the burden of HIV-related care on infected infants.