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Cooper R, Greig J, Piercy H, Collini P. Investigating the Pregnancy and Post-Partum Health Experiences of Women Living with HIV. Matern Child Health J 2024:10.1007/s10995-024-03962-y. [PMID: 38904904 DOI: 10.1007/s10995-024-03962-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2024] [Indexed: 06/22/2024]
Abstract
INTRODUCTION Pregnancy and the postpartum period is a difficult time for women living with HIV (WLWH) and postpartum engagement with HIV care is often reduced, with implications for health and well-being. We aimed to explore the postpartum health experiences of WLWH in relation to engagement in HIV care. METHODS The NESTOR (iNvESTigating the pregnancy and pOst-paRtum health experience of women living with HIV) study was a UK based qualitative semi-structured interview study. 61 eligible women were identified. We used a purposive sampling technique to recruit women with differing levels of engagement in HIV care. Interviews were conducted via telephone or video call. Interviews were audio recorded and fully transcribed. We used a thematic approach for data analysis, and two researchers independently coded the data and established the key themes. RESULTS 11 of 61 (18%) eligible women participated in the interviews, and the three main themes were 'infant feeding decisions', 'managing the risk of mother to child transmission', and 'managing the knowledge of their HIV status'. These themes offer detailed insights into the significant psychological and emotional challenges these women had experienced, and the practical support from healthcare professionals in both HIV and maternity services that had enabled them to navigate those challenges. DISCUSSION There have been life-changing developments in the treatment and care for people living with HIV. However, even in the U = U (undetectable = untransmittable) era, traditional concerns about breastfeeding, risk of transmission to the infant and stigma continue to shape the postpartum experience of WLWH. As these impact on their emotional and psychological wellbeing, support in these areas needs to be prioritised.
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Affiliation(s)
| | - Julia Greig
- Department of Infectious Diseases and Tropical Medicine Sheffield Teaching Hospitals, The University of Sheffield, Sheffield, England
| | | | - Paul Collini
- Department of Infectious Diseases and Tropical Medicine Sheffield Teaching Hospitals, The University of Sheffield, Sheffield, England
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Fairlie L, Sawry S, Pals S, Sherman G, Williamson D, Le Roux J, Ngeno B, Berrie L, Diallo K, Cox MH, Mogashoa M, Chersich M, Modi S. More Frequent HIV Viral Load Testing With Point-Of-Care Tests Detects Elevated Viral Load Earlier in Postpartum HIV-Positive Women in a Randomized Controlled Trial in Two Clinics in Johannesburg, South Africa. J Acquir Immune Defic Syndr 2023; 94:412-420. [PMID: 37949444 DOI: 10.1097/qai.0000000000003295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 08/04/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Elevated maternal HIV viral load (VL) increases vertical transmission risk for breastfeeding children. This randomized controlled trial in Johannesburg primarily evaluated whether 3-monthly point-of-care testing, with laboratory-based standard-of-care testing (arm 2), compared with 6-monthly laboratory-based VL testing (arm 1) in postpartum women living with HIV receiving first-line tenofovir-emtricitabine-efavirenz antiretroviral treatment improved VL suppression, factors associated with nonsuppression, and drug resistance in those with virologic failure. METHODS Mother-child pairs were enrolled July 2018-April 2019 at the child's 6/10/14-week clinic visit. Women were randomized 1:1 to arm 1 or 2. Trained staff performed point-of-care VL testing using the Cepheid's Xpert HIV-1 VL assay. We fitted a generalized linear mixed model with VL suppression (<50 copies/mL (cps/mL) and <1000 cps/mL) at enrollment and 6, 12, and 18 months postpartum as the outcome and indicator variables for time, study site, study arm, and interaction variables. The final model tested for a difference by study arm, pooling across time points. RESULTS Of 405 women enrolled (204 arm 1 and 201 arm 2), 249 (61%) remained in follow-up through 18 months. There was no difference in VL suppression between arms at 6, 12, or 18 months. VL suppression rate (<50 cps/mL) at 18 months was 64.8% in arm 1 and 63.0% in arm 2 (P = 0.27). On bivariate analysis, there was an association with late antenatal booking and being in arm 2 for nonsuppressed VL, but no significant association with breastfeeding. HIV drug resistance was found in 12 of 23 participants (52.2%). CONCLUSION We found no significant difference in VL suppression with more frequent VL testing in postpartum women living with HIV receiving first-line efavirenz-based antiretroviral treatment.
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Affiliation(s)
- Lee Fairlie
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shobna Sawry
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sherri Pals
- Division of Global HIV & Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Gayle Sherman
- Paediatric HIV Surveillance in the Centre for HIV and STI, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
- Department of Paediatrics & Child Health, Faculty of Heath Sciences, University of the Witwatersrand, Johannesburg, South Africa; and
| | - Dhelia Williamson
- Division of Global HIV & Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Jean Le Roux
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bernadette Ngeno
- Division of Global HIV & Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Leigh Berrie
- Division of Global HIV and TB (DGHT), CDC South Africa, Pretoria, South Africa
| | - Karidia Diallo
- Division of Global HIV and TB (DGHT), CDC South Africa, Pretoria, South Africa
| | - Mackenzie Hurlston Cox
- Division of Global HIV & Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Mary Mogashoa
- Division of Global HIV and TB (DGHT), CDC South Africa, Pretoria, South Africa
| | - Matthew Chersich
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Surbhi Modi
- Division of Global HIV & Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Atlanta, GA
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Corlis J, Zhu J, Macul H, Tiberi O, Boothe MAS, Resch SC. Framework for determining the optimal course of action when efficiency and affordability measures differ by perspective in cost-effectiveness analysis-with an illustrative case of HIV treatment in Mozambique. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:62. [PMID: 37705101 PMCID: PMC10498553 DOI: 10.1186/s12962-023-00474-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/03/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Cost-effectiveness analysis (CEA) is a standard tool for evaluating health programs and informing decisions about resource allocation and prioritization. Most CEAs evaluating health interventions in low- and middle-income countries adopt a health sector perspective, accounting for resources funded by international donors and country governments, while often excluding out-of-pocket expenditures and time costs borne by program beneficiaries. Even when patients' costs are included, a companion analysis focused on the patient perspective is rarely performed. We view this as a missed opportunity. METHODS We developed methods for assessing intervention affordability and evaluating whether optimal interventions from the health sector perspective also represent efficient and affordable options for patients. We mapped the five different patterns that a comparison of the perspective results can yield into a practical framework, and we provided guidance for researchers and decision-makers on how to use results from multiple perspectives. To illustrate the methodology, we conducted a CEA of six HIV treatment delivery models in Mozambique. We conducted a Monte Carlo microsimulation with probabilistic sensitivity analysis from both patient and health sector perspectives, generating incremental cost-effectiveness ratios for the treatment approaches. We also calculated annualized patient costs for the treatment approaches, comparing the costs with an affordability threshold. We then compared the cost-effectiveness and affordability results from the two perspectives using the framework we developed. RESULTS In this case, the two perspectives did not produce a shared optimal approach for HIV treatment at the willingness-to-pay threshold of 0.3 × Mozambique's annual GDP per capita per DALY averted. However, the clinical 6-month antiretroviral drug distribution strategy, which is optimal from the health sector perspective, is efficient and affordable from the patient perspective. All treatment approaches, except clinical 1-month distributions of antiretroviral drugs which were standard before Covid-19, had an annual cost to patients less than the country's annual average for out-of-pocket health expenditures. CONCLUSION Including a patient perspective in CEAs and explicitly considering affordability offers decision-makers additional insights either by confirming that the optimal strategy from the health sector perspective is also efficient and affordable from the patient perspective or by identifying incongruencies in value or affordability that could affect patient participation.
