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Gumber L, Agbeleye O, Inskip A, Fairbairn R, Still M, Ouma L, Lozano-Kuehne J, Bardgett M, Isaacs JD, Wason JM, Craig D, Pratt AG. Operational complexities in international clinical trials: a systematic review of challenges and proposed solutions. BMJ Open 2024; 14:e077132. [PMID: 38626966 PMCID: PMC11029458 DOI: 10.1136/bmjopen-2023-077132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 02/27/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVE International trials can be challenging to operationalise due to incompatibilities between country-specific policies and infrastructures. The aim of this systematic review was to identify the operational complexities of conducting international trials and identify potential solutions for overcoming them. DESIGN Systematic review. DATA SOURCES Medline, Embase and Health Management Information Consortium were searched from 2006 to 30 January 2023. ELIGIBILITY CRITERIA All studies reporting operational challenges (eg, site selection, trial management, intervention management, data management) of conducting international trials were included. DATA EXTRACTION AND SYNTHESIS Search results were independently screened by at least two reviewers and data were extracted into a proforma. RESULTS 38 studies (35 RCTs, 2 reports and 1 qualitative study) fulfilled the inclusion criteria. The median sample size was 1202 (IQR 332-4056) and median number of sites was 40 (IQR 13-78). 88.6% of studies had an academic sponsor and 80% were funded through government sources. Operational complexities were particularly reported during trial set-up due to lack of harmonisation in regulatory approvals and in relation to sponsorship structure, with associated budgetary impacts. Additional challenges included site selection, staff training, lengthy contract negotiations, site monitoring, communication, trial oversight, recruitment, data management, drug procurement and distribution, pharmacy involvement and biospecimen processing and transport. CONCLUSIONS International collaborative trials are valuable in cases where recruitment may be difficult, diversifying participation and applicability. However, multiple operational and regulatory challenges are encountered when implementing a trial in multiple countries. Careful planning and communication between trials units and investigators, with an emphasis on establishing adequately resourced cross-border sponsorship structures and regulatory approvals, may help to overcome these barriers and realise the benefits of the approach. OPEN SCIENCE FRAMEWORK REGISTRATION NUMBER: osf-registrations-yvtjb-v1.
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Affiliation(s)
- Leher Gumber
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Northumbria Healthcare NHS Foundation Trust, Northumbria, UK
| | - Opeyemi Agbeleye
- NIHR Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Alex Inskip
- NIHR Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ross Fairbairn
- NIHR Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Madeleine Still
- NIHR Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Ouma
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Jingky Lozano-Kuehne
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Michelle Bardgett
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - John D Isaacs
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Musculoskeletal Unit, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - James Ms Wason
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Dawn Craig
- NIHR Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Arthur G Pratt
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Musculoskeletal Unit, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
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Maternal mental health and caregiver competence of HIV-positive and negative women caring for their singleton newborns in KwaZulu-Natal Province, South Africa. S Afr Med J 2022. [DOI: 10.7196/samj.2022.v112i7.15833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background. Maternal mental health during the perinatal period has been of interest to many researchers, with antenatal depression and postnatal depression (PND) being a leading cause of morbidity. The adverse effects of maternal depression on the offspring throughout infancy, childhood and adolescence are well documented. Studies on the mental health of persons living with HIV have also reported a high prevalence of depression.
Objectives. To describe the prevalence of PND in a sample of HIV-positive and HIV-negative mothers delivering healthy singleton infants at one obstetric unit in KwaZulu-Natal (KZN) Province, South Africa, and the subsequent factors influencing neonatal behaviour and perceptions of caregiver competence. Correlations between the presence of PND and perceptions of caregiver competence (with the mother as caregiver), and between infant behaviour, the mother’s confidence in her competence as caregiver, and demographic and medical variables, were also examined.
Methods. Demographic and clinical data were collected from 132 mothers at initial contact and from 32 mothers at the 6-week follow-up appointment. Mothers independently completed the Edinburgh Postnatal Depression Scale at each time point, and the Mother and Baby Scales (MABS) at the 6-week follow-up appointment.Results. The prevalence of depression among all mothers at initial contact was 72.0%, remaining high (68.8%) among the mothers who returned for follow-up. There was a statistically significant correlation between depression and employment at follow-up (p=0.013), and between depression and delivery method (p=0.030). The majority of mothers reported being ‘able to laugh and see the funny side of things’ and ‘looking forward with enjoyment to things’ at initial contact and follow-up. Thoughts of self-harm were reported by 44.7% of mothers at baseline, and by 53.1% at follow-up. Although most infants scored in the average clinical band for neonatal behavioural factors in the MABS, mothers reported lack of confidence, globally and in caring for their infant.
Conclusion. This study of maternal mental health of a sample of HIV-positive and HIV-negative mothers of infants in KZN revealed a higher prevalence of PND than reported in other studies. This population of mothers and infants is at risk of adverse outcomes of maternal depression, in addition to other possible risk factors.
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Vitalis D, Vilar-Compte M, Nyhan K, Pérez-Escamilla R. Breastfeeding inequities in South Africa: Can enforcement of the WHO Code help address them? - A systematic scoping review. Int J Equity Health 2021; 20:114. [PMID: 33947401 PMCID: PMC8097970 DOI: 10.1186/s12939-021-01441-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 04/01/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Suboptimal breastfeeding rates in South Africa have been attributed to the relatively easy access that women and families have had to infant formula, in part as a result of programs to prevent maternal-to-child transmission (MTCT) of HIV. This policy may have had an undesirable spill-over effect on HIV-negative women as well. Thus, the aims of this scoping review were to: (a) describe EBF practices in South Africa, (b) determine how EBF has been affected by the WHO HIV infant feeding policies followed since 2006, and (c) assess if the renewed interest in The Code has had any impact on breastfeeding practices in South Africa. METHODS We applied the Joanna Briggs Institute guidelines for scoping reviews and reported our work in compliance with the PRISMA Extension (PRISMA-ScR). Twelve databases and platforms were searched. We included all study designs (no language restrictions) from South Africa published between 2006 and 2020. Eligible participants were women in South Africa who delivered a healthy live newborn who was between birth and 24 months of age at the time of study, and with known infant feeding practices. RESULTS A total of 5431 citations were retrieved. Duplicates were removed in EndNote and by Covidence. Of the 1588 unique records processed in Covidence, 179 records met the criteria for full-text screening and 83 were included in the review. It was common for HIV-positive women who initiated breastfeeding to stop doing so prior to 6 months after birth (1-3 months). EBF rates rapidly declined after birth. School and work commitments were also reasons for discontinuation of EBF. HIV-positive women expressed fear of HIV MTCT transmission as a reason for not breastfeeding. CONCLUSION The Review found that while enforcing the most recent WHO HIV infant feeding guidelines and the WHO Code may be necessary to improve breastfeeding outcomes in South Africa, they may not be sufficient because there are additional barriers that impact breastfeeding outcomes. Mixed-methods research, including in-depth interviews with key informants representing different government sectors and civil society is needed to prioritize actions and strategies to improve breastfeeding outcomes in South Africa.
