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Hurwitz KE, Isehunwa OO, Hendrickson KR, Jaggernath M, Kriel Y, Smith PM, Mathenjwa M, Bennett K, Psaros C, Baeten JM, Bangsberg DR, Haberer JE, Smit JA, Matthews LT. Adherence to daily, oral TDF/FTC PrEP during periconception among HIV-exposed South African women. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1263422. [PMID: 37860779 PMCID: PMC10582627 DOI: 10.3389/frph.2023.1263422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/12/2023] [Indexed: 10/21/2023] Open
Abstract
Background Daily, oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) as pre-exposure prophylaxis (PrEP) reduces HIV acquisition for African women. Adherence is key to efficacy and patterns of adherence can be highly variable in real-world settings. Using group-based trajectory modeling (GBTM), we sought to identify distinct patterns of periconception PrEP adherence and evaluate potential baseline predictors of such adherence trajectories. Methods We conducted a single-arm longitudinal study for women aged 18-35 years living in Durban, South Africa with personal or partner plans for pregnancy with a partner with HIV or of unknown serostatus. Participants were offered safer conception counseling, including daily oral PrEP; women who initiated PrEP were given a bottle with an electronic pillcap that recorded when device opens. Weekly adherence to daily PrEP was modeled using GBTM with a censored normal outcome distribution as a function of weeks since PrEP initiation. The number and functional form of the adherence trajectory groups were primarily selected based on Bayesian information criteria (BIC) and confirmed by mean estimated probabilities of group membership. A multivariable version of the selected model assessed baseline predictors of membership in adherence trajectory groups. Results Overall mean (95% CI) adherence to PrEP was 63% (60%, 67%). We identified four groups of women with distinct patterns of adherence: (1) high (i.e., ≥6 doses per week) steady adherence throughout follow-up (22% of PrEP initiators); (2) moderate (i.e., 4-5 doses per week), but steady adherence (31%); (3) initially high, but consistently declining adherence (21%); and (4) initially moderate adherence, followed by a rapid decline and subsequent rebound (26%). In multivariable-adjusted analyses, older age was associated with membership in the high, steady adherence group as compared to the group identified with an adherence trajectory of initially high, then decline, and finally a rebound. Conclusions GBTM is useful for exploring potential heterogeneity in longitudinal patterns of medication adherence. Although a large proportion of women in this study achieved high levels of adherence by electronic pillcap initially, far fewer women maintained these levels consistently. Knowledge of different adherence trajectories could be used to develop targeted strategies for optimizing HIV prevention during periconception.
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Affiliation(s)
- Kathleen E. Hurwitz
- Department of Epidemiology and Statistics, Target RWE, Durham, NC, United States
| | - Oluwaseyi O. Isehunwa
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kayla R. Hendrickson
- Department of Epidemiology and Statistics, Target RWE, Durham, NC, United States
| | - Manjeetha Jaggernath
- MRU (Maternal, Adolescent and Child Health Research Unit), University of the Witwatersrand, Durban, South Africa
| | - Yolandie Kriel
- MRU (Maternal, Adolescent and Child Health Research Unit), University of the Witwatersrand, Durban, South Africa
| | - Patricia M. Smith
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Mxolisi Mathenjwa
- Department of Epidemiology and Prevention, Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Kara Bennett
- Department of Epidemiology and Statistics, Target RWE, Durham, NC, United States
| | - Christina Psaros
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Jared M. Baeten
- Department of Medicine, University of Washington, Seattle, WA, United States
| | | | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Jennifer A. Smit
- MRU (Maternal, Adolescent and Child Health Research Unit), University of the Witwatersrand, Durban, South Africa
| | - Lynn T. Matthews
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
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Matthews LT, Atukunda EC, Owembabazi M, Kalyebera KP, Psaros C, Chitneni P, Hendrix CW, Marzinke MA, Anderson PL, Isehunwa OO, Hurwitz KE, Bennett K, Muyindike W, Bangsberg DR, Haberer JE, Marrazzo JM, Bwana MB. High PrEP uptake and objective longitudinal adherence among HIV-exposed women with personal or partner plans for pregnancy in rural Uganda: A cohort study. PLoS Med 2023; 20:e1004088. [PMID: 36795763 PMCID: PMC9983833 DOI: 10.1371/journal.pmed.1004088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 03/03/2023] [Accepted: 01/23/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND In Uganda, fertility rates and adult HIV prevalence are high, and many women conceive with partners living with HIV. Pre-exposure prophylaxis (PrEP) reduces HIV acquisition for women and, therefore, infants. We developed the Healthy Families-PrEP intervention to support PrEP use as part of HIV prevention during periconception and pregnancy periods. We conducted a longitudinal cohort study to evaluate oral PrEP use among women participating in the intervention. METHODS AND FINDINGS We enrolled HIV-negative women with plans for pregnancy with a partner living, or thought to be living, with HIV (2017 to 2020) to evaluate PrEP use among women participating in the Healthy Families-PrEP intervention. Quarterly study visits through 9 months included HIV and pregnancy testing and HIV prevention counseling. PrEP was provided in electronic pillboxes, providing the primary adherence measure ("high" adherence when pillbox was opened ≥80% of days). Enrollment questionnaires assessed factors associated with PrEP use. Plasma tenofovir (TFV) and intraerythrocytic TFV-diphosphate (TFV-DP) concentrations were determined quarterly for women who acquired HIV and a randomly selected subset of those who did not; concentrations TFV ≥40 ng/mL and TFV-DP ≥600 fmol/punch were categorized as "high." Women who became pregnant were initially exited from the cohort by design; from March 2019, women with incident pregnancy remained in the study with quarterly follow-up until pregnancy outcome. Primary outcomes included (1) PrEP uptake (proportion who initiated PrEP); and (2) PrEP adherence (proportion of days with pillbox openings during the first 3 months following PrEP initiation). We used univariable and multivariable-adjusted linear regression to evaluate baseline predictors selected based on our conceptual framework of mean adherence over 3 months. We also assessed mean monthly adherence over 9 months of follow-up and during pregnancy. We enrolled 131 women with mean age 28.7 years (95% CI: 27.8 to 29.5). Ninety-seven (74%) reported a partner with HIV and 79 (60%) reported condomless sex. Most women (N = 118; 90%) initiated PrEP. Mean electronic adherence during the 3 months following initiation was 87% (95% CI: 83%, 90%). No covariates were associated with 3-month pill-taking behavior. Concentrations of plasma TFV and TFV-DP were high among 66% and 47%, 56% and 41%, and 45% and 45% at months 3, 6, and 9, respectively. We observed 53 pregnancies among 131 women (1-year cumulative incidence 53% [95% CI: 43%, 62%]) and 1 HIV-seroconversion in a non-pregnant woman. Mean pillcap adherence for PrEP users with pregnancy follow-up (N = 17) was 98% (95% CI: 97%, 99%). Study design limitations include lack of a control group. CONCLUSIONS Women in Uganda with PrEP indications and planning for pregnancy chose to use PrEP. By electronic pillcap, most were able to sustain high adherence to daily oral PrEP prior to and during pregnancy. Differences in adherence measures highlight challenges with adherence assessment; serial measures of TFV-DP in whole blood suggest 41% to 47% of women took sufficient periconception PrEP to prevent HIV. These data suggest that women planning for and with pregnancy should be prioritized for PrEP implementation, particularly in settings with high fertility rates and generalized HIV epidemics. Future iterations of this work should compare the outcomes to current standard of care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03832530 https://clinicaltrials.gov/ct2/show/NCT03832530?term=lynn+matthews&cond=hiv&cntry=UG&draw=2&rank=1.
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Affiliation(s)
- Lynn T. Matthews
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- * E-mail:
| | | | | | - Kato Paul Kalyebera
- Mbarara University of Science and Technology, Mbarara, Uganda
- Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Christina Psaros
- Behavioral Medicine Program, Department of Psychiatry, Massachusetts General Hospital, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Pooja Chitneni
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Diseases and General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Craig W. Hendrix
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Mark A. Marzinke
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Peter L. Anderson
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, United States of America
| | - Oluwaseyi O. Isehunwa
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Kathleen E. Hurwitz
- NoviSci, Inc., a Target RWE company, Durham, North Carolina, United States of America
| | - Kara Bennett
- Bennett Statistical Consulting Inc., Ballston Lake, New York, United States of America
| | - Winnie Muyindike
- Mbarara University of Science and Technology, Mbarara, Uganda
- Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - David R. Bangsberg
- School of Public Health, Oregon Health Sciences University–Portland State University, Portland, Oregon, United States of America
| | - Jessica E. Haberer
- Harvard Medical School, Boston, Massachusetts, United States of America
- Center for Global Health, Massachusetts General Hospital, Boston, Boston, Massachusetts, United States of America
| | - Jeanne M. Marrazzo
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
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Wyatt MA, Pisarski EE, Kriel Y, Smith PM, Mathenjwa M, Jaggernath M, Smit JA, Matthews LT, Ware NC. Influences on PrEP Uptake and Adherence Among South African Women During Periconception and Pregnancy: A Qualitative Analysis. AIDS Behav 2023; 27:208-217. [PMID: 35771311 PMCID: PMC9245881 DOI: 10.1007/s10461-022-03757-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2022] [Indexed: 01/24/2023]
Abstract
Pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, yet PrEP delivery to women in periconception and pregnancy has lagged. We report qualitative research from a study evaluating PrEP use as part of safer conception care for 330 South African women. Fifty-two semi-structured interviews were conducted with 25 study participants to identify influences on PrEP adherence. Influences were: (1) changing proximity to male partners; (2) COVID-19 lockdown; (3) mobile lifestyle; (4) PrEP-related stigma; (5) disclosure of PrEP use; and (6) pregnancy and motherhood. Data also revealed important contextual information shaping adherence influences for women, including: (a) not living with partners, (b) partners as drivers of pregnancy intention, and (c) feeling at high risk for HIV. Disclosure of PrEP use, addressing stigma, strategies for traveling with pills, and counseling on prevention effective adherence are promising components of PrEP-inclusive HIV prevention interventions for South African women who are pregnant or planning pregnancy.
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Affiliation(s)
- Monique A. Wyatt
- Department of Global Health & Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, USA ,Harvard Global, Cambridge, MA USA
| | - Emily E. Pisarski
- Department of Global Health & Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, USA
| | - Yolandie Kriel
- Maternal Adolescent and Child Health Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, KZN South Africa
| | - Patricia M. Smith
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL USA
| | - Mxolisi Mathenjwa
- Maternal Adolescent and Child Health Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, KZN South Africa
| | - Manjeetha Jaggernath
- Maternal Adolescent and Child Health Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, KZN South Africa
| | - Jennifer A. Smit
- Maternal Adolescent and Child Health Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, KZN South Africa
| | - Lynn T. Matthews
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL USA
| | - Norma C. Ware
- Department of Global Health & Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, USA ,Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
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Chitneni P, Muyindike W, Bwana MB, Owembabazi M, O'Neil K, Kalyebara PK, Hedt-Gauthier B, Bangsberg DR, Marrazzo JM, Kaida A, Haberer JE, Matthews LT. STI prevalence, incidence, and partner notification among women in a periconception HIV prevention program in Uganda. Int J STD AIDS 2022; 33:856-863. [PMID: 35775125 DOI: 10.1177/09564624221110992] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND We provided sexually transmitted infection (STI) screening and facilitated partner notification and treatment among women participating in a periconception HIV prevention program in southwestern Uganda to understand follow-up STI incidence. METHODS Women at-risk for HIV exposure while planning for pregnancy completed laboratory screening for chlamydia, gonorrhea, trichomoniasis, and syphilis at enrollment and 6 months of follow-up and/or incident pregnancy; facilitated partner notification and treatment were offered for those with positive tests. We performed a logistic regression to determine correlates of follow-up STI. RESULTS Ninety-four participants completed enrollment STI screening with a median age of 29 (IQR 26-34); 23 (24%) had ≥1 STI. Of the 23 participants with enrollment STI(s), all completed treatment and 19 (83%) returned for follow-up; 18 (78%) reported delivering partner notification cards and discussing STIs with partner(s), and 14 (61%) reported all partners received STI treatment. Of the 81 (86%) who successfully completed follow-up STI screening, 17 (21%) had ≥1 STI. The STI incidence rate was 29.0 per 100 person-years. In univariable regression analysis, enrollment STI, younger age, less education, and alcohol consumption were all significantly associated with follow-up STI. CONCLUSIONS We demonstrated high enrollment and follow-up STI rates and moderate participant-reported partner treatment among women planning for pregnancy in Uganda despite partner notification and treatment. Novel STI partner notification and treatment interventions are needed to decrease the STI burden, especially among women planning for and with pregnancy.