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Affiliation(s)
| | - Jinyi Zhu
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Hélder Macul
- Programa Nacional de Controle de ITS-HIV/SIDA, Ministério da Saúde, Maputo, Mozambique
| | - Orrin Tiberi
- Programa Nacional de Controle de ITS-HIV/SIDA, Ministério da Saúde, Maputo, Mozambique
| | | | - Stephen C. Resch
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA USA
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Chohan BH, Ronen K, Khasimwa B, Matemo D, Osborn L, Unger JA, Drake AL, Beck IA, Frenkel LM, Kinuthia J, John-Stewart G. Food insecurity, drug resistance and non-disclosure are associated with virologic non-suppression among HIV pregnant women on antiretroviral treatment. PLoS One 2021; 16:e0256249. [PMID: 34407133 PMCID: PMC8372899 DOI: 10.1371/journal.pone.0256249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 07/29/2021] [Indexed: 11/25/2022] Open
Abstract
We determined social and behavioral factors associated with virologic non-suppression among pregnant women receiving Option B+ antiretroviral treatment (ART). Baseline data was used from women in Mobile WAChX trial from 6 public maternal child health (MCH) clinics in Kenya. Virologic non-suppression was defined as HIV viral load (VL) ≥1000 copies/ml. Antiretroviral resistance testing was performed using oligonucleotide ligation (OLA) assay. ART adherence information, motivation and behavioral skills were assessed using Lifewindows IMB tool, depression using PHQ-9, and food insecurity with the Household Food Insecurity Access Scale. Correlates of virologic non-suppression were assessed using Poisson regression. Among 470 pregnant women on ART ≥4 months, 57 (12.1%) had virologic non-suppression, of whom 65% had HIV drug resistance mutations. In univariate analyses, risk of virologic non-suppression was associated with moderate-to-severe food insecurity (RR 1.80 [95% CI 1.06–3.05]), and varied significantly by clinic site (range 2%-22%, p <0.001). In contrast, disclosure (RR 0.36 [95% CI 0.17–0.78]) and having higher adherence skills (RR 0.70 [95% CI 0.58–0.85]) were associated with lower risk of virologic non-suppression. In multivariate analysis adjusting for clinic site, disclosure, depression symptoms, adherence behavior skills and food insecurity, disclosure and food insecurity remained associated with virologic non-suppression. Age, side-effects, social support, physical or emotional abuse, and distance were not associated with virologic non-suppression. Prevalence of virologic non-suppression among pregnant women on ART was appreciable and associated with food insecurity, disclosure and frequent drug resistance. HIV VL and resistance monitoring, and tailored counseling addressing food security and disclosure, may improve virologic suppression in pregnancy.
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Affiliation(s)
- Bhavna H Chohan
- Department of Global Health, University of Washington, Seattle, Washington, United States of America.,Center for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Keshet Ronen
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Brian Khasimwa
- Department of Pediatrics, University of Nairobi, Nairobi, Kenya
| | - Daniel Matemo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Lusi Osborn
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Jennifer A Unger
- Department of Global Health, University of Washington, Seattle, Washington, United States of America.,Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
| | - Alison L Drake
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Ingrid A Beck
- Center for Infectious Diseases Research, Seattle Children's Research Institute, Seattle, Washington, United States of America
| | - Lisa M Frenkel
- Department of Global Health, University of Washington, Seattle, Washington, United States of America.,Center for Infectious Diseases Research, Seattle Children's Research Institute, Seattle, Washington, United States of America.,Department of Medicine, University of Washington, Seattle, Washington, United States of America.,Department of Pediatrics, University of Washington, Seattle, Washington, United States of America.,Department of Laboratory Medicine, University of Washington, Seattle, Washington, United States of America
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, Washington, United States of America.,Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington, United States of America.,Department of Medicine, University of Washington, Seattle, Washington, United States of America.,Department of Pediatrics, University of Washington, Seattle, Washington, United States of America.,Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
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Early post-partum viremia predicts long-term non-suppression of viral load in HIV-positive women on ART in Malawi: Implications for the elimination of infant transmission. PLoS One 2021; 16:e0248559. [PMID: 33711066 PMCID: PMC7954347 DOI: 10.1371/journal.pone.0248559] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/01/2021] [Indexed: 12/03/2022] Open
Abstract
Background Long-term viral load (VL) suppression among HIV-positive, reproductive-aged women on ART is key to eliminating mother-to-child transmission (MTCT) but few data exist from sub-Saharan Africa. We report trends in post-partum VL in Malawian women on ART and factors associated with detectable VL up to 24 months post-partum. Methods 1–6 months post-partum mothers, screened HIV-positive at outpatient clinics in Malawi, were enrolled (2014–2016) with their infants. At enrollment, 12- and 24-months post-partum socio-demographic and PMTCT indicators were collected. Venous samples were collected for determination of maternal VL (limit of detection 40 copies/ml). Results were returned to clinics for routine management. Results 596/1281 (46.5%) women were retained in the study to 24 months. Those retained were older (p<0.01), had higher parity (p = 0.03) and more likely to have undetectable VL at enrollment than those lost to follow-up (80.0% vs 70.2%, p<0.01). Of 590 women on ART (median 30.1 months; inter-quartile range 26.8–61.3), 442 (74.9%) with complete VL data at 3 visits were included in further analysis. Prevalence of detectable VL at 12 and 24 months was higher among women with detectable VL at enrollment than among those with undetectable VL (74 detectable VL results/66 women vs. 19/359; p<0.001). In multivariable analysis (adjusted for age, parity, education, partner disclosure, timing of ART start and self-reported adherence), detectable VL at 24 months was 9 times more likely among women with 1 prior detectable VL (aOR 9.0; 95%CI 3.5–23.0, p<0.001) and 226 times more likely for women with 2 prior detectable VLs (aOR 226.4; 95%CI 73.0–701.8, p<0.001). Conclusions Detectable virus early post-partum strongly increases risk of ongoing post-partum viremia. Due to high loss to follow-up, the true incidence of detectable VL over time is probably underestimated. These findings have implications for MTCT, as well as for the mothers, and call for intensified VL monitoring and targeted adherence support for women during pregnancy and post-partum.
