1
|
Boisson-Walsh A, Ravelomanana NLR, Tabala M, Malongo F, Kawende B, Babakazo P, Yotebieng M. Association of comprehensiveness of antiretroviral care and detectable HIV viral load suppression among pregnant and postpartum women in the Democratic Republic of the Congo: a cross-sectional study. Front Glob Womens Health 2024; 5:1308019. [PMID: 38903153 PMCID: PMC11188341 DOI: 10.3389/fgwh.2024.1308019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 05/21/2024] [Indexed: 06/22/2024] Open
Abstract
Introduction Worldwide, over two-thirds of people living with HIV are on antiretroviral therapy (ART). Despite increased ART access, high virological suppression prevalence remains out of reach. Few studies consider the quality of ART services and their impact on recipients' viral suppression. We assessed the association between ART service readiness and HIV viral load suppression among pregnant and breastfeeding women living with HIV (WLH) receiving ART in maternal and child health (MCH) clinics in Kinshasa, Democratic Republic of Congo. Methods We performed a cross-sectional analysis leveraging data from a continuous quality improvement intervention on WLH's long-term ART outcomes. From November 2016 to May 2020, we enrolled WLH from the three largest clinics in each of Kinshasa'Łs 35 health zones. We measured clinic's readiness using three WHO-identified ART care quality indicators: relevant guidelines in ART service area, stocks of essential ART medicines, and relevant staff training in ≥24 months, scoring clinics 0-3 based on observed indicators. We defined viral load suppression as ≤1,000 cp/ml. Multilevel mixed-effect logistic models were used to estimate prevalence odds ratios (ORs) measuring the strength of the association between ART service readiness and viral suppression. Results Of 2,295 WLH, only 1.9% received care from a clinic with a score of 3, 24.1% received care from a 0-scoring clinic, and overall, 66.5% achieved virologically suppression. Suppression increased from 65% among WLH receiving care in 0-scoring clinics to 66.9% in 1-scoring clinics, 65.8% in 2-scoring clinics, and 76.1% in 3-scoring clinics. We did not observe a statistically significant association between ART service readiness score and increased viral suppression prevalence, however we did find associations between other factors, such as the location of the health center and pharmacist availability with suppressed viral load. Discussion A lack of comprehensive ART care underscores the need for enhanced structural and organizational support to improve virological suppression and overall health outcomes for women living with HIV..
Collapse
Affiliation(s)
- Alix Boisson-Walsh
- Department of Health Policy and Management, University of Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Martine Tabala
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Fathy Malongo
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Bienvenu Kawende
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Pélagie Babakazo
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Marcel Yotebieng
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, United States
| |
Collapse
|
2
|
Jiang W, Ronen K, Osborn L, Drake AL, Unger JA, Matemo D, Richardson BA, Kinuthia J, John-Stewart G. HIV Viral Load Patterns and Risk Factors Among Women in Prevention of Mother-To-Child Transmission Programs to Inform Differentiated Service Delivery. J Acquir Immune Defic Syndr 2024; 95:246-254. [PMID: 37977207 PMCID: PMC10922247 DOI: 10.1097/qai.0000000000003352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Differentiated service delivery (DSD) approaches decrease frequency of clinic visits for individuals who are stable on antiretroviral therapy. It is unclear how to optimize DSD models for postpartum women living with HIV (PWLH). We evaluated longitudinal HIV viral load (VL) and cofactors, and modelled DSD eligibility with virologic failure (VF) among PWLH in prevention of mother-to-child transmission programs. METHODS This analysis used programmatic data from participants in the Mobile WAChX trial (NCT02400671). Women were assessed for DSD eligibility using the World Health Organization criteria among general people living with HIV (receiving antiretroviral therapy for ≥6 months and having at least 1 suppressed VL [<1000 copies/mL] within the past 6 months). Longitudinal VL patterns were summarized using group-based trajectory modelling. VF was defined as having a subsequent VL ≥1000 copies/mL after being assessed as DSD-eligible. Predictors of VF were determined using log-binomial models among DSD-eligible PWLH. RESULTS Among 761 women with 3359 VL results (median 5 VL per woman), a 3-trajectory model optimally summarized longitudinal VL, with most (80.8%) women having sustained low probability of unsuppressed VL. Among women who met DSD criteria at 6 months postpartum, most (83.8%) maintained viral suppression until 24 months. Residence in Western Kenya, depression, reported interpersonal abuse, unintended pregnancy, nevirapine-based antiretroviral therapy, low-level viremia (VL 200-1000 copies/mL), and drug resistance were associated with VF among DSD-eligible PWLH. CONCLUSIONS Most postpartum women maintained viral suppression from early postpartum to 24 months and may be suitable for DSD referral. Women with depression, drug resistance, and detectable VL need enhanced services.
