Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial

Missed Opportunities: A Narrative Review on Why Nonoccupational Postexposure Prophylaxis for HIV Is Underutilized

Postexposure prophylaxis (PEP) is an important tool for preventing HIV infection but remains underutilized. In this narrative review, we aim to summarize the frequency of missed opportunities for prescribing PEP among studies from around the world, discuss the complexities of the challenges facing PEP provision, and describe possible solutions. We identified 20 studies published in the last 10 years among 43 832 individuals, of whom an estimated 41 477 were eligible for PEP. Of those eligible for PEP, PEP was prescribed among 27 705 (66.8%). There was a significant difference in PEP prescriptions in acute compared with non-acute care settings (63.5% vs 94.5%; P < .001). Emergent themes contributing to PEP underutilization included lack of provider and patient awareness, reduced PEP acceptability, HIV stigma and homophobia, lack of access (either to care or to medication), and stigmatizing policies. Each of those issues should be the focus of future PEP implementation efforts.

Trends and predictors of unmet need for family planning among women living with HIV in Zambia: implications for elimination of vertical transmission of HIV

BACKGROUND

Prevention of vertical (mother to child) transmission of HIV is one of the key strategies towards HIV epidemic control. Despite considerable progress over the past decade in Zambia, the country is yet to reach global and national target for elimination of vertical transmission of HIV. Avoidance of unintended pregnancy among women living with HIV is one of the cost-effective interventions in a comprehensive approach to prevent vertical transmission of HIV. Therefore, this study aimed at ascertaining trends in and predictors of unmet need for family planning among women living with HIV in Zambia.

METHODS

The study employed a repeated cross sectional (RCS) study design, using data from the three (3) most recent consecutive rounds of the Zambia Demographic and Health Survey (ZDHS) conducted in 2007, 2013/2014 and 2018. The study used data from a total of 27,153 women aged 15-49 years over the three survey periods among whom 4,113 had an HIV positive result following a rigorous HIV testing algorithm of the demographic and health surveys, and these constituted our sample size of women living with HIV. We used descriptive statistics and logistic regression analyses to respectively ascertain trends in and predictors of unmet need for family planning among women living with HIV.

RESULTS

Over the three survey points, unmet need for family planning among women living with HIV has largely remained unchanged from 20.8% in 2007 to 20.5% in 2013/14 and 21.1% in 2018 DHS. Residence, age of women, household wealth, woman's parity, employment, and age of spouse emerged as significant predictors of unmet need for family planning among women living with HIV in Zambia.

CONCLUSION

Preventing HIV infection in a child preserves life, contributes to improving quality of life from its early stages and averts lifetime costs of HIV treatment and associated healthcare costs. There is need to consider optimization of interventions to prevent vertical transmission of HIV including shaping programming regarding preventing unintended pregnancies among women living with HIV. Among other aspects, policy and practice need to strengthen SRH/HIV integration and better target rural residents, younger women, those with high parity and consider positive male engagement to reduce unmet need for family planning among women living with HIV.

Challenges, risks, and opportunities of antiretroviral drugs in women of reproductive potential

INTRODUCTION

The HIV/AIDS epidemic has been one of the greatest challenges in global health, significantly affecting women of reproductive potential. Considerable advances in antiretroviral therapy for women living with HIV have contributed to improvements in quality of life, better reproductive and birth outcomes, and a reduced risk of perinatal transmission.

AREAS COVERED

Despite the progress made, persistent challenges in access and adherence to antiretroviral drugs may limit their benefits for some women. More pharmacokinetic and safety studies in pregnant and lactating women are urgently needed, as are prospective surveillance systems to evaluate associations between fetal and infant antiretroviral exposures, drug-drug interactions, and pregnancy outcomes.

EXPERT OPINION

Multipurpose technologies, such as combined HIV and other STI or unintended pregnancy prevention, and innovative delivery methods, such as the development of long-acting antiretrovirals, have the potential to reduce adherence challenges and enhance quality of life for women with HIV. Parallel advances in drug safety testing and surveillance are needed to ensure the health and safety of women with or at risk for HIV and children at risk for perinatal transmission.

Breastfeeding Among Women Living With HIV in the Era of Lifelong ART: An Observational Multicountry Study in Eastern and Southern Africa

BACKGROUND

Lifelong antiretroviral treatment (ART) use is recommended for pregnant and breastfeeding (BF) women living with HIV (WLWH) to prevent perinatal HIV transmission and improve maternal health. We address 2 objectives in this analysis: (1) determine timing and factors associated with BF cessation and (2) assess the impact of BF on health of WLWH on ART.

SETTING

This multicountry study included 8 sites in Uganda, Malawi, Zimbabwe, and South Africa.

METHODS

This was a prospective study of WLWH on lifelong ART. These women initially participated from 2011 to 2016 in a randomized clinical trial (PROMISE) to prevent perinatal HIV transmission and subsequently reenrolled in an observational study (PROMOTE, 2016-2021) to assess ART adherence, safety, and impact.

RESULTS

The PROMOTE cohort included 1987 women on ART. Of them, 752 breastfed and were included in analyses of objective 1; all women were included in analyses of objective 2. The median time to BF cessation varied by country (11.2-19.7 months). Country of residence, age, and health status of women were significantly associated with time to BF cessation (compared with Zimbabwe: Malawi, adjusted hazard ratio [aHR] 0.50, 95% confidence interval [95% CI]: 0.40 to 0.62, P < 0.001; South Africa, aHR 1.49, 95% CI: 1.11 to 2.00, P = 0.008; and Uganda, aHR 1.77, 95% CI: 1.37 to 2.29, P < 0.001). Women who breastfed had lower risk of being "unwell" compared with women who never breastfed (adjusted rate ratio 0.87, 95% CI: 0.81 to 0.95 P = 0.030).

CONCLUSION

Women on lifelong ART should be encouraged to continue BF with no concern for their health. Time to BF cessation should be monitored for proper counseling in each country.

Can newborn infants with positive HIV soon after birth be diagnosed with intrauterine infection?

BACKGROUND

Mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) can occur intrauterine, intrapartum, and postpartum. Currently, infants with confirmed positive results in virological tests before 48 h of age are defined as having intrauterine infection.

AIM

We herein review the literature that identifies emerging challenges in diagnosing intrauterine HIV infection to rethink the current diagnostic criteria.

FINDINGS

A number of reports have shown that some infants who were diagnosed with intrauterine HIV infection after birth became negative for HIV in the subsequent follow-ups, including negative HIV antibodies at the age of 12-18 months. Such "clearance" of HIV was attributed to various reasons: neonatal antiretroviral treatment (ART), false positivity, strong host immune response, or unknown factors in maternal breast milk.

DISCUSSIONS

Positive HIV tests in newborn infants shortly after birth do not necessarily indicate HIV infection, because maternal HIV can enter fetal circulation intrapartum due to the repetitive, strong uterine contractions. The infants are therefore exposed to, but may not yet be infected with HIV at that time. The current diagnostic criteria cannot differentiate HIV exposure from HIV infection, leading to so-called "challenges in diagnosing intrauterine HIV infection". Those infants diagnosed with intrauterine infection who cleared HIV later were less likely to have been truly infected with HIV, but more likely to have been exposed to HIV. Moreover, we suggest that the determination of HIV antibody titers in infants' serial serum samples can provide valuable information to distinguish intrapartum exposure from intrauterine infection.

The End Is in Sight: Current Strategies for the Elimination of HIV Vertical Transmission

PURPOSE OF REVIEW

The goal of this review is to highlight and interpret recent trends and developments in the diagnosis, treatment, and prevention of HIV vertical transmission from a clinical perspective.

RECENT FINDINGS

Universal third-trimester retesting and partner testing may better identify incident HIV among pregnant patients and result in early initiation of antiretroviral therapy to prevent vertical transmission. The proven safety and efficacy of integrase inhibitors such as dolutegravir may be particularly useful in suppressing viremia in pregnant persons who present late for ART treatment. Pre-exposure prophylaxis (PrEP) during pregnancy may play a role in preventing HIV acquisition; however, its role in preventing vertical transmission is difficult to elucidate. Substantial progress has been made in recent years to eliminate HIV perinatal transmission. Future research hinges upon a multipronged approach to improving HIV detection, risk-stratified treatment strategies, and prevention of primary HIV infection among pregnant persons.

