Predictors of anaemia and iron deficiency in HIV-infected pregnant women in Tanzania: a potential role for vitamin D and parasitic infections

Association of Vitamin D in Different Trimester with Hemoglobin during Pregnancy

The association between vitamin D and hemoglobin has been suggested. Vitamin D can affect erythropoiesis by the induction of erythroid progenitor cell proliferation and enhance iron absorption by regulating the iron-hepcidin-ferroportin axis in monocytes. However, this relationship in pregnant women is scarce. The purpose of this study was to investigate the association between plasma vitamin D levels with hemoglobin concentration in pregnant women considering each trimester and iron supplementation. The data were obtained from Zhoushan Pregnant Women Cohort, collected from 2011 to 2018. Plasma 25(OH)D was measured in each trimester using liquid chromatography−tandem mass spectrometry. Generalized estimating equations and multiple linear regressions were performed. Finally, 2962 pregnant women and 4419 observations in the first trimester were included in this study. Plasma 25(OH)D in first trimester (T1) (β = 0.06, p = 0.0177), second trimester (T2) (β = 0.15, p < 0.0001), and third trimester (T3) (β = 0.12, p = 0.0006) were positively associated with Hb. Association between plasma 25(OH)D levels in T1 and Hb concentration was positively associated with gestational age (β = 0.005, p = 0.0421). Pregnant women with VD deficiency in T1 (OR = 1.42, 95% CI: 1.07−1.88) or T2 (OR = 1.94, 95% CI: 1.30−2.89) presented an increased risk of anemia, compared with women without VD deficiency. Moreover, the significant relationship between VD and Hb was only observed among women with iron supplementation during pregnancy. Plasma 25(OH)D levels in each trimester were positively associated with Hb concentration. Iron supplementation might be an important factor affecting the relationship between VD and Hb.

Prevalence of post-partum anemia and associated factors among women attending public primary health care facilities: An institutional based cross-sectional study

Background

Severe post-partum anemia is an important cause of maternal deaths and severe morbidity in sub-Saharan Africa. In Tanzania, little information is available to guide health care professionals in ensuring good health of women after delivery. The objective of our study was to determine the prevalence of post-partum anemia and associated factors among women attending public primary health care facilities.

Materials and methods

An institutional based cross sectional study was carried out. Women in post-partum period (the period from child birth to six weeks after delivery) attending the public primary health care facilities from October to December 2019 for children vaccination were recruited. The prick method was used to obtain blood for haemoglobin estimation. Post-partum anemia was defined as a haemoglobin level of less than 11g/dl. Participants found anaemic were asked to undertake malaria and helminths parasites tests from blood and stool samples respectively. The samples were examined by an experienced laboratory scientist on study sites according to the Tanzania national standard for medical laboratories protocols.

Results

A total of 424 women were enrolled with mean age of 27.8 years (SD 5.93). Most of the participants 234(55.2%) had primary education and nearly half 198(46.7%) of them were house wives. The overall prevalence of post-partum anemia was 145(34.2%). Among the anaemic participants, 34(23.5%) had positive blood slide for malaria parasite while 15(10.3%) had positive test for stool helminths infection. Delivery by vaginal route and low parity were protective against post-partum anemia (p<0.001).Other factors that were associated with post-partum anemia included absence of a marital partner (p<0.001) and inter pregnancy interval of less than two years (p<0.001). The risk of post-partum anemia in women with less than two years interval between their last two pregnancies was about 18 times more as compared to women with more than two years interval between their last two pregnancies, (COR = 18; 95% CI 8.617–38.617).Women without marital partners were 10 times more likely to get anemia as compared to married women, (COR = 10; 01.910–54.935).

Conclusions

The prevalence of anaemia among post-partum women found in this study points to a situation of public health problem according to WHO cut-off values for the public health significance of anaemia. Inter pregnancy interval of less than two years and absence of a marital partner were associated with post-partum anemia while delivery by vaginal route and low parity were protective against post-partum anemia. Strategies should therefore be put in place to encourage thorough health education and promotion programs among both pregnant and post-partum women.

Intermittent preventive treatment comparing two versus three doses of sulphadoxine pyrimethamine (IPTp-SP) in the prevention of anaemia in pregnancy in Ghana: A cross-sectional study

In 2012 the World Health Organisation (WHO) revised the policy on Intermittent Preventive Treatment with Sulphadoxine Pyrimethamine (IPTp-SP) to at least three doses for improved protection against malaria parasitaemia and its associated effects such as anaemia during pregnancy. We assessed the different SP dosage regimen available under the new policy to determine the dose at which women obtained optimal protection against anaemia during pregnancy. A cross-sectional study was conducted among pregnant women who attended antenatal clinic at four different health facilities in Ghana. The register at the facilities served as a sampling frame and simple random sampling was used to select all the study respondents; they were enrolled consecutively as they kept reporting to the facility to receive antenatal care to obtain the required sample size. The haemoglobin level was checked using the Cyanmethemoglobin method. Multivariable logistic regression was performed to generate odds ratios, confidence intervals and p-values. The overall prevalence of anaemia among the pregnant women was 62.6%. Pregnant women who had taken 3 or more doses of IPTp-SP had anaemia prevalence of 54.1% compared to 66.6% of those who had taken one or two doses IPTp-SP. In the multivariable logistic model, primary (aOR 0.61; p = 0.03) and tertiary education (aOR 0.40; p = <0.001) decreased the odds of anaemia in pregnancy. Further, pregnant women who were anaemic at the time of enrollment (aOR 3.32; p = <0.001) to the Antenatal Care clinic and had malaria infection at late gestation (aOR 2.36; p = <0.001) had higher odds of anaemia in pregnancy. Anaemia in pregnancy remains high in the Northern region of Ghana. More than half of the pregnant women were anaemic despite the use of IPTp-SP. Maternal formal education reduced the burden of anaemia in pregnancy. The high prevalence of anaemia in pregnancy amid IPTp-SP use in Northern Ghana needs urgent attention to avert negative maternal and neonatal health outcomes.