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Myer L, Redd AD, Mukonda E, Lynch BA, Phillips TK, Eisenberg A, Hsiao NY, Capoferri A, Zerbe A, Clarke W, Lesosky M, Breaud A, McIntyre J, Bruno D, Martens C, Abrams EJ, Reynolds SJ. Antiretroviral Adherence, Elevated Viral Load, and Drug Resistance Mutations in Human Immunodeficiency Virus-infected Women Initiating Treatment in Pregnancy: A Nested Case-control Study. Clin Infect Dis 2021; 70:501-508. [PMID: 30877752 DOI: 10.1093/cid/ciz209] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/15/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Elevated viral load (VL) early after antiretroviral therapy (ART) initiation appears frequently in pregnant and postpartum women living with human immunodeficiency virus; however the relative contributions of pre-ART drug resistance mutations (DRMs) vs nonadherence in the etiology of elevated VL are unknown. METHODS Within a cohort of women initiating ART during pregnancy in Cape Town, South Africa, we compared women with elevated VL after initial suppression (cases, n = 80) incidence-density matched to women who maintained suppression over time (controls, n = 87). Groups were compared on pre-ART DRMs and detection of antiretrovirals in stored plasma. RESULTS The prevalence of pre-ART DRMs was 10% in cases and 5% in controls (adjusted odds ratio [aOR], 1.53 [95% confidence interval {CI}, .4-5.9]); all mutations were to nonnucleoside reverse transcriptase inhibitors. At the time of elevated VL, 19% of cases had antiretrovirals detected in plasma, compared with 87% of controls who were suppressed at a matched time point (aOR, 131.43 [95% CI, 32.8-527.4]). Based on these findings, we estimate that <10% of all elevated VL in the cohort may be attributable to pre-ART DRMs vs >90% attributable to ART nonadherence. CONCLUSIONS DRMs account for a small proportion of all elevated VL among women occurring in the 12 months after ART initiation during pregnancy in this setting, with nonadherence appearing to drive most episodes of elevated VL. Alongside the drive for access to more robust antiretroviral agents in resource-limited settings, there is an ongoing need for effective strategies to support ART adherence in this patient population.
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Affiliation(s)
- Landon Myer
- Division of Epidemiology and Biostatistics, University of Cape Town, South Africa.,Centre for Infectious Diseases Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Andrew D Redd
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda.,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Elton Mukonda
- Division of Epidemiology and Biostatistics, University of Cape Town, South Africa
| | - Briana A Lynch
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda
| | - Tamsin K Phillips
- Division of Epidemiology and Biostatistics, University of Cape Town, South Africa.,Centre for Infectious Diseases Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Anna Eisenberg
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda
| | - Nei-Yuan Hsiao
- Division of Medical Virology, Department of Pathology, University of Cape Town, South Africa.,National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa
| | - Adam Capoferri
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alison Zerbe
- ICAP at Columbia University Mailman School of Public Health, New York, New York
| | - William Clarke
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Maia Lesosky
- Division of Epidemiology and Biostatistics, University of Cape Town, South Africa
| | - Autumn Breaud
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - James McIntyre
- Division of Epidemiology and Biostatistics, University of Cape Town, South Africa.,Anova Health Institute, Johannesburg, South Africa
| | - Daniel Bruno
- Genomics Unit, Research Technologies Branch, Rocky Mountain Laboratories, NIAID, NIH, Hamilton, Montana
| | - Craig Martens
- Genomics Unit, Research Technologies Branch, Rocky Mountain Laboratories, NIAID, NIH, Hamilton, Montana
| | - Elaine J Abrams
- ICAP at Columbia University Mailman School of Public Health, New York, New York.,Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Steven J Reynolds
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda.,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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Atuhaire P, S. Brummel S, Mmbaga BT, Angelidou K, Fairlie L, Violari A, Theron G, Mukuzunga C, Mawlana S, Mubiana-Mbewe M, Naidoo M, Makanani B, Mandima P, Nematadzira T, Suryavanshi N, Mbengeranwa T, Loftis A, Basar M, McCarthy K, Currier JS, Fowler MG. The impact of short term Antiretroviral Therapy (ART) interruptions on longer term maternal health outcomes-A randomized clinical trial. PLoS One 2020; 15:e0228003. [PMID: 31999753 PMCID: PMC6992010 DOI: 10.1371/journal.pone.0228003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 01/03/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Given well documented challenges faced by pregnant women living with HIV taking lifetime ART, it is critical to understand the impact of short-term ART exposure followed by treatment interruption on maternal health outcomes. METHODS HIV+ breastfeeding (BF) and Formula Feeding (FF) women with CD4 counts > 350 cells/mm3, enrolled in the 1077BF/1077FF PROMISE trial were followed to assess the effect of ART during pregnancy and breastfeeding respectively. The first analysis compared ART use limited to the antepartum period (AP-only) relative to women randomized to Zidovudine. The second analysis included women with no pregnancy combination ART exposure; and compared women randomized to either ART or no ART during postpartum (PP-only). Both analyses included follow-up time beyond breastfeeding period. The primary outcome was progression to AIDS and/or death. Secondary outcomes included adverse events and HIV-related events. RESULTS 3490 and 1137 HIV+ women were enrolled from 14 sites in Africa and India from April 2011 through September 2014 in cohort AP-only and PP-only, respectively. Most were Black African (96%); median age was 27 years; 97% were WHO Clinical Stage I; and most had a screening CD4 count ≥500 cells/mm3 (78%). The rate of progression to AIDS and/or death was similar and low across all comparison arms (AP comparison, HR = 1.14, 95%CI (0.44, 2.96), p-value = 0.79). In the PP-only cohort, the rate of WHO stage 2-3 events was lower for women randomized to ART(HR = 0.65, 95% CI 0.42, 1.01, p-value = 0.05). CONCLUSION The incidence of AIDS and/or death was low in pregnant/postpartum HIV+ women with highCD4 cell counts for all comparison arms. This provides some reassurance that there were limited consequences for short term ART interruption in this group of asymptomatic HIV+ women during up to 4 years of follow up; and underscores that even short term ART exposure postpartum may reduce the risk of WHO grade 2-3 disease progression.
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Affiliation(s)
- Patience Atuhaire
- Makerere University –John Hopkins University Research Collaboration (MUJHU CARE LTD) CRS, Kampala, Uganda
- * E-mail:
| | - Sean S. Brummel
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | | | - Konstantia Angelidou
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Lee Fairlie
- Wits RHI Shandukani Research Centre CRS, Johannesburg, South Africa
| | - Avy Violari
- Soweto IMPAACT CRS, Johannesburg, South Africa
| | | | | | | | | | | | | | | | | | | | | | - Amy Loftis
- UNC, Chapel Hill, North Carolina, United States of America
| | - Michael Basar
- Frontier Science, Amherst, Massachusetts, United States of America
| | - Katie McCarthy
- FHI 360, Durham, North Carolina, United States of America
| | - Judith S. Currier
- UCLA center for Clinical AIDS Research and Education, Los Angeles, California, United States of America
| | - Mary Glenn Fowler
- Departments of Pathology and Epidemiology, Johns Hopkins University, Baltimore, Maryland, United States of America
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Atuhaire P, Hanley S, Yende-Zuma N, Aizire J, Stranix-Chibanda L, Makanani B, Milala B, Cassim H, Taha T, Fowler MG. Factors associated with unsuppressed viremia in women living with HIV on lifelong ART in the multi-country US-PEPFAR PROMOTE study: A cross-sectional analysis. PLoS One 2019; 14:e0219415. [PMID: 31647806 PMCID: PMC6812809 DOI: 10.1371/journal.pone.0219415] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/10/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite recent efforts to scale-up lifelong combination antiretroviral therapy (cART) in sub-Saharan Africa, high rates of unsuppressed viremia persist among cART users, and many countries in the region fall short of the UNAIDS 2020 target to have 90% virally suppressed. We sought to determine the factors associated with unsuppressed viremia (defined for the purpose of this study as >200 copies/ml) among sub-Saharan African women on lifelong cART. METHODS This cross-sectional analysis was based on baseline data of the PROMOTE longitudinal cohort study at 8 sites in Uganda, Malawi, Zimbabwe and South Africa. The study enrolled 1987 women living with HIV who initiated lifelong cART at least 1-5 years ago. Socio-demographic, clinical, and cART adherence data were collected. We used multivariable Poisson regression with robust variance to identify factors associated with unsuppressed viremia. RESULTS At enrolment, 1947/1987 (98%) women reported taking cART. Of these, HIV-1 remained detectable in 293/1934 (15%), while 216/1934 (11.2%) were considered unsuppressed (>200 copies/ml). The following factors were associated with an increased risk of unsuppressed viremia: not having household electricity (adjusted prevalence risk ratio (aPRR) 1.74, 95% confidence interval (CI) 1.28-2.36, p<0.001); not being married (aPRR 1.32, 95% CI 0.99-1.78, p = 0.061), self-reported missed cART doses (aPRR 1.63, 95% CI 1.24-2.13, p<0.001); recent hospitalization (aPRR 2.48, 95% CI 1.28-4.80, p = 0.007) and experiencing abnormal vaginal discharge in the last three months (aPRR 1.88; 95% CI 1.16-3.04, p = 0.010). Longer time on cART (aPRR 0.75, 95% CI 0.64-0.88, p<0.001) and being older (aPRR 0.77, 95% CI 0.76-0.88, p<0.001) were associated with reduced risk of unsuppressed viremia. CONCLUSION Socioeconomic barriers such as poverty, and individual barriers like not being married, young age, and self-reported missed doses are key predictors of unsuppressed viremia. Targeted interventions are needed to improve cART adherence among women living with HIV with this risk factor profile.