Prevention of the Vertical Transmission of HIV; A Recap of the Journey so Far

In 1989, one in four (25%) infants born to women living with HIV were infected; by the age of 2 years, there was 25% mortality among them due to HIV. These and other pieces of data prompted the development of interventions to offset vertical transmission, including the landmark Pediatric AIDS Clinical Trial Group Study (PACTG 076) in 1994. This study reported a 67.5% reduction in perinatal HIV transmission with prophylactic antenatal, intrapartum, and postnatal zidovudine. Numerous studies since then have provided compelling evidence to further optimize interventions, such that annual transmission rates of 0% are now reported by many health departments in the US and elimination has been validated in several countries around the world. Despite this success, the elimination of HIV's vertical transmission on the global scale remains a work in progress, limited by socioeconomic factors such as the prohibitive cost of antiretrovirals. Here, we review some of the key trials underpinning the development of guidelines in the US as well as globally, and discuss the evidence through a historic lens.

Review of antiretroviral therapy coverage in 10 highest burden HIV countries in Africa: 2015-2020

Africa is responsible for two-thirds of the global total of new HIV infections. South Africa, Nigeria, Mozambique, Uganda, Tanzania, Zambia, Zimbabwe, Kenya, Malawi, and Ethiopia were responsible for 80% of HIV cases in Africa in 2014 according to the Joint United Nations Programme on HIV/AIDS (UNAIDS). This study assesses antiretroviral coverage strategies implemented by these countries after the initiation of the "Fast-Track strategy to end the AIDS epidemic by 2030." Data reported in this review were obtained from different e-bibliographic including PubMed, Google Scholar, and Research Gate. Key terms were "Antiretroviral therapy," "Antiretroviral treatment," "HIV treatment," "HIV medication," "HIV/AIDS therapy," "HIV/AIDS treatment" + each of the countries listed earlier. We also extracted data on antiretroviral therapy (ART) coverage from the UNAIDS database. About 50 papers published from 2015 to 2021 met the inclusion criteria. All 10 countries have experienced an increase in ART coverage from 2015 to 2020 with an average of 47.6% increment. Nigeria recorded the highest increase in the rate of ART coverage (72% increase) while Ethiopia had the least (30%). New strategies adopted to increase ART coverage and retention in most countries were community-based models and the use of mobile health technology rather than clinic-based. These strategies focus on promoting task shifting, door-to-door access to HIV services, and a long-term supply of antiretroviral medications. Most of these strategies are still in the piloting stage. However, some new strategies and frameworks have been adopted nationwide in countries like Mozambique, Tanzania, Zambia, Zimbabwe, Kenya, and Malawi. Identified challenges include lack of funding, inadequate testing and surveillance services, poor digital penetration, and cultural/religious beliefs. The adoption of community-based and digital health strategies could have contributed to increased ART coverage and retention. African countries should facilitate nationwide scaling of ART coverage strategies to attain the 95-95-95 goal by 2030.

Factors associated with antiretroviral therapy use among pregnant women in rural and urban settings in Southern Province, Zambia: 2016-2019

OBJECTIVES

To assess antiretroviral therapy (ART) coverage among pregnant women living with HIV and compare the characteristics of women who received and did not receive ART during pregnancy in Zambia.

METHODS

A cross-sectional study was conducted at urban and rural health facilities in Southern Province, Zambia, from 2016 to 2019. Pregnant women living with HIV delivering at study sites were enrolled and administered a questionnaire, and the results of infant diagnostic testing for HIV at birth was documented.

RESULTS

About 1184 mother/infant pairs were enrolled. ART coverage was 93.7%. Most women who did not receive ART during pregnancy reported HIV diagnosis at delivery (18.0%) or during pregnancy (57.7%). The primary reported reason for not receiving ART was not wanting to take the drugs. Women who did not receive ART during pregnancy were significantly younger, less likely to have disclosed their HIV-infection status to others, and less likely to have received antenatal care than women who received ART. ART use correlated with higher levels of education in urban but not rural sites. Overall, 1.0% of infants were infected with HIV at birth, including 0.8% of infants born to women who received ART and 4.1% of infants born to women who did not.

CONCLUSIONS

Most women received ART according to guidelines, resulting in low perinatal transmission rates of HIV to infants. Efforts to increase ART coverage and prevent vertical transmission should focus on identifying incident HIV infections during pregnancy and strengthening counselling for newly diagnosed pregnant women.

Sulfation of 12-hydroxy-nevirapine by human SULTs and the effects of genetic polymorphisms of SULT1A1 and SULT2A1

Nevirapine (NVP) is an effective drug for the treatment of HIV infections, but its use is limited by a high incidence of severe skin rash and liver injury. 12-Hydroxynevirapine (12-OH-NVP) is the major metabolite of nevirapine. There is strong evidence that the sulfate of 12-OH-NVP is responsible for the skin rash. While several cytosolic sulfotransferases (SULTs) have been shown to be capable of sulfating 12-OH-NVP, the exact mechanism of sulfation in vivo is unclear. The current study aimed to clarify human SULT(s) and human organs that are capable of sulfating 12-OH-NVP and investigate the metabolic sulfation of 12-OH-NVP using cultured HepG2 human hepatoma cells. Enzymatic assays revealed that of the thirteen human SULTs, SULT1A1 and SULT2A1 displayed strong 12-OH-NVP-sulfating activity. 1-Phenyl-1-hexanol (PHHX), which applied topically prevents the skin rash in rats, inhibited 12-OH-NVP sulfation by SULT1A1 and SULT2A1, implying the involvement of these two enzymes in the sulfation of 12-OH-NVP in vivo. Among five human organ cytosols analyzed, liver cytosol displayed the strongest 12-OH-NVP-sulfating activity, while a low but significant activity was detected with skin cytosol. Cultured HepG2 cells were shown to be capable of sulfating 12-OH-NVP. The effects of genetic polymorphisms of SULT1A1 and SULT2A1 genes on the sulfation of 12-OH-NVP by SULT1A1 and SULT2A1 allozymes were investigated. Two SULT1A1 allozymes, Arg37Asp and Met223Val, showed no detectable 12-OH-NVP-sulfating activity, while a SULT2A1 allozyme, Met57Thr, displayed significantly higher 12-OH-NVP-sulfating activity compared with the wild-type enzyme. Collectively, these results contribute to a better understanding of the involvement of sulfation in NVP-induced skin rash and provide clues to the possible role of SULT genetic polymorphisms in the risk of this adverse reaction.

Determinants of HIV Testing during Pregnancy among Pregnant Sudanese Women: A Cross-Sectional Study

More than 90% of children who are HIV positive were infected via mother-to-child transmission (MTCT). In Sudan, HIV testing rates during pregnancy remain low. This study aimed to understand the key determinants of HIV testing and their association with pregnant women’s intention to undergo HIV test during pregnancy. A cross-sectional survey was conducted among 770 Sudanese pregnant women attending Antenatal care (ANC) visits at maternity hospitals. Based on the flow of antenatal care attendants, the calculated sample size was proportionally allocated to the hospitals. Doctors were most influential regarding pregnant women’s decision to undergo an HIV test during pregnancy (78.8%). Younger women were more likely to be tested. Most participants (68.9%) had high susceptibility with respect to HIV. Nearly half (48.3%) had a positive attitude towards HIV testing. Self-efficacy with regard to HIV testing was high (59.1%). Women with high self-efficacy and perceived susceptibility were more likely to have a greater intention to be tested for HIV. No significant association was found with perceived severity and stigma. Our study shows that the intention to undergo HIV testing among pregnant women is influenced by doctors and associated with self-efficacy and perceived susceptibility, which are important avenues for future intervention efforts.

