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Hicks S, Odhiambo B, Abuna F, Dettinger JC, Ngumbau N, Gómez L, Sila J, Oketch G, Sifuna E, Weiner BJ, John-Stewart G, Kinuthia J, Wagner AD. Selecting implementation strategies to improve implementation of integrated PrEP for pregnant and postpartum populations in Kenya: a sequential explanatory mixed methods analysis. Implement Sci Commun 2023; 4:93. [PMID: 37580795 PMCID: PMC10424426 DOI: 10.1186/s43058-023-00481-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 07/29/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND There is a higher risk for HIV acquisition during pregnancy and postpartum. Pre-exposure prophylaxis (PrEP) is recommended during this period for those at high risk of infection; integrated delivery in maternal and child health (MCH) clinics is feasible and acceptable but requires implementation optimization. METHODS The PrEP in Pregnancy, Accelerating Reach and Efficiency study (PrEPARE; NCT04712994) engaged stakeholders to prioritize determinants of PrEP delivery (using Likert scores) and prioritize PrEP delivery implementation strategies. Using a sequential explanatory mixed methods design, we conducted quantitative surveys with healthcare workers at 55 facilities in Western Kenya and a stakeholder workshop (including nurses, pharmacists, counselors, and county and national policymakers), yielding visual plots of stakeholders' perceived feasibility and effectiveness of the strategies. A stepwise elimination process was used to identify seven strategies for empirical testing. Facilitator debriefing reports from the workshop were used to qualitatively assess the decision-making process. RESULTS Among 146 healthcare workers, the strongest reported barriers to PrEP delivery were insufficient providers and inadequate training, insufficient space, and high volume of patients. Sixteen strategies were assessed, 14 of which were included in the final analysis. Among rankings from 182 healthcare workers and 44 PrEP policymakers and implementers, seven strategies were eliminated based on low post-workshop ranking scores (bottom 50th percentile) or being perceived as low feasibility or low effectiveness for at least 50% of the workshop groups. The top seven strategies included delivering PrEP within MCH clinics instead of pharmacies, fast-tracking PrEP clients to reduce waiting time, delivering PrEP-related health talks in waiting bays, task shifting PrEP counseling, task shifting PrEP risk assessments, training different providers to deliver PrEP, and retraining providers on PrEP delivery. All top seven ranked strategies were grouped into bundles for subsequent testing. Facilitator debriefing reports generally aligned with rankings but noted how stakeholders' decision-making changed when considering the impact of strategies on facility staff and non-PrEP clients. CONCLUSIONS The most impactful barriers to integrated PrEP delivery in MCH clinics were insufficient staffing and space. Implementation strategies prioritized through multiple methods of stakeholder input focused on co-location of services and increasing clinic efficiency. Future testing of these stakeholder-prioritized strategy bundles will be conducted to assess the effectiveness and implementation outcomes.
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Affiliation(s)
- Sarah Hicks
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | | | | | - Julia C Dettinger
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Laurén Gómez
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | | | | | - Bryan J Weiner
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Grace John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Departments of Medicine, University of Washington, Seattle, WA, USA
- Departments of Pediatrics, University of Washington, Seattle, WA, USA
| | | | - Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, WA, USA
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Hicks S, Abuna F, Odhiambo B, Dettinger JC, Ngumbau N, Gómez L, Sila J, Oketch G, Sifuna E, Weiner BJ, John-Stewart GC, Kinuthia J, Wagner AD. Comparison of methods to engage diverse stakeholder populations in prioritizing PrEP implementation strategies for testing in resource-limited settings: a cross-sectional study. Implement Sci Commun 2023; 4:76. [PMID: 37438779 PMCID: PMC10337117 DOI: 10.1186/s43058-023-00457-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 06/17/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND There is a lack of consensus about how to prioritize potential implementation strategies for HIV pre-exposure prophylaxis (PrEP) delivery. We compared several prioritization methods for their agreement and pragmatism in practice in a resource-limited setting. METHODS We engaged diverse stakeholders with clinical PrEP delivery and PrEP decision-making experience across 55 facilities in Kenya to prioritize 16 PrEP delivery strategies. We compared four strategy prioritization methods: (1) "past experience surveys" with experienced practitioners reflecting on implementation experience (N = 182); (2 and 3) "pre- and post-small-group ranking" surveys before and after group discussion (N = 44 and 40); (4) "go-zone" quadrant plots of perceived effectiveness vs feasibility. Kendall's correlation analysis was used to compare strategy prioritization using the four methods. Additionally, participants were requested to group strategies into three bundles with up to four strategies/bundle by phone and online survey. RESULTS The strategy ranking correlation was strongest between the pre- and post-small-group rankings (Tau: 0.648; p < 0.001). There was moderate correlation between go-zone plots and post-small-group rankings (Tau: 0.363; p = 0.079) and between past-experience surveys and post-small-group rankings (Tau: 0.385; p = 0.062). For strategy bundling, participants primarily chose bundles of strategies in the order in which they were listed, reflecting option ordering bias. Neither the phone nor online approach was effective in selecting strategy bundles. Participants agreed that the strategy ranking activities conducted during the workshop were useful in prioritizing a final set of strategies. CONCLUSIONS Both experienced and inexperienced stakeholder participants' strategy rankings tended to prioritize strategies perceived as feasible. Small group discussions focused on feasibility and effectiveness revealed moderately different priorities than individual rankings. The strategy bundling approach, though less time- and resource-intensive, was not effective. Future research should further compare the relative effectiveness and pragmatism of methodologies to prioritize implementation strategies.