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Affiliation(s)
- Debbie Vitalis
- Yale University School of Public Health, New Haven, CT, 06510, USA.
| | | | - Kate Nyhan
- Yale University, Cushing/Whitney Medical Library, 333 Cedar St., New Haven, CT, 06510, USA
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Type-Specific Human Papillomavirus Prevalence, Incident Cases, Persistence, and Associated Pregnancy Outcomes Among HIV-Infected Women in Kenya. Sex Transm Dis 2020; 46:532-539. [PMID: 31295222 DOI: 10.1097/olq.0000000000001029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Persistent infection with high-risk types of human papillomavirus (HPV) is the preeminent factor driving the development of cervical cancer. There are large gaps in knowledge about both the role of pregnancy in the natural history of HPV infection and the impact of HPV on pregnancy outcomes. METHODS This single-site prospective cohort substudy, nested within an international multisite randomized controlled trial, assessed prevalence, incident cases, and persistence of type-specific HPV infection, and the association between persistence of high-risk HPV infection with pregnancy outcomes among HIV-infected pregnant women in Kenya, including HIV transmission to infants. Type-specific HPV was assessed using a line probe assay in pregnancy and again at 3 months after delivery. HIV status of children was determined using polymerase chain reaction at 6 weeks. RESULTS In total, 84.1% (206/245) of women had a high-risk HPV infection at enrollment. Three quarters (157/206) of these infections persisted postpartum. Persistence of HPV16 and/or HPV18 types was observed in more than half (53.4%; 39/73) of women with this infection at enrollment. Almost two-thirds had an incident high-risk HPV infection postpartum, which was not present in pregnancy (62.5%), most commonly HPV52 (19.0%). After adjustments, no association was detected between persistent high-risk HPV and preterm birth. All mothers of the 7 cases of infant HIV infection had persistent high-risk HPV infection (P = 0.044). CONCLUSIONS High levels of high-risk HPV infection and type-specific persistence were documented, heightening the urgency of mass role out of HPV vaccination. The association between HPV persistence and HIV transmission is a novel finding, warranting further study.
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Higher Transplacental Pathogen-Specific Antibody Transfer Among Pregnant Women Randomized to Triple Antiretroviral Treatment Versus Short Course Zidovudine. Pediatr Infect Dis J 2018; 37:246-252. [PMID: 28834955 PMCID: PMC5807132 DOI: 10.1097/inf.0000000000001749] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND HIV-1 infection may impair transplacental antibody transfer to infants. The impact of highly active antiretroviral treatment (ART) given during pregnancy on transplacental antibody transport is unknown. METHODS HIV-1 infected pregnant women with CD4 counts between 200 - 500 were randomized to short-course zidovudine (ZDV) or triple ART at 32 weeks gestation for prevention of mother-to-child HIV-1 transmission. Levels of maternal antibody against measles, pneumococcus and rotavirus at delivery, and antibody transfer to the baby through cord blood, were compared between trial arms. RESULTS Overall, 141 and 148 women were randomized to triple ART and ZDV, respectively; cord blood was available for a subset (n = 20 in triple ART and n = 22 in ZDV). Maternal antibody levels to all pathogens during pregnancy and at delivery were not significantly different between arms. Within each arm, antibody levels at delivery were lower than at enrolment. For all antibodies, a woman's levels before delivery were an important predictor of amount transferred to her infant. Women on triple ART transferred higher levels of pathogen-specific antibodies when compared with women on short course ZDV. CONCLUSIONS Women on triple ART transferred higher levels of pathogen-specific antibodies compared with women on ZDV alone.
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Somé EN, Engebretsen IMS, Nagot N, Meda NY, Vallo R, Kankasa C, Tumwine JK, Singata M, Hofmeyr JG, Van de Perre P, Tylleskär T. Changes in body mass index and hemoglobin concentration in breastfeeding women living with HIV with a CD4 count over 350: Results from 4 African countries (The ANRS 12174 trial). PLoS One 2017; 12:e0177259. [PMID: 28486519 PMCID: PMC5423645 DOI: 10.1371/journal.pone.0177259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 04/25/2017] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Breastfeeding is recommended for infants born to HIV-infected women in low-income settings. Both breastfeeding and HIV-infection are energy demanding. Our objective was to explore how exclusive and predominant breastfeeding changes body mass index (BMI) among breastfeeding HIV1-positive women participating in the ANRS12174 trial (clinical trial no NCT0064026). METHODS HIV-positive women (n = 1 267) with CD4 count >350, intending to breastfeed HIV-negative infants were enrolled from Burkina Faso, South Africa, Uganda and Zambia and counselled on breastfeeding. N = 1 216 were included in the analysis. The trial compared Lamivudine and Lopinavir/Ritonavir as a peri-exposure prophylaxis. We ran a linear mixed-effect model with BMI as the dependent variable and exclusive or predominant breastfeeding duration as the key explanatory variable. RESULTS Any breastfeeding or exclusive/predominant) breastfeeding was initiated by 99.6% and 98.6% of the mothers respectively in the first week after birth. The median (interquartile range: IQR) duration of the group that did any breastfeeding or the group that did exclusive /predominant breastfeeding were 9.5 (7.5; 10.6) and 5.8 (5.6; 5.9)) months, respectively. The median (IQR) age, BMI, CD4 count, and HIV viral load at baseline (day 7) were 27 (23.3; 31) years, 23.7 (21.3; 27.0) kg/m2, 530 (432.5; 668.5) cells/μl and 0.1 (0.8; 13.7)1000 copies/mL, respectively. No major change in mean BMI was seen in this cohort over a 50-week period during lactation. The mean change between 26 and 50 weeks after birth was 0.7 kg/m2. Baseline mean BMI (measured on day 7 postpartum) and CD4 count were positively associated with maternal BMI change, with a mean increase of 1.0 kg/m2 (0.9; 1.0) per each additional baseline-BMI kilogram and 0.3 kg/m2 (0.2; 0.5) for each additional CD4 cell/μl, respectively. CONCLUSION Breastfeeding was not negatively correlated with the BMI of HIV-1 infected Sub-Saharan African mothers. However, a higher baseline BMI and a CD4 count >500 cells/μl were associated with maternal BMI during the exclusive/ predominant breastfeeding period. Considering the benefits of breast milk for the infants and the recurrent results from different studies that breastfeeding is not harmful to the HIV-1-infected mothers, this study also supports the WHO 2016 guidelines on infant feeding that mothers living with HIV should breastfeed where formula is not safe for at least 12 months and up to 24 months, given that the right treatment or prophylaxis for the infection is administered. These findings and conclusions cannot be extrapolated to women who are immune-compromised or have AIDS.