Collapse
Affiliation(s)
- Wenwen Jiang
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Keshet Ronen
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Lusi Osborn
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Alison L. Drake
- Global Health, University of Washington, Seattle, Washington, USA
| | - Jennifer A. Unger
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA, Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Daniel Matemo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Barbra A. Richardson
- Departments of Biostatistics and Global Health, University of Washington, Division of Vaccine and Infectious Disease, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - John Kinuthia
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
| |
Collapse
|
3
|
Shi P, Wang X, Su M, Meng J, Wang H, Fan W. Treatment with Antiviral Drugs Will Significantly Inhibit the HIV-1 RNA POL Gene Expression and Viral Load in AIDS Patients. DISEASE MARKERS 2023; 2023:9910542. [PMID: 37091892 PMCID: PMC10121356 DOI: 10.1155/2023/9910542] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/02/2022] [Accepted: 10/03/2022] [Indexed: 04/25/2023]
Abstract
Objective This study is to investigate the difference in HIV-1 RNA pol gene expression in AIDS patients before and after antiviral treatment and its effect on the expression level of CD4+/CD8+ T cells in peripheral blood. Methods The participants included 200 AIDS patients who had undergone antiviral medication, and the quantity of HIV-1 RNA pol gene was determined using nested polymerase chain reaction (nPCR). The levels of CD3+, CD4+, and CD8+ T lymphocytes in peripheral blood were measured by flow cytometry before and after therapy. The receiver operating characteristics (ROC) curve was used to assess the impact of HIV-1 RNA pol gene expression and the CD4+/CD8+ ratio on the prognosis of AIDS patients. Results After three months of therapy, the levels of HIV-1 RNA and viral load in the patients showed a drastic decline, while the levels of CD4+/CD8+ were markedly elevated (P < 0.05). Logistic analysis revealed that patients' viral loads were positively correlated with HIV-1 RNA and negatively correlated with CD4+/CD8+ (P < 0.05). The alanine aminotransferase (ALT), white blood cell (WBC) count, Serum creatinine (Cr), total cholesterol (TC), triglyceride (TG), and platelet (PLT) levels significantly increased following a 24-month therapy, while no significant changes were observed in the level of aspartate aminotransferase (AST), red blood cell (RBC), and neutrophil (NEU) (%). (P > 0.05). Conclusion Antiviral drugs significantly inhibit the HIV-1 RNA POL gene expression and viral load in AIDS patients but upregulate the expression level of CD4+/CD8+ T cells in peripheral blood.
Collapse
Affiliation(s)
- Penghui Shi
- Department of Laboratory Medicine, Baoding People's Hospital, Baoding City, Hebei Province 071000, China
| | - Xiaodong Wang
- Baoding People's Hospital, Baoding City, Hebei Province 071000, China
| | - Miaomiao Su
- Department of Infectious Diseases, Baoding People's Hospital, Baoding City, Hebei Province 071000, China
| | - Juan Meng
- Department of Infectious Diseases, Baoding People's Hospital, Baoding City, Hebei Province 071000, China
| | - Hao Wang
- Department of Laboratory Medicine, Baoding People's Hospital, Baoding City, Hebei Province 071000, China
| | - Weiguang Fan
- Department of Laboratory Medicine, Baoding People's Hospital, Baoding City, Hebei Province 071000, China
| |
Collapse
|
4
|
Eke AC, Gebreyohannes RD, Powell AM. Understanding clinical outcome measures reported in HIV pregnancy studies involving antiretroviral-naive and antiretroviral-experienced women. THE LANCET. INFECTIOUS DISEASES 2023; 23:e151-e159. [PMID: 36375478 PMCID: PMC10040432 DOI: 10.1016/s1473-3099(22)00687-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/02/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022]
Abstract
HIV infection is a clinically significant public health disease and contributes to increased risk of maternal and fetal morbidity and mortality. HIV pregnancy studies use outcome measures as metrics to show how people with HIV feel, function, or survive. These endpoints are crucial for tracking the evolution of HIV illness over time, assessing the effectiveness of antiretroviral therapy (ART), and comparing outcomes across studies. Although the need for ideal outcome measures is widely acknowledged, selecting acceptable outcome measures for these HIV pregnancy studies can be challenging. We discuss the many outcome measures that have been implemented over time to assess HIV in pregnancy studies, their benefits, and drawbacks. Finally, we offer suggestions for improving the reporting of outcome measures in HIV in pregnancy studies. Medical professionals can best care for pregnant women living with HIV receiving ART by having a thorough understanding of these outcome metrics.
Collapse
Affiliation(s)
- Ahizechukwu C Eke
- Division of Maternal Foetal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Rahel D Gebreyohannes
- Department of Obstetrics and Gynaecology, Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
| | - Anna M Powell
- Department of Gynaecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
5
|
Rucinski KB, Schwartz SR, Powers KA, Pence BW, Chi BH, Black V, Rees H, Pettifor AE. Fertility Intentions and Clinical Care Attendance Among Women Living with HIV in South Africa. AIDS Behav 2020; 24:1585-1591. [PMID: 31228024 DOI: 10.1007/s10461-019-02564-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Poor HIV care retention impedes optimal treatment outcomes in persons living with HIV. Women trying to become pregnant may be motivated by periconception horizontal and vertical transmission concerns and thus more likely to attend HIV care visits than women not trying to conceive. We estimated the effect of fertility intentions on HIV care attendance over 12 months among non-pregnant, HIV-positive women aged 18-35 years who were on or initiating antiretroviral therapy in Johannesburg, South Africa. The percentage of women attending an HIV care visit decreased from 93.4% in the first quarter to 82.8% in the fourth quarter. Fertility intentions were not strongly associated with care attendance in this cohort of reproductive-aged women; however, attendance declined over time irrespective of childbearing plans. These findings suggest a need for reinforced efforts to support care engagement and risk reduction, including safer conception practices for women wishing to conceive.
Collapse
Affiliation(s)
- Katherine B Rucinski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E7133A, Baltimore, MD, 21205, USA.
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa.
| | - Sheree R Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E7133A, Baltimore, MD, 21205, USA
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Kimberly A Powers
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Brian W Pence
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Vivian Black
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
- Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Helen Rees
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey E Pettifor
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| |
Collapse
|
6
|
Phillips TK, Myer L. Shifting to the long view: engagement of pregnant and postpartum women living with HIV in lifelong antiretroviral therapy services. Expert Rev Anti Infect Ther 2019; 17:349-361. [PMID: 30978126 DOI: 10.1080/14787210.2019.1607296] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: The advent of policies promoting lifelong antiretroviral therapy (ART) for all pregnant and postpartum women living with HIV has shifted focus from short-term prevention of mother-to-child transmission (PMTCT) to lifelong engagement in ART services. However, disengagement from care threatens the long-term treatment and prevention benefits of lifelong ART. Areas covered: A framework for considering the unique aspects of ART for pregnant and postpartum women is presented along with a review of the literature on maternal engagement in care in sub-Saharan Africa and a discussion of potential interventions to sustain engagement in lifelong ART. Expert opinion: Engaging women and mothers in ART services for life is critical for maternal health, PMTCT, and prevention of sexual transmission. Evidence-based interventions exist to support engagement in care but most focus on periods of mother-to-child transmission risk. In the long term, life transitions and health-care transfers are inevitable. Thus, interventions that can reach beyond a single facility or provide a bridge between health services should be prioritized. Multicomponent interventions will also be essential to address the numerous intersecting barriers to sustained engagement in ART services.
