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Espinal M, Yee LM, Fisher SA. Advances in HIV Management During Pregnancy and Infant Feeding. Infect Dis Clin North Am 2024; 38:423-452. [PMID: 38969531 DOI: 10.1016/j.idc.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2024]
Abstract
Recent advances in human immunodeficiency virus (HIV) management during pregnancy and infant feeding encompass several key elements: expanded HIV testing guidance; growing evidence of safety, efficacy, and pharmacokinetic data favoring the use of preferred antiretroviral therapy (ART) during pregnancy and breastfeeding; increasing advocacy for the inclusion of pregnant individuals with HIV in clinical trials to expedite access to new ART; and updated guidelines supporting shared decision-making for choice of infant feeding methods in people with HIV.
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Affiliation(s)
- Mariana Espinal
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 East Superior Street, Suite 05-2303, Chicago, IL, USA
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 East Superior Street, Suite 05-2303, Chicago, IL, USA.
| | - Stephanie A Fisher
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 East Superior Street, Suite 05-2303, Chicago, IL, USA
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2
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Powell A, Agwu A. In Support of Breast-/Chestfeeding by People With HIV in High-Income Settings. Clin Infect Dis 2024; 79:202-207. [PMID: 38270916 DOI: 10.1093/cid/ciae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/28/2023] [Accepted: 01/23/2024] [Indexed: 01/26/2024] Open
Abstract
Given that HIV can be transmitted through breastfeeding, historically, breastfeeding among women with HIV in the US and other resource-rich settings was discouraged. Formula feeding was the mandated feeding option out of concern for breast-milk transmission of HIV, which occurred in 16-24% of cases pre-antiretroviral therapy (pre-ART) use. In January 2023, the US Department of Health and Human Services' Perinatal Guidelines were revised to support shared decision-making for infant feeding choices. Updated clinical trials' data from resource-limited settings suggest the actual breastmilk HIV transmission rate in the context of maternal ART or neonatal postexposure prophylaxis is 0.3-1%. High-income countries are reporting more people with HIV breastfeeding their infants without cases of HIV transmission. We present the reasons for fully embracing breast-/chestfeeding as a viable, safe infant feeding option for HIV-exposed infants in high-income settings, while acknowledging unanswered questions and the need to continually craft more nuanced clinical guidance.
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Affiliation(s)
- Anna Powell
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Allison Agwu
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Infectious Diseases, Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Abuogi L, Noble L, Smith C. Infant Feeding for Persons Living With and at Risk for HIV in the United States: Clinical Report. Pediatrics 2024; 153:e2024066843. [PMID: 38766700 DOI: 10.1542/peds.2024-066843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 05/22/2024] Open
Abstract
Pediatricians and pediatric health care professionals caring for infants born to people living with and at risk for HIV infection are likely to be involved in providing guidance on recommended infant feeding practices. Care team members need to be aware of the HIV transmission risk from breastfeeding and the recommendations for feeding infants with perinatal HIV exposure in the United States. The risk of HIV transmission via breastfeeding from a parent with HIV who is receiving antiretroviral treatment (ART) and is virally suppressed is estimated to be less than 1%. The American Academy of Pediatrics recommends that for people with HIV in the United States, avoidance of breastfeeding is the only infant feeding option with 0% risk of HIV transmission. However, people with HIV may express a desire to breastfeed, and pediatricians should be prepared to offer a family-centered, nonjudgmental, harm reduction approach to support people with HIV on ART with sustained viral suppression below 50 copies per mL who desire to breastfeed. Pediatric health care professionals who counsel people with HIV who are not on ART or who are on ART but without viral suppression should recommend against breastfeeding. Pediatric health care professionals should recommend HIV testing for all pregnant persons and HIV preexposure prophylaxis to pregnant or breastfeeding persons who test negative for HIV but are at high risk of HIV acquisition.
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Affiliation(s)
- Lisa Abuogi
- Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Lawrence Noble
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York
| | - Christiana Smith
- Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
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Mehrabi F, Karamouzian M, Farhoudi B, Moradi Falah Langeroodi S, Mehmandoost S, Abbaszadeh S, Motaghi S, Mirzazadeh A, Sadeghirad B, Sharifi H. Comparison of safety and effectiveness of antiretroviral therapy regimens among pregnant women living with HIV at preconception or during pregnancy: a systematic review and network meta-analysis of randomized trials. BMC Infect Dis 2024; 24:417. [PMID: 38641597 PMCID: PMC11031873 DOI: 10.1186/s12879-024-09303-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 04/08/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Mother-to-child transmission is the primary cause of HIV cases among children. Antiretroviral therapy (ART) plays a critical role in preventing mother-to-child transmission and reducing HIV progression, morbidity, and mortality among mothers. However, after more than two decades of ART during pregnancy, the comparative effectiveness and safety of ART medications during pregnancy are unclear, and existing evidence is contradictory. This study aimed to assess the effectiveness and safety of different ART regimens among pregnant women living with HIV at preconception or during pregnancy. METHODS We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science. We included randomized trials that enrolled pregnant women living with HIV and randomized them to receive ART for at least four weeks. Pairs of reviewers independently completed screening for eligible studies, extracted data, and assessed the risk of bias using the Cochrane risk of bias tool. Our outcomes of interest included low birth weight, stillbirth, preterm birth, mother-to-child transmission of HIV, neonatal death, and congenital anomalies. Network meta-analysis was performed using a random-effects frequentist model, and the certainty of evidence was evaluated using the GRADE approach. RESULTS We found 14 eligible randomized trials enrolling 9,561 pregnant women. The median duration of ART uptake ranged from 6.0 to 17.4 weeks. No treatment was statistically better than a placebo in reducing the rate of neonatal mortality, stillbirth, congenital defects, preterm birth, or low birth weight deliveries. Compared to placebo, zidovudine (ZDV)/lamivudine (3TC) and ZDV monotherapy likely reduce mother-to-child transmission (odds ratio (OR): 0.13; 95% CI: 0.05 to 0.31, high-certainty; and OR: 0.50; 95% CI: 0.33 to 0.74, moderate-certainty). Moderate-certainty evidence suggested that ZDV/3TC was associated with decreased odds of stillbirth (OR: 0.47; 95% CI: 0.09 to 2.60). CONCLUSIONS Our analysis provides high- to moderate-certainty evidence that ZDV/3TC and ZDV are more effective in reducing the odds of mother-to-child transmission, with ZDV/3TC also demonstrating decreased odds of stillbirth. Notably, our findings suggest an elevated odds of stillbirth and preterm birth associated with all other ART regimens.
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Affiliation(s)
- Fatemeh Mehrabi
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Karamouzian
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Behnam Farhoudi
- Social Determinants of Health Research Center, Amir-al-momenin Hospital, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Shahryar Moradi Falah Langeroodi
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
- Pharmaceutics Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Soheil Mehmandoost
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Samaneh Abbaszadeh
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Shahrzad Motaghi
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Ali Mirzazadeh
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
| | - Hamid Sharifi
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA.
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Miller AP, Dean SS, Court L, Mvududu R, Mashele N, Wara NJ, Myer L, Shoptaw S, Davey DLJ. "So that's why I found PrEP to be safest way to protect yourself": exploring IPV experiences and impact on HIV prevention among pregnant and postpartum women in Cape Town, South Africa. BMC Public Health 2024; 24:481. [PMID: 38360616 PMCID: PMC10870618 DOI: 10.1186/s12889-024-17871-w] [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: 10/04/2023] [Accepted: 01/24/2024] [Indexed: 02/17/2024] Open
Abstract
Intimate partner violence (IPV) occurs at alarmingly high rates towards pregnant women in South Africa. Experiences of emotional, physical, and sexual IPV in pregnancy can adversely impact the health and safety of mother and fetus. Furthermore, IPV is associated with increased risk of HIV, exacerbating the public health impact of violence among pregnant women in this HIV endemic setting. In-depth understanding of cultural and contextual drivers of experiences of IPV is a critical precursor to development of interventions effectively addressing this issue among pregnant women in South Africa. The present study examines factors contributing to IPV among pregnant women to identify potential points of intervention. We conducted twenty in-depth interviews with postpartum women who used oral pre-exposure prophylaxis (PrEP) in pregnancy and reported recent experiences of IPV and/or ongoing alcohol use in a township near Cape Town, South Africa that experiences a heavy burden of both HIV and IPV. Interpretive thematic analysis was used. Several patterns of IPV during pregnancy were identified and violence was frequently described as co-occurring with male partner alcohol use. A majority of women referenced oral PrEP as their preferred method for HIV prevention, highlighting the agency and discretion it provided as beneficial attributes for women experiencing IPV. Fear of judgement from peers for remaining with an abusive partner and a lack of clear community messaging around IPV were identified as barriers to disclosure and support-seeking. Addressing the lack of social support received by women experiencing IPV during pregnancy in South Africa is essential to comprehensive IPV programming.
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Affiliation(s)
- Amanda P Miller
- Division of Epidemiology and Biostatistics, School of Public Health, San Diego State University, San Diego, CA, USA.
| | - Sarah Schoetz Dean
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Lara Court
- Division of Socio-behavioural Sciences, School of Public Health and Family Medicine, 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, Cape Town, South Africa
| | - Nyiko Mashele
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nafisa J Wara
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Steven Shoptaw
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Dvora L Joseph Davey
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Lazenby GB, Sundstrom B, Momplaisir FM, Badell ML, Rahangdale L, Nissim OR, Tarleton JL, Dempsey AR. Attitudes on breast feeding among persons with HIV who have given birth and their perceptions of coercion during counseling on safe infant feeding practices. AIDS Care 2023; 35:1852-1862. [PMID: 36435965 PMCID: PMC10213150 DOI: 10.1080/09540121.2022.2147481] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 11/08/2022] [Indexed: 11/28/2022]
Abstract
Persons with HIV can receive mixed messages about the safety of breastfeeding. We sought to assess if they felt coerced to formula feed when counseled about practices to reduce HIV transmission. Persons with HIV who had given birth were eligible to complete a survey to describe their experiences with infant feeding counseling and if they felt coerced to formula feed. An Iowa Infant Feeding Attitude Scale (IIFAS) assessed attitudes towards breastfeeding. Qualitative analyses were performed on narrative responses. One hundred surveys were collected from sites in Georgia, North Carolina, Pennsylvania, and South Carolina. The mean IIFAS score (n, 85) was 47 (SD 9.2), suggesting relatively favorable attitudes toward breastfeeding. Thirteen persons reported feeling coerced to formula feed. When controlling for choosing to give any breast milk, persons with any college education were more likely to report feeling coerced (aOR 9.8 [95% CI 1.8-52.5]). Qualitative analyses revealed three themes: perceiving breastfeeding as unsafe, engaging in shared decision-making, and resisting advice to formula feed. Persons with HIV desire to be counseled about safe infant feeding practices and have their questions answered without judgement. We highlight experiences of persons with HIV that reflect a need for a nuanced approach to infant feeding counseling.
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Affiliation(s)
- Gweneth B Lazenby
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC, USA
| | - Beth Sundstrom
- Department of Communication, College of Charleston, Charleston, SC, USA
| | - Florence M Momplaisir
- Department of Medicine, Division of Infectious Diseases, University of Pennsylvania, Philadelphia, PA, USA
| | - Martina L Badell
- Department of Obstetrics of Gynecology, Emory University, Atlanta, GA, USA
| | - Lisa Rahangdale
- Department of Obstetrics of Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - Oriel R Nissim
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC, USA
| | - Jessica L Tarleton
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC, USA
| | - Angela R Dempsey
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC, USA
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Cardenas MC, Farnan S, Hamel BL, Mejia Plazas MC, Sintim-Aboagye E, Littlefield DR, Behl S, Punia S, Enninga EAL, Johnson E, Temesgen Z, Theiler R, Gray CM, Chakraborty R. Prevention of the Vertical Transmission of HIV; A Recap of the Journey so Far. Viruses 2023; 15:v15040849. [PMID: 37112830 PMCID: PMC10142818 DOI: 10.3390/v15040849] [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: 12/26/2022] [Revised: 03/24/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
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.
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Affiliation(s)
- Maria Camila Cardenas
- Pediatric Residency Program, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Sheila Farnan
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Benjamin L. Hamel
- Pediatric Residency Program, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Maria Camila Mejia Plazas
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Pediatric Residency Program, Nicklaus Children’s Hospital, 3100 SW 62nd Ave, Miami, FL 33155, USA
| | - Elise Sintim-Aboagye
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Dawn R. Littlefield
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Supriya Behl
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Sohan Punia
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Elizabeth Ann L Enninga
- Maternal Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN 33155, USA
| | - Erica Johnson
- Department of Microbiology, Biochemistry, and Immunology, Morehouse School of Medicine, Atlanta, GA 30310, USA
| | - Zelalem Temesgen
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Rochester, MN 55905, USA
| | - Regan Theiler
- Maternal Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN 33155, USA
| | - Clive M. Gray
- Division of Molecular Biology and Human Genetics, Biomedical Research Institute, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town 7600, South Africa
| | - Rana Chakraborty
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Correspondence: ; Tel.: +1-507-293-9531
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Schrubbe LA, Stöckl H, Hatcher AM, Marston M, Kuchukhidze S, Calvert C. Prevalence and risk factors of unsuppressed viral load among pregnant and breastfeeding women in sub-Saharan Africa: analysis from population-based surveys. AIDS 2023; 37:659-669. [PMID: 36511117 DOI: 10.1097/qad.0000000000003459] [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] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To examine the prevalence of viral suppression and risk factors for unsuppressed viral load among pregnant and breastfeeding women living with HIV (WLH). DESIGN Pooled analysis among pregnant and breastfeeding WLH from Population-Based HIV Impact Assessment (PHIA) cross-sectional surveys from 10 sub-Saharan African countries. METHODS Questionnaires included sociodemographic, relationship-related, and HIV-related items, while blood tests examined HIV serostatus and viral load (data collected 2015-2018). The weighted prevalence of viral suppression was calculated. Logistic regression was used to examine risk factors for unsuppressed viral load (≥1000 copies/ml). RESULTS Of 1685 pregnant or breastfeeding WLH with viral load results, 63.8% (95% confidence interval (CI): 60.8-66.7%) were virally suppressed at the study visit. Among all included women, adolescence (adjusted odds ratio (aOR): 4.85, 95% CI: 2.58-9.14, P < 0.001) and nondisclosure of HIV status to partner (aOR: 1.48, 95% CI: 1.02-2.14, P = 0.04) were associated with unsuppressed viral load. Among only partnered women, adolescence (aOR: 7.95, 95% CI: 3.32-19.06, P < 0.001), and lack of paid employment (aOR: 0.67, 95% CI: 0.47-0.94, P = 0.02) were associated with unsuppressed viral load. Examining only women on ART, nondisclosure of HIV status to partner (aOR: 1.85, 95% CI: 1.19-2.88, P = 0.006) was associated with unsuppressed viral load. CONCLUSION Viral suppression among pregnant and breastfeeding WLH in sub-Saharan Africa remains suboptimal. Relationship dynamics around nondisclosure of HIV-positive status to partners was an important risk factor for unsuppressed viral load. Improving HIV care via sensitive discussions around partner dynamics in pregnant and breastfeeding women could improve maternal HIV outcomes and prevention of mother-to-child transmission of HIV (PMTCT).