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Affiliation(s)
- Eric Nagaonlé Somé
- Centre for International Health, University of Bergen, Bergen, Norway
- National Health Research Institute, Centre National pour la Recherche Scientifique et Technologique, Ouagadougou, Burkina Faso
| | | | - Nicolas Nagot
- INSERM UMR 1058, Pathogenesis and control of chronic infections, Montpellier, France
- Université de Montpellier, Montpellier, France
- Centre Hospitalier Universitaire, Montpellier, France
| | - Nicolas Y. Meda
- University of Ouagadougou, Faculty of Health Sciences, Centre de Recherche International en Santé (CRIS) Ouagadougou, Burkina Faso
| | - Roselyne Vallo
- INSERM UMR 1058, Pathogenesis and control of chronic infections, Montpellier, France
- Université de Montpellier, Montpellier, France
| | - Chipepo Kankasa
- University of Zambia, School of Medicine, Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - James K. Tumwine
- Makerere University, Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Kampala, Uganda
| | - Mandisa Singata
- University of Fort Hare, Effective Care Research Unit, Eastern Cape, South Africa
| | - Justus G. Hofmeyr
- University of Fort Hare, Effective Care Research Unit, Eastern Cape, South Africa
| | - Philippe Van de Perre
- INSERM UMR 1058, Pathogenesis and control of chronic infections, Montpellier, France
- Université de Montpellier, Montpellier, France
- Centre Hospitalier Universitaire, Montpellier, France
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Bork KA, Cames C, Newell ML, Read JS, Ayassou K, Musyoka F, Mbatia G, Cournil A. Formula-Feeding of HIV-Exposed Uninfected African Children Is Associated with Faster Growth in Length during the First 6 Months of Life in the Kesho Bora Study. J Nutr 2017; 147:453-461. [PMID: 28122933 DOI: 10.3945/jn.116.242339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 11/17/2016] [Accepted: 12/21/2016] [Indexed: 11/14/2022] Open
Abstract
Background: Early feeding patterns may affect the growth of HIV-exposed children and thus their subsequent health and cognition.Objective: We assessed the association of infant feeding (IF) mode with length-for-age z score (LAZ) and stunting from age 2 d to 18 mo in HIV-exposed African children within a controlled randomized trial, which evaluated triple antiretrovirals initiated during pregnancy and continued for 6 mo postpartum to prevent HIV transmission.Methods: HIV-infected pregnant women with CD4+ counts of 200-500 cells/mm3 from Burkina Faso, Kenya, and South Africa were advised to exclusively breastfeed for up to 6 mo or to formula-feed from birth. Factors associated with LAZ were investigated in all uninfected children by using mixed-effects linear models; those associated with stunting (LAZ <-2) at 6 or 12 mo were assessed in multiple logistic regression after exclusion of children stunted at age 2 d. Independent variables were IF mode: formula feeding (FF), exclusive breastfeeding (EBF) <3 mo, or EBF ≥3 mo (reference); sex; trial arm; maternal characteristics; and site.Results: Among 728 children, FF was associated with a greater increase in LAZ from 2 d to 6 mo (+0.07 z score/mo, P < 0.001). Between 6 and 18 mo, FF and EBF <3 mo were both associated with greater mean LAZ than was EBF ≥3 mo (+0.52 z scores and +0.43 z scores, respectively, P < 0.001). Among children not stunted at 2 d, FF was independently associated with a reduced risk of stunting at 6 mo (OR: 0.24; 95% CI: 0.07, 0.81; P = 0.021), whereas EBF <3 mo was not (OR: 0.49; 95% CI: 0.22, 1.10; P = 0.09).Conclusions: In this observational study of HIV-exposed uninfected infants, growth in length in the first 6 mo of life was faster in formula-fed infants than in exclusively breastfed infants. The plausibility of residual confounding and reverse causality is discussed. This trial was registered at www.controlled-trials.com as ISRCTN71468401.
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Affiliation(s)
- Kirsten A Bork
- Institut de Recherche pour le Développement UMI233, INSERM U1175, Université de Montpellier, Unité TransVIHMI, Montpellier, France;
| | - Cécile Cames
- Institut de Recherche pour le Développement UMI233, INSERM U1175, Université de Montpellier, Unité TransVIHMI, Montpellier, France
| | - Marie-Louise Newell
- Global Health Research Institute, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Jennifer S Read
- University of California at San Francisco, San Francisco, CA
| | | | - Faith Musyoka
- International Centre for Reproductive Health, Mombasa, Kenya; and
| | - Grace Mbatia
- Kenyatta National Hospital and University of Nairobi, Nairobi, Kenya
| | - Amandine Cournil
- Institut de Recherche pour le Développement UMI233, INSERM U1175, Université de Montpellier, Unité TransVIHMI, Montpellier, France
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Manji KP, Duggan C, Liu E, Bosch R, Kisenge R, Aboud S, Kupka R, Fawzi WW. Exclusive Breast-feeding Protects against Mother-to-Child Transmission of HIV-1 through 12 Months of Age in Tanzania. J Trop Pediatr 2016; 62:301-7. [PMID: 26999011 PMCID: PMC6089093 DOI: 10.1093/tropej/fmw012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The jury on transmission of HIV through breast-feeding is still on. Data from a clinical trial in children born to HIV-positive mothers were evaluated with respect to their relationship to mother-to-child transmission. A total of 1629 infants who were not infected at age 6 weeks, had HIV results available at 12 months and who were breast-fed were included in this study. Exclusive breast feeding (EBF) rates declined from 85% at 2 months to < 30% by 4 months. EBF was associated with a sustained and significant reduction in HIV infection. With every incremental month of EBF, HIV infection was reduced by 16% [multivariable (risk ratio) RR: 0.84, CI: 0.72-0.98, p = 0.03] from enrollment to 6 months of age and by 18% (multivariable RR: 0.82, CI: 0.72-0.94, p = 0.005) from enrollment to 12 months of age. EBF significantly reduces the risk of vertical HIV transmission through 12 months of age.
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Affiliation(s)
- Karim P Manji
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar-es-Salaam, Tanzania
| | - Christopher Duggan
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health/Department of Gastroenterology, Boston Children's Hospital Harvard Medical School, Boston, MA, USA
| | - Enju Liu
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ronald Bosch
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Rodrick Kisenge
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar-es-Salaam, Tanzania
| | - Said Aboud
- Department of Microbiology and Immunology, MUHAS, Dar-es-Salaam, Tanzania
| | - Ronald Kupka
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health/Department of Gastroenterology, Boston Children's Hospital Harvard Medical School, Boston, MA, USA
| | - Wafaie W Fawzi
- Departments of Global Health and Population, Nutrition, and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Liu Y, Wang M, Yao S, Yuan J, Lu J, Li H, Zeng W, Deng Y, Zou R, Li J, Xiao J. Efficacy and safety of telbivudine in different trimesters of pregnancy with high viremia for interrupting perinatal transmission of hepatitis B virus. Hepatol Res 2016; 46:E181-8. [PMID: 25869545 DOI: 10.1111/hepr.12525] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 04/03/2015] [Accepted: 04/08/2015] [Indexed: 01/05/2023]
Abstract
AIM We aimed to investigate the efficacy and safety of telbivudine (LdT) on the intervention of mother-to-child transmission (MTCT) in different trimesters of pregnant women with high viral loads. METHODS In this prospective cohort study, 160 cases of mothers with high viral loads were included. Eighty-two subjects received 600 mg/day LdT therapy. Fifty of them started LdT therapy before the third trimester of gestation, including 17 cases before pregnancy, nine and 24 cases in the first and second trimesters of pregnancy, respectively. The other 32 cases started LdT in the third trimester of gestation. Control pregnant women (78 cases) did not take LdT therapy. MTCT rate was determined by hepatitis B surface antigen (HBsAg) and hepatitis B virus (HBV) DNA data of infants at the 51st week post-partum. Adverse events were also evaluated throughout the study. RESULTS One hundred and sixty infants were born from 160 pregnant women. Both LdT-treated groups displayed a marked decline in HBV DNA levels from the beginning to delivery. Positive rate of serum HBsAg in infants born from the above two groups of mothers were 0% and 3.1%, respectively, which was significantly lower than that in the untreated controls (24.4%). The incidence of detectable HBV DNA levels was significantly lower in infants born to LdT-treated mothers than in the controls (16.7%) at the 51st week post-partum. No infant had birth defects. No severe adverse event or complication were observed in LdT-treated mothers or infants followed until the 51st week post-partum. CONCLUSION The earlier application of LdT during pregnancy, the better preventive effects it offered on MTCT.