Slower response to treatment of iron-deficiency anaemia in pregnant women infected with HIV: a prospective cohort study

OBJECTIVE

Antenatal anaemia is associated with increased peripartum transfusion requirement in South Africa. We studied whether HIV was associated with the response to treatment of iron-deficiency anaemia.

DESIGN

Prospective cohort study.

SETTING

Hospital-based antenatal anaemia clinic in South Africa.

SAMPLE

Equal-sized cohorts of pregnant women testing positive for HIV (HIV+) and testing negative for HIV (HIV-) with iron-deficiency anaemia.

METHODS

Haemoglobin trajectories of women with confirmed iron-deficiency anaemia (ferritin < 50 ng/ml) were estimated from the initiation of iron supplementation using mixed-effects modelling, adjusted for baseline HIV status, ferritin level, maternal and gestational ages and time-varying iron supplementation.

MAIN OUTCOME MEASURES

Haemoglobin trajectories.

RESULTS

Of 469 women enrolled, 51% were HIV+, 90% of whom were on antiretroviral therapy (with a mean CD4+ lymphocyte count of 403 cells/mm³ ). Anaemia diagnoses did not differ by HIV status. A total of 400 women with iron-deficiency anaemia were followed during treatment with oral or intravenous (6%) iron therapy. In multivariable analysis, haemoglobin recovery was 0.10 g/dl per week slower on average in women who were HIV+ versus women who were HIV- (P = 0.001), 0.01 g/dl per week slower in women with higher baseline ferritin (P < 0.001) and 0.06 g/dl per week faster in women who were compliant with oral iron therapy (P = 0.002).

CONCLUSIONS

Compared with women who were HIV-, women who were HIV+ with iron-deficiency anaemia had slower but successful haemoglobin recovery with iron therapy. Earlier effective management of iron deficiency could reduce the incidence of peripartum blood transfusion.

TWEETABLE ABSTRACT

Among pregnant women with iron-deficiency anaemia in South Africa, HIV slows haemoglobin recovery in response to oral iron therapy.

Anemia and Micronutrient Status during Pregnancy, and Their Associations with Obstetric and Infant Outcomes among HIV-Infected Ugandan Women Receiving Antiretroviral Therapy

BACKGROUND

Women living with HIV (WLHIV) are at higher risk of micronutrient deficiencies and adverse health outcomes. There are limited data on the burden or sequelae of micronutrient deficiencies among pregnant WLHIV receiving antiretroviral therapy (ART).

OBJECTIVES

We aimed to examine anemia and vitamin B-12, folate, and vitamin D deficiencies, and their associations with obstetric and infant outcomes, among pregnant WLHIV initiating combination antiretroviral therapy (cART) in rural Uganda.

METHODS

This was a prospective analysis among pregnant WLHIV (12-28 weeks of gestation) in PROMOTE-Pregnant Women and Infants (PIs), a randomized trial comparing the effects of protease inhibitor (PI)-based ART with those of a non-PI-based ART on placental malaria risk. We conducted a substudy on the burden of anemia [trimester 1/3: hemoglobin (Hb) <11.0 g/dL; trimester 2: Hb <10.5 g/dL; n = 367] and micronutrient deficiencies (n = 127) in pregnant WLHIV and their associations with obstetric and infant outcomes. Hb was measured by cyanmethemoglobin, vitamin B-12 and folate were measured via electrochemiluminescence, and vitamin D was measured by ELISA. Linear and binomial regression were used to evaluate associations between micronutrient status during pregnancy and perinatal outcomes.

RESULTS

26.8% women were anemic, 30.2% were vitamin B-12 insufficient (<221.0 pmol/L), 66.1% were folate insufficient (<13.5 nmol/L), and 65.4% were vitamin D insufficient (<30.0 ng/mL) at enrollment. Anemia during pregnancy was associated with a greater risk of small for gestational age (SGA) (RR: 1.88; 95% CI: 1.28, 2.77; P = 0.001); each 1-g/dL decrease in Hb was associated with greater risk of SGA (RR: 0.76; 95% CI: 0.65, 0.90; P = 0.001). Multivariate models showed that increased vitamin D concentrations predicted lower risk of infant wasting (WLZ < -2; RR: 0.94; 95% CI: 0.89, 0.99; P = 0.04). Multivariate models also indicated that maternal vitamin B-12 and folate concentrations at enrollment predicted maternal (P < 0.001) and infant (P = 0.02) concentrations postpartum.

CONCLUSIONS

Anemia and micronutrient deficiencies are associated with a variety of adverse obstetric and infant outcomes and are an important public health concern in perinatal WLHIV on cART and their children.This trial was registered at clinicaltrials.gov as NCT00993031.

Screening of nutritional and genetic anemias using elastic light scattering

Anemia affects more than ¼ of the world's population, mostly concentrated in low-resource areas, and carries serious health risks. Yet current screening methods are inadequate due to their inability to separate iron deficiency anemia (IDA) from genetic anemias such as thalassemia trait (TT), thus preventing targeted supplementation of oral iron. Here we present an accurate approach to diagnose anemia and anemia type using measures of pediatric red cell morphology determined through machine learning applied to optical light scattering measurements. A partial least squares model shows that our system can accurately extract mean cell volume, red cell size heterogeneity, and mean cell hemoglobin concentration with high accuracy. These clinical parameters (or the raw data itself) can be submitted to machine learning algorithms such as quadratic discriminants or support vector machines to classify a patient into healthy, IDA, or TT. A clinical trial conducted on 268 Chinese children, of which 49 had IDA and 24 had TT, shows >98% sensitivity and specificity for diagnosing anemia, with 81% sensitivity and 86% specificity for discriminating IDA and TT. The majority of the misdiagnoses are IDA patients with particularly severe anemia, possibly requiring hospital care. Therefore, in a screening paradigm where anyone testing positive for TT is sent to the hospital for gold-standard diagnosis and care, we maximize patient benefit while minimizing use of scarce resources.