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Affiliation(s)
- Pooja Chitneni
- Division of Infectious Diseases, 2348Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Diseases and General Internal Medicine, 1861Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Winnie Muyindike
- 108123Mbarara Regional Referral Hospital and Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mwebesa Bosco Bwana
- 108123Mbarara Regional Referral Hospital and Mbarara University of Science and Technology, Mbarara, Uganda
| | - Moran Owembabazi
- 108123Mbarara Regional Referral Hospital and Mbarara University of Science and Technology, Mbarara, Uganda
| | - Kasey O'Neil
- Division of Infectious Diseases, 2348Massachusetts General Hospital, Boston, MA, USA.,Mbarara University of Science and Technology Global Health Collaborative, Mbarara, Uganda
| | - Paul Kato Kalyebara
- 108123Mbarara Regional Referral Hospital and Mbarara University of Science and Technology, Mbarara, Uganda
| | - Bethany Hedt-Gauthier
- Department of Global Health and Social Medicine, 1811Harvard Medical School, Boston, MA, USA
| | | | - Jeanne M Marrazzo
- Division of Infectious Diseases, 9968University of Alabama, Birmingham, AL, USA
| | - Angela Kaida
- 1763Simon Fraser University, Burnaby, British Columbia, Canada
| | - Jessica E Haberer
- Harvard Medical School, Boston, MA, USA.,108123Mbarara Regional Referral Hospital and Mbarara University of Science and Technology, Mbarara, Uganda.,Center for Global Health, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Lynn T Matthews
- Division of Infectious Diseases, 9968University of Alabama, Birmingham, AL, USA
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Kecojevic A, Meleo-Erwin ZC, Basch CH, Hammouda M. A Thematic Analysis of Pre-Exposure Prophylaxis (PrEP) YouTube Videos. JOURNAL OF HOMOSEXUALITY 2021; 68:1877-1898. [PMID: 31939710 DOI: 10.1080/00918369.2020.1712142] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Pre-exposure prophylaxis (PrEP) is an encouraging approach to HIV prevention, yet there is a paucity of research aimed at understanding individual PrEP experiences. The current study aims to examine first-hand narratives of individuals detailing their PrEP experiences via the YouTube platform. We searched YouTube.com using the keywords, "pre-exposure prophylaxis" and "Truvada". Search results were limited to the 15 most-viewed videos. Informed by a thematic/content analysis approach, we conducted an iterative analysis of video transcripts. Narratives covered a wide range of topics including the reasons to start PrEP, interaction with providers, side effects, insurance coverage, and stigma. By and large, the videos encouraged those at risk for HIV to consider PrEP. Narratives were often characterized by emotional engagement. Given that YouTube videos are used to share individual PrEP experiences with a wider audience, our analysis may inform the development of strategies aimed at utilizing YouTube for increasing uptake of PrEP.
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Affiliation(s)
- Aleksandar Kecojevic
- Department of Public Health, William Paterson University, College of Science and Health, Wayne, New Jersey, USA
| | - Zoe C Meleo-Erwin
- Department of Public Health, William Paterson University, College of Science and Health, Wayne, New Jersey, USA
| | - Corey H Basch
- Department of Public Health, William Paterson University, College of Science and Health, Wayne, New Jersey, USA
| | - Mariam Hammouda
- Department of Public Health, William Paterson University, College of Science and Health, Wayne, New Jersey, USA
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Chilaka VN, Konje JC. HIV in pregnancy - An update. Eur J Obstet Gynecol Reprod Biol 2020; 256:484-491. [PMID: 33246666 PMCID: PMC7659513 DOI: 10.1016/j.ejogrb.2020.11.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 11/16/2022]
Abstract
Human immunodeficiency virus (HIV) is an infection with a global prevalence and currently no cure or vaccine. Women living with HIV who become pregnant or who acquire the virus during pregnancy are at risk of both maternal and perinatal morbidity and mortality mainly if the virus is poorly controlled. Furthermore, there is a risk of vertical transmission to the fetus during pregnancy labour and postpartum through breastfeeding. Appropriate management must be instituted to reduce the consequences of HIV in pregnancy, ideally starting with preconception counselling and planning pregnancies when the viral load is minimum. During pregnancy, an appropriate combined anti-retroviral (cART) medication is mandatory with very close monitoring of the viral load, cluster of differentiation 4 (CD4) cell counts, blood counts, liver and kidney function tests. Planning delivery should not be different in women on cART and suppressed viral loads. However, special care must be taken to limit vertical transmission in those who present late and in whom viral load is unknown or not controlled at the time of delivery. Breastfeeding remains a potential source of infection for the baby and is being discouraged in high-income countries for women living with HIV; however, in low-income countries, the recommendation is exclusive breastfeeding. If breastfeeding must happen, it is best when viral load is suppressed, and cART continued until weaning. Serodiscordant couples present unique problems, and their management should begin with the planning of pregnancy. Emphasis should be on taking steps to prevent HIV transmission to the negative partner and vertical transmission to the new-born.
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Affiliation(s)
- Victor N Chilaka
- Women's Wellness Research Center, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine, Doha, Qatar.
| | - Justin C Konje
- Weill Cornell Medicine, Doha, Qatar; Sidra Medicine, Doha, Qatar; University of Leicester, UK
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Preconception Care Uptake and Immediate Outcomes among Discordant Couples Accessing Routine HIV Care in Kenya. Obstet Gynecol Int 2020; 2020:1675987. [PMID: 32565820 PMCID: PMC7301190 DOI: 10.1155/2020/1675987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 01/16/2020] [Accepted: 03/23/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction A large proportion of new HIV infections occur within discordant partnerships making discordance a significant contributor to new HIV infections in Africa. Despite the role of preconception care for HIV discordant couples, there is little data on fertility desire and preconception care uptake. This study aimed at documenting fertility desire (desire to conceive), determining the uptake of preconception care, identifying HIV prevention strategies used during preconception care, and determining immediate conception outcomes among HIV discordant couples in Kenya. Methods We retrospectively extracted electronic medical record data on discordant couples at an HIV care discordant couples' clinic. We included data on couples who expressed a desire to conceive and were offered preconception care and followed up for 29 months. We collected data on sociodemographic characteristics, preconception prevention methods, and associated outcomes. Results Among couples, with male HIV-positive partners, there was a twofold likelihood of accepting preconception services (OR = 2.3, CI 95% (1, 1, 5.0)). A shorter discordant union was independently associated with the uptake of preconception services (OR = 0.92, CI 95% (0.86, 0.98)). The most used prevention intervention (38.5%) among discordant couples was a combination of pre-exposure prophylaxis (PrEP) by the uninfected partner, alongside HAART by the partner living with HIV. Pregnancy rates did not significantly (p = 0.06) differ among those who took up preconception care versus those who did not. HIV-negative partners of couples who declined preconception care had a significantly (p = 0.04) higher attrition from clinic follow-up. One confirmed seroconversion occurred; an HIV incidence rate of 0.19 per 100 person-years. Conclusion The study demonstrates the feasibility of implementing safe and effective preconception servicesas part of routine HIV care for discordant couples living in low resource settings. The provision and the utilisation of safer conception services may be hindered by the poor retention to follow-up and care of HIV-negative partners. This challenge may impede the expected benefits of preconception care as an HIV prevention intervention.
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Holmes LE, Kaufman MR, Casella A, Mudavanhu M, Mutunga L, Polzer T, Bassett J, Van Rie A, Schwartz S. Qualitative characterizations of relationships among South African adolescent girls and young women and male partners: implications for engagement across HIV self-testing and pre-exposure prophylaxis prevention cascades. J Int AIDS Soc 2020; 23 Suppl 3:e25521. [PMID: 32603025 PMCID: PMC7325584 DOI: 10.1002/jia2.25521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/22/2020] [Accepted: 04/23/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Adolescent girls and young women (AGYW) in sub-Saharan Africa have emerged as a priority population in need of HIV prevention interventions. Secondary distribution of home-based HIV self-test kits by AGYW to male partners (MP) is a novel prevention strategy that complements pre-exposure prophylaxis (PrEP), a female-controlled prevention intervention. The objective of this analysis was to qualitatively operationalize two HIV prevention cascades through the lens of relationship dynamics for secondary distribution of HIV self-tests to MP and PrEP for AGYW. METHODS From April 2018 to December 2018, 2200 HIV-negative AGYW aged 16-24 years were enrolled into an HIV prevention intervention which involved secondary distribution of self-tests to MP and PrEP for AGYW; of these women, 91 participants or MP were sampled for in-depth interviews based on their degree of completion of the two HIV prevention cascades. A grounded theory approach was used to characterize participants' relationship profiles, which were mapped to participants' engagement with the interventions. RESULTS In cases where AGYW had a MP with multiple partners, AGYW perceived both interventions as inviting distrust into the relationship and insinuating non-monogamy. Many chose not to accept either intervention, while others accepted and attempted to deliver the self-test kit but received a negative reaction from their MP. In the few cases where AGYW held multiple partnerships, both interventions were viewed as mechanisms for protecting one's health, and these AGYW exhibited confidence in accepting and delivering the self-test kits and initiating PrEP. Women who indicated intimate partner violence experiences chose not to accept either intervention because they feared it would elicit a violent reaction from their MP. For AGYW in relationships described as committed and emotionally open, self-test kit delivery was completed with ease, but PrEP was viewed as unnecessary. MP experience with the cascade corroborated AGYW perspectives and demonstrated how men can perceive female-initiated HIV prevention options as beneficial for AGYW and a threat to MP masculinity. CONCLUSIONS Screening to identify AGYW relationship dynamics can support tailoring prevention services to relationship-driven barriers and facilitators. HIV prevention counseling for AGYW should address relationship goals or partner's influence, and engage with MP around female-controlled prevention interventions.
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Affiliation(s)
- Leah E Holmes
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Michelle R Kaufman
- Department of Health. Behavior & SocietyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Albert Casella
- Department of Health. Behavior & SocietyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | | | | | - Tara Polzer
- Social Surveys AfricaJohannesburgSouth Africa
| | - Jean Bassett
- Witkoppen Health and Welfare ClinicJohannesburgSouth Africa
| | - Annelies Van Rie
- Department of Epidemiology and Social MedicineUniversity of AntwerpAntwerpBelgium
| | - Sheree Schwartz
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
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Pleasure and HIV biomedical discourse: The structuring of sexual and drug-related risks for gay and bisexual men who Party-n-Play. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 74:181-190. [PMID: 31627160 DOI: 10.1016/j.drugpo.2019.09.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 08/21/2019] [Accepted: 09/23/2019] [Indexed: 11/23/2022]
Abstract
Party-n-Play (PNP) is a social practice that refers to sex that occurs under the influence of drugs. This study critically examined the risk and pleasure discourses of gay and bisexual men who PNP to explore how epistemic shifts associated with advancements in HIV biomedical sciences influence gay and bisexual men's perceptions of HIV risks and their sexual and drug-related practices. This study also aims to provide a more nuanced understanding of how sexual and drug-related risk practices of gay and bisexual men are entangled with their search for pleasure. The study was framed within poststructural Critical Discourse Analysis (CDA) methodology. In-depth one-hour interviews were conducted with 44 self-identified gay, bisexual, queer, or Two-Spirit men, who lived in Toronto, and who reported using drugs before or during sex with another man. The findings from this study demonstrated the capacity of biomedical discourses to affect respondents' HIV risk perceptions and practices. The transition from condom-centered prevention to today's context where new highly effective biomedical tools for HIV prevention are available created possibilities for greater intimacy, increased pleasure, and less anxiety about HIV tranmission, while challenging many years of preventive socialization among gay and bisexual men. However, this new context also rekindled deep-seated fears about HIV risk and viral load verifiability, reinforced unequal forms of biomedical self-governance and citizenship, and reproduced practices of biopolitics. While discourses on risk and pleasure were interwoven within complex PNP assemblages, the notion of pleasure was mobilized as a discursive tactic of self-control, and the division between normative and non-normative pleasures highlighted the consequence of biopolitical forces governing the production of discourses on sex and drugs. Future HIV social science research needs to attend to the fluid nature of the discursive environments of HIV prevention science, and consider how both the material context of PNP and its social/discursive elements operate together.
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Matthews LT, Jaggernath M, Kriel Y, Smith PM, O'Neil K, Haberer JE, Hendrix C, Baeten JM, Ware NC, Wirth K, Psaros C, Bangsberg DR, Smit JA. Protocol for a longitudinal study to evaluate the use of tenofovir-based PrEP for safer conception and pregnancy among women in South Africa. BMJ Open 2019; 9:e027227. [PMID: 31350241 PMCID: PMC6661571 DOI: 10.1136/bmjopen-2018-027227] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 03/06/2019] [Accepted: 06/12/2019] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Women who choose to conceive a baby with a partner living with HIV or a partner whose HIV serostatus is unknown in HIV-endemic settings need prevention strategies to mitigate HIV acquisition during conception and pregnancy. METHODS AND ANALYSIS We are conducting a single-arm longitudinal study offering oral tenofovirdisoproxil fumarate/emtricitabine (TDF/FTC) as pre-exposure prophylaxis (PrEP) for periconception use to 350 HIV-uninfected women in KwaZulu-Natal, South Africa. PrEP is offered as part of woman-centred safer conception programme that promotes couples-based HIV counselling and testing, antiretroviral therapy for partners who are HIV-infected, treatment for sexually transmitted infections and safer conception strategies, such as limiting condomless sex to peak fertility. We enrol HIV-uninfected women who are not currently pregnant, in a stable relationship (≥6 months) with a partner living with HIV or of unknown serostatus, and personal or partner plans for pregnancy in the next 12 months. We follow enrolled women for 12 months. Women who become pregnant are followed through pregnancy outcome, independent of their decisions regarding PrEP use. The primary objective of the study is to evaluate the uptake of and adherence to PrEP during the periconception period and pregnancy. Secondary outcomes include the uptake of other safer conception strategies. We also measure clinical outcomes including HIV seroconversion rates and pregnancy and infant outcomes. Finally, we will explore conduct and evaluate qualitative interviews in 25 participants to further inform our conceptual framework for periconception PrEP uptake and adherence among HIV-exposed women in South Africa. ETHICS AND DISSEMINATION The protocol has been approved by the Human Research Ethics Committee at the University of the Witwatersrand (Johannesburg, South Africa) and the Institutional Review Board of Partners Healthcare (Boston, Massachusetts, USA). Study findings will be made available to interested participants. Results will be presented to local health officials and stakeholders at meetings. Investigators will share the results at meetings and in manuscripts. De-identified quantitative data will be made available. TRIAL REGISTRATION NUMBER The protocol is registered with the South African Health Products Regulatory Agency (SAHPRA, formerly known as the Medicine Controls Council, MCC#20170131) and ClinicalTrials.gov (NCT03194308); Pre-results.