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Affiliation(s)
- Leah A Schrubbe
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - Heidi Stöckl
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-University, Munich, Germany
| | - Abigail M Hatcher
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Milly Marston
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - Salome Kuchukhidze
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
| | - Clara Calvert
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
- Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK
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McKinney J, Mirani G, Levison J. Providers Have a Responsibility to Discuss Options for Infant Feeding With Pregnant People With Human Immunodeficiency Virus in High-Income Countries. Clin Infect Dis 2023; 76:535-539. [PMID: 36097892 DOI: 10.1093/cid/ciac761] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/29/2022] [Accepted: 09/08/2022] [Indexed: 11/12/2022] Open
Abstract
Guidelines in high-income countries generally recommend against breastfeeding for a pregnant person with HIV due to the historical risk of transmission to the infant and generally acceptable, safe, and sustainable access to formula. Maternal antiretroviral therapy and infant prophylaxis have been shown to significantly decrease the risk of transmission during breastfeeding. In addition, formula may not be acceptable to patients for a variety of cultural, social, or personal reasons, and its sustainability is called into question in the setting of the current nationwide formula shortage. Providers caring for pregnant people with HIV have a responsibility to discuss infant feeding with their patients, and help them weigh the risks and benefits within the limits of the current body of evidence. We outline a process, including a written agreement, that can be used to discuss infant feeding with all patients and help them make the best decision for their family.
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Affiliation(s)
- Jennifer McKinney
- Department of Maternal Fetal Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Gayatri Mirani
- Division of Allergy, Immunology, and Retrovirology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Judy Levison
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
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10
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Portwood C, Sexton H, Kumarendran M, Brandon Z, Kirtley S, Hemelaar J. Adverse perinatal outcomes associated with antiretroviral therapy in women living with HIV: A systematic review and meta-analysis. Front Med (Lausanne) 2023; 9:924593. [PMID: 36816720 PMCID: PMC9935588 DOI: 10.3389/fmed.2022.924593] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 12/20/2022] [Indexed: 02/05/2023] Open
Abstract
Background Maternal HIV infection is associated with an increased risk of adverse perinatal outcomes. The World Health Organization (WHO) recommends immediate initiation of lifelong antiretroviral therapy (ART) for all people living with HIV, including pregnant women living with HIV (WLHIV). We aimed to assess the risk of adverse perinatal outcomes in WLHIV receiving ART compared to ART-naïve WLHIV and HIV-negative women. Materials and methods We conducted a systematic literature review by searching PubMed, CINAHL, Global Health, and EMBASE for studies published between Jan 1, 1980, and April 20, 2020. Two investigators independently selected relevant studies and extracted data from studies reporting on the association of pregnant WLHIV receiving ART with adverse perinatal outcomes. Perinatal outcomes examined were preterm birth (PTB), very PTB, spontaneous PTB (sPTB), low birth weight (LBW), very LBW (VLBW), term LBW, preterm LBW, small for gestational age (SGA), very SGA (VSGA), stillbirth, and neonatal death. Random-effects meta-analyses examined the risk of adverse perinatal outcomes in WLHIV receiving ART compared to ART-naïve WLHIV and HIV-negative women. Subgroup and sensitivity analyses were performed based on country income status and study quality, and adjustment for confounding factors assessed. Results Of 94,594 studies identified, 73 cohort studies, including 424,277 pregnant women, met the inclusion criteria. We found that WLHIV receiving ART are associated with a significantly decreased risk of PTB (relative risk 0.79, 95% CI 0.67-0.93), sPTB (0.46, 0.32-0.66), LBW (0.86, 0.79-0.93), and VLBW (0.62, 0.39-0.97) compared to ART-naïve WLHIV. However, WLHIV receiving ART are associated with a significantly increased risk of PTB (1.42, 1.28-1.57), sPTB (2.20, 1.32-3.67), LBW (1.58, 1.36-1.84), term LBW (1.88, 1.23-2.85), SGA (1.69, 1.32-2.17), and VSGA (1.22, 1.10-1.34) compared to HIV-negative women. Conclusion ART reduces the risk of adverse perinatal outcomes in pregnant WLHIV, but the risk remains higher than in HIV-negative women. Our findings support the WHO recommendation of immediate initiation of lifelong ART for all people living with HIV, including pregnant WLHIV. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42021248987.
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Affiliation(s)
- Clara Portwood
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Harriet Sexton
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Mary Kumarendran
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Zoe Brandon
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Joris Hemelaar
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom,*Correspondence: Joris Hemelaar,
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Sexton H, Kumarendran M, Brandon Z, Shi C, Kirtley S, Hemelaar J. Adverse perinatal outcomes associated with timing of initiation of antiretroviral therapy: Systematic review and meta-analysis. HIV Med 2023; 24:111-129. [PMID: 35665582 DOI: 10.1111/hiv.13326] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 05/05/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The World Health Organization (WHO) recommends immediate initiation of lifelong antiretroviral therapy (ART) for all people living with HIV, including pregnant women. As a result, an increasing number of women living with HIV conceive while taking ART, the vast majority of whom reside in low- and middle-income countries (LMICs). We aimed to assess the association between timing of ART initiation and perinatal outcomes. METHODS We conducted a systematic literature review by searching PubMed, CINAHL (EBSCOhost), Global Health (Ovid), EMBASE (Ovid), and the Cochrane Central Register of Controlled Trials and four clinical trial databases (WHO International Clinical Trials Registry Platform, the Pan African Clinical Trials Registry, the ClinicalTrials.gov database, and the ISRCTN Registry) from 1 January 1980 to 28 April 2018. We identified studies reporting specific perinatal outcomes among pregnant women living with HIV according to timing of ART initiation and extracted data. Perinatal outcomes assessed were preterm birth (<37 weeks), very preterm birth (<32 weeks), low birthweight (<2500 g), very low birthweight (<1500 g), small for gestational age (<10th centile), very small for gestational age (<3rd centile) and neonatal death (<29 days). Random-effects meta-analyses examined perinatal outcomes associated with preconception and antenatal ART initiation as well as according to trimesters of antenatal initiation. We performed quality assessments and subgroup and sensitivity analyses, and assessed the effect of adjustment for confounders. This systematic review and meta-analyses is registered with PROSPERO, number CRD42021248987. RESULTS Of 51 874 unique citations, 25 studies (eight prospective and 17 retrospective cohort studies) were eligible for analysis, including 40 920 women living with HIV. Preconception ART initiation was associated with a significantly increased risk of preterm birth (relative risk 1.16; 95% confidence interval [CI] 1.03-1.31) compared with antenatal ART initiation. Preconception ART initiation was not significantly associated with very preterm birth, low birthweight, very low birthweight, small for gestational age, very small for gestational age, or neonatal death. First trimester exposure (i.e. preconception or first trimester initiation) was not significantly associated with any increased risk of adverse perinatal outcomes. No significant association between timing of ART initiation and adverse perinatal outcomes was found in the studies of higher quality and those conducted in LMICs. CONCLUSION Preconception ART initiation is associated with preterm birth but no other adverse perinatal outcomes. In LMICs, where most pregnant women living with HIV reside, the timing of ART initiation was not associated with any adverse perinatal outcomes.
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Affiliation(s)
- Harriet Sexton
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mary Kumarendran
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Zoe Brandon
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Christine Shi
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK
| | - Joris Hemelaar
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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12
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Chi BH, Sebikari D, Brummel SS, DeMarrais P, Chamanga R, Owor M, Dadabhai S, Price JT, Taha T, Stringer J, Fowler MG. Progesterone and prolactin levels in pregnant women living with HIV who delivered preterm and low birthweight infants: A nested case-control study. PLoS One 2023; 18:e0280730. [PMID: 36689442 PMCID: PMC9870101 DOI: 10.1371/journal.pone.0280730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 12/20/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) is associated with high rates of adverse birth outcomes, including preterm birth and low birthweight. Studies suggest that progesterone and prolactin may play important intermediary roles. METHODS We analyzed data from the Antenatal Component of the PROMISE trial, a multi-center study of pregnant women taking antiretroviral regimens (lopinavir/ritonavir-containing ART or zidovudine alone) to prevent mother-to-child HIV transmission. In a nested case-control study, we compared data from women who gave birth to preterm (<37 weeks gestation) and/or low birthweight (<2500 g) infants to matched individuals who did not. We measured serum progesterone and prolactin at 24-34 weeks gestation. We used conditional logistic regression to describe relationships between hormone levels, birth outcomes, and antiretroviral regimens. RESULTS 299 women and their newborns were included (146 cases, 153 controls). When compared to women receiving zidovudine alone, those on ART had higher odds of progesterone levels under the 10th percentile (adjusted odds ratio [AOR]:2.34, 95%CI:1.41-3.89) and 25th percentile (AOR:2.07, 95%CI:1.46-2.94). However, higher levels of progesterone-rather than lower levels-were associated with our composite case outcome at the 10th percentile (AOR:1.88, 95%CI:0.77-4.59) and 25th percentile (AOR:1.96, 95%CI:1.06-3.61). Associations were not observed between prolactin, antiretroviral regimen, and birth outcomes. CONCLUSION We observed lower progesterone levels among women allocated to ART regimens; however, higher progesterone levels were associated with preterm birth and/or low birthweight. While features of the study design may have contributed to these findings, they nevertheless highlight the potentially complex mechanisms underpinning adverse birth outcomes and HIV.
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Affiliation(s)
- Benjamin H. Chi
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Dorothy Sebikari
- Makerere University–Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Sean S. Brummel
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Patricia DeMarrais
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Rachel Chamanga
- College of Medicine-Johns Hopkins Research Project, Blantyre, Malawi
| | - Maxensia Owor
- Makerere University–Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Sufia Dadabhai
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Joan T. Price
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Taha Taha
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Jeffrey Stringer
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Mary Glenn Fowler
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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13
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Zheng Y, Zhao J, Shan Y, Guo S, Schrodi SJ, He D. Role of the granzyme family in rheumatoid arthritis: Current Insights and future perspectives. Front Immunol 2023; 14:1137918. [PMID: 36875082 PMCID: PMC9977805 DOI: 10.3389/fimmu.2023.1137918] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/03/2023] [Indexed: 02/18/2023] Open
Abstract
Rheumatoid arthritis (RA) is a complex autoimmune disease characterized by chronic inflammation that affects synovial tissues of multiple joints. Granzymes (Gzms) are serine proteases that are released into the immune synapse between cytotoxic lymphocytes and target cells. They enter target cells with the help of perforin to induce programmed cell death in inflammatory and tumor cells. Gzms may have a connection with RA. First, increased levels of Gzms have been found in the serum (GzmB), plasma (GzmA, GzmB), synovial fluid (GzmB, GzmM), and synovial tissue (GzmK) of patients with RA. Moreover, Gzms may contribute to inflammation by degrading the extracellular matrix and promoting cytokine release. They are thought to be involved in RA pathogenesis and have the potential to be used as biomarkers for RA diagnosis, although their exact role is yet to be fully elucidated. The purpose of this review was to summarize the current knowledge regarding the possible role of the granzyme family in RA, with the aim of providing a reference for future research on the mechanisms of RA and the development of new therapies.
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Affiliation(s)
- Yixin Zheng
- Department of Rheumatology, Shanghai Guanghua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Guanghua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Institute of Arthritis Research in Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, Shanghai, China
| | - Jianan Zhao
- Department of Rheumatology, Shanghai Guanghua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Guanghua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Institute of Arthritis Research in Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, Shanghai, China
| | - Yu Shan
- Department of Rheumatology, Shanghai Guanghua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Guanghua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Institute of Arthritis Research in Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, Shanghai, China
| | - Shicheng Guo
- Center for Human Genomics and Precision Medicine, University of Wisconsin-Madison, Madison, WI, United States.,Department of Medical Genetics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Steven J Schrodi
- Center for Human Genomics and Precision Medicine, University of Wisconsin-Madison, Madison, WI, United States.,Department of Medical Genetics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Dongyi He
- Department of Rheumatology, Shanghai Guanghua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Guanghua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Institute of Arthritis Research in Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, Shanghai, China.,Arthritis Institute of Integrated Traditional and Western medicine, Shanghai Chinese Medicine Research Institute, Shanghai, China
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14
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Nematadzira TG, Murnane PM, Odiase OJ, Bacchetti P, Okochi H, Tallerico R, Chanaiwa VM, Vhembo T, Mutambanengwe-Jacob MT, Louie A, Chipato T, Gandhi M, Stranix-Chibanda L. Antiretroviral Therapy Adherence During and Postbreastfeeding Cessation Measured by Tenofovir Levels in Hair. J Acquir Immune Defic Syndr 2022; 91:237-241. [PMID: 35952357 PMCID: PMC9561228 DOI: 10.1097/qai.0000000000003076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND We examined change in antiretroviral treatment (ART) adherence after breastfeeding (BF) cessation using hair tenofovir (TFV) concentrations as an objective metric of medication consumption. METHODS A subset of postpartum women in Zimbabwe randomized in IMPAACT PROMISE to take ART while BF and post-BF cessation had hair TFV measured longitudinally. Using linear mixed-effect models, we estimated differences in hair TFV levels after BF cessation, accounting for trends in levels over time regardless of BF status and change in slope after breastfeeding cessation. We also estimated the relative risk of viremia (>50 copies/mL) per doubling of hair TFV concentration. RESULTS Among 55 women (median age 26, interquartile range 24-29 years), hair TFV levels (n = 305) were available for a median of 9 visits per woman between 3 and 29 months postpartum. Hair TFV levels ranged from undetected to 0.25 ng/mg (median 0.04 ng/mg). Controlling for trends since delivery [decline of 2.2% per month, 95% confidence interval (CI): -5.3 to 1.0], TFV levels averaged 24.4% higher (95% CI: -5.1 to 63.1) post-BF cessation than during BF, with no change in slope (0.0% per month, 95% CI: -3.8 to 3.9). Postpartum, 42% of women were ever viremic. Higher TFV levels were strongly protective; relative risk of viremia per doubling of TFV was 0.52 (95% CI: 0.43 to 0.63; P < 0.0001). CONCLUSIONS Leveraging an objective metric of ART use, we observed modestly declining adherence across the postpartum period, but no additional decline associated with breastfeeding cessation. High viremia frequency and varying postpartum TFV levels observed highlight the importance of enhanced adherence support with viral load monitoring among postpartum women.