Hunger and Adherence to Antiretroviral Therapy: Learning From HIV Positive Caregivers of Orphans and Vulnerable Children in Tanzania

The association between hunger and adherence to antiretroviral therapy (ART) is less known especially in vulnerable populations receiving HIV care and treatment services. Caregivers of orphans and vulnerable children (OVC) are vulnerable and likely to experience hunger due to additional economic pressure in caring for OVC. Using data from the community–based, USAID–funded Kizazi Kipya project, this study assesses the association between hunger and ART adherence among caregivers of OVC in Tanzania. HIV positive caregivers enrolled in the project from January to July 2017 were analyzed. The outcome variable was adherence to ART, defined as “not having missed any ART dose in the last 30 days,” and household hunger, measured using the Household Hunger Scale (HHS), was the main independent variable. Data analysis included multivariable logistic regression. The study analyzed 11,713 HIV positive caregivers who were on ART at the time of enrollment in the USAID Kizazi Kipya project in 2017. Aged 48.2 years on average, 72.9% of the caregivers were female. While 34.6% were in households with little to no hunger, 59.4 and 6.0% were in moderate hunger and severe hunger households, respectively. Overall, 90.0% of the caregivers did not miss any ART dose in the last 30 days. ART adherence rates declined as household hunger increased (p < 0.001). Multivariable analysis showed that the odds of adhering to ART was significantly lower by 42% among caregivers in moderate hunger households than those in little to no hunger households (OR = 0.58, 95% CI 0.50–0.68). The decline increased to 47% among those in severe hunger households (OR = 0.53, 95% CI 0.41–0.69). Hunger is an independent and a significant barrier to ART adherence among caregivers LHIV in Tanzania. Improving access to adequate food as part of HIV care and treatment services is likely to improve ART adherence in this population.

From Undetectable Equals Untransmittable (U=U) to Breastfeeding: Is the Jump Short?

Background: Vertical transmission of HIV infection may occur during pregnancy, at childbirth or through breastfeeding. Recommendations on the safety of breastfeeding of HIV-infected women on effective antiretroviral treatment are not univocal among international guidelines (WHO 2010, EACS 2017, DHHS 2017), leaving space for variability at the patient’s level. Methods: We collected clinical, laboratory and outcome data from 13 HIV-infected pregnant women who, between March 2017 and June 2021, elected to breastfeed their children against specific medical advice. All mothers were on antiretroviral therapy with darunavir or raltegravir plus emtricitabine/tenofovir disoproxil and remained HIV-RNA undetectable and >400 cells/mmc CD4+ lymphocytes during pregnancy and breastfeeding. Prophylactic antiretroviral therapy (zidovudine for 4 weeks) was started immediately after birth in all newborns. The mean duration of breastfeeding was 5.4 months. Newborns were tested for HIV-RNA multiple times: at birth, 1, 3, and 6 months after birth, and 1, 3 and 6 months after the end of breastfeeding. Results: None of the infants were infected by HIV. Conclusions: Our experience, gathered in the setting of freedom of choice on the patient’s side, while insufficient to address the eventual safety of breastfeeding in HIV-infected mothers since the represented cohort is numerically irrelevant, supports the extension of the U=U (Undetectable Equals Untransmittable) paradigm to this setting. Since breastfeeding is often requested by women with HIV planning pregnancy, more extensive comparative studies should be performed.

Prevention of Mother-to-Child Human Immunodeficiency Virus Transmission in Resource-Limited Countries

The first pediatric AIDS cases were reported in 1982. A decade later, the World Health Organization estimated there were more than 500,000 pediatric AIDS cases resulting from mother-to-child transmission, 90% of which were in sub-Saharan Africa. Although the rate of new infections globally has been cut in half since the peak of the pandemic, human immunodeficiency virus (HIV) remains a public health threat, and rates of new infections continue to increase in some regions. Mother-to-child transmission of HIV has now been virtually eliminated in many parts of the world but remains an issue in resource-limited countries.

A Pilot Study to Evaluate the Impact of the HIV Infant Tracking System (HITSystem 2.0) on Priority Prevention of Mother-to-Child Transmission (PMTCT) Outcomes

We assessed the preliminary impact of the adapted HIV Infant Tracking System (HITSystem v2.0) intervention on prevention of mother-to-child transmission (PMTCT) outcomes using a matched cluster randomized design in two Kenyan government hospitals. Between November 2017 and June 2019, n = 157 pregnant women with HIV were enrolled and followed from their first PMTCT appointment until 12-weeks postpartum. Data from 135 women were analyzed (HITSystem 2.0: n = 53, standard of care (SOC): n = 82), excluding eight deaths, eight pregnancy losses, and six transfers/moves. The primary outcome, complete PMTCT retention, is an aggregate measure of attendance at all scheduled antenatal appointments, hospital-based delivery, and infant HIV-testing before 7-weeks postnatal. HITSystem 2.0 participants were more likely to receive complete PMTCT services compared to SOC (56.6% vs. 17.1% p < 0.001). In multivariate modeling, HITSystem 2.0 was the strongest predictor of complete PMTCT retention (aOR 5.7, [1.2-90.8], p = 0.032). SOC participants had 1.91 increased hazard rate of PMTCT disengagement; (aHR 6.8, [2.2-21.1]; p < 0.001).

HIV in Neonates and Infants

Advances in perinatal HIV management have averted a significant number of infections in neonates and have made the possibility of elimination of mother-to-child transmission a reality; however, significant gaps in implementation of early testing programs as well as the expansion of therapeutic strategies to neonates are hindering prevention efforts and access to safer, more effective and easier to administer treatment. This article provides insights on the current state of perinatal HIV, recent advances, and future needs.

AIDS and COVID: A tale of two pandemics and the role of statisticians

The world has experienced three global pandemics over the last half-century: HIV/AIDS, H1N1, and COVID-19. HIV/AIDS and COVID-19 are still with us and have wrought extensive havoc worldwide. There are many differences between these two infections and their global impacts, but one thing they have in common is the mobilization of scientific resources to both understand the infection and develop ways to combat it. As was the case with HIV, statisticians have been in the forefront of scientists working to understand transmission dynamics and the natural history of infection, determine prognostic factors for severe disease, and develop optimal study designs to assess therapeutics and vaccines.

An observational study of initial HIV RNA decay following initiation of combination antiretroviral treatment during pregnancy

Background

In pregnancy, reduction of HIV plasma viral load (pVL) for the prevention of vertical transmission is time-constrained. The study primary objective is to investigate factors associated with faster initial HIV RNA half-life decay when combination antiretroviral treatment (cART) is initiated in pregnancy.

Methods

This was a multicentre, retrospective, observational study, conducted in south England, United Kingdom, between August 2001 and February 2018. Data were extracted from case notes of eligible women initiating cART during the index pregnancy. Anonymised data were collated and analysed centrally. Regression analyses were conducted to determine factors associated with faster HIV RNA half-life decay in the first 14 days after commencing cART (first-phase), and with achieving an undetectable maternal pVL by 36 weeks’ gestation. We then assessed whether HIV- and obstetric- related parameters differed by antiretroviral third agent class and whether the proportions of women with undetectable pVL at 36 weeks’ gestation and at delivery differed by antiretroviral third agent class.

Results

Baseline pVL was the only independent factor associated with faster first-phase HIV RNA half-life decay on commencing cART. Lower pVL on day 14 after starting cART was associated with an increased likelihood of achieving an undetectable pVL by 36 weeks’ gestation. Integrase inhibitor-based cART was associated with a faster first-phase HIV RNA half-life decay on commencing cART. Overall, 73% and 85% of women had an undetectable pVL at 36 weeks’ gestation and at delivery respectively, with no significant difference by antiretroviral third agent class.

Conclusions

Only high baseline pVL independently contributed to a faster rate of first-phase viral half-life decay. pVL at 14 days after initiating cART allows early identification of treatment failure. In the first 14 days after initiating cART in pregnancy, integrase inhibitor-based cART reduced maternal pVL faster than protease inhibitor- and non-nucleoside reverse transcriptase-based cART. While our study findings support INSTI use when initiated in pregnancy especially when initiated at later gestations and in those with higher baseline pVL, other non-INSTI based cART with more data on safety in pregnancy also performed well.