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Affiliation(s)
- Lynn T Matthews
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Manjeetha Jaggernath
- Department of Gynecology and Obstetrics, Faculty of Health Sciences, MatCH Research Unit, University of Witwatersrand, Durban, South Africa
| | - Yolandie Kriel
- Department of Gynecology and Obstetrics, Faculty of Health Sciences, MatCH Research Unit, University of Witwatersrand, Durban, South Africa
| | - Patricia M Smith
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Kasey O'Neil
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Craig Hendrix
- Division of Clinical Pharmacology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Norma C Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Kathleen Wirth
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Christina Psaros
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - David R Bangsberg
- Dean's Office, Portland State University School of Public Health, Oregon Health and Science University, Portland, Oregon, USA
| | - Jennifer A Smit
- Department of Gynecology and Obstetrics, Faculty of Health Sciences, MatCH Research Unit, University of Witwatersrand, Durban, South Africa
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Kimemia G, Ngure K, Baeten JM, Celum C, Dew K, Njuguna N, Mugo N, Heffron R. Perceptions of pregnancy occurring among HIV-serodiscordant couples in Kenya. Reprod Health 2019; 16:85. [PMID: 31215447 PMCID: PMC6582525 DOI: 10.1186/s12978-019-0751-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 06/10/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Among HIV serodiscordant couples, most conception involves condomless sex and may confer a period with increased HIV transmission risk if HIV viral load is not suppressed and other precautions are not used. Safer conception strategies enable HIV serodiscordant couples to attain their pregnancy goals while markedly reducing this risk. We explored the perceptions and beliefs held by HIV serodiscordant couples and health care providers concerning pregnancy among HIV serodiscordant couples in Kenya and gathered their thoughts about how these might influence use of safer conception methods. METHODS We conducted 20 Key Informant Interviews (KIIs) with health care providers offering safer conception counseling and 21 In-Depth Interviews (IDIs) and 4 Focus Group Discussions (FGDs) with members of HIV serodiscordant couples with immediate pregnancy goals in Thika, Kenya. Data were analyzed using an inductive approach that identified two emergent themes: perceptions towards pregnancy among HIV serodiscordant couples and access to safer conception services. RESULTS The perceptions held by the community towards couples in HIV serodiscordant relationships having children were largely negative. The participants were aware of the increased HIV transmission risk to the HIV uninfected partners while trying to become pregnant. In the community, having biological children was cherished yet the majority of the couples shied away from accessing safer conception services offered at health facilities due to stigma and lack of knowledge of the existence of such services. Some providers had limited knowledge on safer conception strategies and services and consequently discouraged HIV serodiscordant couples from natural conception. CONCLUSIONS Negative perceptions towards HIV serodiscordant couples becoming pregnant has hindered access to safer conception services. Therefore, there is need to create a supportive environment for HIV serodiscordant couples with fertility intentions that normalizes their desire to have children and informs the community about the availability of safer conception services.
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Affiliation(s)
- Grace Kimemia
- African Population & Health Research Center, Nairobi, Kenya
| | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Jared M. Baeten
- Department of Global Health, University of Washington, 325 Ninth Avenue Box 359927, Seattle, WA 98104 USA
- Department of Epidemiology, University of Washington, 325 Ninth Avenue Box 359927, Seattle, WA 98104 USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Connie Celum
- Department of Global Health, University of Washington, 325 Ninth Avenue Box 359927, Seattle, WA 98104 USA
- Department of Epidemiology, University of Washington, 325 Ninth Avenue Box 359927, Seattle, WA 98104 USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Kristin Dew
- Department of Human Centered Design and Engineering, University of Washington, Seattle, USA
| | | | - Nelly Mugo
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Renee Heffron
- Department of Global Health, University of Washington, 325 Ninth Avenue Box 359927, Seattle, WA 98104 USA
- Department of Epidemiology, University of Washington, 325 Ninth Avenue Box 359927, Seattle, WA 98104 USA
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Mmeje O, Njoroge B, Wekesa P, Murage A, Ondondo RO, van der Poel S, Guzé MA, Shade SB, Bukusi EA, Cohan D, Cohen CR. Empowering HIV-infected women in low-resource settings: A pilot study evaluating a patient-centered HIV prevention strategy for reproduction in Kisumu, Kenya. PLoS One 2019; 14:e0212656. [PMID: 30840672 PMCID: PMC6402674 DOI: 10.1371/journal.pone.0212656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 02/08/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Female positive/male negative HIV-serodiscordant couples express a desire for children and may engage in condomless sex to become pregnant. Current guidelines recommend antiretroviral treatment in HIV-serodiscordant couples, yet HIV RNA viral suppression may not be routinely assessed or guaranteed and pre-exposure prophylaxis may not be readily available. Therefore, options for becoming pregnant while limiting HIV transmission should be offered and accessible to HIV-affected couples desiring children. METHODS A prospective pilot study of female positive/male negative HIV-serodiscordant couples desiring children was conducted to evaluate the acceptability, feasibility, and effectiveness of timed vaginal insemination. Eligible women were 18-34 years with regular menses. Prior to timed vaginal insemination, couples were observed for two months, and tested and treated for sexually transmitted infections. Timed vaginal insemination was performed for up to six menstrual cycles. A fertility evaluation and HIV RNA viral load assessment was offered to couples who did not become pregnant. FINDINGS Forty female positive/male negative HIV-serodiscordant couples were enrolled; 17 (42.5%) exited prior to timed vaginal insemination. Twenty-three couples (57.5%) were introduced to timed vaginal insemination; eight (34.8%) achieved pregnancy, and six live births resulted without a case of HIV transmission. Seven couples completed a fertility evaluation. Four women had no demonstrable tubal patency bilaterally; one male partner had decreased sperm motility. Five women had unilateral/bilateral tubal patency; and seven women had an HIV RNA viral load (≥ 400 copies/mL). CONCLUSION Timed vaginal insemination is an acceptable, feasible, and effective method for attempting pregnancy. Given the desire for children and inadequate viral suppression, interventions to support safely becoming pregnant should be integrated into HIV prevention programs.
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Affiliation(s)
- Okeoma Mmeje
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, United States of America
| | - Betty Njoroge
- Kenya Medical Research Institute (KEMRI), Centre for Microbiology Research, Nairobi, Kenya
| | - Pauline Wekesa
- Kenya Medical Research Institute (KEMRI), Centre for Microbiology Research, Nairobi, Kenya.,Research Care and Treatment Program (RCTP)-Family AIDS Care & Education Services (FACES), Kisumu, Kenya
| | - Alfred Murage
- Department of Obstetrics and Gynaecology, Aga Khan University, Nairobi, Kenya
| | - Raphael O Ondondo
- Kenya Medical Research Institute (KEMRI), Centre for Microbiology Research, Nairobi, Kenya.,Research Care and Treatment Program (RCTP)-Family AIDS Care & Education Services (FACES), Kisumu, Kenya.,Masinde Muliro University of Science and Technology (MMUST), Kakamega, Kenya
| | - Sheryl van der Poel
- WHO/HRP (the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction), Geneva, Switzerland
| | - Mary A Guzé
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, United States of America
| | - Starley B Shade
- Department of Medicine, Division of Prevention Services, University of California, San Francisco, San Francisco, CA, United States of America
| | - Elizabeth A Bukusi
- Kenya Medical Research Institute (KEMRI), Centre for Microbiology Research, Nairobi, Kenya.,Research Care and Treatment Program (RCTP)-Family AIDS Care & Education Services (FACES), Kisumu, Kenya
| | - Deborah Cohan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, United States of America
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, United States of America.,Research Care and Treatment Program (RCTP)-Family AIDS Care & Education Services (FACES), Kisumu, Kenya
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A Systematic Review of the Current Status of Safer Conception Strategies for HIV Affected Heterosexual Couples in Sub-Saharan Africa. AIDS Behav 2018; 22:2916-2946. [PMID: 29869184 DOI: 10.1007/s10461-018-2170-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
We conducted a systematic review of safer conception strategies (SCS) for HIV-affected couples in sub-Saharan Africa to inform evidence-based safer conception interventions. Following PRISMA guidelines, we searched fifteen electronic databases using the following inclusion criteria: SCS research in HIV-affected couples; published after 2007; in sub-Saharan Africa; primary research; peer-reviewed; and addressed a primary topic of interest (SCS availability, feasibility, and acceptability, and/or education and promotion). Researchers independently reviewed each study for eligibility using a standardized tool. We categorize studies by their topic area. We identified 41 studies (26 qualitative and 15 quantitative) that met inclusion criteria. Reviewed SCSs included: antiretroviral therapy (ART), pre-exposure prophylaxis, timed unprotected intercourse, manual/self-insemination, sperm washing, and voluntary male medical circumcision (VMMC). SCS were largely unavailable outside of research settings, except for general availability (i.e., not specifically for safer conception) of ART and VMMC. SCS acceptability was impacted by low client and provider knowledge about safer conception services, stigma around HIV-affected couples wanting children, and difficulty with HIV disclosure in HIV-affected couples. Couples expressed desire to learn more about SCS; however, provider training, patient education, SCS promotions, and integration of reproductive health and HIV services remain limited. Studies of provider training and couple-based education showed improvements in communication around fertility intentions and SCS knowledge. SCS are not yet widely available to HIV-affected African couples. Successful implementation of SCS requires that providers receive training on effective SCS and provide couple-based safer conception counseling to improve disclosure and communication around fertility intentions and reproductive health.
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14
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Beyeza-Kashesya J, Wanyenze RK, Goggin K, Finocchario-Kessler S, Woldetsadik MA, Mindry D, Birungi J, Wagner GJ. Stigma gets in my way: Factors affecting client-provider communication regarding childbearing among people living with HIV in Uganda. PLoS One 2018; 13:e0192902. [PMID: 29462171 PMCID: PMC5819785 DOI: 10.1371/journal.pone.0192902] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 02/01/2018] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Many HIV-affected couples living in sub-Saharan Africa desire to have children, but few quantitative studies have examined support for their childbearing needs. Our study explored client-provider communication about childbearing and safer conception among HIV clients in Uganda. METHODS 400 Ugandan HIV clients in committed relationships and with intentions to conceive were surveyed. Knowledge, attitudes and practices related to childbearing, and use of safer conception methods were assessed, including communication with providers about childbearing needs, the correlates of which were examined with bivariate statistics and logistic multivariate analysis. RESULTS 75% of the sample was female; 61% were on antiretroviral therapy; and 61% had HIV-negative or unknown status partners. Nearly all (98%) reported the desire to discuss childbearing intentions with their HIV provider; however, only 44% reported such discussions, the minority (28%) of which was initiated by the provider. Issues discussed with HIV providers included: HIV transmission risk to partner (30%), HIV transmission risk to child (30%), and how to prevent transmission to the child (27%); only 8% discussed safer conception methods. Regression analysis showed that those who had communicated with providers about childbearing were more likely to have been diagnosed with HIV for a longer period [OR (95% CI) = 1.09 (1.03, 1.15)], while greater internalized childbearing stigma was associated with lower odds of this communication [OR (95% CI) = 0.70 (0.49, 0.99)], after controlling for all bivariate correlates and basic demographics. CONCLUSIONS Communication between HIV clients and providers about childbearing needs is poor and associated with stigma. Innovations to mitigate stigma among clients as well as training to improve health worker communication and skills related to safer conception counseling is needed.
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Affiliation(s)
- Jolly Beyeza-Kashesya
- Mulago Hospital Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rhoda K. Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, College of Health Sciences, Kampala, Uganda
| | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Schools of Medicine and Pharmacy, University of Missouri–Kansas City, Missouri, United States of America
| | - Sarah Finocchario-Kessler
- University of Kansas Medical Center, Department of Family Medicine, Kansas City, Missouri, United States of America
| | | | - Deborah Mindry
- University of California, Los Angeles Center for Culture and Health, Los Angeles, California, United States of America
| | | | - Glenn J. Wagner
- RAND Corporation, Santa Monica, California, United States of America
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Difficult decisions: Evaluating individual and couple-level fertility intentions and HIV acquisition among HIV serodiscordant couples in Zambia. PLoS One 2018; 13:e0189869. [PMID: 29364895 PMCID: PMC5783339 DOI: 10.1371/journal.pone.0189869] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 12/04/2017] [Indexed: 11/19/2022] Open
Abstract
Introduction Attempts to conceive and pregnancy may increase HIV transmission to sex partners and infants. Our study evaluated the association between fertility intentions and HIV acquisition among Zambian HIV-serodiscordant couples. Methods We collected demographic, behavioral, clinical exposures, and data on fertility intentions in a cohort of HIV-serodiscordant couples in Lusaka, Zambia from 2005 to 2012. We evaluated factors associated with fertility intentions stratified by gender using multivariable logistic regression. Multivariable Cox proportional hazard models were used to evaluate the associations between fertility intentions and HIV acquisition controlling for a priori confounders and covariates that substantially (>10%) changed the effect estimates in univariate analyses. Results Among 1,029 serodiscordant couples, 311 agreed that they wanted children in the future (30%), 368 agreed they did not want children (36%), and 344 couples disagreed about having children (34%), with men more likely than women to want children. Women wanting child(ren) was associated with increased odds of baseline pregnancy (adjusted odds ratio [aOR] = 4.80 (95% confidence interval [CI] = 2.93, 7.85)), fewer previous pregnancies (aOR = 0.85 per additional pregnancy (95% CI = 0.78, 0.93)), and partner fertility intention (aOR = 2.89 (95% CI = 2.14, 3.91)) adjusting for woman’s age, literacy, years cohabiting and HIV status. Men wanting child(ren) was associated with younger age (aOR = 0.96 per year (95% CI = 0.93, 0.99)), fewer years cohabiting (aOR = 0.95 (95% CI = 0.92, 0.98)), number of previous partners’ pregnancies (aOR = 0.90 (95% CI = 0.82, 0.98)), and partner fertility intention (aOR = 3.00 (95% CI = 2.21, 4.07)) adjusting for partner’s age, literacy, HIV status and partner’s baseline pregnancy. In adjusted survival analyses, HIV-negative women were more likely to seroconvert if they themselves wanted children (aHR = 2.36 (95% CI = 1.41, 3.96)) vs. did not want children, or if their partner wanted children (aHR = 2.34 (95% CI = 1.33, 4.11)) vs. did not want children, or if the couple agreed that they wanted children (aHR = 2.08 (95% CI = 1.01, 4.30)), adjusting for women’s age, women’s literacy, previous pregnancies and time in study. HIV-negative men were more likely to seroconvert if their female partner wanted a child in the next 12-months (aHR = 1.94 (95% CI = 1.02, 3.68)) vs. did not want children, and when both partners wanted children (aHR = 2.02 (CI = 1.09, 3.73)) vs. they did not want children, adjusting for men’s age and literacy, couple income, number of live children, male circumcision status and time in study. Conclusion Women had increased risk of HIV acquisition if they and/or their partner wanted a child, while men had increased risk of HIV acquisition when their partner or if both partners agreed that they wanted children. Safer-conception interventions are needed to protect HIV uninfected women and men from HIV acquisition in HIV-serodiscordant couples who want children.
