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Abrams EJ, Jao J, Madlala HP, Zerbe A, Catalano P, Gerschenson M, Goedecke JH, Gomba Y, Josefson J, Kurland IJ, Legbedze J, McComsey GA, Matyesini S, Mukonda E, Robinson D, Myer L. An observational cohort study to investigate the impact of dolutegravir in pregnancy and its obesogenic effects on the metabolic health of women living with HIV and their children: Study protocol. PLoS One 2024; 19:e0307296. [PMID: 39159183 PMCID: PMC11332920 DOI: 10.1371/journal.pone.0307296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 06/28/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION Dolutegravir (DTG)-based antiretroviral therapy is the World Health Organization's preferred first-line regimen for all persons with HIV, including pregnant women. While DTG has been implicated as an obesogen associated with greater weight gain compared to other antiretrovirals, there is a paucity of data in pregnant women and their children. The Obesogenic oRigins of maternal and Child metabolic health Involving Dolutegravir (ORCHID) study is investigating associations between DTG, weight gain, and metabolic outcomes in the context of HIV. MATERIALS & METHODS ORCHID is a prospective observational study taking place in Cape Town, South Africa (NCT04991402). A total of 1920 pregnant women with and without HIV infection are being followed from ≤18 weeks gestational age to 24 months postpartum with their children. Participants attend eleven study visits: 3 antenatal, delivery, and 7 postnatal visits. Several embedded sub-studies address specific scientific aims. Primary outcome measurements in mothers include anthropometry, blood pressure, body composition, dysglycemia, insulin resistance (IR), and dyslipidemia. Other maternal measures include demographics, resting energy expenditure, viral load, physical activity, dietary intake, hepatic steatosis, and repository specimens. Sub-study measurements include markers of adipose inflammation, gut integrity, and satiety/hunger, subcutaneous adipose tissue morphology and mitochondrial function, and metabolomics. Primary outcome measurements in children include anthropometry, adipose tissue mass, dysglycemia, IR, and dyslipidemia. Other variables include fetal growth, birth outcomes, medical/breastfeeding history, caloric intake, neurodevelopment, and repository specimens. Sub-study measurements include metabolites/lipid subspecies in umbilical cord blood, as well as breast milk composition and DTG exposure. DISCUSSION ORCHID will play a pivotal role in defining obesogenic mechanisms and clinical consequences of DTG use in pregnancy in women with HIV and their children. It will provide insights into metabolic disease risk reduction in the context of HIV/DTG, identify intervention targets, and inform public health approaches to diminish chronic metabolic co-morbidities for women and children.
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Affiliation(s)
- Elaine J. Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States of America
- Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, United States of America
| | - Jennifer Jao
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Hlengiwe P. Madlala
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Western Cape, Cape Town, South Africa
| | - Allison Zerbe
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Patrick Catalano
- Maternal Infant Research Institute, Obstetrics and Gynecology Research, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University School of Medicine, Tufts University, Boston, MA, United States of America
| | - Mariana Gerschenson
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, United States of America
| | - Julia H. Goedecke
- Biomedical Research and Innovation Platform, South African Medical Research Council, Cape Town, South Africa
- Health through Physical Activity, Lifestyle and Sport Research Centre (HPALS), Division of Physiological Sciences, Department of Human Biology, University of Cape Town, Cape Town, South Africa
| | - Yolanda Gomba
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Western Cape, Cape Town, South Africa
| | - Jami Josefson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Irwin J. Kurland
- Department of Medicine, Stable Isotope and Metabolomics Core Facility, Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Justine Legbedze
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Grace A. McComsey
- University Hospitals Health System, Cleveland, OH, United States of America
- Department of Medicine and Pediatrics of Case Western Reserve University, Cleveland, OH, United States of America
| | - Sandisiwe Matyesini
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Western Cape, Cape Town, South Africa
| | - Elton Mukonda
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Western Cape, Cape Town, South Africa
| | - Daniel Robinson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Western Cape, Cape Town, South Africa
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Brittain K, Brown K, Phillips T, Zerbe A, Pellowski J, Remien RH, Mellins CA, Abrams EJ, Myer L. Why do Integrated Maternal HIV and Infant Healthcare Services work? A Secondary Analysis of a Randomised Controlled Trial in South Africa. AIDS Behav 2023; 27:3831-3843. [PMID: 37306847 PMCID: PMC10598190 DOI: 10.1007/s10461-023-04097-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2023] [Indexed: 06/13/2023]
Abstract
In a randomised trial, we found that integrated maternal HIV and infant health services through the end of breastfeeding were significantly associated with the primary outcome of engagement in HIV care and viral suppression at 12 months postpartum, compared to the standard of care. Here, we quantitatively explore potential psychosocial modifiers and mediators of this association. Our findings suggest that the intervention was significantly more effective among women experiencing an unintended pregnancy but did not improve outcomes among women reporting risky alcohol use. Although not statistically significant, our results suggest that the intervention may also be more effective among women experiencing higher levels of poverty and HIV-related stigma. We observed no definitive mediator of the intervention effect, but women allocated to integrated services reported better relationships with their healthcare providers through 12 months postpartum. These findings point to high-risk groups that may benefit the most from integrated care, as well as groups for whom these benefits are hampered and that warrant further attention in intervention development and evaluation.