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Affiliation(s)
| | - Pamela M. Murnane
- Institute for Global Health Sciences, University of California-San Francisco, San Francisco, CA
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA
| | - Osamuedeme J. Odiase
- Hair Analytical Laboratory, University of California-San Francisco, San Francisco, CA; and
| | - Peter Bacchetti
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA
| | - Hideaki Okochi
- Hair Analytical Laboratory, University of California-San Francisco, San Francisco, CA; and
| | - Regina Tallerico
- Hair Analytical Laboratory, University of California-San Francisco, San Francisco, CA; and
| | - Vongai M. Chanaiwa
- University of Zimbabwe-Clinical Trials Research Centre, Harare, Zimbabwe
| | - Tichaona Vhembo
- University of Zimbabwe-Clinical Trials Research Centre, Harare, Zimbabwe
| | | | - Alexander Louie
- Hair Analytical Laboratory, University of California-San Francisco, San Francisco, CA; and
| | - Tsungai Chipato
- University of Zimbabwe-Clinical Trials Research Centre, Harare, Zimbabwe
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Monica Gandhi
- Hair Analytical Laboratory, University of California-San Francisco, San Francisco, CA; and
| | - Lynda Stranix-Chibanda
- University of Zimbabwe-Clinical Trials Research Centre, Harare, Zimbabwe
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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15
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Habib N, Hughes MD, Broutet N, Thorson A, Gaillard P, Landoulsi S, McDonald SLR, Formenty P. Statistical methodologies for evaluation of the rate of persistence of Ebola virus in semen of male survivors in Sierra Leone. PLoS One 2022; 17:e0274755. [PMID: 36197875 PMCID: PMC9534448 DOI: 10.1371/journal.pone.0274755] [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: 02/19/2021] [Accepted: 09/03/2022] [Indexed: 11/24/2022] Open
Abstract
The 2013-2016 Ebola virus (EBOV) outbreak in West Africa was the largest and most complex outbreak ever, with a total number of cases and deaths higher than in all previous EBOV outbreaks combined. The outbreak was characterized by rapid spread of the infection in nations that were weakly prepared to handle it. EBOV ribonucleic acid (RNA) is known to persist in body fluids following disease recovery, and studying this persistence is crucial for controlling such epidemics. Observational cohort studies investigating EBOV persistence in semen require following up recently recovered survivors of Ebola virus disease (EVD), from recruitment to the time when their semen tests negative for EBOV, the endpoint being time-to-event. Because recruitment of EVD survivors takes place weeks or months following disease recovery, the event of interest may have already occurred. Survival analysis methods are the best suited for the estimation of the virus persistence in body fluids but must account for left- and interval-censoring present in the data, which is a more complex problem than that of presence of right censoring alone. Using the Sierra Leone Ebola Virus Persistence Study, we discuss study design issues, endpoint of interest and statistical methodologies for interval- and right-censored non-parametric and parametric survival modelling. Using the data from 203 EVD recruited survivors, we illustrate the performance of five different survival models for estimation of persistence of EBOV in semen. The interval censored survival analytic methods produced more precise estimates of EBOV persistence in semen and were more representative of the source population than the right censored ones. The potential to apply these methods is enhanced by increased availability of statistical software to handle interval censored survival data. These methods may be applicable to diseases of a similar nature where persistence estimation of pathogens is of interest.
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Affiliation(s)
- Ndema Habib
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research, Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
- * E-mail:
| | - Michael D. Hughes
- Department of Biostatistics, Harvard T.H Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Nathalie Broutet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research, Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Anna Thorson
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research, Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Philippe Gaillard
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research, Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Sihem Landoulsi
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research, Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Suzanne L. R. McDonald
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research, Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Pierre Formenty
- Department of Health Emergency Interventions, World Health Organization, Geneva, Switzerland
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16
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Kiyaga C, Fong Y, Okiira C, Kushemererwa GE, Kayongo I, Tadeo I, Namulindwa C, Bigira V, Ssewanyana I, Peter T, Doherty M, Sacks JA, Vojnov L. HIV viral load assays when used with whole blood perform well as a diagnostic assay for infants. PLoS One 2022; 17:e0268127. [PMID: 35771878 PMCID: PMC9246233 DOI: 10.1371/journal.pone.0268127] [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: 04/16/2021] [Accepted: 04/25/2022] [Indexed: 11/22/2022] Open
Abstract
Objective Over the past several years, only approximately 50% of HIV-exposed infants received an early infant diagnosis test within the first two months of life. While high attrition and mortality account for some of the shortcomings in identifying HIV-infected infants early and putting them on life-saving treatment, fragmented and challenging laboratory systems are an added barrier. We sought to determine the accuracy of using HIV viral load assays for infant diagnosis of HIV. Methods We enrolled 866 Ugandan infants between March–April 2018 for this study after initial laboratory diagnosis. The median age was seven months, while 33% of infants were less than three months of age. Study testing was done using either the Roche or Abbott molecular technologies at the Central Public Health Laboratory. Dried blood spot samples were prepared according to manufacturer-recommended protocols for both the qualitative and quantitative assays. Viral load test samples for the Roche assay were processed using two different buffers: phosphate-buffered saline (PBS: free virus elution viral load protocol [FVE]) and Sample Pre-Extraction Reagent (SPEX: qualitative buffer). Dried blood spot samples were processed for both assays on the Abbott using the manufacturer’s standard infant diagnosis protocol. All infants received a qualitative test for clinical management and additional paired quantitative tests. Results 858 infants were included in the analysis, of which 50% were female. Over 75% of mothers received antiretroviral therapy, while approximately 65% of infants received infant prophylaxis. The Roche SPEX and Abbott technologies had high sensitivity (>95%) and specificity (>98%). The Roche FVE had lower sensitivity (85%) and viral load values. Conclusions To simplify and streamline laboratory practices, HIV viral load may be used to diagnose HIV infection in infants, particularly using the Roche SPEX and Abbott technologies.
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Affiliation(s)
- Charles Kiyaga
- Central Public Health Laboratory, Kampala, Uganda
- * E-mail:
| | - Youyi Fong
- Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | | | | | | | - Iga Tadeo
- Central Public Health Laboratory, Kampala, Uganda
| | | | - Victor Bigira
- Uganda National Health Laboratory Services, Kampala, Uganda
| | | | - Trevor Peter
- Clinton Health Access Initiative, Boston, MA, United States of America
| | - Meg Doherty
- World Health Organization, Geneva, Switzerland
| | - Jilian A. Sacks
- Clinton Health Access Initiative, Boston, MA, United States of America
| | - Lara Vojnov
- World Health Organization, Geneva, Switzerland
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17
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Caniglia EC, Zash R, Swanson SA, Smith E, Sudfeld C, Finkelstein JL, Diseko M, Mayondi G, Mmalane M, Makhema J, Fawzi W, Lockman S, Shapiro RL. Iron, folic acid, and multiple micronutrient supplementation strategies during pregnancy and adverse birth outcomes in Botswana. Lancet Glob Health 2022; 10:e850-e861. [PMID: 35561720 PMCID: PMC9309424 DOI: 10.1016/s2214-109x(22)00126-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 02/10/2022] [Accepted: 03/16/2022] [Indexed: 12/18/2022]
Abstract
Background Methods Findings Interpretation Funding
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Affiliation(s)
- Ellen C Caniglia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Rebecca Zash
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana; Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Emily Smith
- School of Public Health, George Washington University, Washington DC, USA
| | - Christopher Sudfeld
- Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Julia L Finkelstein
- Division of Nutritional Sciences, Cornell College of Human Ecology, Cornell University, Ithaca, NY, USA
| | - Modiegi Diseko
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Gloria Mayondi
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mompati Mmalane
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Joseph Makhema
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Wafaie Fawzi
- Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Shahin Lockman
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana; Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Roger L Shapiro
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana; Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
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18
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Musiime V, Kiggwe A, Beinomugisha J, Kakooza L, Thembo-Mwesige J, Nkinzi S, Naguti E, Atuhaire L, Segawa I, Ssengooba W, Mukonzo JK, Babirekere-Iriso E, Musoke P. Strategies to Reduce Mortality Among Children Living With HIV and Children Exposed to HIV but Are Uninfected, Admitted With Severe Acute Malnutrition at Mulago Hospital, Uganda (REDMOTHIV): A Mixed Methods Study. Front Pediatr 2022; 10:880355. [PMID: 35813373 PMCID: PMC9263204 DOI: 10.3389/fped.2022.880355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/02/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Children living with HIV (CLHIV) and children who are exposed to HIV but uninfected (CHEU) are at increased risk of developing malnutrition. Severely malnourished children have high mortality rates, but mortality is higher in CLHIV/CHEU. This study aims to investigate whether empiric use of an antibiotic with greater antimicrobial sensitivity (ceftriaxone) than standard-of-care (ampicillin plus gentamicin) will reduce mortality among CLHIV/CHEU admitted with severe acute malnutrition. METHODS This is an open label randomized controlled trial involving 300 children; 76 CLHIV and 224 CHEU. The participants are being randomized to receive 1 week of ceftriaxone (n = 150) or standard-of-care (ampicillin/gentamicin) (n = 150), in addition to other routine care. The trial's primary outcome is in-hospital mortality. Secondary outcomes are: length of hospitalization; weight-for-height, weight-for-age and height-for-age z-scores; and pattern/antimicrobial sensitivity of pathogens. In addition, 280 severely malnourished children of unknown serostatus will be tested for HIV at admission to determine the prevalence and factors associated with HIV-infection. Furthermore, all the CLHIV on LPV/r will each provide sparse pharmacokinetic (PK) samples to evaluate the PK of LPV/r among malnourished children. In this PK sub-study, geometric means of steady-state LPV PK parameters [Area Under the Curve (AUC) 0-12h , maximum concentration (Cmax) and concentration at 12 h after dose (C12h)] will be determined. They will then be put in pharmacokinetic-pharmacodynamic (PK-PD) models to determine optimal doses for the study population. DISCUSSION This study will ascertain whether antibiotics with higher sensitivity patterns to common organisms in Uganda and similar settings, will produce better treatment outcomes. The study will also provide insights into the current pattern of organisms isolated from blood cultures and their antimicrobial sensitivities, in this population. In addition, the study will ascertain whether there has been a significant change in the prevalence of HIV-infection among children presenting with severe malnutrition in the WHO recommended option B plus era, while determining the social/structural factors associated with HIV-infection. There will also be an opportunity to study PK parameters of antiretroviral drugs among severely malnourished children which is rarely done, and yet it is very important to understand the dosing requirements of this population. TRIAL REGISTRATION ClinicalTrials.gov, identifier: NCT05051163.
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Affiliation(s)
- Victor Musiime
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda.,Department of Research, Joint Clinical Research Centre, Kampala, Uganda
| | - Andrew Kiggwe
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Judith Beinomugisha
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Lawrence Kakooza
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Josam Thembo-Mwesige
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sharafat Nkinzi
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Erusa Naguti
- Mwanamugimu Nutrition Unit, Directorate of Paediatrics and Child Care, Mulago National Referral Hospital, Kampala, Uganda
| | - Loice Atuhaire
- Mwanamugimu Nutrition Unit, Directorate of Paediatrics and Child Care, Mulago National Referral Hospital, Kampala, Uganda
| | - Ivan Segawa
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Willy Ssengooba
- BSL 3 Mycobacteriology Laboratory, Department of Medical Microbiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jackson K Mukonzo
- Department of Pharmacology and Therapeutics, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Esther Babirekere-Iriso
- Mwanamugimu Nutrition Unit, Directorate of Paediatrics and Child Care, Mulago National Referral Hospital, Kampala, Uganda
| | - Philippa Musoke
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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19
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Flynn PM, Taha TE, Cababasay M, Butler K, Fowler MG, Mofenson LM, Owor M, Fiscus S, Stranix-Chibanda L, Coutsoudis A, Gnanashanmugam D, Chakhtoura N, McCarthy K, Frenkel L, Beck I, Mukuzunga C, Makanani B, Moodley D, Nematadzira T, Kusakara B, Patil S, Vhembo T, Bobat R, Mmbaga BT, Masenya M, Nyati M, Theron G, Mulenga H, Shapiro DE. Association of Maternal Viral Load and CD4 Count With Perinatal HIV-1 Transmission Risk During Breastfeeding in the PROMISE Postpartum Component. J Acquir Immune Defic Syndr 2021; 88:206-213. [PMID: 34108383 PMCID: PMC8434954 DOI: 10.1097/qai.0000000000002744] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/11/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Breastfeeding mothers with HIV infection not qualifying for antiretroviral therapy (ART) based on country-specific guidelines at the time of the Promoting Maternal-Infant Survival Everywhere trial and their uninfected neonates were randomized to maternal ART (mART) or infant nevirapine prophylaxis (iNVP) postpartum. HIV transmission proportions were similar (<1%) in the 2 arms. We assessed whether maternal viral load (MVL) and CD4 cell counts were associated with breastfeeding HIV transmission. METHODS MVL was collected at entry (7-14 days postpartum) and at weeks 6, 14, 26, and 50 postpartum. CD4 cell counts were collected at entry and weeks 14, 26, 38, and 50 postpartum. Infant HIV-1 nucleic acid test was performed at weeks 1 and 6, every 4 weeks until week 26, and then every 12 weeks. The associations of baseline and time-varying MVL and CD4 cell counts with transmission risk were assessed using time-to-event analyses by randomized treatment arm. RESULTS Two thousand four hundred thirty-one mother-infant pairs were enrolled in the study. Baseline MVL (P = 0.11) and CD4 cell counts (P = 0.51) were not significantly associated with infant HIV-1 infection. Time-varying MVL was significantly associated with infant HIV-1 infection {hazard ratio [95% confidence interval (CI)]: 13.96 (3.12 to 62.45)} in the mART arm but not in the iNVP arm [hazard ratio (95% CI): 1.04 (0.20 to 5.39)]. Time-varying CD4 cell counts were also significantly associated with infant HIV-1 infection [hazard ratio (95% CI): 0.18 (0.03 to 0.93)] in the mART arm but not in the iNVP arm [hazard ratio (95% CI): 0.38 (0.08 to 1.77)]. CONCLUSIONS In women receiving mART, increased MVL and decreased CD4 cell counts during breastfeeding were associated with increased risk of infant HIV-1 infection.
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Affiliation(s)
- Patricia M. Flynn
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN
| | - Taha E Taha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mae Cababasay
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Kevin Butler
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Mary Glenn Fowler
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Maxensia Owor
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Susan Fiscus
- Department of Microbiology and Immunology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Lynda Stranix-Chibanda
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, , University of Zimbabwe, Harare, Zimbabwe
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Anna Coutsoudis
- Department of Pediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
| | - Devasena Gnanashanmugam
- Division of AIDS, National Institute of Allergy and Immunology, National Institutes of Health, Bethesda, MD
| | - Nahida Chakhtoura
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver Institute of Child Health and Human Development, National Institutes of Health, Rockville, MD
| | | | - Lisa Frenkel
- Department of Pediatrics, University of Washington, Seattle, WA
- Seattle Children’s Research Institute, Seattle, WA
| | - Ingrid Beck
- Seattle Children’s Research Institute, Seattle, WA
| | - Cornelius Mukuzunga
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Bonus Makanani
- Department of Obstetrics and Gynecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Dhayendre Moodley
- Centre for the AIDS Programme of Research in South Africa and School of Clinical Medicine, College of Health Sciences, University of KwaZulu Natal, Durban, South Africa
| | | | - Bangani Kusakara
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Sandesh Patil
- Department of Obstetrics and Gynecology, Byramjee Jeejeebhoy Government Medical College and Johns Hopkins Clinical Trials Unit, Pune, India
| | - Tichaona Vhembo
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Raziya Bobat
- Department of Pediatrics and Child Health, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Blandina T Mmbaga
- Department of Pediatrics, Kilimanjaro Christian Medical Centre and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Maysseb Masenya
- Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
| | - Mandisa Nyati
- Perinatal HIV Research Unit, Chris Baragwanath Hospital, Johannesburg, South Africa
| | - Gerhard Theron
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Helen Mulenga
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - David E. Shapiro
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, MA
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Caniglia EC, Abrams J, Diseko M, Mayondi G, Mabuta J, Makhema J, Mmalane M, Lockman S, Bernstein A, Zash R, Shapiro R. Seasonality of adverse birth outcomes in women with and without HIV in a representative birth outcomes surveillance study in Botswana. BMJ Open 2021; 11:e045882. [PMID: 34479931 PMCID: PMC8420660 DOI: 10.1136/bmjopen-2020-045882] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 08/05/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Sub-Saharan Africa has the largest number of people with HIV, one of the most severe burdens of adverse birth outcomes globally and particular vulnerability to climate change. We examined associations between seasonality and adverse birth outcomes among women with and without HIV in a large geographically representative birth outcomes surveillance study in Botswana from 2015 to 2018. METHODS We evaluated stillbirth, preterm delivery, very preterm delivery, small for gestational age (SGA), very SGA, and combined endpoints of any adverse or severe birth outcome. We estimated the risk of each outcome by month and year of delivery, and adjusted risks ratios (ARRs) of outcomes during the early wet (1 November-15 January), late wet (16 January-31 March) and early dry (1 April-15 July) seasons, compared with the late dry (16 July-31 October) season. Analyses were conducted overall and separately by HIV status. RESULTS Among 73 178 women (24% with HIV), the risk of all adverse birth outcomes peaked in November-January and reached low points in September. Compared with the late dry season, the ARRs for any adverse birth outcome were 1.03 (95% CI 1.00 to 1.06) for the early dry season, 1.08 (95% CI 1.04 to 1.11) for the early wet season and 1.07 (95% CI 1.03 to 1.10) for the late wet season. Comparing the early wet season to the late dry season, we found that ARRs for stillbirth and very preterm delivery were higher in women with HIV (1.23, 95% CI 0.96 to 1.59, and 1.33, 95% CI 1.10 to 1.62, respectively) than in women without HIV (1.07, 95% CI 0.91 to 1.26, and 1.19, 95% CI 1.04 to 1.36, respectively). CONCLUSIONS We identified a modest association between seasonality and adverse birth outcomes in Botswana, which was greatest among women with HIV. Understanding seasonal patterns of adverse birth outcomes and the role of HIV status may allow for mitigation of their impact in the face of seasonal extremes related to climate change.