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Affiliation(s)
- Patience Atuhaire
- Makerere University-Johns Hopkins University (MU-JHU) Kampala, Uganda
| | - Sherika Hanley
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Umlazi Clinical Research Site, Nelson R. Mandela School of Medicine, Durban, South Africa
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Jim Aizire
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, United States of America
| | - Lynda Stranix-Chibanda
- University of Zimbabwe College of Health Sciences Department of Paediatrics and Child Health, Harare, Zimbabwe
| | - Bonus Makanani
- Malawi College of Medicine-John's Hopkins Research Project, Blantyre, Malawi
| | - Beteniko Milala
- University of North Carolina (UNC) Project, Lilongwe, Malawi
| | - Haseena Cassim
- Perinatal HIV Research Unit (PHRU), Chris Hani Baragwanath Hospital, University of Witwatersrand, Johannesburg, South Africa
| | - Taha Taha
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, United States of America
| | - Mary Glenn Fowler
- Johns Hopkins University, Departments of Pathology and Epidemiology, Baltimore, MD, United States of America
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Spooner E, Govender K, Reddy T, Ramjee G, Mbadi N, Singh S, Coutsoudis A. Point-of-care HIV testing best practice for early infant diagnosis: an implementation study. BMC Public Health 2019; 19:731. [PMID: 31185962 PMCID: PMC6560857 DOI: 10.1186/s12889-019-6990-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 05/15/2019] [Indexed: 01/05/2023] Open
Abstract
Background With Universal Health Coverage and Integrated People-centred Health Care, streamlined health-systems and respectful care are necessary. South Africa has made great strides in prevention of mother-to-child transmission (PMTCT) but with the great burden of HIV, a minimum of birth and 10-week HIV-PCR testing are required for the estimated 360,000 HIV-exposed infants born annually which presents many challenges including delayed results and loss to follow-up. Point-of-care (POC) HIV testing of infants addresses these challenges well and facilitates initiation of HIV-infected infants rapidly after diagnosis for best clinical outcomes. Methods Objectives were to determine accuracy, feasibility and acceptability of POC testing compared to standard-of-care (SOC) central-laboratory testing. HIV-exposed infants for birth PCR testing in hospital (n = 323) and follow-up at a primary health care clinic (n = 117) in Durban, South Africa were included. A baseline situational-analysis reviewed registers and phoned mothers of HIV-exposed infants prior to the intervention. An effectiveness-implementation study of the Alere™q HIV-1/2 Detect POC test (heel-prick specimen processed in 50 min) was compared with SOC with questionnaires to mothers and staff. Stata 14 was used for analysis. Results At baseline 2% of birth HIV tests were missed; only 40% of mothers could be contacted; 17% did not receive birth test result; 19% did not have a 10-week test; 39% had not received the 10-week results. There were 5(1.5%) HIV-infected and 318(98.5%) HIV-negative infants detected in hospital with all clinic babies negative. All positive infants commenced ART before discharge. Ultimately POC and SOC had perfect concordance but for 10 SOC tests researchers actively tracked-down results or repeated tests. Turn around times for SOC tests were on average 8-days (IQR 6-10 days) and for POC testing was 0-days. The POC error-rate was 9,6% with all giving a result when repeated. The majority of mothers (92%) preferred POC testing with 7% having no preference. No staff preferred SOC testing with 79% preferring POC and 21% having no preference. Conclusions Point-of-care HIV testing for EID is accurate, feasible and acceptable, with benefits of early ART for all positive infants at birth facilities. We recommend that it be considered best practice for EID. Trial registration ISRCTN38911104 registered 9 January 2018 – retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s12889-019-6990-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elizabeth Spooner
- Department of Paediatrics and Child Health, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - Kerusha Govender
- Department of Virology, Inkosi Albert Luthuli Central Hospital, National Health Laboratory Service, Durban, KwaZulu-Natal, South Africa
| | - Tarylee Reddy
- South African Medical Research Council, Biostatistics Unit, Durban, South Africa
| | - Gita Ramjee
- South African Medical Research Council, HIV Prevention Research Unit, Durban, South Africa
| | - Noxolo Mbadi
- Department of Paediatrics, Addington Hospital, Durban, South Africa
| | - Swaran Singh
- Department of Paediatrics, Addington Hospital, Durban, South Africa
| | - Anna Coutsoudis
- Department of Paediatrics and Child Health, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
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Ntlantsana V, Hift RJ, Mphatswe WP. HIV viraemia during pregnancy in women receiving preconception antiretroviral therapy in KwaDukuza, KwaZulu-Natal. South Afr J HIV Med 2019; 20:847. [PMID: 31061722 PMCID: PMC6494933 DOI: 10.4102/sajhivmed.v20i1.847] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 02/05/2019] [Indexed: 01/01/2023] Open
Abstract
Background Preconception antiretroviral therapy (PCART) followed by sustained viral suppression is effective in preventing mother-to-child transmission of HIV. The rates of persistent and transient viraemia in such patients have not been prospectively assessed in South Africa. Objectives We determined the prevalence of transient and persistent viraemia in HIV-positive women entering antenatal care on PCART and studied variables associated with viraemia. Methods We performed a prospective cross-sectional observational study of HIV-positive pregnant women presenting to a primary healthcare facility in KwaZulu-Natal. All had received at least 6 months of first-line PCART. Viral load (VL) was measured, patients were interviewed, adherence estimated using a visual analogue scale and adherence counselling provided. Viral load was repeated after 4 weeks where baseline VL exceeded 50 copies/mL. Results We enrolled 82 participants. Of them, 59 (72%) pregnancies were unplanned. Fifteen participants (18.3%) were viraemic at presentation with VL > 50 copies/mL. Of these, seven (8.5%) had viral suppression (VL < 50 copies/mL), and eight remained viraemic at the second visit. Adherence correlated significantly with viraemia at baseline. Level of knowledge correlated with adherence but not with lack of viral suppression at baseline. Socio-economic indicators did not correlate with viraemia. No instances of vertical transmission were observed at birth. Conclusions Approximately 20% of women receiving PCART may demonstrate viraemia. Half of these may be transient. Poor adherence is associated with viraemia, and efforts to encourage and monitor adherence are essential. The rate of unplanned pregnancies is high, and antiretroviral therapy programmes should focus on family planning needs of women in the reproductive age group to prevent viral non-suppression prior to pregnancy. Keywords Preconception Antiretroviral Therapy; HIV; Viraemia; Antenatal Care; Adherence.
