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Espinal M, Yee LM, Fisher SA. Advances in HIV Management During Pregnancy and Infant Feeding. Infect Dis Clin North Am 2024; 38:423-452. [PMID: 38969531 DOI: 10.1016/j.idc.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2024]
Abstract
Recent advances in human immunodeficiency virus (HIV) management during pregnancy and infant feeding encompass several key elements: expanded HIV testing guidance; growing evidence of safety, efficacy, and pharmacokinetic data favoring the use of preferred antiretroviral therapy (ART) during pregnancy and breastfeeding; increasing advocacy for the inclusion of pregnant individuals with HIV in clinical trials to expedite access to new ART; and updated guidelines supporting shared decision-making for choice of infant feeding methods in people with HIV.
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Affiliation(s)
- Mariana Espinal
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 East Superior Street, Suite 05-2303, Chicago, IL, USA
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 East Superior Street, Suite 05-2303, Chicago, IL, USA.
| | - Stephanie A Fisher
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 East Superior Street, Suite 05-2303, Chicago, IL, USA
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2
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Hampanda K, Grubbs H, Castillo-Mancilla J, Anderson PL, Thorne J, Helova A, Turan JM, Onono M, Abuogi LL. Antiretroviral therapy adherence among peripartum women with HIV in Kenya: an explanatory mixed methods study using dry blood spot measures and narrative interviews. AIDS Care 2024:1-12. [PMID: 39106970 DOI: 10.1080/09540121.2024.2383885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 07/18/2024] [Indexed: 08/09/2024]
Abstract
ABSTRACTAdherence to antiretroviral therapy (ART) remains sub-optimal among pregnant and postpartum women with HIV (PPWH) in high HIV prevalence low resource settings with few effective behavioral interventions. A large body of qualitative literature has established general barriers and facilitators to ART adherence in PPWH at various levels (individual, interpersonal, structural). However, research exploring the underlying behavioral mechanisms of ART adherence in PPWH with objectively verified adherence biomarkers is extremely limited. We conducted 24 in-depth interviews with postpartum women in western Kenya who had linked ART drug concentrations obtained from three dried blood spot samples across the peripartum period. Among PPWH with a low drug concentration (n = 13) compared to those with continuously high drug concentrations (n = 11), distinct themes emerged related to HIV status disclosure, social support, interactions with the health system, and health beliefs. By combining ART biomarkers with patient reported challenges, there is the potential for real-time interventions to support sustained ART adherence among PPWH and improve maternal and infant health outcomes.
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Affiliation(s)
- K Hampanda
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, CO, USA
- Center for Global Health, University of Colorado, Aurora, CO, USA
| | - H Grubbs
- Department of Surgery, University of Oklahoma, Oklahoma City, OK, USA
| | - J Castillo-Mancilla
- Division of Infectious Diseases, Department of Medicine, University of Colorado Denver, Aurora, CO, USA
| | - P L Anderson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - J Thorne
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, CO, USA
- Center for Global Health, University of Colorado, Aurora, CO, USA
| | - A Helova
- Department of Health Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Sparkman Center for Global Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J M Turan
- Department of Health Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Sparkman Center for Global Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Public Health, School of Medicine, Koc University, Istanbul, Turkey
| | - M Onono
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - L L Abuogi
- Center for Global Health, University of Colorado, Aurora, CO, USA
- Department of Pediatrics, University of Colorado, Aurora, CO, USA
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Xu F, Xiong Y, Gu M, Wan L, Wang Y. Interventions to prevent mother-to-child transmission in breastfeeding mothers with HIV: a systematic review and meta-analysis of randomized controlled trials. Rev Inst Med Trop Sao Paulo 2024; 66:e45. [PMID: 39082484 PMCID: PMC11295290 DOI: 10.1590/s1678-9946202466045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/23/2024] [Indexed: 08/04/2024] Open
Abstract
This study aimed to systematically review interventions to prevent mother-to-child transmission of HIV during breastfeeding. We conducted a systematic review and meta-analysis using specific criteria to identify randomized controlled trials that focused on pregnant and breastfeeding women living with HIV and their children from birth to 2 years of age. We extensively searched electronic databases, including Web of Science, Scopus, PubMed, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Google Scholar up to October 24, 2023. After screening 3,110 titles and abstracts, we reviewed 306 full texts. Of these, we assessed the quality and risk of bias of fifty-five articles, ultimately identifying seven studies. Four of these studies, which focused on antiretroviral therapy (ART), were included in the meta-analysis. There was little heterogeneity in study methodology and pooled estimates. The postnatal HIV transmission rate was found to be 0.01 (95%CI: 0.00 - 0.02). Therefore, the risk of mother-to-child transmission among breastfeeding mothers with HIV was significantly lower in the intervention groups than in the placebo groups. Analysis of funnel plots and Egger's test (p = 0.589) showed no evidence of publication bias. In addition to the four articles, two studies compared different ART regimens and one study compared the administration of high-dose vitamin A to the mother or the child. The results suggest that the use of ART significantly reduces the risk of postnatal HIV transmission compared with placebo. However, the effectiveness of different ART regimens or other therapies, including high-dose vitamin A, is unclear.
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Affiliation(s)
- Fangping Xu
- Jiangxi Maternal and Child Health Hospital, Obstetrical Department, Jiangxi, Nanchang, China
| | - Ying Xiong
- Jiangxi Maternal and Child Health Hospital, Obstetrical Department, Jiangxi, Nanchang, China
| | - Min Gu
- Jiangxi Maternal and Child Health Hospital, Obstetrical Department, Jiangxi, Nanchang, China
| | - Lingling Wan
- Jiangxi Maternal and Child Health Hospital, Obstetrical Department, Jiangxi, Nanchang, China
| | - Yun Wang
- Jiangxi Maternal and Child Health Hospital, Obstetrical Department, Jiangxi, Nanchang, China
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Barr EA, Abuogi LL, Smith C. A Review of Updated Guidelines on Breastfeeding with Human Immunodeficiency Virus Using Relational Decision-Making and Intellectual Humility to Support Infant Feeding Choices. Nurs Clin North Am 2024; 59:309-327. [PMID: 38670697 DOI: 10.1016/j.cnur.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
This article summarizes the updated guidelines on breastfeeding with HIV with an emphasis on using relational decision-making and intellectual humility to support the conversation around infant feeding choices. The complex cultural experiences and historical disparities that influence these decisions are highlighted, along with an overview of the recent changes to recommendations for breastfeeding in people with HIV. The article describes individualized clinical scenarios that consider infant feeding decisions, outlines communication and support strategies for health care providers, and proposes a relational decision-making model to guide discussions on infant feeding options.
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Affiliation(s)
- Emily A Barr
- University of Texas Health Science Center at Houston, Cizik School of Nursing, 6901 Bertner Avenue, SON 5th Floor, Houston, TX 77030, USA.
| | - Lisa L Abuogi
- Department of Pediatrics, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 055, Aurora, CO 80045, USA
| | - Christiana Smith
- Department of Pediatrics, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 055, Aurora, CO 80045, USA
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Abuogi L, Noble L, Smith C. Infant Feeding for Persons Living With and at Risk for HIV in the United States: Clinical Report. Pediatrics 2024; 153:e2024066843. [PMID: 38766700 DOI: 10.1542/peds.2024-066843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 05/22/2024] Open
Abstract
Pediatricians and pediatric health care professionals caring for infants born to people living with and at risk for HIV infection are likely to be involved in providing guidance on recommended infant feeding practices. Care team members need to be aware of the HIV transmission risk from breastfeeding and the recommendations for feeding infants with perinatal HIV exposure in the United States. The risk of HIV transmission via breastfeeding from a parent with HIV who is receiving antiretroviral treatment (ART) and is virally suppressed is estimated to be less than 1%. The American Academy of Pediatrics recommends that for people with HIV in the United States, avoidance of breastfeeding is the only infant feeding option with 0% risk of HIV transmission. However, people with HIV may express a desire to breastfeed, and pediatricians should be prepared to offer a family-centered, nonjudgmental, harm reduction approach to support people with HIV on ART with sustained viral suppression below 50 copies per mL who desire to breastfeed. Pediatric health care professionals who counsel people with HIV who are not on ART or who are on ART but without viral suppression should recommend against breastfeeding. Pediatric health care professionals should recommend HIV testing for all pregnant persons and HIV preexposure prophylaxis to pregnant or breastfeeding persons who test negative for HIV but are at high risk of HIV acquisition.