Tropical Parasitic Infections in Individuals Infected with HIV

PURPOSE OF REVIEW

Neglected tropical diseases share both geographic and socio-behavioral epidemiological risk factors with HIV infection. In this literature review, we describe interactions between parasitic diseases and HIV infection, with a focus on the impact of parasitic infections on HIV infection risk and disease progression, and the impact of HIV infection on clinical characteristics of tropical parasitic infections. We limit our review to tropical parasitic infections of the greatest public health burden, and exclude discussion of classic HIV-associated opportunistic infections that have been well reviewed elsewhere.

RECENT FINDINGS

Tropical parasitic infections, HIV-infection, and treatment with antiretroviral therapy alter host immunity, which can impact susceptibility, transmissibility, diagnosis, and severity of both HIV and parasitic infections. These relationships have a broad range of consequences, from putatively increasing susceptibility to HIV acquisition, as in the case of schistosomiasis, to decreasing risk of protozoal infections through pharmacokinetic interactions between antiretroviral therapy and antiparasitic agents, as in the case of malaria. However, despite this intimate interplay in pathophysiology and a broad overlap in epidemiology, there is a general paucity of data on the interactions between HIV and tropical parasitic infections, particularly in the era of widespread antiretroviral therapy availability.

SUMMARY

Additional data are needed to motivate clinical recommendations for detection and management of parasitic infections in HIV-infected individuals, and to consider the implications of and potential opportunity granted by HIV treatment programs on parasitic disease control.

The relationship between history of hormonal contraceptive use and iron status among women in Tanzania: A population-based study

OBJECTIVES

Approximately 30% of the Tanzanian women in the reproductive age group are iron deficient. At population-level, there is a dearth of research on the relationship between hormonal contraceptive use and iron deficiency. The study objective was to examine the relationship between history of hormonal contraceptive use and iron status among women in Tanzania.

STUDY DESIGN

We conducted a cross-sectional study analysis including 4186 women who participated in the population-based 2010 Tanzania Demographic and Health Survey.

MAIN OUTCOME MEASURE

Iron status determined by iron deficiency, anemia, and iron deficiency anemia.

RESULTS

Almost 19.0% women reported history of hormonal contraceptive use. Nearly, 30.0%, 39.5%, and 14.3% women had iron deficiency, anemia and iron deficiency anemia respectively. History of hormonal contraceptive use was negatively associated with iron deficiency, anemia and iron deficiency anemia, independent of potential confounders. Compared to non-users, the multivariable-adjusted odds ratio OR (95% CI) among hormonal contraceptive users was 0.73 (0.56-0.94, p<0.05) for iron deficiency, 0.58 (0.46-0.72, p<0.001) for anemia, and 0.53 (0.37-0.74; p<0.001) for iron deficiency anemia. Longer duration of hormonal contraceptive use (>2years) had lesser odds of iron deficiency 0.63 (0.43-0.91, p for trend 0.005), anemia 0.51 (0.36-0.73, p for trend <0.001) and iron deficiency anemia 0.35 (0.19-0.65, p for trend <0.001).

CONCLUSION

Our finding has important implications for educating healthcare providers and women about additional nutritional benefits of the use of hormonal contraceptives.

Lower incidence of respiratory infections among iron-deficient children in Kilimanjaro, Tanzania

Objective: We posited a trade-off in iron nutrition, with iron deficiency decreasing risk for infection by depriving infectious agents of iron while increasing risk for infection by compromising immune protection. We described associations between iron deficiency and prevalent and incident infectious disease episodes and cell-mediated immunity (CMI) among 283 children in Kilimanjaro, Tanzania.

Methodology: Whole blood specimens were evaluated for hemoglobin and dried blood spots (DBS) were evaluated for biomarkers of iron deficiency (transferrin receptor) and inflammation (C-reactive protein and α₁-acid glycoprotein). Prevalent and incident infectious disease episodes were identified by physician’s diagnosis. CMI was evaluated as delayed-type hypersensitivity to Candida albicans (DTH-Candida). Associations between iron status and elevated inflammation, prevalent infectious disease episodes and DTH-Candida were described with logistic regression models; associations between iron status and incident infectious disease episodes were described with Cox proportional hazards models.

Results: Elevated inflammation and diagnosed infectious diseases were more common among children with iron-deficiency anemia (IDA, severe iron deficiency), but not significantly so. The incidence of infectious disease was lowest among children with moderate iron deficiency (iron-deficient erythropoiesis, IDE); this pattern was most apparent for respiratory infections (aHR: 0.24; p: 0.030). DTH-Candida was not compromised among children with any degree of iron deficiency.

Conclusions and implications: We observed no adverse effect of iron deficiency on CMI, but did observe patterns consistent with the hypothesis that moderate iron deficiency protects against respiratory infections and may represent a nutritional adaptation to infectious disease. This suggests that interventions targeting iron deficiency should be coupled with effective infectious disease control measures.

