Risk of Perinatal HIV Infection in Infants Born in Italy to Immigrant Mothers

TO THE EDITOR—Increasing numbers of human immunodeficiency virus (HIV)–infected children immigrating from countries where HIV infection is endemic have been reported in Europe [1–3]. However, information regarding mother-to-child transmission (MTCT) in infants born in Western countries to immigrant mothers is lacking. We describe characteristics of infants born to HIV-infected mothers in Italy, focusing on potential inequalities between infants born to native and immigrant women, considered as those originating from countries where HIV infection is endemic [4]. Data from 4470 children born in Italy to HIV-infected mothers during 1996–2010 and enrolled in the Italian Register for HIV infection in children from birth, with an ascertained infectious status, were analyzed. Details regarding data collection and status definitions are described elsewhere [5]. Factors potentially associated with MTCT of HIV infection were explored by logistic regression analysis. Differences among proportions were evaluated using the χ2 test with Mantel-Haenzel correction. Crude total rate of MTCT significantly decreased from 5.1% (56 of 1049 cases; 95% confidence interval [CI], 3.98%–6.70%) during 1996–1999 to 2.2% (46 of 2016 cases; 95% CI,1.63%–2.93%) during 2000–2005 and 1.0% (13 of 1298 cases; 95% CI, 0.46%–1.55%) during 2005–2010 (P < .0001). The numbers of children born in Italy to immigrant mothers increased from 110 (10.0%) of 1105 during 1996–1999 to 522 (25.5%) of 2049 during 2000–2005 and 561 (43.3%) of 1295 during 2005–2010 (P < .0001); 799 (67.0%) of 1193 immigrant mothers originated from sub-Saharan Africa. The rate of MTCT was 2.8% (95% CI, 1.91%–3.79%) among infants born to immigrant mothers and 1.8% (95% CI, 0.89%–2.68%) among infants born to native mothers. In multivariable analysis, being born to an immigrant mother was associated with increased risk of MTCT (adjusted odds ratio, 2.269; 95% CI, 1.115–4.619; P = .024) (Table 1). Immigrant mothers less frequently had received combined antiretroviral therapy with ≥3 drugs (679 [56.9%] of 1193 vs 609 of [71.2%] of 855; P < .0001) and had less frequently undetectable viral load at delivery, compared with native mothers (531 [44.5%] of 1193 vs 529 [61.9%] of 855; P < .0001). A higher proportion of immigrant mothers breastfed their infants, compared with native mothers (1.6% vs 0.3%; P = .007). No difference was observed with respect to the proportion of elective caesarean delivery, incidence of premature deliveries, and receipt of intrapartum or postnatal prophylaxis. Factors Associated With Mother-to-Child Transmission (MTCT) of HIV Infection in 4470 Infants Born in Italy to HIV-Infected Mothers NOTE. aOR, adjusted odds ratio; CI, confidence interval; ZDV, zidovudine. OR are adjusted for all other variables included in the table and calculated by logistic regression analysis. Factors Associated With Mother-to-Child Transmission (MTCT) of HIV Infection in 4470 Infants Born in Italy to HIV-Infected Mothers NOTE. aOR, adjusted odds ratio; CI, confidence interval; ZDV, zidovudine. OR are adjusted for all other variables included in the table and calculated by logistic regression analysis. Considering data from all the 1478 children with perinatal HIV infection and enrolled in the Italian Register for HIV Infection in Children from 1985, followed up or not since birth, the proportion of HIV-infected children born to immigrant mothers significantly increased over time from 132 (9.9%) of 1328 before 2000 to 79 (54.5%) of 159 during or after 2000 (P < .0001). This is consistent with similar findings reported in US [6], French [1], Spanish [2], UK, and Irish [3] pediatric cohorts. However, in our dataset, 115 (54.4%) of 211 infected children born to an immigrant mother were born in Italy, in contrast to what has been observed in other countries, such as the United Kingdom, where the large majority of these children were born abroad [3]. One limit of our study is lack of detailed information regarding time of HIV infection diagnosis in the mothers, time spent in Italy, compliance, and resistance profile. Data regarding mothers’ origins and viral loads at delivery were missing in many cases. However, our findings are indicators for social alarm in Italy and shed light on possible barriers to accessing health care facilities, to receiving appropriate counseling and prophylaxis measures, and to existence of possible cultural barriers [7]. Comorbidities may also be more frequent in immigrant mothers [7]. Public health interventions are needed to minimize these missed opportunities for the prevention of HIV infection. Participants. Maccabruni A (Pavia), Mazza A (Trento), Rabusin M (Trieste), Acutis MS (Genova), Ruggeri M (Bergamo), Anzidei G, Casadei AM, Catania S (Roma), Consolini R (Pisa), Abbagnato L (Como), Quercia M (Bari); La rovere D. (Bari), Masi M (Bologna), Fortunati P (Verona), Romano A (Palermo), Gariel D (Cagliari), Fiumana E (Ferrara), Dedoni M (Cagliari), Anastasio E (Catanzaro), Magnani C (Reggio Emilia), Dalle Nogare E (Palermo), Ciccia M (Bologna), Bigi M (Rimini), Cristiano L (Taranto), Lipreri R (Milano), Deiana M (Sassari), Tarallo L (Napoli), Aliffi A (Catania), Pellegatta A (Varese), Portelli V (Trapani), Merlino S (Cuneo), Baldi F (Bologna), Moretti C (Imperia), Dessì C (Cagliari), Felici L (Pesaro), Sabatino G (Chieti), Antonellini A (Ravenna), Bondi E, Gotta C (Genova), Di Palma A (Ferrara), Stronati M. (Mantova), Chiriaco G (Brindisi), Ruggeri C (Messina), Ferraris G (Milano), Giorni PL (Salesi), Memmini G (Livorno), Contardi I (Milano), Audenino E (Asti), Moscardini L (Verbania). Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed in the Acknowledgments section.