Timing of maternal and neonatal dosing of nevirapine and the risk of mother-to-child transmission of HIV-1: HIVNET 024

OBJECTIVE

Despite a growing emphasis worldwide on complex and potent antiretroviral drug regimens for the prevention of mother-to-child transmission of HIV-1 (MTCT), two-dose nevirapine (NVP) prophylaxis remains an important choice in many settings. We analyzed data from a multicenter clinical trial to determine whether timing of maternal or infant NVP was associated with MTCT between delivery and 6 weeks of age (intrapartum/early postnatal transmission; I/EP).

METHODS

HIVNET 024 was a placebo-controlled, double-blind trial of empiric antibiotics to reduce chorioamnionitis-associated MTCT. This secondary analysis used data collected in the original randomized trial. Enrolled women were instructed to self-administer NVP at labor onset; infants were to receive a dose within 72 h of birth.

RESULTS

Data regarding 1491 mother-infant pairs were analyzed. The overall I/EP HIV-1 transmission rate was 8.1% at 6 weeks. Almost all women (93%) ingested NVP within 24 h of delivery; 90% of infants were given NVP within 48 h after delivery. Variations in mother or infant dose timing did not influence transmission rates, even when the combined pattern of both was taken into account through multivariate analysis. In the subset of women ingesting NVP <or= 2 h before delivery, early NVP administration to the infant (< 4 h after birth) was not associated with lower MTCT risk when compared with later administration (>or= 4 h).

CONCLUSION

Variations in the timing of maternal and infant NVP doses (within reasonable proximity to delivery) do not appear to affect the risk of MTCT.

Affordable, abbreviated roche monitor assay for quantification of human immunodeficiency virus type 1 RNA in plasma

The cost for the Roche Monitor assay kit can be reduced 50% by using only the 1:1, 1:25, and 1:625 human immunodeficiency virus (HIV) and the 1:1 quantitation standard dilutions. This abbreviated test applied to 1,774 mostly African samples had results nearly identical to those obtained following the package insert instructions. To make this approach feasible, Roche would have to provide additional lysis buffer and master mix.

Herpes simplex virus 2 and syphilis among young drug users in Baltimore, Maryland

OBJECTIVES

To examine the sex specific seroprevalence and correlates of herpes simplex virus 2 (HSV-2) and syphilis among a cohort of young drug users.

METHODS

Drug users aged 15-30 years old who used heroin, cocaine, or crack were recruited between October 1999 and August 2002. Baseline interviews gathered information on sociodemographics, drug use and sexual behaviours. Serum was tested at baseline for HSV-2 and syphilis seroreactivity. For each sexually transmitted infection (STI), infected and non-infected participants were stratified by sex and compared using chi2, Mann-Whitney tests, and logistic regression.

RESULTS

Of the 543 participants recruited, 42.4% were female and 39.3% were African-American. The seroprevalence of STIs among females and males, respectively, were HSV-2: 58.7% and 22.0%; syphilis: 4.3% and 0.3%. In multivariate models, older age, African-American race, having over 30 lifetime sex partners, current HIV infection and previous incarceration were independently associated with HSV-2 infection among males. For females, older age, African-American race, sex trade, and daily heroin use were independently associated with HSV-2. For females, only a self reported previous syphilis diagnosis was associated with current syphilis seroreactivity in multivariate analyses.

CONCLUSIONS

Examination of this cohort revealed a particularly high seroprevalence of HSV-2 and syphilis, especially among female drug users. Few infected participants had been previously diagnosed with these infections.

Safety, Acceptability, and Potential Efficacy of a Topical Penile Microbicide Wipe

Innovative, low-cost, and acceptable measures are needed to reduce sexually transmitted infections (STIs) including HIV. Use of a topical microbicide wipe for penile cleaning before and after sex might be effective in preventing STIs. However, evaluation of this simple method has not been done. Two studies were conducted in Malawi to determine the safety, acceptability, and potential efficacy of a benzalkonium chloride topical penile microbicide wipe. The first study was a phase 1 dose-escalating clinical trial among low-risk circumcised or uncircumcised HIV-negative men. The second study was a pilot before-after efficacy study among uncircumcised HIV-negative or -positive men. In the first study 24 circumcised and 27 uncircumcised men were enrolled. During the entire study period, 18 adverse events (AEs) were reported, and 3 AEs were confirmed by physical examination. Acceptability concerns did not increase with dose escalation, and adherence to use of the wipe ranged from 89%-95%. In the second study, 27 men were enrolled. Gram stain and culture tests showed significant reductions in frequency of several organisms after use of the wipe, including STI-associated bacteria. This penile wipe is safe, acceptable, and can decrease the frequency of penile colonization with microorganisms. The clinical relevance remains to be determined in larger clinical trials.

Prevalence and Correlates of Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis infections, and Bacterial Vaginosis Among a Cohort of Young Injection Drug Users in Baltimore, Maryland

OBJECTIVES

Injection drug users (IDUs) consistently demonstrate high-risk behaviors for sexually transmitted infections (STIs). This study examines STI prevalence and correlates among young IDUs.

STUDY

This cross-sectional study recruited IDUs aged 18 to 30 years. Participants completed a behavioral risk assessment and were tested for chlamydia, gonorrhea, and trichomoniasis by nucleic acid amplification methods. Women were also tested for bacterial vaginosis (BV). Gender-specific analyses were done comparing infected with noninfected participants using chi-square, Mann-Whitney tests, and logistic regression.

RESULTS

Of the 115 (35.3%) women and 211 (64.7%) men in the study, STI prevalence, respectively, was: chlamydia, 5.3% and 3.3%; gonorrhea, 3.5% and 0%; and trichomoniasis, 8.6% and 1.9%. Most (68.0%) participants had 2 or more sex partners in the past 3 months, of whom fewer than half consistently used condoms. Independent correlates for prevalent STIs included douching (adjusted odds ratio [AOR], 4.9; 95% confidence interval [CI], 1.5-23.6) for women and anal sex with female partners (AOR, 6.3; 95% CI, 1.5-25.8) for men. BV prevalence was 56.3% and was associated with douching (OR, 2.5; 95% CI, 1.1-5.7).

CONCLUSIONS

Despite high sexual risk, STI prevalence among young IDUs was similar to that of the general population. BV prevalence was high, suggesting that future STI assessments among female IDUs should include BV.

Epidemiology and microbiology of subclinical mastitis among HIV-infected women in Malawi

The epidemiology and microbiology of subclinical mastitis, a risk factor for perinatal HIV transmission, have not been well characterized. In all, 250 HIV-infected women were followed from two weeks to 12 months postpartum in Blantyre, Malawi, and subclinical mastitis was assessed by breast milk leukocyte counts. The point prevalence of subclinical mastitis at 2, 4, 6, 10, and 14 weeks, and 6, 9, and 12 months was 12.2%, 7.8%, 6.8%, 3.7%, 10.6%, 5.1%, 4.9%, and 1.9%, respectively (P = 0.002), and 27.2% of women had at least one episode of subclinical mastitis. There was no significant relationship between maternal plasma HIV load or parity and subclinical mastitis. Staphylococcus aureus was isolated in 30% of women with subclinical mastitis, and the proportion of women with positive cultures decreased during follow-up (P = 0.02). Subclinical mastitis is prevalent among breastfeeding mothers and further studies are needed to characterize the differences between infectious and non-infectious subclinical mastitis.

Gender differences in perinatal HIV acquisition among African infants

OBJECTIVE

We investigated gender-specific risks of mother-to-child transmission (MTCT) at birth and at 6 to 8 weeks among infants born to HIV-infected African women.

DESIGN

Follow-up study of infants enrolled in 2 randomized, phase III, clinical trials to prevent MTCT, conducted in Blantyre, Malawi, in southeast Africa.

METHODS

Infants were enrolled at birth and monitored postnatally, and their HIV status was assessed at birth and at 6 to 8 weeks (assessment beyond 6-8 weeks is ongoing). Statistical analyses were stratified according to gender, and comparisons were made with descriptive, univariate, and multivariate statistical tests. MTCT was estimated at birth and at 6 to 8 weeks among infants who were not infected at birth.

RESULTS

Overall, 966 boys and 998 girls were enrolled. The rate of HIV transmission at birth was 9.5% (187 of 1964 infants). However, at birth significantly more girls (12.6%) than boys (6.3%) were infected with HIV. This association remained significant after controlling for maternal viral load and other factors. Among infants who were uninfected at birth, 8.7% (135 of 1554 infants) acquired HIV by 6 to 8 weeks; of these infants, more girls acquired HIV (10.0%), compared with boys (7.4%).

