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Miller AP, Shoptaw S, Mvududu R, Mashele N, Coates TJ, Bekker LG, Essack Z, Groenewald C, Petersen Z, Gorbach PM, Myer L, Joseph Davey DL. Sexual Risk among Pregnant Women at Risk of HIV Infection in Cape Town, South Africa: What Does Alcohol Have to Do with It? AIDS Behav 2023; 27:37-50. [PMID: 35737280 PMCID: PMC9780404 DOI: 10.1007/s10461-022-03742-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 01/24/2023]
Abstract
This study examines baseline associations between alcohol use and HIV sexual risk among a cohort of HIV-uninfected pregnant women (n = 1201) residing in a high HIV burdened community in Cape Town, South Africa. Alcohol use was measured using a modified version of the Alcohol Use Disorder Identification Test (AUDIT). HIV sexual risk was measured through a composite variable of four risk factors: diagnosis with a STI, self-report of > 1 recent sex partners, partner HIV serostatus (unknown or HIV+) and condomless sex at last sex. Any past year alcohol use prior to pregnancy was reported by half of participants (50%); 6.0% reported alcohol use during pregnancy. Alcohol use prior to pregnancy was associated with increased odds of being at high risk of HIV (aOR = 1.33, 95% CI 1.05-1.68, for 2 risks and aOR = 1.47, 95% CI 0.95-2.27 for 3 risks). In addition to reducing alcohol use, several other strategies to address HIV sexual risk were identified. Evidence-based interventions to address alcohol use and other HIV sexual risk behaviors during pregnancy in South Africa are desperately needed. Qualitative work exploring individual and community level drivers of alcohol use among pregnant and breastfeeding women in this setting could support development of a culturally tailored intervention to address these issues in this population.
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Affiliation(s)
- Amanda P Miller
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA.
- Department of Epidemiology, Fielding School of Public Health, 650 Charles E. Young Drive South, Room #41-295CHS, Los Angeles, CA, 90095-1772, USA.
| | - Steven Shoptaw
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Department of Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Rufaro Mvududu
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Nyiko Mashele
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Thomas J Coates
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, Faculty of Health Science, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Zaynab Essack
- Centre for Community-Based Research, Human Sciences Research Council, Pretoria, South Africa
| | - Candice Groenewald
- Centre for Community-Based Research, Human Sciences Research Council, Pretoria, South Africa
- Psychology Department, Rhodes University, Makhanda, South Africa
| | - Zaino Petersen
- Impact and Research Development, Human Sciences Research Council, Pretoria, South Africa
| | - Pamina M Gorbach
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Dvora L Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Observatory, Cape Town, South Africa
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- The Desmond Tutu HIV Centre, Faculty of Health Science, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Sexually transmitted infection screening to prevent adverse birth and newborn outcomes: study protocol for a randomized-controlled hybrid-effectiveness trial. Trials 2022; 23:441. [PMID: 35610666 PMCID: PMC9128231 DOI: 10.1186/s13063-022-06400-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 05/12/2022] [Indexed: 11/24/2022] Open
Abstract
Background Sexually transmitted infections (STIs) during pregnancy are associated with adverse birth outcomes, including preterm birth, low birth weight, perinatal death, and congenital infections such as increased mother-to-child HIV transmission. Prevalence of STIs among pregnant women in South Africa remains high, with most women being asymptomatic for their infection(s). Unfortunately, most STIs remain undetected and untreated due to standard practice syndromic management in accordance with World Health Organization (WHO) guidelines. Although lab-based and point-of-care molecular tests are available, optimal screening strategies during pregnancy, their health impact, and cost-effectiveness are unknown. Methods We will implement a 3-arm (1:1:1) type-1 hybrid effectiveness-implementation randomized-controlled trial (RCT). We will enroll 2500 pregnant women attending their first antenatal care (ANC) visit for their current pregnancy at participating health facilities in Buffalo