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Affiliation(s)
- Sarah Hicks
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
- Department of Medicine, University of Washington, Seattle, WA, USA.
| | | | | | - Julia C Dettinger
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Laurén Gómez
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | | | | | - Bryan J Weiner
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Grace C John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Departments of Pediatrics, University of Washington, Seattle, WA, USA
| | | | - Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, WA, USA
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Hicks S, Abuna F, Odhiambo B, Dettinger JC, Sila J, Oketch G, Sifuna E, Ngumbau N, Gómez L, John-Stewart GC, Kinuthia J, Wagner AD. Integrating PrEP in maternal and child health clinics in Kenya: analysis of a service availability and readiness assessment (SARA) survey. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1206150. [PMID: 37484872 PMCID: PMC10359145 DOI: 10.3389/frph.2023.1206150] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/12/2023] [Indexed: 07/25/2023] Open
Abstract
Background Risk of HIV acquisition is high during pregnancy and postpartum, and pre-exposure prophylaxis (PrEP) is recommended for peripartum populations. Integrating PrEP into maternal and child health (MCH) clinics is feasible and acceptable. Understanding clinics' service availability and readiness is essential for effective scale up. Methods The PrEP in Pregnancy, Accelerating Reach and Efficiency study (PrEPARE; NCT04712994) engaged PrEP-experienced facilities previously linked to a programmatic or research study in Western Kenya to document available services and commodities via a modified service availability and readiness assessment (SARA) survey with 20 PrEP tracer items covering: staffing/guidelines, services/equipment, and medicines/commodities. Facilities' prior study engagement occurred between 2017 and 2019; SARA survey data was collected between April 2020 and June 2021. Descriptive statistics were stratified by prior study engagement. ANOVA tests assessed associations between facility characteristics and gaps. Fisher's tests assessed differences in commodity availability and stockouts. Results Of the 55 facilities surveyed, 60% had received PrEP training in the last two years, 95% offered PrEP integrated into MCH, and 64% and 78% had both auditory and visual privacy in PrEP and HIV testing service (HTS) delivery spaces, respectively. Supervision frequency was heterogeneous, but 82% had received a supervision visit within 3 months. Availability of commodities was variable and the most commonly unavailable commodities were PrEP in MCH (71% available) and risk assessment screening tool (RAST) and PrEP cards (60% and 75% available, respectively). The number of service and commodity gaps per facility ranged from zero to eight (median: 3; IQR: 2, 5). The most frequent gaps were: PrEP training and risk assessment cards (40% each), lack of privacy in PrEP (36%) and HIV testing services (31%) spaces, PrEP pills in MCH (29%), and PrEP cards (25%). There were no differences in mean number of gaps by county, previous study engagement, or public vs. private status. Level 4 facilities had fewer gaps (mean 2.2) than level 2, 3, and 5 facilities (mean 5.7, 4.5, and 5.3 respectively; p < 0.001). Conclusions PrEP service availability and readiness was generally high across MCH facilities. However, there is a need for increased frequency of provider training and supportive supervision focused on fidelity. To address key commodity stockouts such as PrEP pills, implementation of electronic logistics management information systems may be needed. Targeting these gaps is essential to effectively scale up integrated PrEP delivery, especially among facilities with limited infrastructure.
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Affiliation(s)
- Sarah Hicks
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Felix Abuna
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Ben Odhiambo
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Julia C Dettinger
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Joseph Sila
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - George Oketch
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Enock Sifuna
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Nancy Ngumbau
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Laurén Gómez
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Grace C John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
- Departments of Medicine, University of Washington, Seattle, WA, United States
- Departments of Pediatrics, University of Washington, Seattle WA, United States
| | - John Kinuthia
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, WA, United States
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Baltrusaitis K, Makanani B, Tierney C, Fowler MG, Moodley D, Theron G, Nyakudya LH, Tomu M, Fairlie L, George K, Heckman B, Knowles K, Browning R, Siberry GK, Taha TE, Stranix-Chibanda L. Maternal and infant renal safety following tenofovir disoproxil fumarate exposure during pregnancy in a randomized control trial. BMC Infect Dis 2022; 22:634. [PMID: 35858874 PMCID: PMC9297643 DOI: 10.1186/s12879-022-07608-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 06/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tenofovir disoproxil fumarate (TDF) in combination with other antiretroviral (ARV) drugs has been in clinical use for HIV treatment since its approval in 2001. Although the effectiveness of TDF in preventing perinatal HIV infection is well established, information about renal safety during pregnancy is still limited. TRIAL DESIGN The IMPAACT PROMISE study was an open-label, strategy trial that randomized pregnant women to one of three arms: TDF based antiretroviral therapy (ART), zidovudine (ZDV) based ART, and ZDV alone (standard of care at start of enrollment). The P1084s substudy was a nested, comparative study of renal outcomes in women and their infants. METHODS PROMISE participants (n = 3543) were assessed for renal dysfunction using calculated creatinine clearance (CrCl) at study entry (> 14 weeks gestation), delivery, and postpartum weeks 6, 26, and 74. Of these women, 479 were enrolled in the P1084s substudy that also assessed maternal calcium and phosphate as well as infant calculated CrCl, calcium, and phosphate at birth. RESULTS Among the 1338 women who could be randomized to TDF, less than 1% had a baseline calculated CrCl below 80 mL/min. The mean (standard deviation) maternal calculated CrCl at delivery in the TDF-ART arm [147.0 mL/min (51.4)] was lower than the ZDV-ART [155.0 mL/min (43.3); primary comparison] and the ZDV Alone [158.5 mL/min (45.0)] arms; the mean differences (95% confidence interval) were - 8.0 mL/min (- 14.5, - 1.5) and - 11.5 mL/min (- 18.0, - 4.9), respectively. The TDF-ART arm had lower mean maternal phosphate at delivery compared with the ZDV-ART [- 0.14 mg/dL (- 0.28, - 0.01)] and the ZDV Alone [- 0.17 mg/dL (- 0.31, - 0.02)] arms, and a greater percentage of maternal hypophosphatemia at delivery (4.23%) compared with the ZDV-ART (1.38%) and the ZDV Alone (1.46%) arms. Maternal calcium was similar between arms. In infants, mean calculated CrCl, calcium, and phosphate at birth were similar between arms (all CIs included 0). CONCLUSIONS Although mean maternal calculated CrCl at Delivery was lower in the TDF-ART arm, the difference between arms is unlikely to be clinically significant. During pregnancy, the TDF-ART regimen had no observed safety concerns for maternal or infant renal function. TRIAL REGISTRATION NCT01061151 on 10/02/2010 for PROMISE (1077BF). NCT01066858 on 10/02/2010 for P1084s.