Perinatal Antiretroviral Intensification to Prevent Intrapartum HIV Transmission When Antenatal Antiretroviral Therapy Is Initiated Less Than 8 Weeks Before Delivery

INTRODUCTION

Infants born to women living with HIV initiating combination antiretroviral therapy (cART) late in pregnancy are at high risk of intrapartum infection. Mother/infant perinatal antiretroviral intensification may substantially reduce this risk.

METHODS

In this single-arm Bayesian trial, pregnant women with HIV receiving standard of care antiretroviral prophylaxis in Thailand (maternal antenatal lopinavir-based cART; nonbreastfed infants 4 weeks' postnatal zidovudine) were offered "antiretroviral intensification" (labor single-dose nevirapine plus infant zidovudine-lamivudine-nevirapine for 2 weeks followed by zidovudine-lamivudine for 2 weeks) if their antenatal cART was initiated ≤8 weeks before delivery. A negative birth HIV-DNA polymerase chain reaction (PCR) followed by a confirmed positive PCR defined intrapartum transmission. Before study initiation, we modeled intrapartum transmission probabilities using data from 3738 mother/infant pairs enrolled in our previous trials in Thailand using a logistic model, with perinatal maternal/infant antiretroviral regimen and predicted viral load at delivery as main covariates. Using the characteristics of the women enrolled who received intensification, prior intrapartum transmission probabilities (credibility intervals) with/without intensification were estimated. After including the transmission data observed in the current study, the corresponding Bayesian posterior transmission probability was derived.

RESULTS

No intrapartum transmission of HIV was observed among the 88 mother/infant pairs receiving intensification. The estimated intrapartum transmission probability was 2·2% (95% credibility interval 0·5-6·1) without intensification versus 0·3% (0·0-1·6) with intensification. The probability of superiority of intensification over standard of care was 94·4%. Antiretroviral intensification appeared safe.

CONCLUSION

Mother/infant antiretroviral intensification was effective in preventing intrapartum transmission of HIV in pregnant women receiving ≤8 weeks antepartum cART.

Trial designs for evaluating combination HIV prevention approaches

BACKGROUND

Combination HIV prevention approaches that include both biomedical and non-biomedical interventions often hold greater promise to improve health outcomes and reduce the risk of HIV transmission.

OBJECTIVES

Evaluate the relative properties of four leading candidate trial designs - 'single-factor', 'multi-arm', 'all-in-one', and 'factorial' designs - for assessing individual and/or combination prevention intervention approaches.

METHODS

Monte-Carlo simulations are conducted, assuming a putative combination approach could choose its components from two candidate biomedical interventions, i.e. Treatment-as-Prevention (TasP) and Pre-exposure Prophylaxis (PrEP), and three candidate behavioral interventions, i.e. linkage-to-care, counseling, and use of condoms. Various scenarios for individual components' effect sizes, their possible interaction, and the sample size based on real clinical studies are considered.

RESULTS

The all-in-one and factorial designs used to assess a combination approach and the multi-arm design used to assess multiple individual components are consistently more powerful than single-factor designs. The all-in-one design is powerful when the individual components are effective without negative interaction, while the factorial design is more consistently powerful across a broad array of settings.

CONCLUSIONS

The multi-arm design is useful for evaluating single factor regimens, while the all-in-one and factorial designs are sensitive in assessing the overall efficacy when there is interest in combining individual component regimens anticipated to have complementary mechanisms. The factorial design is a preferred approach when assessing combination regimens due to its favorable power properties and since it is the only design providing direct insights about the contribution of individual components to the combination approach's overall efficacy and about potential interactions.

Mid-trimester cervical length not associated with HIV status among pregnant women in Botswana

Objective

HIV-infected women on antiretroviral therapy have a higher risk of preterm birth than HIV-uninfected women in Botswana. To better understand the mechanism for preterm birth among HIV-infected women, we evaluated whether mid-trimester cervical length differed by HIV status as cervical shortening is associated with an increased risk for preterm birth.

Methods

We conducted a prospective cohort study among pregnant women receiving care at the Scottish Livingstone Hospital in Molepolole, Botswana. Consecutive women referred for routine obstetrical ultrasound were consented and enrolled if between 22w0d and 24w6d by ultrasound biometry. Blinded to maternal HIV status, an obstetrician measured transvaginal cervical length using standardized criteria. Cervical length, as well as the proportion of women with a short cervix (<25mm), were compared among HIV-infected and HIV-uninfected women. The acceptability of transvaginal ultrasound was also evaluated.

Results

Between April 2016 and April 2017, 853 women presenting for obstetric ultrasound were screened, 187 (22%) met eligibility criteria, and 179 (96%) were enrolled. Of those enrolled, 50 (28%) were HIV-infected (86% on antiretroviral therapy), 127 (71%) were HIV-uninfected, and 2 (1%) had unknown HIV status. There was no significant difference in mean cervical length between HIV-infected and HIV-uninfected women (32mm vs 31mm, p = 0.21), or in the proportion with a short cervix (10% vs 14%, p = 0.44). Acceptability data was available for 115 women who underwent a transvaginal ultrasound exam. Of these, 112 of 115 (97%) women deemed the transvaginal scan acceptable.

Conclusions

The increased risk of preterm birth observed among HIV-infected women receiving antiretroviral therapy in Botswana is unlikely associated with mid-trimester cervical shortening. Further research is needed to understand the underlying mechanism for preterm birth among HIV-infected women.

Copper (triazole-5-yl)methanamine complexes onto MCM-41: the synthesis of pyridine-containing pseudopeptides through the 6-endo-dig cyclization of 1,5-enynes

An efficient approach for the synthesis of immobilized copper (triazole-5-yl)methanamine complexes onto MCM-41 (Cu@TZMA@MCM-41), as a novel recyclable nanocatalyst, is described. This nanocatalyst was used for the synthesis of pyridine-containing pseudopeptides through a sequential Ugi/nucleophilic addition/1,5-enyne cyclization reaction and elicited good-to-excellent yields. The nanocatalyst was fully characterized by SEM, EDS, TEM, BET, ICP-OES, TGA, and XRD techniques. Furthermore, the catalyst was recovered by simple filtration and could be used for at least 5 cycles without significant loss of activity.

Undetectable proviral deoxyribonucleic acid in an adolescent perinatally infected with human immunodeficiency virus-1C and on long-term antiretroviral therapy resulted in viral rebound following antiretroviral therapy termination: A case report with implications for clinical care

RATIONALE

Early initiation of antiretroviral therapy (ART) leads to long-term viral suppression, reduces proviral reservoir size, and prolongs time to rebound. Since human immunodeficiency virus (HIV) is a lifelong disease, diagnostic monitoring after confirmed infection is typically not performed; therefore, little is known about the impact of early initiation and long-term ART on the sensitivity of assays that detect HIV antibodies and viral nucleic acid in children and adolescents.

PATIENT CONCERNS

Here we report 1 case of diagnosed and confirmed perinatal HIV-1C infection with longstanding viral suppression, who subsequently had a negative HIV-1 deoxyribonucleic acid (DNA) test, undetectable antibodies to HIV-1, and high CD4+ T cell count after 14 years of ART.

DIAGNOSIS

The patient was diagnosed with HIV in 2002 at 1 and 2 months of age using DNA polymerase chain reaction. At 8 months old, his viral load was 1210 HIV ribonucleic acid (RNA) copies/mL and CD4 T cell count was 3768 cells/mm.

INTERVENTION

At the age of 9 months, highly active antiretroviral therapy comprising of zidovudine, nevirapine, and lamivudine was initiated. The patient remained on this treatment for 14 years 11 months and was virally suppressed.

OUTCOMES

At the age of 14 years 4 months, the participant decided to visit a local voluntary HIV testing center, where a rapid HIV test came out negative and the viral load was undetectable (<400 HIV-1 RNA copies/mL). These results led to termination of ART which led to viral rebound within 9 months.

LESSONS

As more people with early HIV infection initiate early ART in the context of "Test and Treat all" recommendations, aspects of this report may become more commonplace, with both clinical and public health implications. If the possibility of functional cure (or false-positive diagnosis) is being considered, decisions to terminate ART should be made cautiously and with expert guidance, and may benefit from highly sensitive quantification of the proviral reservoir.