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Affiliation(s)
- Kirsty Brittain
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.
| | - Karryn Brown
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - Tamsin Phillips
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - Allison Zerbe
- Mailman School of Public Health, ICAP at Columbia University, Columbia University, New York, NY, USA
| | - Jennifer Pellowski
- Department of Behavioral & Social Sciences, Brown University School of Public Health, Providence, RI, USA
- International Health Institute, Brown University School of Public Health, Providence, RI, USA
| | - Robert H Remien
- New York State Psychiatric Institute, HIV Center for Clinical & Behavioral Studies, Columbia University, New York, NY, USA
| | - Claude A Mellins
- New York State Psychiatric Institute, HIV Center for Clinical & Behavioral Studies, Columbia University, New York, NY, USA
| | - Elaine J Abrams
- Mailman School of Public Health, ICAP at Columbia University, Columbia University, New York, NY, USA
- Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
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Rotheram-Borus MJ, Tomlinson M, Worthman CM, Norwood P, le Roux I, O'Connor MJ. Maternal depression, alcohol use, and transient effects of perinatal paraprofessional home visiting in South Africa: Eight-year follow-up of a cluster randomized controlled trial. Soc Sci Med 2023; 324:115853. [PMID: 37001280 PMCID: PMC10121853 DOI: 10.1016/j.socscimed.2023.115853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 03/28/2023]
Abstract
BACKGROUND South African mothers confront synergistic challenges from depression, alcohol use, and HIV/AIDS. The importance of maternal functioning for child development motivates interventions, yet long-term outcomes seldom are tracked. Furthermore, little is known about trajectories and the role of social-cultural factors in maternal depression and alcohol use across parenthood in low- and middle-income countries. METHODS We examined maternal outcomes at 5- and 8-years' post-birth, from the Philani Intervention Program (PIP), a randomized controlled trial of a prenatally-initiated home visiting intervention lasting through 6 months' post-birth which yielded some benefits for children and mothers through 3 years. Longitudinal Bayesian mixed-effects models assessed intervention effects for maternal depression and alcohol use from pre-birth through 8 years post-birth. We plotted trajectories of depression and alcohol use and analyzed their relationship over time. RESULTS Maternal benefits appeared limited and intervention outcomes differed at 5 and 8 years. Reduced depression in PIP versus standard care (SC) mothers at 3 years disappeared by 5 and 8 years. Depression prevalence declined from 35.1% prenatally to 5.5% at 8 years, independent of intervention or alcohol use. Alcohol use in both groups rebounded from a post-birth nadir; fewer PIP than SC mothers drank alcohol and reported problematic use at 5 but not 8 years. HIV+ prevalence did not differ by condition and increased from 26% to 45% over the reported period. CONCLUSIONS Dissipation of early child benefits from home visiting by age 8 years likely reflects lack of durable change in maternal behaviors compounded by social-cultural factors and cumulative effects of community deprivation. High prenatal rates warrant screening and treatment for depression in standard antenatal care. Low-and-middle income countries may need sustained interventions, including alcohol use reduction, to capitalize on initial gains from targeted interventions and address community social-cultural factors. HIV/AIDS continues to spread in this population.