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Affiliation(s)
- Yingxia Liu
- State Key Discipline of Infectious Diseases, Department of Infectious Diseases, Shenzhen, China
| | - Miao Wang
- Department of Obstetrics and Gynecology, Shenzhen Third People's Hospital, Shenzhen, China
| | - Simin Yao
- State Key Discipline of Infectious Diseases, Department of Infectious Diseases, Shenzhen, China
| | - Jing Yuan
- State Key Discipline of Infectious Diseases, Department of Infectious Diseases, Shenzhen, China
| | - Jian Lu
- State Key Discipline of Infectious Diseases, Department of Infectious Diseases, Shenzhen, China
| | - Huijuan Li
- State Key Discipline of Infectious Diseases, Department of Infectious Diseases, Shenzhen, China
| | - Wen Zeng
- State Key Discipline of Infectious Diseases, Department of Infectious Diseases, Shenzhen, China
| | - Yong Deng
- State Key Discipline of Infectious Diseases, Department of Infectious Diseases, Shenzhen, China
| | - Rongrong Zou
- State Key Discipline of Infectious Diseases, Department of Infectious Diseases, Shenzhen, China
| | - Jie Li
- Department of Microbiology and Infectious Disease Center, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China
| | - Jia Xiao
- State Key Discipline of Infectious Diseases, Department of Infectious Diseases, Shenzhen, China.,Department of Immunobiology, Institute of Tissue Transplantation and Immunology, Jinan University, Guangzhou, China
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Bork KA, Cournil A, Read JS, Newell ML, Cames C, Meda N, Luchters S, Mbatia G, Naidu K, Gaillard P, de Vincenzi I. Morbidity in relation to feeding mode in African HIV-exposed, uninfected infants during the first 6 mo of life: the Kesho Bora study. Am J Clin Nutr 2014; 100:1559-68. [PMID: 25411291 PMCID: PMC4232020 DOI: 10.3945/ajcn.113.082149] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Refraining from breastfeeding to prevent HIV transmission has been associated with increased morbidity and mortality in HIV-exposed African infants. OBJECTIVE The objective was to assess risks of common and serious infectious morbidity by feeding mode in HIV-exposed, uninfected infants ≤6 mo of age with special attention to the issue of reverse causality. DESIGN HIV-infected pregnant women from 5 sites in Burkina Faso, Kenya, and South Africa were enrolled in the prevention of mother-to-child transmission Kesho Bora trial and counseled to either breastfeed exclusively and cease by 6 mo postpartum or formula feed exclusively. Maternal-reported morbidity (fever, diarrhea, and vomiting) and serious infectious events (SIEs) (gastroenteritis and lower respiratory tract infections) were investigated for 751 infants for 2 age periods (0-2.9 and 3-6 mo) by using generalized linear mixed models with breastfeeding as a time-dependent variable and adjustment for study site, maternal education, economic level, and cotrimoxazole prophylaxis. RESULTS Reported morbidity was not significantly higher in nonbreastfed compared with breastfed infants [OR: 1.31 (95% CI: 0.97, 1.75) and 1.21 (0.90, 1.62) at 0-2.9 and 3-6 mo of age, respectively]. Between 0 and 2.9 mo of age, never-breastfed infants had increased risks of morbidity compared with those of infants who were exclusively breastfed (OR: 1.49; 95% CI: 1.01, 2.2; P = 0.042). The adjusted excess risk of SIEs in nonbreastfed infants was large between 0 and 2.9 mo (OR: 6.0; 95% CI: 2.2, 16.4; P = 0.001). Between 3 and 6 mo, the OR for SIEs was sensitive to the timing of breastfeeding status, i.e., 4.3 (95% CI: 1.2, 15.3; P = 0.02) when defined at end of monthly intervals and 2.0 (95% CI: 0.8, 5.0; P = 0.13) when defined at the beginning of intervals. Of 52 SIEs, 3 mothers reported changes in feeding mode during the SIE although none of the mothers ceased breastfeeding completely. CONCLUSIONS Not breastfeeding was associated with increased risk of serious infections especially between 0 and 2.9 mo of age. The randomized controlled trial component of the Kesho Bora study was registered at Current Controlled Trials (www.controlled-trials.com) as ISRCTN71468401.
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Affiliation(s)
- Kirsten A Bork
- From the Institut de Recherche pour le Développement (IRD), UMI233 IRD/Université de Montpellier 1, Montpellier, France (KAB, AC, and CC); the Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD (JSR); the Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa (M-LN); the Centre Muraz, Bobo-Dioulasso, Burkina Faso (NM); the International Centre for Reproductive Health, Mombasa, Kenya (SL); the Kenyatta National Hospital and University of Nairobi, Nairobi, Kenya (GM); the University of KwaZulu-Natal, Durban, South African Republic (KN); and the WHO, Reproductive Health and Research, Geneva, Switzerland (PG and IdV)
| | - Amandine Cournil
- From the Institut de Recherche pour le Développement (IRD), UMI233 IRD/Université de Montpellier 1, Montpellier, France (KAB, AC, and CC); the Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD (JSR); the Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa (M-LN); the Centre Muraz, Bobo-Dioulasso, Burkina Faso (NM); the International Centre for Reproductive Health, Mombasa, Kenya (SL); the Kenyatta National Hospital and University of Nairobi, Nairobi, Kenya (GM); the University of KwaZulu-Natal, Durban, South African Republic (KN); and the WHO, Reproductive Health and Research, Geneva, Switzerland (PG and IdV)
| | - Jennifer S Read
- From the Institut de Recherche pour le Développement (IRD), UMI233 IRD/Université de Montpellier 1, Montpellier, France (KAB, AC, and CC); the Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD (JSR); the Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa (M-LN); the Centre Muraz, Bobo-Dioulasso, Burkina Faso (NM); the International Centre for Reproductive Health, Mombasa, Kenya (SL); the Kenyatta National Hospital and University of Nairobi, Nairobi, Kenya (GM); the University of KwaZulu-Natal, Durban, South African Republic (KN); and the WHO, Reproductive Health and Research, Geneva, Switzerland (PG and IdV)
| | - Marie-Louise Newell
- From the Institut de Recherche pour le Développement (IRD), UMI233 IRD/Université de Montpellier 1, Montpellier, France (KAB, AC, and CC); the Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD (JSR); the Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa (M-LN); the Centre Muraz, Bobo-Dioulasso, Burkina Faso (NM); the International Centre for Reproductive Health, Mombasa, Kenya (SL); the Kenyatta National Hospital and University of Nairobi, Nairobi, Kenya (GM); the University of KwaZulu-Natal, Durban, South African Republic (KN); and the WHO, Reproductive Health and Research, Geneva, Switzerland (PG and IdV)
| | - Cécile Cames
- From the Institut de Recherche pour le Développement (IRD), UMI233 IRD/Université de Montpellier 1, Montpellier, France (KAB, AC, and CC); the Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD (JSR); the Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa (M-LN); the Centre Muraz, Bobo-Dioulasso, Burkina Faso (NM); the International Centre for Reproductive Health, Mombasa, Kenya (SL); the Kenyatta National Hospital and University of Nairobi, Nairobi, Kenya (GM); the University of KwaZulu-Natal, Durban, South African Republic (KN); and the WHO, Reproductive Health and Research, Geneva, Switzerland (PG and IdV)
| | - Nicolas Meda
- From the Institut de Recherche pour le Développement (IRD), UMI233 IRD/Université de Montpellier 1, Montpellier, France (KAB, AC, and CC); the Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD (JSR); the Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa (M-LN); the Centre Muraz, Bobo-Dioulasso, Burkina Faso (NM); the International Centre for Reproductive Health, Mombasa, Kenya (SL); the Kenyatta National Hospital and University of Nairobi, Nairobi, Kenya (GM); the University of KwaZulu-Natal, Durban, South African Republic (KN); and the WHO, Reproductive Health and Research, Geneva, Switzerland (PG and IdV)
| | - Stanley Luchters
- From the Institut de Recherche pour le Développement (IRD), UMI233 IRD/Université de Montpellier 1, Montpellier, France (KAB, AC, and CC); the Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD (JSR); the Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa (M-LN); the Centre Muraz, Bobo-Dioulasso, Burkina Faso (NM); the International Centre for Reproductive Health, Mombasa, Kenya (SL); the Kenyatta National Hospital and University of Nairobi, Nairobi, Kenya (GM); the University of KwaZulu-Natal, Durban, South African Republic (KN); and the WHO, Reproductive Health and Research, Geneva, Switzerland (PG and IdV)