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Affiliation(s)
- Lisa Abuogi
- Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Lawrence Noble
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York
| | - Christiana Smith
- Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
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Odayar J, Myer L, Kabanda S, Knight L. Experiences of transfer of care among postpartum women living with HIV attending primary healthcare services in South Africa. Glob Public Health 2024; 19:2356624. [PMID: 38820565 DOI: 10.1080/17441692.2024.2356624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 05/13/2024] [Indexed: 06/02/2024]
Abstract
Transfers between health facilities for postpartum women living with HIV are associated with disengagement from care. In South Africa, women must transfer from integrated antenatal/HIV care to general HIV services post-delivery. Thereafter, women transfer frequently e.g. due to geographic mobility. To explore barriers to transfer, we conducted in-depth interviews >2 years post-delivery in 28 participants in a trial comparing postpartum HIV care at primary health care (PHC) antiretroviral therapy (ART) facilities versus a differentiated service delivery model, the adherence clubs, which are the predominant model implemented in South Africa. Data were thematically analysed using inductive and deductive approaches. Women lacked information including where they could transfer to and transfer processes. Continuity mechanisms were affected when women transferred silently i.e. without informing facilities or obtaining referral letters. Silent transfers often occurred due to poor relationships with healthcare workers and were managed inconsistently. Fear of disclosure to family and community stigma led to transfers from local PHC ART facilities to facilities further away affecting accessibility. Mobility and the postpartum period presented unique challenges requiring specific attention. Information regarding long-term care options and transfer processes, ongoing counselling regarding disclosure and social support, and increased health system flexibility are required.
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Affiliation(s)
- Jasantha Odayar
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Siti Kabanda
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Lucia Knight
- Division of Social and Behavioural Sciences, School of Public Health, University of Cape Town, Cape Town, South Africa
- School of Public Health, University of the Western Cape, Bellville, South Africa
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Francese R, Peila C, Donalisio M, Lamberti C, Cirrincione S, Colombi N, Tonetto P, Cavallarin L, Bertino E, Moro GE, Coscia A, Lembo D. Viruses and Human Milk: Transmission or Protection? Adv Nutr 2023; 14:1389-1415. [PMID: 37604306 PMCID: PMC10721544 DOI: 10.1016/j.advnut.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 07/14/2023] [Accepted: 08/15/2023] [Indexed: 08/23/2023] Open
Abstract
Human milk (HM) is considered the best source of nutrition for infant growth and health. This nourishment is unique and changes constantly during lactation to adapt to the physiological needs of the developing infant. It is also recognized as a potential route of transmission of some viral pathogens although the presence of a virus in HM rarely leads to a disease in an infant. This intriguing paradox can be explained by considering the intrinsic antiviral properties of HM. In this comprehensive and schematically presented review, we have described what viruses have been detected in HM so far and what their potential transmission risk through breastfeeding is. We have provided a description of all the antiviral compounds of HM, along with an analysis of their demonstrated and hypothesized mechanisms of action. Finally, we have also analyzed the impact of HM pasteurization and storage methods on the detection and transmission of viruses, and on the antiviral compounds of HM. We have highlighted that there is currently a deep knowledge on the potential transmission of viral pathogens through breastfeeding and on the antiviral properties of HM. The current evidence suggests that, in most cases, it is unnecessarily to deprive an infant of this high-quality nourishment and that the continuation of breastfeeding is in the best interest of the infant and the mother.
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Affiliation(s)
- Rachele Francese
- Department of Clinical and Biological Sciences, Laboratory of Molecular Virology and Antiviral Research, University of Turin, Orbassano (TO), Italy
| | - Chiara Peila
- Department of Public Health and Pediatrics, Neonatal Intensive Care Unit, University of Turin, Turin, Italy
| | - Manuela Donalisio
- Department of Clinical and Biological Sciences, Laboratory of Molecular Virology and Antiviral Research, University of Turin, Orbassano (TO), Italy
| | - Cristina Lamberti
- Institute of the Science of Food Production - National Research Council, Grugliasco, TO, Italy
| | - Simona Cirrincione
- Institute of the Science of Food Production - National Research Council, Grugliasco, TO, Italy
| | - Nicoletta Colombi
- Biblioteca Federata di Medicina "Ferdinando Rossi", University of Turin, Turin, Italy
| | - Paola Tonetto
- Department of Public Health and Pediatrics, Neonatal Intensive Care Unit, University of Turin, Turin, Italy
| | - Laura Cavallarin
- Institute of the Science of Food Production - National Research Council, Grugliasco, TO, Italy
| | - Enrico Bertino
- Department of Public Health and Pediatrics, Neonatal Intensive Care Unit, University of Turin, Turin, Italy
| | - Guido E Moro
- Italian Association of Human Milk Banks (AIBLUD), Milan, Italy.
| | - Alessandra Coscia
- Department of Public Health and Pediatrics, Neonatal Intensive Care Unit, University of Turin, Turin, Italy.
| | - David Lembo
- Department of Clinical and Biological Sciences, Laboratory of Molecular Virology and Antiviral Research, University of Turin, Orbassano (TO), Italy.
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Pagano-Therrien J, Griswold MK, Amoah RK. "Go With the Flow": A Qualitative Description of Infant Feeding Experiences Among Women With HIV in the United States. J Assoc Nurses AIDS Care 2023; 34:376-388. [PMID: 37199426 DOI: 10.1097/jnc.0000000000000411] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
ABSTRACT Breastfeeding affords numerous health benefits to mothers and children, but for women with HIV in the United States, avoidance of breastfeeding is recommended. Evidence from low-income countries demonstrates low risk of HIV transmission during breastfeeding with antiretroviral therapy, and the World Health Organization recommends exclusive breastfeeding and shared decision making about infant feeding options in low-income and middle-income countries. In the United States, gaps in knowledge exist surrounding the experiences, beliefs, and feelings of women with HIV surrounding infant feeding decisions. Undergirded by a framework of person-centered care, this study describes the experiences, beliefs, and feelings of women with HIV in the United States surrounding recommendations for breastfeeding avoidance. Although no participants reported consideration of breastfeeding, multiple gaps were identified with implications for the clinical care and counseling of the mother-infant dyad.