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Delivering safer conception services to HIV serodiscordant couples in Kenya: perspectives from healthcare providers and HIV serodiscordant couples. J Int AIDS Soc 2017; 20:21309. [PMID: 28361508 PMCID: PMC5577704 DOI: 10.7448/ias.20.2.21309] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction: For HIV serodiscordant couples in resource-limited settings, pregnancy is common despite the risk of sexual and/or perinatal HIV transmission. Some safer conception strategies to reduce HIV transmission during pregnancy attempts are available but often not used for reasons including knowledge, accessibility, preference and others. We sought to understand Kenyan health providers’ and HIV serodiscordant couples’ perspectives and experiences with safer conception. Methods: Between August 2015 and March 2016, we conducted key informant interviews (KIIs) with health providers from public and private HIV care and fertility clinics and in-depth interviews (IDIs) and focus group discussions (FGDs) with HIV serodiscordant couples participating in an open-label study of integrated pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) for HIV prevention (the Partners Demonstration Project). An inductive analytic approach identified a number of themes related to experiences with and perceptions of safer conception strategies. Results: We conducted 20 KIIs with health providers, and 21 IDIs and 4 FGDs with HIV serodiscordant couples. HIV clinic providers frequently discussed timed condomless sex and antiretroviral medications while providers at private fertility care centres were more comfortable recommending medically assisted reproduction. Couples experienced with ART and PrEP reported that they were comfortable using these strategies to reduce HIV risk when attempting pregnancy. Timed condomless sex in conjunction with ART and PrEP was a preferred strategy, often owing to them being available for free in public and research clinics, as well as most widely known; however, couples often held inaccurate knowledge of how to identify days with peak fertility in the upcoming menstrual cycle. Conclusions: Antiretroviral-based HIV prevention is acceptable and accessible to meet the growing demand for safer conception services in Kenya, since medically assisted interventions are currently cost prohibitive. Cross-disciplinary training for health providers would expand confidence in all prevention options and foster the tailoring of counselling to couples’ preferences.
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Safier LZ, Sauer MV. Fertility care interventions should be provided as the first line options for HIV+ serodiscordant couples who desire children in settings with affordable access to care, regardless of their fertility status. J Int AIDS Soc 2017; 20:21294. [PMID: 28361501 PMCID: PMC5577707 DOI: 10.7448/ias.20.2.21294] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 01/03/2017] [Accepted: 01/04/2017] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION With increasing life expectancy, couples with at least one partner afflicted with HIV are more commonly pursuing the opportunity to have biologic offspring. Currently, there are no universally accepted recommendations regarding first line reproductive treatments for HIV serodiscordant couples lacking a history of infertility. We strongly believe that fertility care intervention should be the first line treatment, when affordably accessible, over natural conception for HIV serodiscordant couples to achieve pregnancy in a safe and efficacious manner. Discussion In the era of highly active anti-retroviral therapy, in combination with timed intercourse and pre-exposure prophylaxis for the HIV negative partner, some members of the medical community are arguing in favour of natural conception as a means of achieving pregnancy in this patient population. In our opinion, laboratory assisted fertility methods, including intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection with semen washing should be the first line treatment recommendation for HIV serodiscordant couples desiring pregnancy for the following reasons: (1) abundance of evidence in the medical literature supporting the safety profile and efficacy of fertility care intervention in couples with HIV; paucity of data addressing safety of natural conception in comparison to fertility intervention techniques (2) unknown public health impact of promoting natural conception as a safe means of achieving pregnancy (3) ethical implications: patients should be offered the available and accessible treatment option posing the lowest possible known risk to the uninfected partner. Conclusions We believe that physician assisted fertility care, when affordably accessible, should be the treatment of choice over natural conception. While the preliminary data on natural conception in couples using highly active anti-retroviral therapy/pre-exposure prophylaxis/timed intercourse appears promising, we believe that this approach should be limited to patients in resource poor settings where more sophisticated measures do not exist or for patients that simply cannot afford subspecialty care. There are likely to be unknown psychological and behavioural factors impacted by promoting natural conception and diminishing the importance of safe sex practices. Additionally, it is our moral obligation to patients to offer the affordably accessible treatment interventions that pose the least known risk when considering reproductive options.
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Affiliation(s)
- Lauren Zakarin Safier
- Department of Obstetrics and Gynecology, New York Presbyterian-Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Mark V Sauer
- Department of Obstetrics and Gynecology, New York Presbyterian-Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Mason J, Medley A, Yeiser S, Nightingale VR, Mani N, Sripipatana T, Abutu A, Johnston B, Watts DH. The role of family planning in achieving safe pregnancy for serodiscordant couples: commentary from the United States government's interagency task force on family planning and HIV service integration. J Int AIDS Soc 2017; 20:21312. [PMID: 28361500 PMCID: PMC5461116 DOI: 10.7448/ias.20.2.21312] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 12/21/2016] [Accepted: 12/27/2016] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION People living with HIV (PLHIV) have the right to exercise voluntary choices about their health, including their reproductive health. This commentary discusses the integral role that family planning (FP) plays in helping PLHIV, including those in serodiscordant relationships, achieve conception safely. The United States (US) President's Emergency Plan for AIDS Relief (PEPFAR) is committed to meeting the reproductive health needs of PLHIV by improving their access to voluntary FP counselling and services, including prevention of unintended pregnancy and counselling for safer conception. DISCUSSION Inclusion of preconception care and counselling (PCC) as part of routine HIV services is critical to preventing unintended pregnancies and perinatal infections among PLHIV. PLHIV not desiring a current pregnancy should be provided with information and counselling on all available FP methods and then either given the method onsite or through a facilitated referral process. PLHIV, who desire children should be offered risk reduction counselling, support for HIV status disclosure and partner testing, information on safer conception options to reduce the risk of HIV transmission to the partner and the importance of adhering to antiretroviral treatment during pregnancy and breastfeeding to reduce the risk of vertical transmission to the infant. Integration of PCC, HIV and FP services at the same location is recommended to improve access to these services for PLHIV. Other considerations to be addressed include the social and structural context, the health system capacity to offer these services, and stigma and discrimination of providers. CONCLUSION Evaluation of innovative service delivery models for delivering PCC services is needed, including provision in community-based settings. The US Government will continue to partner with local organizations, Ministries of Health, the private sector, civil society, multilateral and bilateral donors, and other key stakeholders to strengthen both the policy and programme environment to ensure that all PLHIV and serodiscordant couples have access to FP services, including prevention of unintended pregnancy and safer conception counselling.
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Affiliation(s)
- Jennifer Mason
- Office of Population and Reproductive Health, U.S. Agency for International Development, Arlington, VA, USA
| | - Amy Medley
- Division of Global HIV and AIDS, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sarah Yeiser
- Office of HIV/AIDS, U.S. Agency for International Development, Arlington, VA, USA
| | | | - Nithya Mani
- Office of HIV/AIDS, U.S. Agency for International Development, Arlington, VA, USA
| | - Tabitha Sripipatana
- Office of Population and Reproductive Health, U.S. Agency for International Development, Arlington, VA, USA
| | - Andrew Abutu
- Division of Global HIV and AIDS, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Beverly Johnston
- Office of Population and Reproductive Health, U.S. Agency for International Development, Arlington, VA, USA
| | - D. Heather Watts
- Office of the U.S. Global AIDS Coordinator, U.S. Department of State, Washington, DC, USA
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Spieldenner A. PrEP Whores and HIV Prevention: The Queer Communication of HIV Pre-Exposure Prophylaxis (PrEP). JOURNAL OF HOMOSEXUALITY 2016; 63:1685-1697. [PMID: 26930025 DOI: 10.1080/00918369.2016.1158012] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
HIV pre-exposure prophylaxis (PrEP) has been introduced as another biomedical tool in HIV prevention. Whereas other such tools-including post-exposure prophylaxis (PEP) and interruption of perinatal transmission-have been embraced by those impacted by HIV, PrEP has been met with more conflict, especially within the gay community and HIV organizations. The "PrEP whore" has come to designate the social value and personal practices of those taking PrEP. This study examines the "PrEP whore" discourse by using queer theory and quare theory. Within these theoretical vantage points, the study explicates four discursive areas: slut shaming, dirty/clean binaries, mourning the loss of condoms, and reclaiming the inner whore. The study illuminates possible discursive strategies that lie outside of the domains of public health and within the individual and community.
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Affiliation(s)
- Andrew Spieldenner
- a Department of Rhetoric , Hofstra University , Hempstead , New York , USA
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20
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Global implementation of PrEP as part of combination HIV prevention - Unsolved challenges. J Int AIDS Soc 2016. [DOI: 10.7448/ias.19.7.21479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Cowan FM, Delany-Moretlwe S, Sanders EJ, Mugo NR, Guedou FA, Alary M, Behanzin L, Mugurungi O, Bekker LG. PrEP implementation research in Africa: what is new? J Int AIDS Soc 2016; 19:21101. [PMID: 27760680 PMCID: PMC5071780 DOI: 10.7448/ias.19.7.21101] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 07/11/2016] [Accepted: 07/16/2016] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Of the two million new HIV infections in adults in 2014, 70% occurred in sub-Saharan Africa. Several African countries have already approved guidelines for pre-exposure prophylaxis (PrEP) for individuals at substantial risk of HIV as part of combination HIV prevention but key questions remain about how to identify and deliver PrEP to those at greatest need. Throughout the continent, individuals in sero-discordant relationships, and members of key populations (sex workers, men who have sex with men (MSM), transgender women and injection drug users) are likely to benefit from the availability of PrEP. In addition, adolescent girls and young women (AGYW) are at substantial risk in some parts of the continent. It has been estimated that at least three million individuals in Africa are likely to be eligible for PrEP according to WHO's criteria. Tens of demonstration projects are planned or underway across the continent among a range of countries, populations and delivery settings. DISCUSSION In each of the target populations, there are overarching issues related to (i) creating demand for PrEP, (ii) addressing supply-side issues and (iii) providing appropriate and tailored adherence support. Critical for creating demand for PrEP is the normalization of HIV prevention. Community-level interventions which engage opinion leaders as well as empowerment interventions for those at highest risk will be key. Critical to supply of PrEP is that services are accessible for all, including for stigmatized populations. Establishing accessible integrated services provides the opportunity to address other public health priorities including the unmet need for HIV testing, contraception and sexually transmitted infections treatment. National policies need to include minimum standards for training and quality assurance for PrEP implementation and to address supply chain issues. Adherence support needs to recognize that social and structural factors are likely to have an important influence. Combining interventions that build self-efficacy, empowerment and social cohesion, with evidence-based individualized adherence support for PrEP, are most likely to be effective. CONCLUSIONS Efficacy of tenfovir-based PrEP is proven but many issues related to implementation remain unclear. Here, we have summarized some of the important implementation questions that need to be assessed as PrEP is rolled out across Africa.