Maternal Vitamin D Status and Adverse Birth Outcomes in Children from Rural Western Kenya

Maternal plasma 25-hydroxyvitamin D (25(OH)D) status and its association with pregnancy outcomes in malaria holoendemic regions of sub-Saharan Africa is poorly defined. We examined this association and any potential interaction with malaria and helminth infections in an ongoing pregnancy cohort study in Kenya. The association of maternal plasma 25(OH)D status with pregnancy outcomes and infant anthropometric measurements at birth was determined in a subset of women (n = 63). Binomial and linear regression analyses were used to examine associations between maternal plasma 25(OH)D and adverse pregnancy outcomes. Fifty-one percent of the women had insufficient (<75 nmol/L) and 21% had deficient (<50 nmol/L) plasma 25(OH)D concentration at enrollment. At birth, 74.4% of the infants had insufficient and 30% had deficient plasma 25(OH)D concentrations, measured in cord blood. Multivariate analysis controlling for maternal age and body mass index (BMI) at enrollment and gestational age at delivery found that deficient plasma 25(OH)D levels were associated with a four-fold higher risk of stunting in neonates (p = 0.04). These findings add to the existing literature about vitamin D and its association with linear growth in resource-limited settings, though randomized clinical trials are needed to establish causation.

Association of hematology profile with serum 25-hydroxy vitamin D and Bsml polimorphism in community-dwelling older adults

ABSTRACT Objective: To investigate the association between serum level of 25-hydroxy vitamin D and the Vitamin D Receptos gene BsmI polymorphism in the blood profile of community-dwelling older adults. Methods: This cross-sectional study included 142 older males and females. A questionnaire collected socio demographic information, medical history, and factors associated with sun exposure. Weight, height, and waist circumference were measured. Biological material was collected to analyze biochemical parameters 25-hydroxy vitamin D, parathormone, serum calcium, urea, creatinine, liver enzymes, and blood profile) and to verify the presence of the vitamin D receptos gene BsmI polymorphism. Results: Most participants were female (80.3%). The mean levels of 25-hydroxy vitamin D, hemoglobin, and hematocrit were 32.1±7.3 ng/dL, 13.5±1.5 d/dL, and 40.0±4.4%, respectively. Fifty-eight (40.8%) participants had vitamin D insufficiency/deficiency (25.7±3.3 ng/mL), and 18 (12.6%) had anemia. Serum vitamin D was associated with hemoglobin (p=0.030) and hematocrit (p=0.032). However, when subjects were categorized as anemic or not anemic, said association was not maintained (p=0.270). Moreover, the BsmI polymorphism was not associated with hemoglobin and hematocrit levels, regardless of vitamin D status. Conclusion: The serum level of vitamin D is associated with hematocrit and hemoglobin levels in older adults. However, these blood parameters were not associated with the vitamin D receptor gene BsmI polymorphism.

Antihelminthics in helminth-endemic areas: effects on HIV disease progression

BACKGROUND

Helminth infections, such as soil-transmitted helminths, schistosomiasis, onchocerciasis, and lymphatic filariasis, are prevalent in many countries where human immunodeficiency virus (HIV) infection is also common. There is some evidence from observational studies that HIV and helminth co-infection may be associated with higher viral load and lower CD4+ cell counts. Treatment of helminth infections with antihelminthics (deworming drugs) may have benefits for people living with HIV beyond simply clearance of worm infections.This is an update of a Cochrane Review published in 2009 and we have expanded it to include outcomes of anaemia and adverse events.

OBJECTIVES

To evaluate the effects of deworming drugs (antihelminthic therapy) on markers of HIV disease progression, anaemia, and adverse events in children and adults.

SEARCH METHODS

In this review update, we searched online for published and unpublished studies in the Cochrane Library, MEDLINE, EMBASE, CENTRAL, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICRTP), ClinicalTrials.gov, and the WHO Global Health Library up to 29 September 2015. We also searched databases listing conference abstracts, scanned reference lists of articles, and contacted the authors of included studies.

SELECTION CRITERIA

We searched for randomized controlled trials (RCTs) that compared antihelminthic drugs with placebo or no intervention in HIV-positive people.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trials for eligibility and risk of bias. The primary outcomes were changes in HIV viral load and CD4+ cell count, and secondary outcomes were anaemia, iron deficiency, adverse events, and mortality events. We compared the effects of deworming using mean differences, risk ratios (RR), and 95% confidence intervals (CIs). We assessed the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Eight trials met the inclusion criteria of this review, enrolling a total of 1612 participants. Three trials evaluated the effect of providing antihelminthics to all adults with HIV without knowledge of their helminth infection status, and five trials evaluated the effects of providing deworming drugs to HIV-positive individuals with confirmed helminth infections. Seven trials were conducted in sub-Saharan Africa and one in Thailand. Antihelminthics for people with unknown helminth infection statusProviding antihelminthics (albendazole and praziquantel together or separately) to HIV-positive adults with unknown helminth infection status may have a small suppressive effect on mean viral load at six weeks but the 95% CI includes the possibility of no effect (difference in mean change -0.14 log10 viral RNA/mL, 95% CI -0.35 to 0.07, P = 0.19; one trial, 166 participants, low quality evidence).Repeated dosing with deworming drugs over two years (albendazole every three months plus annual praziquantel), probably has little or no effect on mean viral load (difference in mean change 0.01 log10 viral RNA, 95% CI: -0.03 to -0.05; one trial, 917 participants, moderate quality evidence), and little or no effect on mean CD4+ count (difference in mean change 2.60 CD4+ cells/µL, 95% CI -10.15 to 15.35; P = 0.7; one trial, 917 participants, low quality evidence). Antihelminthics for people with confirmed helminth infectionsTreating confirmed helminth infections in HIV-positive adults may have a small suppressive effect on mean viral load at six to 12 weeks following deworming (difference in mean change -0.13 log10 viral RNA, 95% CI -0.26 to -0.00; P = 0.04; four trials, 445 participants, low quality evidence). However, this finding is strongly influenced by a single study of praziquantel treatment for schistosomiasis. There may also be a small favourable effect on mean CD4+ cell count at 12 weeks after deworming in HIV-positive populations with confirmed helminth infections (difference in mean change 37.86 CD4+ cells/µL, 95% CI 7.36 to 68.35; P = 0.01; three trials, 358 participants, low quality evidence). Adverse events and mortality There is no indication that antihelminthic drugs impart additional risks in HIV-positive populations. However, adverse events were not well reported (very low quality evidence) and trials were underpowered to evaluate effects on mortality (low quality evidence).