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Affiliation(s)
- Vuyokazi Ntlantsana
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Richard J Hift
- School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Wendy P Mphatswe
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
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Abuogi LL, Humphrey JM, Mpody C, Yotebieng M, Murnane PM, Clouse K, Otieno L, Cohen CR, Wools-Kaloustian K. Achieving UNAIDS 90-90-90 targets for pregnant and postpartum women in sub-Saharan Africa: progress, gaps and research needs. J Virus Erad 2018; 4:33-39. [PMID: 30515312 PMCID: PMC6248851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The implementation of the 2013 World Health Organization Option B+ recommendations for HIV treatment during pregnancy has helped drive significant progress in achieving universal treatment for pregnant and postpartum women in sub-Saharan Africa (SSA). Yet, critical research and implementation gaps exist in achieving the UNAIDS 90-90-90 targets. To help guide researchers, programmers and policymakers in prioritising these areas, we undertook a comprehensive review of the progress, gaps and research needs to achieve the 90-90-90 targets for this population in the Option B+ era, including early infant HIV diagnosis (EID) for HIV-exposed infants. Salient areas where progress has been achieved or where gaps remain include: (1) knowledge of HIV status is higher among people with HIV in southern and eastern Africa compared to western and central Africa (81% versus 48%, UNAIDS); (2) access to antiretroviral therapy (ART) for pregnant women has doubled in 22 of 42 SSA countries, but only six have achieved the second 90, and nearly a quarter of pregnant women initiating ART become lost to follow-up; (3) viral suppression data for this population are sparse (estimates range from 30% to 98% peripartum), with only half of women maintaining suppression through 12 months postpartum; and (4) EID rates range from 15% to 62%, with only three of 21 high-burden SSA countries testing >50% HIV-exposed infants within the first 2 months of life. We have identified and outlined promising innovations and research designed to address these gaps and improve the health of pregnant and postpartum women living with HIV and their infants.
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Affiliation(s)
- Lisa L Abuogi
- Department of Pediatrics, University of Colorado,
Denver, Aurora, CO,
USA,Corresponding author:
Lisa Abuogi, Department of Pediatrics, University of Colorado,
Denver, Aurora,
CO,
USA
| | - John M Humphrey
- Department of Medicine, Indiana University School of Medicine,
Indianapolis, IN,
USA
| | - Christian Mpody
- Division of Epidemiology, Ohio State University,
Columbus, OH,
USA
| | - Marcel Yotebieng
- Division of Epidemiology, Ohio State University,
Columbus, OH,
USA
| | - Pamela M Murnane
- Center for AIDS Prevention Studies, University of California San Francisco,
San Francisco, CA,
USA
| | - Kate Clouse
- Vanderbilt Institute for Global Health, Vanderbilt University,
Nashville, TN,
USA
| | - Lindah Otieno
- Center for Microbial Research, Research Care and Training Program, Kenya Medical Research Institute,
Nairobi,
Kenya
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences,
University of California San Francisco, CA,
USA
| | - Kara Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine,
Indianapolis, IN,
USA
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Achieving UNAIDS 90-90-90 targets for pregnant and postpartum women in sub-Saharan Africa: progress, gaps and research needs. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30343-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Delicio AM, Lajos GJ, Amaral E, Lopes F, Cavichiolli F, Myioshi I, Milanez H. Adverse effects of antiretroviral therapy in pregnant women infected with HIV in Brazil from 2000 to 2015: a cohort study. BMC Infect Dis 2018; 18:485. [PMID: 30261855 PMCID: PMC6161436 DOI: 10.1186/s12879-018-3397-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 09/19/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) use in pregnancy presents unquestionable benefits in preventing mother-to-child transmission (MTCT) of HIV although it is associated with maternal adverse effects. The aim of this study was to evaluate the adverse effects of antiretroviral therapy in pregnant women infected with HIV. METHODS Cohort study of pregnant women infected with HIV followed at the CAISM/UNICAMP Obstetric Clinic from 2000 to 2015. The following maternal adverse effects were observed: anemia, thrombocytopenia, allergy, liver function test abnormalities, dyslipidemia and diabetes. Data collected from patients' files was added to a specific database. Descriptive analysis was shown in terms of absolute (n) and relative (%) frequencies and mean, median and standard deviation calculations. Chi-square or Fisher exact test (n < 5) and relative risk (RR) with its respective p values were used for categorical variables and Student t-test (parametric data) or Mann-Whitney (non-parametric data) for the quantitative ones. A 95% confidence interval (CI) and a significant level of 0.05 were used. A multivariate Cox Logistic Regression was also done. Data analysis was conducted using SAS version 9.4. RESULTS Data from 793 pregnancies were included. MTCT rate was 2.3%, with 0.8% in the last 5 years. Maternal adverse effects were: dyslipidemia (82%), anemia (56%), liver function test abnormalities (54.5%), including hyperbilirubinemia (11.6%), fasting glycemia alteration (19.2%), thrombocytopenia (14.1%), and allergic reaction (2.7%). The majority of adverse effects deemed related to ART in this study were mild according to DAIDS scale. In the multivariate analysis, co-infections and starting ART during pregnancy were risk factors for maternal anemia, while CD4 count higher than 200 cells/mm3 was protective. Nevirapine, nelfinavir and atazanavir regimens increased the risk for liver function tests abnormalities. Lopinavir use during pregnancy increased the risk for fasting glycemia alteration. CONCLUSION The evolution of the national guidelines of antiretroviral therapy for pregnant women improved adherence to the treatment and resulted in a significant reduction of MTCT. Despite the high frequency of maternal adverse effects, they are mostly of low severity. Newer ART medications with improved efficacy and significantly more favorable tolerability profiles should reduce the incidence of ART-related adverse effects.