City Metro District, Eastern Cape Province, South Africa. Participants allocated to arms 1 and 2 (intervention) will receive GeneXpert® point-of-care diagnostic testing for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis, with same-day treatment for detected infection(s). Arm 1 will additionally receive a test-of-cure 3 weeks post-treatment, while Arm 2 will receive a repeat test at 30–34 weeks’ gestation. Those allocated to Arm 3 will receive syndromic management (standard-of-care). The RE-AIM framework will be used to guide collection of implementation indicators to inform potential future scale up. Primary outcome measures include (1) frequency of adverse birth outcomes among study arms, defined by a composite measure of low birth weight and pre-term delivery, and (2) change in STI prevalence between baseline and birth outcome among intervention arms and compared to standard-of-care. Estimates and comparative costs of the different screening strategies relative to standard-of-care and the costs of managing adverse birth outcomes will be calculated. Cost-effectiveness will be assessed per STI and disability-adjusted life year averted. Discussion This trial is the first RCT designed to identify optimal, cost-effective screening strategies that decrease the burden of STIs during pregnancy and reduce adverse birth outcomes. Demonstrating the impact of diagnostic screening and treatment, compared to syndromic management, on birth outcomes will provide critical evidence to inform changes to WHO guidelines for syndromic management of STIs during pregnancy. Trial registration ClinicalTrials.gov NCT04446611. Registered on 25 June 2020.
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Medina-Marino A, Bezuidenhout D, Hosek S, Barnabas RV, Atujuna M, Bezuidenhout C, Ngwepe P, Peters RPH, Little F, Celum CL, Daniels J, Bekker LG. The Community PrEP Study: a randomized control trial leveraging community-based platforms to improve access and adherence to pre-exposure prophylaxis to prevent HIV among adolescent girls and young women in South Africa-study protocol. Trials 2021; 22:489. [PMID: 34311754 PMCID: PMC8314507 DOI: 10.1186/s13063-021-05402-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/26/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND HIV incidence among South African adolescent girls and young women (AGYW) remains high, but could be reduced by highly effective pre-exposure prophylaxis (PrEP). Unfortunately, AGYW report significant barriers to clinic-based sexual and reproductive health services. Even when AGYW access PrEP as an HIV prevention method, poor prevention-effective use was a serious barrier to achieving its optimal HIV prevention benefits. Determining the acceptability and feasibility of community-based platforms to increase AGYW's access to PrEP, and evaluating behavioural interventions to improve prevention-effective use of PrEP are needed. METHODS We propose a mixed-methods study among AGYW aged 16-25 years in Eastern Cape Province, South Africa. In the first component, a cross-sectional study will assess the acceptability and feasibility of leveraging community-based HIV counselling and testing (CBCT) platforms to refer HIV-negative, at-risk AGYW to non-clinic-based, same-day PrEP initiation services. In the second component, we will enrol 480 AGYW initiating PrEP via our CBCT platforms into a three-armed (1:1:1) randomized control trial (RCT) that will evaluate the effectiveness of adherence support interventions to improve the prevention-effective use of PrEP. Adherence will be measured over 24 months via tenofovir-diphosphate blood concentration levels. Qualitative investigations will explore participant, staff, and community experiences associated with community-based PrEP services, adherence support activities, study implementation, and community awareness. Costs and scalability of service platforms and interventions will be evaluated. DISCUSSION This will be the first study to assess the acceptability and feasibility of leveraging CBCT platforms to identify and refer at-risk AGYW to community-based, same-day PrEP initiation services. It will also provide quantitative and qualitative results to inform adherence support activities and services that promote the prevention-effective use of PrEP among AGYW. By applying principles of implementation science, behavioural science, and health economics research, we aim to inform strategies to improve access to and prevention-effective use of PrEP by AGYW. TRIAL REGISTRATION ClinicalTrials.gov NCT03977181 . Registered on 6 June 2019-retrospectively registered.