AUTHORS' CONCLUSIONS

There is low quality evidence that treating confirmed helminth infections in HIV-positive adults may have small, short-term favourable effects on markers of HIV disease progression. Further studies are required to confirm this finding. Current evidence suggests that deworming with antihelminthics is not harmful, and this is reassuring for the routine treatment of confirmed or suspected helminth infections in people living with HIV in co-endemic areas.Further long-term studies are required to make confident conclusions regarding the impact of presumptively deworming all HIV-positive individuals irrespective of helminth infection status, as the only long-term trial to date did not demonstrate an effect.

Determinants of Anemia Among Human Immunodeficiency Virus-Positive Adults at Care and Treatment Clinics in Dar es Salaam, Tanzania

Anemia is often a comorbidity of human immunodeficiency virus (HIV) infection. Many cross-sectional studies have been conducted on anemia and HIV, but few, if any, have addressed incidence of anemia prospectively. A longitudinal analysis was conducted in 48,068 nonpregnant HIV-infected adults in Dar es Salaam, Tanzania, seen at Management and Development for Health-U.S. President's Emergency Plan for AIDS Relief HIV care and treatment programs between 2004 and 2011. Almost 56% (N = 27,184) of study participants had anemia (hemoglobin < 11 g/dL) at the time of enrollment at the clinic. Female gender, low body mass index (BMI), low CD4 T-cell count, high levels of liver enzyme alanine aminotransferase, antiretroviral treatment (ART) regimens, and concurrent tuberculosis treatment were all independently significantly associated with an increased risk of anemia. Low BMI and low CD4 T-cell count were independently significantly associated with an increased risk for iron deficiency anemia (IDA). Higher BMI status and ART use were associated with recovery from anemia. Anemia, including IDA, is a comorbidity that is associated with other adverse consequences (e.g., low BMI and CD4 T-cell count) among individuals with HIV infection, including those on ART. Interventions to prevent anemia and its complications need to be examined in the context of future studies.

HIV infection in pregnancy: maternal and perinatal outcomes in a tertiary care hospital in Calabar, Nigeria

BACKGROUND

Human immunodeficiency virus (HIV) infection is likely to have untoward effects on pregnancy and its outcome. This study assessed the impact of maternal HIV infection on pregnancy outcomes in a tertiary centre in Calabar, Nigeria.

METHODS

This retrospective study analysed delivery records of 258 HIV-positive and 257 HIV-negative women for pregnancy and delivery complications. Maternal and fetal outcomes of HIV-positive pregnancies were compared with those of HIV-negative controls.

RESULTS

Adverse pregnancy outcomes significantly associated with HIV status were: anaemia: 33 (8.1%) vs. 8 (3.1%) in controls; puerperal sepsis: 18 (7%) vs. 2 (0.8%); and low birth weight: 56 (21.7%) vs. 37 (14.4%). Caesarean delivery was higher among HIV-positive women than controls: 96 (37.2%) vs. 58 (22.6%). Preterm births were higher in those HIV cohorts who did not receive antiretroviral therapy (ART): 13 (16.9%) vs. 7 (3.9%).

CONCLUSION

HIV-positive status increased adverse birth outcome of pregnancy. ART appeared to reduce the risk of preterm births in HIV-positive cohorts.

Antiretroviral Treatment Is Associated With Iron Deficiency in HIV-Infected Malawian Women That Is Mitigated With Supplementation, but Is Not Associated With Infant Iron Deficiency During 24 Weeks of Exclusive Breastfeeding

OBJECTIVE

In resource-limited settings without safe alternatives to breastfeeding, the WHO recommends exclusive breastfeeding and antiretroviral (ARV) prophylaxis. Given the high prevalence of anemia among HIV-infected women, mothers and their infants (through fetal iron accretion) may be at risk of iron deficiency. We assessed the effects of maternal micronutrient-fortified lipid-based nutrient supplements (LNS) and maternal ARV treatment or infant ARV prophylaxis on maternal and infant iron status during exclusive breastfeeding from birth to 24 weeks.

METHODS

The Breastfeeding, Antiretrovirals, and Nutrition study was a randomized controlled trial conducted in Lilongwe, Malawi, from 2004 to 2010. HIV-infected mothers (CD4 >200 cells/μL) and their infants were randomly assigned to 28-week interventions: maternal LNS/maternal ARV (n = 424), maternal LNS/infant ARV (n = 426), maternal LNS (n = 334), maternal ARV (n = 425), infant ARV (n = 426), or control (n = 334). Longitudinal models tested intervention effects on hemoglobin (Hb). In a subsample (n = 537) with multiple iron indicators, intervention effects on Hb, transferrin receptors (TfR), and ferritin were tested with linear and Poisson regression.

RESULTS

In longitudinal models, LNS effects on maternal and infant Hb were minimal. In subsample mothers, maternal ARVs were associated with tissue iron depletion (TfR >8.3 mg/L) (risk ratio: 3.1, P < 0.01), but not in ARV-treated mothers receiving LNS (P = 0.17). LNS without ARVs was not associated with iron deficiency or anemia (P > 0.1). In subsample infants, interventions were not associated with impaired iron status (all P > 0.1).

CONCLUSIONS

Maternal ARV treatment with protease inhibitors is associated with maternal tissue iron depletion; but LNS mitigates adverse effects. ARVs do not seem to influence infant iron status; however, extended use needs to be evaluated.

A Randomized Trial of Iron-Biofortified Pearl Millet in School Children in India

BACKGROUND

Iron deficiency is the most widespread nutritional deficiency in the world.

OBJECTIVE

The objective of this randomized efficacy trial was to determine the effects of iron-biofortified pearl millet (Fe-PM) on iron status compared with control pearl millet (Control-PM).