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Affiliation(s)
- Ellen C Caniglia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jasmyn Abrams
- Department of Population Health, NYU Langone Health, New York, New York, USA
| | - Modiegi Diseko
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Gloria Mayondi
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Judith Mabuta
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Joseph Makhema
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mompati Mmalane
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Shahin Lockman
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Infectious Disease, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Aaron Bernstein
- Immunology and Infectious Diseases, Center for Climate, Health, and the Global Environment, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Rebecca Zash
- Department of Infectious Diseases, BIDMC, Boston, Massachusetts, USA
| | - Roger Shapiro
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Immunology and Infectious Diseases, Center for Climate, Health, and the Global Environment, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Thompson AL. Greater male vulnerability to stunting? Evaluating sex differences in growth, pathways and biocultural mechanisms. Ann Hum Biol 2021; 48:466-473. [PMID: 35105202 PMCID: PMC9205267 DOI: 10.1080/03014460.2021.1998622] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/28/2021] [Accepted: 07/03/2021] [Indexed: 10/19/2022]
Abstract
CONTEXT Child stunting has increasingly become the focus of large-scale global health efforts with the inclusion of stunting eradication as one of the Sustainable Development Goals of the United Nations. Child sex has been identified as a biological risk factor for stunting, and sex-specific approaches to stunting prevention have been proposed. OBJECTIVE This paper examines four pathways, developmental sensitivity, energetics, caretaking and measurement, proposed to contribute to sex differences in linear growth faltering and stunting risk. METHODS Anthropological, public health and clinical literature on sex differences in stunting and the mechanisms contributing to variability across contexts are reviewed. RESULTS The direction of sex differences in stunting prevalence varies across countries and between households. Sex differences in growth trajectories and immune function beginning prenatally place boys at greater risk of infection and undernutrition, but these biological differences are interpreted by parents and within household contexts that are shaped by social and cultural norms which, in turn, influence care and feeding practices. CONCLUSION A perspective that incorporates an examination of the social and environmental factors shaping child growth in specific contexts is needed to understand sex-based vulnerability to stunting and to develop context-appropriate interventions.
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Affiliation(s)
- Amanda L Thompson
- Department of Anthropology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Weis N, Katzenstein TL, Ørbæk M, Storgaard M, Pedersen G, Johansen IS, Moseholm E. The Danish HIV Birth Cohort (DHBC) - a nationwide, prospective cohort. BMJ Open 2021; 11:e044565. [PMID: 34244252 PMCID: PMC8268920 DOI: 10.1136/bmjopen-2020-044565] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The purpose of the Danish HIV Birth Cohort (DHBC) is to investigate the significance of HIV-1 infection in pregnancy and after delivery in women living with HIV (WLWH) in Denmark and their children, in the era of antiretroviral therapy and other interventions for treatment and prophylaxis. PARTICIPANTS All WLWH giving birth to one or more children in Denmark after 31 December 1999 are included, with consecutive ongoing enrolment, if they are living with HIV and pregnant, or if they are diagnosed with HIV in relation to pregnancy, delivery or shortly after delivery. FINDINGS TO DATE DHBC has been used to describe trends in the management of pregnancies in WLWH and their outcomes on a nationwide basis, mode of delivery and predictors of emergency caesarean section as well as risk factors during pregnancy in WLWH for birth-related complications compared with women from the general population (WGP). We have found that HIV-exposed, but uninfected (HEU) children born to WLWH had a lower median birth weight and gestational age and were at higher risk of intrauterine growth retardation than children born to WGP. We have investigated risk of in-hospital admission and use of antibiotics during the first 4 years of life among HEU children and showed that HEU children had an increased risk of overall hospital admission compared with a matched control group of unexposed children.Further, we compared anthropometric outcomes in children with a matched control group of children not exposed to HIV. FUTURE PLANS To continuously investigate the significance of HIV infection and antiretroviral therapy in pregnancy and after delivery in WLWH in Denmark and their HEU children and compare these findings with children born to WGP.
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Affiliation(s)
- Nina Weis
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Terese L Katzenstein
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mathilde Ørbæk
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark
| | - Merete Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Gitte Pedersen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Isik S Johansen
- Department of Infectious Diseases, Odense Universitetshospital, Odense, Denmark
| | - Ellen Moseholm
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark
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23
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Zash R, Caniglia EC, Diseko M, Mayondi G, Mabuta J, Luckett R, Hofmeyr GJ, Morroni C, Ramogola‐Masire D, Williams PL, Zera C, Wylie BJ, Makhema J, Lockman S, Shapiro RL. Maternal weight and birth outcomes among women on antiretroviral treatment from conception in a birth surveillance study in Botswana. J Int AIDS Soc 2021; 24:e25763. [PMID: 34176240 PMCID: PMC8236225 DOI: 10.1002/jia2.25763] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 05/13/2021] [Accepted: 05/25/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Antiretrovirals such as dolutegravir (DTG) and tenofovir alafenamide (TAF) have been associated with excessive weight gain. The objective of this study was to understand the potential impact of ART-associated weight gain on pregnancy outcomes among women living with HIV. METHODS Using data from the Tsepamo birth outcomes surveillance study in Botswana, we evaluated the relationship between maternal weight (and weight gain) and severe birth outcomes (very preterm delivery <32 weeks, very small for gestational age (SGA) <3rd percentile, perinatal death), macrosomia (birthweight > 4000 g) and maternal hypertension. We estimated the relative risk of each outcome by baseline weight (first weight in pregnancy <24 weeks) and second trimester average weekly weight gain (kg/week from 12 ± 2 to 24 ± 2 weeks) using log binomial regression and evaluated effect modification by ART regimen (DTG vs. Efavirenz (EFV)). RESULTS Of 22,828 women on ART at conception with singleton deliveries between August 2014 and April 2020, 16,300 (71.4%) had a weight measured <24 weeks' gestation (baseline weight) and 4437 (19.2%) had weight measured both at 12 (±2) weeks and 24 (±2) weeks, allowing second trimester weight gain calculation. Compared to women with baseline weight 60 to 70 kg, low baseline weight (<50 kg) was associated with increased risk of very preterm delivery (aRR 1.30, 95% CI 1.03, 1.65) and very SGA (aRR1.96, 95% CI 1.69, 2.28). High baseline weight (>90 kg) was associated with increased risk of macrosomia (aRR 3.24, 95% CI 2.36, 4.44) and maternal hypertension (aRR 1.79, 95% CI 1.62, 1.97). Baseline weight was not associated with stillbirth or early neonatal death. For all outcomes, second trimester weight gain showed weaker associations than did baseline weight. Duration of pre-pregnancy ART (years) was associated with higher baseline weight for DTG but not for EFV, and the risk of maternal hypertension by baseline weight category was higher for DTG than EFV for all strata. CONCLUSIONS ART regimens associated with weight gain may reduce the number of women at risk for certain severe adverse pregnancy outcomes associated with low weight but increase the number at risk of macrosomia and maternal hypertension. Further research could determine whether weight-based ART treatment strategies improve maternal and child health.
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Affiliation(s)
- Rebecca Zash
- Beth Israel Deaconess Medical CenterBostonMAUSA
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Harvard T.H. Chan School of Public HealthBostonMAUSA
| | | | - Modiegi Diseko
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Gloria Mayondi
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Judith Mabuta
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Rebecca Luckett
- Beth Israel Deaconess Medical CenterBostonMAUSA
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- University of BotswanaGaboroneBotswana
| | | | - Chelsea Morroni
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Liverpool School of Tropical MedicineLiverpoolUK
| | | | | | - Chloe Zera
- Beth Israel Deaconess Medical CenterBostonMAUSA
| | | | - Joseph Makhema
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Shahin Lockman
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Harvard T.H. Chan School of Public HealthBostonMAUSA
- Brigham and Women’s HospitalBostonMAUSA
| | - Roger L Shapiro
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Liverpool School of Tropical MedicineLiverpoolUK
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24
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Woldesenbet S, Kufa-Chakezha T, Lombard C, Manda S, Cheyip M, Ayalew K, Chirombo B, Barron P, Diallo K, Parekh B, Puren A. Recent HIV infection among pregnant women in the 2017 antenatal sentinel cross-sectional survey, South Africa: Assay-based incidence measurement. PLoS One 2021; 16:e0249953. [PMID: 33852629 PMCID: PMC8046194 DOI: 10.1371/journal.pone.0249953] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 03/27/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction New HIV infection during pre-conception and pregnancy is a significant contributor of mother–to–child transmission of HIV in South Africa. This study estimated HIV incidence (defined as new infection within the last one year from the time of the survey which included both new infections occurred during pregnancy or just before pregnancy) among pregnant women and described the characteristics of recently infected pregnant women at national level. Methods Between 1 October and 15 November 2017, we conducted a national cross–sectional survey among pregnant women aged 15–49 years old attending antenatal care at 1,595 public facilities. Blood specimens were collected from pregnant women and tested for HIV in a centralised laboratory. Plasma viral load and Limiting Antigen Avidity Enzyme Immunosorbent Assay (LAg) tests were further performed on HIV positive specimens to differentiate between recent and long–term infections. Recent infection was defined as infection that occurred within one year from the date of collection of blood specimen for the survey. Data on age, age of partner, and marital status were collected through interviews. Women whose specimens were classified as recent by LAg assay and with viral loads >1,000 copies/mL were considered as recently infected. The calculated proportion of HIV positive women with recent infection was adjusted for assay–specific parameters to estimate annual incidence. Survey multinomial logistic regression was used to examine factors associated with being recently infected using HIV negative women as a reference group. Age–disparate relationship was defined as having a partner 5 or more years older. Results Of 10,049 HIV positive participants with LAg and viral load data, 1.4% (136) were identified as recently infected. The annual HIV incidence was 1.5% (95% confidence interval (CI): 1.2–1.7). In multivariable analyses, being single (adjusted odds ratio, aOR: 3.4, 95% CI: 1.8–6.2) or cohabiting (aOR: 3.8, 95% CI: 1.8–7.7), compared to being married as well as being in an age–disparate relationship among young women (aOR: 3.1, 95% CI: 2.0–4.7; reference group: young women (15–24years) whose partners were not 5 years or more older) were associated with higher odds of recent infection. Conclusions Compared to previous studies among pregnant women, the incidence estimated in this study was substantially lower. However, the UNAIDS target to reduce incidence by 75% by 2020 (which is equivalent to reducing incidence to <1%) has not been met. The implementation of HIV prevention and treatment interventions should be intensified, targeting young women engaged in age–disparate relationship and unmarried women to fast track progress towards the UNAIDS target.
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Affiliation(s)
- Selamawit Woldesenbet
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Tendesayi Kufa-Chakezha
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Samuel Manda
- Biostatistics Unit, South African Medical Research Council, Pretoria, South Africa
- Department of Statistics, University of Pretoria, Pretoria, South Africa
| | - Mireille Cheyip
- Strategic Information Unit, Center for Disease Control and Prevention, Pretoria, South Africa
| | - Kassahun Ayalew
- Strategic Information Unit, Center for Disease Control and Prevention, Pretoria, South Africa
| | - Brian Chirombo
- HIV and Hepatitis Program, World Health Organization, Pretoria, South Africa
| | - Peter Barron
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Karidia Diallo
- Laboratory Branch, Centers for Disease Control and Prevention South Africa, Pretoria, South Africa
| | - Bharat Parekh
- Division of Global HIV/AIDS, International Laboratory Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Adrian Puren
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- Division of Virology, School of Pathology University of the Witwatersrand, Johannesburg, South Africa
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Gutin SA, Harper GW, Moshashane N, Bitsang C, Harries J, Ramogola-Masire D, Morroni C. "What if they are pre-conception? What should we do?": Knowledge, practices, and preferences for safer conception among women living with HIV and healthcare providers in Gaborone, Botswana. Front Glob Womens Health 2021; 1. [PMID: 33693437 PMCID: PMC7943178 DOI: 10.3389/fgwh.2020.582463] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Safer conception interventions that address HIV care, treatment, and prevention for HIV-affected couples are increasingly available in sub-Saharan Africa. Botswana, an HIV endemic country, is yet to offer formal safer conception services although universal test-and-treat approaches mean that increasing numbers of young, sexually active people living with HIV will start treatment and likely desire childbearing. In order to advance the safer conception discussion in Botswana, it is necessary to understand the current safer conception knowledge, practices, and preferences of healthcare providers and women living with HIV (WLHIV). We conducted qualitative in-depth interviews with 10 HIV healthcare providers and 10 WLHIV in Gaborone. Interviews were analyzed using a phenomenological approach. Safer conception knowledge was limited and safer conception discussions were rare. Healthcare provider and WLHIV preferences were at odds, with providers preferring WLHIV to initiate safer conception discussions, and WLHIV desiring providers to initiate safer conception discussions. Quotes from women and providers highlight deeper issues about power dynamics, concerns about stigma among women, and provider fears about promoting pregnancy. Providers emphasized the need for guidelines and training in order to improve the provision of safer conception counseling. These findings point to areas where safer conception in Botswana can be improved. Both WLHIV and providers would benefit from having information about a range of safer conception methods and approaches. In addition, since WLHIV felt hesitant about initiating safer conception conversations and feared stigma, and because putting the onus for starting safer conception discussions on women is a reversal of normal roles and power structures, providers must take the lead and routinely initiate fertility desire and safer conception discussions. Assisting healthcare providers with clear safer conception guidelines and training would improve the provision of accurate safer conception counseling and facilitate reproductive choice.