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Affiliation(s)
- Kristin Baltrusaitis
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, 651 Huntington Avenue, Boston, MA, 02115, USA.
| | - Bonus Makanani
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Camlin Tierney
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, 651 Huntington Avenue, Boston, MA, 02115, USA
| | - Mary Glenn Fowler
- Department of Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - Dhayendre Moodley
- Centre for AIDS Prevention Research in South Africa and Department of Obstetrics and Gynecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Gerhard Theron
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Lynette H Nyakudya
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Musunga Tomu
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Lee Fairlie
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Renee Browning
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - George K Siberry
- United States Agency for International Development, Washington, DC, USA
| | - Taha E Taha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lynda Stranix-Chibanda
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe.,Child and Adolescent Health Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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Scott RK, Hull SJ, Richards RC, Klemmer K, Salmoran F, Huang JC. Awareness, acceptability, and intention to initiate HIV pre-exposure prophylaxis among pregnant women. AIDS Care 2022; 34:201-213. [PMID: 33874801 PMCID: PMC8523573 DOI: 10.1080/09540121.2021.1916870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
HIV prevention is critically important during pregnancy, however, pre-exposure prophylaxis (PrEP) is underutilized. We conducted a survey of pregnant and non-pregnant women in a high HIV prevalence community in Washington D.C. to evaluate determinants of PrEP initiation during pregnancy. 201 pregnant women and a reference population of 1103 non-pregnant women completed the survey. Among pregnant women, mean age was 26.9 years; the majority were Black with household-incomes below the federal poverty level. Despite low perceived risk of HIV acquisition and low prior awareness of PrEP, 10.5% of respondents planned to initiate PrEP during pregnancy. Pregnant women identified safety, efficacy, and social network and medical provider support as key factors in PrEP uptake intention. The belief that PrEP will "protect (their) baby from HIV" was associated with PrEP uptake intention during pregnancy. Concerns regarding maternal/fetal side effects, and safety in pregnancy or while breastfeeding were not identified as deterrents to uptake intention. When compared to a nonpregnant sample, there were no significant differences in uptake intention between the two samples. These findings support the need for prenatal educational interventions to promote HIV prevention during pregnancy, as well as interventions that center on the role of providers in the provision of PrEP.
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Affiliation(s)
- Rachel K. Scott
- Women’s Health Research, MedStar Health Research Institute (MHRI), Washington, DC, USA,Women’s & Infants’ Services, MedStar Washington Hospital Center (MWHC), Washington, DC, USA,Obstetrics & Gynecology, Georgetown University School of Medicine (GUSOM), Washington, DC, USA
| | - Shawnika J. Hull
- School of Communication & Information, Rutgers University, New Brunswick, NJ, USA
| | - Robin C. Richards
- Women’s & Infants’ Services, MedStar Washington Hospital Center (MWHC), Washington, DC, USA
| | - Kristen Klemmer
- Obstetrics & Gynecology, Georgetown University School of Medicine (GUSOM), Washington, DC, USA
| | - Frida Salmoran
- Women’s Health Research, MedStar Health Research Institute (MHRI), Washington, DC, USA
| | - Jim C. Huang
- Women’s Health Research, MedStar Health Research Institute (MHRI), Washington, DC, USA,Department of Business Management, National Sun Yat-sen University, Kaohsiung, Taiwan
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Lee YS, Lee HS, Kim JH, Chang SW, Hyun MH, Bak H, Kim S, Lee MJ, Lee CU, Jung YK, Seo YS, Yim HJ, Yeon JE, Um SH, Byun KS. Role of tenofovir disoproxil fumarate in prevention of perinatal transmission of hepatitis B virus from mother to child: a systematic review and meta-analysis. Korean J Intern Med 2021; 36:76-85. [PMID: 31878771 PMCID: PMC7820648 DOI: 10.3904/kjim.2018.465] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/23/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS To prevent the perinatal transmission of hepatitis B virus (HBV) from mother to child, administration of an antiviral agent during pregnancy has been attempted in women who are either hepatitis B e antigen positive or have a high viral load. In this systematic review and meta-analysis with randomized controlled trials, we analyzed the efficacy and safety of tenofovir disoproxil fumarate (TDF) in preventing the perinatal transmission of HBV in pregnant women who have high HBV DNA titers. METHODS Multiple comprehensive databases (PubMed, EMBASE, and Cochrane databases) were searched for studies evaluating the efficacy of TDF for the prevention of perinatal transmission of HBV. RESULTS Two studies (one open label study and one double blind study) were included and analyzed. Intention-to-treat analysis (527 pregnancies) showed that the preventive effect of TDF was not significant (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.13 to 2.17; p = 0.38, I2 = 81%). However, the per-protocol analysis showed that TDF significantly reduced perinatal transmission (OR, 0.10; 95% CI, 0.01 to 0.77; p = 0.03, I2 = 0%). There was no significant difference between the TDF group and the control group with respect to maternal and fetal safety outcomes. CONCLUSION In pregnant women who have high HBV DNA titers, TDF can reduce the perinatal transmission from mother to child without significant adverse events.
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Affiliation(s)
- Young-Sun Lee
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Ha Seok Lee
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Ji Hoon Kim
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
- Correspondence to Ji Hoon Kim, M.D. Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea Tel: +82-2-2626-1038 Fax: +82-2-2626-3011 E-mail:
| | - Sung Won Chang
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Myung Han Hyun
- Divisions of Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Haein Bak
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Sehwa Kim
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Min-jin Lee
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Chan Uk Lee
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Young Kul Jung
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Yeon Seok Seo
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Hyung Joon Yim
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Jong Eun Yeon
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Soon Ho Um
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Kwan Soo Byun
- Divisions of Gastroenterology and Hepatology Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
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Onono M, Odwar T, Wahome S, Helova A, Bukusi EA, Hampanda K, Turan J, Abuogi L. Behavioral Interventions can Mitigate Adverse Pregnancy Outcomes Among Women Conceiving on ART and Those Initiated on ART During Pregnancy: Findings From the MOTIVATE Trial in Southwestern Kenya. J Acquir Immune Defic Syndr 2021; 86:46-55. [PMID: 33306563 PMCID: PMC7851482 DOI: 10.1097/qai.0000000000002521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Antiretroviral therapy (ART) is essential for the elimination of mother-to-child transmission and improved health outcomes for women living with HIV (WLWH). However, adverse pregnancy outcomes (APOs) among pregnant women on ART are a growing concern. METHODS We investigated the associations between timing of ART initiation and APOs among pregnant WLWH receiving behavioral interventions (community mentor mothers and text messaging) in the Mother-Infant Visit Adherence and Treatment Engagement (MOTIVATE) study in southwestern Kenya. Log binomial models were used for estimation of relative risks (RRs) (adjusted for the clustered nature of data) evaluating APOs with 3 exposure comparisons: (1) preconception ART initiation vs. postconception initiation; (2) among postconception ART initiating women, comparisons across gestational ages at cART initiation (first versus second and third trimester exposure), and (3) intervention allocation. RESULTS Of the 1275 women included in this analysis, 388 (30%) had an APO: 306 preterm births, 38 low birth weight infants, 33 stillbirths, and 11 miscarriages. In multivariable analysis, viral load ≥1000 copies/mL, moderate and severe anemia at baseline increased risk of APOs. Among women initiating ART before and after conception, no difference was observed in the composite APO. Women who received community mentor mother visits alone (aRR 0.74: 95% CI: 0.71 to 0.76) or text messages alone (aRR 0.79: 95% CI: 0.70 to 0.89) had lower risks of experiencing any APOs. CONCLUSIONS Receiving supportive behavioral interventions may mitigate the risk of experiencing an APO among WLWH on ART. Further studies are needed to investigate the underlying mechanisms and optimize the benefits of these interventions.