Collapse
Affiliation(s)
- Tamsin K Phillips
- a Division of Epidemiology & Biostatistics and Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa
| | - Landon Myer
- a Division of Epidemiology & Biostatistics and Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Omonaiye O, Nicholson P, Kusljic S, Manias E. A meta-analysis of effectiveness of interventions to improve adherence in pregnant women receiving antiretroviral therapy in sub-Saharan Africa. Int J Infect Dis 2018; 74:71-82. [PMID: 30003952 DOI: 10.1016/j.ijid.2018.07.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 07/03/2018] [Accepted: 07/03/2018] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE We evaluated the effectiveness of interventions aimed at improving antiretroviral therapy (ART) adherence during pregnancy in sub-Saharan Africa. METHODS For this meta-analysis, the following databases were searched: MEDLINE Complete, Embase, Global Health, CINAHL Complete, and Google Scholar. Randomized and nonrandomized studies were considered for inclusion if they involved an intervention with the intent of improving medication adherence among pregnant women taking ART in sub-Saharan Africa. Databases were searched from inception to the end of August 2017. The primary outcome assessed was adherence to ART, defined as the proportion of women adherent to treatment in the control and intervention groups. Risk ratios and random effect meta-analysis were undertaken, and heterogeneity was examined with the I2 statistic. RESULTS The systematic search of databases yielded a total of 402 articles, of which 19 studies were selected for meta-analysis with a total of 27,974 participants. Nine types of interventions were identified in the 19 studies to improve ART adherence. The test for the subgroup differences showed that there was a statistically significant difference among the 9 subgroups of interventions, χ2 (8)=102.38; p=0.00001. Collectively, in the meta-analysis, the various intervention types made a significant impact on improving medication adherence. The overall effect estimate with 95% CI was as follows: 1.25 (95% CI=1.03, 1.52, p=0.03). The following risk ratio results for meta-analysis were obtained for the three interventions that showed significant impact on adherence; namely social support and structural support, 1.58 (95% CI=1.36, 1.84, p<0.00001); education, social support and structural support=2.60 (95% CI=1.95, 3.45, p<0.00001); and device reminder=1.13 (95% CI=1.05, 1.20, p=0.0004). The proportion of women who were adherent to ART as a result of the interventions was 59.3% compared with 22.5% in the control groups. CONCLUSION The use of device reminder, a combination of social support and structural support, and education, social support and structural support has the potential to improve ART adherence during pregnancy. Good quality prospective observational studies and randomized control trials are needed in sub-Saharan Africa to determine the most effective interventions.
Collapse
Affiliation(s)
- Olumuyiwa Omonaiye
- Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, Melbourne Burwood, Victoria, Australia.
| | - Pat Nicholson
- Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, Melbourne Burwood, Victoria, Australia
| | - Snezana Kusljic
- Department of Nursing, The University of Melbourne, Melbourne, Australia
| | - Elizabeth Manias
- Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, Melbourne Burwood, Victoria, Australia
| |
Collapse
|
9
|
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.
Collapse
|
10
|
Omonaiye O, Kusljic S, Nicholson P, Manias E. Medication adherence in pregnant women with human immunodeficiency virus receiving antiretroviral therapy in sub-Saharan Africa: a systematic review. BMC Public Health 2018; 18:805. [PMID: 29945601 PMCID: PMC6020364 DOI: 10.1186/s12889-018-5651-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/31/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of antiretroviral therapy (ART) is a core strategy proposed by the World Health Organization in preventing mother to child transmission (MTCT) of HIV. This systematic review aimed to examine the enablers and barriers of medication adherence among HIV positive pregnant women in sub-Saharan Africa. METHODS We used the following keywords: HIV AND (Pregnancy OR Pregnant*) AND (PMTCT OR "PMTCT Cascade" OR "Vertical Transmission" OR "Mother-to-Child") AND (Prevent OR Prevention) AND (HAART OR "Antiretroviral Therapy" OR "Triple Therapy") AND (Retention OR Concordance OR Adherence OR Compliance) to conduct electronic searches in the following databases: MEDLINE Complete (1916-Dec 2017), Embase (1947-Dec 2017), Global Health (1910-Dec 2017) and CINAHL Complete (1937-Dec 2017). Of the four databases searched, 401 studies were identified with 44 meeting the inclusion criteria. Seven studies were added after searching reference lists of included articles, resulting in 51 articles in total. RESULTS The review demonstrated that stigma, cost of transportation, food deprivation and a woman's disclosure or non-disclosure of her HIV status to a partner, family and the community, could limit or define the extent of her adherence to prescribed antiretroviral drugs during pregnancy. Furthermore, the review indicated that knowledge of HIV status, either before or during pregnancy, was significantly associated with medication adherence. Women who knew their HIV status before pregnancy demonstrated good adherence while women who found out their HIV infection status during pregnancy were linked with non-adherence to ART. CONCLUSION This review revealed several barriers and enablers of adherence among pregnant women taking ART in sub-Saharan Africa. Major barriers included the fear of HIV infection status disclosure to partners and family members, stigma and discrimination. A major enabler of adherence in women taking ART was women's knowledge of their HIV status prior to becoming pregnant. Enhanced effort is needed to facilitate women's knowledge of their HIV status before pregnancy to enable disease acceptance and management, and to support pregnant women and her partner and family in dealing with fear, stigma and discrimination about HIV.