METHODS

A randomized trial of biofortified pearl millet (Pennisetum glaucum), bred to enhance iron content, was conducted in 246 children (12-16 y) for 6 mo in Maharashtra, India. Iron status [hemoglobin, serum ferritin (SF), soluble transferrin receptor (sTfR), and total body iron (TBI)], inflammation (C-reactive protein and α-1 acid glycoprotein), and anthropometric indices were evaluated at enrollment and after 4 and 6 mo. Hodges-Lehmann-Sen 95% CIs were used to examine the effect of the Fe-PM on iron status compared with commercially available Control-PM. Linear and binomial regression models were used to evaluate the effects of Fe-PM on iron status and incidence of anemia and iron deficiency, compared with Control-PM.

RESULTS

At baseline, 41% of children were iron deficient (SF <15 μg/L) and 28% were anemic (hemoglobin <12.0 g/dL). Fe-PM significantly increased SF concentrations and TBI after 4 mo compared with Control-PM. Among children who were iron deficient at baseline, those who received Fe-PM were 1.64 times more likely to become iron replete by 6 mo than were those receiving Control-PM (RR: 1.64, 95% CI: 1.07, 2.49, P = 0.02). The effects of Fe-PM on iron status were greater among children who were iron deficient at baseline than among children who were not iron deficient at baseline.

CONCLUSIONS

Fe-PM significantly improved iron status in children by 4 mo compared with Control-PM. This study demonstrated that feeding Fe-PM is an efficacious approach to improve iron status in school-age children and it should be further evaluated for effectiveness in a broader population context. This trial was registered at clinicaltrials.gov as NCT02152150.

Eliminating preventable HIV-related maternal mortality in sub-Saharan Africa: what do we need to know?

INTRODUCTION

HIV makes a significant contribution to maternal mortality, and women living in sub-Saharan Africa are most affected. International commitments to eliminate preventable maternal mortality and reduce HIV-related deaths among pregnant and postpartum women by 50% will not be achieved without a better understanding of the links between HIV and poor maternal health outcomes and improved health services for the care of women living with HIV (WLWH) during pregnancy, childbirth, and postpartum.

METHODS

This article summarizes priorities for research and evaluation identified through consultation with 30 international researchers and policymakers with experience in maternal health and HIV in sub-Saharan Africa and a review of the published literature.

RESULTS

Priorities for improving the evidence about effective interventions to reduce maternal mortality and improve maternal health among WLWH include better quality data about causes of maternal death among WLWH, enhanced and harmonized program monitoring, and research and evaluation that contributes to improving: (1) clinical management of pregnant and postpartum WLWH, including assessment of the impact of expanded antiretroviral therapy on maternal mortality and morbidity, (2) integrated service delivery models, and (3) interventions to create an enabling social environment for women to begin and remain in care.

CONCLUSIONS

As the global community evaluates progress and prepares for new maternal mortality and HIV targets, addressing the needs of WLWH must be a priority now and after 2015. Research and evaluation on maternal health and HIV can increase collaboration on these 2 global priorities, strengthen political constituencies and communities of practice, and accelerate progress toward achievement of goals in both areas.

Pregnancy and helminth infections

It has been proposed that helminth infection may be particularly detrimental during pregnancy, through adverse effects on maternal anaemia and on birth outcomes, and that anthelminthic treatment during pregnancy will therefore be particularly beneficial. However, the few treatment trials that have been conducted have given, but little support to this notion and further trials in settings of nutritional stress are needed. It has also been proposed that prenatal exposure to helminth infection has an important effect on the development of the foetal immune response. There is evidence that this may impact, long-term, upon responses to helminth and nonhelminth antigens, and to allergens. Exposure to helminths in utero may also have nonspecific effects that may modify the offspring's susceptibility to diseases mediated by inflammation, including metabolic disorders. The mechanisms of such effects are not known, but they deserve to be explored as current epidemiological findings suggest the possibility of primary prevention for inflammatory conditions such as allergy, through intervention during pregnancy.

Vitamin D Status Affects Serum Metabolomic Profiles in Pregnant Adolescents

Vitamin D is linked to a number of adverse pregnancy outcomes through largely unknown mechanisms. This study was conducted to examine the role of vitamin D status in metabolomic profiles in a group of 30 pregnant, African American adolescents (17.1 ± 1.1 years) at midgestation (26.8 ± 2.8 weeks), in 15 adolescents with 25-hydroxy vitamin D (25(OH)D) ≥20 ng/mL, and in 15 teens with 25(OH)D <20 ng/mL. Serum metabolomic profiles were examined using gas chromatography-mass spectrometry and liquid chromatography-tandem mass spectrometry. A novel hierarchical mixture model was used to evaluate differences in metabolite profiles between low and high groups. A total of 326 compounds were identified and included in subsequent statistical analyses. Eleven metabolites had significantly different means between the 2 vitamin D groups, after correcting for multiple hypothesis testing: pyridoxate, bilirubin, xylose, and cholate were higher, and leukotrienes, 1,2-propanediol, azelate, undecanedioate, sebacate, inflammation associated complement component 3 peptide (HWESASXX), and piperine were lower in serum from adolescents with 25(OH)D ≥20 ng/mL. Lower maternal vitamin D status at midgestation impacted serum metabolic profiles in pregnant adolescents.

Haemoglobin status and predictors of anaemia among pregnant women in Mpigi, Uganda

Background

Anaemia in pregnancy is a major public health problem especially in the low-income countries where it is highly prevalent. There has been no recent study in Uganda about the factors associated with anaemia in pregnancy. We aimed to assess the current haemoglobin (Hb) status and factors associated with anaemia (Hb < 11.0 g/dl) in pregnant women in Mpigi, Uganda.