CONCLUSIONS

Female infants may be more susceptible to HIV infection before birth and continuing after birth. Alternatively, in utero mortality rates of HIV-infected male infants may be disproportionately higher and thus more HIV-infected female infants are born. In areas of sub-Saharan Africa, where HIV infection rates are high among women of reproductive age, the magnitude of the gender transmission differences observed in this study could have clinical, preventive, and demographic implications.

Breast milk retinol concentrations are not associated with systemic inflammation among breast-feeding women in Malawi

The acute phase response and inflammation are associated with lower plasma retinol concentrations, but their effect on breast milk retinol concentrations is unclear. We measured plasma retinol concentrations, acute phase proteins, and breast milk retinol concentrations in 237 breast-feeding women at 2 wk postpartum in Blantyre, Malawi; 16.5% of the women had plasma retinol < 0.70 micromol/L and 14.8% had breast milk retinol < 1.05 micromol/L. Among women with and without inflammation [alpha(1)-acid glycoprotein (AGP) > 1 g/L and/or C-reactive protein (CRP) > 5 mg/L], geometric mean (95% CI) plasma retinol was 0.89 (0.84, 0.94) and 1.05 (1.01, 1.17) mumol/L, respectively (P < 0.0001). Among women with and without inflammation, geometric mean (95% CI) breast milk retinol was 2.12 (1.89, 2.36) and 2.05 (1.75, 2.39) micromol/L, respectively (P = 0.74). In multiple linear regression models adjusting for age, parity, education, BMI, and days postpartum, plasma retinol concentrations were associated with plasma AGP and CRP concentrations (P < 0.0001 and P = 0.01, respectively), whereas breast milk retinol concentrations were unaffected by plasma AGP and CRP concentrations (P = 0.22 and P = 0.86, respectively). These findings suggest that breast milk retinol concentrations are not affected by systemic inflammation.

Micronutrient malnutrition and wasting in adults with pulmonary tuberculosis with and without HIV co-infection in Malawi

BACKGROUND

Wasting and micronutrient malnutrition have not been well characterized in adults with pulmonary tuberculosis. We hypothesized that micronutrient malnutrition is associated with wasting and higher plasma human immunodeficiency virus (HIV) load in adults with pulmonary tuberculosis.

METHODS

In a cross-sectional study involving 579 HIV-positive and 222 HIV-negative adults with pulmonary tuberculosis in Zomba, Malawi, anthropometry, plasma HIV load and plasma micronutrient concentrations (retinol, alpha-tocopherol, carotenoids, zinc, and selenium) were measured. The risk of micronutrient deficiencies was examined at different severity levels of wasting.

RESULTS

Body mass index (BMI), plasma retinol, carotenoid and selenium concentrations significantly decreased by increasing tertile of plasma HIV load. There were no significant differences in plasma micronutrient concentrations between HIV-negative individuals and HIV-positive individuals who were in the lowest tertile of plasma HIV load. Plasma vitamin A concentrations <0.70 micromol/L occurred in 61%, and zinc and selenium deficiency occurred in 85% and 87% respectively. Wasting, defined as BMI<18.5 was present in 59% of study participants and was independently associated with a higher risk of low carotenoids, and vitamin A and selenium deficiency. Severe wasting, defined as BMI<16.0 showed the strongest associations with deficiencies in vitamin A, selenium and plasma carotenoids.

CONCLUSIONS

These data demonstrate that wasting and higher HIV load in pulmonary tuberculosis are associated with micronutrient malnutrition.

Nonoxynol-9 100 mg gel: multi-site safety study from sub-Saharan Africa

OBJECTIVES

To evaluate the safety of 100 mg nonoxynol-9 (N-9) gel, a vaginal microbicide, on the genital mucosa of women from Malawi and Zimbabwe in preparation for a phase III efficacy study.

METHODS

HIV-uninfected women (180) were enrolled and randomized to either N-9 or placebo gel and instructed to insert gel into the vagina twice daily for 14 days. Follow up examinations were conducted at 7 and 14 days.

RESULTS

The number of adverse events in the N-9 gel group was higher than in the placebo group (40% versus 13%; P < 0.01). Reported number of any genital symptoms was significantly higher in the N-9 group (38% N-9, 13% placebo; P = 0.01). The number of total epithelial disruptions was higher in the N-9 group (20% versus 3%; P < 0.01); however, the number of genital ulcers and abrasions in the N-9 group was low (2% and 3%, respectively) and not different from that in the placebo group (1% and 2%, respectively).

CONCLUSIONS

N-9 gel 100 mg caused a significant increase in the rate of genital symptoms and epithelial disruptions compared with placebo. The clinical significance of these epithelial disruptions is unknown. Although these findings alone were not sufficient to cancel the planned phase III study, when considered together with the negative results from the COL-1492 effectiveness trial of 52.5 mg N-9 gel, the decision was made to cancel the planned phase III trial of 100 mg N-9 gel.

Nevirapine and zidovudine at birth to reduce perinatal transmission of HIV in an African setting: a randomized controlled trial

CONTEXT

Antenatal counseling and human immunodeficiency virus (HIV) testing are not universal in Africa; thus, women often present in labor with unknown HIV status without receiving the HIVNET 012 nevirapine (NVP) regimen (a single oral dose of NVP to the mother at the start of labor and to the infant within 72 hours of birth).

OBJECTIVE

To determine risk of mother-to-child transmission of HIV when either standard use of NVP alone or in combination with zidovudine (ZDV) was administered to infants of women tested at delivery.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, open-label, phase 3 trial conducted between April 1, 2000, and March 15, 2003, at 6 clinics in Blantyre, Malawi, Africa. The trial included all infants born to 894 women who were HIV positive, received NVP intrapartum, and were previously antiretroviral treatment-naive. Infants were randomly assigned to NVP (n = 448) and NVP plus ZDV (n = 446). Infants were enrolled at birth, observed at 6 to 8 weeks, and followed up through 3 to 18 months. The HIV status of 90% of all infants was established at 6 to 8 weeks.

INTERVENTION

Mothers received a 200-mg single oral dose of NVP intrapartum and infants received either 2-mg/kg oral dose of NVP or NVP (same dose) plus 4 mg/kg of ZDV twice per day for a week.

MAIN OUTCOME MEASURES

HIV infection of infant at birth and 6 to 8 weeks, and adverse events.

RESULTS

The mother-to-child transmission of HIV at birth was 8.1% (36/445) in infants administered NVP only and 10.1% (45/444) in those administered NVP plus ZDV (P =.30). A life table estimate of transmission at 6 to 8 weeks was 14.1% (95% confidence interval [CI], 10.7%-17.4%) in infants who received NVP and 16.3% (95% CI, 12.7%-19.8%) in those who received NVP plus ZDV (P =.36). For infants not infected at birth and retested at 6 to 8 weeks, transmission was 6.5% (23/353) in those who received NVP only and 6.9% (25/363) in those who received NVP plus ZDV (P =.88). Almost all infants (99%-100%) were breastfed at 1 week and 6 to 8 weeks. Grades 3 and 4 adverse events were comparable; 4.9% (22/448) and 5.4% (24/446) in infants receiving NVP only and NVP plus ZDV, respectively (P =.76).

CONCLUSIONS

The frequency of mother-to-child HIV transmission at 6 to 8 weeks in our 2 study groups was comparable with that observed for other perinatal HIV intervention studies among breastfeeding women in Africa. The safety of the regimen containing neonatal ZDV was similar to that of a standard NVP regimen.

Malnutrition and the severity of lung disease in adults with pulmonary tuberculosis in Malawi

SETTING

Zomba Central Hospital, Zomba, Malawi.

OBJECTIVE

To examine the relationship between malnutrition and the severity of lung disease in human immunodeficiency virus (HIV) positive and negative adults with pulmonary tuberculosis (PTB).

DESIGN

Cross-sectional study.

METHODS

Chest radiographs and anthropometric measurements were obtained and bioelectrical impedance analysis was conducted in sputum-positive patients with pulmonary tuberculosis. Lung disease in chest radiographs was graded as normal, minimal, moderately advanced and far advanced according to a conventional classification system.