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Affiliation(s)
- Jesica Pagano-Therrien
- Jesica Pagano-Therrien, PhD, RN, CPNP-PC is an Associate Professor, Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, Massachusetts, USA. Michele K. Griswold, PhD, MPH, RN, IBCLC is an Assistant Professor, Department of Public Health, College of Health and Human Services, Southern Connecticut State University, New Haven, Connecticut, USA. Rita Amoah, PhD, RN, is an Assistant Professor, Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, Massachusetts, USA
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Bukkems VE, Finkenflügel RN, Grintjes K, Marneef M, de Haan M, Mielitz I, van Hulzen A, Rokx C, van Leeuwen E, Nellen JF, Burger DM, Colbers A. Exploring the Breastfeeding Desires and Decision-Making of Women Living with HIV in the Netherlands: Implications for Perinatal HIV Management in Developed Countries. Breastfeed Med 2023; 18:356-361. [PMID: 37083439 PMCID: PMC10254968 DOI: 10.1089/bfm.2023.0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Introduction: Guidelines in high-income countries recommend women living with human immunodeficiency virus (HIV) to formula feed their newborns, because the possibility of mother-to-child-transmission of HIV during breastfeeding cannot be ruled out. It is an ongoing debate if the possible transmission risk outweighs the medical, cultural, psychological, and social importance of breastfeeding in women stable on current first-line suppressive antiretroviral regimens. The study aim was to explore breastfeeding desires and decision-making of immigrant and nonimmigrant women living with HIV in the Netherlands. Method: A questionnaire was administered orally or online to 82 women living with HIV in the Netherlands. The breastfeeding desires of the participants were collected as categorical data, and breastfeeding decision-making and willingness to adhere to additional monitoring were collected on a 5-point Likert scale. Categorical data were presented as proportions, and Likert scale data were presented in Likert scale bar plots. Results: Seventy-one percent of the participants expressed a desire to breastfeed in the future. The most important factors influencing decision-making to breastfeed were the chance of transmission of HIV to the infant and the advice by the doctor or nurse practitioner. Of the participants, 42% expressed their interest in breastfeeding with a <1/100 transmission risk. More than half of the participants expressed their interest to breastfeed with additional monitoring. Conclusions: A substantial proportion of the women living with HIV in the Netherlands has a desire to breastfeed, of which the majority are willing to adhere to additional monitoring to do so.
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Affiliation(s)
- Vera E. Bukkems
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Karin Grintjes
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Manon Marneef
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Martine de Haan
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Astrid van Hulzen
- Department of Internal Medicine, Isala Hospital, Zwolle, the Netherlands
| | - Casper Rokx
- Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands
| | - Elisabeth van Leeuwen
- Department of Obstetrics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jeannine F. Nellen
- Division of Infectious Diseases, Tropical Medicine and AIDS, Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - David M. Burger
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Angela Colbers
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, the Netherlands
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Dugdale CM, Ufio O, Alba C, Permar SR, Stranix‐Chibanda L, Cunningham CK, Fouda GG, Myer L, Weinstein MC, Leroy V, McFarland EJ, Freedberg KA, Ciaranello AL. Cost-effectiveness of broadly neutralizing antibody prophylaxis for HIV-exposed infants in sub-Saharan African settings. J Int AIDS Soc 2023; 26:e26052. [PMID: 36604316 PMCID: PMC9816086 DOI: 10.1002/jia2.26052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 11/28/2022] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Infant HIV prophylaxis with broadly neutralizing anti-HIV antibodies (bNAbs) could provide long-acting protection against vertical transmission. We sought to estimate the potential clinical impact and cost-effectiveness of hypothetical bNAb prophylaxis programmes for children known to be HIV exposed at birth in three sub-Saharan African settings. METHODS We conducted a cost-effectiveness analysis using the CEPAC-Pediatric model, simulating cohorts of infants from birth through death in Côte d'Ivoire, South Africa and Zimbabwe. These settings were selected to reflect a broad range of HIV care cascade characteristics, antenatal HIV prevalence and budgetary constraints. We modelled strategies targeting bNAbs to only WHO-designated "high-risk" HIV-exposed infants (HR-HIVE) or to all HIV-exposed infants (HIVE). We compared four prophylaxis approaches within each target population: standard of care oral antiretroviral prophylaxis (SOC), and SOC plus bNAbs at birth (1-dose), at birth and 3 months (2-doses), or every 3 months throughout breastfeeding (Extended). Base-case model inputs included bNAb efficacy (60%/dose), effect duration (3 months/dose) and costs ($60/dose), based on published literature. Outcomes included paediatric HIV incidence and incremental cost-effectiveness ratios (ICERs) calculated from discounted life expectancy and lifetime HIV-related costs. RESULTS The model projects that bNAbs would reduce absolute infant HIV incidence by 0.3-2.2% (9.6-34.9% relative reduction), varying by country, prophylaxis approach and target population. In all three settings, HR-HIVE-1-dose would be cost-saving compared to SOC. Using a 50% GDP per capita ICER threshold, HIVE-Extended would be cost-effective in all three settings with ICERs of $497/YLS in Côte d'Ivoire, $464/YLS in South Africa and $455/YLS in Zimbabwe. In all three settings, bNAb strategies would remain cost-effective at costs up to $200/dose if efficacy is ≥30%. If the bNAb effect duration were reduced to 1 month, the cost-effective strategy would become HR-HIVE-1-dose in Côte d'Ivoire and Zimbabwe and HR-HIVE-2-doses in South Africa. Findings regarding the cost-effectiveness of bNAb implementation strategies remained robust in sensitivity analyses regarding breastfeeding duration, maternal engagement in postpartum care, early infant diagnosis uptake and antiretroviral treatment costs. CONCLUSIONS At current efficacy and cost estimates, bNAb prophylaxis for HIV-exposed children in sub-Saharan African settings would be a cost-effective intervention to reduce vertical HIV transmission.
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Affiliation(s)
- Caitlin M. Dugdale
- Medical Practice Evaluation CenterDepartment of MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Division of Infectious DiseasesDepartment of MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Ogochukwu Ufio
- Medical Practice Evaluation CenterDepartment of MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Christopher Alba
- Medical Practice Evaluation CenterDepartment of MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Sallie R. Permar
- Department of PediatricsWeill Cornell MedicineNew YorkNew YorkUSA
- Department of PediatricsNew York‐Presbyterian/Weill Cornell Medical CenterNew YorkNew YorkUSA
| | - Lynda Stranix‐Chibanda
- Child and Adolescent Health UnitFaculty of Medicine and Health SciencesUniversity of ZimbabweHarareZimbabwe
| | - Coleen K. Cunningham
- Department of PediatricsUniversity of California IrvineIrvineCaliforniaUSA
- Department of PediatricsChildren's Hospital of Orange CountyOrangeCaliforniaUSA
| | - Genevieve G. Fouda
- Department of PediatricsDuke University Medical CenterDurhamNorth CarolinaUSA
- Duke Human Vaccine InstituteDurhamNorth CarolinaUSA
| | - Landon Myer
- Division of Epidemiology and BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Milton C. Weinstein
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Valériane Leroy
- CERPOP, InsermToulouse UniversityUniversité Paul SabatierToulouseFrance
| | - Elizabeth J. McFarland
- Department of PediatricsUniversity of Colorado Anschutz Medical Campus and Children's Hospital ColoradoAuroraColoradoUSA
| | - Kenneth A. Freedberg
- Medical Practice Evaluation CenterDepartment of MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Division of Infectious DiseasesDepartment of MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of General Internal MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Andrea L. Ciaranello
- Medical Practice Evaluation CenterDepartment of MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Division of Infectious DiseasesDepartment of MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
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11
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Nevrekar N, Butler K, Shapiro DE, Atuhaire P, Taha TE, Makanani B, Chinula L, Owor M, Moodley D, Chipato T, McCarthy K, Flynn PM, Currier J, Fowler MG, Gupta A, Suryavanshi N. Self-reported Antiretroviral Adherence: Association With Maternal Viral Load Suppression in Postpartum Women Living With HIV-1 From Promoting Maternal and Infant Survival Everywhere, a Randomized Controlled Trial in Sub-Saharan Africa and India. J Acquir Immune Defic Syndr 2023; 92:76-83. [PMID: 36170749 PMCID: PMC9722360 DOI: 10.1097/qai.0000000000003102] [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: 06/09/2022] [Accepted: 09/06/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Optimal adherence to antiretroviral therapy (ART) is crucial to promoting maternal-infant health. SETTING Fourteen sites in 7 countries within sub-Saharan Africa and India. METHODS The multicomponent, open-label strategy PROMISE trial enrolled breastfeeding mother-infant pairs not meeting in-country criteria for maternal ART (mART) initiation in the postpartum component within 5 days of delivery. Randomization was to mART versus infant NVP (iNVP) prophylaxis. Infants in the mART arm also received 6 weeks of iNVP. Self-reported adherence was assessed in a secondary analysis. Time-to-event analyses were performed to explore the association between adherence and maternal viral load (mVL) in the mART arm. RESULTS Two thousand four hundred thirty-one mother-infant pairs were enrolled between 2011 and 2014; the baseline maternal median CD4 was 686 (IQR 553-869), and the median mVL was 322 copies/mL (IQR 40-1422). Self-reported adherence was lower in the mART arm compared with the iNVP arm (no missed doses within 4 weeks of all study visits: 66% vs 83%; within 2 weeks: 71% vs 85%; P < 0.0001). The iNVP adherence at week 6 was high in both arms: 97% in mART arm; 95% in iNVP arm. Time-to-event analyses showed that adherence to mART was associated with time to first mVL ≥400 copies/mL ( P < 0.0001). Missing 1 full day of doses over 3 days was associated with a 66% risk of mVL ≥1000 copies/mL (HR: 1.66; 95% CI: 1.37, 1.99). CONCLUSIONS Postpartum women were less adherent to their own ART than mothers providing their infant's nevirapine prophylaxis. The self-reported missed mART doses were associated with high mVL. Strategies to optimize postpartum mART adherence are urgently needed. CLINICAL TRIAL NUMBER ClinicalTrials.gov: NCT01061151; closed to follow-up.