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Affiliation(s)
- Maricianah Onono
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Tobias Odwar
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Samuel Wahome
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Anna Helova
- Department of Health Care Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, United States
| | | | - Karen Hampanda
- Department of Community and Behavioral Health, School of Public Health, University of Colorado Denver, Aurora, United States
| | - Janet Turan
- Department of Health Care Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, United States
| | - Lisa Abuogi
- Department of Pediatrics, University of Colorado Denver, Aurora, United States
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Menon S, Benova L, Mabeya H. Epilepsy management in pregnant HIV+ women in sub-Saharan Africa, clinical aspects to consider: a scoping review. BMC Med 2020; 18:341. [PMID: 33198766 PMCID: PMC7670685 DOI: 10.1186/s12916-020-01799-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/25/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Since the introduction of highly active antiretroviral therapy (HAART), acquired immune deficiency syndrome (AIDS) related mortality has markedly declined. As HAART is becoming increasingly available, the infection with human immunodeficiency virus (HIV+) in sub-Saharan Africa (SSA) is becoming a chronic condition. While pregnancy in HIV+ women in SSA has always been considered a challenging event for the mother and the fetus, for pregnant HIV+ women also diagnosed with epilepsy (WWE), there are additional risks as HIV increases the odds of developing seizures due to the vulnerability of the central nervous system to other infections, immune dysfunction, and overall metabolic disturbances. In light of a growing proportion of HIV+ WWE on HAART and an increasing number of pregnant women accessing mother-to-child transmission of HIV programs through provision of HAART in SSA, there is a need to develop contextualized and evidenced-based clinical strategies for the management of epilepsy in this population. In this study, we conduct a literature scoping review to identify issues that warrant consideration for clinical management. RESULT Twenty-three articles were retained after screening, which covered six overarching clinical aspects: status epilepticus (SE), Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), dyslipidemia, congenital malformation (CM), chronic kidney disease (CKD), and neurological development. No studies for our population of interest were identified, highlighting the need for a cautionary approach to be employed when extrapolating findings. CONCLUSION High risks of CM and drug interactions with first-line antiepileptic drugs (AEDs) warrant measures to increase the accessibility and choices of safer second-line AEDs. To ensure evidence-based management of epilepsy within this population, the potential high prevalence of SE, CKD, dyslipidemia, and SJS/TEN and the cumulative effect of drug-drug interactions should be considered. Further understanding of the intersections between pregnancy and drug-drug interactions in SSA is needed to ensure evidenced-based management of epilepsy in pregnant HIV+ WWE. To prevent SE, the barriers for AED treatment adherence in pregnant HIV+ women should be explored. Our review underscores the need to conduct cohort studies of HIV+ WWE in reproductive age over time and across pregnancies to capture the cumulative effect of HAART and AED to inform clinical management.
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Affiliation(s)
- Sonia Menon
- Instiute of Tropical Medicine Antwerp, Antwerp, Belgium.
| | - Lenka Benova
- Instiute of Tropical Medicine Antwerp, Antwerp, Belgium
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Abstract
Advances in the management of human immunodeficiency virus infection during pregnancy have led to improved maternal health and significant declines in rates of mother-to-child transmission of human immunodeficiency virus. A critical contributor to this success has been the development of better tolerated, safer, and more convenient antiretroviral medication regimens. Today, 12 fixed-dose, single-tablet combination antiretroviral regimens are available in the United States. These regimens are commonly used in nonpregnant individuals. However, because of altered pharmacokinetics of many drugs during pregnancy and concerns regarding short- and long-term fetal safety, few of these regimens are appropriate for routine use in pregnancy.
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Akoto C, Chan CYS, Tshivuila-Matala COO, Ravi K, Zhang W, Vatish M, Norris SA, Hemelaar J. Innate lymphoid cells are reduced in pregnant HIV positive women and are associated with preterm birth. Sci Rep 2020; 10:13265. [PMID: 32764636 PMCID: PMC7413261 DOI: 10.1038/s41598-020-69966-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 07/21/2020] [Indexed: 01/13/2023] Open
Abstract
Preterm birth is the leading cause of neonatal and child mortality worldwide. Globally, 1.4 million pregnant women are estimated to be living with HIV/AIDS, the majority of whom live in sub-Saharan Africa. Maternal HIV infection and antiretroviral treatment (ART) have been associated with increased rates of preterm birth, but the underlying mechanisms remain unknown. Acute HIV infection is associated with a rapid depletion of all three subsets of innate lymphoid cells (ILCs), ILC1s, ILC2s and ILC3s, which is not reversed by ART. ILCs have been found at the maternal-fetal interface and we therefore investigated the potential association between maternal HIV infection, peripheral ILC frequencies and preterm birth. In our study of pregnant South African women with accurately dated pregnancies, we show that maternal HIV infection is associated with reduced levels of all three ILC subsets. Preterm birth was also associated with lower levels of all three ILC subsets in early pregnancy. ILC frequencies were lowest in HIV positive women who experienced preterm birth. Moreover, ILC levels were reduced in pregnancies resulting in spontaneous onset of preterm labour and in extreme preterm birth (< 28 weeks gestation). Our findings suggest that reduced ILC frequencies may be a link between maternal HIV infection and preterm birth. In addition, ILC frequencies in early pregnancy may serve as predictive biomarkers for women who are at risk of delivering preterm.