Safety of 6-week Neonatal Triple-combination Antiretroviral Postexposure Prophylaxis in High-risk HIV-exposed Infants

BACKGROUND

Combination antiretroviral drug regimens are increasingly preferred for neonatal postexposure prophylaxis (PEP) among HIV-exposed infants with high-risk of transmission. We evaluated the adverse events associated with the use of zidovudine (ZDV)/lamivudine (3TC)/nevirapine (NVP) for neonatal PEP during the first 6 weeks of life.

METHODS

A prospective cohort of non-breast-fed HIV-exposed infants was conducted at 5 clinical sites in Thailand. Study population included 100 high-risk HIV-exposed infants (maternal HIV RNA > 50 copies/mL prior to delivery or received antiretroviral therapy less than 12 weeks) and 100 low-risk HIV-exposed neonates. High-risk infants received ZDV/3TC/NVP for 6 weeks whereas low-risk HIV-exposed neonates received a 4-week regimen of ZDV. Complete blood count, aspartate transaminase and alanine transaminase were assessed at birth, 1, 2 and 4 months of life.

RESULTS

From October 2015 to November 2017, 200 infants were enrolled, of which 18.5% had low birth weight < 2500 g. The proportion of infants with anemia grade 2 or higher at 1 and 2 months of life between ZDV/3TC/NVP and ZDV prophylaxis was 48.5% vs 32.3% (P=0.02); nevertheless, severe anemia (grade 3) was not significantly different; 9.2% vs 10.2% (P=0.81), respectively. At 1 month old, infants on ZDV/3TC/NVP prophylaxis had significantly higher grade 2 anemia versus infants on ZDV alone (33.0% vs 13.4%; P=0.001); however, no difference was observed at 2 months old. No differences in neutropenia or hepatotoxicity between infant prophylactic regimens were observed.

CONCLUSIONS

Triple antiretroviral neonatal PEP with ZDV/3TC/NVP for 6 weeks in high-risk HIV-exposed infants did not significantly increase the risk of short-term toxicity compared with ZDV-monotherapy prophylaxis.

Population uptake and effectiveness of test-and-treat antiretroviral therapy guidelines for preventing the global spread of HIV: an ecological cross-national analysis

OBJECTIVES

Although the benefits of adopting test-and-treat antiretroviral therapy (ART) guidelines that recommend initiation of ART regardless of CD4 cell counts have been demonstrated at the individual level, there is uncertainty about how this translates to the population level. Here, we explored whether adopting ART guidelines recommending earlier treatment initiation improves population ART access and viral suppression and reduces overall disease transmission.

METHODS

Data on ART initiation guidelines and treatment coverage, viral suppression, and HIV incidence from 37 European and Central Asian countries were collected from the European Centre for Disease Prevention and Control and the Global HIV Policy Watch and HIV 90-90-90 Watch databases. We used multivariate linear regression models to quantify the association of ART initiation guidelines with population ART access, viral suppression, and HIV incidence, adjusting for potential confounding factors.

RESULTS

Test-and-treat policies were associated with 15.2 percentage points (pp) [95% confidence interval (CI) 0.8-29.6 pp; P = 0.039] greater treatment coverage (proportion of HIV-positive people on ART) compared with countries with ART initiation at CD4 cell counts ≤ 350 cells/μL. The presence of test-and-treat policies was associated with 15.8 pp (95% CI 2.4-29.1 pp; P = 0.023) higher viral suppression rates (people on ART virally suppressed) compared with countries with treatment initiation at CD4 counts ≤ 350 cells/μL. ART initiation at CD4 counts ≤ 500 cells/μL did not significantly improve ART coverage compared to initiation at CD4 counts ≤ 350 cells/μL but achieved similar degrees of viral suppression as test-and-treat.

CONCLUSIONS

Test-and-treat was found to be associated with substantial improvements in population-level access to ART and viral suppression, further strengthening evidence that rapid initiation of treatment will help curb the spread of HIV.

An Evaluation of Introduction of Rapid HIV Testing in a Perinatal Program

OBJECTIVE

This study was conducted to evaluate the roll-out of rapid HIV testing as part of an emergency Prevention of Perinatal HIV Transmission Program. Specifically, HIV prevalence in this population, the reason(s) for performing the rapid HIV test, and compliance with recommendations for antiretroviral prophylaxis were assessed.

METHODS

Since November 2011, all women presenting to a tertiary labour and delivery unit with unknown HIV status or with ongoing risk of HIV infection since their last HIV test were offered rapid HIV testing. Through retrospective chart review, demographic data, HIV risk and prior testing history, and antiretroviral prophylaxis, data were collected and descriptive statistics were performed.

RESULTS

One hundred fourteen rapid HIV tests were conducted and there were two preliminary reactive rapid results (one true positive, one false positive). None of the infants was HIV infected. Sixty-three percent of women had multiple risk factors for HIV acquisition, most commonly intravenous drug use (54%). Forty-four percent of women were within the 4-week seroconversion window at the time of delivery; 25% of these women and 52% of their infants received prophylactic drug therapy.

CONCLUSION

Rapid HIV testing identified a high-risk cohort and enabled aggressive management of a newly diagnosed HIV-positive pregnancy, successfully preventing perinatal HIV transmission. Risk factors for HIV acquisition were ongoing within the seroconversion window for over half of the women, impacting the utility of the test in eliminating unnecessary antiretroviral prophylaxis in this population because prophylaxis is recommended despite a negative rapid HIV test in these cases.

No. 185-HIV Screening in Pregnancy

OBJECTIVE

The purpose of this guideline is to provide recommendations to obstetric health care providers and to minimize practice variations for HIV screening, while taking provincial and territorial recommendations into account.

OUTCOMES

The risk of transmission of HIV from mother to fetus is significant if the mother is not treated. The primary outcome of screening for and treating HIV in pregnancy is a marked decrease in the rate of vertical transmission of HIV from mother to fetus. Secondary outcomes include confirmation of HIV infection in the woman, which allows optimization of her health and long-term management.

EVIDENCE

The Cochrane Library and Medline were searched for English-language articles published related to HIV screening and pregnancy. Additional articles were identified through the references of these articles. All study types were reviewed.

RECOMMENDATIONS

An overview of advances in global maternal health: From broad to specific improvements

After the declaration of the Millennium Development Goals in 2000 by the United Nations, many stakeholders allocated financial resources to "global maternal health." Research to expand care and improve delivery of maternal health services has exponentially increased. The present article highlights an overview, namely 10 of the health system, clinical, and technology-based advancements that have occurred in the past three decades in the field of global maternal health. The list of topics has been selected through the cumulative clinical and public health expertise of the authors and is certainly not exhaustive. Rather, the list is intended to provide a mapping of key topics arranged from broad to specific that span from the global policy level to the level of individual care. The list of health system, clinical, and technology-based advancements include: (10) Millennium Development Goals and Sustainable Development Goals; (9) Development of clinical training programs, including the potential for subspecialty development; (8) Prenatal care expansion and potential; (7) Decentralized health systems, including the use of skilled birth attendants; (6) Antiretroviral therapy for HIV; (5) Essential medicines; (4) Vaccines; (3) mHealth/eHealth; (2) Ultrasonography; and (1) Obstetric hemorrhage management. With the Sustainable Development Goals now underway, the field must build upon past successes to sustain maternal and neonatal well-being in the future global health agenda.

Adapting the HIV Infant Tracking System to Support Prevention of Mother-to-Child Transmission of HIV in Kenya: Protocol for an Intervention Development Pilot Study in Two Hospitals

Background

Despite progress to expand access to HIV testing and treatment during pregnancy in Kenya, gaps still remain in prevention of mother-to-child transmission of HIV (PMTCT) services. This study addresses the need for effective and scalable interventions to support women throughout the continuum of care for PMTCT services in low-resource settings. Our research team has successfully implemented the HIV Infant Tracking System (HITSystem), a Web-based, system-level intervention to improve early infant diagnosis (EID) outcomes.

Objective

This study will expand the scope of the HITSystem to address PMTCT services to bridge the gap between maternal and pediatric HIV services and improve outcomes. This paper describes the intervention development protocol to adapt and pilot an HITSystem version 2.0 to assess acceptability, feasibility, and preliminary PMTCT outcomes in Kenya.