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Affiliation(s)
- Sarah A Gutin
- Dept. of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Center for AIDS Prevention Studies, Division of Prevention Science, University of California San Francisco, San Francisco, CA, USA
| | - Gary W Harper
- Dept. of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Christina Bitsang
- Career and Counseling Services, University of Botswana, Gaborone, Botswana
| | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Chelsea Morroni
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Botswana U-Penn Partnership, Gaborone, Botswana.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
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Mdletshe N, Thobakgale C, Malaba TR, Madlala H, Myer L, Muema DM, Mogeni P, Gray CM, Altfeld M, Newell ML, Ndung'u T. Low immune activation in early pregnancy is associated with preterm but not small-for-gestational age delivery in HIV infected women initiating antiretroviral therapy in pregnancy: a PIMS case-control study in Cape Town, South Africa. Clin Infect Dis 2021; 73:2205-2216. [PMID: 33606024 PMCID: PMC8677566 DOI: 10.1093/cid/ciab151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Indexed: 12/24/2022] Open
Abstract
Background Mechanisms underlying an association between human immunodeficiency virus (HIV) or antiretroviral therapy (ART) during pregnancy with risk of preterm delivery (PTD) and small-for-gestational-age (SGA) remain unclear. We explored the association between cellular immune activation and PTD or SGA in women with HIV initiating ART during or before pregnancy. Methods Women with HIV enrolled at median 15 weeks’ gestation, were analyzed for immune markers, and matched on ART initiation timing (15 women initiated pre- and 15 during pregnancy). There were 30 PTD (delivery <37 weeks), 30 SGA (weight for age ≤10th percentile) cases, and 30 controls (term, weight for gestational age >25th percentile) as outcomes. Lymphocytes, monocytes, and dendritic cell populations and their activation status or functionality were enumerated by flow cytometry. Results PTD cases initiating ART in pregnancy showed decreased CD8+ T cell, monocyte, and dendritic cell activation; increased classical (CD14+CD16–) and intermediate (CD14+CD16+) monocyte frequencies; and decreased inflammatory monocytes (CD14dimCD16+) compared with SGA cases and term controls (all P < .05). Allowing for baseline viral load, the immune markers remained significantly associated with PTD but only in women initiating ART in pregnancy. Lower monocyte activation was predictive of PTD. TLR ligand-induced interferon-α and macrophage inflammatory protein-1β levels in monocytes were significantly lower in PTD women initiating ART in pregnancy. Conclusion Low immune activation, skewing toward anti-inflammatory monocytes, and lower monocyte cytokine production in response to TLR ligand stimulation were associated with PTD but not SGA among women initiating ART in, but not before, pregnancy, suggesting immune anergy to microbial stimulation as a possible underlying mechanism for PTD in women initiating ART in pregnancy.
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Affiliation(s)
- Nontlantla Mdletshe
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal (UKZN), Durban, South Africa
| | - Christina Thobakgale
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal (UKZN), Durban, South Africa.,School of Pathology, National Institute for Communicable Diseases and the University of the Witwatersrand, Johannesburg, South Africa
| | - Thokozile R Malaba
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Hlengiwe Madlala
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Polycarp Mogeni
- Africa Health Research Institute, Durban, South Africa.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,KwaZulu-Natal Innovation and Sequencing Platform (KRISP), University of KwaZulu-Natal, Durban, South Africa
| | - Clive M Gray
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Marcus Altfeld
- Department of Viral Immunology, Heinrich-Pette-Institute, Leibniz Institute for Experimental Virology, Hamburg, Germany
| | - Marie-Louise Newell
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Thumbi Ndung'u
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal (UKZN), Durban, South Africa.,Africa Health Research Institute, Durban, South Africa.,Max Planck Institute for Infection Biology, Berlin, Germany.,Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, Cambridge, Massachusetts, USA.,Division of Infection and Immunity, University College London, London, United Kingdom
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Lyatuu GW, Mwashemele SZ, Urrio R, Naburi H, Kashmir N, Machumi L, Kibao A, Sellah Z, Ulenga N, Orsini N, Biberfeld G, Kilewo C, Ekström AM. Long-term virological outcomes in women who started option B+ care during pregnancy for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania: a cohort study. Lancet HIV 2021; 8:e256-e265. [PMID: 33581776 DOI: 10.1016/s2352-3018(20)30308-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 10/20/2020] [Accepted: 11/09/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Option B+ marked a milestone in prevention of mother-to-child transmission (PMTCT) of HIV by recommending lifelong antiretroviral therapy (ART) for all pregnant women with HIV. Nevertheless, concerns remain regarding long-term outcomes in settings with a high HIV burden. We analysed long-term virological outcomes in women enrolled on option B+ in Tanzania. METHODS In this prospective cohort study, we extracted data for pregnant women with HIV starting PMTCT care between Oct 1, 2014, and Sept 30, 2016, in routine health-care settings in Dar es Salaam, Tanzania, from national HIV and district health information system databases. We then excluded women who exited study sites before 6 months of ART follow-up and women who did not have a viral load test. Women were followed up until March 8, 2019. We used Poisson generalised estimating equations to examine trends in HIV viral suppression (<400 copies per mL) and virological failure (≥400 copies per mL), reporting relative risks (RRs) and 95% CIs adjusted for maternal age, gestational age, and several clinical characteristics. FINDINGS We identified 15 586 pregnant women with HIV, of whom 10 161 were eligible for follow-up. Women were followed up for a median of 37 months (IQR 31-45) and a maximum of 53 months. The median age at PMTCT initiation was 31 years (IQR 27-35). At PMTCT enrolment, 1245 (17·0%) of 7318 women with available data were in their third trimester, 4901 (48·2%) of 10 161 women started ART at least 1 month before PMTCT enrolment, and 3380 (33·4%) of 10 131 women with available data had advanced HIV. Overall, a viral suppression rate of 88·2% (95% CI 87·8-88·7) was observed over the entire follow-up period, ranging from 85·1% (84·3-85·9) in viral load tests done at 0-11 months to 90·6% (89·7-91·4) at 36 months or longer since PMTCT enrolment. In a complete-case analysis (ie, including patients with <30% missing data; n=7306), the risk of virological failure among women who remained in HIV care decreased over time (adjusted RR 0·87 [95% CI 0·80-0·95] at 12-23 months since PMTCT enrolment; 0·65 [0·59-0·72] at 24-35 months; and 0·63 [0·55-0·71] at ≥36 months vs at 0-11 months). Younger women (aged <20 years: 1·76 [1·40-2·23] vs aged 30-39 years) and those starting PMTCT late in pregnancy (third trimester: 1·28 [1·10-1·50] vs first trimester) or with advanced HIV (1·33 [1·16-1·51] vs without advanced HIV) had increased risk of virological failure. Women who attended an antenatal care facility where more than 50% of attendees received couples HIV testing had a decreased risk of virological failure (adjusted RR 0·81 [0·65-0·99] vs <50% having couples testing). INTERPRETATION High rates of viral suppression among women starting option B+ who remain in HIV care are sustainable, and might increase, at least up to 53 months. This rate might be further improved by addressing challenges of adolescent mothers, late presenters, and couples HIV testing at antenatal care. FUNDING Swedish International Development Agency.
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Affiliation(s)
- Goodluck W Lyatuu
- Management and Development for Health, Dar es Salaam, Tanzania; Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | | | - Roseline Urrio
- Management and Development for Health, Dar es Salaam, Tanzania; Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Helga Naburi
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Nassir Kashmir
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Lameck Machumi
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Ayoub Kibao
- Dar es Salaam Regional Administrative Secretary, Dar es Salaam, Tanzania
| | - Ziada Sellah
- Dar es Salaam Regional Administrative Secretary, Dar es Salaam, Tanzania
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Nicola Orsini
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Gunnel Biberfeld
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Charles Kilewo
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Dunning L, Gandhi AR, Penazzato M, Soeteman DI, Revill P, Frank S, Phillips A, Dugdale C, Abrams E, Weinstein MC, Newell M, Collins IJ, Doherty M, Vojnov L, Fassinou Ekouévi P, Myer L, Mushavi A, Freedberg KA, Ciaranello AL. Optimizing infant HIV diagnosis with additional screening at immunization clinics in three sub-Saharan African settings: a cost-effectiveness analysis. J Int AIDS Soc 2021; 24:e25651. [PMID: 33474817 PMCID: PMC8992471 DOI: 10.1002/jia2.25651] [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] [Received: 04/09/2020] [Revised: 10/19/2020] [Accepted: 11/17/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Uptake of early infant HIV diagnosis (EID) varies widely across sub-Saharan African settings. We evaluated the potential clinical impact and cost-effectiveness of universal maternal HIV screening at infant immunization visits, with referral to EID and maternal antiretroviral therapy (ART) initiation. METHODS Using the CEPAC-Pediatric model, we compared two strategies for infants born in 2017 in Côte d'Ivoire (CI), South Africa (SA), and Zimbabwe: (1) existing EID programmes offering six-week nucleic acid testing (NAT) for infants with known HIV exposure (EID), and (2) EID plus universal maternal HIV screening at six-week infant immunization visits, leading to referral for infant NAT and maternal ART initiation (screen-and-test). Model inputs included published Ivoirian/South African/Zimbabwean data: maternal HIV prevalence (4.8/30.8/16.1%), current uptake of EID (40/95/65%) and six-week immunization attendance (99/74/94%). Referral rates for infant NAT and maternal ART initiation after screen-and-test were 80%. Costs included NAT ($24/infant), maternal screening ($10/mother-infant pair), ART ($5 to 31/month) and HIV care ($15 to 190/month). Model outcomes included mother-to-child transmission of HIV (MTCT) among HIV-exposed infants, and life expectancy (LE) and mean lifetime per-person costs for children with HIV (CWH) and all children born in 2017. We calculated incremental cost-effectiveness ratios (ICERs) using discounted (3%/year) lifetime costs and LE for all children. We considered two cost-effectiveness thresholds in each country: (1) the per-capita GDP ($1720/6380/2150) per year-of-life saved (YLS), and (2) the CEPAC-generated ICER of offering 2 versus 1 lifetime ART regimens (e.g. offering second-line ART; $520/500/580/YLS). RESULTS With EID, projected six-week MTCT was 9.3% (CI), 4.2% (SA) and 5.2% (Zimbabwe). Screen-and-test decreased total MTCT by 0.2% to 0.5%, improved LE by 2.0 to 3.5 years for CWH and 0.03 to 0.07 years for all children, and increased discounted costs by $17 to 22/child (all children). The ICER of screen-and-test compared to EID was $1340/YLS (CI), $650/YLS (SA) and $670/YLS (Zimbabwe), below the per-capita GDP but above the ICER of 2 versus 1 lifetime ART regimens in all countries. CONCLUSIONS Universal maternal HIV screening at immunization visits with referral to EID and maternal ART initiation may reduce MTCT, improve paediatric LE, and be of comparable value to current HIV-related interventions in high maternal HIV prevalence settings like SA and Zimbabwe.
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Affiliation(s)
- Lorna Dunning
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
| | - Aditya R Gandhi
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
| | - Martina Penazzato
- Global HIV, Hepatitis, and STIs ProgrammeWorld Health OrganizationGenevaSwitzerland
| | - Djøra I Soeteman
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Paul Revill
- Center for Health EconomicsUniversity of YorkYorkUnited Kingdom
| | - Simone Frank
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
| | - Andrew Phillips
- Institute for Global HealthUniversity College LondonLondonUnited Kingdom
| | - Caitlin Dugdale
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Elaine Abrams
- Mailman School of Public HealthICAP at Columbia UniversityNew York CityNYUSA
| | - Milton C Weinstein
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Marie‐Louise Newell
- Institute for Development StudiesHuman Development and HealthFaculty of MedicineUniversity of SouthamptonSouthamptonUnited Kingdom
- School of Public HealthFaculty of Health SciencesUniversity of WitwatersrandJohannesburgSouth Africa
| | - Intira J Collins
- Medical Research Council Clinical Trials UnitUniversity College LondonLondonUnited Kingdom
| | - Meg Doherty
- Global HIV, Hepatitis, and STIs ProgrammeWorld Health OrganizationGenevaSwitzerland
| | - Lara Vojnov
- Global HIV, Hepatitis, and STIs ProgrammeWorld Health OrganizationGenevaSwitzerland
| | | | - Landon Myer
- Division of Epidemiology & BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | | | - Kenneth A Freedberg
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Andrea L Ciaranello
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
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Mujugira A, Baeten JM, Hodges-Mameletzis I, Haberer JE. Lamivudine/Tenofovir Disoproxil Fumarate is an Appropriate PrEP Regimen. Drugs 2020; 80:1881-1888. [PMID: 33040323 PMCID: PMC7710557 DOI: 10.1007/s40265-020-01419-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Oral pre-exposure prophylaxis (PrEP) containing tenofovir disoproxil fumarate (TDF) co-formulated with emtricitabine (FTC) or lamivudine (3TC) is recommended as an additional prevention option for persons at substantial risk of HIV infection by both the World Health Organization (WHO) and the US President's Emergency Plan for AIDS Relief (PEPFAR). The WHO and PEPFAR consider 3TC clinically interchangeable with FTC for PrEP given comparable pharmacologic equivalence, resistance and toxicity patterns, and indirect clinical trial evidence from TDF-containing studies. Globally, FTC/TDF has been widely used in clinical trials, open-label extension studies and demonstration projects. Thus, most PrEP efficacy and safety data are based on FTC/TDF use in heterosexual women and men, men who have sex with men, and people who inject drugs. However, generic 3TC/TDF is less expensive than FTC/TDF, is already available in supply chains for HIV drugs, and has 60-70% of the global adult market share, making it particularly appealing in settings with limited availability or affordability of FTC/TDF. Compelling indirect evidence suggests that scaling up use of 3TC/TDF is potentially cost saving for HIV programs in settings where restricting drug choice to FTC/TDF would delay PrEP implementation. Guideline committees and public health decision-makers in countries should encourage flexibility in PrEP drug selection, support off-label use of 3TC/TDF, and approve use of generic formulations to decrease the cost of PrEP medications and accelerate PrEP delivery through the public and private sectors.
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Affiliation(s)
- Andrew Mujugira
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.
- Department of Epidemiology and Biostatistics, College of Health Sciences, Makerere University, Kampala, Uganda.
| | - Jared M Baeten
- Departments of Global Health, Epidemiology and Medicine, University of Washington, Seattle, USA
| | | | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital and Harvard Medical School, Boston, USA
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Chamie G, Hickey MD, Kwarisiima D, Ayieko J, Kamya MR, Havlir DV. Universal HIV Testing and Treatment (UTT) Integrated with Chronic Disease Screening and Treatment: the SEARCH study. Curr HIV/AIDS Rep 2020; 17:315-323. [PMID: 32507985 DOI: 10.1007/s11904-020-00500-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW The growing burden of untreated chronic disease among persons with HIV (PWH) threatens to reverse heath gains from ART expansion. Universal test and treat (UTT)'s population-based approach provides opportunity to jointly identify and treat HIV and other chronic diseases. This review's purpose is to describe SEARCH UTT study's integrated disease strategy and related approaches in Sub-Saharan Africa. RECENT FINDINGS In SEARCH, 97% of adults were HIV tested, 85% were screened for hypertension, and 79% for diabetes at health fairs after 2 years, for an additional $1.16/person. After 3 years, population-level hypertension control was 26% higher in intervention versus control communities. Other mobile/home-based multi-disease screening approaches have proven successful, but data on multi-disease care delivery are extremely limited and show little effect on clinical outcomes. Integration of chronic disease into HIV in the UTT era is feasible and can achieve population level effects; however, optimization and implementation remain a huge unmet need.