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Affiliation(s)
- Charlene Akoto
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Christina Y S Chan
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Chrystelle O O Tshivuila-Matala
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK.,South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Krithi Ravi
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Wei Zhang
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Manu Vatish
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Shane A Norris
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK.,South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Joris Hemelaar
- Nuffield Department of Women's & Reproductive Health, University of Oxford, The Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK. .,South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.
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11
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Chi BH, Mbori‐Ngacha D, Essajee S, Mofenson LM, Tsiouris F, Mahy M, Luo C. Accelerating progress towards the elimination of mother-to-child transmission of HIV: a narrative review. J Int AIDS Soc 2020; 23:e25571. [PMID: 32820609 PMCID: PMC7440973 DOI: 10.1002/jia2.25571] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/28/2020] [Accepted: 06/08/2020] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Findings from biomedical, behavioural and implementation studies provide a rich foundation to guide programmatic efforts for the prevention of mother-to-child HIV transmission (PMTCT). METHODS We summarized the current evidence base to support policy makers, programme managers, funding agencies and other stakeholders in designing and optimizing PMTCT programmes. We searched the scientific literature for PMTCT interventions in the era of universal antiretroviral therapy for pregnant and breastfeeding women (i.e. 2013 onward). Where evidence was sparse, relevant studies from the general HIV treatment literature or from prior eras of PMTCT programme implementation were also considered. Studies were organized into six categories: HIV prevention services for women, timely access to HIV testing, timely access to ART, programme retention and adherence support, timely engagement in antenatal care and services for infants at highest risk of HIV acquisition. These were mapped to specific missed opportunities identified by the UNAIDS Spectrum model and embedded in UNICEF operational guidance to optimize PMTCT services. RESULTS AND DISCUSSION From May to November 2019, we identified numerous promising, evidence-based strategies that, properly tailored and adopted, could contribute to population reductions in vertical HIV transmission. These spanned the HIV and maternal and child health literature, emphasizing the importance of continued alignment and integration of services. We observed overlap between several intervention domains, suggesting potential for synergies and increased downstream impact. Common themes included integration of facility-based healthcare; decentralization of health services from facilities to communities; and engagement of partners, peers and lay workers for social support. Approaches to ensure early HIV diagnosis and treatment prior to pregnancy would strengthen care across the maternal lifespan and should be promoted in the context of PMTCT. CONCLUSIONS A wide range of effective strategies exist to improve PMTCT access, uptake and retention. Programmes should carefully consider, prioritize and plan those that are most appropriate for the local setting and best address existing gaps in PMTCT health services.
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Affiliation(s)
- Benjamin H Chi
- University of North Carolina at Chapel HillChapel HillNCUSA
| | | | | | | | | | - Mary Mahy
- Joint United Nations Programme on HIV/AIDS (UNAIDS)GenevaSwitzerland
| | - Chewe Luo
- United Nations Children’s Fund (UNICEF)New YorkNYUSA
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12
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Akoto C, Chan CYS, Ravi K, Zhang W, Vatish M, Norris SA, Hemelaar J. γδ T cell frequencies are altered in HIV positive pregnant South African women and are associated with preterm birth. PLoS One 2020; 15:e0235162. [PMID: 32584913 PMCID: PMC7316337 DOI: 10.1371/journal.pone.0235162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 06/10/2020] [Indexed: 12/24/2022] Open
Abstract
Background Preterm birth is the leading cause of neonatal and child mortality worldwide. Maternal HIV infection and antiretroviral treatment (ART) increase the rate of preterm birth, but the underlying mechanisms remain unknown, limiting progress in prediction, prevention and treatment. While overall γδ T cell levels remain constant, acute HIV infection is associated with a depletion of the Vδ2 subset and an increase in the Vδ1 subset, which do not return to baseline with ART. γδ T cells have also been implicated in adverse pregnancy outcomes and we therefore investigated the potential association between maternal HIV infection, peripheral γδ T cell frequencies and preterm birth. Methods Study participants were HIV positive (n = 47) and HIV negative (n = 45) women enrolled in a prospective pregnancy cohort study at Chris Hani Baragwanath Academic Hospital in Soweto, South Africa. Women were enrolled in early pregnancy and gestational age was accurately determined by first trimester ultrasound scan. Peripheral blood samples were collected in each trimester and peripheral blood mononuclear cells isolated. Frequencies of γδ T cells, Vδ1+ and Vδ2+ γδ T cell subsets, and CCR6 chemokine receptor expression were determined by flow cytometry. Results Total γδ T cell levels were similar between HIV positive and HIV negative women throughout pregnancy. However, in each trimester maternal HIV infection was associated with reduced levels of the Vδ2+ subset and increased levels of the Vδ1+ subset, leading to a reversal of the Vδ1/Vδ2 ratio. Timing of ART initiation among HIV positive women did not affect levels of γδ T cells, the Vδ1+ and Vδ2+ subsets, or the Vδ1/Vδ2 ratio. Importantly, preterm birth was associated with lower total γδ T cell levels in early pregnancy and γδ T cell frequencies were lowest in HIV positive women who delivered preterm. Moreover, in the first trimester the proportion of Vδ1+ T cells that were CCR6+ was significantly reduced in HIV+ women and women who delivered preterm, resulting in the lowest proportion of CCR6+ Vδ1 T cells in HIV positive women who delivered preterm. Conclusions Our findings suggest that altered γδ T cell frequencies may link maternal HIV infection and preterm birth. γδ T cell frequencies in early pregnancy may serve as predictive biomarkers to identify women at risk of delivering preterm.