| | - Grace Mbatia
- From the Institut de Recherche pour le Développement (IRD), UMI233 IRD/Université de Montpellier 1, Montpellier, France (KAB, AC, and CC); the Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD (JSR); the Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa (M-LN); the Centre Muraz, Bobo-Dioulasso, Burkina Faso (NM); the International Centre for Reproductive Health, Mombasa, Kenya (SL); the Kenyatta National Hospital and University of Nairobi, Nairobi, Kenya (GM); the University of KwaZulu-Natal, Durban, South African Republic (KN); and the WHO, Reproductive Health and Research, Geneva, Switzerland (PG and IdV)
| | - Kevindra Naidu
- From the Institut de Recherche pour le Développement (IRD), UMI233 IRD/Université de Montpellier 1, Montpellier, France (KAB, AC, and CC); the Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD (JSR); the Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa (M-LN); the Centre Muraz, Bobo-Dioulasso, Burkina Faso (NM); the International Centre for Reproductive Health, Mombasa, Kenya (SL); the Kenyatta National Hospital and University of Nairobi, Nairobi, Kenya (GM); the University of KwaZulu-Natal, Durban, South African Republic (KN); and the WHO, Reproductive Health and Research, Geneva, Switzerland (PG and IdV)
| | - Philippe Gaillard
- From the Institut de Recherche pour le Développement (IRD), UMI233 IRD/Université de Montpellier 1, Montpellier, France (KAB, AC, and CC); the Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD (JSR); the Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa (M-LN); the Centre Muraz, Bobo-Dioulasso, Burkina Faso (NM); the International Centre for Reproductive Health, Mombasa, Kenya (SL); the Kenyatta National Hospital and University of Nairobi, Nairobi, Kenya (GM); the University of KwaZulu-Natal, Durban, South African Republic (KN); and the WHO, Reproductive Health and Research, Geneva, Switzerland (PG and IdV)
| | - Isabelle de Vincenzi
- From the Institut de Recherche pour le Développement (IRD), UMI233 IRD/Université de Montpellier 1, Montpellier, France (KAB, AC, and CC); the Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD (JSR); the Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa (M-LN); the Centre Muraz, Bobo-Dioulasso, Burkina Faso (NM); the International Centre for Reproductive Health, Mombasa, Kenya (SL); the Kenyatta National Hospital and University of Nairobi, Nairobi, Kenya (GM); the University of KwaZulu-Natal, Durban, South African Republic (KN); and the WHO, Reproductive Health and Research, Geneva, Switzerland (PG and IdV)
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Sartorius BKD, Chersich MF, Mwaura M, Meda N, Temmerman M, Newell ML, Farley TMM, Luchters S. Maternal anaemia and duration of zidovudine in antiretroviral regimens for preventing mother-to-child transmission: a randomized trial in three African countries. BMC Infect Dis 2013; 13:522. [PMID: 24192332 PMCID: PMC3829097 DOI: 10.1186/1471-2334-13-522] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 10/22/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although substantiated by little evidence, concerns about zidovudine-related anaemia in pregnancy have influenced antiretroviral (ARV) regimen choice for preventing mother-to-child transmission of HIV-1, especially in settings where anaemia is common. METHODS Eligible HIV-infected pregnant women in Burkina Faso, Kenya and South Africa were followed from 28 weeks of pregnancy until 12-24 months after delivery (n = 1070). Women with a CD4 count of 200-500 cells/mm(3) and gestational age 28-36 weeks were randomly assigned to zidovudine-containing triple-ARV prophylaxis continued during breastfeeding up to 6-months, or to zidovudine during pregnancy plus single-dose nevirapine (sd-NVP) at labour. Additionally, two cohorts were established, women with CD4 counts: <200 cells/mm(3) initiated antiretroviral therapy, and >500 cells/mm(3) received zidovudine during pregnancy plus sd-NVP at labour. Mild (haemoglobin 8.0-10.9 g/dl) and severe anaemia (haemoglobin < 8.0 g/dl) occurrence were assessed across study arms, using Kaplan-Meier and multivariable Cox proportional hazards models. RESULTS At enrolment (corresponded to a median 32 weeks gestation), median haemoglobin was 10.3 g/dl (IQR = 9.2-11.1). Severe anaemia occurred subsequently in 194 (18.1%) women, mostly in those with low baseline haemoglobin, lowest socio-economic category, advanced HIV disease, prolonged breastfeeding (≥ 6 months) and shorter ARV exposure. Severe anaemia incidence was similar in the randomized arms (equivalence P-value = 0.32). After 1-2 months of ARV's, severe anaemia was significantly reduced in all groups, though remained highest in the low CD4 cohort. CONCLUSIONS Severe anaemia occurs at a similar rate in women receiving longer triple zidovudine-containing regimens or shorter prophylaxis. Pregnant women with pre-existing anaemia and advanced HIV disease require close monitoring. TRIAL REGISTRATION NUMBER ISRCTN71468401.
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Affiliation(s)
| | | | | | | | | | | | | | - Stanley Luchters
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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Ahmadu-Ali UA, Couper ID. The practice of exclusive breastfeeding among mothers attending a postnatal clinic in Tswaing subdistrict, North West province. S Afr Fam Pract (2004) 2013. [DOI: 10.1080/20786204.2013.10874381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- UA Ahmadu-Ali
- Department of Health Tswaing Subdistrict, North West Department of Health
- Faculty of Health Science, University of the Witwatersrand
| | - ID Couper
- Centre for Rural Health, Faculty of Health Sciences, University of the Witwatersrand, North West Department of Health
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Vallely LM, Kelly A, Kupul M, Neo R, Fiya V, Kaldor JM, Mola GD, Worth H. Infant feeding in the context of HIV: a qualitative study of health care workers' knowledge of recommended infant feeding options in Papua New Guinea. Int Breastfeed J 2013; 8:6. [PMID: 23742201 PMCID: PMC3681562 DOI: 10.1186/1746-4358-8-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 06/02/2013] [Indexed: 01/01/2023] Open
Abstract
Background Interventions to prevent mother to child transmission of human immunodeficiency virus (HIV) during childbirth and breastfeeding can reduce HIV infections in infants to less than 5% in low and middle income countries. The World Health Organization (WHO) recommends all mothers, regardless of their HIV status, practice exclusive breastfeeding for the first six months of an infant’s life. In line with these recommendations and to protect, promote and support breastfeeding, in 2009 the PNG National Department of Health revised their National HIV infant feeding guidelines, reinforcing the WHO recommendation of exclusive breastfeeding for the first six months followed by the introduction of other food and fluids, while continuing breastfeeding. The overall aim of this paper is to explore health care workers’ knowledge regarding infant feeding options in PNG, specifically as they relate to HIV exposed infants. Methods As part of a study investigating women’s and men’s experiences of prevention of mother to child transmission (PMTCT) services in two sites in PNG, 28 key informant interviews were undertaken. This paper addresses one theme that emerged from thematic data analysis: Health care workers’ knowledge regarding infant feeding options, specifically how this knowledge reflects the Papua New Guinea National HIV Care and Treatment Guidelines on HIV and infant feeding (2009). Results Most informants mentioned exclusive breastfeeding, the majority of whom reflected the most up-to-date National Guidelines of exclusive breastfeeding for six months. The importance of breastfeeding continuing beyond this time, along with the introduction of food and fluids was less well understood. The most senior people involved in PMTCT were the informants who most accurately reflected the national guidelines of continuing breastfeeding after six months. Conclusion Providing advice on optimal infant feeding in resource poor settings is problematic, especially in relation to HIV transmission. Findings from our study reflect those found elsewhere in identifying that key health care workers are not aware of up-to-date information relating to infant feeding, especially within the context of HIV. Greater emphasis needs to be placed on ensuring the most recent feeding guidelines are disseminated and implemented in clinical practice in PNG.