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Affiliation(s)
- Gabriel Chamie
- Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital / University of California, San Francisco, UCSF Box 0874, San Francisco, CA, 94143-0874, USA.
| | - Matthew D Hickey
- Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital / University of California, San Francisco, UCSF Box 0874, San Francisco, CA, 94143-0874, USA
| | | | | | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda.,Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V Havlir
- Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital / University of California, San Francisco, UCSF Box 0874, San Francisco, CA, 94143-0874, USA
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Belachew A, Tewabe T, Malede GA. Prevalence of vertical HIV infection and its risk factors among HIV exposed infants in East Africa: a systematic review and meta-analysis. Trop Med Health 2020; 48:85. [PMID: 33088209 PMCID: PMC7572247 DOI: 10.1186/s41182-020-00273-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 09/30/2020] [Indexed: 11/10/2022] Open
Abstract
Background Human immunodeficiency virus (HIV) is one of the most important global health problems. More than one and half million of children are living with HIV in the world, and majority of them are found in sub-Saharan Africa. There are primary fragmented study findings, and no review was conducted with regard to vertical HIV infection in East Africa. Therefore, this review aimed to assess the prevalence of vertical HIV infection and its risk factors among HIV-exposed infants in East Africa. Main body Eligible studies were retrieved by relevant search terms in CINHAL, Pub-MED, Google Scholar, EMBASE, Web of Science, SCOPUS, Cochrane, African Journals Online databases, and Ethiopian University research repositories. Data were extracted with Microsoft Excel and analyzed with Stata version 11 software. The random effect model was used to estimate the pooled prevalence of vertical HIV infection in East Africa. The variation between studies was quantified with an I 2 statistic test. Furthermore, sub-group and meta-regression analyses were done to identify the sources of heterogeneity between the studies. The publication bias was assessed by Egger test. This systematic review and meta-analysis have included a total of 33 research articles. The overall pooled prevalence of vertical HIV infection in East Africa was 7.68% with a 95% confidence interval [CI]: (6.23, 9.12) with a heterogeneity of I 2 = 86.8 with a p value < 0.001. In subgroup analysis, the pooled prevalence of vertical HIV infection in cross-sectional studies was 6.58%, while in cohort studies were 9.37%. Mixed feeding, AOR = 6.22 (1.02, 11.41); home delivery, AOR = 2 (1.01, 3); mothers took ART less than 4 weeks, AOR = 1.92 (1.79, 2.06); and infants who have not received ARV prophylaxis, AOR = 2.02 (1.05, 2.98) were the associated factors for vertical HIV infection for exposed infants. Conclusions The pooled prevalence of the mother to child transmission of HIV is way more than the desired target of the World Health Organization, which is less than 5% in breastfeeding populations. Thus, strengthening the prevention of vertical HIV transmission, promotion of exclusive breastfeeding, timely initiation of ART prophylaxis for HIV exposed infants, encouragement of hospital delivery, and the start of ART at the time of diagnosis of every HIV-positive person may all reduce the transmission of vertical HIV infection.
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Affiliation(s)
- Amare Belachew
- Department of Pediatrics and Child Health Nursing, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Tilahun Tewabe
- Department of Pediatrics and Child Health Nursing, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Gizat Abinet Malede
- Department of Laboratory Science, Bahir Dar Health Science College, Bahir Dar, Ethiopia
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Goga AE, Lombard C, Jackson D, Ramokolo V, Ngandu NK, Sherman G, Puren A, Chirinda W, Bhardwaj S, Makhari N, Ramraj T, Magasana V, Singh Y, Pillay Y, Dinh TH. Impact of breastfeeding, maternal antiretroviral treatment and health service factors on 18-month vertical transmission of HIV and HIV-free survival: results from a nationally representative HIV-exposed infant cohort, South Africa. J Epidemiol Community Health 2020; 74:1069-1077. [PMID: 32980812 DOI: 10.1136/jech-2019-213453] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 05/02/2020] [Accepted: 07/07/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND We analysed the impact of breastfeeding, antiretroviral drugs and health service factors on cumulative (6 weeks to 18 months) vertical transmission of HIV (MTCT) and 'MTCT-or-death', in South Africa, and compared estimates with global impact criteria to validate MTCT elimination: (1) <5% final MTCT and (2) case rate ≤50 (new paediatric HIV infections/100 000 live births). METHODS 9120 infants aged 6 weeks were enrolled in a nationally representative survey. Of 2811 HIV-exposed uninfected infants (HEU), 2644 enrolled into follow-up (at 3, 6, 9, 12, 15 and 18 months). Using Kaplan-Meier analysis and weighted survey domain-based Cox proportional hazards models, we estimated cumulative risk of MTCT and 'MTCT or death' and risk factors for time-to-event outcomes, adjusting for study design and loss-to-follow-up. RESULTS Cumulative (final) MTCT was 4.3% (95% CI 3.7% to 5.0%); case rate was 1290. Postnatal MTCT (>6 weeks to 18 months) was 1.7% (95% CI 1.2% to 2.4%). Cumulative 'MTCT-or-death' was 6.3% (95% CI 5.5% to 7.3%); 81% and 62% of cumulative MTCT and 'MTCT-or-death', respectively, occurred by 6 months. Postnatal MTCT increased with unknown maternal CD4-cell-count (adjusted HR (aHR 2.66 (1.5-5.6)), undocumented maternal HIV status (aHR 2.21 (1.0-4.7)) and exclusive (aHR 2.3 (1.0-5.2)) or mixed (aHR 3.7 (1.2-11.4)) breastfeeding. Cumulative 'MTCT-or death' increased in households with 'no refrigerator' (aHR 1.7 (1.1-2.9)) and decreased if infants used nevirapine at 6 weeks (aHR 0.4 (0.2-0.9)). CONCLUSIONS While the <5% final MTCT target was met, the case rate was 25-times above target. Systems are needed in the first 6 months post-delivery to optimise HEU health and fast-track ART initiation in newly diagnosed mothers.
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Affiliation(s)
- Ameena Ebrahim Goga
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa .,HIV Prevention Research Unit, South African Medical Research Council, Tygerberg, South Africa.,Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa
| | - Carl Lombard
- Biostatistics Research Unit, South African Medical Research Council, Tygerberg, South Africa.,Division of Epidemiology and Biostatistics, University of Stellenbosch Faculty of Science, Tygerberg, South Africa
| | - Debra Jackson
- University of the Western Cape, Bellville, South Africa.,UNICEF, New York, USA
| | - Vundli Ramokolo
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Nobubelo Kwanele Ngandu
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Gayle Sherman
- Centre for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa.,Department of Paediatrics and Child Health, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Adrian Puren
- Centre for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa.,Division of Virology and Communicable Diseases, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Witness Chirinda
- Medical Research Council of South Africa, Tygerberg, South Africa
| | | | - Nobuntu Makhari
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Trisha Ramraj
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Vuyolwethu Magasana
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Yagespari Singh
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
| | - Thu-Ha Dinh
- Center for Global Health, CDC, Atlanta, Georgia, USA
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Adverse perinatal outcomes associated with antiretroviral therapy regimens: systematic review and network meta-analysis. AIDS 2020; 34:1643-1656. [PMID: 32701581 DOI: 10.1097/qad.0000000000002593] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Assess adverse perinatal outcomes associated with antenatal antiretroviral therapy (ART) regimens. DESIGN Systematic review and network meta-analysis of randomized controlled trials (RCTS). METHODS We conducted a systematic literature review by searching PubMed, CINAHL, Global Health, EMBASE, and the Cochrane Central Register of Controlled Trials and four clinical trial databases from 1 January 1980 to 28 April 2018. We included RCTs of antenatal ART regimens in HIV-positive pregnant women, which assessed preterm birth (PTB), spontaneous preterm birth (sPTB), very preterm birth (VPTB), low birthweight (LBW), very low birthweight (VLBW), small-for-gestational-age (SGA), neonatal death (NND), and mother-to-child-transmission. We used random-effects network meta-analysis models to calculate relative risks for treatment comparisons and the hierarchy of treatments. RESULTS Of 83 260 citations identified, 10 manuscripts were included, assessing 6285 women. Compared with zidovudine (ZDV) monotherapy, we found a higher risk of LBW after exposure to zidovudine/lamivudine/efavirenz (ZDV/3TC/EFV; relative risk 1.61; 95% CI 1.03-2.51), tenofovir disoproxil fumarate/emtricitabine/ritonavir-boosted lopinavir (TDF/FTC/LPV/r; 1.64; 1.18-2.29), or zidovudine/lamivudine/ritonavir-boosted lopinavir (ZDV/3TC/LPV/r; 1.87; 1.58-2.20). TDF/FTC/LPV/r carried an increased risk of VLBW, compared with ZDV monotherapy (5.40; 1.08-27.08). ZDV/3TC/LPV/r posed a higher risk of PTB than ZDV monotherapy (1.43; 1.08-1.91) and a higher risk of sPTB than zidovudine/lamivudine/abacavir (ZDV/3TC/ABC) (1.81; 1.21-2.71). LPV/r-containing regimens also carried the highest risks of VPTB, SGA and NND, although the limited data showed no significant differences. CONCLUSION Of the ART regimens assessed in RCTs in pregnancy, LPV/r-containing regimens were associated with the highest risks of adverse perinatal outcomes.
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Abstract
Background Elimination of mother-to-child transmission (MTCT) of HIV by 2020 is a goal of the World Health Organization (WHO) action plan for the European Region. However, data to monitor progress towards MTCT elimination are not readily available in Germany. Aim We aimed to estimate the number of pregnant women with HIV and MTCT rates in Germany. Methods We triangulated retrospectively obtained data from: (i) healthcare reimbursement for HIV screening tests, (ii) a statutory health insurance subsample of prevalent and incident HIV diagnoses among pregnant women, (iii) a mathematical model of the German HIV epidemic with number, region of origin and risk factors for women of childbearing age, and (iv) the statutory anonymous HIV registry on children infected through HIV MTCT. Results The number of women aged 15–49 years with HIV increased from ca 6,000 in 1993 to ca 11,000 in 2016. Risk of injecting drug use (IDU) declined from 65% in 1993 to 16% in 2016. The annual proportion of women living with HIV giving live birth increased from a mean of 1.9% during 1993 to 1998 to 4.9% in 2011 to 2015. HIV screening rates during pregnancy increased from ca 50% in 2001 to ca 90% in 2016. The HIV MTCT rate dropped from 6.8% in 2001 to 1.1% in 2016. Conclusions The population of women living with HIV in Germany shifted from predominantly IDU-associated infections to predominantly sexually acquired infections, while fertility rates more than doubled. MTCT rates dropped, mainly because of improved detection and management of HIV in pregnancy.
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Zhao J, Chen Q, Fu C, Qin Q, Huang H, Feng Y, Wei Y, Li Y, Huang A, Xu Q, She S. Rate of the HIV Transmission and Associated Factors Among HIV-Exposed Infants in Guangxi, China: 2014-2019. AIDS Res Hum Retroviruses 2020; 36:647-655. [PMID: 32498619 DOI: 10.1089/aid.2020.0073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
This study aims to evaluate the epidemiological characteristics of mother-to-child transmission (MTCT) of HIV and identify the possible factors leading to infant HIV infection using a retrospective cohort study of early infant diagnosis (EID). Information on a total of 3,145 exposed infant-mother pairs was collected from the EID platform from July 2014 to December 2019. The MTCT rate was 2.1%. Spatial-temporal maps showed that rates varied by year and by region, with four districts (Baise, Guigang, Guilin, and Hechi) maintaining rates of >2.0% in 2019. The rate of antiretroviral therapy (ART) use was 94.4%, with a gradual increase in prescriptions of highly active ART (HAART) from 83.0% in 2014 to 92.4% in 2019. A majority of 99.5% of infants were receiving artificial feeding. Factors associated with MTCT were ART use (odds ratio [OR] = 0.065, confidence interval [95% CI] = 0.035-0.121) and artificial feeding (OR = 0.091, 95% CI = 0.018-0.452). HAART was more helpful in decreasing the risk of MTCT compared with monotherapy (OR = 0.115, 95% CI = 0.014-0.933). ART during the postpartum period correlated with an increased risk (OR = 11.579, 95% CI = 1.402-95.960) compared with use of ART during pregnancy. This study indicates that MTCT rate of HIV is decreasing meaningfully in Guangxi. Some areas still face challenges in elimination of MTCT and need further resources and interventions. Future program planning should take into consideration the fact that ART use-in particular the use of HAART or ART during pregnancy-and replacement feeding may contribute to the prevention of MTCT.
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Affiliation(s)
- Jiangyang Zhao
- Department of Clinical Laboratory, Children's Hospital, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Qiaopei Chen
- Department of Clinical Laboratory, Children's Hospital, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Chunyun Fu
- Department of Clinical Laboratory, Children's Hospital, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Qinghua Qin
- Department of Maternal Health, Children's Hospital, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Haifeng Huang
- Department of Clinical Laboratory, Children's Hospital, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Yuanyuan Feng
- Department of Clinical Laboratory, Children's Hospital, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Yuchen Wei
- Department of Clinical Laboratory, Children's Hospital, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Yan Li
- Department of Clinical Laboratory, Children's Hospital, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Aidan Huang
- Department of Clinical Laboratory, Children's Hospital, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Qingqing Xu
- National HIV/HCV Reference Laboratory, National Center for AIDS/STD Control and Prevention, Beijing, China
| | - Shangyang She
- Department of Clinical Laboratory, Children's Hospital, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
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Population-level viral suppression among pregnant and postpartum women in a universal test and treat trial. AIDS 2020; 34:1407-1415. [PMID: 32472768 DOI: 10.1097/qad.0000000000002564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE(S) We sought to determine whether universal 'test and treat' (UTT) can achieve gains in viral suppression beyond universal antiretroviral treatment (ART) eligibility during pregnancy and postpartum, among women living with HIV. DESIGN A community cluster randomized trial. METHODS The SEARCH UTT trial compared an intervention of annual population testing and universal ART with a control of baseline population testing with ART by country standard, including ART eligibility for all pregnant/postpartum women, in 32 communities in Kenya and Uganda. When testing, women were asked about current pregnancy and live births over the prior year and, if HIV-infected, had their viral load measured. Between arms, we compared population-level viral suppression (HIV RNA <500 copies/ml) among all pregnant/postpartum HIV-infected women at study close (year 3). We also compared year-3 population-level viral suppression and predictors of viral suppression among all 15 to 45-year-old women by arm. RESULTS At baseline, 92 and 93% of 15 to 45-year-old women tested for HIV: HIV prevalence was 12.6 and 12.3%, in intervention and control communities, respectively. Among HIV-infected women self-reporting pregnancy/live birth, prevalence of viral suppression was 42 and 44% at baseline, and 81 and 76% (P = 0.02) at year 3, respectively. Among all 15 to 45-year-old HIV-infected women, year-3 population-level viral suppression was higher in intervention (77%) versus control (68%; P < 0.001). Pregnancy/live birth was a predictor of year-3 viral suppression in control (P = 0.016) but not intervention (P = 0.43). Younger age was a risk factor for nonsuppression in both arms. CONCLUSION The SEARCH intervention resulted in higher population viral suppression among pregnant/postpartum women than a control of baseline universal testing with ART eligibility for pregnant/postpartum women.