RESULTS

Among 319 adults with PTB with or without HIV co-infection, body mass index (BMI), fat mass and phase angle were independently associated with increasing severity of lung disease. Multiple logistic regression analyses showed that BMI, fat mass and phase angle were associated with increasing severity of lung disease among 236 HIV-positive adults, when adjusted for sex, age, and plasma HIV load.

CONCLUSION

The severity of lung disease in adults with PTB is associated with the extent of malnutrition, as reflected by BMI and body composition studies using bioelectrical impedance analysis.

Short postexposure prophylaxis in newborn babies to reduce mother-to-child transmission of HIV-1: NVAZ randomised clinical trial

BACKGROUND

In sub-Saharan Africa, most women present late for delivery with unknown HIV status, which limits the use of intrapartum nevirapine to prevent mother-to-child transmission of HIV. We aimed to determine whether post-exposure prophylaxis of nevirapine plus zidovudine given to babies only reduced transmission of HIV more than did a regimen of nevirapine alone.

METHODS

We randomly assigned 1119 babies of Malawian women with HIV-1 who presented late (ie, within 2 h of expected delivery) to either nevirapine alone or nevirapine and zidovudine. Both drugs were given immediately after birth: one dose of nevirapine (2 mg/kg weight) was given as a single dose; babies in the nevirapine plus zidovudine group also received zidovudine twice daily for 1 week (4 mg/kg weight). Infant HIV infection was determined at birth and at 6-8 weeks. Primary outcome was HIV infection in babies at 6-8 weeks in those not infected at birth. Analysis was by intention to treat.

FINDINGS

The overall rate of mother-to-child transmission at 6-8 weeks was 15.3% in 484 babies who received nevirapine and zidovudine and 20.9% in 468 babies who received nevirapine only (p=0.03). At 6-8 weeks, in babies who were HIV negative at birth, 34 (7.7%) babies who had nevirapine and zidovudine and 51 (12.1%) who received nevirapine only were infected (p=0.03)-a protective efficacy of 36%. This finding remained after controlling for maternal viral load and other factors at baseline. Adverse events were mild and of similar frequency in the two groups.

INTERPRETATION

Postexposure prophylaxis can offer protection against HIV infection to babies of women who missed opportunities to be counselled and tested before or during pregnancy. The nevirapine and zidovudine regimen is safe and easy to implement.

HIV-1 prevalence and herpes simplex virus 2, hepatitis C virus, and hepatitis B virus infections among male workers at a sugar estate in Malawi

HIV-1 prevalence is approximately 23% among men working at a sugar estate in Malawi. Given the scale of the HIV epidemic in this country, it is important to determine possible cofactors of infection. The authors investigated associations between HIV-1 prevalence and herpes simplex virus 2 (HSV-2), hepatitis C virus (HCV), and hepatitis B virus (HBV) infections (indicated by anti-HSV-2, anti-HCV and HBsAg positivity, respectively) in a nested case-control study of 279 HIV-positive and 280 HIV-negative male workers. The prevalence of HSV-2 infection was 88.1% among HIV-positive persons and 64.3% among HIV-negative control subjects (p <.01). This difference persisted after adjusting for sexual behavior and history of sexually transmitted diseases (OR = 4.12; 95% CI, 2.21-7.68). The prevalence of HCV seropositivity was 12.7% among HIV-positive persons and 10.0% among control subjects (p =.31), whereas that of HBV infection was 16.9% among HIV-positive persons and 14.4% among control subjects (p =.46). HSV-2 infection is significantly associated with prevalent HIV-1 infection in this population. Therefore, preventive measures for HSV-2 and HIV infection should be emphasized.

Antenatal vitamin A supplementation increases birth weight and decreases anemia among infants born to human immunodeficiency virus-infected women in Malawi

Vitamin A is essential for immunity and growth. A controlled clinical that involved 697 human immunodeficiency virus (HIV)-infected pregnant women was conducted to determine whether vitamin A prevents anemia, low birth weight, growth failure, HIV transmission, and mortality. Women received daily doses of iron and folate, either alone or combined with vitamin A (3 mg retinol equivalent), from 18-28 weeks' gestation until delivery. In the vitamin A and control groups, respectively, the mean (+/-SE) birth weights were 2895+/-31 g and 2805+/-32 g (P=.05), the proportions of low-birth-weight infants were 14.0% and 21.1% (P=.03), the proportions of anemic infants at 6 weeks postpartum were 23.4% and 40.6% (P<.001), and the respective cumulative proportions of infants who were HIV infected at 6 weeks and 24 months of age were 26.6% and 27.8% (P=.76) and 27.7% and 32.8% (P=.21). Receipt of vitamin A improved birth weight and neonatal growth and reduced anemia, but it did not affect perinatal HIV transmission.

Three surveys of HIV-1 prevalence and risk factors among men working at a sugar estate in Malawi

BACKGROUND

HIV-1 surveys in defined populations identify underlying risks and trends useful to mount interventions.

GOAL

The goal of the study was to determine HIV-1 prevalence and risk factors among men working at a Malawian sugar estate.

STUDY DESIGN

Three independent surveys were conducted in 1994, 1997, and 1998. Procedures included obtaining informed consent, interviewing, and drawing blood for HIV and syphilis testing. Analyses determined prevalence of HIV and associated risk factors.

RESULTS

HIV prevalence was 24.3% in 1994 (n = 1691), 22.8% in 1997 (n = 615), and 20.9% in 1998 (n = 1354; P < 0.03). From 1994 to 1998, the percentage of subjects with a history of sexually transmitted disease (STD) decreased from 43.6% to 29.5% (P < 0.0001), accompanied by a substantial rise in STDs confirmed by physical examination (from 7.5% to 16.8%; P < 0.0001) and by laboratory testing for syphilis (from 6.5% to 10.4%; P < 0.0001). The percentage with multiple sex partners declined (from 62.0% to 35.2%; P < 0.0001), and condom use rose (from 10.9% to 18.9%; P < 0.0001). STDs were significantly associated with prevalent HIV infection each year.

CONCLUSIONS

The prevalence of HIV has remained relatively stable and high in this cohort.

Effect of HIV-1 antiretroviral prophylaxis on hepatic and hematological parameters of African infants

OBJECTIVE

To measure hepatic and hematological parameters among neonates randomized to receive ultra-short antiretroviral regimens.

DESIGN

As part of an on-going clinical trial in Malawi, infants born to women who received (early presenters) or did not receive (late presenters) standard intrapartum nevirapine (NVP) dosing were randomized to receive orally either single dose NVP alone or NVP plus zidovudine (twice daily for 1 week). An additional group of untreated infants (born to HIV-uninfected women) was enrolled as a control.

METHODS

Laboratory measurements were performed at birth and repeated at 6 weeks of age. Serum alanine aminotransferase (ALT) was measured on approximately 200 infants consecutively enrolled and randomized at the start of the trial. Complete blood count (CBC) was performed on approximately 800 infants at birth and 600 infants at 6 weeks of age. ALT and CBC were also determined on approximately 200 control infants.

RESULTS

At birth there were no differences in ALT values between the groups of children. At 6 weeks of age, ALT levels were significantly higher among the treated groups compared with control group (geometric mean of 11.5 U/l for controls and 16.2-19.1 U/l for treated groups; P < 0.0001). Hematological parameters did not differ between groups at birth. At 6 weeks of age, levels of hemoglobin, hematocrit, granulocytes, and platelets were significantly (P < 0.0001) lower among antiviral drug-treated groups compared with controls. These changes were consistent with grade 1 (mild) toxicity, and were more noticeable among HIV-infected infants.

CONCLUSIONS

Hepatic and hematologic abnormalities associated with short-term neonatal antiretrovirals among African children are minimal.

Viral levels in newborn African infants undergoing primary HIV-1 infection

We examined weekly changes in viral levels in seven untreated infants infected with HIV at birth. Viral levels spiked immediately but reverted quickly to plateau levels typical of infant HIV infection within 2 weeks of first detected viraemia. We speculated that the depletion of naive, susceptible cells is responsible for the rapid decrease in spike levels and that the rapid replacement of lymphocytes in infants causes the high plateau viral levels (10(5) copies/ml) to be sustained.

Impact of vitamin A supplementation on anaemia and plasma erythropoietin concentrations in pregnant women: a controlled clinical trial

INTRODUCTION

Although studies suggest that vitamin A or its metabolites influence the synthesis of erythropoietin in vitro and in animal models, it is unclear whether vitamin A supplementation increases plasma erythropoietin concentrations in humans.