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Affiliation(s)
- Lisa M Vallely
- Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Eastern Highlands Province, Papua New Guinea.
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Infant feeding modes and determinants among HIV-1-infected African Women in the Kesho Bora Study. J Acquir Immune Defic Syndr 2013; 62:109-18. [PMID: 23075919 DOI: 10.1097/qai.0b013e318277005e] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess breastfeeding modes and determinants in a prevention of mother-to-child transmission study. DESIGN HIV-1-infected pregnant women from 5 sites in Burkina Faso, Kenya, and South Africa were enrolled in the study that comprised 2 prospective cohorts and 1 randomized controlled trial. Women were counseled to either breastfeed exclusively up to 6 months or formula feed from birth. METHODS Determinants of breastfeeding initiation and continuation by 3 months postpartum were investigated using multiple logistic regression analysis. Neonatal morbidity was defined as mother-reported fever, diarrhea, or vomiting during the first month of life. RESULTS Among 1028, 781 women (76%) initiated breastfeeding and 565 of 995 (56%) were still breastfeeding at 3 months postpartum (30% exclusively, 18% predominantly, and 8% partially). Study site (Durban, Mombasa, and Nairobi compared with Bobo-Dioulasso), CD4 cell count (<200 cells/mm), secondary schooling (compared with none), and emergency cesarean delivery (compared with vaginal delivery) were independently associated with a lower probability of ever breastfeeding. The odds of still breastfeeding by 3 months postpartum (among those breastfeeding by 1 month) were lower in Mombasa, Nairobi, and Somkhele (compared with Bobo-Dioulasso) and among infants with neonatal morbidity [0.60 (0.37-0.976)]. The odds of exclusive breastfeeding (EBF) by 3 months (if EBF by 1 month) were lower in Mombasa and Nairobi, in ill neonates [0.54 (0.31-0.93)] and boys [0.51 (0.34-0.77)]. CONCLUSIONS EBF was of short duration, particularly for boys. The importance of neonatal morbidity for breastfeeding cessation requires further investigation. Infant feeding counseling might need adaptation to better support mothers of boys and ill neonates.
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Benagiano G, d'Arcangues C, Harris Requejo J, Schafer A, Say L, Merialdi M. The special programme of research in human reproduction: forty years of activities to achieve reproductive health for all. Gynecol Obstet Invest 2012; 74:190-217. [PMID: 23146950 DOI: 10.1159/000343067] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The Special Programme of Research in Human Reproduction (HRP), co-sponsored by the UNDP, UNFPA, WHO, and the World Bank, is celebrating 40 years of activities with an expansion of its mandate and new co-sponsors. When it began, in 1972, the main focus was on evaluating the acceptability, effectiveness, and safety of existing fertility-regulating methods, as well as developing new, improved modalities for family planning. In 1994, HRP not only made major contributions to the Plan of Action of the International Conference on Population and Development (ICPD); it also broadened its scope of work to include other aspects of health dealing with sexuality and reproduction, adding a specific perspective on gender issues and human rights. In 2002, HRP's mandate was once again broadened to include sexually transmitted infections and HIV/AIDS and in 2003 it was further expanded to research activities on preventing violence against women and its many dire health consequences. Today, the work of the Programme includes research on: the sexual and reproductive health of adolescents, women, and men; maternal and perinatal health; reproductive tract and sexually transmitted infections (including HIV/AIDS); family planning; infertility; unsafe abortion; sexual health; screening for cancer of the cervix in developing countries, and gender and reproductive rights. Additional activities by the Programme have included: fostering international cooperation in the field of human reproduction; the elaboration of WHO's first Global Reproductive Health Strategy; work leading to the inclusion of ICPD's goal 'reproductive health for all by 2015' into the Millennium Development Goal framework; the promotion of critical interagency statements on the public health, legal, and human rights implications of female genital mutilation and gender-biased sex selection. Finally, HRP has been involved in the creation of guidelines and tools, such as the 'Medical eligibility criteria for contraceptive use', the 'Global handbook for family planning providers', the 'Definition of core competencies in primary health care', and designing tools for operationalizing a human rights approach to sexual and reproductive health programmes.
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Affiliation(s)
- Giuseppe Benagiano
- UNDP/UNFPA/WHO/World Bank Special Programme of Research in Human Reproduction, World Health Organization, Geneva, Switzerland.
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Louvain de Souza T, de Souza Campos Fernandes RC, Medina-Acosta E. HIV-1 control in battlegrounds: important host genetic variations for HIV-1 mother-to-child transmission and progression to clinical pediatric AIDS. Future Virol 2012. [DOI: 10.2217/fvl.12.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
HIV-1 mother-to-child transmission (MTCT) is the passing of maternal HIV-1 to the offspring during pregnancy, labor and delivery, and/or breastfeeding. HIV-1 MTCT and the evolution to pediatric AIDS are multifactorial, dynamic and variable phenotypic conditions. Both genetic and nongenetic variables can influence susceptibility to HIV-1 MTCT or the rate of progression to clinical pediatric AIDS. In this review, we summarize the current state of knowledge about the roles of genetic variations seen in host immune response genes, and those that have been independently associated, mostly through population genetics of candidate genes, with interindividual susceptibility to HIV-1 MTCT, and progression to pediatric AIDS. We examine common and rare host genetic variations at coding and noncoding polymorphisms, whether functional or not, in agonists and antagonists of the immune response, which have been implicated in HIV-1 control in battlegrounds of cell entry, replication and evolution to AIDS. Further, we point to over 380 single-nucleotide polymorphisms, mostly within the HLA super region, recently identified in unbiased genome-wide association studies of HIV replication and evolution in adults, still unexplored in the context of HIV-1 MTCT, and which are likely to also influence susceptibility to pediatric HIV-1/AIDS.