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Affiliation(s)
- Neetal Nevrekar
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site, Pune, India
| | - Kevin Butler
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - David E. Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Patience Atuhaire
- Makerere University–John Hopkins University Research Collaboration (MUJHU CARE LTD) CRS, Kampala, Uganda
| | - Taha E. Taha
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Bonus Makanani
- College of Medicine-Johns Hopkins Project, Blantyre, Malawi
| | | | - Maxensia Owor
- Makerere University–John Hopkins University Research Collaboration (MUJHU CARE LTD) CRS, Kampala, Uganda
| | - Dhayendre Moodley
- Centre for the AIDS Programme of Research in South Africa and Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
- Nelson R. Mandela School of Medicine, Durban, South Africa
| | - Tsungai Chipato
- Department of Obstetrics and Gynaecology, University of Zimbabwe, Harare, Zimbabwe
| | | | - Patricia M. Flynn
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN
| | - Judith Currier
- UCLA Centre for Clinical AIDS Research and Education, Los Angeles, CA
| | - Mary Glenn Fowler
- Department of Pathology, Johns Hopkins University, School of Medicine, Baltimore, MD; and
| | - Amita Gupta
- Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Nishi Suryavanshi
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site, Pune, India
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Kufa T. Dolutegravir in late pregnancy: where to from here? Lancet HIV 2022; 9:e522-e523. [PMID: 35905749 DOI: 10.1016/s2352-3018(22)00193-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 06/20/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Tendesayi Kufa
- National Institute for Communicable Diseases, Johannesburg, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg 2131, South Africa.
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Malaba TR, Nakatudde I, Kintu K, Colbers A, Chen T, Reynolds H, Read L, Read J, Stemmet LA, Mrubata M, Byrne K, Seden K, Twimukye A, Theunissen H, Hodel EM, Chiong J, Hu NC, Burger D, Wang D, Byamugisha J, Alhassan Y, Bokako S, Waitt C, Taegtmeyer M, Orrell C, Lamorde M, Myer L, Khoo S. 72 weeks post-partum follow-up of dolutegravir versus efavirenz initiated in late pregnancy (DolPHIN-2): an open-label, randomised controlled study. Lancet HIV 2022; 9:e534-e543. [PMID: 35905752 DOI: 10.1016/s2352-3018(22)00173-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/12/2022] [Accepted: 06/08/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Late initiation of antiretrovirals in pregnancy is associated with increased risk of perinatal transmission and higher infant mortality. We report the final 72-week postpartum results for efficacy and safety of dolutegravir-based compared with efavirenz-based regimens in mothers and infants. METHODS DolPHIN-2 was a randomised, open-label trial. Pregnant women in South Africa and Uganda aged at least 18 years, with untreated but confirmed HIV infection and an estimated gestation of at least 28 weeks, initiating antiretroviral therapy in third trimester were eligible for inclusion. Eligible women were randomly assigned (1:1) to receive either dolutegravir-based (50 mg dolutegravir, 300 mg tenofovir disoproxil fumarate, and either 200 mg emtricitabine in South Africa or 300 mg lamivudine in Uganda) or efavirenz-based (fixed dose combination 600 mg tenofovir disoproxil fumarate plus either emtricitabine in South Africa or lamivudine in Uganda) therapy. The primary efficacy outcome was the time to a viral load of less than 50 copies per mL measured at 6, 12, 24, 48, and 72 weeks postpartum with a Cox model adjusting for viral load and CD4 cell count. Safety endpoints were summarised by the number of women and infants with events. This trial is registered with ClinicalTrials.gov, NCT03249181. FINDINGS Between Jan 23 and Aug 15, 2018, 280 women were screened for inclusion, of whom 268 (96%) women were randomly assigned: 133 (50%) to the efavirenz group and 135 (50%) to the dolutegravir group. 250 (93%; 125 [50%] in the efavirenz group and 125 [50%] in the dolutegravir group) women were included in the intention-to-treat analysis of efficacy. Median time to viral load of less than 50 copies per mL was 4·1 weeks (IQR 4·0-5·1) in the dolutegravir group compared with 12·1 weeks (10·7-13·3) in the efavirenz group (adjusted hazard ratio [HR] 1·93 [95% CI 1·5-2·5]). At 72 weeks postpartum, 116 (93%) mothers in the dolutegravir group and 114 (91%) in the efavirenz group had a viral load of less than 50 copies per mL. Of 57 (21%) mothers with a severe adverse event, three (2%) in the dolutegravir group and five (4%) in the efavirenz group were related to the drug (dolutegravir drug-related events were one woman each with suicidal ideation, suicide attempt, herpes zoster meningitis; efavirenz drug-related events were one woman each with suicide attempt and liver cirrhosis, and three people with drug-induced liver injury). Of 136 (56%) infants in whom severe adverse events were recorded, none were related to the study drugs. In addition to the three infant HIV infections detected at birth in the dolutegravir group that have been previously reported, an additional transmission in the efavirenz group occurred during breastfeeding despite optimal maternal viral suppression and serial negative infant tests in the first year of life. INTERPRETATION Dolutegravir was safe and well tolerated, supporting updated WHO treatment recommendations in pregnant and breastfeeding women. Infant HIV transmissions can occur during breastfeeding despite persistently undetectable maternal viral load highlighting the need for continued infant testing. FUNDING Unitaid.