OBJECTIVE

To determine whether daily vitamin A supplementation increases plasma erythropoietin concentrations in pregnant women with a high prevalence of anaemia.

METHODS

A randomized, double-blind, controlled clinical trial was conducted to examine the effect of daily vitamin A (3000 microg retinol equivalent), iron (30 mg), and folate (400 microg) versus iron (30 mg) and folate (400 microg) (control) on haemoglobin and plasma erythropoietin concentrations in 203 pregnant women in Malawi, Africa.

RESULTS

Mean gestational age at enrollment was 23 wk, at which time 50% of the women were anaemic (haemoglobin <110 g/L). Mean (+/-SEM) change in haemoglobin from enrollment to 38 wk was 4.7+/-1.6 g/L (p=0.003) and 7.3+/-2.3 g/L (p=0.003) in the vitamin A and control groups, respectively. Mean change in plasma erythropoietin concentrations from enrollment to 38 wk was 2.39+/-5.00 (p=0.63) and -2.87+/-3.92 IU/L (p=0.46) in the vitamin A and controls groups, respectively. There were no significant differences between vitamin A and control groups in the slope of the regression line between log10 erythropoietin and haemoglobin at enrollment or 38 wk, and between enrollment and follow-up within either group.

CONCLUSIONS

Vitamin A supplementation does not appear to increase haemoglobin and plasma erythropoietin concentrations among pregnant women with a high prevalence of anaemia in Malawi.

HIV-1 incidence among male workers at a sugar estate in rural Malawi

OBJECTIVES

To determine incidence of HIV and associated risk factors in two cohorts of men working at a sugar estate in rural Malawi.

DESIGN

Prospective studies.

METHODS

After counseling and obtaining informed consent, male workers were tested for HIV-1 and syphilis. Baseline HIV-seronegative men were enrolled in two follow-up studies in 1994 and 1998, and were retested for HIV and syphilis at 6-month follow-up visits. Demographic, behavioral, and medical history was collected at baseline. Cumulative HIV incidence based on Kaplan-Meier methods was estimated. HIV incidence was also estimated per 100 person-years (p-y). Crude and adjusted rate ratios for the association of risk factors with incident HIV infection were obtained using Cox proportional hazards models.

RESULTS

HIV prevalence was 24.3% among 1692 men screened in 1994 and 21.0% among 1349 men screened in 1998 (p <.03). HIV incidence was extremely high during 1994 to 1995 (17.1% for that 1-year period). Incidence dramatically declined in 1996, averaging about 3.5% per year from 1996 through 1999. Among men enrolled in the 1998 cohort, HIV incidence during 1998 to 1999 was 3.8%. After controlling for potential confounders reactive syphilis was associated with a twofold risk of HIV acquisition in each cohort.

CONCLUSIONS

Urgent preventive measures are needed to control the spread of HIV in this economically important occupational cohort. In addition to conventional educational messages to reduce risky sexual behavior, treatment of other sexually transmitted diseases should be considered.

Iron status and indicators of human immunodeficiency virus disease severity among pregnant women in Malawi

The relationships among hemoglobin, ferritin, and transferrin receptor levels and 2 markers of human immunodeficiency virus (HIV) disease severity--HIV load and CD4(+) lymphocyte count--were characterized among 483 pregnant women in Malawi, Africa. The only significant correlation was an inverse correlation between hemoglobin level and plasma HIV load (r=-.104; P<.03). The prevalence of iron deficiency anemia was not significantly different across quartiles of HIV load or CD4(+) lymphocyte count. In contrast to previous studies, these data suggest that iron status is not related to markers of HIV disease severity in pregnant women in Africa.

Plasma and breast milk vitamin A as indicators of vitamin A status in pregnant women

Breast milk vitamin A is not well characterized as an indicator of vitamin A status in women with infections. A controlled trial of vitamin A, 3 mg retinol equivalent/day, was conducted among 697 pregnant women with human immunodeficiency virus (HIV) infection in Malawi which allowed comparison of plasma versus breast milk vitamin A as indicators of vitamin A status. Retinol concentrations were measured in plasma at baseline (18-28 weeks) and 38 weeks gestation and breast milk at 6 weeks post-partum. Plasma alpha 1-acid glycoprotein (AGP) and C-reactive protein (CRP) were measured at baseline. Plasma retinol (geometric mean, SD) at 38 weeks was 0.72 (0.44, 1.18) and 0.61 (0.38, 0.98) mumol/L (P < 0.0002) and breast milk retinol was 1.32 (0.71, 2.43) and 0.95 (0.49, 1.82) mumol/L (P < 0.0001) in vitamin A and placebo groups, respectively. Women with elevated acute phase protein (AGP > 1 gm/L and/or CRP > 5 mg/L) at baseline who received vitamin A had significantly higher plasma and breast milk vitamin A at follow-up compared with placebo. Elevated acute phase proteins did not distinguish women with low body stores of vitamin A. Breast milk retinol appears to be a better indicator of vitamin A status than plasma retinol in women with infections.

Morbidity among human immunodeficiency virus-1-infected and -uninfected African children

OBJECTIVE

To assess patterns of morbidity and associated factors in late infancy and early childhood among human immunodeficiency virus (HIV)-infected and -uninfected African children.

DESIGN

Prospective study.

SETTING

The Queen Elizabeth Central Hospital, Blantyre, Malawi.

PARTICIPANTS

Children with known HIV status from an earlier perinatal intervention trial were enrolled during the first year of life and followed to approximately 36 months of age.

OUTCOME MEASURES

Morbidity and mortality information was collected every 3 months by a questionnaire. A physical examination was conducted every 6 months. Blood to determine CD4(+) values was also collected. Age-adjusted and Kaplan-Meier analyses were performed to compare rates of morbidity and mortality among infected and uninfected children.

RESULTS

Overall, 808 children (190 HIV-infected, 499 HIV-uninfected but born to infected mothers, and 119 born to HIV-uninfected mothers) were included in this study. Of these, 109 died during a median follow-up of 18 months. Rates of childhood immunizations were high among all children (eg, lowest was measles vaccination [87%] among HIV-infected children). Age-adjusted morbidity rates were significantly higher among HIV-infected than among HIV-uninfected children. HIV-infected children were more immunosuppressed than were uninfected children. By 3 years of age, 89% of the infected children died, 10% were in HIV disease category B or C, and only approximately 1% were without HIV symptoms. Among HIV-infected children, median survival after the first occurrence of acquired immunodeficiency syndrome-related conditions, such as splenomegaly, oral thrush, and developmental delay, was <10 months. These same conditions, in addition to frequent bouts of fever, were the main morbidity predictors of mortality.

CONCLUSIONS

The frequency of diseases was high, and progression from asymptomatic or symptomatic HIV disease to death was rapid. Management strategies that effectively reduce morbidity for HIV-infected children are needed.

Assessment of iron status using plasma transferrin receptor in pregnant women with and without human immunodeficiency virus infection in Malawi

BACKGROUND

Although anemia is highly prevalent during pregnancy and is common during human immunodeficiency virus (HIV) infection, anemia and iron status have not been well characterized in HIV-infected pregnant women.

OBJECTIVE

To gain insight into iron status in HIV-infected pregnant women using plasma transferrin receptor and related indicators of anemia.

STUDY DESIGN

Plasma transferrin receptor, ferritin, alpha1-acid glycoprotein, C-reactive protein and hemoglobin concentrations were measured in pregnant women, gestational age 18-28 weeks, seen in an urban antenatal clinic in Blantyre, Malawi.

RESULTS

The prevalence of anemia among 662 HIV-positive and 190 HIV-negative pregnant women was 73.1% and 50.0%, respectively (P<0.0001). Among HIV-positive and HIV-negative women, median plasma transferrin receptor concentrations were 24.4 and 24.1 nmol/l (P=0.5), respectively, and median plasma ferritin concentrations were 17.8 and 20.8 microg/l (P<0.05), respectively. There was a large overlap in plasma transferrin receptor concentrations among women with and without anemia. Using the combination of hemoglobin and ferritin as a standard, the sensitivity and specificity of plasma transferrin receptor in diagnosing iron deficiency anemia was estimated at 45.9% and 68.1%, respectively.

CONCLUSION

The use of plasma transferrin receptor concentrations as an indicator of iron deficiency anemia may be limited in pregnant women with chronic inflammation and infection.