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Affiliation(s)
- Frances M Cowan
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR), Harare, Zimbabwe;
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa
| | - Eduard J Sanders
- Kenya Medical Research Institute, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nelly R Mugo
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, WA, USA
- Partners in Health Research and Development, Thika, Kenya
| | | | - Michel Alary
- Centre de Recherche du CHU de Québec, Université Laval, Québec, Canada
| | | | | | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
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Tang H, Wu Z, Mao Y, Cepeda J, Morano J. Risk Factor Associated with Negative Spouse HIV Seroconversion among Sero-Different Couples: A Nested Case-Control Retrospective Survey Study in 30 Counties in Rural China. PLoS One 2016; 11:e0164761. [PMID: 27741292 PMCID: PMC5065194 DOI: 10.1371/journal.pone.0164761] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 10/02/2016] [Indexed: 11/19/2022] Open
Abstract
Background Antiretroviral therapy (ART) and condom use have been proven to reduce the risk of sexual transmission of human immunodeficiency virus (HIV) among HIV sero-different couples, but its full implementation remains a challenge. This study aims to assess HIV seroconversion rate of HIV-negative spouse and its associated risk factors among HIV sero-different couples in rural China. Methods An open cohort of HIV sero-different couples enrolled in 30 counties in China between October 1, 2010, and September 30, 2012, and followed-up to December 31, 2012, was constructed retrospectively. A nested case-control study of risk factors of HIV seroconversion among sero-different couples was conducted in April and May of 2013, based on the open cohort. Sero-different couples with the HIV-negative spouse seroconverting at least 3 months after the previous negative diagnosis during cohort observation period were labeled as “case couples”. The “control couples” were selected randomly from the same cohort that did not have the HIV-negative spouse seroconversion during the same period. The “case couples” and “control couples” were matched on gender, age, and region of residence. Sexual behaviors among HIV sero-different couples before and after the index spouses notifying their HIV infection status to their HIV-negative spouses were collected via face-to-face interview. Univariate and multivariate logistic regression models were used to assess factors associated with HIV seroconversion among HIV sero-different couples. Results Of 4481 HIV sero-different couples, a total of 53 seroconversions were observed within 5218 person-years of follow-up. The incidence rate was 1.02 (95%CI: 0.76–1.33) per 100 person-years. Forty “case couples” confirmed HIV-negative spouse seroconversions infected via marital sexual transmission, were matched to 80 “control couples”. Of the 120 couples, 81(67.5%) were receiving ART, and 70 (58.3%) reported consistently used condoms during intercourse after the index spouse was diagnosed HIV infection. Multivariate conditional logistic regression analysis showed that the desire to conceive a child (OR = 5.18, 95% CI: 1.19–22.58) significantly increased the odds of HIV seroconversion. Protective factors of spousal HIV seroconversion were currently receiving ART (OR = 0.09, 95% CI: 0.01–0.67) and consistent condom use (OR = 0.05, 95% CI: 0.01–0.28). Conclusions Intention to conceive a child is the most important risk factor for HIV seroconversion among sero-different couples. Specific efforts on scientific use of ART to assist sero-different couples to achieve their wish to conceive a healthy child are needed to minimize the risk of HIV transmission.
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Affiliation(s)
- Houlin Tang
- Division of Integration and Evaluation, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zunyou Wu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
- * E-mail: ,
| | - Yurong Mao
- Division of Integration and Evaluation, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Javier Cepeda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Jamie Morano
- Division of Infectious Diseases and International Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida, United States of America
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Low Receipt and Uptake of Safer Conception Messages in Routine HIV Care: Findings From a Prospective Cohort of Women Living With HIV in South Africa. J Acquir Immune Defic Syndr 2016; 72:105-13. [PMID: 26855247 DOI: 10.1097/qai.0000000000000945] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Safer conception strategies may be used by people living with HIV to reduce HIV transmission to partners resulting from condomless sex for conception. The extent to which people living with HIV receive safer conception messages and use risk reduction strategies is largely unknown. METHODS We use prospective data from a clinic-based cohort study in Johannesburg, South Africa. Women living with HIV (WLWH) aged 18-35 on antiretroviral therapy (n = 831) completed a baseline survey and ≥1 follow-up visits assessing fertility intentions and pregnancy incidence; an endline survey was administered 1 year postenrollment. Multivariate negative binomial regression models examined differences in the number of condomless sex acts by fertility intentions. Chi-squared statistics compared receipt of safer conception messages by fertility intentions and indicators of safer conception method use by partner HIV status. RESULTS The median baseline age of participants was 30.4 years and 25.3% were in serodiscordant partnerships. WLWH trying to conceive were over 3 times more likely to have condomless sex compared with those not trying to conceive (adjusted incidence rate ratio: 3.17, 95% confidence interval: 1.95 to 5.16). Receipt of specific safer conception messages was low, although women with positive fertility intentions were more likely to have received any fertility-related advice compared with those with unplanned pregnancies (76.3% vs. 49.1%, P < 0.001). Among WLWH trying to conceive (n = 111), use of timed unprotected intercourse was infrequent (17.1%) and lower in serodiscordant vs. concordant partnerships (8.5% vs. 26.9%, P = 0.010). CONCLUSIONS These findings suggest that clinic and patient-level interventions are needed to ensure that WLWH receive and use safer conception strategies.
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Saleem HT, Surkan PJ, Kerrigan D, Kennedy CE. Childbearing Experiences Following an HIV Diagnosis in Iringa, Tanzania. QUALITATIVE HEALTH RESEARCH 2016; 26:1473-1482. [PMID: 26443798 DOI: 10.1177/1049732315605273] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
People living with HIV (PLHIV) continue to have children after being diagnosed with HIV, yet little research attention has been paid to actual lived childbearing experiences of PLHIV post-HIV diagnosis. We interviewed 10 HIV-positive women and 11 HIV-positive men in Iringa, Tanzania, about their experiences of conceiving and having children after being diagnosed with HIV. We adopted an approach to data analysis based on grounded theory and phenomenology. Participants' experiences were shaped by social and institutional factors. Some participants reported pressures to bear children by partners and relatives, whereas others reported negative reactions from others concerning their pregnancies. Most participants had not discussed having children with a provider before attempting to conceive. Some reported being reprimanded by health providers for getting pregnant without seeking their advice. Consideration of support systems and challenges surrounding the childbearing experiences of PLHIV can help inform reproductive health interventions for those who desire children.
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Falcão JRSP, Bradshaw CC, Garrett CC, Bilardi JE, Chen MY, Zablotska I, Fairley CK, Williams H. Views of HIV-negative partners in heterosexual serodiscordant relationships regarding HIV pre-exposure prophylaxis: a qualitative study. Sex Health 2016; 13:SH15143. [PMID: 27224942 DOI: 10.1071/sh15143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 03/08/2016] [Indexed: 11/23/2022]
Abstract
Background: Pre-exposure prophylaxis (PrEP) may be an effective option for HIV prevention among heterosexual serodiscordant couples. However, there are knowledge gaps in social research about PrEP in heterosexual serodiscordant relationships, including motivations and barriers to its use and possible impacts of PrEP uptake on the sexual practices of these couples. The aim of this study was to explore the views of HIV-negative men and women in stable serodiscordant heterosexual relationships about the possible use of PrEP. Methods: Semi-structured interviews were used to understand participants' views on the use of PrEP. Interviews were conducted face-to-face or by telephone and transcribed verbatim for thematic analysis. Results: In total, 13 HIV-negative partners were interviewed; six men and seven women. Participants demonstrated a high interest in the use of PrEP for conception. PrEP was also considered an option for general HIV prevention, although men saw more benefits for this use than women. Participants' main concerns around PrEP usage were about cost, efficacy, daily adherence and side-effects. HIV-positive partner support is likely to play a central role for PrEP uptake and adherence. Conclusions: This study is one of the first studies to explore the views of HIV-negative heterosexual partners in serodiscordant relationships around the use of PrEP while trying to conceive, as well as for general HIV prevention. These study results provide new insights for the further development of guidelines governing the use of PrEP for serodiscordant couples.
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Bujan L, Pasquier C. People living with HIV and procreation: 30 years of progress from prohibition to freedom? Hum Reprod 2016; 31:918-25. [PMID: 26975324 DOI: 10.1093/humrep/dew036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 02/07/2016] [Indexed: 01/26/2023] Open
Abstract
The emergence of human immunodeficiency virus (HIV) infection in the 1980s drastically changed the prospects of conceiving a child for the man or woman infected with the virus. Advances in treatment then made it possible to envisage pregnancy while decreasing the risk of transmission to the child when the mother was infected. For couples where one partner was HIV-positive and who desired a child, recourse to medical help, notably medically assisted procreation, was discouraged, and very few centres offered such assistance in the 1980s and 1990s. Improved knowledge of viral excretion in the genital tracts, together with more effective treatment, made it possible to envisage medically assisted procreation for these couples, allowing them to have a child while at the same time likely reducing the risk of transmitting HIV to their partner. Several programmes have demonstrated their effectiveness in this domain. Owing to continually increasing knowledge over the past decade, natural conception can now be proposed. Couples where one or both partners are HIV-positive may opt for medically assisted procreation or natural reproduction. Specialists in reproductive medicine and HIV specialists need to provide couples with objective information allowing them to achieve near-optimal conditions that minimize HIV transmission risk. Couples will then be able to choose freely the mode of procreation most appropriate for them.
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Affiliation(s)
- L Bujan
- Université Toulouse-III Paul Sabatier, Groupe de Recherche en Fertilité Humaine (EA 3694, Human Fertility Research Group), Toulouse, France CECOS, Centre Hospitalier Universitaire Paule de Viguier, Toulouse, France
| | - C Pasquier
- INSERM U1043, CPTP, Centre Hospitalier Universitaire Toulouse-Purpan, BP 3028, F-31024 Toulouse, France Université Toulouse-III Paul Sabatier, CPTP, F-31024 Toulouse, France Laboratoire de Virologie, Centre Hospitalier Universitaire Toulouse-Purpan, F-31059 Toulouse, France
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Mmeje O, Njoroge B, Akama E, Leddy A, Breitnauer B, Darbes L, Brown J. Perspectives of healthcare providers and HIV-affected individuals and couples during the development of a Safer Conception Counseling Toolkit in Kenya: stigma, fears, and recommendations for the delivery of services. AIDS Care 2016; 28:750-7. [PMID: 26960581 DOI: 10.1080/09540121.2016.1153592] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Reproduction is important to many HIV-affected individuals and couples and healthcare providers (HCPs) are responsible for providing resources to help them safely conceive while minimizing the risk of sexual and perinatal HIV transmission. In order to fulfill their reproductive goals, HIV-affected individuals and their partners need access to information regarding safer methods of conception. The objective of this qualitative study was to develop a Safer Conception Counseling Toolkit that can be used to train HCPs and counsel HIV-affected individuals and couples in HIV care and treatment clinics in Kenya. We conducted a two-phased qualitative study among HCPs and HIV-affected individuals and couples from eight HIV care and treatment sites in Kisumu, Kenya. We conducted in-depth interviews (IDIs) and focus group discussions (FGDs) to assess the perspectives of HCPs and HIV-affected individuals and couples in order to develop and refine the content of the Toolkit. Subsequently, IDIs were conducted among HCPs who were trained using the Toolkit and FGDs among HIV-affected individuals and couples who were counseled with the Toolkit. HIV-related stigma, fears, and recommendations for delivery of safer conception counseling were assessed during the discussions. One hundred and six individuals participated in FGDs and IDIs; 29 HCPs, 49 HIV-affected women and men, and 14 HIV-serodiscordant couples. Participants indicated that a safer conception counseling and training program for HCPs is needed and that routine provision of safer conception counseling may promote maternal and child health by enhancing reproductive autonomy among HIV-affected couples. They also reported that the Toolkit may help dispel the stigma and fears associated with reproduction in HIV-affected couples, while supporting them in achieving their reproductive goals. Additional research is needed to evaluate the Safer Conception Toolkit in order to support its implementation and use in HIV care and treatment programs in Kenya and other HIV endemic regions of sub-Saharan Africa.
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Affiliation(s)
- Okeoma Mmeje
- a Department of Obstetrics and Gynecology , University of Michigan , Ann Arbor , MI , USA.,b Department of Health Behavior and Health Education , University of Michigan , Ann Arbor , MI , USA
| | - Betty Njoroge
- c Kenya Medical Research Institute (KEMRI), Centre for Microbiology Research , Nairobi City , Kenya
| | - Eliud Akama
- c Kenya Medical Research Institute (KEMRI), Centre for Microbiology Research , Nairobi City , Kenya.,d Family AIDS Care and Education Services (FACES) , Kisumu , Kenya
| | - Anna Leddy
- e Department of Health, Behavior and Society , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Brooke Breitnauer
- f Department of Obstetrics and Gynecology , University of Colorado, School of Medicine , Aurora , CO , USA
| | - Lynae Darbes
- g Center for AIDS Prevention Studies and Global Health Sciences, University of California , San Francisco , CA , USA
| | - Joelle Brown
- h Department of Obstetrics, Gynecology, and Reproductive Science , University of California , San Francisco , CA , USA.,i Department of Epidemiology and Biostatistics , University of California , San Francisco , CA , USA
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Matthews LT, Smit JA, Moore L, Milford C, Greener R, Mosery FN, Ribaudo H, Bennett K, Crankshaw TL, Kaida A, Psaros C, Safren SA, Bangsberg DR. Periconception HIV Risk Behavior Among Men and Women Reporting HIV-Serodiscordant Partners in KwaZulu-Natal, South Africa. AIDS Behav 2015; 19:2291-303. [PMID: 26080688 PMCID: PMC4926315 DOI: 10.1007/s10461-015-1050-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
HIV-infected men and women who choose to conceive risk infecting their partners. To inform safer conception programs we surveyed HIV risk behavior prior to recent pregnancy amongst South African, HIV-infected women (N = 209) and men (N = 82) recruited from antenatal and antiretroviral clinics, respectively, and reporting an uninfected or unknown-HIV-serostatus pregnancy partner. All participants knew their HIV-positive serostatus prior to the referent pregnancy. Only 11 % of women and 5 % of men had planned the pregnancy; 40 % of women and 27 % of men reported serostatus disclosure to their partner before conception. Knowledge of safer conception strategies was low. Around two-thirds reported consistent condom use, 41 % of women and 88 % of men reported antiretroviral therapy, and a third of women reported male partner circumcision prior to the referent pregnancy. Seven women (3 %) and two men (2 %) reported limiting sex without condoms to peak fertility. None reported sperm washing or manual insemination. Safer conception behaviors including HIV-serostatus disclosure, condom use, and ART at the time of conception were not associated with desired pregnancy. In light of low pregnancy planning and HIV-serostatus disclosure, interventions to improve understandings of serodiscordance and motivate mutual HIV-serostatus disclosure and pregnancy planning are necessary first steps before couples or individuals can implement specific safer conception strategies.