Methods

We assessed Hb levels of 2436 pregnant women at 28+ weeks of gestation at six health facilities, who were approached to participate in a stepped-wedge cluster-randomised trial of antenatal distribution of misoprostol (for self-administration after home birth or when oxytocin is not available). Women were administered a questionnaire and their baseline blood haemoglobin was examined using portable HemoCueR Hb 301 system. Predictors of anaemia were estimated using linear and logistic regression analysis.

Results

The mean Hb was 11.5 (±1.38) g/dl and prevalence of anaemia (Hb < 11.0 g/dl) was 32.5% (95% CI 30.6%, 34.3%). After adjusting for measured confounders, factors associated with increased risk of anaemia in pregnancy were malaria infection (OR: 1.32, 95% CI: 1.11, 1.58), Human Immuno-deficiency Virus infection (OR: 2.13, 95% CI: 1.36, 2.90) and lack of iron supplementation (OR: 1.66, 95% CI: 1.36, 2.03). Intermittent presumptive treatment of malaria, maternal age and parity showed a weak association with anaemia in pregnancy

Conclusion

The high prevalence of anaemia in pregnancy in our setting highlights the need to put more effort in the fight against malaria and HIV, and also ensure that pregnant women access iron supplements early in pregnancy.

Hemoglobin concentration and parasitemia on hospital admission predict risk of multiple organ dysfunction syndrome among adults with malaria

Risk factors for progression from acute malaria to multiple organ dysfunction syndrome (MODS) are poorly understood. The MODS is commonly diagnosed with the sequential organ failure assessment (SOFA) scale, but this scale has been understudied in patients with severe malaria. We conducted a cohort study among 426 adult males admitted to hospital with malaria in Bogotá, Colombia. We estimated SOFA scores and relative risks (RRs) for MODS during hospitalization according to patients' characteristics on admission. Risk of MODS was 7.3% over a median 6.0 days in hospital. Baseline hemoglobin was strongly, inversely associated with MODS (adjusted RR for hemoglobin ≤ 8.5 g/dL versus hemoglobin > 11 g/dL = 9.5, 95% confidence interval [CI]: 3.6, 25.3). Plasmodium falciparum malaria and parasitemia were positively associated with MODS. There was a strong interaction between baseline parasitemia and hemoglobin on MODS risk. In conclusion, the use of parasitemia and hemoglobin on admission to identify high-risk patients deserves consideration.

Prevalence of malaria and anaemia among HIV infected pregnant women receiving co-trimoxazole prophylaxis in Tanzania: a cross sectional study in Kinondoni Municipality

Background

HIV-infected pregnant women are particularly more susceptible to the deleterious effects of malaria infection particularly anaemia. In order to prevent opportunistic infections and malaria, a policy of daily co-trimoxazole prophylaxis without the standard Suphadoxine-Pyrimethamine intermittent preventive treatment (SP-IPT) was introduced to all HIV infected pregnant women in the year 2011. However, there is limited information about the effectiveness of this policy.

Methods

This was a cross sectional study conducted among HIV-infected pregnant women receiving co-trimoxazole prophylaxis in eight public health facilities in Kinondoni Municipality from February to April 2013. Blood was tested for malaria infection and anaemia (haemoglobin <11 g/dl). Data were collected on the adherence to co-trimoxazole prophylaxis and other risk factors for malaria infection and anaemia. Pearson chi-square test, Fischer’s exact test and multivariate logistic regression were used in the statistical analysis.

Results

This study enrolled 420 HIV infected pregnant women. The prevalence of malaria infection was 4.5%, while that of anaemia was 54%. The proportion of subjects with poor adherence to co-trimoxazole was 50.5%. As compared to HIV infected pregnant women with good adherence to co-trimoxazole prophylaxis, the poor adherents were more likely to have a malaria infection (Adjusted Odds Ratio, AOR = 6.81, 95% CI = 1.35-34.43, P = 0.02) or anaemia (AOR = 1.75, 95% CI = 1.03-2.98, P = 0.039). Other risk factors associated with anaemia were advanced WHO clinical stages, current malaria infection and history of episodes of malaria illness during the index pregnancy.

Conclusion

The prevalence of malaria was low; however, a significant proportion of subjects had anaemia. Good adherence to co-trimoxazole prophylaxis was associated with reduction of both malaria infection and anaemia among HIV infected pregnant women.

The association between malaria and iron status or supplementation in pregnancy: a systematic review and meta-analysis

Introduction

Malaria prevention and iron supplementation are associated with improved maternal and infant outcomes. However, evidence from studies in children suggests iron may adversely modify the risk of malaria. We reviewed the evidence in pregnancy of the association between malaria and markers of iron status, iron supplementation or parenteral treatment.

Methods and Findings

We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Global Health Library, and the Malaria in Pregnancy library to identify studies that investigated the association between iron status, iron treatment or supplementation during pregnancy and malaria. Thirty one studies contributed to the analysis; 3 experimental and 28 observational studies. Iron supplementation was not associated with an increased risk of P. falciparum malaria during pregnancy or delivery in Africa (summary Relative Risk = 0.89, 95% Confidence Interval (CI) 0.66–1.20, I² = 78.8%, 5 studies). One study in Asia reported an increased risk of P. vivax within 30 days of iron supplementation (e.g. adjusted Hazard Ratio = 1.75, 95% CI 1.14–2.70 for 1–15 days), but not after 60 days. Iron deficiency (based on ferritin and C-reactive protein) was associated with lower odds for malaria infection (summary Odds Ratio = 0.35, 0.24–0.51, I² = 59.2%, 5 studies). With the exception of the acute phase protein ferritin, biomarkers of iron deficiency were generally not associated with malaria infection.

Conclusions

Iron supplementation was associated with a temporal increase in P vivax, but not with an increased risk of P. falciparum; however, data are insufficient to rule out the potential for an increased risk of P. falciparum. Iron deficiency was associated with a decreased malaria risk in pregnancy only when measured with ferritin. Until there is more evidence, it is prudent to provide iron in combination with malaria prevention during pregnancy.