Genital tract infections and perinatal transmission of HIV

In areas of the world where genital tract infections (GTIs) are common, the prevalence of HIV and the rate of mother-to-child transmission (MTCT) of HIV are also high. Although observational studies suggested that GTIs are associated with MTCT of HIV, no controlled clinical trial has confirmed this finding. It is likely that GTIs that cause either discharges or ulcers during pregnancy increase perinatal transmission of HIV. Several potential biological mechanisms might facilitate perinatal transmission. For example, chorioamnionitis, increased viral shedding in cervicovaginal secretions, increased HIV acquisition during pregnancy, inflammatory cytokine production, preterm labor, prolonged rupture of membranes, ascending infection, and increased intrapartum infectious secretions are factors that can be associated with GTIs. Several studies have shown that treating clinical conditions associated with inflammation might alter HIV shedding. It is conceivable that preventing ascending infection or reducing exposure of the infant to infectious material during birth could reduce MTCT. This can possibly be achieved by antimicrobial therapy during pregnancy and intrapartum. Such an approach is practical, is less expensive, and has secondary benefits related to prevention of adverse pregnancy outcomes associated with GTIs. Antibiotics might also complement reductions in MTCT of HIV obtained by antiretrovirals given to the mother around the time of delivery. In addition, antibiotics could reduce infectious causes of morbidity and mortality in infant and mother.

Association of HIV-1 load and CD4 lymphocyte count with mortality among untreated African children over one year of age

OBJECTIVE

To examine the association of viral load and CD4 lymphocyte count with mortality among HIV-infected children over one year of age.

DESIGN

A prospective study. HIV-infected children were enrolled during the first year of life and followed for more than 2 years at the Queen Elizabeth Central Hospital in Blantyre, Malawi (southeast Africa).

METHODS

Morbidity and mortality information was collected every 3 months, and physical examination and blood testing (for viral level and CD4 cell percentage) were performed every 6 months. Kaplan-Meier analyses and proportional hazards models were used to estimate survival and to examine the association of primary predictors with mortality.

RESULTS

Of 155 HIV-infected children originally enrolled, 115 (74%) had viral load testing and 82 (53%) had both viral load and CD4 cell percentage testing after their first year. Among children over one year of age, significant associations were found between mortality and the log10 viral load and CD4 cell percentage in both univariate and multivariate models. Independent of the CD4 cell value, a one unit log10 increase in HIV RNA level increased the hazard of child mortality by more than twofold. Children with low CD4 cell counts (< 15%) and high viral loads (> or = 250,000 copies/ml median value) had the worst survival; children with high CD4 cell counts (> or = 15%) and low viral loads (< 250,000 copies/ml) had the best survival.

CONCLUSION

As in developed countries, viral load and CD4 cell count are the main predictors of mortality among African children. Making these tests available adds to the challenges to be considered if antiviral therapies were to be adopted in these countries.

Mastitis and immunological factors in breast milk of human immunodeficiency virus-infected women

Human milk contains important immunological factors that protect the breast from infection and are thought to protect infants from infection, including human immunodeficiency virus (HIV) infection. Human milk immunological factors have not been well characterized in HIV-infected lactating women. Lysozyme, secretory leukocyte protease inhibitor (SLPI), sodium (an indicator of mastitis), and HIV were measured in breast milk of 334 HIV-infected women at 6 weeks postpartum. Women with mastitis, as indicated by elevated breast milk sodium concentrations, had higher median levels lysozyme (290 vs 221 mg/L, p < 0.04), SLPI (38 vs 19 mg/L, p < 0.0001) and HIV (920 copies/mL vs undetectable, p < 0.0001) compared with women without mastitis. Lower total plasma carotenoid levels (p < 0.02) and higher maternal HIV load (p < 0.006) by quartile were risk factors for mastitis. Mastitis, as indicated by elevated breast milk sodium levels, is associated with high concentrations of immunological factors and higher HIV load in breast milk.

Virus levels in untreated African infants infected with human immunodeficiency virus type 1

In developed areas, human immunodeficiency virus (HIV)-infected infants have high virus levels and rapidly progress to death. HIV levels were assessed in 1994-1997 in untreated infants in Malawi by analysis of dried blood spots tested by nucleic acid silica-bound amplification. Of 24 umbilical cord blood (CB)-positive samples, 83% had >10,000 copies/mL. The median virus level was 78,000 copies/mL. First positive sample median levels were 355,000 copies/mL among 52 perinatally infected infants and 130,000 copies/mL among 43 infants infected by breast-feeding. Virus levels were stable, and initial levels predicted levels 1 year after infection (P=.005), at which time levels did not significantly differ among in utero, perinatally, or postnatally infected infants. Thus, neither age at infection nor route of infection significantly influenced HIV levels measured 1 year after infection. Most (87%) CB-positive infants were infected before labor onset, since virus levels greatly exceeded those expected in their mothers.

Mastitis and immunological factors in breast milk of lactating women in Malawi

Although an elevated sodium concentration in human milk is suggested to be an indicator of mastitis, it is unclear whether elevated sodium concentrations are associated with immunological and inflammatory mediators in human milk. We conducted a cross-sectional study to evaluate the relationships between elevated breast milk sodium concentrations and levels of lactoferrin, lysozyme, secretory leukocyte protease inhibitor (SLPI), interleukin-8 (IL-8), and RANTES (regulated on activation normal T cell expressed and secreted) in human milk at 6 weeks postpartum in 96 lactating women in Blantyre, Malawi. Mastitis, as indicated by an elevated breast milk sodium concentration, was present in 15.6% of the women. Women with and without mastitis had respective median levels of other factors as follows: lactoferrin, 1,230 versus 565 mg/liter (P < 0. 0007); lysozyme, 266 versus 274 mg/liter (P = 0.55); SLPI, 76 versus 15 microg/liter, (P < 0.0002); IL-8, 339 versus 25 ng/liter (P < 0. 0001); and RANTES, 82 versus 3 ng/liter (P < 0.0001). Elevated sodium concentrations in breast milk are associated with an increase in levels of some immunological and inflammatory factors in breast milk.

HIV transmission through breastfeeding: a study in Malawi

CONTEXT

Understanding the risk of human immunodeficiency virus (HIV) transmission through breastfeeding is essential for advising HIV-infected mothers and formulating public health policy recommendations.

OBJECTIVE

To measure the frequency, timing, and risk factors of HIV transmission through breast milk.

DESIGN

Prospective cohort study conducted between 1994 and 1997, with follow-up of infants through 24 months of age.

SETTING

Postnatal clinic of tertiary care hospital, Blantyre, Malawi.

PARTICIPANTS

A total of 672 infants (HIV-negative at birth) born to HIV-infected women who had not received antiretroviral drugs during or after pregnancy.

MAIN OUTCOME MEASURE

Incidence of HIV in breastfed infants by age and maternal and infant risk factors for HIV transmission, using proportional hazard models to derive risk ratios (RRs) and 95% confidence intervals (CIs).

RESULTS

Forty-seven children became HIV-infected while breastfeeding but none after breastfeeding had stopped. The cumulative infection rate while breastfeeding, from month 1 to the end of months 5, 11,17, and 23, was 3.5%, 7.0%, 8.9%, and 10.3%, respectively. Incidence per month was 0.7% during age 1 to 5 months, 0.6% during age 6 to 11 months, and 0.3% during age 12 to 17 months (P = .01 for trend). The only factors significantly associated with low risk of postnatal HIV transmission in a multivariate model were high maternal parity (RR, 0.23; 95% CI, 0.09-0.56) and older maternal age (RR, 0.44; 95% CI, 0.23-0.84).

CONCLUSIONS

Our data suggest that the risk of HIV infection is highest in the early months of breastfeeding, which should be considered in formulating breastfeeding policy recommendations.

Mortality after the first year of life among human immunodeficiency virus type 1-infected and uninfected children

BACKGROUND

HIV-infected and uninfected children who survived their first year of life were prospectively followed in Malawi to assess levels of mortality and related risk factors during the second and third years of life.

METHODS

Children with known HIV status from an earlier perinatal intervention trial were enrolled. These children [HIV-infected (Group A); HIV-uninfected but born to HIV-seropositive mothers (Group B); and children born to HIV-seronegative mothers (Group C)] were followed every 3 months until age 36 months. Mortality data were collected at each visit. Immunologic data (CD4+ percent) were collected at or immediately after enrollment.