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Affiliation(s)
- Adriane M. Delicio
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
- Department of Clinics, School of Medical Sciences, University of Campinas, Campinas, Brazil
- Referral Center for STIs and AIDS of Campinas, Campinas, Brazil
| | - Giuliane J. Lajos
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Eliana Amaral
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Fabia Lopes
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Fernanda Cavichiolli
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Isabeli Myioshi
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Helaine Milanez
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
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Adeniyi OV, Ajayi AI, Ter Goon D, Owolabi EO, Eboh A, Lambert J. Factors affecting adherence to antiretroviral therapy among pregnant women in the Eastern Cape, South Africa. BMC Infect Dis 2018; 18:175. [PMID: 29653510 PMCID: PMC5899366 DOI: 10.1186/s12879-018-3087-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 04/05/2018] [Indexed: 11/25/2022] Open
Abstract
Background Context-specific factors influence adherence to antiretroviral therapy (ART) among pregnant women living with HIV. Gaps exist in the understanding of the reasons for the variable outcomes of the prevention of mother-to-child transmission (PMTCT) programme at the health facility level in South Africa. This study examined adherence levels and reasons for non-adherence during pregnancy in a cohort of parturient women enrolled in the PMTCT programme in the Eastern Cape, South Africa. Methods This was a mixed-methods study involving 1709 parturient women in the Eastern Cape, South Africa. We conducted a multi-centre retrospective analysis of the mother-infant pair in the PMTCT electronic database in 2016. Semi-structured interviews of purposively selected parturient women with self-reported poor adherence (n = 177) were conducted to gain understanding of the main barriers to adherence. Binary logistic regression was used to determine the independent predictors of ART non-adherence. Results A high proportion (69.0%) of women reported perfect adherence. In the logistic regression analysis, after adjusting for confounding factors, marital status, cigarette smoking, alcohol use and non-disclosure to a family member were the independent predictors of non-adherence. Analysis of the qualitative data revealed that drug-related side-effects, being away from home, forgetfulness, non-disclosure, stigma and work-related demand were among the main reasons for non-adherence to ART. Conclusions Non-adherence to the antiretroviral therapy among pregnant women in this setting is associated with lifestyle behaviours, HIV-related stigma and ART side-effects. In order to eliminate mother-to-child transmission of HIV, clinicians need to screen for these factors at every antenatal clinic visit.
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Affiliation(s)
- Oladele Vincent Adeniyi
- Department of Family Medicine & Rural Health, Faculty of Health Science, Walter Sisulu University, Mthatha/East London Hospital Complex, Cecilia Makiwane Hospital, East London, South Africa
| | - Anthony Idowu Ajayi
- Department of Sociology, Faculty of Social Sciences & Humanities, University of Fort Hare, 50, Church Street, East London, South Africa.
| | - Daniel Ter Goon
- Department of Nursing Sciences, Faculty of Health Sciences, University of Fort Hare, East London, South Africa
| | - Eyitayo Omolara Owolabi
- Department of Nursing Sciences, Faculty of Health Sciences, University of Fort Hare, East London, South Africa
| | - Alfred Eboh
- Department of Sociology, Kogi State University, Anyigba, Kogi, State, P.M.B 1008, Nigeria
| | - John Lambert
- Department of Infectious Diseases, Medicine and Sexual Health, Mater, Rotunda and University College, Dublin, Ireland
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe recent clinical trial, laboratory and observational findings that highlight both the progress that can be achieved in elimination of new pediatric infections in international clinical trial settings among HIV-infected breastfeeding women while also describing recent safety concerns related to currently used antiretroviral regimens. The article will also address the ongoing adherence challenges for HIV-infected mothers in taking their antiretroviral drugs. This information is timely and relevant as new regimens are being considered for both prevention of mother-to-child transmission (PMTCT) of HIV and HIV treatment options worldwide. RECENT FINDINGS The main themes described in this article include both efficacy of different antiretroviral therapy (ART) regimens currently being rolled out internationally for PMTCT as well as safety findings from recent research including a large multisite international trial, PROMISE. SUMMARY The findings from the IMPAACT PROMISE trial as well as other recent trial and observational findings suggest that while progress has been steady in reducing PMTCT worldwide, the goal of virtual elimination of pediatric HIV worldwide will require careful attention to optimizing safety of new regimens which are less dependent on maternal daily ART adherence and safer in preventing certain toxicities.
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Affiliation(s)
- Mary G Fowler
- Department of Pathology, Johns Hopkins U. School of Medicine, Baltimore, Maryland
| | - Patricia Flynn
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Jim Aizire
- Department of Epidemiology, Johns Hopkins U. Bloomberg School of Public Health, Baltimore, Maryland, USA
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Differentiated models of care for postpartum women on antiretroviral therapy in Cape Town, South Africa: a cohort study. J Int AIDS Soc 2017; 20:21636. [PMID: 28770593 PMCID: PMC5577773 DOI: 10.7448/ias.20.5.21636] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: The numbers of women initiating lifelong antiretroviral therapy (ART) during pregnancy and postpartum is increasing rapidly, presenting a burden on health systems and an urgent need for scalable models of care for this population. In a pilot project, we referred postpartum women who initiated ART during pregnancy to a community-based model of differentiated ART services. Methods: Eligible women (on ART for at least 3 months with viral load (VL)<1000 copies/mL) were offered a choice of two ART models of care: (i) referral to an existing system of community-based ‘adherence clubs’, operated by lay counsellors with medication collection every 2–4 months; or (ii) referral to local primary healthcare clinics (PHC) with services provided by clinicians and medication collection every 1–2 months (local standard of care for postpartum ART). For evaluation, women were followed through 6-months postpartum with VL testing separate from either ART service. Results: Through September 2015, n = 129 women were enrolled (median age, 28 years; median time postpartum, 10 days). Overall, 65% (n = 84) chose adherence clubs and 35% (n = 45) chose PHCs; there were no demographic or clinical predictors of this choice. Location of service delivery was commonly cited as a reason for choice by women selecting either model of care; shorter waiting times, ability to receive ART from lay counsellors and less frequent appointments were motivations for choosing adherence clubs. Among women choosing adherence clubs, 15% never attended the service and another 11% attended the service but were not retained through six months postpartum. Overall, 86% of women (n = 111) remained in the evaluation through 6 months postpartum; in this group, there were no differences in VL<1000 copies/mL at six months postpartum between women choosing PHCs (88%) vs. adherence clubs (92%; p = 0.483), but women who were not retained in adherence clubs were more likely to have VL≥1000 copies/mL compared to those who remained (p = 0.002). Discussion: Adherence clubs may be a valuable model for postpartum women initiating ART in pregnancy, with good short-term outcomes observed during this critical period. To support optimal implementation, further research is needed into patient preferences for models of care, with consideration of integration of maternal and child health services, while ART adherence and retention require ongoing consideration in this population.
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Sam-Agudu NA, Ramadhani HO, Isah C, Anaba U, Erekaha S, Fan-Osuala C, Galadanci H, Charurat M. The Impact of Structured Mentor Mother Programs on 6-Month Postpartum Retention and Viral Suppression among HIV-Positive Women in Rural Nigeria: A Prospective Paired Cohort Study. J Acquir Immune Defic Syndr 2017; 75 Suppl 2:S173-S181. [PMID: 28498187 DOI: 10.1097/qai.0000000000001346] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Peer support (PS) has reportedly improved Prevention of mother-to-child transmission (PMTCT) outcomes in high HIV-burden settings; however, evidence of impact on retention in care is limited. Retention in care implies consistent engagement and treatment adherence. The MoMent study evaluated the impact of structured vs unstructured PS on postpartum retention and viral load suppression among rural Nigerian women. METHODS A total of 497 HIV-positive pregnant women were consecutively enrolled at 10 primary health care centers with structured mentor mother (MM) support, and at 10 pair-matched primary health care centers with routine, ad hoc PS. The structured MM intervention comprised an outcome-specific scope of work, close MM supervision, standardized documentation, performance evaluations, and retraining as appropriate. Retention was defined by clinic attendance during the first 6-month postpartum. Participants with ≥3 of 6 expected monthly visits were considered retained. Women with a 6-month postpartum plasma viral load of <20 copies/mL were considered suppressed. A logistic regression model with generalized estimating equation was used to assess the effect of MMs on retention and viral suppression. RESULTS Exposure to structured MM support was associated with higher odds of retention than routine PS (adjusted odds ratio = 5.9, 95% confidence interval: 3.0 to 11.6). Similarly, the odds of viral suppression at 6-month postpartum were higher for MM-supported women (adjusted odds ratio = 4.9, 95% confidence interval: 2.6 to 9.2). CONCLUSIONS Structured PS significantly improved postpartum PMTCT retention and viral suppression rates among women in rural Nigeria. Introduction of structure can enhance the impact of PS interventions on PMTCT outcomes.