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Affiliation(s)
- L T Matthews
- Division of Infectious Disease and Center for Global Health, Massachusetts General Hospital, 100 Cambridge Street, 15th Floor, Boston, MA, 02114, USA.
| | - J A Smit
- MatCH Research [Maternal, Adolescent and Child Health Research], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
- School of Pharmacy and Pharmacology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - L Moore
- MatCH Research [Maternal, Adolescent and Child Health Research], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - C Milford
- MatCH Research [Maternal, Adolescent and Child Health Research], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - R Greener
- MatCH Research [Maternal, Adolescent and Child Health Research], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - F N Mosery
- MatCH Research [Maternal, Adolescent and Child Health Research], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - H Ribaudo
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, MA, USA
| | - K Bennett
- Bennett Statistical Consulting, Inc., Ballston Lake, NY, USA
| | - T L Crankshaw
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - A Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - C Psaros
- Behavioral Medicine, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - S A Safren
- Behavioral Medicine, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - D R Bangsberg
- Division of Infectious Disease and Center for Global Health, Massachusetts General Hospital, 100 Cambridge Street, 15th Floor, Boston, MA, 02114, USA
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Hoffman RM, Jaycocks A, Vardavas R, Wagner G, Lake JE, Mindry D, Currier JS, Landovitz RJ. Benefits of PrEP as an Adjunctive Method of HIV Prevention During Attempted Conception Between HIV-uninfected Women and HIV-infected Male Partners. J Infect Dis 2015; 212:1534-43. [PMID: 26092856 PMCID: PMC4621256 DOI: 10.1093/infdis/jiv305] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 03/23/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Data on effectiveness of preexposure prophylaxis (PrEP) for human immunodeficiency virus (HIV)-uninfected women attempting conception with HIV-infected male partners are limited to observational studies. METHODS To explore the benefits of PrEP for conception, we developed a model to estimate the average annual probability of a woman remaining HIV-uninfected and having a child ("successful" outcome) via condomless sex with an HIV-infected male. The outcome likelihood is dependent upon parameters defining HIV-1 infectivity. We simulated 2 scenarios: optimal (condomless sex acts limited to the ovulation window), and suboptimal (acts not limited to ovulation). RESULTS In the optimal scenario when the male is on antiretroviral therapy (ART), the average annual probability of the successful outcome is 29.1%, increasing to 29.2% with the addition of PrEP (P = .45). In the suboptimal scenario, the probability is 26.8% with ART alone versus 27.3% with ART/PrEP (P < .0001). Older maternal age reduces the probability of success in both scenarios, particularly after age 30. CONCLUSIONS In our model, PrEP provides little added benefit when the HIV-infected male partner is on ART, condomless sex is limited to the ovulation window, and other modifiable transmission risks are optimized. Older female age decreases the probability of success by increasing the number of condomless sex acts required for conception.
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Affiliation(s)
- Risa M. Hoffman
- Department of Medicine, Division of Infectious Diseases, University of California, David Geffen School of Medicine, Los Angeles
| | | | | | | | - Jordan E. Lake
- Department of Medicine, Division of Infectious Diseases, University of California, David Geffen School of Medicine, Los Angeles
| | - Deborah Mindry
- Department of Psychiatry and Behavioral Sciences, University of California, Center for Culture and Health, Los Angeles
| | - Judith S. Currier
- Department of Medicine, Division of Infectious Diseases, University of California, David Geffen School of Medicine, Los Angeles
| | - Raphael J. Landovitz
- Department of Medicine, Division of Infectious Diseases, University of California, David Geffen School of Medicine, Los Angeles
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Pintye J, Ngure K, Curran K, Vusha S, Mugo N, Celum C, Baeten JM, Heffron R. Fertility Decision-Making Among Kenyan HIV-Serodiscordant Couples Who Recently Conceived: Implications for Safer Conception Planning. AIDS Patient Care STDS 2015; 29:510-6. [PMID: 26301703 DOI: 10.1089/apc.2015.0063] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
HIV-serodiscordant couples often choose to attempt pregnancy despite their HIV transmission risk. Optimizing delivery of HIV risk reduction strategies during peri-conception periods (i.e., safer conception) requires understanding how HIV-serodiscordant couples approach fertility decisions. We conducted 36 in-depth individual interviews with male and female partners of Kenyan heterosexual HIV-serodiscordant couples who recently conceived. Transcripts were analyzed by gender and HIV serostatus using open coding. Matrices were used to identify patterns and emerging themes. Most participants expressed acceptance of being in an HIV-serodiscordant couple and affirmed their resilience to live with serodiscordance and achieve their fertility goals. Overall, while the goal for childbearing was unchanged, conception became an urgent desire so that both partners could experience childrearing together while the HIV-infected partner was still healthy. Children also add value to the relationship, and multiple children were a commonly expressed desire. Couples' desires dominated those of individual partners in fertility decision-making, but male preferences were more influential when the individual desires differed. Values and preferences of the couple as a unit may mediate fertility decision-making in HIV-discordant couples. Thus, it is important that safer conception programs include both partners when appropriate and consider the relationship context during risk reduction counseling and when recommending risk reduction interventions.
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Affiliation(s)
- Jillian Pintye
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Nursing, University of Washington, Seattle, Washington
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, Washington
- College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | - Kathryn Curran
- Department of Global Health, University of Washington, Seattle, Washington
| | - Sophie Vusha
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, Washington
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
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Saleem HT, Surkan PJ, Kerrigan D, Kennedy CE. Application of an ecological framework to examine barriers to the adoption of safer conception strategies by HIV-affected couples. AIDS Care 2015; 28:197-204. [PMID: 26288153 DOI: 10.1080/09540121.2015.1074652] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Safer conception interventions can significantly reduce the risk of horizontal HIV transmission between HIV-serodiscordant partners. However, prior to implementing safer conception interventions, it is essential to understand potential barriers to their adoption so that strategies can be developed to overcome these barriers. This paper examines potential barriers to the adoption of safer conception strategies by HIV-affected couples in Iringa, Tanzania using an ecological framework. We interviewed 30 HIV-positive women, 30 HIV-positive men and 30 health providers engaged in delivering HIV-related services. We also conducted direct observations at five health facilities. Findings suggest that there are multiple barriers to safer conception that operate at the individual, relational, environmental, structural, and super-structural levels. The barriers to safer conception identified are complex and interact across these levels. Barriers at the individual level included antiretroviral adherence, knowledge of HIV status, knowledge and acceptability of safer conception strategies, and poor nutrition. At the relational level, unplanned pregnancies, non-disclosure of status, gendered power dynamics within relationships, and patient-provider interactions posed a threat to safer conception. HIV stigma and distance to health facilities were environmental barriers to safer conception. At the structural level there were multiple barriers to safer conception, including limited safer conception policy guidelines for people living with HIV (PLHIV), lack of health provider training in safer conception strategies and preconception counseling for PLHIV, limited resources, and lack of integration of HIV and sexual and reproductive health services. Poverty and gender norms were super-structural factors that influenced and reinforced barriers to safer conception, which influenced and operated across different levels of the framework. Multi-level interventions are needed to ensure adoption of safer conception strategies and reduce the risk of HIV transmission between partners within HIV-serodiscordant couples.
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Affiliation(s)
- Haneefa T Saleem
- a Department of International Health , Bloomberg School of Public Health, Johns Hopkins University , 615 N. Wolfe Street, Baltimore , MD 21205 , USA
| | - Pamela J Surkan
- a Department of International Health , Bloomberg School of Public Health, Johns Hopkins University , 615 N. Wolfe Street, Baltimore , MD 21205 , USA
| | - Deanna Kerrigan
- b Department of Health , Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University , 624 North Broadway, Hampton House, 257, Baltimore , MD 21205 , USA
| | - Caitlin E Kennedy
- a Department of International Health , Bloomberg School of Public Health, Johns Hopkins University , 615 N. Wolfe Street, Baltimore , MD 21205 , USA
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Venter WDF, Cowan F, Black V, Rebe K, Bekker LG. Pre-exposure prophylaxis in Southern Africa: feasible or not? J Int AIDS Soc 2015; 18:19979. [PMID: 26198344 PMCID: PMC4509894 DOI: 10.7448/ias.18.4.19979] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 04/06/2015] [Accepted: 04/15/2015] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Southern and Eastern Africa bear the brunt of the AIDS epidemic, and current prevention interventions remain inadequate. Antiretroviral-based pre-exposure prophylaxis (PrEP) is gaining momentum as an effective prevention intervention. DISCUSSION Discussions have been started on how this strategy could be employed in Africa such that the populations most in need can be reached urgently for the greatest impact. This requires the selection of specific risk groups and service environments in which PrEP can be distributed safely and cost effectively while being mindful of any ethical issues. CONCLUSIONS Given the need for an integrated public health approach to this, a number of potential populations and opportunities for PrEP distribution exist and are discussed in this commentary.
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Affiliation(s)
| | - Frances Cowan
- Research Department of Infection and Population Health, University College London, London, UK
| | - Vivian Black
- Wits Reproductive Health and HIV Institute (Wits RHI), University of Witwatersrand, Johannesburg, South Africa
| | - Kevin Rebe
- Health4Men, Anova Health Institute, Cape Town, South Africa
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Cáceres CF, Mayer KH, Baggaley R, O'Reilly KR. PrEP Implementation Science: State-of-the-Art and Research Agenda. J Int AIDS Soc 2015; 18:20527. [PMID: 26198351 PMCID: PMC4581083 DOI: 10.7448/ias.18.4.20527] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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Cooper D, Mantell JE, Moodley J, Mall S. The HIV epidemic and sexual and reproductive health policy integration: views of South African policymakers. BMC Public Health 2015; 15:217. [PMID: 25879464 PMCID: PMC4389705 DOI: 10.1186/s12889-015-1577-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 02/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Integration of sexual and reproductive health (SRH) and HIV policies and services delivered by the same provider is prioritised worldwide, especially in sub-Saharan Africa where HIV prevalence is highest. South Africa has the largest antiretroviral treatment (ART) programme in the world, with an estimated 2.7 million people on ART, elevating South Africa's prominence as a global leader in HIV treatment. In 2011, the Southern African HIV Clinicians Society published safer conception guidelines for people living with HIV (PLWH) and in 2013, the South African government published contraceptive guidelines highlighting the importance of SRH and fertility planning services for people living with HIV. Addressing unintended pregnancies, safer conception and maternal health issues is crucial for improving PLWH's SRH and combatting the global HIV epidemic. This paper explores South African policymakers' perspectives on public sector SRH-HIV policy integration, with a special focus on the need for national and regional policies on safer conception for PLWH and contraceptive guidelines implementation. METHODS It draws on 42 in-depth interviews with national, provincial and civil society policymakers conducted between 2008-2009 and 2011-2012, as the number of people on ART escalated. Interviews focused on three key domains: opinions on PLWH's childbearing; the status of SRH-HIV integration policies and services; and thoughts and suggestions on SRH-HIV integration within the restructuring of South African primary care services. Data were coded and analysed according to themes. RESULTS Participants supported SRH-HIV integrated policy and services. However, integration challenges identified included a lack of policy and guidelines, inadequately trained providers, vertical programming, provider work overload, and a weak health system. Participants acknowledged that SRH-HIV integration policies, particularly for safer conception, contraception and cervical cancer, had been neglected. Policymakers supported public sector adoption of safer conception policy and services. Participants interviewed after expanded ART were more positive about safer conception policies for PLWH than participants interviewed earlier. CONCLUSION The past decade's HIV policy changes have increased opportunities for SRH-HIV integration. The findings provide important insights for international, regional and national SRH-HIV policy and service integration initiatives.
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Affiliation(s)
- Diane Cooper
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.
- School of Public Health, University of Western Cape, Private Bag X17, Bellville, 7535, South Africa.
| | - Joanne E Mantell
- HIV Center for Clinical and Behavioral Studies, Division of Gender, Sexuality, and Health, New York State Psychiatric Institute and Columbia University, New York, NY, USA.
| | - Jennifer Moodley
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.
- Cancer Research Initiative, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Sumaya Mall
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
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Flash CA, Stone VE, Mitty JA, Mimiaga MJ, Hall KT, Krakower D, Mayer KH. Perspectives on HIV prevention among urban black women: a potential role for HIV pre-exposure prophylaxis. AIDS Patient Care STDS 2014; 28:635-42. [PMID: 25295393 DOI: 10.1089/apc.2014.0003] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Limited data exist regarding attitudes and acceptability of topical and oral HIV pre-exposure prophylaxis (PrEP) among US black women. This investigation explored interest in HIV chemoprophylaxis and modes of use. Five focus groups enrolled 26 black women recruited from an inner-city community health center and affiliated HIV testing sites. Thematic analysis utilized Atlas.ti. Most women expressed interest in PrEP, as many reported condom failure concerns. Most women preferred a pill formulation to intravaginal gel because of greater perceived privacy and concerns about vaginal side effects and gel leakage. Women who had taken pills previously advocated daily dosing and indicated adherence concerns about episodic or post-coital PrEP. Many women desired prophylactic strategies that included partner testing. Urban black women are interested in utilizing PrEP; however, misgivings exist about gel inconvenience and potential side effects for themselves and their partners. Most women preferred oral PrEP, dosed daily.