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Affiliation(s)
- Mary Jane Rotheram-Borus
- Semel Institute Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, 10920 Wilshire Blvd. Suite 350, Los Angeles, CA, 90024, USA.
| | - Mark Tomlinson
- Institute for Life Course Health Research, Department of Global Health, Education Building, Francie Van Zijl Drive, Stellenbosch University, Tygerberg 7505, South Africa.
| | - Carol M Worthman
- Department of Anthropology, Emory University, 1557 Dickey Dr., Atlanta, GA, 30307, USA.
| | - Peter Norwood
- Semel Institute Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, 10920 Wilshire Blvd. Suite 350, Los Angeles, CA, 90024, USA.
| | - Ingrid le Roux
- Philani Maternal, Child Health and Nutrition Trust, P.O. Box 40188, Elonwabeni 7791, Cape Town, South Africa.
| | - Mary J O'Connor
- Semel Institute Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, 760 Westwood Plaza, Los Angeles, CA 90095, USA.
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Brittain K, Pellowski J, Noholoza S, Mellins CA, Bekker LG, Kagee A, Remien RH, Abrams EJ, Myer L. Perinatal alcohol use among young women living with HIV in South Africa: Context, experiences, and implications for interventions. Glob Public Health 2023; 18:2221732. [PMID: 37302089 PMCID: PMC10413958 DOI: 10.1080/17441692.2023.2221732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/31/2023] [Indexed: 06/13/2023]
Abstract
Perinatal alcohol use is common in South Africa, including among young women living with HIV (WLHIV), but there are few insights into the drivers of alcohol use in this population. Following the completion of a pilot trial of a peer support intervention for WLHIV aged 16-24 years in Cape Town, we purposively selected participants who had reported perinatal alcohol use at ≥1 study visits to complete a qualitative in-depth interview exploring their experiences of substance use. Of 119 women enrolled, 28 reported alcohol use, and 24 were interviewed, with ≥1/3 reporting drinking throughout their pregnancy. Women described living in a community where heavy perinatal alcohol consumption is normalised, including among their peers, leading to social pressure. Despite being aware of the risks of perinatal alcohol use, women described a disconnect between public health messaging and their experiences. Although most acknowledged the negative effects of alcohol in their lives, self-efficacy to reduce consumption was diminished by peer influences and the lack of formal employment and opportunities for recreation. These findings provide insights into the drivers of perinatal alcohol use in this setting, and suggest that without meaningful community-level changes, including employment opportunities and alternatives for socialising, interventions may have limited impact.
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Affiliation(s)
- Kirsty Brittain
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Jennifer Pellowski
- Department of Behavioral & Social Sciences, Brown University School of Public Health, Providence, RI, USA
- International Health Institute, Brown University School of Public Health, Providence, RI, USA
| | - Sandisiwe Noholoza
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Claude A. Mellins
- HIV Center for Clinical & Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Ashraf Kagee
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Robert H. Remien
- HIV Center for Clinical & Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - Elaine J. Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
- Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
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Miller AP, Shoptaw S, Mvududu R, Mashele N, Coates TJ, Bekker LG, Essack Z, Groenewald C, Petersen Z, Gorbach PM, Myer L, Joseph Davey DL. Sexual Risk among Pregnant Women at Risk of HIV Infection in Cape Town, South Africa: What Does Alcohol Have to Do with It? AIDS Behav 2023; 27:37-50. [PMID: 35737280 PMCID: PMC9780404 DOI: 10.1007/s10461-022-03742-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 01/24/2023]
Abstract
This study examines baseline associations between alcohol use and HIV sexual risk among a cohort of HIV-uninfected pregnant women (n = 1201) residing in a high HIV burdened community in Cape Town, South Africa. Alcohol use was measured using a modified version of the Alcohol Use Disorder Identification Test (AUDIT). HIV sexual risk was measured through a composite variable of four risk factors: diagnosis with a STI, self-report of > 1 recent sex partners, partner HIV serostatus (unknown or HIV+) and condomless sex at last sex. Any past year alcohol use prior to pregnancy was reported by half of participants (50%); 6.0% reported alcohol use during pregnancy. Alcohol use prior to pregnancy was associated with increased odds of being at high risk of HIV (aOR = 1.33, 95% CI 1.05-1.68, for 2 risks and aOR = 1.47, 95% CI 0.95-2.27 for 3 risks). In addition to reducing alcohol use, several other strategies to address HIV sexual risk were identified. Evidence-based interventions to address alcohol use and other HIV sexual risk behaviors during pregnancy in South Africa are desperately needed. Qualitative work exploring individual and community level drivers of alcohol use among pregnant and breastfeeding women in this setting could support development of a culturally tailored intervention to address these issues in this population.