Methods

This is a 3-year intervention development study to adapt the current HITSystem intervention to support a range of PMTCT outcomes including appointment attendance, antiretroviral therapy (ART) adherence, hospital deliveries, and integration of maternal and pediatric HIV services in low-resource settings. The study will be conducted in 3 phases. Phase 1 will elicit feedback from intervention users (patients and providers) to guide development and refinement of the new PMTCT components and inform optimal implementation. In Phase 2, we will design and develop the HITSystem 2.0 features to support key PMTCT outcomes guided by clinical content experts and findings from Phase 1. Phase 3 will assess complete PMTCT retention (before, during, and after delivery) using a matched randomized pilot study design in 2 hospitals over 18 months. A total of N=108 HIV-positive pregnant women (n=54 per site) will be enrolled and followed from their first PMTCT appointment until infant HIV DNA Polymerase Chain Reaction testing at the target age of 6 weeks (<7 weeks) postnatal.

Results

Funding for this study was received in August 2015, enrollment in Phase 1 began in March 2016, and completion of data collection is expected by May 2019.

Conclusions

This protocol will extend, adapt, and pilot an HITSystem 2.0 version to improve attendance of PMTCT appointments, increase ART adherence and hospital-based deliveries, and prompt EID by 6 weeks postnatal. The HITSystem 2.0 aims to improve the integration of maternal and pediatric HIV services.

Trial Registration

ClinicalTrials.gov NCT02726607; https://clinicaltrials.gov/ct2/show/NCT02726607 (Archived by WebCite at http://www.webcitation.org/78VraLrOb)

International Registered Report Identifier (IRRID)

DERR1-10.2196/13268

Serum n-6 Fatty Acids are Positively Associated with Growth in 6-to-10-Year Old Ugandan Children Regardless of HIV Status-A Cross-Sectional Study

Fatty acids (FAs) are crucial in child growth and development. In Uganda, antiretroviral therapy (ART) has drastically reduced perinatal human immunodeficiency virus (HIV) infection of infants, however, the interplay of FAs, ART, and HIV in relation to child growth is not well understood. To investigate this, serum was collected from 240 children between 6–10 years old in Uganda and analyzed for FAs using gas-chromatography mass-spectrometry. HIV status and anthropometric measurements were taken, and relationships with FAs were assessed. No significant differences in growth parameters or serum FAs were found between HIV uninfected children with and without exposure to ART. HIV positive children had significantly lower height-for-age-z-scores (HAZ) than uninfected children (p < 0.001). HIV-positive children had higher arachidonic acid than uninfected children (p = 0.003). Total omega-6 FAs were significantly associated with HAZ regardless of HIV status (p = 0.035). Mean total omega-3 FAs (2.90%) were low in this population compared to other cohorts in Africa. These results provide reference serum FA values for 6–10-year-old children in Uganda and may be used to inform lipid supplementation programs to promote child growth. Future studies should investigate the relationships between child growth trajectories in relation to HIV status and serum FAs.

Minority and majority pretreatment HIV-1 drug resistance associated with failure of first-line nonnucleoside reverse-transcriptase inhibitor antiretroviral therapy in Kenyan women

OBJECTIVES

Among women initiating first-line nonnucleoside reverse-transcriptase inhibitor (NNRTI)-based-ART with and without a history of single-dose nevirapine (sdNVP) with or without zidovudine with or without lamivudine (ZDV with and without 3TC) for prevention of mother-to-child HIV transmission (PMTCT), we hypothesized that pre-ART HIV-drug resistance would be associated with virologic failure DESIGN/METHODS:: In a prospectively enrolled study, three genotypic drug-resistance assays [oligonucleotide-ligation-assay (OLA), consensus sequencing, and next-generation sequencing by Illumina] were retrospectively performed to detect pre-ART drug resistance. Minority or majority drug-resistant variants identified in pre-ART RNA and/or DNA, a history of antiretrovirals for PMTCT, and other risk factors were assessed for association with virologic failure.

RESULTS

Failure occurred in 38/169 (22.5%) women, and was associated with pre-ART drug resistance detected by any assay (OLA of plasma or PBMC, consensus sequencing of PBMC and/or plasma, and next-generation sequencing of PBMC at frequencies of at least 10% and as minority variants; all P < 0.0001). Failure was also associated with PMTCT using sdNVP and ZDV with or without 3TC, but not sdNVP only; however, the longer time-interval between PMTCT and ART initiation observed for sdNVP-only women showed no interaction with failure. Viral loads and OLA of PBMC in longitudinal specimens demonstrated rapid failure and emergence of drug resistance, particularly among sdNVP and ZDV with or without 3TC-experienced women with pre-ART drug-resistant minority variants by next-generation sequencing but without drug resistance by OLA or consensus sequencing.

CONCLUSION

Pre-ART drug resistance was detected similarly by OLA of PBMC or plasma and by consensus sequencing, and was associated with virologic failure soon after initiation of first-line NVP-based ART. A history of sdNVP and ZDV with or without 3TC for PMTCT or minority variants detected by next-generation sequencing identified additional women with failure. These findings emphasize the value of assessing individual antiretroviral history, particularly nonsuppressive antiretrovirals with at least two drug classes, and testing for pre-ART drug resistance, including minority variants.

Option B+ prevention of mother-to-child transmission of HIV/AIDS service intervention outcomes in selected health facilities, Adama town, Ethiopia

Background: Vertical HIV transmission from mother-to-child accounts for more than 90% of pediatric HIV/AIDS infection. Virtual elimination of mother-to-child transmission (MTCT) of HIV is possible by giving comprehensive prevention of HIV/AIDS mother-to-child transmission (PMTCT) care. The objective of this study was to assess Option B+ (initiation of antiretroviral therapy for all pregnant mothers) PMTCT service intervention and outcomes in selected health facilities of Adama town, Ethiopia. Methods: A retrospective study was employed. A total of 248 medical records of mother-infant cohorts were included. Data wer collected from logbooks and/or records and individual medical records using a data abstraction tool. Results: Mean±SD age of mothers was 26.8±4.3 years. Half (50.8%) of the mothers were enrolled in PMTCT at 13-24 weeks of gestational age. The majority (79.6%) of mothers' CD4 counts were ≥351/mm3. Most of the mothers (71%) were on a tenofovir-lamivudine-evafrenz regimen. One-quarter of mothers were prescribed co-trimoxazole prophylactic therapy. Loss to follow-up from the Option B+ continuum was 10 (4.2%). Almost all (98.4%) of the infants were prescribed nevirapine prophylaxis. Nearly 90% (n=223) of the HIV-exposed infants were discharged as HIV negative. Conclusions: The Option B+ PMTCT service can minimize the chances of MTCT of HIV infection if used optimally. The magnitudes of loss to follow-up and death were lower than in comparable studies. Initiating all pregnant mothers on antiretroviral therapy irrespective of their clinical stage and CD4 count may have contributed to the optimal retention in care and near elimination of MTCT of HIV infection.

Incidence, prevalence and associated factors of mother-to-child transmission of HIV, among children exposed to maternal HIV, in Belgaum district, Karnataka, India

BACKGROUND

India lacks data on the incidence of Paediatric HIV. In 2010, the Indian Council of Medical Research commissioned a task force study to estimate the paediatric HIV burden in Belgaum district, Karnataka, India. We estimated the HIV incidence, prevalence and associated risk factors of mother to child transmission of HIV among children exposed to maternal HIV by age 24 months.

METHODS

We included Belgaum resident pregnant women who tested HIV positive between January 1st, 2011 and May 31st, 2013 and who provided consent. Their babies were tested for HIV at three time intervals using DNA PCR dry blood spot (DBS) method at 6-10 weeks and 6-9 months, and using Antibody tests at 18-24 months of age. We estimated cumulative incidence using survival analysis that considered censoring of cases and prevalence rates of HIV by age 24 months. Using competing-risk survival regression model, we examined the correlates of transmission of HIV among babies exposed to maternal HIV.