RESULTS

Overall 702 children were enrolled and 83 children died during follow-up. The mortality rate per 1000 person years of observation was 339.3 among Group A children, 46.3 among Group B children and 35.7 among Group C children. Among HIV-infected children the cumulative proportion surviving to age 24 months was 70% and those surviving to age 36 months was 55%. By age 32 months none of the severely immunosuppressed (CD4% < 15%) children had survived. The mortality differentials between HIV-infected and uninfected children persisted after adjusting for several risk factors. The major causes of death among infected children (n = 52) were wasting and respiratory conditions.

CONCLUSIONS

Although all HIV-infected children had received childhood immunizations, mortality was high. Management of these children should include aggressive antimicrobial treatment, and evaluation of prophylactic regimens should be considered.

Predictors and impact of losses to follow-up in an HIV-1 perinatal transmission cohort in Malawi

BACKGROUND

Large simple trials which aim to study therapeutic interventions and epidemiological associations of human immunodeficiency virus (HIV) infection, including perinatal transmission, in Africa may have substantial rates of loss to follow-up. A better understanding of the characteristics and the impact of women and children lost to follow-up is needed.

METHODS

We studied predictors and the impact of losses to follow-up of infants born in a large cohort of delivering women in urban Malawi. The cohort was established as part of a trial of vaginal cleansing with chlorhexidine during delivery to prevent mother-to-infant transmission of HIV.

RESULTS

The HIV infection status could not be determined for 797 (36.9%) of 2156 infants born to HIV-infected mothers; 144 (6.7%) with missing status because of various sample problems and 653 (30.3%) because they never returned to the clinic. Notably, the observed rates of perinatal transmission were significantly lower in infants who returned later for determination of their infection status (odds ratio = 0.94 per month, P = 0.03), even though these infants must have had an additional risk of infection from breastfeeding. In multivariate models, infants of lower birthweight (P = 0.003) and, marginally, singletons (P = 0.09) were less likely to return for follow-up. The parents of infants lost to follow-up tended to be less educated (P < 0.001) and more likely to be in farming occupations, although one educated group, teachers and students, were also significantly less likely to return. Of these variables, infant birthweight, twins versus singletons, and maternal education were also associated with significant variation in the observed risk of perinatal transmission among infants of known HIV status.

CONCLUSIONS

Several predictors of loss to follow-up were identified in this large HIV perinatal cohort. Losses to follow-up can impact the observed transmission rate and the risk associations in different studies.

Human immunodeficiency virus load in breast milk, mastitis, and mother-to-child transmission of human immunodeficiency virus type 1

Human immunodeficiency virus (HIV) type 1 load in breast milk and mastitis were examined as risk factors for vertical transmission of HIV-1. Six weeks after delivery, HIV-1 load and sodium (an indicator of mastitis) were measured in breast milk from 334 HIV-1-infected women in Malawi. Median breast milk HIV-1 load was 700 copies/mL among women with HIV-1-infected infants versus undetectable (<200 copies/mL) among those with uninfected infants, respectively (P<. 0001). Elevated breast milk sodium levels consistent with mastitis occurred in 16.4% of HIV-1-infected women and were associated with increased vertical transmission of HIV-1 (P<.0001). Median breast milk HIV-1 load was 920 copies/mL among women with versus undetectable among those without elevated breast milk sodium levels, respectively (P<.0001). Mastitis and breast milk HIV-1 load may increase the risk of vertical transmission of HIV-1 through breast-feeding.

The effect of Plasmodium falciparum malaria on HIV-1 RNA blood plasma concentration

OBJECTIVES

This study was undertaken to determine the relative effect of malaria infection on HIV concentration in blood plasma, and prospectively to monitor viral concentrations after antimalarial therapy.

DESIGN

A prospective, double cohort study was designed to compare the blood HIV-1 RNA concentrations of HIV-positive individuals with and without acute malaria illness. Subjects were followed for 4 weeks after successful malaria therapy, or for 4 weeks from enrollment (controls).

METHODS

Malawian adults with symptomatic Plasmodium falciparum parasitemia (malaria group) and asymptomatic, aparasitemic blood donors (control group) were tested for HIV-1 antibodies to identify appropriate study groups. The malaria group received antimalarial chemotherapy only and were followed with sequential blood films. In both groups, blood plasma HIV-1 RNA viral concentrations were determined at enrollment and again at 1, 2 and 4 weeks.

RESULTS

Forty-seven malaria patients and 42 blood donors were enrolled. At enrollment blood plasma HIV-1 RNA concentrations were approximately sevenfold higher in patients with malaria than in blood donors (medians 15.1 x 10(4) and 2.24 x 10(4) copies/ml, respectively, P = 0.0001). No significant changes in median HIV-1 concentrations occurred in the 21 blood donors followed to week 4 (P = 0.68). In the 27 subjects successfully treated for malaria who were followed to week 4, a reduction in plasma HIV-1 RNA was observed from a median of 19.1 x 10(4) RNA copies/ml at enrollment, to 12.0 x 10(4) copies/ml at week 4, (P = 0.02). Plasma HIV-1 concentrations remained higher in malaria patients than controls (median 12.0 x 10(4) compared with 4.17 x 10(4) copies/ml, P = 0.086).

CONCLUSIONS

HIV-1 blood viral burden is higher in patients with P. falciparum malaria than in controls and this viral burden can, in some patients, be partly reduced with antimalarial therapy.

Carotenoid status of pregnant women with and without HIV infection in Malawi

OBJECTIVE

To characterise the major plasma carotenoids in pregnant women with and without HIV infection attending antenatal clinic in Blantyre, Malawi.

DESIGN

A cross sectional study.

SETTING

Antenatal clinic of Queen Elizabeth Central Hospital, Blantyre, Malawi.

SUBJECTS

Nine hundred women (697 HIV-positive and 203 HIV-negative women) in their second trimester of pregnancy.

MAIN OUTCOME MEASURES

Plasma carotenoid levels as related to HIV status and level of disease progression.

RESULTS

There were no significant differences in plasma carotenoid levels between HIV-positive and HIV-negative women. Median (25th, 75th percentiles) plasma levels of carotenoids for all women in the study were alpha-carotene, 0.040 (0.23, 0.071) mumol/L; beta-carotene, 0.350 (0.192, 0.595) mumol/L; beta-cryptoxanthin, 0.050 (0.029, 0.091) mumol/L; lutein/zeaxanthin 0.646 (0.426, 0.976) mumol/L; lycopene, 0.088 (0.055, 0.138) mumol/L, and total carotenoids 1.321 (0.884, 1.874) mumol/L. Mothers had higher mean plasma concentrations of alpha-carotene (p < 0.04), beta-carotene (p < 0.0001), lutein/zeaxanthin (p < 0.0001), and total carotenoids (p < 0.0001) in the wet season than the dry season. No seasonality was observed for beta-cryptoxanthin, lycopene, or retinol.

CONCLUSION

This study suggests that pregnant women with and without HIV infection in Blantyre, Malawi have relatively low plasma carotenoid levels and poor dietary intake of provitamin A carotenoids.

HIV infection and disturbances of vaginal flora during pregnancy

Disturbances of vaginal flora are common among women of reproductive age. In areas of sub-Saharan Africa where the prevalence of HIV is high, the frequency of bacterial vaginosis (BV) is also high. In this study, we assessed the association of BV and other disturbances of vaginal flora with prevalent HIV infection in two cross-sectional studies among pregnant women in urban Malawi. The prevalence of HIV-1 was 23% in 1990 and 30% in 1993. Overall, 30% of the women had BV, 59% had mild or moderate disturbance of vaginal flora, and only 11% had normal vaginal flora. Increasing prevalence of HIV was significantly associated with increasing severity of disturbance of vaginal flora (p < .00001, chi2 trend test). This trend of increased prevalence persisted after controlling for concurrent sexually transmitted diseases (STDs), sexual activity, and socioeconomic factors. After multivariate adjustment for potential confounders, the odds ratio for the association of BV with prevalent HIV infection was 3.0 (95% confidence interval [CI], 2.4-3.8), that of moderate vaginal disturbance with HIV infection was 2.2 (95% CI, 1.7-2.8), and that of mild vaginal disturbance with HIV infection was 1.6 (95% CI, 1.3-2.1). Among women with BV, HIV infection was higher among younger women than older, implying more recent infection. Although these studies were cross-sectional, our data suggest that BV could be associated with increased susceptibility to HIV infection.