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Affiliation(s)
- Thokozile R Malaba
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Irene Nakatudde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kenneth Kintu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Angela Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Tao Chen
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Helen Reynolds
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Lucy Read
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jim Read
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Lee-Ann Stemmet
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Megan Mrubata
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly Byrne
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kay Seden
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Adelline Twimukye
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Helene Theunissen
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Eva Maria Hodel
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Justin Chiong
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Nai-Chung Hu
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - David Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Duolao Wang
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Josaphat Byamugisha
- Department of Gynaecology and Obstetrics, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Yussif Alhassan
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sharon Bokako
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Catriona Waitt
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK; Tropical Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Catherine Orrell
- Desmond Tutu Health Foundation, Department of Medicine, Institute of Infectious Diseases & Molecular Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; Centre for Infectious Diseases Epidemiology & Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Saye Khoo
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK; Tropical Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
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Retention in care and viral suppression in the PMTCT continuum at a large referral facility in western Kenya. AIDS Behav 2022; 26:3494-3505. [PMID: 35467229 PMCID: PMC9550706 DOI: 10.1007/s10461-022-03666-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2022] [Indexed: 11/20/2022]
Abstract
Medical records of pregnant and postpartum women living with HIV and their infants attending a large referral facility in Kenya from 2015 to 2019 were analyzed to identify characteristics associated with retention in care and viral suppression. Women were stratified based on the timing of HIV care enrollment: known HIV-positive (KHP; enrolled pre-pregnancy) and newly HIV-positive (NHP; enrolled during pregnancy). Associations with retention at 18 months postpartum and viral suppression (< 1000 copies/mL) were determined. Among 856 women (20% NHP), retention was 83% for KHPs and 53% for NHPs. Viral suppression was 88% for KHPs and 93% for NHPs, but 19% of women were missing viral load results. In a competing risk model, viral suppression increased by 18% for each additional year of age but was not associated with other factors. Overall, 1.9% of 698 infants with ≥ 1 HIV test result were HIV-positive. Tailored interventions are needed to promote retention and viral load testing, particularly for NHPs, in the PMTCT continuum.
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Mmotsa TM, Ngandu NK, Adetokunboh OO, Nyasulu P. Male partner unknown HIV status as a risk factor for HIV incidence and clinical outcomes in prevention of mother-to-child transmission of HIV programmes in 21 WHO priority countries: a systematic review protocol. BMJ Open 2022; 12:e057190. [PMID: 35393320 PMCID: PMC8990715 DOI: 10.1136/bmjopen-2021-057190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Research has shown an association between increased disclosure of HIV status by pregnant and breastfeeding women and improved clinical health and that of their infant. Increasing awareness about their male partner's HIV status will no doubt lead to even better outcomes at the population level. Male partner involvement is important for improving outcomes of prevention of mother-to-child transmission of HIV (MTCT) as it improves social support and commitment from both parents of the baby to ensure sustained good health. Although lack of knowledge of the HIV status of a male partner is of great concern, limited research has been done to determine whether it remains one of the barriers to reaching the proposed goals of eliminating MTCT in pregnant or postpartum women. Our aim is to determine if lack of knowledge of a male partner's HIV status is a significant risk factor for HIV incidence and poor HIV clinical outcomes among pregnant women and postpartum women and their infants. METHODS AND ANALYSIS A systematic review and meta-analysis of experimental and observational studies will be conducted. The review will focus on knowledge of male partner's HIV status in the 21 priority countries most affected by HIV in Africa. We will search electronic databases such as PubMed/Medline, Scopus, Web of Science and Cochrane library, Science Direct, CINAHL, LILACS and SciELO databases from January 2011 to December 2021. We will also search the Pan African and WHO clinical trial registries and conference archives. We will conduct a quality assessment of eligible studies and evaluate the heterogeneity of the pooled studies using the I 2 statistic. The statistical analysis will be performed using STATA statistical software V.16. ETHICS AND DISSEMINATION The study will use publicly available data and ethics exemption has been obtained from Human Research Ethics Committees, Faculty of Medicine & Health Sciences, Stellenbosch University. The protocol was registered on Prospective Register of Systematic Reviews, registration number CRD42021247686, in May 2021. Findings of this systematic review will be disseminated in peer-review journals including various media platforms, that is, webinars, symposia, conferences or congresses. PROSPERO REGISTRATION NUMBER Registration number CRD42021247686.
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Affiliation(s)
| | - Nobubelo Kwanele Ngandu
- HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Olatunji O Adetokunboh
- DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, Western Cape, South Africa
- Division of Epidemiology and Biostatistics, Stellenbosch University, Stellenbosch, South Africa
- The University of the People, Pasadena, California, USA
| | - Peter Nyasulu
- Division of Epidemiology and Biostatistics, Stellenbosch University, Stellenbosch, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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16
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Weinberg GA, Nachman S. Breastfeeding by Women Living with HIV in the United States: Are the Risks Truly Manageable? J Pediatric Infect Dis Soc 2022; 11:92-93. [PMID: 34939650 DOI: 10.1093/jpids/piab129] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 12/05/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Geoffrey A Weinberg
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sharon Nachman
- Department of Pediatrics, Renaissance School of Medicine, SUNY Stony Brook, Stony Brook, New York, USA
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Abuogi LL, Castillo-Mancilla J, Hampanda K, Owuor K, Odwar T, Onono M, Helova A, Turan JM, Anderson PL. Tenofovir Diphosphate in Dried Blood Spots in Pregnant and Postpartum Women With HIV in Kenya: A Novel Approach to Measuring Peripartum Adherence. J Acquir Immune Defic Syndr 2022; 89:310-317. [PMID: 34889866 PMCID: PMC8837670 DOI: 10.1097/qai.0000000000002859] [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: 07/15/2021] [Accepted: 10/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adherence to antiretroviral therapy (ART) among pregnant and postpartum women with HIV (PWLWH) is critical to promote maternal health and prevent HIV transmission. Tenofovir diphosphate (TFV-DP) in dried blood spots (DBS) is an objective assessment of cumulative ART adherence that has not been fully assessed in PWLWH. SETTING Southwestern Kenya. METHODS PWLWH receiving tenofovir disoproxil fumarate-based ART from 24 health facilities provided DBS samples at 3 time points [pregnancy/early postpartum (PP), 6 months PP, and 9-12 months PP]. Thresholds for daily adherence were defined as TFV-DP in DBS ≥650 fmol/punch in pregnancy and ≥950 PP. Descriptive analysis is presented. Cluster adjusted χ2 and t-tests were used to test for association with clinical and demographic factors. RESULTS A total of 419 DBS samples were collected from 150 PWLWH. Median TFV-DP in DBS was lowest, 552 fmol/punch [interquartile range (IQR), 395-759] in pregnancy and declined over time [914 (IQR, 644-1176) fmol/punch; early PP; 838 (IQR, 613-1063) fmol/punch 6 months PP; and 785 (IQR, 510-1009) fmol/punch 9-12 months; P < 0.001]. Only 42% of samples in pregnancy and 38.5% of samples in PP met thresholds for daily adherence. Clinical or demographic factors were not associated with suboptimal adherence levels. CONCLUSION Cumulative ART exposure in PWLWH, quantified by TFV-DP in DBS, demonstrated a stepwise decrease (ie, adherence) PP. Most women demonstrated less than daily adherence throughout the peripartum period. Use of TFV-DP in DBS as a measure of cumulative ART adherence could help optimize health outcomes in PWLWH and their infants.