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Affiliation(s)
- Charlene A. Flash
- Department of Medicine, Division of Infectious Disease, Baylor College of Medicine, Houston, Texas
| | - Valerie E. Stone
- Divisions of General Medicine and Infectious Diseases, Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jennifer A. Mitty
- Divisions of Infectious Diseases, Beth Israel Deaconess Medical Center Harvard Medical School, Boston, Massachusetts
- The Fenway Institute, Fenway Health, Boston, Massachusetts
| | - Matthew J. Mimiaga
- The Fenway Institute, Fenway Health, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital Harvard Medical School, Boston, Massachusetts
| | - Kathryn T. Hall
- Divisions of General Medicine and Primary Care, Beth Israel Deaconess Medical Center Harvard Medical School, Boston, Massachusetts
| | - Douglas Krakower
- Divisions of Infectious Diseases, Beth Israel Deaconess Medical Center Harvard Medical School, Boston, Massachusetts
| | - Kenneth H. Mayer
- Divisions of Infectious Diseases, Beth Israel Deaconess Medical Center Harvard Medical School, Boston, Massachusetts
- The Fenway Institute, Fenway Health, Boston, Massachusetts
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Abstract
Introduction Infections can impact the reproductive health of women and hence may influence pregnancy related outcomes for both the mother and the child. These infections range from sexually transmitted infections (STIs) to TORCHS infections to periodontal disease to systemic infections and may be transmitted to the fetus during pregnancy, labor, delivery or breastfeeding. Methods A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture. Results Preconception behavioral interventions significantly declines re-infection or new STI rates by 35% (95% CI: 20-47%). Further, condom use has been shown to be the most effective way to prevent HIV infection (85% protection in prospective studies) through sexual intercourse. Intervention trials showed that preconception vaccination against tetanus averted a significant number of neonatal deaths (including those specifically due to tetanus) when compared to placebo in women receiving more than 1 dose of the vaccine (OR 0.28; 95% CI: 0.15-0.52); (OR 0.02; 95% CI: 0.00-0.28) respectively. Conclusion Preconception counseling should be offered to women of reproductive age as soon as they test HIV-positive, and conversely women of reproductive age should be screened with their partners before pregnancy. Risk assessment, screening, and treatment for specific infections should be a component of preconception care because there is convincing evidence that treatment of these infections before pregnancy prevents neonatal infections.
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Abstract
The notion of preconception care aims to target the existing risks before pregnancy, whereby resources may be used to improve reproductive health and optimize knowledge before conceiving. The preconception period provides an opportunity to intervene earlier to optimize the health of potential mothers (and fathers) and to prevent harmful exposures from affecting the developing fetus. These interventions include birth spacing and preventing teenage pregnancy, promotion of contraceptive use, optimization of weight and micronutrient status, prevention and management of infectious diseases, and screening for and managing chronic conditions. Given existing interventions and the need to organize services to optimize delivery of care in a logical and effective manner, interventions are frequently co-packaged or bundled together. This paper highlights packages of preconception interventions that can be combined and co-delivered to women through various delivery channels and provides a logical framework for development of such packages in varying contexts.
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Affiliation(s)
- Zohra S Lassi
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Sohni V Dean
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Dania Mallick
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
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Matthews LT, Heffron R, Mugo NR, Cohen CR, Hendrix CW, Celum C, Bangsberg DR, Baeten JM. High medication adherence during periconception periods among HIV-1-uninfected women participating in a clinical trial of antiretroviral pre-exposure prophylaxis. J Acquir Immune Defic Syndr 2014; 67:91-7. [PMID: 25118795 PMCID: PMC4149628 DOI: 10.1097/qai.0000000000000246] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 05/23/2014] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Pre-exposure prophylaxis (PrEP) may be an important safer conception strategy for HIV-1-uninfected women with HIV-1-infected partners. Understanding medication adherence in this population may inform whether PrEP is a feasible safer conception strategy. METHODS We evaluated predictors of pregnancy and adherence to study medication among HIV-1-uninfected women enrolled in a randomized placebo-controlled trial of PrEP among African HIV-1-serodiscordant couples. Participants were counseled on HIV-1 risk reduction, contraception, and adherence and tested for pregnancy at monthly study visits. Pill counts of dispensed drug were performed and, at a subset of visits, plasma was collected to measure active drug concentration. RESULTS Among 1785 women, pregnancy incidence was 10.2 per 100 person-years. Younger age, not using contraception, having an additional sexual partner, and reporting unprotected sex were associated with increased likelihood of pregnancy. Monthly clinic pill counts estimated that women experiencing pregnancy took 97% of prescribed doses overall, with at least 80% pill adherence for 98% of study months, and no difference in adherence in the periconception period compared with previous periods (P = 0.98). Tenofovir was detected in plasma at 71% of visits where pregnancy was discovered. By multiple measures, adherence was similar for women experiencing and not experiencing pregnancy (P ≥ 0.1). CONCLUSIONS In this clinical trial of PrEP, pregnancy incidence was 10% per year despite excellent access to effective contraception. Women experiencing pregnancy had high medication adherence, suggesting that PrEP may be an acceptable and feasible safer conception strategy for HIV-1-uninfected women with HIV-1-serodiscordant partners.
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Affiliation(s)
- Lynn T. Matthews
- Division of Infectious Disease and Center for Global Health, Massachusetts General Hospital, Boston, MA
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, MA
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, WA
| | - Nelly R. Mugo
- Department of Global Health, University of Washington, Seattle, WA
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, San Francisco, CA
| | | | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA
- Department of Medicine, University of Washington, Seattle, WA; and
- Department of Epidemiology, University of Washington, Seattle, WA
| | - David R. Bangsberg
- Division of Infectious Disease and Center for Global Health, Massachusetts General Hospital, Boston, MA
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, WA
- Department of Medicine, University of Washington, Seattle, WA; and
- Department of Epidemiology, University of Washington, Seattle, WA
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McMahon JM, Myers JE, Kurth AE, Cohen SE, Mannheimer SB, Simmons J, Pouget ER, Trabold N, Haberer JE. Oral pre-exposure prophylaxis (PrEP) for prevention of HIV in serodiscordant heterosexual couples in the United States: opportunities and challenges. AIDS Patient Care STDS 2014; 28:462-74. [PMID: 25045996 PMCID: PMC4135325 DOI: 10.1089/apc.2013.0302] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Oral HIV pre-exposure prophylaxis (PrEP) is a promising new biomedical prevention approach in which HIV-negative individuals are provided with daily oral antiretroviral medication for the primary prevention of HIV-1. Several clinical trials have demonstrated efficacy of oral PrEP for HIV prevention among groups at high risk for HIV, with adherence closely associated with level of risk reduction. In the United States (US), three groups have been prioritized for initial implementation of PrEP-injection drug users, men who have sex with men at substantial risk for HIV, and HIV-negative partners within serodiscordant heterosexual couples. Numerous demonstration projects involving PrEP implementation among MSM are underway, but relatively little research has been devoted to study PrEP implementation in HIV-serodiscordant heterosexual couples in the US. Such couples face a unique set of challenges to PrEP implementation at the individual, couple, and provider level with regard to PrEP uptake and maintenance, adherence, safety and toxicity, clinical monitoring, and sexual risk behavior. Oral PrEP also provides new opportunities for serodiscordant couples and healthcare providers for primary prevention and reproductive health. This article provides a review of the critical issues, challenges, and opportunities involved in the implementation of oral PrEP among HIV-serodiscordant heterosexual couples in the US.
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Affiliation(s)
- James M. McMahon
- School of Nursing, University of Rochester Medical Center, Rochester, New York
| | - Julie E. Myers
- Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, New York, New York
- Division of Infectious Diseases, Department of Medicine, Columbia University, New York, New York
| | - Ann E. Kurth
- College of Nursing, New York University, New York, New York
| | - Stephanie E. Cohen
- San Francisco Department of Public Health, STD Prevention and Control, San Francisco, California
| | - Sharon B. Mannheimer
- Department of Medicine, Harlem Hospital, Columbia University College of Physicians and Surgeons, New York, New York
| | - Janie Simmons
- National Development and Research Institutes, New York, New York
| | | | - Nicole Trabold
- School of Nursing, University of Rochester Medical Center, Rochester, New York
| | - Jessica E. Haberer
- Massachusetts General Hospital Center for Global Health and Harvard Medical School, Boston, Massachusetts
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Abstract
BACKGROUND There is a paucity of data on the effect of antiretroviral medications on male fertility. Couples affected by HIV-1 often have fertility intentions, and antiretroviral medications, as both treatment of HIV-1-infected persons and pre-exposure prophylaxis (PrEP) for uninfected persons, are part of peri-conception risk reduction. METHODS Within a randomized, placebo-controlled trial of daily oral tenofovir disoproxil fumarate (TDF) and combination emtricitabine (FTC)/TDF PrEP for HIV-1 prevention conducted among heterosexual HIV-1-serodiscordant couples, we assessed the impact of TDF and FTC/TDF use on male fertility, measured as incident pregnancy in female partners of men assigned to PrEP vs. placebo. RESULTS Of the 2962 HIV-1-uninfected men partners, 986 were randomized to TDF, 1013 to FTC/TDF, and 963 to placebo. The overall pregnancy incidence in their HIV-1-infected female partners was 12.9 per 100 person-years and did not differ significantly across the study arms (13.2 TDF, 12.4 FTC/TDF, 13.2 placebo). The frequency of live births, pregnancy losses, and gestational age at birth or loss was also statistically similar in the three randomization groups. CONCLUSION TDF and FTC/TDF, when used as PrEP by HIV-1-uninfected men, did not adversely affect male fertility or pregnancy outcomes.
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Mmeje O, van der Poel S, Workneh M, Njoroge B, Bukusi E, Cohen CR. Achieving pregnancy safely: perspectives on timed vaginal insemination among HIV-serodiscordant couples and health-care providers in Kisumu, Kenya. AIDS Care 2014; 27:10-6. [PMID: 25105422 DOI: 10.1080/09540121.2014.946385] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In female-positive HIV-serodiscordant couples desiring children, home timed vaginal insemination (TVI) of semen during the fertile period along with consistent condom use may reduce the risk of HIV transmission when the man is HIV-uninfected. In sub-Saharan Africa, up to 45% of HIV-infected women desire to have more children. HIV viral load assessment is not routinely available in low-resource countries for monitoring adherence and response to antiretroviral therapy. Therefore, in these settings, timed unprotected intercourse without assurance of HIV viral suppression may pose unnecessary risks. TVI, a simple and affordable intervention, can be considered an adjunct method and option of safer conception for HIV prevention with treatment of the HIV-infected partner and/or pre-exposure prophylaxis. We conducted five mixed and single-sex focus group discussions comprised of 33 HIV-serodiscordant couples and health-care providers in the Nyanza region of Kenya to assess the acceptability and feasibility of TVI as a safer method of conception. The transcribed data were analyzed using a grounded theory approach. We found that educating and counseling HIV-serodiscordant couples on TVI could make it an acceptable and feasible safer conception method when associated with frequent communication and home visits by health-care providers. The findings of this study indicate that implementation studies that integrate training and counseling of HIV-serodiscordant couples and health-care providers on TVI combined with consistent condom use are needed. Acknowledging and supporting the reproductive choice and needs of female positive, male negative HIV-serodiscordant couples who desire children should also include the use of assisted reproductive services at the same time as pharmaceutical options that prevent sexual HIV transmission.
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Affiliation(s)
- Okeoma Mmeje
- a Department of Obstetrics and Gynecology , University of Michigan , Ann Arbor , MI , USA
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Mugo NR, Hong T, Celum C, Donnell D, Bukusi EA, John-Stewart G, Wangisi J, Were E, Heffron R, Matthews LT, Morrison S, Ngure K, Baeten JM. Pregnancy incidence and outcomes among women receiving preexposure prophylaxis for HIV prevention: a randomized clinical trial. JAMA 2014; 312:362-71. [PMID: 25038355 PMCID: PMC4362516 DOI: 10.1001/jama.2014.8735] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Antiretroviral preexposure prophylaxis (PrEP), using tenofovir disoproxil fumarate (TDF) and combination emtricitabine/tenofovir disoproxil fumarate (FTC+TDF), is efficacious for prevention of human immunodeficiency virus (HIV) acquisition. PrEP could reduce periconception HIV risk, but the effect on pregnancy outcomes is not well defined. OBJECTIVE To assess pregnancy incidence and outcomes among women using PrEP during the periconception period. DESIGN, SETTING, AND PARTICIPANTS Randomized trial among 1785 HIV-serodiscordant heterosexual couples (the Partners PrEP Study) in which the female partner was HIV uninfected that demonstrated that PrEP was efficacious for HIV prevention, conducted between July 2008 and June 2013 at 9 sites in Kenya and Uganda. INTERVENTIONS Daily oral TDF (n = 598), combination FTC+TDF (n = 566), or placebo (n = 621) through July 2011, when PrEP demonstrated efficacy for HIV prevention. Thereafter, participants continued receiving active PrEP without placebo. Pregnancy testing occurred monthly and study medication was discontinued when pregnancy was detected. MAIN OUTCOMES AND MEASURES Pregnancy incidence, birth outcomes (live births, pregnancy loss, preterm birth, congenital anomalies), and infant growth. RESULTS A total of 431 pregnancies occurred. Pregnancy incidence was 10.0 per 100 person-years among women assigned placebo, 11.9 among those assigned TDF (incidence difference, 1.9; 95% CI, -1.1 to 4.9 [P = .22 vs placebo]), and 8.8 among those assigned FTC+TDF (incidence difference, -1.3; 95% CI, -4.1 to 1.5 [P = .39 vs placebo]). Before discontinuation of the placebo treatment group in July 2011, the occurrence of pregnancy loss (96 of 288 pregnancies) was 42.5% for women receiving FTC+TDF compared with 32.3% for those receiving placebo (difference for FTC+TDF vs placebo, 10.2%; 95% CI, -5.3% to 25.7%; P = .16) and was 27.7% for those receiving TDF alone (difference vs placebo, -4.6%; 95% CI, -18.1% to 8.9%; P = .46). After July 2011, the frequency of pregnancy loss (52 of 143 pregnancies) was 37.5% for FTC+TDF and 36.7% for TDF alone (difference, 0.8%; 95% CI, -16.8% to 18.5%; P = .92). Occurrence of preterm birth, congenital anomalies, and growth throughout the first year of life did not differ significantly for infants born to women who received PrEP vs placebo. CONCLUSIONS AND RELEVANCE Among HIV-serodiscordant heterosexual African couples, differences in pregnancy incidence, birth outcomes, and infant growth were not statistically different for women receiving PrEP with TDF alone or combination FTC+TDF compared with placebo at conception. Given that PrEP was discontinued when pregnancy was detected and that CIs for the birth outcomes were wide, definitive statements about the safety of PrEP in the periconception period cannot be made. These results should be discussed with HIV-uninfected women receiving PrEP who are considering becoming pregnant. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00557245.