Bacterial vaginosis and disturbances of vaginal flora: association with increased acquisition of HIV

BACKGROUND

Cross-sectional studies suggest an association between bacterial vaginosis (BV) and HIV-1 infection. However, an assessment of a temporal effect was not possible.

OBJECTIVES

To determine the association of BV and other disturbances of vaginal flora with HIV seroconversion among pregnant and postnatal women in Malawi, Africa.

DESIGN

Longitudinal follow-up of pregnant and postpartum women.

METHODS

Women attending their first antenatal care visit were screened for HIV after counselling and obtaining informed consent. HIV-seronegative women were enrolled and followed during pregnancy and after delivery. These women were again tested for HIV at delivery and at 6-monthly visits postnatally. Clinical examinations and collection of laboratory specimens (for BV and sexually transmitted diseases) were conducted at screening and at the postnatal 6-monthly visits. The diagnosis of BV was based on clinical criteria. Associations of BV and other risk factors with HIV seroconversion, were examined using contingency tables and multiple logistic regression analyses on antenatal data, and Kaplan-Meier proportional hazards analyses on postnatal data.

RESULTS

Among 1196 HIV-seronegative women who were followed antenatally for a median of 3.4 months, 27 women seroconverted by time of delivery. Postnatally, 97 seroconversions occurred among 1169 seronegative women who were followed for a median of 2.5 years. Bacterial vaginosis was significantly associated with antenatal HIV seroconversion (adjusted odds ratio = 3.7) and postnatal HIV seroconversion (adjusted rate ratio = 2.3). There was a significant trend of increased risk of HIV seroconversion with increasing severity of vaginal disturbance among both antenatal and postnatal women. The approximate attributable risk of BV alone was 23% for antenatal HIV seroconversions and 14% for postnatal seroconversions.

CONCLUSIONS

This prospective study suggests that progressively greater disturbances of vaginal flora, increase HIV acquisition during pregnancy and postnatally. The screening and treating of women with BV could restore normal flora and reduce their susceptibility to HIV.

Trends of HIV-1 and sexually transmitted diseases among pregnant and postpartum women in urban Malawi

OBJECTIVES

To examine rates of HIV-1 and sexually transmitted disease (STD) among pregnant and postpartum women in urban Malawi, Africa.

DESIGN

Serial cross-sectional surveys and a prospective study.

METHODS

Three major surveys were conducted in 1990, 1993 and 1994/1995. Consecutive first-visit antenatal women and women giving birth at the Queen Elizabeth Central Hospital were tested for HIV and STD after counseling and obtaining informed consent. Unlinked, anonymous HIV testing was also conducted on smaller samples of antenatal women in the same hospital to provide annual prevalence data. HIV-seronegative postpartum women from the 1990 and 1993 surveys were enrolled in a prospective study to determine HIV incidence.

RESULTS

HIV seroprevalence rose from 2.0% in 1985 to 32.8% in 1996, a 16-fold increase. The highest age-specific HIV prevalence was in the following age-groups: 20-24 years during 1990, 25-29 years during 1993, and 30-34 years during 1996. Among 1173 women followed for a median of 30.9 months, HIV incidence was 5.98 per 100 person-years in women aged < 20 years and declined steadily in older women. The prevalence of STD significantly declined among both HIV-positive and negative women. This decline in STD prevalence, however, was not accompanied by increased condom use over time.

CONCLUSIONS

Among urban childbearing women in Malawi, incidence of HIV is highest among young women while, currently, prevalence is highest among older women. Recent declines in STD prevalence suggest that HIV prevention programs are having an impact either through improved STD diagnosis and treatment or reduced risk behaviors. Sequential cross-sectional STD prevalence measures may be useful in monitoring effectiveness of STD and HIV prevention activities.

Does umbilical cord blood polymerase chain reaction positivity indicate in utero (pre-labor) HIV infection?

OBJECTIVE

To compare risk factors for infants whose cord blood was positive for HIV DNA with those who were cord blood-negative but found to be HIV DNA-positive in early infancy.

METHODS

In 1994, infants born to HIV-infected women were enrolled in a study in Blantyre, Malawi. Birth weight and transmission risk factors from cord blood-positive infants were compared with cord blood-negative/HIV-positive infants on their first postnatal visit (4-7 weeks of age). Testing for HIV DNA on cord and peripheral blood was performed by polymerase chain reaction.

RESULTS

Of 249 HIV-infected infants (overall transmission rate, 26%), 83 (33%) were cord blood-positive and 166 were initially cord blood-negative. The mean birth weight was 2.1% (59 g) lighter in cord blood-positive infants than initially cord blood-negative infants; initially cord blood-negative infants were 2.8% (80 g) lighter than uninfected infants born to HIV-infected women. There were no significant differences in the risk factors for infection between HIV-infected cord blood-positive and -negative infants; when transmission was increased, both HIV-infected cord blood-positive and -negative infants contributed to the increase in a similar proportion.

INTERPRETATION

It was concluded that umbilical cord blood positivity for HIV DNA did not identity a subset of in utero HIV-infected infants and suggested that HIV-infected cord blood-positive and -negative infants have similar timing and routes of HIV infection.

Effect of cleansing the birth canal with antiseptic solution on maternal and newborn morbidity and mortality in Malawi: clinical trial

OBJECTIVE

To determine if cleansing the birth canal with an antiseptic at delivery reduces infections in mothers and babies postnatally.

DESIGN

Clinical trial; two months of no intervention were followed by three months of intervention and a final month of no intervention.

SETTING

Queen Elizabeth Central Hospital (tertiary care urban hospital), Blantyre, Malawi.

SUBJECTS

A total of 6965 women giving birth in a six month period and their 7160 babies.

INTERVENTION

Manual wipe of the maternal birth canal with a 0.25% chlorhexidine solution at every vaginal examination before delivery. Babies born during the intervention were also wiped with chlorhexidine.

MAIN OUTCOME MEASURES

Effects of the intervention on neonatal and maternal morbidity and mortality.

RESULTS

3635 women giving birth to 3743 babies were enrolled in the intervention phase and 3330 women giving birth to 3417 babies were enrolled in the non-intervention phase. There were no adverse reactions related to the intervention among the mothers or their children. Among infants born in the intervention phase, overall neonatal admissions were reduced (634/3743 (16.9%) v 661/3417 (19.3%), P < 0.01), as were admissions for neonatal sepsis (7.8 v 17.9 per 1000 live births, P < 0.0002), overall neonatal mortality (28.6 v 36.9 per 1000 live births, P < 0.06), and mortality due to infectious causes (2.4 v 7.3 per 1000 live births, P < 0.005). Among mothers receiving the intervention, admissions related to delivery were reduced (29.4 v 40.2 per 1000 deliveries, P < 0.02), as were admissions due to postpartum infections (1.7 v 5.1 per 1000 deliveries, P = 0.02) and duration of hospitalisation (Wilcoxon P = 0.008).

CONCLUSIONS

Cleansing the birth canal with chlorhexidine reduced early neonatal and maternal postpartum infectious problems. The safety, simplicity, and low cost of the procedure suggest that it should be considered as standard care to lower infant and maternal morbidity and mortality.

Blood collection on filter paper: a practical approach to sample collection for studies of perinatal HIV transmission

The use of dried blood spots lends itself to widespread application in large field studies, especially in remote areas. We present experience gained during a perinatal HIV transmission study in southern Africa in which dried blood spot samples were used for polymerase chain reaction (PCR) tests. In this study, 15,810 filter paper cards with dried blood spots were collected. Infants were seen at age 6 and 12 weeks, and PCR was routinely done in duplicate on each sample. Of 186 negative controls (infants born to HIV-negative women), two (1.1%) had a single strongly reactive PCR result; the repeated duplicates were both negative. In contrast, all 24 known positive samples were strongly positive in both tests. Results were available from 1,976 duplicate tests on 1,235 infants born to HIV-infected women. Based on the PCR result on a later sample, the positive predictive value was 97.6% if both replicates were strongly positive (absorbance: 0.8 OD450 U), 100% when one of the replicates was strongly positive, and 27% when one or both replicates were weakly positive (but none strongly positive). When both replicates were negative, the negative predictive value was > or = 96.2%. Thus, when a single HIV PCR test has a strongly positive result, the infant is very likely to be infected. A positive PCR result after age 1 month was 98.9% accurate in predicting antibody positivity after 15 months. Suggestions for sample collection, storage, and PCR testing are provided.