Collapse
Affiliation(s)
- Olumuyiwa Omonaiye
- Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Faculty of Health, Deakin University, 221 Burwood Highway, Burwood Campus, Melbourne, VIC, 3125, Australia.
| | - Snezana Kusljic
- Department of Nursing, School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Pat Nicholson
- Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Faculty of Health, Deakin University, 221 Burwood Highway, Burwood Campus, Melbourne, VIC, 3125, Australia
| | - Elizabeth Manias
- Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Faculty of Health, Deakin University, 221 Burwood Highway, Burwood Campus, Melbourne, VIC, 3125, Australia
| |
Collapse
|
11
|
Bebell LM, Ngonzi J, Siedner MJ, Muyindike WR, Bwana BM, Riley LE, Boum Y, Bangsberg DR, Bassett IV. HIV Infection and risk of postpartum infection, complications and mortality in rural Uganda. AIDS Care 2018; 30:943-953. [PMID: 29451005 DOI: 10.1080/09540121.2018.1434119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
HIV infection may increase risk of postpartum infection and infection-related mortality. We hypothesized that postpartum infection incidence and attributable mortality in Mbarara, Uganda would be higher in HIV-infected than HIV-uninfected women. We performed a prospective cohort study of 4231 women presenting to a regional referral hospital in 2015 for delivery or postpartum care. All febrile or hypothermic women, and a subset of randomly selected normothermic women were followed during hospitalization and with 6-week postpartum phone interviews. The primary outcome was in-hospital postpartum infection. Secondary outcomes included in-hospital complications (mortality, re-operation, intensive care unit transfer, need for imaging or blood transfusion) and 6-week mortality. We performed multivariable regression analyses to estimate adjusted differences in each outcome by HIV serostatus. Mean age was 25.2 years and 481 participants (11%) were HIV-infected. Median CD4+ count was 487 (IQR 325, 696) cells/mm3, and 90% of HIV-infected women (193/215 selected for in-depth survey) were on antiretroviral therapy. Overall, 5% (205/4231) of women developed fever or hypothermia. Cumulative in-hospital postpartum infection incidence was 2.0% and did not differ by HIV status (aOR 1.4, 95% CI 0.6-3.3, P = 0.49). However, more HIV-infected women developed postpartum complications (4.4% vs. 1.2%, P = 0.001). In-hospital mortality was rare (2/1768, 0.1%), and remained so at 6 weeks (4/1526, 0.3%), without differences by HIV serostatus (P = 1.0 and 0.31, respectively). For women in rural Uganda with high rates of antiretroviral therapy coverage, HIV infection did not predict postpartum infection or mortality, but was associated with increased risk of postpartum complications.
Collapse
Affiliation(s)
- Lisa M Bebell
- a Division of Infectious Diseases , Massachusetts General Hospital , Boston , MA , USA.,b Massachusetts General Hospital Center for Global Health , Boston , MA , USA
| | - Joseph Ngonzi
- c Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda
| | - Mark J Siedner
- a Division of Infectious Diseases , Massachusetts General Hospital , Boston , MA , USA.,b Massachusetts General Hospital Center for Global Health , Boston , MA , USA.,c Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda
| | - Winnie R Muyindike
- d Department of Medicine , Mbarara Regional Referral Hospital , Mbarara , Uganda
| | - Bosco M Bwana
- c Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda
| | - Laura E Riley
- e Division of Obstetrics and Gynecology , Massachusetts General Hospital , Boston , MA , USA
| | - Yap Boum
- c Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda.,f Epicentre Mbarara Research Centre , Mbarara , Uganda
| | - David R Bangsberg
- a Division of Infectious Diseases , Massachusetts General Hospital , Boston , MA , USA.,b Massachusetts General Hospital Center for Global Health , Boston , MA , USA
| | - Ingrid V Bassett
- a Division of Infectious Diseases , Massachusetts General Hospital , Boston , MA , USA
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Dunkley E, Ashaba S, Burns B, O’Neil K, Sanyu N, Akatukwasa C, Kastner J, Berry NS, Psaros C, Matthews LT, Kaida A. "I beg you…breastfeed the baby, things changed": infant feeding experiences among Ugandan mothers living with HIV in the context of evolving guidelines to prevent postnatal transmission. BMC Public Health 2018; 18:188. [PMID: 29378548 PMCID: PMC5789624 DOI: 10.1186/s12889-018-5081-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 01/16/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND For women living with HIV (WLWH) in low- and middle-income countries, World Health Organization (WHO) infant feeding guidelines now recommend exclusive breastfeeding until six months followed by mixed feeding until 24 months, alongside lifelong maternal antiretroviral therapy (ART). These recommendations represent the sixth major revision to WHO infant feeding guidelines since 1992. We explored how WLWH in rural Uganda make infant feeding decisions in light of evolving recommendations. METHODS We conducted semi-structured interviews with 20 postpartum Ugandan WLWH accessing ART, who reported pregnancy < 2 years prior to recruitment. Interviews were conducted between February-August 2014 with babies born between March 2012-October 2013, over which time, the regional HIV treatment clinic recommended lifelong ART for all pregnant and breastfeeding women (Option B+). Content analysis was used to identify major themes. Infant feeding experiences was an emergent theme. NVivo 10 software was used to organize analyses. RESULTS Among 20 women, median age was 33 years [IQR: 28-35], number of livebirths was 3 [IQR: 2-5], years on ART was 2.3 [IQR: 1.5-5.1], and 95% were virally suppressed. Data revealed that women valued opportunities to reduce postnatal transmission. However, women made infant feeding choices that differed from recommendations due to: (1) perception of conflicting recommendations regarding infant feeding; (2) fear of prolonged infant HIV exposure through breastfeeding; and (3) social and structural constraints shaping infant feeding decision-making. CONCLUSIONS WLWH face layered challenges navigating evolving infant feeding recommendations. Further research is needed to examine guidance and decision-making on infant feeding choices to improve postpartum experiences and outcomes. Improved communication about changes to recommendations is needed for WLWH, their partners, community members, and healthcare providers.