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Affiliation(s)
- Amanda P Miller
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA.
- Department of Epidemiology, Fielding School of Public Health, 650 Charles E. Young Drive South, Room #41-295CHS, Los Angeles, CA, 90095-1772, USA.
| | - Steven Shoptaw
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Department of Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Rufaro Mvududu
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Nyiko Mashele
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Thomas J Coates
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, Faculty of Health Science, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Zaynab Essack
- Centre for Community-Based Research, Human Sciences Research Council, Pretoria, South Africa
| | - Candice Groenewald
- Centre for Community-Based Research, Human Sciences Research Council, Pretoria, South Africa
- Psychology Department, Rhodes University, Makhanda, South Africa
| | - Zaino Petersen
- Impact and Research Development, Human Sciences Research Council, Pretoria, South Africa
| | - Pamina M Gorbach
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Dvora L Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Observatory, Cape Town, South Africa
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- The Desmond Tutu HIV Centre, Faculty of Health Science, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Stanton AM, Hornstein BD, Musinguzi N, Dolotina B, Orrell C, Amanyire G, Asiimwe S, Cross A, Psaros C, Bangsberg D, Hahn JA, Haberer JE, Matthews LT. Factors Associated With Changes in Alcohol Use During Pregnancy and the Postpartum Transition Among People With HIV in South Africa and Uganda. J Int Assoc Provid AIDS Care 2023; 22:23259582231161029. [PMID: 36945860 PMCID: PMC10034296 DOI: 10.1177/23259582231161029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
Identifying factors associated with alcohol use changes during pregnancy is important for developing interventions for people with HIV (PWH). Pregnant PWH (n = 202) initiating antiretroviral therapy in Uganda and South Africa completed two assessments, 6 months apart (T1, T2). Categories were derived based on AUDIT-C scores: "no use" (AUDIT-C = 0 at T1 and T2), "new use" (AUDIT-C = 0 at T1, >0 at T2), "quit" (AUDIT-C > 0 at T1, =0 at T2), and "continued use" (AUDIT-C > 0, T1 and T2). Factors associated with these categories were assessed. Most participants had "no use" (68%), followed by "continued use" (12%), "quit" (11%), and "new use" (9%). Cohabitating with a partner was associated with lower relative risk of "continued use." Borderline significant associations between food insecurity and higher risk of "new use" and between stigma and reduced likelihood of "quitting" also emerged. Alcohol use interventions that address partnership, food security, and stigma could benefit pregnant and postpartum PWH.