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Affiliation(s)
- Lisa L. Abuogi
- Department of Pediatrics, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jose Castillo-Mancilla
- Department of Medicine, Division of Infectious Diseases, Kenya Medical Research Institute, Nairobi, Kenya
| | - Karen Hampanda
- School of Public Health, Kenya Medical Research Institute, Nairobi, Kenya
| | - Kevin Owuor
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Tobias Odwar
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Maricianah Onono
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Anna Helova
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Janet M. Turan
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Peter L. Anderson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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18
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Murnane PM, Ayieko J, Vittinghoff E, Gandhi M, Katumbi C, Milala B, Nakaye C, Kanda P, Moodley D, Nyati ME, Loftis AJ, Fowler MG, Flynn P, Currier JS, Cohen CR. Machine Learning Algorithms Using Routinely Collected Data Do Not Adequately Predict Viremia to Inform Targeted Services in Postpartum Women Living With HIV. J Acquir Immune Defic Syndr 2021; 88:439-447. [PMID: 34520443 PMCID: PMC8585692 DOI: 10.1097/qai.0000000000002800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/18/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adherence to antiretroviral treatment (ART) among postpartum women with HIV is essential for optimal health and prevention of perinatal transmission. However, suboptimal adherence with subsequent viremia is common, and adherence challenges are often underreported. We aimed to predict viremia to facilitate targeted adherence support in sub-Saharan Africa during this critical period. METHODS Data are from PROMISE 1077BF/FF, which enrolled perinatal women between 2011 and 2014. This analysis includes postpartum women receiving ART per study randomization or country-specific criteria to continue from pregnancy. We aimed to predict viremia (single and confirmed events) after 3 months on ART at >50, >400, and >1000 copies/mL within 6-month intervals through 24 months. We built models with routine clinical and demographic data using the least absolute shrinkage and selection operator and SuperLearner (which incorporates multiple algorithms). RESULTS Among 1321 women included, the median age was 26 years and 96% were in WHO stage 1. Between 0 and 24 months postpartum, 42%, 31%, and 28% of women experienced viremia >50, >400, and >1000 copies/mL, respectively, at least once. Across models, the cross-validated area under the receiver operating curve ranged from 0.74 [95% confidence interval (CI): 0.72 to 0.76] to 0.78 (95% CI: 0.76 to 0.80). To achieve 90% sensitivity predicting confirmed viremia >50 copies/mL, 64% of women would be classified as high risk. CONCLUSIONS Using routinely collected data to predict viremia in >1300 postpartum women with HIV, we achieved moderate model discrimination, but insufficient to inform targeted adherence support. Psychosocial characteristics or objective adherence metrics may be required for improved prediction of viremia in this population.
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Affiliation(s)
- Pamela M. Murnane
- Department of Epidemiology & Biostatistics, University of California, San Francisco, USA
- Institute for Global Health Sciences, University of California, San Francisco, USA
| | - James Ayieko
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Eric Vittinghoff
- Department of Epidemiology & Biostatistics, University of California, San Francisco, USA
| | - Monica Gandhi
- Department of Medicine, University of California, San Francisco, USA
| | | | - Beteniko Milala
- University of North Carolina-Project Malawi, Lilongwe, Malawi
| | - Catherine Nakaye
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Peter Kanda
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Dhayendre Moodley
- Centre for the AIDS Programme of Research in South Africa and Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Mandisa E Nyati
- Perinatal HIV Research Unit, University of the Witwatersrand, Soweto, South Africa
| | - Amy James Loftis
- Institute for Global Health and Infectious Diseases, University of North Carolina Chapel Hill, USA
| | - Mary Glenn Fowler
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Pat Flynn
- Department of Infectious Diseases, St. Jude Children’s Research Hospital Memphis, USA
| | - Judith S. Currier
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, CA USA
| | - Craig R. Cohen
- Institute for Global Health Sciences, University of California, San Francisco, USA
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA USA
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Flynn PM, Taha TE, Cababasay M, Butler K, Fowler MG, Mofenson LM, Owor M, Fiscus S, Stranix-Chibanda L, Coutsoudis A, Gnanashanmugam D, Chakhtoura N, McCarthy K, Frenkel L, Beck I, Mukuzunga C, Makanani B, Moodley D, Nematadzira T, Kusakara B, Patil S, Vhembo T, Bobat R, Mmbaga BT, Masenya M, Nyati M, Theron G, Mulenga H, Shapiro DE. Association of Maternal Viral Load and CD4 Count With Perinatal HIV-1 Transmission Risk During Breastfeeding in the PROMISE Postpartum Component. J Acquir Immune Defic Syndr 2021; 88:206-213. [PMID: 34108383 PMCID: PMC8434954 DOI: 10.1097/qai.0000000000002744] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/11/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Breastfeeding mothers with HIV infection not qualifying for antiretroviral therapy (ART) based on country-specific guidelines at the time of the Promoting Maternal-Infant Survival Everywhere trial and their uninfected neonates were randomized to maternal ART (mART) or infant nevirapine prophylaxis (iNVP) postpartum. HIV transmission proportions were similar (<1%) in the 2 arms. We assessed whether maternal viral load (MVL) and CD4 cell counts were associated with breastfeeding HIV transmission. METHODS MVL was collected at entry (7-14 days postpartum) and at weeks 6, 14, 26, and 50 postpartum. CD4 cell counts were collected at entry and weeks 14, 26, 38, and 50 postpartum. Infant HIV-1 nucleic acid test was performed at weeks 1 and 6, every 4 weeks until week 26, and then every 12 weeks. The associations of baseline and time-varying MVL and CD4 cell counts with transmission risk were assessed using time-to-event analyses by randomized treatment arm. RESULTS Two thousand four hundred thirty-one mother-infant pairs were enrolled in the study. Baseline MVL (P = 0.11) and CD4 cell counts (P = 0.51) were not significantly associated with infant HIV-1 infection. Time-varying MVL was significantly associated with infant HIV-1 infection {hazard ratio [95% confidence interval (CI)]: 13.96 (3.12 to 62.45)} in the mART arm but not in the iNVP arm [hazard ratio (95% CI): 1.04 (0.20 to 5.39)]. Time-varying CD4 cell counts were also significantly associated with infant HIV-1 infection [hazard ratio (95% CI): 0.18 (0.03 to 0.93)] in the mART arm but not in the iNVP arm [hazard ratio (95% CI): 0.38 (0.08 to 1.77)]. CONCLUSIONS In women receiving mART, increased MVL and decreased CD4 cell counts during breastfeeding were associated with increased risk of infant HIV-1 infection.