RESULTS

Among 487 children of HIV positive mothers recruited in the study, the cumulative incidence rate by 24 months of age was 4.8 per 1000 person months [95% CI: 3.5-6.6]. The HIV prevalence rate among babies exposed to maternal HIV until 24 months was 7.8% [95% CI: 5.7-10.7]. Mother's age above 30 years, and breastfeeding duration of more than six months were factors that significantly increased the HIV transmission; adjusted hazard ratio (AHR) 6.98 [95% CI: 1.73-28.16] and 5.28 [95% CI, 1.75-15.90], respectively. The risk of MTCT was significantly reduced if both mother and baby had received Nevirapine at delivery [AHR 0.25; 95%CI: 0.10-0.61] and if either mother or baby had been given Nevirapine at delivery [AHR 0.12; 95%CI: 0.03-0.49].

CONCLUSION

The study findings suggest that mother's age above 30 years and breastfeeding beyond 26 weeks is associated with higher rates of HIV transmission from mother to child. It confirms the benefits of providing anti-retrovirals (Nevirapine) in reducing mother to child transmission of HIV. Effective strategies to promote safe infant feeding practices, including avoidance of mixed feeding beyond 26 weeks among HIV infected mothers, is critical to reduce incidence of paediatric HIV in India.

Healthcare worker experiences with Option B+ for prevention of mother-to-child HIV transmission in eSwatini: findings from a two-year follow-up study

BACKGROUND

Prevention of mother-to-child transmission (PMTCT) across sub-Saharan Africa has rapidly shifted towards Option B+, an approach in which all HIV+ pregnant and breastfeeding women initiate lifelong antiretroviral therapy (ART) independent of CD4+ count. Healthcare workers (HCW) are critical to the success of Option B+, yet little is known regarding HCW acceptability of Option B+, particularly over time.

METHODS

Ten health facilities in the Manzini and Lubombo regions of eSwatini transitioned from Option A to Option B+ between 2013 and 2014 as part of the Safe Generations study examining PMTCT retention. Fifty HCWs (5 per facility) completed questionnaires assessing feasibility and acceptability: (1) prior to transitioning to Option B+, (2) two months post transition, and (3) approximately 2 years post Option B+ transition. This analysis describes HCW perceptions and experiences two years after transitioning to Option B+.

RESULTS

Two years after transition, 80% of HCWs surveyed reported that Option B+ was easy for HCWs, noting that it was particularly easy to explain and coordinate. Immediate ART initiation also reduced delays by eliminating need for laboratory tests prior to ART initiation. Additionally, HCWs reported ease of patient follow-up (58%), documentation (56%), and counseling (58%) under Option B+. Findings also indicate that a majority of HCWs reported that their workloads increased under Option B+. Sixty-eight percent of HCWs at two years post-transition reported more work under Option B+, specifically noting increased involvement in adherence counseling, prescribing/monitoring medications, and appointment scheduling/tracking. Some HCWs attributed their higher workloads to increased client loads, now that all HIV-positive women were initiated on ART. New barriers to patient uptake, and issues related to retention, adherence, and follow-up were also noted as challenges face by HCW when implementing Option B+.

CONCLUSIONS

Overall, HCWs found Option B+ to be acceptable and feasible while providing critical insights into the practical issues of universal ART. Further strengthening of the healthcare system may be necessary to alleviate worker burden and to ensure effective monitoring of client retention and adherence. HCW perceptions and experiences with Option B+ should be considered more broadly as countries implement Option B+ and consider universal treatment for all HIV+ individuals.

TRIAL REGISTRATION

http://clinicaltrials.gov NCT01891799 , registered on July 3, 2013.

Viral infections of the central nervous system in Africa

Viral infections are a major cause of human central nervous system infection, and may be associated with significant mortality, and long-term sequelae. In Africa, the lack of effective therapies, limited diagnostic and human resource facilities are especially in dire need. Most viruses that affect the central nervous system are opportunistic or accidental pathogens. Some of these viruses were initially considered harmless, however they have now evolved to penetrate the nervous system efficiently and exploit neuronal cell biology thus resulting in severe illness. A number of potentially lethal neurotropic viruses have been discovered in Africa and over the course of time shown their ability to spread wider afield involving other continents leaving a devastating impact in their trail. In this review we discuss key viruses involved in central nervous system disease and of major public health concern with respect to Africa. These arise from the families of Flaviviridae, Filoviridae, Retroviridae, Bunyaviridae, Rhabdoviridae and Herpesviridae. In terms of the number of cases affected by these viruses, HIV (Retroviridae) tops the list for morbidity, mortality and long term disability, while the Rift Valley Fever virus (Bunyaviridae) is at the bottom of the list. The most deadly are the Ebola and Marburg viruses (Filoviridae). This review describes their epidemiology and key neurological manifestations as regards the central nervous system such as meningoencephalitis and Guillain-Barré syndrome. The potential pathogenic mechanisms adopted by these viruses are debated and research perspectives suggested.

Designing & Conducting Trials To Reliably Evaluate HIV Prevention Interventions

While much has been achieved, much remains to be accomplished in the science of preventing the spread of HIV infection. Clinical trials that are properly designed, conducted and analyzed are of integral importance in the pursuit of reliable insights about HIV prevention. As we build on previous scientific breakthroughs, there will be an increasing need for clinical trials to be designed to efficiently achieve insights without compromising their reliability and generalizability. Key design features should continue to include: 1) the use of randomization and evidence-based controls, 2) specifying the use of intention-to-treat analyses to preserve the integrity of randomization and to increase interpretability of results, 3) obtaining direct assessments of effects on clinical endpoints such as the risk of HIV infection, 4) using either superiority designs or non-inferiority designs with rigorous non-inferiority margins, and 5) enhancing generalizability through the choice of a relative risk rather than risk difference metric. When interventions have complementary and potentially synergistic effects, factorial designs should be considered to increase efficiency as well as to obtain clinically important insights about interaction and the contribution of component interventions to the efficacy and safety of combination regimens. Key trial conduct issues include timely enrollment of participants at high HIV risk recruited from populations with high viral burden, obtaining 'best real-world achievable' levels of adherence to the interventions being assessed and ensuring high levels of retention. High quality of trial conduct occurs through active rather than passive monitoring, using pre-specified targeted levels of performance with defined methods to achieve those targets. During trial conduct, active monitoring of the performance standards not only holds the trial leaders accountable but also can assist in the development and implementation of creative alternative approaches to increase the quality of trial conduct. Designing, conducting and analyzing HIV prevention trials with the quality needed to obtain reliable insights is an ethical as well as scientific imperative.

The Journey of HIV-1 Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) from Lab to Clinic

Human immunodeficiency virus (HIV) infection is now pandemic. Targeting HIV-1 reverse transcriptase (HIV-1 RT) has been considered as one of the most successful targets for the development of anti-HIV treatment. Among the HIV-1 RT inhibitors, non-nucleoside reverse transcriptase inhibitors (NNRTIs) have gained a definitive place due to their unique antiviral potency, high specificity, and low toxicity in antiretroviral combination therapies used to treat HIV. Until now, >50 structurally diverse classes of compounds have been reported as NNRTIs. Among them, six NNRTIs were approved for HIV-1 treatment, namely, nevirapine (NVP), delavirdine (DLV), efavirenz (EFV), etravirine (ETR), rilpivirine (RPV), and doravirine (DOR). In this perspective, we focus on the six NNRTIs and lessons learned from their journey through development to clinical studies. It demonstrates the obligatory need of understanding the physicochemical and biological principles (lead optimization), resistance mutations, synthesis, and clinical requirements for drugs.

Weighing the Evidence of Efficacy of Oral PrEP for HIV Prevention in Women in Southern Africa

As oral tenofovir-based regimens for preexposure prophylaxis (PrEP) are adopted as standard of care for HIV prevention, their utilization in clinical trials among women in southern Africa will require an accurate estimate of oral PrEP efficacy in this population. This information is critical for women in choosing this prevention strategy, and in public health policy making. Estimates of the efficacy of oral PrEP regimens containing tenofovir have varied widely across trials that enrolled women, with some studies reporting high efficacy and others reporting no efficacy. Although poor adherence is strongly associated with lack of efficacy, other factors, such as mode of transmission (sexual vs. parenteral), predominant HIV subtype (C vs. non-C), intensity of exposure, and percentage of stable serodiscordant couples, may also contribute to the variation in efficacy estimates. In this article, we evaluate the evidence for PrEP efficacy in women and propose potential explanations for the observed differences in efficacy among studies. Our review emphasizes the need to continue to refine estimates of efficacy and effectiveness of tenofovir-based oral PrEP so as to best develop the next generation of HIV prevention tools, and to inform public policies directed toward HIV prevention.