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Affiliation(s)
- Nadia A Sam-Agudu
- *International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria; †Division of Epidemiology and Prevention, Institute of Human Virology, School of Medicine, University of Maryland Baltimore, Baltimore, MD; and ‡Department of Obstetrics and Gynaecology, College of Health Sciences, Bayero University, Kano, Nigeria
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Girma M, Wendaferash R, Shibru H, Berhane Y, Hoelscher M, Kroidl A. Uptake and performance of prevention of mother-to-child transmission and early infant diagnosis in pregnant HIV-infected women and their exposed infants at seven health centres in Addis Ababa, Ethiopia. Trop Med Int Health 2017; 22:765-775. [PMID: 28407452 DOI: 10.1111/tmi.12881] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the uptake of WHO-recommended PMTCT procedures in Ethiopia's health services. METHODS Prospective observational study of HIV-positive pregnant mothers and their newborns attending PMTCT services at seven health centres in Addis Ababa. Women were recruited during antenatal care and followed up with their newborns at delivery, Day 6 and Week 6 post-partum. Retention to PMCTC procedures, self-reported antiretroviral treatment (ART) adherence and HIV infant outcome were assessed. Turnaround times of HIV early infant diagnosis (EID) procedures were extracted from health registers. RESULTS Of 494 women enrolled, 4.9% did not complete PMTCT procedures due to active denial or loss to follow-up. HIV was first diagnosed in 223 (45.1%) and ART initiated in 321 (65.0%) women during pregnancy. ART was initiated in a median of 1.3 weeks (IQR 0-4.3) after HIV diagnosis. Poor self-reported treatment adherence was higher post-partum than during pregnancy (12.5% vs. 7.0%, P = 0.002) and significantly associated with divorced/separated marital status (RR 2.2, 95% CI 1.3-3.8), low family income (RR 2.1, 95% CI 1.1-4.1), low CD4 count (RR 1.7, 95% CI 1.0-3.0) and ART initiation during delivery (RR 2.5, 95% CI 1.1-5.6). Of 435 infants born alive, 98.6% received nevirapine prophylaxis. The mother-to-child HIV transmission rate was 0.7% after a median of 6.7 weeks (IQR 6.4-10.4), but EID results were received for only 46.6% within 3 months of birth. CONCLUSION High retention in PMTCT services, triple maternal ART and high infant nevirapine prophylaxis coverage were associated with low mother-to-child HIV transmission. Declining post-partum ART adherence and challenges of EID linkage require attention.
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Affiliation(s)
- Marshet Girma
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia.,Center for International Health, University of Munich, Munich, Germany
| | | | | | - Yemane Berhane
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | - Michael Hoelscher
- Center for International Health, University of Munich, Munich, Germany.,Division of Infectious Diseases and Tropical Medicine, University of Munich, Munich, Germany.,German Centre for Infection Research, Munich, Germany
| | - Arne Kroidl
- Division of Infectious Diseases and Tropical Medicine, University of Munich, Munich, Germany.,German Centre for Infection Research, Munich, Germany
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Viral Suppression and Retention in Care up to 5 Years After Initiation of Lifelong ART During Pregnancy (Option B+) in Rural Uganda. J Acquir Immune Defic Syndr 2017; 74:279-284. [PMID: 27828878 DOI: 10.1097/qai.0000000000001228] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Lifelong antiretroviral therapy (ART) is recommended for all HIV-infected pregnant women, but early studies suggest that women often drop out of care postpartum and data are limited on virologic outcomes. METHODS We evaluated viral suppression (primary outcome) and retention in care up to 5 years after ART initiation among HIV-infected women who started lifelong ART during pregnancy, irrespective of CD4 count, in a study in rural Uganda (NCT00993031). Participants were followed in the study for up to 1 year postpartum, then referred to clinics in surrounding communities. A random sample (N = 200) was invited to participate in a cross-sectional follow-up study after completing the trial, involving one visit for a questionnaire and pregnancy and HIV-1 RNA testing. Retention in care was defined as having attended an HIV clinic in the last 90 days. Logistic regression models were used to examine factors associated with viral suppression (HIV-1 RNA <400 copies/ml) at follow-up. RESULTS One hundred fifty women (75%) were successfully contacted for follow-up at a median of 4.2 years after starting ART; 135 were retained in care [90%, 95% confidence interval (CI): 84.0% to 94.3%] and 121 demonstrated viral suppression (80.7%, 95% CI: 73.4% to 86.7%). Women who had disclosed their HIV status to their primary partner had greater odds of viral suppression (adjusted odds ratio: 4.51, 95% CI: 1.02 to 19.8). CONCLUSIONS High rates of viral suppression can be achieved up to 5 years after initiating ART during pregnancy among women retained in care. Interventions to facilitate disclosure may improve long-term outcomes among women who initiate ART during pregnancy under universal treatment.
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Exclusive breast-feeding promotion among HIV-infected women in South Africa: an Information-Motivation-Behavioural Skills model-based pilot intervention. Public Health Nutr 2017; 20:1481-1490. [PMID: 28173897 DOI: 10.1017/s1368980016003657] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Exclusive breast-feeding (EBF) provides optimal nutrition for infants and mothers. The practice of EBF while adhering to antiretroviral medication decreases the risk of mother-to-child transmission of HIV from approximately 25 % to less than 5 %. Thus the WHO recommends EBF for the first 6 months among HIV-infected women living in resource-limited settings; however, EBF rates remain low. In the present study our aim was to design and implement a pilot intervention promoting EBF among HIV-infected women. DESIGN The Information-Motivation-Behavioural Skills (IMB) model was applied in a brief motivational interviewing counselling session that was tested in a small randomized controlled trial. SETTING Pietermaritzburg, South Africa, at two comparable rural public health service clinics. SUBJECTS Sixty-eight HIV-infected women in their third trimester were enrolled and completed baseline interviews between June and August 2014. Those randomized to the intervention arm received the IMB-based pilot intervention directly following baseline interviews. Follow-up interviews occurred at 6 weeks postpartum. RESULTS While not significantly different between trial arms, high rates of intention and practice of EBF at 6-week follow-up were reported. Findings showed high levels of self-efficacy being significantly predictive of breast-feeding initiation and duration regardless of intervention arm. CONCLUSIONS Future research must account for breast-feeding self-efficacy on sustaining breast-feeding behaviour and leverage strategies to enhance self-efficacy in supportive interventions. Supporting breast-feeding behaviour through programmes that include both individual-level and multi-systems components targeting the role of health-care providers, family and community may create environments that value and support EBF behaviour.