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Affiliation(s)
- Thais Louvain de Souza
- Molecular Identification & Diagnosis Unit, Universidade Estadual do Norte Fluminense Darcy Ribeiro, Brazil
| | - Regina Célia de Souza Campos Fernandes
- Municipal Program for the Surveillance of Sexually Transmitted Diseases & Acquired Immunodeficiency Syndrome of Campos dos Goytacazes, Brazil
- Faculty of Medicine of Campos, Campos dos Goytacazes, Brazil
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Maternal HIV-1 disease progression 18-24 months postdelivery according to antiretroviral prophylaxis regimen (triple-antiretroviral prophylaxis during pregnancy and breastfeeding vs zidovudine/single-dose nevirapine prophylaxis): The Kesho Bora randomized controlled trial. Clin Infect Dis 2012; 55:449-60. [PMID: 22573845 DOI: 10.1093/cid/cis461] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Antiretroviral (ARV) prophylaxis effectively reduces mother-to-child transmission of human immunodeficiency virus type 1 (HIV). However, it is unclear whether stopping ARVs after breastfeeding cessation affects maternal HIV disease progression. We assessed 18-24-month postpartum disease progression risk among women in a randomized trial assessing efficacy and safety of prophylactic maternal ARVs. METHODS From 2005 to 2008, HIV-infected pregnant women with CD4(+) counts of 200-500/mm(3) were randomized to receive either triple ARV (zidovudine, lamivudine, and lopinavir/ritonavir during pregnancy and breastfeeding) or AZT/sdNVP (zidovudine until delivery with single-dose nevirapine without postpartum prophylaxis). Maternal disease progression was defined as the combined endpoint of death, World Health Organization clinical stage 4 disease, or CD4(+) counts of <200/mm(3). RESULTS Among 824 randomized women, 789 had at least 1 study visit after cessation of ARV prophylaxis. Following delivery, progression risk up to 24 months postpartum in the triple ARV arm was significantly lower than in the AZT/sdNVP arm (15.7% vs 28.3%; P = .001), but the risks of progression after cessation of ARV prophylaxis (rather than after delivery) were not different (15.0% vs 13.8% 18 months after ARV cessation). Among women with CD4(+) counts of 200-349/mm(3) at enrollment, 24.0% (95% confidence interval [CI], 15.7-35.5) progressed with triple ARV, and 23.0% (95% CI, 17.8-29.5) progressed with AZT/sdNVP, whereas few women in either arm (<5%) with initial CD4(+) counts of ≥350/mm(3) progressed. CONCLUSIONS Interrupting prolonged triple ARV prophylaxis had no effect on HIV progression following cessation (compared with AZT/sdNVP). However, women on triple ARV prophylaxis had lower progression risk during the time on triple ARV. Given the high rate of progression among women with CD4(+) cells of <350/mm(3), ARVs should not be discontinued in this group. CLINICAL TRIALS REGISTRATION ISRCTN71468410.
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Non-antiretroviral Approaches to Prevention of Breast Milk Transmission of HIV-1: Exclusive Breastfeeding, Early Weaning, Treatment of Expressed Breast Milk. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 743:197-204. [DOI: 10.1007/978-1-4614-2251-8_14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
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Abstract
PURPOSE OF REVIEW The number of women living with HIV continues to increase globally. With the availability of efficacious antiretroviral therapy, there is a pressing need to ensure women are treated effectively throughout their life course. This article reviews information on ways that HIV affects women and discusses recent treatment and prevention approaches. RECENT FINDINGS Because women are at greater risk of heterosexual HIV acquisition than men, new data on biomedical approaches to prevention are of particular relevance. International guidelines for the treatment of pregnant women with HIV now place greater weight on the well being of the mother as well as the prevention of vertical transmission. Although effective HIV treatment for women is associated with better health, longer life, reduced infectiousness and prevention of acquisition of HIV, there is evidence that women experience more adverse effects, discontinue medication more frequently and have more problems with adherence than men. SUMMARY Efficacious anti-HIV drugs exist, but the particular circumstances for women may compromise their effectiveness. Globally, women's access to therapy remains inadequate. More data are needed about the best approaches to HIV therapy for women to include the biological, psychological, social and cultural factors that influence the way women experience HIV infection.
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de Souza Campos Fernandes RC, de Souza TL, Medina-Acosta E. Role of maternal, transplacentally acquired HIV-1-specific neutralizing antibodies in protecting the uninfected offspring against HIV-1 transmission via breast milk. Future Virol 2011. [DOI: 10.2217/fvl.11.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Evaluation of: Lynch JB, Nduati R, Blish CA et al. The breadth and potency of passively acquired human immunodeficiency virus type 1-specific neutralizing antibodies do not correlate with the risk of infant infection. J. Virol. 85(11), 5252–5261 (2011). HIV-1-infected pregnant women may transfer anti-HIV-1 antibodies, at varying lengths, extents and specificities, to their babies during pregnancy via the placenta and after birth via breast milk. In vitro, most antibodies to many viral and bacterial agents, present at birth in the infant serum, are protective, but it is unclear whether the magnitude and breadth of the maternal passively acquired HIV-1-specific neutralizing antibodies constitute, in fact, a predictor variable of protection against mother-to-child HIV-1 transmission via breast milk. In their article, Lynch et al. addressed the issue using a rich source of repository samples from a cohort of pregnant women infected with HIV-1, enrolled before the availability of widespread antiretroviral treatment and management measures of intervention. This type of treasured samples enables us to dissect the significance of maternal passively acquired HIV-1-specific serum antibodies in highly exposed HIV-1-uninfected children for protection against HIV-1 infection via breast milk. Results showed no significant difference in breadth and potency of in vitro neutralizing antibodies between children who became HIV-1 infected and children who remained uninfected throughout the study period. The authors concluded that neither the breadth nor the potency of passively acquired HIV-1-specific neutralizing antibodies correlate with the risk of HIV-1 acquisition via breast milk. The study raises intriguing possibilities to speed the process of refining both in vitro methods to identify protective antibody responses and vaccine development strategies relevant at oral and gastrointestinal mucosal sites.
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Affiliation(s)
- Regina Célia de Souza Campos Fernandes
- Municipal Program for the Surveillance of Sexually Transmitted Diseases & Acquired Immunodeficiency Syndrome, Rua Conselheiro Otaviano 241, Centro, Campos dos Goytacazes RJ, CEP 28010-140, Brazil
- Faculty of Medicine of Campos, Avenida Alberto Torres 217, Centro, Campos dos Goytacazes RJ, CEP 28035-580, Brazil
| | - Thais Louvain de Souza
- Molecular Identification & Diagnosis Unit, Universidade Estadual do Norte Fluminense Darcy Ribeiro, Campos dos Goytacazes, Brazil
| | - Enrique Medina-Acosta
- Laboratory of Biotechnology, Center for Biosciences & Biotechnology, Universidade Estadual do Norte Fluminense Darcy Ribeiro, Avenida Alberto Lamego 2000, Parque Califórnia, Campos dos Goytacazes, RJ, CEP 28013-602, Brazil
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Granich R, Gupta S, Suthar AB, Smyth C, Hoos D, Vitoria M, Simao M, Hankins C, Schwartlander B, Ridzon R, Bazin B, Williams B, Lo YR, McClure C, Montaner J, Hirnschall G. Antiretroviral therapy in prevention of HIV and TB: update on current research efforts. Curr HIV Res 2011; 9:446-69. [PMID: 21999779 PMCID: PMC3531820 DOI: 10.2174/157016211798038597] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 08/14/2011] [Accepted: 08/18/2011] [Indexed: 01/14/2023]
Abstract
There is considerable scientific evidence supporting the use of antiretroviral therapy (ART) in prevention of human immunodeficiency virus (HIV) and tuberculosis (TB) infections. The complex nature of the HIV and TB prevention responses, resource constraints, remaining questions about cost and feasibility, and the need to use a solid evidence base to make policy decisions, and the implementation challenges to translating trial data to operational settings require a well-organised and coordinated response to research in this area. To this end, we aimed to catalogue the ongoing and planned research activities that evaluate the impact of ART plus other interventions on HIV- and/or TB-related morbidity, mortality, risk behaviour, HIV incidence and transmission. Using a limited search methodology, 50 projects were identified examining ART as prevention, representing 5 regions and 52 countries with a global distribution. There are 24 randomised controlled clinical trials with at least 12 large randomised individual or community cluster trials in resource-constrained settings that are in the planning or early implementation stages. There is considerable heterogeneity between studies in terms of methodology, interventions and geographical location. While the identified studies will undoubtedly advance our understanding of the efficacy and effectiveness of ART for prevention, some key questions may remain unanswered or only partially answered. The large number and wide variety of research projects emphasise the importance of this research issue and clearly demonstrate the potential for synergies, partnerships and coordination across funding agencies.