The Collaborative Role of North American Departments of Pediatrics in Global Child Health

Appeals for health equity call for departments of pediatrics to improve the health of all children including those from underserved communities in North America and around the world. Consequently, North American (NA) departments of pediatrics have a role in global child health (GCH) which focuses on providing health care to underserved children worldwide. In this review, we describe how NA departments of pediatrics can collaboratively engage in GCH education, clinical practice, research, and advocacy and summarize best practices, challenges, and next steps for engaging in GCH in each of these areas. For GCH in low- and middle-income countries (LMICs), best practices start with the establishment of ethical, equitable, and collaborative partnerships with LMIC communities, organizations, and institutions engaged in GCH who are responsible for the vast majority of work done in GCH. Other best practices include adequate preparation of trainees and clinicians for GCH experiences; alignment with local clinical and research priorities; contributions to local professional development and ongoing monitoring and evaluation. Challenges for departments include generating funding for GCH activities; recruitment and retention of GCH-focused faculty members; and challenges meeting best practices, particularly adequate preparation of trainees and clinicians and ensuring mutual benefit and reciprocity in NA-LMIC collaborations. We provide examples of how departments have overcome these challenges and suggest next steps for development of the role of NA departments of pediatrics in GCH. Collaborative implementation of best practices in GCH by LMIC-NA partnerships can contribute to reductions of child mortality and morbidity globally.

Tackling HIV and AIDS: contributions by non-human primate models

During the past three decades, non-human primate (NHP) models have gained an increasing importance in HIV basic and translational research. In contrast to natural host models, infection of macaques with virulent simian or simian-human immunodeficiency viruses (SIV, SHIV) results in a disease that closely resembles HIV infection and AIDS. Although there is no perfect animal model, and each of the available models has its benefits and limitations, carefully designed NHP studies with selection of experimental variables have unraveled important questions of basic pathogenesis and have provided the tools to explore and screen intervention strategies. For example, NHP studies have advanced our understanding of the crucial events during early infection, and have provided proof-of-concept of antiretroviral drug treatment and prevention strategies such as pre-exposure prophylaxis (PrEP) regimes that are increasingly used worldwide, and upon overcoming further barriers of implementation, have the potential to make the next generation AIDS-free. Remaining goals include the pursuit of an effective HIV vaccine, and HIV cure strategies that would allow HIV-infected people to ultimately stop taking antiretroviral drugs. Through a reiterative process with feed-back from results of human studies, NHP models can be further validated and strengthened to advance our scientific knowledge and guide clinical trials.

Medicinal Plants Used in the Treatment of Human Immunodeficiency Virus

Since the beginning of the epidemic, human immunodeficiency virus (HIV) has infected around 70 million people worldwide, most of whom reside is sub-Saharan Africa. There have been very promising developments in the treatment of HIV with anti-retroviral drug cocktails. However, drug resistance to anti-HIV drugs is emerging, and many people infected with HIV have adverse reactions or do not have ready access to currently available HIV chemotherapies. Thus, there is a need to discover new anti-HIV agents to supplement our current arsenal of anti-HIV drugs and to provide therapeutic options for populations with limited resources or access to currently efficacious chemotherapies. Plant-derived natural products continue to serve as a reservoir for the discovery of new medicines, including anti-HIV agents. This review presents a survey of plants that have shown anti-HIV activity, both in vitro and in vivo.

Prevention of TB using rifampicin plus isoniazid reduces nevirapine concentrations in HIV-exposed infants

Background

Newborns of HIV-infected mothers are given daily doses of nevirapine to prevent HIV-1 acquisition. Infants born to mothers with TB should also receive TB preventive therapy. TB preventive regimens include isoniazid for 6 months or rifampicin plus isoniazid for 3 months (RH preventive therapy). The effect of concomitant RH preventive therapy on nevirapine concentrations in infants is unknown.

Patients and methods

Tshepiso was a prospective case-control cohort study of pregnant HIV-infected women with and without TB whose newborn infants received standard doses of nevirapine for HIV prophylaxis. Infants born to mothers with TB also received RH preventive therapy. Infant plasma nevirapine concentrations were measured at 1 and 6 weeks. The effects of RH preventive therapy on nevirapine disposition were investigated in a population pharmacokinetic model.

Results

Of 164 infants undergoing pharmacokinetic sampling, 46 received RH preventive therapy. After adjusting for weight using allometric scaling, the model estimated a 33% reduction in nevirapine trough concentrations with RH preventive therapy compared with TB-unexposed infants not receiving concomitant rifampicin and a 30% decline in trough concentrations in a typical infant between day 7 and 35 post-partum.

Conclusions

Rifampicin-based TB preventative treatment reduces nevirapine concentrations significantly in HIV-exposed infants. Although the nevirapine exposures required to prevent HIV acquisition in breastfeeding infants are undefined, given the potential risks associated with underdosing nevirapine in this setting, it is prudent to avoid rifampicin-based preventive therapy in HIV-exposed children receiving prophylactic nevirapine.

Abstinence Funding Was Not Associated With Reductions In HIV Risk Behavior In Sub-Saharan Africa

The President's Emergency Plan for AIDS Relief (PEPFAR) has been the largest funder of abstinence and faithfulness programming in sub-Saharan Africa, with a cumulative investment of over US $1.4 billion in the period 2004-13. We examined whether PEPFAR funding for abstinence and faithfulness programs, which aimed to reduce the risk of HIV transmission, was associated with a relative change in five outcomes indicative of high-risk sexual behavior: number of sexual partners in the past twelve months for men and for women, age at first sexual intercourse for men and for women, and teenage pregnancies. Using nationally representative surveys from twenty-two sub-Saharan African countries, we compared trends between people living in countries that received PEPFAR abstinence and faithfulness funding and those living in countries that did not in the period 1998-2013. We found no evidence to suggest that PEPFAR funding was associated with population-level reductions in any of the five outcomes. These results suggest that alternative funding priorities for HIV prevention may yield greater health benefits.

Trends in Neonatal Prophylaxis and Predictors of Combination Antiretroviral Prophylaxis in US Infants from 1990 to 2015

Postnatal antiretroviral (ARV) prophylaxis for infants born to women with HIV is a critical component of perinatal HIV transmission prevention. However, variability in prophylaxis regimens remains and consistency with guidelines has not been evaluated in the United States. We evaluated trends over time in prophylaxis regimens among 6386 HIV-exposed uninfected (HEU) infants using pooled data spanning two decades from three US-based cohorts: the Women and Infants Transmission Study (WITS, 1990-2007), Pediatric AIDS Clinical Trials Group (PACTG) 219C (1993-2007), and the PHACS Surveillance Monitoring of ART Toxicities (SMARTT) study (2007-2015). We also identified maternal and infant risk factors for use of combination prophylaxis regimens (≥2 ARVs) and examined consistency with US perinatal guidelines. We found that receipt of combination prophylaxis between 1996 and 2015 ranged from 2% to 15%, with a consistent median duration of 6 weeks. Infants whose mothers had lower CD4 T-cell counts, higher viral load (VL), no antepartum ARVs, age <20 years at delivery, and Cesarean delivery had significantly higher rates of combination prophylaxis, while infants born 2006-2010 (vs. 2011-2015), who were Hispanic or with lower maternal education levels, had significantly lower rates. Predictors for combination prophylaxis varied over time, with the strongest associations of maternal VL in later birth cohorts. While use of combination prophylaxis increased over time, only 50% of high-risk infants received such regimens in 2011-2015. In conclusion, HEU infants at higher risk of HIV acquisition are more likely to receive combination neonatal prophylaxis, consistent with US guidelines. However, substantial variability remains, and infants at higher risk often fail to receive combination prophylaxis.