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Affiliation(s)
- Nelly R Mugo
- Department of Global Health, University of Washington, Seattle2Centre for Clinical Research Kenya Medical Research Institute, Nairobi, Kenya3Department of Obstetrics and Gynaecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Ting Hong
- Department of Global Health, University of Washington, Seattle
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle4Department of Medicine, University of Washington, Seattle5Department of Epidemiology, University of Washington, Seattle
| | - Deborah Donnell
- Department of Global Health, University of Washington, Seattle6Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Elizabeth A Bukusi
- Department of Global Health, University of Washington, Seattle7Department of Obstetrics and Gynecology, University of Washington, Seattle8Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle4Department of Medicine, University of Washington, Seattle5Department of Epidemiology, University of Washington, Seattle9Department of Pediatrics, University of Washington, Seattle
| | | | - Edwin Were
- Department of Reproductive Health, Moi University, Eldoret, Kenya
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle
| | - Lynn T Matthews
- Division of Infectious Disease, Massachusetts General Hospital, Boston13Center for Global Health, Massachusetts General Hospital, Boston
| | - Susan Morrison
- Department of Global Health, University of Washington, Seattle
| | - Kenneth Ngure
- Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle4Department of Medicine, University of Washington, Seattle5Department of Epidemiology, University of Washington, Seattle
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Ngure K, Baeten JM, Mugo N, Curran K, Vusha S, Heffron R, Celum C, Shell-Duncan B. My intention was a child but I was very afraid: fertility intentions and HIV risk perceptions among HIV-serodiscordant couples experiencing pregnancy in Kenya. AIDS Care 2014; 26:1283-7. [PMID: 24779445 DOI: 10.1080/09540121.2014.911808] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We sought to understand fertility intentions and HIV risk considerations among Kenyan HIV-serodiscordant couples who became pregnant during a prospective study. We conducted individual in-depth interviews (n = 36) and focus group discussions (n = 4) and performed qualitative data analysis and interpretation using an inductive approach. Although most of the couples were aware of the risk of horizontal and vertical HIV transmission, almost all couples reported that they had intended to become pregnant and that the desire for children superseded HIV risk considerations. Motivations for pregnancy were numerous and complex: satisfying desired family size, desire for biological children, maintaining stability of the union, and sociocultural pressures. Couples desired strategies to reduce HIV risk during conception, but expressed hesitation toward assisted reproductive technologies as unnatural. HIV prevention programs should therefore address conception desires and counsel about coordinated periconception risk-reduction strategies.
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Affiliation(s)
- Kenneth Ngure
- a Institute of Tropical Medicine and Infectious Diseases , Jomo Kenyatta University , Juja , Kenya
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Jallouk AP, Moley KH, Omurtag K, Hu G, Lanza GM, Wickline SA, Hood JL. Nanoparticle incorporation of melittin reduces sperm and vaginal epithelium cytotoxicity. PLoS One 2014; 9:e95411. [PMID: 24748389 PMCID: PMC3991669 DOI: 10.1371/journal.pone.0095411] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 03/27/2014] [Indexed: 11/18/2022] Open
Abstract
Melittin is a cytolytic peptide component of bee venom which rapidly integrates into lipid bilayers and forms pores resulting in osmotic lysis. While the therapeutic utility of free melittin is limited by its cytotoxicity, incorporation of melittin into the lipid shell of a perfluorocarbon nanoparticle has been shown to reduce its toxicity in vivo. Our group has previously demonstrated that perfluorocarbon nanoparticles containing melittin at concentrations <10 µM inhibit HIV infectivity in vitro. In the current study, we assessed the impact of blank and melittin-containing perfluorocarbon nanoparticles on sperm motility and the viability of both sperm and vaginal epithelial cells. We found that free melittin was toxic to sperm and vaginal epithelium at concentrations greater than 2 µM (p<0.001). However, melittin nanoparticles were not cytotoxic to sperm (p = 0.42) or vaginal epithelium (p = 0.48) at an equivalent melittin concentration of 10 µM. Thus, nanoparticle formulation of melittin reduced melittin cytotoxicity fivefold and prevented melittin toxicity at concentrations previously shown to inhibit HIV infectivity. Melittin nanoparticles were toxic to vaginal epithelium at equivalent melittin concentrations ≥20 µM (p<0.001) and were toxic to sperm at equivalent melittin concentrations ≥40 µM (p<0.001). Sperm cytotoxicity was enhanced by targeting of the nanoparticles to the sperm surface antigen sperm adhesion molecule 1. While further testing is needed to determine the extent of cytotoxicity in a more physiologically relevant model system, these results suggest that melittin-containing nanoparticles could form the basis of a virucide that is not toxic to sperm and vaginal epithelium. This virucide would be beneficial for HIV serodiscordant couples seeking to achieve natural pregnancy.
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Affiliation(s)
- Andrew P. Jallouk
- Department of Medicine, Division of Cardiology, Consortium for Translational Research in Advanced Imaging and Nanomedicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Kelle H. Moley
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Kenan Omurtag
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Grace Hu
- Department of Medicine, Division of Cardiology, Consortium for Translational Research in Advanced Imaging and Nanomedicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Gregory M. Lanza
- Department of Medicine, Division of Cardiology, Consortium for Translational Research in Advanced Imaging and Nanomedicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Samuel A. Wickline
- Department of Medicine, Division of Cardiology, Consortium for Translational Research in Advanced Imaging and Nanomedicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Joshua L. Hood
- Department of Medicine, Division of Cardiology, Consortium for Translational Research in Advanced Imaging and Nanomedicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
- * E-mail:
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Challenges with couples, serodiscordance and HIV disclosure: healthcare provider perspectives on delivering safer conception services for HIV-affected couples, South Africa. J Int AIDS Soc 2014; 17:18832. [PMID: 24629843 PMCID: PMC3956311 DOI: 10.7448/ias.17.1.18832] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 12/02/2013] [Accepted: 01/31/2014] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Safer conception interventions should ideally involve both members of an HIV-affected couple. With serodiscordant couples, healthcare providers will need to manage periconception risk behaviour as well tailor safer conception strategies according to available resources and the HIV status of each partner. Prior to widespread implementation of safer conception services, it is crucial to better understand provider perspectives regarding provision of care since they will be pivotal to the successful delivery of safer conception. This paper reports on findings from a qualitative study exploring the viewpoints and experiences of doctors, nurses, and lay counsellors on safer conception care in a rural and in an urban setting in Durban, South Africa. METHODS We conducted six semistructured individual interviews per site (a total of 12 interviews) as well as a focus group discussion at each clinic site (a total of 13 additional participants). All interviews were coded in Atlas.ti using a grounded theory approach to develop codes and to identify core themes and subthemes in the data. RESULTS Managing the clinical and relationship complexities related to serodiscordant couples wishing to conceive was flagged as a concern by all categories of health providers. Providers added that, in the HIV clinical setting, they often found it difficult to balance their professional priorities, to maintain the health of their clients, and to ensure that partners were not exposed to unnecessary risk, while still supporting their clients' desires to have a child. Many providers expressed concern over issues related to disclosure of HIV status between partners, particularly when managing couples where one partner was not aware of the other's status and expressed the desire for a child. Provider experiences were that female clients most often sought out care, and it was difficult to reach the male partner to include him in the consultation. CONCLUSIONS Providers require support in dealing with HIV disclosure issues and in becoming more confident in dealing with couples and serodiscordance. Prior to implementing safer conception programmes, focused training is needed for healthcare professionals to address some of the ethical and relationship issues that are critical in the context of safer conception care.
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[Consensus statement on monitoring of HIV: pregnancy, birth, and prevention of mother-to-child transmission]. Enferm Infecc Microbiol Clin 2014; 32:310.e1-310.e33. [PMID: 24484733 DOI: 10.1016/j.eimc.2013.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 12/02/2013] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The main objective in the management of HIV-infected pregnant women is prevention of mother-to-child transmission; therefore, it is essential to provide universal antiretroviral treatment, regardless of CD4 count. All pregnant women must receive adequate information and undergo HIV serology testing at the first visit. METHODS We assembled a panel of experts appointed by the Secretariat of the National AIDS Plan (SPNS) and the other participating Scientific Societies, which included internal medicine physicians with expertise in the field of HIV infection, gynecologists, pediatricians and psychologists. Four panel members acted as coordinators. Scientific information was reviewed in publications and conference reports up to November 2012. In keeping with the criteria of the Infectious Diseases Society of America, 2levels of evidence were applied to support the proposed recommendations: the strength of the recommendation according to expert opinion (A, B, C), and the level of empirical evidence (I, II, III). This approach has already been used in previous documents from SPNS. RESULTS AND CONCLUSIONS The aim of this paper was to review current scientific knowledge, and, accordingly, develop a set of recommendations regarding antiretroviral therapy (ART), regarding the health of the mother, and from the perspective of minimizing mother-to-child transmission (MTCT), also taking into account the rest of the health care of pregnant women with HIV infection. We also discuss and evaluate other strategies to reduce the MTCT (elective Cesarean, child's treatment…), and different aspects of the topic (ARV regimens, their toxicity, monitoring during pregnancy and postpartum, etc.).
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Baeten JM, Grant R. Use of antiretrovirals for HIV prevention: what do we know and what don't we know? Curr HIV/AIDS Rep 2013; 10:142-51. [PMID: 23494772 DOI: 10.1007/s11904-013-0157-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Pre-exposure prophylaxis (PrEP), in which HIV uninfected persons with ongoing HIV risk use antiretroviral medications as chemoprophylaxis against sexual HIV acquisition, is a promising new HIV prevention strategy. Proof-of-concept that PrEP, as oral or vaginal topical tenofovir-based products, protects against sexual HIV acquisition has been demonstrated in clinical trials conducted among men who have sex with men and heterosexual men and women. The degree of HIV protection in these trials was strongly related to the level of adherence to PrEP. Many questions are yet unanswered--including how to motivate uptake of and sustain adherence to PrEP for HIV prevention, how much PrEP use is enough to achieve HIV protection, and the potential of "next-generation" PrEP agents to improve on this effective technology.
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Affiliation(s)
- Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA 98104, USA.
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MacCarthy S, Rasanathan JJK, Ferguson L, Gruskin S. The pregnancy decisions of HIV-positive women: the state of knowledge and way forward. REPRODUCTIVE HEALTH MATTERS 2013. [PMID: 23177686 DOI: 10.1016/s0968-8080(12)39641-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Despite the growing number of women living with and affected by HIV, there is still insufficient attention to their pregnancy-related needs, rights, decisions and desires in research, policy and programs. We carried out a review of the literature to ascertain the current state of knowledge and highlight areas requiring further attention. We found that contraceptive options for pregnancy prevention by HIV-positive women are insufficient: condoms are not always available or acceptable, and other options are limited by affordability, availability or efficacy. Further, coerced sterilization of women living with HIV is widely reported. Information gaps persist in relation to effectiveness, safety and best practices regarding assisted reproductive technologies. Attention to neonatal outcomes generally outweighs attention to the health of women before, during and after pregnancy. Access to safe abortion and post-abortion care services, which are critical to women's ability to fulfill their sexual and reproductive rights, are often curtailed. There is inadequate attention to HIV-positive sex workers, injecting drug users and adolescents. The many challenges that women living with HIV encounter in their interactions with sexual and reproductive health services shape their pregnancy decisions. It is critical that HIV-positive women be more involved in the design and implementation of research, policies and programs related to their pregnancy-related needs and rights.
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Affiliation(s)
- Sarah MacCarthy
- The Miriam Hospital and Alpert Medical School of Brown University, Providence, RI, USA.
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Preconception care for people living with HIV: recommendations for advancing implementation. AIDS 2013; 27 Suppl 1:S113-9. [PMID: 24088677 DOI: 10.1097/qad.0000000000000059] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Globally, research has documented high fertility desires and intentions among HIV-positive women. Improving implementation of preconception care (PCC) for people living with HIV is critical, given estimates that the majority of HIV-positive women who want future biological children have not received reproductive counseling, largely due to a lack of provider-initiated conversations. This article offers initial recommendations and outlines key considerations for a research agenda to advance PCC implementation efforts in both high-resource and low-resource settings. We consider who should provide PCC; where it can be effectively delivered; when it should be offered; and two potential implementation models depending on available resources. We conclude with a call for PCC-specific implementation science and research translation to help people living with HIV achieve their reproductive goals.
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