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Affiliation(s)
- Charlene Akoto
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Christina Y. S. Chan
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Krithi Ravi
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Wei Zhang
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Manu Vatish
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Shane A. Norris
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
- Department of Paediatrics, South African Medical Research Council Developmental Pathways for Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Joris Hemelaar
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, The Women’s Centre, John Radcliffe Hospital, Oxford, United Kingdom
- Department of Paediatrics, South African Medical Research Council Developmental Pathways for Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
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13
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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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14
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Chauhan N, Desai M, Shah S, Shah A, Gadhavi R. Treatment outcome of different antiretroviral drug regimens in HIV-positive pregnant women. Perspect Clin Res 2020; 12:40-47. [PMID: 33816208 PMCID: PMC8011516 DOI: 10.4103/picr.picr_74_19] [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: 05/17/2019] [Revised: 09/13/2019] [Accepted: 09/16/2019] [Indexed: 11/17/2022] Open
Abstract
Objective: The objective of the study was to compare the maternal and fetal outcomes of currently preferred tenofovir-based regimen with previous zidovudine-based regimen and also to determine whether the time of starting antiretroviral therapy (ART), whether it can affect the pregnancy and fetal outcome. Materials and Methods: Pregnant patients prescribed any of the above regimens were followed up every month till delivery and newborns for initial 6 months. Maternal endpoints were body weight, hemoglobin, and CD4 count, whereas fetal endpoints were birth weight, Apgar score, body weight, and HIV status at 6 months. Data were analyzed using ANOVA and unpaired t-test. P <0.05 was considered statistically significant. Results: A significant increase in CD4 count was observed in patients treated with both the regimens at 12 months as compared to baseline (P < 0.001 and 0.05). Moreover, a significant increase in CD4 count was observed at 12 months as compared to baseline, whether treatment was started before or after the diagnosis of pregnancy (P < 0.05 and 0.001). A significant difference in mean body weight at the end of 9 months was observed in patients wherein ART was started before or after the diagnosis of pregnancy (P < 0.005). Majority of patients had a favorable maternal outcome, while fetal birth weight, Apgar score, body weight, and HIV status were comparable at 6 months irrespective of treatment and time of starting ART. Conclusion: All ART regimens are equally effective in terms of increase in CD4 count, gestational gain in body weight, and pregnancy and fetal outcome. Furthermore, there is no significant difference in efficacy, pregnancy, and fetal outcome in women who were already on ART when diagnosed pregnancy or who were started ART later in antenatal period.
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Affiliation(s)
- Nidhi Chauhan
- Department of Pharmacology, B. J. Medical College, Ahmedabad, India
| | - Mira Desai
- Department of Pharmacology, Nootan Medical College, Visnagar, Gujarat, India
| | - Samidh Shah
- Department of Pharmacology, B. J. Medical College, Ahmedabad, India
| | - Asha Shah
- Department of Medicine, GCS Medical College, Ahmedabad, India
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15
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Eke AC, Brooks KM, Gebreyohannes RD, Sheffield JS, Dooley KE, Mirochnick M. Tenofovir alafenamide use in pregnant and lactating women living with HIV. Expert Opin Drug Metab Toxicol 2020; 16:333-342. [PMID: 32125906 PMCID: PMC9214649 DOI: 10.1080/17425255.2020.1738384] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/02/2020] [Indexed: 12/23/2022]
Abstract
Introduction: Tenofovir alafenamide (TAF)-containing fixed-dose drug combinations (FDCs) are increasingly being used in managing pregnant women living with HIV. However, TAF is not currently recommended during pregnancy due to limited pharmacokinetic and safety data. TAF, a newer nucleotide phosphonamidate prodrug of tenofovir (TFV), achieves high levels of tenofovir-diphosphate in lymphoid cells and hepatocytes, and 90% lower systemic concentrations of TFV compared to tenofovir disoproxil fumarate (TDF), thereby maximizing TAF's antiviral efficacy, potency and clinical safety.Areas covered: This review discusses the currently available information on the pharmacology of TAF in pregnant women living with HIV. Pharmacokinetic studies with TAF during pregnancy have yielded varying results compared to postpartum, but TAF exposures during pregnancy have been within the range of those typically observed in non-pregnant adults. The efficacy and safety of TAF in treatment-naïve pregnant women living with HIV is currently being evaluated in the VESTED study, a phase-III NIH randomized clinical trial.Expert opinion: Initial pregnancy data suggest that TAF-based FDCs have high efficacy and low risk of adverse effects during pregnancy. TAF is likely to become part of first-line regimens for use in pregnant women living with HIV once additional pregnancy data from phase III trials are available.
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Affiliation(s)
- Ahizechukwu C. Eke
- Division of Maternal Fetal Medicine & Clinical Pharmacology, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Doctoral Training Program (Phd), Graduate Training Program in Clinical Investigation (GTPCI), Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | - Kristina M. Brooks
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Rahel D. Gebreyohannes
- Department of Obstetrics & Gynecology, Addis Ababa University College of Health Science, Addis Ababa, Ethiopia
| | - Jeanne S. Sheffield
- Division of Maternal Fetal Medicine & Clinical Pharmacology, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly E. Dooley
- Division of Clinical Pharmacology & Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mark Mirochnick
- Division of Neonatology, Department of Pediatrics, Boston University School of Medicine, Boston, MA, USA
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16
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Zimba C, Maman S, Rosenberg NE, Mutale W, Mweemba O, Dunda W, Phanga T, Chibwe KF, Matenga T, Freeborn K, Schrubbe L, Vwalika B, Chi BH. The landscape for HIV pre-exposure prophylaxis during pregnancy and breastfeeding in Malawi and Zambia: A qualitative study. PLoS One 2019; 14:e0223487. [PMID: 31584987 PMCID: PMC6777778 DOI: 10.1371/journal.pone.0223487] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/23/2019] [Indexed: 01/16/2023] Open
Abstract
High HIV incidence rates have been observed among pregnant and breastfeeding women in sub-Saharan Africa. Oral pre-exposure prophylaxis (PrEP) can effectively reduce HIV acquisition in women during these periods; however, understanding of its acceptability and feasibility in antenatal and postpartum populations remains limited. To address this gap, we conducted in-depth interviews with 90 study participants in Malawi and Zambia: 39 HIV-negative pregnant/breastfeeding women, 14 male partners, 19 healthcare workers, and 18 policymakers. Inductive and deductive approaches were used to identify themes related to PrEP. As a public health intervention, PrEP was not well-known among patients and healthcare workers; however, when it was described to participants, most expressed positive views. Concerns about safety and adherence were raised, highlighting two critical areas for community outreach. The feasibility of introducing PrEP into antenatal services was also a concern, especially if introduced within already strained health systems. Support for PrEP varied among policymakers in Malawi and Zambia, reflecting the ongoing policy discussions in their respective countries. Implementing PrEP during the pregnancy and breastfeeding periods will require addressing barriers at the individual, facility, and policy levels. Multi- level approaches should be considered in the design of new PrEP programs for antenatal and postpartum populations.