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RICH2 is implicated in viraemic control of HIV-1 in black South African individuals. INFECTION GENETICS AND EVOLUTION 2017; 49:78-87. [PMID: 28069446 DOI: 10.1016/j.meegid.2017.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 12/22/2016] [Accepted: 01/05/2017] [Indexed: 11/22/2022]
Abstract
An intronic single nucleotide polymorphism (SNP) in RICH2 (rs2072255; 255i), in complete linkage disequilibrium (LD) with an exonic SNP (rs2072254; 254e), has been identified in a genome wide association study to be associated with progression to AIDS in Caucasian individuals. RICH2 links tetherin to the cortical actin network and the RICH2/tetherin interaction has been shown to be important for the downstream activation of NF-κβ and the consequential promotion of proinflammatory responses. We investigated the role of these two SNPs in natural control of HIV-1 in black South Africans including healthy controls (HCs; N=102) and antiretroviral-naive HIV-1-infected controllers (HICs; N=52) and progressors (N=74). HICs were stratified as elite controllers (ECs; N=11), viraemic controllers (VCs; N=30), high viral load (VL) long term non-progressors (HVL LTNPs; N=11) and also according to VL<400RNA copies/ml (HICs VL<400; N=20) and VL>400RNA copies/ml (HICs VL>400; N=32). Results showed that in contrast to Caucasians who had very strong LD between these SNPs (r2=0.97), black populations exhibited low LD (r2=0.11-0.27), however a 254e minor allele was always present with a 255i minor allele but not vice versa. The SNPs did not show significant over- or underrepresentation in any particular group, however the combination of 254e major allele homozygosity and 255i heterozygosity (254eAA/255iGA) was underrepresented in HICs (OR=3.26; P=0.04) and VCs (OR=7.77; P=0.02) compared to HCs, and in HICs VL>400 compared to both HCs (P=0.002) and progressors (P=0.02). A lower CD4+ T-cell count was associated with 254eAA/255iGA and 255i (GA+AA) in the total HIV-1-infected group (P=0.043) and progressors (P=0.017), respectively. In silico analysis predicted loss of an exonic splice enhancer site with the 254e-G allele. We postulate that altered splicing of RICH2 will affect levels of RICH2 expression and consequently NF-κβ activation. These findings point to a role for RICH2 and tetherin in viraemic natural control of HIV-1.
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Gill MM, Hoffman HJ, Bobrow EA, Mugwaneza P, Ndatimana D, Ndayisaba GF, Baribwira C, Guay L, Asiimwe A. Detectable Viral Load in Late Pregnancy among Women in the Rwanda Option B+ PMTCT Program: Enrollment Results from the Kabeho Study. PLoS One 2016; 11:e0168671. [PMID: 28006001 PMCID: PMC5179044 DOI: 10.1371/journal.pone.0168671] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 12/05/2016] [Indexed: 12/13/2022] Open
Abstract
There are limited viral load (VL) data available from programs implementing “Option B+,” lifelong antiretroviral treatment (ART) to all HIV-positive pregnant and postpartum women, in resource-limited settings. Extent of viral suppression from a prevention of mother-to-child transmission of HIV program in Rwanda was assessed among women enrolled in the Kigali Antiretroviral and Breastfeeding Assessment for the Elimination of HIV (Kabeho) Study. ARV drug resistance testing was conducted on women with VL>2000 copies/ml. In April 2013-January 2014, 608 pregnant or early postpartum HIV-positive women were enrolled in 14 facilities. Factors associated with detectable enrollment VL (>20 copies/ml) were examined using generalized estimating equations. The most common antiretroviral regimen (56.7%, 344/607) was tenofovir/lamivudine/efavirenz. Median ART duration was 13.5 months (IQR 3.0–48.8); 76.1% of women were on ART at first antenatal visit. Half of women (315/603) had undetectable RNA-PCR VL and 84.6% (510) had <1,000 copies/ml. Detectable VL increased among those on ART > 36 months compared to those on ART 4–36 months (72/191, 37.7% versus 56/187, 29.9%), though the difference was not significant. The odds of having detectable enrollment VL decreased significantly as duration on ART at enrollment increased (AOR = 0.99, 95% CI: 0.9857, 0.9998, p = 0.043). There was a higher likelihood of detectable VL for women with lower gravidity (AOR = 0.90, 95% CI: 0.84, 0.97, p = 0.0039), no education (AOR = 2.25, (95% CI: 1.37, 3.70, p = 0.0004), nondisclosure to partner (AOR = 1.97, 95% CI: 1.21, 3.21, p = 0.0063) and side effects (AOR = 2.63, 95% CI: 1.72, 4.03, p<0.0001). ARV drug resistance mutations were detected in all of the eleven women on ART > 36 months with genotyping available. Most women were receiving ART at first antenatal visit, with relatively high viral suppression rates. Shorter ART duration was associated with higher VL, with a concerning increasing trend for higher viremia and drug resistance among women on ART for >3 years.
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Affiliation(s)
- Michelle M. Gill
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, United States of America
- * E-mail:
| | - Heather J. Hoffman
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, United States of America
| | - Emily A. Bobrow
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, United States of America
| | | | | | | | - Cyprien Baribwira
- University of Maryland, Baltimore, Maryland, United States of America
| | - Laura Guay
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, United States of America
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, United States of America
| | - Anita Asiimwe
- Rwanda University Teaching Hospitals, Kigali, Rwanda
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Mancinelli S, Galluzzo CM, Andreotti M, Liotta G, Jere H, Sagno JB, Amici R, Pirillo MF, Scarcella P, Marazzi MC, Vella S, Palombi L, Giuliano M. Virological Response and Drug Resistance 1 and 2 Years Post-Partum in HIV-Infected Women Initiated on Life-Long Antiretroviral Therapy in Malawi. AIDS Res Hum Retroviruses 2016; 32:737-42. [PMID: 27067142 DOI: 10.1089/aid.2015.0366] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The objective of this study was to determine the virological response and the possible emergence of drug resistance at 1 and 2 years postpartum in HIV-positive pregnant women enrolled under the Option B approach and meeting the criteria for treatment. In the study, women with baseline CD4(+) <350/mm(3) received a combination of stavudine, lamivudine, and nevirapine during pregnancy (from week 25 of gestation) and continued it indefinitely after delivery. HIV-RNA was measured at 12 and 24 months postpartum. Drug resistance mutations were assessed in those with HIV-RNA >50 copies/ml. Baseline resistance mutations were assessed in the entire cohort. A total of 107 women were studied. At baseline, resistance mutations were seen in 6.6% of the women. At 12 months, 26.7% of the women had >50 copies/ml and among them 12.9% had virological failure (HIV-RNA >1,000 copies/ml). At 24 months, detectable HIV-RNA was seen in 28.3% of the women and virological failure in 10.1% of the women. Resistance mutations (mainly non-nucleoside reverse transcriptase inhibitors mutations) were seen in 40% of the women with detectable HIV-RNA. Baseline mutations did not correlate with virological failure or the emergence of resistance at later time points. Virological failure 2 years postpartum and emergence of resistance were rare in this cohort of HIV-infected women. These findings are reassuring in the light of the new strategies for the prevention of mother-to-child HIV transmission, recommending life-long antiretroviral therapy administration.
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Affiliation(s)
- Sandro Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Clementina Maria Galluzzo
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Mauro Andreotti
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Giuseppe Liotta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Haswel Jere
- DREAM Program, Community of S. Egidio, Blantyre, Malawi
| | | | - Roberta Amici
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Maria Franca Pirillo
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Paola Scarcella
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - Stefano Vella
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Marina Giuliano
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
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