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Nguyen RN, Ton QC, Tran QH, Nguyen TKL. <p>Mother-to-Child Transmission of HIV and Its Predictors Among HIV-Exposed Infants at an Outpatient Clinic for HIV/AIDS in Vietnam</p>. HIV AIDS (Auckl) 2020; 12:253-261. [PMID: 32765117 PMCID: PMC7371555 DOI: 10.2147/hiv.s259592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/28/2020] [Indexed: 11/26/2022] Open
Abstract
Background Mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) is decreasing worldwide; however, achieving the MTCT elimination target of 2% by 2020 and 0% by 2030 is challenging in resource-limited countries. The purpose of this study is to determine the evolution of the HIV transmission rate in infants from 2007 to 2018 and to identify the risk factors of HIV transmission among HIV-exposed infants in Vietnam. Patients and Methods A prospective cohort study of 608 HIV-exposed infants was conducted at the Pediatric Outpatient Clinic (pOPC) of the Women and Children Hospital of An Giang, Vietnam between September 2007 and December 2019. A follow-up registration book was used to collect data, which were entered into Microsoft Excel and analyzed by SPSS version 22.0. Both bivariate and multivariate analyses were carried out to identify associations. Results A total of 608 HIV-exposed infant were enrolled in the study, of which 472 were included in the final analysis. The median age of infants at enrollment to follow-up was 6.3 weeks (interquartile range [IQR]=6.0–6.9 weeks). A total of 42 infants out of 472 were infected with HIV, giving an overall MTCT rate of 8.9% (95% confidence interval (CI)=6.4–12.0). The transmission rate decreased from 27.9% in 2007 to 0% in 2018. Absence of maternal ARV (antiretrovirals) intervention before or during pregnancy (AOR=40.6, 95% CI=5.5–308) and absence of ARV prophylaxis for HIV-exposed infants (AOR=3.4, 95% CI=1.1–10.3) were significantly and independently associated with MTCT of HIV in this study. Conclusion There is a significant progress on the reduction of MTCT rate in An Giang, Vietnam. Absence of ART interventions for mothers and infants are significant factors associated with HIV transmission. Providing free ARV and increasing the coverage of ARV intervention for pregnant women are keys for reducing the MTCT rate in the future.
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Affiliation(s)
- Rang Ngoc Nguyen
- Department of Pediatrics, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
- Women and Children Hospital of an Giang, An Giang, Vietnam
- Correspondence: Rang Ngoc Nguyen Tel +84 913106404 Email
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Hompe ED, Mangold JF, Kumar A, Eudailey JA, McGuire E, Haynes BF, Moody MA, Wright PF, Fouda GG, Giorgi EE, Gao F, Permar SR. Induction of Neutralizing Responses against Autologous Virus in Maternal HIV Vaccine Trials. mSphere 2020; 5:e00254-20. [PMID: 32493720 PMCID: PMC7273346 DOI: 10.1128/msphere.00254-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 05/19/2020] [Indexed: 02/02/2023] Open
Abstract
A maternal vaccine capable of boosting neutralizing antibody (NAb) responses directed against circulating viruses in HIV-infected pregnant women could effectively decrease mother-to-child transmission of HIV. However, it is not known if an HIV envelope (Env) vaccine administered to infected pregnant women could enhance autologous virus neutralization and thereby reduce this risk of vertical HIV transmission. Here, we assessed autologous virus NAb responses in maternal plasma samples obtained from AIDS Vaccine Evaluation Group (AVEG) protocols 104 and 102, representing historical phase I safety and immunogenicity trials of recombinant HIV Env subunit vaccines administered to HIV-infected pregnant women (ClinicalTrials registration no. NCT00001041). Maternal HIV Env-specific plasma binding and neutralizing antibody responses were characterized before and after vaccination in 15 AVEG 104 (n = 10 vaccine recipients, n = 5 placebo recipients) and 2 AVEG 102 (n = 1 vaccine recipient, n = 1 placebo recipient) participants. Single-genome amplification (SGA) was used to obtain HIV env gene sequences of autologous maternal viruses for pseudovirus production and neutralization sensitivity testing in pre- and postvaccination plasma of HIV-infected pregnant vaccine recipients (n = 6 gp120, n = 1 gp160) and placebo recipients (n = 3). We detected an increase in Env subunit MN gp120-specific IgG binding in the group of vaccine recipients between the first immunization visit and the last visit at delivery (P = 0.027, 2-sided Wilcoxon test). While no difference was observed in the levels of autologous virus neutralization potency between groups, in both groups maternal plasma collected at delivery more effectively neutralized autologous viruses from early pregnancy than late pregnancy. Immunization strategies capable of further enhancing these autologous virus NAb responses in pregnant women will be important to block vertical transmission of HIV.IMPORTANCE Maternal antiretroviral therapy (ART) has effectively reduced but not eliminated the burden of mother-to-child transmission of HIV across the globe, as an estimated 160,000 children were newly infected with HIV in 2018. Thus, additional preventive strategies beyond ART will be required to close the remaining gap and end the pediatric HIV epidemic. A maternal active immunization strategy that synergizes with maternal ART could further reduce infant HIV infections. In this study, we found that two historic HIV Env vaccines did not enhance the ability of HIV-infected pregnant women to neutralize autologous viruses. Therefore, next-generation maternal HIV vaccine candidates must employ alternate approaches to achieve potent neutralizing antibody and perhaps nonneutralizing antibody responses to effectively impede vertical virus transmission. Moreover, these approaches must reflect the broad diversity of HIV strains and widespread availability of ART worldwide.
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Affiliation(s)
- Eliza D Hompe
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Jesse F Mangold
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Amit Kumar
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Joshua A Eudailey
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Erin McGuire
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Barton F Haynes
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - M Anthony Moody
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Peter F Wright
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Genevieve G Fouda
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Elena E Giorgi
- Los Alamos National Laboratory, Los Alamos, New Mexico, USA
| | - Feng Gao
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Sallie R Permar
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
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Poon L.C, Yang H, Dumont S, Lee JCS, Copel JA, Danneels L, Wright A, Costa FDS, Leung TY, Zhang Y, Chen D, Prefumo F. ISUOG Interim Guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium: information for healthcare professionals - an update. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:848-862. [PMID: 32356590 PMCID: PMC7267438 DOI: 10.1002/uog.22061] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Affiliation(s)
- L. . C. Poon
- Department of Obstetrics and GynaecologyThe Chinese University of Hong KongHong Kong SAR
| | - H. Yang
- Department of Obstetrics and GynecologyPeking University First HospitalBeijingChina
| | - S. Dumont
- Department of Gynaecology and ObstetricsUniversity Hospitals Leuven, Leuven, Belgium; and Department of GynaecologyAZ Delta, RoeselareBelgium
| | - J. C. S. Lee
- Division of Obstetrics and GynaecologyKK Women's and Children's HospitalSingapore
| | - J. A. Copel
- Department of Obstetrics, Gynecology & Reproductive SciencesYale School of MedicineNew HavenCTUSA
| | - L. Danneels
- Department of Gynaecology, AZ DeltaRoeselareBelgium
| | - A. Wright
- Department of Obstetrics and GynaecologyRoyal Free Teaching Hospital Foundation TrustLondonUK
| | - F. Da Silva Costa
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil; and Department of Obstetrics and GynaecologyMonash UniversityMelbourneAustralia
| | - T. Y. Leung
- Department of Obstetrics and GynaecologyThe Chinese University of Hong KongHong Kong SAR
| | - Y. Zhang
- Department of Obstetrics and GynaecologyZhongnan Hospital of Wuhan UniversityWuhanChina
| | - D. Chen
- Department of Obstetrics and GynaecologyThe Third Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - F. Prefumo
- Department of Clinical and Experimental SciencesUniversity of BresciaBresciaItaly
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Gilleece DY, Tariq DS, Bamford DA, Bhagani DS, Byrne DL, Clarke DE, Clayden MP, Lyall DH, Metcalfe DR, Palfreeman DA, Rubinstein DL, Sonecha MS, Thorley DL, Tookey DP, Tosswill MJ, Utting MD, Welch DS, Wright MA. British HIV Association guidelines for the management of HIV in pregnancy and postpartum 2018. HIV Med 2020; 20 Suppl 3:s2-s85. [PMID: 30869192 DOI: 10.1111/hiv.12720] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Dr Yvonne Gilleece
- Honorary Clinical Senior Lecturer and Consultant Physician in HIV and Genitourinary Medicine, Brighton and Sussex University Hospitals NHS Trust
| | - Dr Shema Tariq
- Postdoctoral Clinical Research Fellow, University College London, and Honorary Consultant Physician in HIV, Central and North West London NHS Foundation Trust
| | - Dr Alasdair Bamford
- Consultant in Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | - Dr Sanjay Bhagani
- Consultant Physician in Infectious Diseases, Royal Free Hospital NHS Trust, London
| | - Dr Laura Byrne
- Locum Consultant in HIV Medicine, St George's University Hospitals NHS Foundation Trust, London
| | - Dr Emily Clarke
- Consultant in Genitourinary Medicine, Royal Liverpool and Broadgreen University Hospitals NHS Trust
| | - Ms Polly Clayden
- UK Community Advisory Board representative/HIV treatment advocates network
| | - Dr Hermione Lyall
- Clinical Director for Children's Services and Consultant Paediatrician in Infectious Diseases, Imperial College Healthcare NHS Trust, London
| | | | - Dr Adrian Palfreeman
- Consultant in Genitourinary Medicine, University Hospitals of Leicester NHS Trust
| | - Dr Luciana Rubinstein
- Consultant in Genitourinary Medicine, London North West Healthcare University NHS Trust, London
| | - Ms Sonali Sonecha
- Lead Directorate Pharmacist HIV/GUM, Chelsea and Westminster Healthcare NHS Foundation Trust, London
| | | | - Dr Pat Tookey
- Honorary Senior Lecturer and Co-Investigator National Study of HIV in Pregnancy and Childhood, UCL Great Ormond Street Institute of Child Health, London
| | | | - Mr David Utting
- Consultant Obstetrician and Gynaecologist, Brighton and Sussex University Hospitals NHS Trust
| | - Dr Steven Welch
- Consultant in Paediatric Infectious Diseases, Heart of England NHS Foundation Trust, Birmingham
| | - Ms Alison Wright
- Consultant Obstetrician and Gynaecologist, Royal Free Hospitals NHS Foundation Trust, London
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Type-Specific Human Papillomavirus Prevalence, Incident Cases, Persistence, and Associated Pregnancy Outcomes Among HIV-Infected Women in Kenya. Sex Transm Dis 2020; 46:532-539. [PMID: 31295222 DOI: 10.1097/olq.0000000000001029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Persistent infection with high-risk types of human papillomavirus (HPV) is the preeminent factor driving the development of cervical cancer. There are large gaps in knowledge about both the role of pregnancy in the natural history of HPV infection and the impact of HPV on pregnancy outcomes. METHODS This single-site prospective cohort substudy, nested within an international multisite randomized controlled trial, assessed prevalence, incident cases, and persistence of type-specific HPV infection, and the association between persistence of high-risk HPV infection with pregnancy outcomes among HIV-infected pregnant women in Kenya, including HIV transmission to infants. Type-specific HPV was assessed using a line probe assay in pregnancy and again at 3 months after delivery. HIV status of children was determined using polymerase chain reaction at 6 weeks. RESULTS In total, 84.1% (206/245) of women had a high-risk HPV infection at enrollment. Three quarters (157/206) of these infections persisted postpartum. Persistence of HPV16 and/or HPV18 types was observed in more than half (53.4%; 39/73) of women with this infection at enrollment. Almost two-thirds had an incident high-risk HPV infection postpartum, which was not present in pregnancy (62.5%), most commonly HPV52 (19.0%). After adjustments, no association was detected between persistent high-risk HPV and preterm birth. All mothers of the 7 cases of infant HIV infection had persistent high-risk HPV infection (P = 0.044). CONCLUSIONS High levels of high-risk HPV infection and type-specific persistence were documented, heightening the urgency of mass role out of HPV vaccination. The association between HPV persistence and HIV transmission is a novel finding, warranting further study.
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Decreased growth among antiretroviral drug and HIV-exposed uninfected versus unexposed children in Malawi and Uganda. AIDS 2020; 34:215-225. [PMID: 31634154 DOI: 10.1097/qad.0000000000002405] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare growth among antiretroviral drug and maternal HIV-exposed uninfected (AHEU) versus age-matched and sex-matched HIV-unexposed uninfected (HUU) children. DESIGN Prospective cohort of AHEU children identified from the PROMISE trial (NCT01061151: clinicaltrials.gov registry) and age-matched and sex-matched HUU controls from child-wellness clinics, enrolled (September 2013 to October 2014) in Malawi and Uganda. METHODS Weight-for-age (WAZ), length-for-age (LAZ), weight-for-length (WLZ), and head-circumference-for-age (HCAZ) z-scores were derived at 12 months and 24 months of age. Wilcoxon Rank-Sum and Fisher's exact tests were used for unadjusted exposure group comparisons. Generalized Estimating Equations models estimated adjusted relative risks (aRR) for poor growth outcomes. RESULTS Overall, 471 (50.5%) AHEU and 462 (49.5%) HUU children were assessed. Ugandan AHEU compared with HUU children had significantly lower mean LAZ (P < 0.001) and WAZ (P < 0.001) at 12 and 24 months of age and HCAZ (P = 0.016) at 24 months, with similar but not significant differences among Malawian AHEU and HUU children. The risk of stunting (more than two standard deviations below the WHO population LAZ median) was increased among AHEU versus HUU children: aRR = 2.13 (95% confidence interval (CI): 1.36-3.33), P = 0.001 at 12 months, and aRR = 1.67 (95% CI 1.16-2.41), P = 0.006 at 24 months of age in Uganda; and aRR = 1.32 (95% CI 1.10-1.66), P = 0.018, at 24 months of age in Malawi. The risk of HCAZ below WHO median was increased among AHEU versus HUU children at 24 months of age, aRR = 1.35 (95% CI 1.02-1.79), P = 0.038 in Uganda; and aRR = 1.35 (95% CI 0.91-2.02), P = 0.139 in Malawi. CONCLUSION Perinatal exposures to maternal HIV and antiretroviral drugs were associated with lower LAZ (including stunting), WAZ and HCAZ at 24 months of age compared with HUU children.
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Abstract
Guidelines in high-income settings recommend breastfeeding avoidance amongst women living with HIV (WLWH). Increasingly, WLWH in high-income settings, who are well-treated with fully suppressed viral loads, are choosing to breastfeed their infants, even with these recommendations. The purpose of this article is to review existing research and guidance on infant feeding amongst WLWH in high-income countries and to identify gaps in this evidence that require further investigation. Current evidence on the risk of HIV transmission through breastfeeding in the context of antiretroviral therapy (ART), the significance of cell-associated virus, transmission risk factors, retention in care and adherence postpartum, infant prophylaxis and antiretroviral exposure, and monitoring of the breastfeeding WLWH are summarized. A latent HIV reservoir is persistently present in breast milk, even in the context of ART. Thus, suppressive maternal ART significantly reduces, but does not eliminate, the risk of postnatal transmission of HIV. There are currently limited data to guide the optimal frequency of virologic monitoring and the clinical actions to take in case of maternal detectable viral load whilst breastfeeding. Moreover, retention in care and adherence to ART in the postpartum period may be difficult and more research is needed to understand what clinical and psychosocial support would benefit these mothers so that successful engagement in care can be achieved. The long-term effects of antiretroviral drug exposure in the infants also need further exploration. Thus, there is a need for collecting enhanced surveillance data on WLWH who breastfeed and their infants to augment clinical guidance in high-income settings.