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Affiliation(s)
- Patricia M. Flynn
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN
| | - Taha E Taha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mae Cababasay
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Kevin Butler
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Mary Glenn Fowler
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Maxensia Owor
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Susan Fiscus
- Department of Microbiology and Immunology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Lynda Stranix-Chibanda
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, , University of Zimbabwe, Harare, Zimbabwe
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Anna Coutsoudis
- Department of Pediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
| | - Devasena Gnanashanmugam
- Division of AIDS, National Institute of Allergy and Immunology, National Institutes of Health, Bethesda, MD
| | - Nahida Chakhtoura
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver Institute of Child Health and Human Development, National Institutes of Health, Rockville, MD
| | | | - Lisa Frenkel
- Department of Pediatrics, University of Washington, Seattle, WA
- Seattle Children’s Research Institute, Seattle, WA
| | - Ingrid Beck
- Seattle Children’s Research Institute, Seattle, WA
| | - Cornelius Mukuzunga
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Bonus Makanani
- Department of Obstetrics and Gynecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Dhayendre Moodley
- Centre for the AIDS Programme of Research in South Africa and School of Clinical Medicine, College of Health Sciences, University of KwaZulu Natal, Durban, South Africa
| | | | - Bangani Kusakara
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Sandesh Patil
- Department of Obstetrics and Gynecology, Byramjee Jeejeebhoy Government Medical College and Johns Hopkins Clinical Trials Unit, Pune, India
| | - Tichaona Vhembo
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Raziya Bobat
- Department of Pediatrics and Child Health, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Blandina T Mmbaga
- Department of Pediatrics, Kilimanjaro Christian Medical Centre and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Maysseb Masenya
- Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
| | - Mandisa Nyati
- Perinatal HIV Research Unit, Chris Baragwanath Hospital, Johannesburg, South Africa
| | - Gerhard Theron
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Helen Mulenga
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - David E. Shapiro
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, MA
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Goga AE, Van de Perre P, Ngandu N, Nagot N, Abrams EJ, Moodley D, King R, Molès JP, Chirinda W, Scarlatti G, Tylleskär T, Sherman GG, Pillay Y, Dabis F, Gray G. Eliminating HIV transmission through breast milk from women taking antiretroviral drugs. BMJ 2021; 374:n1697. [PMID: 34588170 PMCID: PMC8479590 DOI: 10.1136/bmj.n1697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Ameena Goga and colleagues argue that frequent testing of maternal viral load is needed to eliminate HIV transmission through breast milk in low and middle income settings
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Affiliation(s)
- Ameena E Goga
- South African Medical Research Council, Pretoria and Cape Town, South Africa
- University of Pretoria, Pretoria, South Africa
| | - Philippe Van de Perre
- Pathogenesis and Control of Chronic and Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang; CHU Montpellier, Montpellier, France
| | - Nobubelo Ngandu
- South African Medical Research Council, Pretoria and Cape Town, South Africa
| | - Nicolas Nagot
- Pathogenesis and Control of Chronic and Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang; CHU Montpellier, Montpellier, France
| | - Elaine J Abrams
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, USA
| | - Dhayendre Moodley
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
- Centre for AIDS Research in South Africa, Durban, South Africa
| | - Rachel King
- Pathogenesis and Control of Chronic and Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang; CHU Montpellier, Montpellier, France
- UCSF, San Francisco, CA, USA
| | - Jean-Pierre Molès
- Pathogenesis and Control of Chronic and Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang; CHU Montpellier, Montpellier, France
| | - Witness Chirinda
- South African Medical Research Council, Pretoria and Cape Town, South Africa
| | - Gabriella Scarlatti
- Viral Evolution and Transmission Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Gayle G Sherman
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Centre for HIV & STI, National Institute for Communicable Diseases, National Health Laboratory Services, Johannesburg, South Africa
| | | | - François Dabis
- Agence Nationale de Recherche sur le Sida et les Hépatites Virales (ANRS), Paris, France
- Université Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Glenda Gray
- South African Medical Research Council, Pretoria and Cape Town, South Africa
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21
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Van de Perre P, Goga A, Ngandu N, Nagot N, Moodley D, King R, Molès JP, Mosqueira B, Chirinda W, Scarlatti G, Tylleskär T, Dabis F, Gray G. Eliminating postnatal HIV transmission in high incidence areas: need for complementary biomedical interventions. Lancet 2021; 397:1316-1324. [PMID: 33812490 DOI: 10.1016/s0140-6736(21)00570-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 06/06/2020] [Accepted: 10/02/2020] [Indexed: 11/24/2022]
Abstract
The rate of mother-to-child transmission (MTCT) of HIV from breastfeeding is increasing relative to other causes of MTCT. Early effective preconception and antenatal antiretroviral therapy (ART) reduces intrauterine and intrapartum MTCT, whereas maternal post-partum HIV acquisition, untreated maternal HIV, and suboptimal postnatal maternal ART adherence increase the risk of MTCT through breastfeeding. Although the absolute number of cases of MTCT acquired through breastfeeding is decreasing, the rate of decrease is less than the decrease in intrauterine and intrapartum MTCT. Unless current strategies are universally applied, they might not be sufficient to eliminate MTCT due to breastfeeding. Urgent action is needed to evaluate and implement additional preventive biomedical strategies in high HIV prevalence and incidence settings to eliminate MTCT from breastfeeding. Preventive strategies include: pre-exposure prophylaxis in breastfeeding women who have an increased risk of acquiring HIV; postnatal reinforcement strategies, such as maternal retesting for HIV, maternal care reinforcement, and prophylaxis in infants exposed to HIV via breastmilk; and active (vaccine) or passive immunoprophylaxis with long-acting broadly neutralising antibodies.
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Affiliation(s)
- Philippe Van de Perre
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France.
| | - Ameena Goga
- South African Medical Research Council, Cape Town, South Africa; Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa
| | - Nobubelo Ngandu
- South African Medical Research Council, Cape Town, South Africa
| | - Nicolas Nagot
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France
| | - Dhayendre Moodley
- Centre for AIDS Research in South Africa, and Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Rachel King
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France; School of Medicine, University of California, San Francisco, CA, USA
| | - Jean-Pierre Molès
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France
| | - Beatriz Mosqueira
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France
| | | | - Gabriella Scarlatti
- Viral Evolution and Transmission Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milano, Italy
| | | | - François Dabis
- Agence Nationale de Recherche sur le Sida et les Hépatites Virales (ANRS), Paris, France; Bordeaux Population Health, INSERM U 1219, ISPED, Université de Bordeaux, Bordeaux, France
| | - Glenda Gray
- South African Medical Research Council, Cape Town, South Africa
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22
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Nyatsanza F, Gubbin J, Gubbin T, Seery P, Farrugia P, Croucher A, Gilleece Y, Rosenvinge M, Roedling S, Sarner L, Nayagam D, Stradling C, Namiba A, Fearnley N, Lyall H. Over a third of childbearing women with HIV would like to breastfeed: A UK survey of women living with HIV. Int J STD AIDS 2021; 32:856-860. [PMID: 33629917 DOI: 10.1177/0956462421999951] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The World Health Organisation advice for post-partum women living with HIV (WLHs) in low- and middle-income countries is to breastfeed on suppressive antiretroviral treatment and use infant postnatal prophylaxis. In resource-rich settings, where formula feeding is safe, avoidance of breastfeed is advised. A questionnaire was created to survey attitudes to breastfeeding in WLHs in the United Kingdom. This was offered to all eligible pregnant women in the third trimester or within 3 months post-partum who attended HIV outpatient clinics from 2017 to 2018. Ninety-four women completed the questionnaire, 69% were Black African and 92% had an undetectable HIV viral load. Thirty eight percent stated they would like to breastfeed and 89% said they would breastfeed if they were HIV negative. Sixty two percent had community members question why they did not breastfeed, and 66% felt forced to invent a reason why they were not breastfeeding. Current UK guidelines recommend formula feeding, proposing a harm reduction approach to support women with suppressed HIV who wish to breastfeed. Over a third of respondents said they would like to breastfeed because stigma and secrecy remain an issue for WLHs. This suggests that over time more women may choose this option.
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Affiliation(s)
- Farai Nyatsanza
- 8946Imperial College Healthcare NHS Trust, London, UK.,215332Cambridgeshire Community Services NHS Trust, Huntingdon, UK
| | | | - Thomas Gubbin
- 8946Imperial College Healthcare NHS Trust, London, UK
| | - Paula Seery
- 8946Imperial College Healthcare NHS Trust, London, UK.,9762Chelsea and Westminster NHS Trust, London, UK
| | | | - Adam Croucher
- 4721Homerton University Hospitals NHS Trust, London, UK
| | - Yvonne Gilleece
- 1949Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - Sherie Roedling
- 8964Central and Northwest London NHS Foundation Trust, London, UK
| | | | | | - Clare Stradling
- 1732University Hospitals Birmingham NHS Foundation Trust, Bradford, UK
| | | | - Nicola Fearnley
- 1906Bradford University Teaching Hospitals NHS Trust, Bradford, UK
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23
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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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24
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Lackey KA, Pace RM, Williams JE, Bode L, Donovan SM, Järvinen KM, Seppo AE, Raiten DJ, Meehan CL, McGuire MA, McGuire MK. SARS-CoV-2 and human milk: What is the evidence? MATERNAL & CHILD NUTRITION 2020; 16:e13032. [PMID: 32472745 PMCID: PMC7300480 DOI: 10.1111/mcn.13032] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 04/30/2020] [Accepted: 05/05/2020] [Indexed: 12/18/2022]
Abstract
The novel coronavirus SARS-CoV-2 has emerged as one of the most compelling and concerning public health challenges of our time. To address the myriad issues generated by this pandemic, an interdisciplinary breadth of research, clinical and public health communities has rapidly engaged to collectively find answers and solutions. One area of active inquiry is understanding the mode(s) of SARS-CoV-2 transmission. Although respiratory droplets are a known mechanism of transmission, other mechanisms are likely. Of particular importance to global health is the possibility of vertical transmission from infected mothers to infants through breastfeeding or consumption of human milk. However, there is limited published literature related to vertical transmission of any human coronaviruses (including SARS-CoV-2) via human milk and/or breastfeeding. Results of the literature search reported here (finalized on 17 April 2020) revealed a single study providing some evidence of vertical transmission of human coronavirus 229E; a single study evaluating presence of SARS-CoV in human milk (it was negative); and no published data on MERS-CoV and human milk. We identified 13 studies reporting human milk tested for SARS-CoV-2; one study (a non-peer-reviewed preprint) detected the virus in one milk sample, and another study detected SARS-CoV-2 specific IgG in milk. Importantly, none of the studies on coronaviruses and human milk report validation of their collection and analytical methods for use in human milk. These reports are evaluated here, and their implications related to the possibility of vertical transmission of coronaviruses (in particular, SARS-CoV-2) during breastfeeding are discussed.