Comparison of reported and confirmed malaria during pregnancy: findings from hospital and community studies in Sudan

Hospital case-control and community follow-up studies were conducted to compare the results of laboratory confirmed malaria against the reliability of maternal reported malaria at time of delivery. The studies were carried out in Sudan in Gezira area where malaria is stable and in Sennar area where malaria is unstable. In the hospital study, 348 cases were compared with 812 controls. In the community study, 275 cases were compared with 1248 controls. Overall, reported or confirmed malaria was significantly associated with low birth weight. The results were consistent between the hospital and community populations in Wad Medani (Gezira) area. However, the association of malaria with low birth weight was weaker and inconsistent between the hospital and the community in Sennar area. This discrepancy is related to unbalanced exposure to malaria among cases and controls in the Sennar area where malaria prevalence is higher among urban than among rural populations. The results suggest that maternal history is a reasonably accurate method of assessing clinical episodes of malaria during pregnancy especially where malaria is stable and therefore justifies presumptive treatment of malaria. The unique patterns of malaria transmission in Sennar area emphasise the need for through evaluation of local epidemiological factors for better malaria control activities.

Perinatal intervention trial in Africa: effect of a birth canal cleansing intervention to prevent HIV transmission

BACKGROUND

Perinatal transmission of human immunodeficiency virus (HIV) type 1 contributes significantly to infant mortality. Exposure in the birth canal may account for some transmission. We examined the efficacy of a birth canal washing procedure in reducing perinatal transmission in Malawi.

METHODS

The infection status of infants of 3327 control women (conventional delivery procedures) was compared with that of 3637 infants of intervention-delivered women. The infants' HIV status was determined by polymerase chain reaction on dried blood spots collected at 6 and 12 weeks of age. The intervention consisted of manual cleansing of the birth canal with a cotton pad soaked in 0.25% chlorhexidine, which was done on admission in labour and every 4 h until delivery.

FINDINGS

No adverse reactions to the intervention procedure were seen. 2094 (30%) of the enrolled women were HIV-infected, and 59% of their infants were seen in follow-up. Among 982 vaginal vertex singleton deliveries to HIV-infected women, 269 (27%) infants were infected. The intervention had no significant impact on HIV transmission rates (27% in 505 intervention women compared with 28% in 477 control women), except when membranes were ruptured more than 4 h before delivery (transmission 25% in the intervention group vs 39% in the control group).

INTERPRETATION

If birth canal exposure is an important risk factor, different or additional methods to reduce the risk of perinatal HIV transmission should be tested. Alternatively, perhaps birth canal exposure is not a major contributor to perinatal infection risk.

Longitudinal growth during the first 2 years of life in children born to HIV-infected mothers in Malawi, Africa

To evaluate the longitudinal growth patterns of infants born to HIV-infected and uninfected mothers in Malawi, Africa, 92 HIV-infected infants, 270 uninfected infants born to HIV-infected mothers, and 686 infants born to uninfected mothers between birth and 24 months of life were studied. Weight and length were evaluated longitudinally utilizing generalized estimating equations. HIV-infected children were compared with uninfected children born to HIV-infected and uninfected mothers, and to United States National Center for Health Statistics (NCHS) growth standards. Median weight and length-for-age of seronegative infants born to either seronegative or seropositive mothers approximated the NCHS median from birth to approximately 4 months of age. Median weight and length of HIV-infected infants deviated from the NCHS median at an earlier age, and the deviation was more pronounced than was observed for uninfected infants. Mean growth curves constructed by generalized estimating equations indicated that HIV-infected and uninfected infants born to HIV-infected mothers weighed less and were smaller than infants born to HIV-uninfected mothers initially. Mean weight and length of uninfected infants attained the median of infants born to uninfected mothers by 24 months of age, while HIV-infected infants remained below this median. The difference in mean weight-for-age for HIV-infected and uninfected infants born to HIV-infected mothers was statistically significant from birth. The difference in mean length-for-age was statistically significant after 5 months of age. Thus, although infants born to HIV-infected mothers were smaller and weighed less initially, uninfected infants caught up, while HIV-infected infants remained below the median, and the deficit in weight occurred earlier in life than the deficit in length.

Reported condom use is not associated with incidence of sexually transmitted diseases in Malawi

OBJECTIVES

To establish frequency of reported condom use and validate reliability of self-reporting among urban women in Malawi.

DESIGN

Cross-sectional survey in antenatal women in 1989 and 1993. Prospective study in cohort first surveyed in 1989.

METHODS

A total of 6561 women in 1989 and 2460 women in 1993 answered questions about condom use and sexual activity, had a physical examination and were screened for HIV. A subset of women from the 1989 screening were administered a questionnaire and tested for syphilis, Neisseria gonorrhoeae and Trichomonas vaginalis infections every 6 months.

RESULTS

Although between the two cross-sectional studies intermittent condom use increased from 6 to 15% (P < 0.001) with no difference according to HIV infection, consistent use was reported by less than 1%. In the prospective study, women reported a higher condom use at any visit than either group assessed cross-sectionally. Consistent condom use peaked at 62% in the first 6 months, but declined to as low as 8% in the second year of follow-up. Condom use at each visit, either intermittent or consistent, was higher in HIV-seropositive than HIV-seronegative women. Overall, the incidence of gonorrhea, trichomoniasis and syphilis did not decline in women reporting consistent condom use.

CONCLUSIONS

In prospectively followed women reports of consistent condom use was substantially higher than in cross-sectional surveys, but rapidly decreased over time, irrespective of HIV status. The presence of new sexually transmitted diseases suggests that this population of urban women overreports condom use or underreports sexual activity, or both. Intensive and sustained education is needed to achieve consistent condom use. Biologic markers of sexual activity are useful in interpreting reported condom use.

The effect of human immunodeficiency virus infection on birthweight, and infant and child mortality in urban Malawi

BACKGROUND

Low birthweight, prematurity and intra-uterine growth retardation (IUGR) are major determinants of child survival. Therefore, it is important to assess excess mortality due to human immunodeficiency virus (HIV) infection in populations where low birthweight is common.

METHODS

A prospective study was conducted on 1385 children born to seropositive and seronegative women in urban Malawi. Children were regularly examined and tested for HIV.

RESULTS

The mortality rate of children of HIV seropositive mothers was substantially higher (223/1000 at 12 months, 317/1000 at 24 months and 360/1000 at 30 months) than that of children of seronegative mothers (68/1000 at 12 months, 106/1000 at 24 months and 118/1000 at 30 months). The incidence of prematurity and IUGR was also higher in infants of HIV seropositive mothers than in infants of seronegative mothers (12.7% versus 3.8%, P < 0.001 for premature and 7.7% versus 4.4%, P = 0.02 for IUGR infants). The mother-to-infant HIV-1 transmission rate was 35.1%. After 12 months of age, HIV infected children showed the highest mortality; however, uninfected children of HIV seropositive and children of HIV seronegative mothers had similar mortality. The mean birthweight of HIV infected and uninfected children was not significantly different. In HIV infected children the most frequent causes of death were diarrhoea, pneumonia and failure to thrive. Less common risk factors for child mortality included active maternal syphilis and cervicitis/vaginitis.

CONCLUSION

The substantial difference in survival among children of HIV infected and uninfected mothers suggests that mortality could be reduced if HIV infection were not a risk factor. To decrease childhood mortality, a combination of interventions such as treatment of sexually transmitted infections during pregnancy and measures to reduce mother-to-infant transmission should be adopted.

An intervention to reduce the risk of mother-to-infant HIV transmission: results of a pilot toxicity study

Although unproven, vaginal cleansing with antiseptics during labour could be a practical approach to reducing the rate of transmission of HIV infection from mother to infant. Before initiating a large scale clinical trial of the antiseptic chlorhexidine, we conducted a study to assess possible toxic effects as well as beneficial outcomes in 160 women volunteers: 40 non-pregnant chlorhexidine washed, 40 pregnant not washed, 40 pregnant saline washed, and 40 pregnant chlorhexidine washed. The wash was easily administered by the nurse-midwives. The participants generally felt better after the procedure, and had no complaints or adverse reactions in the subsequent 24 hours. Bacteriologically, the procedures lowered the carriage of Group B streptococcus and Staphylococcus aureus, but did not affect the frequency of T. vaginalis detection. No clinical problems were seen, and therefore the larger clinical trial of efficacy will proceed. Results of this trial are expected in late 1995.