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Affiliation(s)
- Reuben Granich
- Antiretroviral Treatment and HIV Care, Department of HIV/AIDS, Building D, 1st Floor, Room 1005, World Health Organization, Avenue Appia 20, CH-1211, Geneva 27, Switzerland.
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Cames C, Cassard F, Cournil A, Mouquet-Rivier C, Ayassou K, Meda N, Bork K. Nonbreast-fed HIV-1-exposed Burkinabe infants have low energy intake between 6 and 11 months of age despite free access to infant food aid. J Nutr 2011; 141:674-9. [PMID: 21325474 DOI: 10.3945/jn.110.127894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In a WHO-coordinated, mother-to-child HIV transmission (MTCT) prevention trial in Burkina Faso, HIV-1-infected mothers were advised to either stop breast-feeding by 6 mo or totally avoid it. Participants were provided with cereal-based, infant fortified mix (IFM) from 6 to 12 mo postpartum along with infant feeding counseling. Our objective was to describe nonbreast-fed infants' food consumption and adequacy of nutrient intake. A 1-d weighed food record and one 24-h dietary recall were performed in 68 nonbreast-fed, non-HIV-infected 6- to 11-mo-old infants. Mean food energy density and feeding frequency were satisfactory in 6-8 mo olds [0.8 ± 0.2 kcal/g (3.3 ± 0.9 kJ/g) and 7.2 ± 1.6 times/d] and in 9-11 mo olds [0.9 ± 0.2 kcal/g (3.6 ± 0.8 kJ/g) and 7.7 ± 2.1 times/d]. Median energy intake was 523 kcal [range: 82-1053 (2187 kJ, range: 345-4401)] in 6-8- and 811 kcal [range: 34-1543 (3392 kJ, range: 144-6452)] in 9-11-mo-old infants, respectively. Approximately 75% of their energy intake was provided by subsidized foods (milk that mothers obtained from support networks and IFM). One-half of the infants had intakes < 80 kcal/kg (<334 kJ/kg) on the day of the survey, mainly because IFM and milk were consumed in amounts that were too low. Thus, coverage of energy needs required a diet with sufficient amounts of both IFM and milk in these vulnerable infants. These findings argue for the development of adequate, sustainable infant fortified foods and their rapid integration into MTCT prevention services. They also lend support to the recent revision of WHO infant feeding guidance for future MTCT prevention programming that recommends breast-feeding up to 12 mo postpartum (under cover of antiretroviral prophylaxis) as the safest feeding option for infants of HIV-infected mothers.
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de Vincenzi I. Triple antiretroviral compared with zidovudine and single-dose nevirapine prophylaxis during pregnancy and breastfeeding for prevention of mother-to-child transmission of HIV-1 (Kesho Bora study): a randomised controlled trial. THE LANCET. INFECTIOUS DISEASES 2011; 11:171-80. [PMID: 21237718 DOI: 10.1016/s1473-3099(10)70288-7] [Citation(s) in RCA: 292] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Breastfeeding is essential for child health and development in low-resource settings but carries a significant risk of transmission of HIV-1, especially in late stages of maternal disease. We aimed to assess the efficacy and safety of triple antiretroviral compared with zidovudine and single-dose nevirapine prophylaxis in pregnant women infected with HIV. METHODS Pregnant women with WHO stage 1, 2, or 3 HIV-1 infection who had CD4 cell counts of 200-500 cells per μL were enrolled at five study sites in Burkina Faso, Kenya, and South Africa to start study treatment at 28-36 weeks' gestation. Women were randomly assigned (1:1) by a computer generated random sequence to either triple antiretroviral prophylaxis (a combination of 300 mg zidovudine, 150 mg lamivudine, and 400 mg lopinavir plus 100 mg ritonavir twice daily until cessation of breastfeeding to a maximum of 6·5 months post partum) or zidovudine and single-dose nevirapine (300 mg zidovudine twice daily until delivery and a dose of 600 mg zidovudine plus 200 mg nevirapine at the onset of labour and, after a protocol amendment in December, 2006, 1 week post-partum zidovudine 300 mg twice daily and lamivudine 150 mg twice daily). All infants received a 0·6 mL dose of nevirapine at birth and, from December, 2006, 4 mg/kg twice daily of zidovudine for 1 week after birth. Patients and investigators were not masked to treatment. The primary endpoints were HIV-free infant survival at 6 weeks and 12 months; HIV-free survival at 12 months in infants who were ever breastfed; AIDS-free survival in mothers at 18 months; and serious adverse events in mothers and babies. Analysis was by intention to treat. This trial is registered with Current Controlled Trials, ISRCTN71468401. FINDINGS From June, 2005, to August, 2008, 882 women were enrolled, 824 of whom were randomised and gave birth to 805 singleton or first, liveborn infants. The cumulative rate of HIV transmission at 6 weeks was 3·3% (95% CI 1·9-5·6%) in the triple antiretroviral group compared with 5·0% (3·3-7·7%) in the zidovudine and single-dose nevirapine group, and at 12 months was 5·4% (3·6-8·1%) in the triple antiretroviral group compared with 9·5% (7·0-12·9%) in the zidovudine and single-dose nevirapine group (p=0·029). The cumulative rate of HIV transmission or death at 12 months was 10·2% (95% CI 7·6-13·6%) in the triple antiretroviral group compared with 16·0% (12·7-20·0%) in the zidovudine and single-dose nevirapine group (p=0·017). In infants whose mothers declared they intended to breastfeed, the cumulative rate of HIV transmission at 12 months was 5·6% (95% CI 3·4-8·9%) in the triple antiretroviral group compared with 10·7% (7·6-14·8%) in the zidovudine and single-dose nevirapine group (p=0·02). AIDS-free survival in mothers at 18 months will be reported in a different publication. The incidence of laboratory and clinical serious adverse events in both mothers and their babies was similar between groups. INTERPRETATION Triple antiretroviral prophylaxis during pregnancy and breastfeeding is safe and reduces the risk of HIV transmission to infants. Revised WHO guidelines now recommend antiretroviral prophylaxis (either to the mother or to the baby) during breastfeeding if the mother is not already receiving antiretroviral treatment for her own health. FUNDING Agence nationale de recherches sur le sida et les hépatites virales, Department for International Development, European and Developing Countries Clinical Trials Partnership, Thrasher Research Fund, Belgian Directorate General for International Cooperation, Centers for Disease Control and Prevention, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and UNDP/UNFPA/World Bank/WHO Special Programme of Research, Development and Research Training in Human Reproduction.
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