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Affiliation(s)
- Chifundo Zimba
- UNC Project-Malawi, Tidziwe Center, Lilongwe, Malawi
- * E-mail:
| | - Suzanne Maman
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Nora E. Rosenberg
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Wilbroad Mutale
- Department of Health Policy, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Oliver Mweemba
- Department of Health Promotion and Education, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Wezzie Dunda
- UNC Project-Malawi, Tidziwe Center, Lilongwe, Malawi
| | | | - Kasapo F. Chibwe
- Department of Health Promotion and Education, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Tulani Matenga
- Department of Health Promotion and Education, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Kellie Freeborn
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Leah Schrubbe
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Bellington Vwalika
- Department of Obstetrics and Gynecology, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Benjamin H. Chi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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17
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Mofenson LM. Risk of HIV Acquisition During Pregnancy and Postpartum: A Call for Action. J Infect Dis 2019; 218:1-4. [PMID: 29506075 DOI: 10.1093/infdis/jiy118] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 02/27/2018] [Indexed: 01/22/2023] Open
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18
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Dettinger JC, Kinuthia J, Pintye J, Abuna F, Begnel E, Mugwanya K, Sila J, Lagat H, Baeten JM, John‐Stewart G. Perinatal outcomes following maternal pre-exposure prophylaxis (PrEP) use during pregnancy: results from a large PrEP implementation program in Kenya. J Int AIDS Soc 2019; 22:e25378. [PMID: 31498563 PMCID: PMC6733245 DOI: 10.1002/jia2.25378] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 07/31/2019] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION The World Health Organization, while recommending pre-exposure prophylaxis (PrEP) for HIV-negative pregnant and postpartum women in HIV high-burden settings, advocates for continued safety evaluation of PrEP in this population. METHODS The PrEP Implementation in Young Women and Adolescents (PrIYA) program delivered PrEP to pregnant and postpartum women integrated within routine maternal and child health clinics (MCH) at 16 sites in Western Kenya. PrEP exposure and perinatal outcome data were collected among women obtaining postnatal services during programme evaluation. PrEP use was self-reported and confirmed with clinical records. Perinatal outcomes including gestational age at birth, birthweight, congenital malformations and infant growth outcomes were abstracted from clinical records for mother-infant pairs attending the six week visit. Associations between infant outcomes and maternal prenatal PrEP use were assessed using univariate and multivariate logistic and linear regression. RESULTS The PrIYA evaluation identified 1530 postpartum mother-infant pairs with data on prenatal PrEP exposure: 206 with prenatal PrEP use, 1324 without. Median maternal age was 24 years in both groups. PrEP users (any reported PrEP use) were significantly more likely to report HIV risk factors such as: intimate partner violence, sexually transmitted infections and having a partner with positive or unknown HIV status. Most mothers initiated PrEP during the second trimester (n = 116, 57%) and used PrEP for more than one month (n = 110, 58%). The mean birthweight was 3.3 kg and gestational age at birth was 38.5 weeks in both groups. There were no major differences between PrEP exposed and unexposed infants in rates of preterm birth and low birthweight. There were no congenital malformations identified in the PrEP-exposed group and five reported in the PrEP unexposed group. At six weeks postpartum, infants in both groups had similar growth. No differences in infant outcomes were found by duration PrEP exposure, trimester of PrEP initiation, a subset analysis of women 15 to 24 years old or in multivariate analyses. This analysis demonstrates that monitoring of infant outcomes is feasible within large-scale programmatic implementation of PrEP among pregnant and postpartum populations. CONCLUSIONS Pregnancy outcomes and early infant growth did not differ by PrEP exposure.
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Affiliation(s)
| | - John Kinuthia
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of Obstetrics/GynecologyKenyatta National HospitalNairobiKenya
| | - Jillian Pintye
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Felix Abuna
- University of Washington – KenyaNairobiKenya
| | - Emily Begnel
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | | | - Joseph Sila
- University of Washington – KenyaNairobiKenya
| | | | - Jared M Baeten
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
| | - Grace John‐Stewart
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
- Department of PediatricsUniversity of WashingtonSeattleWAUSA
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19
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Selph SS, Bougatsos C, Dana T, Grusing S, Chou R. Screening for HIV Infection in Pregnant Women: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2019; 321:2349-2360. [PMID: 31184704 DOI: 10.1001/jama.2019.2593] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Prenatal screening for HIV can inform use of interventions to reduce the risk of mother-to-child transmission. The US Preventive Services Task Force (USPSTF) previously found strong evidence that prenatal HIV screening reduced risk of mother-to-child transmission. The previous evidence review was conducted in 2012. OBJECTIVE To update the 2012 review on prenatal HIV screening to inform the USPSTF. DATA SOURCES Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews from 2012 to June 2018, with surveillance through January 2019. STUDY SELECTION Pregnant persons 13 years and older; randomized clinical trials and cohort studies of screening vs no screening; risk of mother-to-child transmission or maternal or infant harms associated with antiretroviral therapy (ART) during pregnancy; screening yield at different intervals or in different risk groups. DATA EXTRACTION AND SYNTHESIS One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. MAIN OUTCOMES AND MEASURES Mother-to-child transmission; harms of screening and treatment; screening yield. RESULTS Sixty-two studies were included in this review, including 29 new studies. There remains no direct evidence on effects of prenatal screening vs no screening on risk of mother-to-child HIV transmission, maternal or infant clinical outcomes, or the yield of repeat or alternative screening strategies. New evidence confirms that combination ART is highly effective at reducing the risk of mother-to-child transmission, with some new cohort studies reporting rates of mother-to-child transmission less than 1% when combination ART was started early in pregnancy (when begun in first trimester, 0%-0.4%; when begun after first trimester, or at any time if timing of ART initiation not reported, 0.4%-2.8%). New evidence on harms of ART was also largely consistent with the previous review. Evidence from primarily observational studies found prenatal combination ART with a boosted protease inhibitor associated with increased risk of preterm delivery (range, 14.4%-26.1%). For other birth outcomes (low birth weight, small for gestational age, stillbirth, birth defects, neonatal death), results were mixed and depended on the specific antiretroviral drug or drug regimen given and timing of prenatal therapy. CONCLUSIONS AND RELEVANCE Combination ART was highly effective at reducing risk of mother-to-child HIV transmission. Use of certain ART regimens during pregnancy was associated with increased risk of harms that may be mitigated by selection of ART regimen. The 2012 review found that avoidance of breastfeeding and cesarean delivery in women with viremia also reduced risk of transmission and that prenatal screening accurately diagnosed HIV infection.