Collapse
Affiliation(s)
- Emma Dunkley
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall Rm 10522, 8888 University Drive, Burnaby, B.C. V5A 1S6 Canada
| | - Scholastic Ashaba
- Mbarara University of Science and Technology (MUST), Mbarara, Uganda
| | - Bridget Burns
- Massachusetts General Hospital (MGH) Global Health, Boston, MA USA
| | - Kasey O’Neil
- Massachusetts General Hospital (MGH) Global Health, Boston, MA USA
| | - Naomi Sanyu
- Mbarara University of Science and Technology (MUST), Mbarara, Uganda
| | | | - Jasmine Kastner
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall Rm 10522, 8888 University Drive, Burnaby, B.C. V5A 1S6 Canada
| | - Nicole S. Berry
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall Rm 10522, 8888 University Drive, Burnaby, B.C. V5A 1S6 Canada
| | - Christina Psaros
- Behavioral Medicine, Department of Psychiatry, Massachusetts General Hospital (MGH), Boston, MA USA
| | - Lynn T. Matthews
- Massachusetts General Hospital (MGH) Global Health, Boston, MA USA
- Division of Infectious Disease, Massachusetts General Hospital (MGH), Boston, MA USA
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall Rm 10522, 8888 University Drive, Burnaby, B.C. V5A 1S6 Canada
| |
Collapse
|
14
|
Chetty T, Newell ML, Thorne C, Coutsoudis A. Viraemia before, during and after pregnancy in HIV-infected women on antiretroviral therapy in rural KwaZulu-Natal, South Africa, 2010-2015. Trop Med Int Health 2017; 23:79-91. [PMID: 29121445 DOI: 10.1111/tmi.13001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Pregnancy and post-partum viral load suppression is critical to prevent mother-to-child HIV transmission and ensure maternal health. We measured viraemia risk before, during and after pregnancy in HIV-infected women. METHODS Between 2010 and 2015, 1425 HIV-infected pregnant women on lifelong antiretroviral therapy (ART) for at least six months pre-pregnancy were enrolled in a cohort study in rural KwaZulu-Natal, South Africa. Odds ratios were estimated in multilevel logistic regression, with pregnancy period time-varying. RESULTS Over half of 1425 women received tenofovir-based regimens (n = 791). Median pre-pregnancy ART duration was 2.1 years. Of 988 women (69.3%) with pre-pregnancy viral loads, 82.0%, 6.8% and 11.2% had VL <50, 50-999 and ≥1000 copies/ml, respectively. During pregnancy and at six, 12 and 24 months, viral load was ≥1000 copies/ml in 15.2%, 15.7%, 17.8% and 16.6% respectively; viral load <50 was 76.9%, 77%, 75.5% and 75.8%, respectively. Adjusting for age, clinical and pregnancy factors, viraemia risk (viral load ≥50 copies/ml) was not significantly associated with pregnancy [adjusted OR (aOR) 1.31; 95% CI 0.90-1.92], six months (aOR 1.30; 95% CI 0.83-2.04), 12 months (aOR 0.96; 95% CI 0.58-1.58) and 24 months (aOR 1.40; 95% CI 0.89-2.22) post-partum. Adjusting for ART duration-pregnancy period interaction, viraemia risk was 1.8 during pregnancy and twofold higher post-partum. CONCLUSIONS While undetectable viral load before pregnancy through post-partum was common, the UNAIDS goal to suppress viraemia in 90% of women was not met. Women on preconception ART remain vulnerable to viraemia; additional support is required to prevent mother-to-child HIV transmission and maintain maternal health.
Collapse
Affiliation(s)
- Terusha Chetty
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Marie-Louise Newell
- Faculty of Medicine, Institute for Developmental Sciences, University of Southampton, Southampton, UK
| | - Claire Thorne
- UCL Institute of Child Health, University College London, London, UK
| | - Anna Coutsoudis
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| |
Collapse
|
15
|
Offering pre-exposure prophylaxis for HIV prevention to pregnant and postpartum women: a clinical approach. J Int AIDS Soc 2017; 20:21295. [PMID: 28361503 PMCID: PMC5577744 DOI: 10.7448/ias.20.2.21295] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Introduction: HIV prevention during pregnancy and lactation is critical for both maternal and child health. Pregnancy provides a critical opportunity for clinicians to elicit women’s vulnerabilities to HIV and offer HIV testing, treatment and referral and/or comprehensive HIV prevention options for the current pregnancy, the postpartum period and safer conception options for future pregnancies. In this commentary, we review the safety of oral pre-exposure prophylaxis with tenofovir/emtricitabine in pregnant and lactating women and suggest opportunities to identify pregnant and postpartum women at substantial risk of HIV. We then describe a clinical approach to caring for women who both choose and decline pre-exposure prophylaxis during pregnancy and postpartum, highlighting areas for future research. Discussion: Evidence suggests that pre-exposure prophylaxis with tenofovir/emtricitabine is safe in pregnancy and lactation. Identifying women vulnerable to HIV and eligible for pre-exposure prophylaxis is challenging in light of the myriad of individual, community, and structural forces impacting HIV acquisition. Validated risk calculators exist for specific populations but have not been used to screen and offer HIV prevention methods. Partner testing and engagement of men living with HIV are additional means of reaching at-risk women. However, women’s vulnerabilities to HIV change over time. Combining screening for HIV vulnerability with HIV and/or STI testing at standard intervals during pregnancy is a practical way to prompt providers to incorporate HIV screening and prevention counselling. We suggest using shared decision-making to offer women pre-exposure prophylaxis as one of multiple HIV prevention strategies during pregnancy and postpartum, facilitating open conversations about HIV vulnerabilities, preferences about HIV prevention strategies, and choosing a method that best meets the needs of each woman. Conclusion: Growing evidence suggests that pre-exposure prophylaxis with tenofovir/emtricitabine during pregnancy and lactation is safe and effective. Shared decision-making provides one approach to identify at-risk women and offers pre-exposure prophylaxis but requires implementation research in diverse clinical settings. Including pregnant and breastfeeding women in future HIV prevention research is critical for the creation of evidence-driven public health policies and clinical guidelines.