Determinants of moderate-to-severe anaemia among women of reproductive age in Tanzania: analysis of data from the 2010 Tanzania Demographic and Health Survey

OBJECTIVE

To identify determinants of moderate-to-severe anaemia among women of reproductive age in Tanzania.

METHODS

We included participants from the 2010 Tanzania Demographic and Health Survey, which collected data on socio-demographic and maternal health and determined haemoglobin levels from blood samples. We performed logistic regression to calculate adjusted odds ratios for associations between socio-demographic, contextual, reproductive and lifestyle factors, and moderate-to-severe anaemia and investigated interactions between certain risk factors.

RESULTS

Of 9477 women, 20.1% were anaemic. Pregnancy was significantly associated with anaemia (adjusted OR 1.75, 95% CI 1.43-2.15), but the effect varied significantly by urban/rural residence, wealth and education. The effect of pregnancy was stronger in women without education and those who were in lower wealth groups, with significant interactions observed for each of these factors. Education was associated with a lower anaemia risk, particularly in the poorest group (OR 0.58, 95% CI 0.43-0.80), and in pregnant women. The risk of anaemia fell with rising iron supplementation coverage. Lack of toilet facilities increased anaemia risk (OR 1.26, 95% CI 1.00-1.60), whereas using hormonal contraception reduced it. There was no association with age, urban/rural residence, wealth or type of cooking fuel in adjusted analysis.

CONCLUSION

Pregnant women in Tanzania are particularly at risk of moderate-to-severe anaemia, with the effect modified by urban/rural residence, education and wealth. Prevention interventions should target women with lower education or without proper sanitation facilities, and women who are pregnant, particularly if they are uneducated or in lower wealth groups.

Exploring gender dimensions of treatment programmes for neglected tropical diseases in Uganda

Background

Gender remains a recognized but relatively unexamined aspect of the potential challenges for treatment programmes for Neglected Tropical Diseases (NTDs). We sought to explore the role of gender in access to treatment in the Uganda National Neglected Tropical Disease Control Programme.

Methodology/Principal Findings

Quantitative and qualitative data was collected in eight villages in Buyende and Kamuli districts, Eastern Uganda. Quantitative data on the number of persons treated by age and gender was identified from treatment registers in each village. Qualitative data was collected through semi-structured interviews with sub-county supervisors, participant observation and from focus group discussions with community leaders, community medicine distributors (CMDs), men, women who were pregnant or breastfeeding at the time of mass-treatment, and adolescent males and females. Findings include the following: (i) treatment registers are often incomplete making it difficult to obtain accurate estimates of the number of persons treated; (ii) males face more barriers to accessing treatment than women due to occupational roles which keep them away from households or villages for long periods, and males may be more distrustful of treatment; (iii) CMDs may be unaware of which medicines are safe for pregnant and breastfeeding women, resulting in women missing beneficial treatments.

Conclusions/Significance

Findings highlight the need to improve community-level training in drug distribution which should include gender-specific issues and guidelines for treating pregnant and breastfeeding women. Accurate age and sex disaggregated measures of the number of community members who swallow the medicines are also needed to ensure proper monitoring and evaluation of treatment programmes.

This study explored gender-related factors that may influence community member access and adherence to treatment programmes for NTDs in Uganda. A large number of previous studies have identified community-based mass-treatment programmes as an effective strategy to treat affected populations. However, limited evidence is available to discuss challenges to treatment access, adherence, delivery and monitoring at community level. Quantitative data from treatment registers suggested that men were less likely to access treatment than women in at least two villages. It also revealed difficulties in community-based monitoring of the programmes, creating challenges in ascertaining how many persons are able to access the programme. Qualitative data collected from district health workers, community leaders, community medicine distributors and community members suggested that socio-behavioural and structural barriers to treatment access may be present for both genders. Results of the study identify gender-based challenges to treatment access that should be considered in planning, implementing and evaluating national treatment programmes for NTDs.

Vitamin D and HIV infection: a review of the clinical evidence

The positive effects of vitamin D in different acute and chronic diseases (e.g., bone and renal disorders, acute and chronic respiratory tract infections, and diabetes mellitus), and regulation of immune system function have been shown. In this review vitamin D status and the effects of its supplementation alone or in combination with other bone-modifying substances like calcium and bisphosphonates on the different aspects of human health have been investigated in HIV+ individuals. Three scientific electronic databases have been investigated for extracting related articles. Searching only PubMed yielded 59 results with ‘HIV OR AIDS’ and ‘Vitamin D’ keywords. Because many of the studies in this field are observational or cross-sectional, designing comprehensive and eligible randomized clinical trials has been recommended by several authors in order to develop evidence-based clinical practice guidelines to determine the best regimen of vitamin D supplementation in HIV-infected patients.

Relevance of vitamin D in reproduction

The steroid hormone vitamin D is historically recognized for its relevance to bone health and calcium homeostasis. Recent years have witnessed a shift in focus to non-skeletal benefits of vitamin D; in this latter context, an accruing body of literature attests to a relevance of vitamin D to reproductive physiology. This article reviews the existing data about the diverse and previously underappreciated roles for vitamin D in reproductive health. A large body of available literature suggests that vitamin D deficiency may be detrimental to reproductive biology. However, given that our appreciation of vitamin D's role in reproductive physiology is almost entirely shaped by 'associative' studies and that data based on prospective interventional trials are limited, these concepts remain predominantly conjectural. Exact mechanisms whereby vitamin D may participate in the regulation of reproductive physiology remain far from clear. This review underscores a need for appropriately designed intervention trials to address the existing knowledge gaps and to delineate the specific roles of vitamin D signaling in reproductive biology.