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Affiliation(s)
- Andrew Medina-Marino
- Research Unit, Foundation for Professional Development, 10 Rochester Rd, Vincent, East London, Buffalo City Metro, Eastern Cape Province, South Africa.
- The Desmond Tutu HIV Centre, University of Cape Town, Anzio Road, Observatory, Cape Town, South Africa.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Dana Bezuidenhout
- Research Unit, Foundation for Professional Development, 10 Rochester Rd, Vincent, East London, Buffalo City Metro, Eastern Cape Province, South Africa
| | - Sybil Hosek
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Stroger Hospital of Cook County, Chicago, IL, USA
| | - Ruanne V Barnabas
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Millicent Atujuna
- The Desmond Tutu HIV Centre, University of Cape Town, Anzio Road, Observatory, Cape Town, South Africa
| | - Charl Bezuidenhout
- Research Unit, Foundation for Professional Development, 10 Rochester Rd, Vincent, East London, Buffalo City Metro, Eastern Cape Province, South Africa
| | - Phuti Ngwepe
- Research Unit, Foundation for Professional Development, 10 Rochester Rd, Vincent, East London, Buffalo City Metro, Eastern Cape Province, South Africa
| | - Remco P H Peters
- Research Unit, Foundation for Professional Development, 10 Rochester Rd, Vincent, East London, Buffalo City Metro, Eastern Cape Province, South Africa
| | - Francesca Little
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Connie L Celum
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Joseph Daniels
- Department of Psychiatry and Human Behaviors, Charles R. Drew University of Medicine and Science, Los Angeles, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Anzio Road, Observatory, Cape Town, South Africa.
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Medina-Marino A, Glockner K, Grew E, De Vos L, Olivier D, Klausner J, Daniels J. The role of trust and health literacy in nurse-delivered point-of-care STI testing for pregnant women living with HIV, Tshwane District, South Africa. BMC Public Health 2020; 20:577. [PMID: 32345293 PMCID: PMC7189538 DOI: 10.1186/s12889-020-08689-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 04/13/2020] [Indexed: 01/28/2023] Open
Abstract
Background Sexually transmitted infections (STIs) during pregnancy result in neonatal morbidity and mortality, and may increase mother-to-child-transmission of HIV. Yet the World Health Organization’s current syndromic management guidelines for STIs leaves most pregnant women undiagnosed and untreated. Point-of-care (POC) diagnostic tests for STIs can drastically improve detection and treatment. Though acceptable and feasible, poor medication adherence and re-infection due to lack of partner treatment threaten the programmatic effectiveness of POC diagnostic programmes. Methods To engender patient-provider trust, and improve medication adherence and disclosure of STI status to sexual partners, we trained study nurses in compassionate care, good clinical practices and motivational interviewing. Using qualitative methods, we explored the role patient-provider communications may play in supporting treatment adherence and STI disclosure to sexual partners. Nurses were provided training in motivational interviewing, compassionate care and good clinical practices. Participants were interviewed using a semi-structured protocol, with domains including STI testing experience, patient-provider communication, and HIV and STI disclosure. Interviews were audio-recorded, transcribed and analyzed using a constant comparison approach. Results Twenty-eight participants treated for Chlamydia trachomatis (CT), Trichomonas vaginalis (TV), and/or Neisseria gonorrhea (NG) were interviewed. Participants described strong communications and trusting relationships with nurses trained in patient-centered care training and implementing POC STI diagnostic testing. However, women described a delayed trust in treatment until their symptoms resolved. Women expressed a limited recall of their exact diagnosis, which impacted their ability to fully disclose their STI status to sexual partners. Conclusions We recommend implementing patient health literacy programmes as part of POC services to support women in remembering and disclosing their specific STI diagnosis to sexual partners, which may facilitate partner treatment uptake and thus decrease the risk of re-infection.