Collapse
|
16
|
Implementation and Operational Research: Impact of a Systems Engineering Intervention on PMTCT Service Delivery in Côte d'Ivoire, Kenya, Mozambique: A Cluster Randomized Trial. J Acquir Immune Defic Syndr 2017; 72:e68-76. [PMID: 27082507 DOI: 10.1097/qai.0000000000001023] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Efficacious interventions to prevent mother-to-child HIV transmission (PMTCT) have not translated well into effective programs. Previous studies of systems engineering applications to PMTCT lacked comparison groups or randomization. METHODS Thirty-six health facilities in Côte d'Ivoire, Kenya, and Mozambique were randomized to usual care or a systems engineering intervention, stratified by country and volume. The intervention guided facility staff to iteratively identify and then rectify barriers to PMTCT implementation. Registry data quantified coverage of HIV testing during first antenatal care visit, antiretrovirals (ARVs) for HIV-positive pregnant women, and screening HIV-exposed infants (HEI) for HIV by 6-8 weeks. We compared the change between baseline (January 2013-January 2014) and postintervention (January 2015-March 2015) periods using t-tests. All analyses were intent-to-treat. RESULTS ARV coverage increased 3-fold [+13.3% points (95% CI: 0.5 to 26.0) in intervention vs. +4.1 (-12.6 to 20.7) in control facilities] and HEI screening increased 17-fold [+11.6 (-2.6 to 25.7) in intervention vs. +0.7 (-12.9 to 14.4) in control facilities]. In prespecified subgroup analyses, ARV coverage increased significantly in Kenya [+20.9 (-3.1 to 44.9) in intervention vs. -21.2 (-52.7 to 10.4) in controls; P = 0.02]. HEI screening increased significantly in Mozambique [+23.1 (10.3 to 35.8) in intervention vs. +3.7 (-13.1 to 20.6) in controls; P = 0.04]. HIV testing did not differ significantly between arms. CONCLUSIONS In this first randomized trial of systems engineering to improve PMTCT, we saw substantially larger improvements in ARV coverage and HEI screening in intervention facilities compared with controls, which were significant in prespecified subgroups. Systems engineering could strengthen PMTCT service delivery and protect infants from HIV.
Collapse
|
17
|
Miller K, Muyindike W, Matthews LT, Kanyesigye M, Siedner MJ. Program Implementation of Option B+ at a President's Emergency Plan for AIDS Relief-Supported HIV Clinic Improves Clinical Indicators But Not Retention in Care in Mbarara, Uganda. AIDS Patient Care STDS 2017; 31:335-341. [PMID: 28650703 PMCID: PMC5564010 DOI: 10.1089/apc.2017.0034] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
2013 WHO guidelines for prevention of mother to child transmission recommend combination antiretroviral therapy (ART) for all pregnant women, regardless of CD4 count (Option B/B+). We conducted a retrospective analysis of data from a government-operated HIV clinic in Mbarara, Uganda before and after implementation of Option B+ to assess the impact on retention in care. We limited our analysis to women not on ART at the time of their first reported pregnancy with CD4 count >350. We fit regression models to estimate relationships between calendar period (Option A vs. Option B+) and the primary outcome of interest, retention in care. One thousand and sixty-two women were included in the analysis. Women were more likely to start ART within 6 months of pregnancy in the Option B+ period (68% vs. 7%, p < 0.0001) and had significantly greater increases in CD4 count 1 year after pregnancy (+172 vs. -5 cells, p < 0.001). However, there was no difference in the proportion of women retained in care 1 year after pregnancy (73% vs. 70%, p = 0.34). In models adjusted for age, distance to clinic, marital status, and CD4 count, Option B+ was associated with a nonsignificant 30% increased odds of retention in care at 1 year [adjusted odds ratio (AOR) = 1.30, 95% CI 0.98-1.73, p = 0.06]. After transition to an Option B+ program, pregnant women with CD4 count >350 were more likely to initiate combination therapy; however, interventions to mitigate losses from HIV care during pregnancy are needed to improve the health of women, children, and families.
Collapse
Affiliation(s)
- Kathleen Miller
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Winnie Muyindike
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lynn T. Matthews
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Kanyesigye
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mark J. Siedner
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
18
|
Myer L, Essajee S, Broyles LN, Watts DH, Lesosky M, El-Sadr WM, Abrams EJ. Pregnant and breastfeeding women: A priority population for HIV viral load monitoring. PLoS Med 2017; 14:e1002375. [PMID: 28809929 PMCID: PMC5557351 DOI: 10.1371/journal.pmed.1002375] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Landon Myer and colleagues discuss viral load monitoring for pregnant HIV-positive women and those breastfeeding; ART treatments can suppress viral load and are key to preventing transmission to the child.