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Affiliation(s)
- Amelia M Stanton
- Department of Psychological and Brain Sciences, 1846Boston University, Boston, USA
- 446213The Fenway Institute, Boston, USA
- Department of Psychiatry, 2348Massachusetts General Hospital, Boston, USA
| | - Benjamin D Hornstein
- Department of Medicine, 9967University of Alabama at Birmingham, Birmingham, USA
| | - Nicholas Musinguzi
- Makerere-Mbarara Universities Joint AIDS Program (MJAP), Mbarara, Uganda
- 108123Mbarara University of Science and Technology, Mbarara, Uganda
| | - Brett Dolotina
- Department of Epidemiology, 33638Mailman School of Public Health, Columbia University, New York, USA
| | - Catherine Orrell
- Desmond Tutu Health Foundation, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gideon Amanyire
- Makerere-Mbarara Universities Joint AIDS Program (MJAP), Mbarara, Uganda
- 560159Africa Health Research Institute, Durban, South Africa
| | - Stephen Asiimwe
- Global Health Collaborative, Mbarara, Uganda
- Kabwohe Clinical Research Center (KCRC), Kabwohe, Uganda
| | - Anna Cross
- Desmond Tutu Health Foundation, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Christina Psaros
- Department of Psychiatry, 2348Massachusetts General Hospital, Boston, USA
- 1811Harvard Medical School, Boston, USA
| | - David Bangsberg
- School of Public Health, Oregon Health and Science University/Portland State, Portland, USA
| | - Judith A Hahn
- Department of Medicine, 8785University of California San Francisco, San Francisco, USA
| | - Jessica E Haberer
- 1811Harvard Medical School, Boston, USA
- Center for Global Health, 2348Massachusetts General Hospital, Boston, USA
| | - Lynn T Matthews
- Department of Medicine, 9967University of Alabama at Birmingham, Birmingham, USA
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JOSEPH DAVEY DL, LE ROUX SM, BRITTAIN K, DOVELL K, SHOPTAW S, Miller AP, PHILLIPS TK, ZERBE A, ABRAMS EJ, MYER L. Alcohol use and intimate partner violence in HIV-uninfected pregnant women in Cape Town, South Africa. AIDS Care 2022; 34:214-219. [PMID: 34495777 PMCID: PMC8857014 DOI: 10.1080/09540121.2021.1975626] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In settings with a high burden of HIV, pregnant women often experience a cluster of risk factors, including alcohol use and intimate partner violence (IPV). These interrelated risks are poorly understood among pregnant women at risk of HIV in sub-Saharan Africa. We aim to determine cross-sectional associations between pregnant women's alcohol use and victimization due to IPV in the HIV-Unexposed-Uninfected Mother-Infant Cohort Study in Cape Town, South Africa. Women who tested HIV-negative at first antenatal care (ANC) visit were followed to delivery. Trained interviewers collected demographic and psychosocial information, including recent alcohol use and experiences of IPV victimization. We assess the prevalence of alcohol use and associations with IPV using multivariable logistic regression. In 406 HIV-uninfected pregnant women (mean age = 28 years; mean gestational age = 21 weeks), 41 (10%) reported alcohol consumption in the past 12 months; 30/41 (73%) of these at hazardous levels. Any and hazardous alcohol use were associated with greater odds of reporting past year IPV (adjusted odds ratio [aOR] for hazardous use: 3.24, 95% CI = 1.11, 7.56; aOR for any alcohol use: 2.97, 95% CI = 1.19, 7.45). These data suggest the occurrence of overlapping HIV risk factors among pregnant women and may help design improved health interventions in this population.