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Affiliation(s)
- E Moseholm
- Department of Infectious Disease, Copenhagen University Hospital, Hvidovre, Denmark
| | - N Weis
- Department of Infectious Disease, Copenhagen University Hospital, Hvidovre, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Vubil A, Nhachigule C, Loquiha O, Meggi B, Mabunda N, Bollinger T, Sacks JA, Jani I, Vojnov L. Viral load assay performs comparably to early infant diagnosis assay to diagnose infants with HIV in Mozambique: a prospective observational study. J Int AIDS Soc 2020; 23:e25422. [PMID: 31912960 PMCID: PMC6948022 DOI: 10.1002/jia2.25422] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 09/26/2019] [Accepted: 11/08/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Viral load testing is essential to manage HIV disease, especially in infants and children. Early infant diagnosis is performed using nucleic-acid testing in children under 18 months. Resource-limited health systems face severe challenges to scale-up both viral load and early infant diagnosis to unprecedented levels. Streamlining laboratory systems would be beneficial to improve access to quality testing and to increase efficiency of antiretroviral treatment programmes. We evaluated the performance of viral load testing to serve as an early infant diagnosis assay in children younger than 18 months. METHODS This study was an observational, prospective study, including children between one and 18 months of age who were born to HIV-positive mothers in 134 health facilities in Maputo City and Maputo Province, Mozambique. Dried blood spot specimens from heel or toe pricks were collected between January and April 2018, processed using SPEX buffer for both assays, and tested for routine EID and VL testing using the Roche CAP/CTM HIV-1 Qualitative v2 and Roche CAP/CTM HIV-1 Quantitative v2 assays respectively. The sensitivity, specificity and positive and negative predictive values were estimated using the EID results as the reference standard. RESULTS A total of 1021 infants were included in the study, of which 47% were female. Over 95% of mothers and children were on antiretroviral treatment or received antiretroviral prophylaxis respectively. The sensitivity and specificity of using the viral load assay to detect infection were 100% (95% CI: 96.2 to 100%) and 99.9% (95% CI: 99.4 to 100%). The positive and negative predictive values were 99.0% (95% CI: 94.3 to 100%) and 100% (95% CI: 99.6 to 100%). The McNemar's test was 1.000 and Cohen's kappa was 0.994. CONCLUSIONS The comparable performance suggests that viral load assays can be used as an infant diagnostic assay. Infants with either low levels of viraemia or high cycle threshold values should be repeat tested to ensure the result is truly positive prior to treatment initiation, regardless of assay used. Viral load assays could replace traditional early infant diagnosis testing, substantially streamlining molecular laboratory services for children and lowering costs, with the additional advantage of providing baseline viral load results for antiretroviral treatment management.
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Affiliation(s)
| | | | - Osvaldo Loquiha
- Clinton Health Access InitiativeMaputoMozambique
- Department of Mathematics and InformaticsUniversidade Eduardo MondlaneMaputoMozambique
| | | | | | | | | | - Ilesh Jani
- Instituto Nacional de SaudeMaputoMozambique
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Tiam A, Kassaye SG, Machekano R, Tukei V, Gill MM, Mokone M, Letsie M, Tsietso M, Seipati I, Barasa J, Isavwa A, Tylleskär T, Guay L. Comparison of 6-week PMTCT outcomes for HIV-exposed and HIV-unexposed infants in the era of lifelong ART: Results from an observational prospective cohort study. PLoS One 2019; 14:e0226339. [PMID: 31877153 PMCID: PMC6932788 DOI: 10.1371/journal.pone.0226339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/25/2019] [Indexed: 01/04/2023] Open
Abstract
Background Lifelong antiretroviral therapy (ART) reduces mother-to-child HIV transmission (MTCT) and improves maternal health. Data on the outcomes of HIV-exposed infants (HEI) compared to their unexposed counterparts in the era of universal ART is limited. We compared birth and 6-week outcomes among infants born to HIV-positive and HIV-negative women in Lesotho. Methods 941 HIV-negative and 653 HIV-positive pregnant women were enrolled in an observational cohort to evaluate the effectiveness of prevention of mother-to-child HIV transmission (PMTCT) program after implementation of universal maternal ART in 14 health facilities. Pregnancy, delivery, birth, and 6-week data were collected through participant interviews and medical record review. DNA PCR testing for HEI was conducted within 2 weeks of birth and at around 6 weeks of age. Data were analysed to estimate the distribution of birth outcomes, mortality, HIV transmission and HIV-free survival at 6 weeks. Results HIV-positive women were older (mean age of 28.7 vs. 24.4 years) and presented for antenatal care earlier (mean gestational age of 23.0 weeks vs 25.3 weeks) than HIV-negative women. Prematurity was more frequent among HEI, 7.8% vs. 3.6%. There was no difference in rates of congenital anomalies between HEI (1.0%) and HIV-unexposed infants (HUI) (0.6%). Cumulative HIV transmission was 0.9% (N = 4/431) (95% CI:0.25–2.36) at birth and 1.0% (N = 6/583) (95% CI:0.38–2.23) at 6 weeks. Overall mortality, including stillbirths, was 5.2% and 6.0% by 6 weeks for HUI and HEI respectively. Among liveborn infants, 6-week HIV-free survival for HEI was 95.6% (95% CI:93.7–97.1) compared to 96.8% (95% CI:95.4–97.9) survival for HUI. Conclusions Implementation of universal maternal ART lowers MTCT at 6 weeks of age with no differences in congenital anomalies or early mortality between HIV exposed Infants and HIV unexposed infants. However, HIV exposed infants continue to have high rates of prematurity despite improved maternal health on ART.
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Affiliation(s)
- Appolinaire Tiam
- Elizabeth Glaser Pediatric AIDS Foundation, Washington D.C., United States of America
- Centre for International Health, University of Bergen, Bergen, Norway
- * E-mail:
| | - Seble G. Kassaye
- Department of Medicine Georgetown University School of Medicine, Washington D.C., United States of America
| | - Rhoderick Machekano
- Elizabeth Glaser Pediatric AIDS Foundation, Washington D.C., United States of America
| | - Vincent Tukei
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Michelle M. Gill
- Elizabeth Glaser Pediatric AIDS Foundation, Washington D.C., United States of America
| | | | | | | | | | - Janety Barasa
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Anthony Isavwa
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | | | - Laura Guay
- Elizabeth Glaser Pediatric AIDS Foundation, Washington D.C., United States of America
- Department of Epidemiology and Biostatistics, George Washington University Milken Institute School of Public Health, Washington D.C., United States of America
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Venkatesh KK, Farhad M, Fenton T, Moodley D, Naik S, Nakabiito C, Fairlie L, Fowler MG, Stringer JSA, Chi BH. Association between HIV antiretroviral therapy and preterm birth based on antenatal ultrasound gestational age determination: a comparative analysis. AIDS 2019; 33:2403-2413. [PMID: 31764105 PMCID: PMC7293898 DOI: 10.1097/qad.0000000000002367] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the association between HIV antiretroviral therapy (ART) and preterm birth (PTB), when defined by gold standard antenatal ultrasound versus newborn exam. DESIGN A secondary analysis of the PROMISE 1077BF/1077FF randomized controlled trial, which compared antiretroviral strategies to reduce perinatal HIV transmission and improve maternal health. The trial used newborn exam (i.e. New Ballard Score, NBS) to assess gestational age. This analysis included liveborn singleton pregnancies with both newborn exam and ultrasound data. The primary exposure was the trial's antiretroviral strategies: zidovudine with intrapartum nevirapine ('ZDV alone'); zidovudine/lamivudine/lopinavir-ritonavir ('ZDV-based ART'); or tenofovir/emtricitabine/lopinavir-ritonavir ('TDF-based ART'). The primary outcome was PTB less than 37 and less than 34 weeks based on the gold standard of ultrasound dating. We evaluated the association between antiretroviral strategy and PTB. We fit multivariable logistic regression models, adjusting for maternal characteristics, obstetric history, and HIV disease severity. RESULTS Among 720 assessed pregnant women, PTB less than 37 weeks was 15.4% by NBS and 18.3% by ultrasound. The NBS was specific but not sensitive for PTB less than 37 weeks (92.0% and 48.5%). Women receiving ZDV-based and TDF-based ART had significantly higher odds of PTB less than 37 by ultrasound compared with ZDV alone (adjusted odds ratios: 1.68; 95% confidence interval 1.10-2.57, and 2.71; 95% confidence interval 1.39-5.29), as well as for PTB less than 34 weeks. These results held for ultrasounds performed less than 24 weeks, and were generally consistent with prior analyses from the PROMISE trial using the NBS. CONCLUSION Women starting HIV ART in pregnancy remained at higher risk of PTB when determined by ultrasound, consistent with prior data using newborn exam. However, newborn exam misclassified cases of PTB compared with gold standard ultrasound.
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Affiliation(s)
- Kartik Kailas Venkatesh
- aDivision of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina bHarvard T.H. Chan School of Public Health, Center for Biostatistics in AIDS Research, Boston, Massachusetts, USA cCentre for AIDS Research in South Africa and Department of Obstetrics and Gynecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa dByramiee Jeejeebhoy Government Medical College, Pune, India eMakerere University, Kampala, Uganda fWits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa gDepartment of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland hDivision of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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48
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Theilgaard ZP, Chiduo MG, Flamholc L, Gerstoft J, Bygbjerg IC, Lemnge MM, Katzenstein TL. Retired Nurses Can Improve Retention in Prevention of Mother-to-Child Transmission Programmes. East Afr Health Res J 2019; 3:88-95. [PMID: 34308201 PMCID: PMC8279289 DOI: 10.24248/eahrj-d-19-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 09/06/2019] [Indexed: 12/03/2022] Open
Abstract
Background: The success of prevention of mother-to-child transmission (PMTCT) programmes depends on retention of mothers throughout the PMTCT cascade. Methods: In a clinical trial of short-course combination antiretroviral therapy (cART) for PMTCT in Tanzania, senior nurses were employed to reduce the substantial loss-to-follow up (LTFU) rate. Results: Following intervention, the relative risk (RR) of receiving a CD4 count result and antiretroviral therapy was 1.16 (95% confidence interval [CI], 1.05 to 1.27), the RR of delivery at clinic was 2.51 (95% CI, 2.06 to 3.06), the RR for reporting for follow-up at 6 to 8 weeks postpartum was 4.63 (95% CI, 3.41 to 6.27), and the RR for being retained until 9 months postpartum was 28.19 (95% CI, 11.81 to 67.28). No significant impact on transmission was found. Conclusion: Significantly higher retention was found after senior nurses were employed. No impact on transmission was found. Relatively low transmission was found in both study arms.
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Affiliation(s)
- Zahra Persson Theilgaard
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mercy G Chiduo
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Leo Flamholc
- Department of Infectious Diseases, University Hospital of Malmö, Malmö, Sweden
| | - Jan Gerstoft
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ib C Bygbjerg
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Terese L Katzenstein
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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49
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Ndarukwa V, Zunza M. Combination antiretroviral treatment use in prevention of mother-to-child transmission programmes: 6-week HIV prevalence and relationship to time of antiretroviral treatment initiation and mixed feeding. S Afr J Infect Dis 2019; 34:117. [PMID: 34485455 PMCID: PMC8378092 DOI: 10.4102/sajid.v34i1.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/04/2019] [Indexed: 11/01/2022] Open
Abstract
Background In Zimbabwe, 16% of pregnant women aged 15-49 years are infected with HIV. More than 90% of HIV infection in children is through mother-to-child transmission (MTCT). We investigated the effectiveness of the Option B+ in reducing HIV infection and factors associated with HIV transmission among infants born to mothers enrolled in the prevention of mother-to-child transmission (PMTCT) programme. Methods We randomly selected 1204 early infant HIV diagnosis test results for HIV-exposed infants and linked these results to maternal clinical records at primary healthcare clinics in Harare to estimate the prevalence of MTCT and to determine the clinical factors associated with MTCT of HIV at 6 weeks. Results Of the 1204 infants in the study, 2.5% (95% confidence interval [CI], 1.7-3.5) were infected with HIV at 6 weeks post-delivery. Antiretroviral adherence reduced the odds of HIV infection by about 99% (odds ratio [OR] 0.01 [95% CI, 0.00-0.06]). Both mixed feeding (OR 3.89 [95% CI, 0.92-16.50]) and late initiation of antiretroviral treatment (ART) (after delivery) (OR 3.18 [95% CI, 0.42-23.94]) increased the odds of HIV infection. Conclusion Early initiation of combination ART reduces 6-week MTCT of HIV in PMTCT programmes to levels similar to those found in controlled trial settings. Exclusive breastfeeding remains important even in the presence of ART.
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Affiliation(s)
- Victoria Ndarukwa
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Moleen Zunza
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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50
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Dugdale CM, Phillips TK, Myer L, Hyle EP, Brittain K, Freedberg KA, Cunnama L, Walensky RP, Zerbe A, Weinstein MC, Abrams EJ, Ciaranello AL. Cost-effectiveness of integrating postpartum antiretroviral therapy and infant care into maternal & child health services in South Africa. PLoS One 2019; 14:e0225104. [PMID: 31730630 PMCID: PMC6857940 DOI: 10.1371/journal.pone.0225104] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 10/29/2019] [Indexed: 11/29/2022] Open
Abstract
Background Poor engagement in postpartum maternal HIV care is a challenge worldwide and contributes to adverse maternal outcomes and vertical transmission. Our objective was to project the clinical and economic impact of integrated postpartum maternal antiretroviral therapy (ART) and pediatric care in South Africa. Methods Using the CEPAC computer simulation models, parameterized with data from the Maternal and Child Health–Antiretroviral Therapy (MCH-ART) randomized controlled trial, we evaluated the cost-effectiveness of integrated postpartum care for women initiating ART in pregnancy and their children. We compared two strategies: 1) standard of care (SOC) referral to local clinics after delivery for separate standard ART services for women and pediatric care for infants, and 2) the MCH-ART intervention (MCH-ART) of co-located maternal/pediatric care integrated in Maternal and Child Health (MCH) services throughout breastfeeding. Trial-derived inputs included: 12-month maternal retention in care and virologic suppression (SOC: 49%, MCH-ART: 67%), breastfeeding duration (SOC: 6 months, MCH-ART: 8 months), and postpartum healthcare costs for mother-infant pairs (SOC: $50, MCH-ART: $69). Outcomes included pediatric HIV infections, maternal and infant life expectancy (LE), lifetime HIV-related per-person costs, and incremental cost-effectiveness ratios (ICERs; ICER <US$903/YLS considered “cost-effective”). Results Compared to SOC, MCH-ART increased maternal LE (SOC: 25.26 years, MCH-ART: 26.20 years) and lifetime costs (SOC: $9,912, MCH-ART: $10,207; discounted). Projected pediatric outcomes for all HIV-exposed children were similar between arms, although undiscounted LE for HIV-infected children was shorter in SOC (SOC: 23.13 years, MCH-ART: 23.40 years). Combining discounted maternal and pediatric outcomes, the ICER was $599/YLS. Conclusion Co-located maternal HIV and pediatric care, integrated in MCH services throughout breastfeeding, is a cost-effective strategy to improve maternal and pediatric outcomes and should be implemented in South Africa.
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Affiliation(s)
- Caitlin M. Dugdale
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- * E-mail:
| | - Tamsin K. Phillips
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Emily P. Hyle
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Kirsty Brittain
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kenneth A. Freedberg
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Lucy Cunnama
- Health Economics Unit, School of Public Health & Family Medicine, University of Cape Town, South Africa
| | - Rochelle P. Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Allison Zerbe
- ICAP at Columbia and the Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Milton C. Weinstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Elaine J. Abrams
- ICAP at Columbia and the Mailman School of Public Health, Columbia University, New York, NY, United States of America
- College of Physicians & Surgeons, Columbia University, New York, NY, United States of America
| | - Andrea L. Ciaranello
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
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