Collapse
Affiliation(s)
- Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Shaffiq Essajee
- HIV Department, World Health Organization, Geneva, Switzerland
| | - Laura N. Broyles
- Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
| | - D. Heather Watts
- Office of the Global AIDS Coordinator and Health Diplomacy, US Department of State, Washington DC, United States of America
| | - Maia Lesosky
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Wafaa M. El-Sadr
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, United States of America
- College of Physicians & Surgeons, Columbia University, New York, New York, United States of America
| | - Elaine J. Abrams
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, United States of America
- College of Physicians & Surgeons, Columbia University, New York, New York, United States of America
| |
Collapse
|
19
|
Onoya D, Sineke T, Brennan AT, Long L, Fox MP. Timing of pregnancy, postpartum risk of virologic failure and loss to follow-up among HIV-positive women. AIDS 2017; 31:1593-1602. [PMID: 28463877 PMCID: PMC5491237 DOI: 10.1097/qad.0000000000001517] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/20/2017] [Accepted: 04/20/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We assessed the association between the timing of pregnancy with the risk of postpartum virologic failure and loss from HIV care in South Africa. DESIGN This is a retrospective cohort study of 6306 HIV-positive women aged 15-49 at antiretroviral therapy (ART) initiation, initiated on ART between January 2004 and December 2013 in Johannesburg, South Africa. METHODS The incidence of virologic failure (two consecutive viral load measurements of >1000 copies/ml) and loss to follow-up (>3 months late for a visit) during 24 months postpartum were assessed using Cox proportional hazards modelling. RESULTS The rate of postpartum virologic failure was higher following an incident pregnancy on ART [adjusted hazard ratio 1.8, 95% confidence interval (CI): 1.1-2.7] than among women who initiated ART during pregnancy. This difference was sustained among women with CD4 cell count less than 350 cells/μl at delivery (adjusted hazard ratio 1.8, 95% CI: 1.1-3.0). Predictors of postpartum virologic failure were being viremic, longer time on ART, being 25 or less years old and low CD4 cell count and anaemia at delivery, as well as initiating ART on stavudine-containing or abacavir-containing regimen. There was no difference postpartum loss to follow-up rates between the incident pregnancies group (hazard ratio 0.9, 95% CI: 0.7-1.1) and those who initiated ART in pregnancy. CONCLUSION The risk of virologic failure remains high among postpartum women, particularly those who conceive on ART. The results highlight the need to provide adequate support for HIV-positive women with fertility intention after ART initiation and to strengthen monitoring and retention efforts for postpartum women to sustain the benefits of ART.
Collapse
Affiliation(s)
- Dorina Onoya
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tembeka Sineke
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alana T. Brennan
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P. Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
20
|
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.
Collapse
|
21
|
Bebell LM, Siedner MJ, Musinguzi N, Boum Y, Bwana BM, Muyindike W, Hunt PW, Martin JN, Bangsberg DR. Trends in one-year cumulative incidence of death between 2005 and 2013 among patients initiating antiretroviral therapy in Uganda. Int J STD AIDS 2016; 28:800-807. [PMID: 27651351 DOI: 10.1177/0956462416671431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Recent ecological data demonstrate improving outcomes for HIV-infected people in sub-Saharan Africa. Recently, Uganda has experienced a resurgence in HIV incidence and prevalence, but trends in HIV-related deaths have not been well described. Data were collected through the Uganda AIDS Rural Treatment Outcomes (UARTO) Study, an observational longitudinal cohort of Ugandan adults initiating antiretroviral therapy (ART) between 2005 and 2013. We calculated cumulative incidence of death within one year of ART initiation, and fit Poisson models with robust variance estimators to estimate the effect enrollment period on one-year risk of death and loss to follow-up. Of 760 persons in UARTO who started ART, 30 deaths occurred within one year of ART initiation (cumulative incidence 3.9%, 95% confidence interval [CI] 2.7-5.6%). Risk of death was highest for those starting ART in 2005 (13.0%, 95% CI 6.0-24.0%), decreased in 2006-2007 to 4% (95% CI 2.0-6.0%), and did not change thereafter ( P = 0.61). These results were robust to adjustment for age, sex, CD4 cell count, viral load, asset wealth, baseline depression, and body mass index. Here, we demonstrate that one-year cumulative incidence of death was high just after free ART rollout, decreased the following year, and remained low thereafter. Once established, ART programs in President's Emergency Fund for AIDS Relief-supported countries can maintain high quality care.
Collapse
Affiliation(s)
- Lisa M Bebell
- 1 Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,2 Massachusetts General Hospital Center for Global Health, Boston, MA, USA
| | - Mark J Siedner
- 1 Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,2 Massachusetts General Hospital Center for Global Health, Boston, MA, USA
| | | | - Yap Boum
- 3 Mbarara University of Science and Technology, Mbarara, Uganda.,4 Epicentre Research Base, Mbarara, Uganda
| | - Bosco M Bwana
- 3 Mbarara University of Science and Technology, Mbarara, Uganda
| | - Winnie Muyindike
- 5 Department of Medicine, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Peter W Hunt
- 6 Department of Medicine, University of California, Berkeley, CA, USA
| | - Jeffrey N Martin
- 7 Department of Epidemiology and Biostatistics, University of California, Berkeley, CA, USA
| | - David R Bangsberg
- 1 Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,2 Massachusetts General Hospital Center for Global Health, Boston, MA, USA
| |
Collapse
|
22
|
Haas AD, Msukwa MT, Egger M, Tenthani L, Tweya H, Jahn A, Gadabu OJ, Tal K, Salazar-Vizcaya L, Estill J, Spoerri A, Phiri N, Chimbwandira F, van Oosterhout JJ, Keiser O. Adherence to Antiretroviral Therapy During and After Pregnancy: Cohort Study on Women Receiving Care in Malawi's Option B+ Program. Clin Infect Dis 2016; 63:1227-1235. [PMID: 27461920 PMCID: PMC5064160 DOI: 10.1093/cid/ciw500] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 07/17/2016] [Indexed: 12/28/2022] Open
Abstract
One-third of women enrolled in Malawi's program to prevent human immunodeficiency virus mother-to-child-transmission (Option B+) adhered inadequately to antiretroviral therapy during pregnancy and breastfeeding. Long-term virological outcomes must be closely monitored, and effective interventions to improve adherence should be deployed. Background. Adherence to antiretroviral therapy (ART) is crucial to preventing mother-to-child transmission of human immunodeficiency virus (HIV) and ensuring the long-term effectiveness of ART, yet data are sparse from African routine care programs on maternal adherence to triple ART. Methods. We analyzed data from women who started ART at 13 large health facilities in Malawi between September 2011 and October 2013. We defined adherence as the percentage of days “covered” by pharmacy claims. Adherence of ≥90% was deemed adequate. We calculated inverse probability of censoring weights to adjust adherence estimates for informative censoring. We used descriptive statistics, survival analysis, and pooled logistic regression to compare adherence between pregnant and breastfeeding women eligible for ART under Option B+, and nonpregnant and nonbreastfeeding women who started ART with low CD4 cell counts or World Health Organization clinical stage 3/4 disease. Results. Adherence was adequate for 73% of the women during pregnancy, for 66% in the first 3 months post partum, and for about 75% during months 4–21 post partum. About 70% of women who started ART during pregnancy and breastfeeding adhered adequately during the first 2 years of ART, but only about 30% of them had maintained adequate adherence at every visit. Risk factors for inadequate adherence included starting ART with an Option B+ indication, at a younger age, or at a district hospital or health center. Conclusions. One-third of women retained in the Option B+ program adhered inadequately during pregnancy and breastfeeding, especially soon after delivery. Effective interventions to improve adherence among women in this program should be implemented.