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Affiliation(s)
- Dvora L. JOSEPH DAVEY
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, US,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Stanzi M. LE ROUX
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Kirsty BRITTAIN
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Kathryn DOVELL
- Division of Infectious Diseases, Geffen School of Medicine, University of California, Los Angeles, US
| | - Steve SHOPTAW
- Department of Family Medicine, Geffen School of Medicine, University of California, Los Angeles, US,Department of Psychiatry, University of Cape Town, South Africa
| | - Amanda P. Miller
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Tamsin K. PHILLIPS
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Allison ZERBE
- Department of Psychiatry, University of Cape Town, South Africa
| | - Elaine J. ABRAMS
- Department of Psychiatry, University of Cape Town, South Africa,ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, US,Vagelos College of Physicians and Surgeons, Columbia University, New York, US
| | - Landon MYER
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa
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De Jong M, George A, Jacobs T. A scoping review of the determinants of foetal alcohol spectrum disorder in South Africa: an intersectional perspective. Health Policy Plan 2021; 36:1459-1469. [PMID: 34508361 PMCID: PMC8505989 DOI: 10.1093/heapol/czab101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 07/30/2021] [Accepted: 09/10/2021] [Indexed: 11/14/2022] Open
Abstract
Foetal alcohol spectrum disorder (FASD) affects babies born to mothers who consume alcohol while pregnant. South Africa has the highest prevalence of FASD in the world. We review the social determinants underpinning FASD in South Africa and add critical insight from an intersectional feminist perspective. We undertook a scoping review, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews guidelines. Drawing from EBSCOhost and PubMed, 95 articles were screened, with 21 selected for analysis. We used the intersectionality wheel to conceptualize how the social and structural determinants of FASD identified by the literature are interconnected and indicative of broader inequalities shaping the women and children affected. Key intersecting social determinants that facilitate drinking during pregnancy among marginalized populations in South Africa documented in the existing literature include social norms and knowledge around drinking and drinking during pregnancy, alcohol addiction and biological dependence, gender-based violence, inadequate access to contraception and abortion services, trauma and mental health, and moralization and stigma. Most of the studies found were quantitative. From an intersectional perspective, there was limited analysis of how the determinants identified intersect with one another in ways that exacerbate inequalities and how they relate to the broader structural and systemic factors undermining healthy pregnancies. There was also little representation of pregnant women’s own perspectives or discussion about the power dynamics involved. While social determinants are noted in the literature on FASD in South Africa, much more is needed from an intersectionality lens to understand the perspectives of affected women, their social contexts and the nature of the power relations involved. A critical stance towards the victim/active agent dichotomy that often frames women who drink during pregnancy opens up space to understand the nuances needed to support the women involved while also illustrating the contextual barriers to drinking cessation that need to be addressed through holistic approaches.
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Affiliation(s)
- Michelle De Jong
- School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville 7535, Cape Town, Republic of South Africa
| | - Asha George
- School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville 7535, Cape Town, Republic of South Africa
| | - Tanya Jacobs
- School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville 7535, Cape Town, Republic of South Africa
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Addila AE, Azale T, Gete YK, Yitayal M. The effects of maternal alcohol consumption during pregnancy on adverse fetal outcomes among pregnant women attending antenatal care at public health facilities in Gondar town, Northwest Ethiopia: a prospective cohort study. Subst Abuse Treat Prev Policy 2021; 16:64. [PMID: 34446055 PMCID: PMC8390259 DOI: 10.1186/s13011-021-00401-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The teratogenic effect of fetal alcohol exposure may lead to actual and potential problems, instantly after birth, at infancy; or even later, and mental impairment in life. This study aimed to investigate the effects of maternal alcohol consumption during pregnancy on adverse fetal outcomes at Gondar town public health facilities, Northwest Ethiopia. METHODS A facility-based prospective cohort study was performed among 1778 pregnant women who were booked for antenatal care in selected public health facilities from 29 October 2019 to 7 May 2020 in Gondar town. We used a two-stage random sampling technique to recruit and include participants in the cohort. Data were collected using the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) standardized and pre-tested questionnaire. Multivariable analysis was performed to examine the association between reported prenatal alcohol exposure (non-hazardous and hazardous) and interested adverse birth outcomes using log-binomial regression modeling. The burden of outcomes was reported using the adjusted risk ratio and population-attributable risk (PAR). RESULTS A total of 1686 pregnant women were included in the analysis, which revealed that the incidences of low birth weight, preterm, and stillbirth were 12.63% (95% CI: 11.12, 14.31), 6.05% (95% CI: 5.00, 7.29) and 4.27% (95% CI: 3.4, 5.35), respectively. Non-hazardous and hazardous alcohol consumption during pregnancy was significantly associated with low birth weight (ARR = 1.50; 95% CI: 1.31, 1.98) and (ARR = 2.34; 95% CI: 1.66, 3.30), respectively. Hazardous alcohol consumption during pregnancy was also significantly associated with preterm birth (ARR = 2.06; 95% CI: 1.21, 3.52). The adjusted PAR of low birth weight related to non-hazardous and hazardous alcohol drinking during pregnancy was 11.72 and 8.44%, respectively. The adjusted PAR of hazardous alcohol consumption was 6.80% for preterm. CONCLUSIONS Our findings suggest that there is an increasing risk of adverse birth outcomes, particularly preterm delivery and low birth weight, with increasing levels of alcohol intake. This result showed that the prevention of maternal alcohol use during pregnancy has the potential to reduce low birth weight and preterm birth. Hence, screening women for alcohol use during antenatal care visits and providing advice with rigorous follow-up of women who used alcohol may save the fetus from the potential risks of adverse birth outcomes.