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Affiliation(s)
- Andrew Medina-Marino
- Fundation for Professional Development, 10 Rochester Road, East London, 5217, South Africa. .,The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa.
| | - Katherine Glockner
- Fundation for Professional Development, 10 Rochester Road, East London, 5217, South Africa.,Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Emily Grew
- Northeastern University, Boston, MA, USA
| | - Lindsey De Vos
- Fundation for Professional Development, 10 Rochester Road, East London, 5217, South Africa
| | - Dawie Olivier
- Fundation for Professional Development, 10 Rochester Road, East London, 5217, South Africa
| | - Jeffrey Klausner
- David Geffen School of Medicine and Fielding School of Public Health, UCLA, Los Angeles, CA, USA
| | - Joseph Daniels
- Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
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Medina-Marino A, Mudau M, Kojima N, Peters RP, Feucht UD, Vos LD, Olivier D, Muzny CA, McIntyre JA, Klausner JD. Persistent Chlamydia trachomatis, Neisseria gonorrhoeae or Trichomonas vaginalis positivity after treatment among human immunodeficiency virus-infected pregnant women, South Africa. Int J STD AIDS 2020; 31:294-302. [PMID: 32089090 PMCID: PMC7174825 DOI: 10.1177/0956462419898612] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The objective of this study is to assess the predictors and frequency of persistent sexually transmitted infection (STI) positivity in human immunodeficiency virus (HIV)-infected pregnant women treated for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) or Trichomonas vaginalis (TV) infection. We enrolled HIV-infected pregnant women attending their first antenatal care visit and tested them for urogenital CT, NG and TV infection using Xpert® CT/NG and TV assays (Cepheid, Sunnyvale, CA). Those testing positive were treated. Participants either notified partners to seek treatment or were given extra medication to deliver to partners for treatment. Repeat testing was conducted approximately 21 days post-treatment or treatment initiation. Among 427 participants, 172 (40.3%) tested positive for any STI. Of the 136 (79.1%) that returned for repeat testing, 36 (26.5%) tested positive for the same organism: CT = 27 (26.5%), NG = 1 (6.3%), TV = 11 (16.7%). Persistent CT positivity was independently associated with having more than one sex partner in the preceding 12 months (adjusted-prevalence ratio [aPR] = 3.03, 95% CI: 1.44–6.37) and being newly diagnosed with HIV infection during the first antenatal care visit compared to those currently on antiretroviral therapy (aPR = 3.97, 95% CI: 1.09–14.43). Persistent TV positivity was associated with not knowing if a partner sought treatment following STI disclosure (aPR = 12.6, 95% CI: 2.16–73.5) and prior diagnosis of HIV but not currently on antiretroviral therapy. (aPR = 4.14; 95% CI: 1.25–13.79). We identified a high proportion of HIV-infected pregnant women with persistent CT or TV positivity after treatment. To decrease the risk of re-infection, enhanced strategies for partner treatment programmes are needed to improve the effectiveness of STI screening and treatment in pregnancy. The relationship between not being on antiretroviral therapy and persistent STI positivity needs further study.
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Affiliation(s)
- Andrew Medina-Marino
- Research Unit, Foundation for Professional Development, East London, South Africa.,The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Maanda Mudau
- Research Unit, Foundation for Professional Development, East London, South Africa
| | - Noah Kojima
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Remco Ph Peters
- Anova Health Institute, Johannesburg, South Africa.,Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,Department of Medical Microbiology, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ute D Feucht
- Department of Health, Tshwane District, Gauteng, South Africa.,Department of Pediatrics, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, South African Medical Research Council, Pretoria, South Africa
| | - Lindsey De Vos
- Research Unit, Foundation for Professional Development, East London, South Africa
| | - Dawie Olivier
- Research Unit, Foundation for Professional Development, East London, South Africa
| | - Christina A Muzny
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James A McIntyre
- Anova Health Institute, Johannesburg, South Africa.,School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Jeffrey D Klausner
- Department of Medicine, 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
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