Collapse
Affiliation(s)
| | - Malango T Msukwa
- Institute of Social & Preventive Medicine The Baobab Health Trust
| | - Matthias Egger
- Institute of Social & Preventive Medicine Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Lyson Tenthani
- Institute of Social & Preventive Medicine International Training & Education Center for Health
| | - Hannock Tweya
- Institute of Social & Preventive Medicine Lighthouse Trust The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Andreas Jahn
- International Training & Education Center for Health Department of HIV and AIDS, Ministry of Health, Lilongwe
| | | | - Kali Tal
- Institute of Social & Preventive Medicine
| | - Luisa Salazar-Vizcaya
- Institute of Social & Preventive Medicine Department of Infectious Diseases, Bern University Hospital, University of Bern, Switzerland
| | | | | | | | | | - Joep J van Oosterhout
- Dignitas International, Zomba Department of Medicine, College of Medicine, University of Malawi, Blantyre
| | | |
Collapse
|
23
|
Jain V, Chang W, Byonanebye DM, Owaraganise A, Twinomuhwezi E, Amanyire G, Black D, Marseille E, Kamya MR, Havlir DV, Kahn JG. Estimated Costs for Delivery of HIV Antiretroviral Therapy to Individuals with CD4+ T-Cell Counts >350 cells/uL in Rural Uganda. PLoS One 2015; 10:e0143433. [PMID: 26632823 PMCID: PMC4669141 DOI: 10.1371/journal.pone.0143433] [Citation(s) in RCA: 14] [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: 06/10/2015] [Accepted: 11/04/2015] [Indexed: 12/22/2022] Open
Abstract
Background Evidence favoring earlier HIV ART initiation at high CD4+ T-cell counts (CD4>350/uL) has grown, and guidelines now recommend earlier HIV treatment. However, the cost of providing ART to individuals with CD4>350 in Sub-Saharan Africa has not been well estimated. This remains a major barrier to optimal global cost projections for accelerating the scale-up of ART. Our objective was to compute costs of ART delivery to high CD4+count individuals in a typical rural Ugandan health center-based HIV clinic, and use these data to construct scenarios of efficient ART scale-up. Methods Within a clinical study evaluating streamlined ART delivery to 197 individuals with CD4+ cell counts >350 cells/uL (EARLI Study: NCT01479634) in Mbarara, Uganda, we performed a micro-costing analysis of administrative records, ART prices, and time-and-motion analysis of staff work patterns. We computed observed per-person-per-year (ppy) costs, and constructed models estimating costs under several increasingly efficient ART scale-up scenarios using local salaries, lowest drug prices, optimized patient loads, and inclusion of viral load (VL) testing. Findings Among 197 individuals enrolled in the EARLI Study, median pre-ART CD4+ cell count was 569/uL (IQR 451–716). Observed ART delivery cost was $628 ppy at steady state. Models using local salaries and only core laboratory tests estimated costs of $529/$445 ppy (+/-VL testing, respectively). Models with lower salaries, lowest ART prices, and optimized healthcare worker schedules reduced costs by $100–200 ppy. Costs in a maximally efficient scale-up model were $320/$236 ppy (+/- VL testing). This included $39 for personnel, $106 for ART, $130/$46 for laboratory tests, and $46 for administrative/other costs. A key limitation of this study is its derivation and extrapolation of costs from one large rural treatment program of high CD4+ count individuals. Conclusions In a Ugandan HIV clinic, ART delivery costs—including VL testing—for individuals with CD4>350 were similar to estimates from high-efficiency programs. In higher efficiency scale-up models, costs were substantially lower. These favorable costs may be achieved because high CD4+ count patients are often asymptomatic, facilitating more efficient streamlined ART delivery. Our work provides a framework for calculating costs of efficient ART scale-up models using accessible data from specific programs and regions.
Collapse
Affiliation(s)
- Vivek Jain
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco (UCSF), San Francisco, CA, United States of America
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
- * E-mail:
| | - Wei Chang
- Philip R. Lee Institute for Health Policy Studies, UCSF, San Francisco, CA, United States of America
| | | | | | - Ellon Twinomuhwezi
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
| | - Gideon Amanyire
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Douglas Black
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco (UCSF), San Francisco, CA, United States of America
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
| | - Elliot Marseille
- Health Strategies International, Oakland, CA, United States of America
| | - Moses R. Kamya
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V. Havlir
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco (UCSF), San Francisco, CA, United States of America
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
| | - James G. Kahn
- Philip R. Lee Institute for Health Policy Studies, UCSF, San Francisco, CA, United States of America
| |
Collapse
|