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Affiliation(s)
- Alemu Earsido Addila
- Department of Public Health, College of Medicine and Health Sciences, Wachemo University, Hossana, Ethiopia.
- Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia.
| | - Telake Azale
- Department of Health Education and Behavioral Sciences, College of Medicine and Health Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Yigzaw Kebede Gete
- Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Mezgebu Yitayal
- Department of Health Systems and Policy, College of Medicine and Health Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia
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Arfer KB, O’Connor MJ, Tomlinson M, Rotheram-Borus MJ. South African mothers' immediate and 5-year retrospective reports of drinking alcohol during pregnancy. PLoS One 2020; 15:e0231518. [PMID: 32298313 PMCID: PMC7162489 DOI: 10.1371/journal.pone.0231518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 03/24/2020] [Indexed: 11/18/2022] Open
Abstract
Prenatal alcohol-drinking is often measured with self-report, but it is unclear whether mothers give more accurate answers when asked while pregnant or some time after their pregnancy. There is also the question of whether to measure drinking in a dichotomous or continuous fashion. We sought to examine how the timing and scale of self-reports affected the content of reports. From a sample of 576 black mothers around Cape Town, South Africa, we compared prenatal reports of prenatal drinking with 5-year retrospective reports, and dichotomous metrics (drinking or abstinent) with continuous metrics (fluid ounces of absolute alcohol drunk per day). Amounts increased over the 5-year period, whereas dichotomous measures found mothers less likely to report drinking later. All four measures were weakly associated with birth weight, birth height, child head circumference soon after birth, and child intelligence at age 5. Furthermore, neither reporting time nor the scale of measurement were consistently related to the strengths of these associations. Our results point to problems with self-report, particularly with this population, but we recommend post-birth continuous measures as the best of the group for their flexibility and their consistency with previous research.
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Affiliation(s)
- Kodi B. Arfer
- Icahn School of Medicine, Mount Sinai Health System, New York, New York, United States of America
| | - Mary J. O’Connor
- Semel Institute, University of California Los Angeles, Los Angeles, California, United States of America
| | - Mark Tomlinson
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Mary Jane Rotheram-Borus
- Global Center for Children and Families, University of California Los Angeles, Los Angeles, California, United States of America
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Raggio GA, Psaros C, Fatch R, Goodman G, Matthews LT, Magidson JF, Amanyire G, Cross A, Asiimwe S, Hahn JA, Haberer JE. High Rates of Biomarker-Confirmed Alcohol Use Among Pregnant Women Living With HIV in South Africa and Uganda. J Acquir Immune Defic Syndr 2019; 82:443-451. [PMID: 31567551 PMCID: PMC6857734 DOI: 10.1097/qai.0000000000002156] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/22/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Alcohol use is common among people living with HIV and particularly harmful during pregnancy. However, objective data on alcohol use in pregnant women living with HIV (WLWH) are lacking. In areas with high levels of alcohol use generally, such as South Africa and Uganda, these data are needed to inform interventions. METHODS Pregnant and nonpregnant, antiretroviral therapy-naive WLWH were recruited from outpatient clinics in South Africa and Uganda. Women provided self-report data on previous three-month alcohol use and potential mental health correlates of alcohol use (depression and stigma). Blood samples were used to measure phosphatidylethanol (PEth), an objective biomarker of recent alcohol intake. We analyzed any alcohol use (ie, any self-reported use or PEth-positive [≥8 ng/mL]) and under-reporting of alcohol use (ie, no self-reported use with concurrent PEth-positive). RESULTS Among pregnant WLWH (n = 163, median age was 26 [interquartile range: 23-29], median gestational age was 20 weeks [interquartile range: 16-26]), 40% were using alcohol and 16% under-reported alcohol use. Neither any alcohol use nor under-reporting of alcohol use differed significantly between pregnant and nonpregnant women or by country (P > 0.05). Greater depression (but not greater stigma) was significantly associated with any alcohol use (adjusted odds ratio = 1.41, 95% confidence interval: [1.01 to 1.99]; P = 0.045). CONCLUSIONS Alcohol use was prevalent and under-reported among pregnant WLWH in South Africa and Uganda, similar to nonpregnant participants, and associated with depression. General health care and antenatal clinic settings present opportunities to provide integrated alcohol-based counseling and depression treatment.