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Affiliation(s)
- Shelley S Selph
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Department of Family Medicine, Oregon Health & Science University, Portland
| | - Christina Bougatsos
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Tracy Dana
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Sara Grusing
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Roger Chou
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
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Yap PK, Loo Xin GL, Tan YY, Chellian J, Gupta G, Liew YK, Collet T, Dua K, Chellappan DK. Antiretroviral agents in pre-exposure prophylaxis: emerging and advanced trends in HIV prevention. ACTA ACUST UNITED AC 2019; 71:1339-1352. [PMID: 31144296 DOI: 10.1111/jphp.13107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 05/05/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Antiretroviral agents (ARVs) have been the most promising line of therapy in the management of human immunodeficiency virus (HIV) infections. Some of these ARVs are used in the pre-exposure prophylaxis (PrEP) to suppress the transmission of HIV. Prophylaxis is primarily used in uninfected people, before exposure, to effectively prevent HIV infection. Several studies have shown that ART PrEP prevents HIV acquisition from sexual, blood and mother-to-child transmissions. However, there are also several challenges and limitations to PrEP. This review focuses on the current antiretroviral therapies used in PrEP. KEY FINDINGS Among ARVs, the most common drugs employed from the class of entry inhibitors are maraviroc (MVC), which is a CCR5 receptor antagonist. Other entry inhibitors like emtricitabine (FTC) and tenofovir (TFV) are also used. Rilpivirine (RPV) and dapivirine (DPV) are the most common drugs employed from the Non-nucleoside reverse transcriptase inhibitor (NNRTIs) class, whereas, tenofovir disoproxil fumarate (TDF) is primarily used in the Nucleoside Reverse Transcriptase Inhibitor (NRTIs) class. Cabotegravir (CAB) is an analog of dolutegravir, and it is an integrase inhibitor. Some of these drugs are also used in combination with other drugs from the same class. SUMMARY Some of the most common pre-exposure prophylactic strategies employed currently are the use of inhibitors, namely entry inhibitors, non-nucleoside reverse transcriptase inhibitors, nucleoside reverse transcriptase inhibitors, integrase and protease inhibitors. In addition, we have also discussed on the adverse effects caused by ART in PrEP, pharmacoeconomics factors and the use of antiretroviral prophylaxis in serodiscordant couples.
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Affiliation(s)
- Pui Khee Yap
- School of Health Sciences, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Griselda Lim Loo Xin
- School of Health Sciences, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Yoke Ying Tan
- School of Health Sciences, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Jestin Chellian
- Department of Life Sciences, School of Pharmacy, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Gaurav Gupta
- School of Pharmacy, Suresh Gyan Vihar University, Jaipur, India
| | - Yun Khoon Liew
- Department of Life Sciences, School of Pharmacy, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Trudi Collet
- Innovative Medicines Group, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Qld, Australia
| | - Kamal Dua
- Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney (UTS), Ultimo, NSW, Australia.,Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute (HMRI) & School of Biomedical Sciences and Pharmacy, The University of Newcastle (UoN), Callaghan, NSW, Australia
| | - Dinesh Kumar Chellappan
- Department of Life Sciences, School of Pharmacy, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
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Li J, Peng L, Gilmour S, Gu J, Ruan Y, Zou H, Hao C, Hao Y, Lau JTF. A mathematical model of biomedical interventions for HIV prevention among men who have sex with men in China. BMC Infect Dis 2018; 18:600. [PMID: 30486800 PMCID: PMC6263536 DOI: 10.1186/s12879-018-3516-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/15/2018] [Indexed: 12/03/2022] Open
Abstract
Background The new HIV treatment guidelines in China recommend antiretroviral therapy (ART) for all people living with HIV, but significant gaps in implementation still exist. Pre-exposure prophylaxis (PrEP) can effectively reduce the risk of HIV transmission among men who have sex with men (MSM). This study assessed the epidemiological impact and cost effectiveness of PrEP, enhanced biomedical interventions and their combination among MSM in China. Methods A deterministic mathematical model was developed and projected over 20 years to assess the impact of the PrEP, biomedical interventions and their combinations. Incidence and prevalence of HIV were measured, and cost-effectiveness was assessed using incremental cost (international dollars, Int.$) per quality-adjusted life year (QALY) gained. Results A total of 0.78 million new HIV infections were estimated to occur over the next 20 years if no additional interventions are implemented among MSM. The PrEP-only strategy covering 25–75% of HIV-negative high-risk MSM can prevent 0.09–0.20 million (12.1–25.7%) new infections, at a cost of 17,277–18,452 Int.$/QALY. The optimal cost-effectiveness path is from test-and-treat to the combination strategy of test-and-treat and PrEP. Some strategies could almost eliminate new HIV infections over the next 20 years. Conclusions PrEP, test-and-treat, and their combinations among MSM are effective and cost-effective relative to current policy. PrEP is an important and cost-effective addition to current policy in China. Electronic supplementary material The online version of this article (10.1186/s12879-018-3516-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jinghua Li
- Department of Health Policy and Management & Sun Yat-sen Global Health Institute, School of Public Health and Institute of State Governance, Sun Yat-sen University, Guangzhou, China
| | - Liping Peng
- Department of Health Policy and Management, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Stuart Gilmour
- Graduate School of Public Health, St. Luke's International University, Tokyo, Japan.
| | - Jing Gu
- Department of Medical Statistics and Epidemiology & Sun Yat-sen Global Health Institute, School of Public Health and Institute of State Governance, Sun Yat-sen University, Guangzhou, China
| | - Yuhua Ruan
- Division of Virology and Immunology, National Center for AIDS/STD Control and Prevention (NCAIDS), Chinese Center for Disease Control and Prevention, Beijing, China
| | - Huachun Zou
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China.,Kirby Institute, University of New South Wales, Sydney, Australia
| | - Chun Hao
- Department of Medical Statistics and Epidemiology & Sun Yat-sen Global Health Institute, School of Public Health and Institute of State Governance, Sun Yat-sen University, Guangzhou, China
| | - Yuantao Hao
- Department of Medical Statistics and Epidemiology & Sun Yat-sen Global Health Institute, School of Public Health and Institute of State Governance, Sun Yat-sen University, Guangzhou, China
| | - Joseph Tak-Fai Lau
- The School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
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