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Affiliation(s)
- Greer A. Raggio
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- National Center for Weight and Wellness, Washington, DC
| | - Christina Psaros
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Robin Fatch
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Georgia Goodman
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lynn T. Matthews
- Center for Global Health, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Infectious Disease, University of Alabama at Birmingham, Birmingham, AL
| | | | | | - Anna Cross
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa;
| | - Stephen Asiimwe
- Center for Global Health, Massachusetts General Hospital, Boston, MA
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda; and
- Kabwohe Clinical Research Center, Kabwohe, Uganda.
| | - Judith A. Hahn
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Gender Differences and Psychosocial Factors Associated with Problem Drinking Among Adults Enrolling in HIV Care in Tanzania. AIDS Behav 2019; 23:1612-1622. [PMID: 30465107 DOI: 10.1007/s10461-018-2340-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Problem drinking is commonly reported among people living with HIV (PLWH), associated with suboptimal HIV care outcomes and differs by gender. Psychosocial factors associated with problem drinking among PLWH remain poorly understood, including whether they differ by gender. This analysis examines the relationship between psychosocial factors and problem drinking separately by gender among PLWH in Tanzania. Cross-sectional data were collected from 812 men and non-pregnant women living with HIV aged 18 or older enrolling in HIV care at four health facilities in Tanzania. Problem drinking was assessed with the CAGE Questionnaire and defined as responding yes to two or more items. Sex-stratified multivariable logistic regression modeled the association of social support, HIV-related stigma, and physical or sexual violence on problem drinking, controlling for age, relationship status, employment, having been away from home for more than one month, and timing of first HIV-positive diagnosis. Thirteen percent of the sample reported problem drinking, with problem drinking significantly more commonly reported among men than non-pregnant women (17.6% vs. 9.5%). Among men and non-pregnant women, in multivariable analyses, enacted and internalized HIV-related stigma were significantly positively associated with problem drinking. Screening and treatment of problem drinking should be integrated into HIV care. Evidence-based substance abuse interventions should be adapted to address HIV-related stigma. Future research should longitudinally investigate the interrelationships between stigma, violence, and problem drinking among PLWH.
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A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries. BMC Med 2019; 17:17. [PMID: 30764819 PMCID: PMC6376728 DOI: 10.1186/s12916-019-1250-8] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 01/02/2019] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Stigma is associated with health conditions that drive disease burden in low- and middle-income countries (LMICs), including HIV, tuberculosis, mental health problems, epilepsy, and substance use disorders. However, the literature discussing the relationship between stigma and health outcomes is largely fragmented within disease-specific siloes, thus limiting the identification of common moderators or mechanisms through which stigma potentiates adverse health outcomes as well as the development of broadly relevant stigma mitigation interventions. METHODS We conducted a scoping review to provide a critical overview of the breadth of research on stigma for each of the five aforementioned conditions in LMICs, including their methodological strengths and limitations. RESULTS Across the range of diseases and disorders studied, stigma is associated with poor health outcomes, including help- and treatment-seeking behaviors. Common methodological limitations include a lack of prospective studies, non-representative samples resulting in limited generalizability, and a dearth of data on mediators and moderators of the relationship between stigma and health outcomes. CONCLUSIONS Implementing effective stigma mitigation interventions at scale necessitates transdisciplinary longitudinal studies that examine how stigma potentiates the risk for adverse outcomes for high-burden health conditions in community-based samples in LMICs.
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