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Affiliation(s)
- Kimberly A. Lackey
- Margaret Ritchie School of Family and Consumer SciencesUniversity of IdahoMoscowIdahoUSA
| | - Ryan M. Pace
- Margaret Ritchie School of Family and Consumer SciencesUniversity of IdahoMoscowIdahoUSA
| | - Janet E. Williams
- Department of Animal and Veterinary SciencesUniversity of IdahoMoscowIdahoUSA
| | - Lars Bode
- Department of Pediatrics and Larsson‐Rosenquist Foundation Mother‐Milk‐Infant Center of Research Excellence (MOMI CORE)University of CaliforniaSan DiegoCaliforniaUSA
| | - Sharon M. Donovan
- Department of Food Science and Human Nutrition and Institute of Genomic BiologyUniversity of IllinoisUrbanaIllinoisUSA
| | - Kirsi M. Järvinen
- Department of Pediatrics, Division of Allergy and ImmunologyUniversity of Rochester School of Medicine and DentistryRochesterNew YorkUSA
| | - Antti E. Seppo
- Department of Pediatrics, Division of Allergy and ImmunologyUniversity of Rochester School of Medicine and DentistryRochesterNew YorkUSA
| | - Daniel J. Raiten
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)National Institutes of Health (NIH)BethesdaMarylandUSA
| | - Courtney L. Meehan
- Department of AnthropologyWashington State UniversityPullmanWashingtonUSA
| | - Mark A. McGuire
- Department of Animal and Veterinary SciencesUniversity of IdahoMoscowIdahoUSA
| | - Michelle K. McGuire
- Margaret Ritchie School of Family and Consumer SciencesUniversity of IdahoMoscowIdahoUSA
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25
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Sandbulte M, Brown M, Wexler C, Maloba M, Gautney B, Goggin K, Muchoki E, Babu S, Maosa N, Finocchario-Kessler S. Maternal viral load monitoring: Coverage and clinical action at 4 Kenyan hospitals. PLoS One 2020; 15:e0232358. [PMID: 32469876 PMCID: PMC7259657 DOI: 10.1371/journal.pone.0232358] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/13/2020] [Indexed: 12/13/2022] Open
Abstract
Background Kenya’s guidelines for prevention of mother-to-child transmission of HIV (PMTCT) recommend routine viral load (VL) monitoring for pregnant and breastfeeding women. Method We assessed PMTCT VL monitoring and clinical action occurring between last menstrual period (LMP) and 6 months postpartum at 4 Kenyan government hospitals. Pregnant women enrolled in the HIV Infant Tracking System from May 2016-March 2018 were included. We computed proportions who received VL testing within recommended timeframes and who received clinical action after unsuppressed VL result. Results Of 424 participants, any VL testing was documented for 305 (72%) women and repeat VL testing was documented for 79 (19%). Only 115 women (27%) received a guideline-adherent baseline VL test and 27 (6%) received a guideline-adherent baseline and repeat VL test sequence. Return of baseline and repeat VL test results to the facility was high (average 96%), but patient notification of VL results was low (36% baseline and 49% repeat). Clinical action for unsuppressed VL results was even lower: 11 of 38 (29%) unsuppressed baseline results and 2 of 14 (14%) unsuppressed repeat results triggered clinical action. Discussion Guideline-adherent VL testing and clinical intervention during PMTCT must be prioritized to improve maternal care and reduce the risk of HIV transmission to infants.
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Affiliation(s)
- Matthew Sandbulte
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Brad Gautney
- Global Health Innovations, Dallas, TX, United States of America
| | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, United States of America.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States of America
| | | | | | | | - Sarah Finocchario-Kessler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
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26
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Lackey KA, Pace RM, Williams JE, Bode L, Donovan SM, Järvinen KM, Seppo AE, Raiten DJ, Meehan CL, McGuire MA, McGuire MK. SARS-CoV-2 and human milk: what is the evidence? MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020:2020.04.07.20056812. [PMID: 32511431 PMCID: PMC7217082 DOI: 10.1101/2020.04.07.20056812] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The novel coronavirus SARS-CoV-2 has emerged as one of the most compelling public health challenges of our time. To address the myriad issues generated by this pandemic, an interdisciplinary breadth of research, clinical, and public health communities have rapidly engaged to find answers and solutions. One area of active inquiry is understanding the mode(s) of SARS-CoV-2 transmission. While respiratory droplets are a known mechanism of transmission, other mechanisms are possible. Of particular importance to global health is the possibility of vertical transmission from infected mothers to infants through breastfeeding or consumption of human milk. However, there is limited published literature related to vertical transmission of any human coronavirus (including SARS-CoV-2) via human milk and/or breastfeeding. There is a single study providing some evidence of vertical transmission of human coronavirus 229E, a single study evaluating presence of SARS-CoV in human milk (it was negative), and no published data on MERS-CoV and human milk. There are 9 case studies of human milk tested for SARS-CoV-2; none detected the virus. Importantly, none of the published studies on coronaviruses and human milk report validation of their analytical methods for use in human milk. These reports are evaluated here, and their implications related to the possibility of vertical transmission of coronaviruses (in particular, SARS-CoV-2) during breastfeeding are discussed.
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Affiliation(s)
- Kimberly A. Lackey
- Margaret Ritchie School of Family and Consumer Sciences, University of Idaho, Moscow, ID, USA
| | - Ryan M. Pace
- Margaret Ritchie School of Family and Consumer Sciences, University of Idaho, Moscow, ID, USA
| | - Janet E. Williams
- Department of Animal and Veterinary Sciences, University of Idaho, Moscow, ID, USA
| | - Lars Bode
- Department of Pediatrics and Larsson-Rosenquist Foundation Mother-Milk-Infant Center of Research Excellence (MOMI CORE), University of California, San Diego, La Jolla, CA, USA
| | - Sharon M. Donovan
- Department of Food Science and Human Nutrition and Institute of Genomic Biology, University of Illinois, Urbana, IL USA
| | - Kirsi M. Järvinen
- Department of Pediatrics, Division of Allergy and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Antti E. Seppo
- Department of Pediatrics, Division of Allergy and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Daniel J. Raiten
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Courtney L. Meehan
- Department of Anthropology, Washington State University, Pullman, WA, USA
| | - Mark A. McGuire
- Department of Animal and Veterinary Sciences, University of Idaho, Moscow, ID, USA
| | - Michelle K. McGuire
- Margaret Ritchie School of Family and Consumer Sciences, University of Idaho, Moscow, ID, USA
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27
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Level and determinants of postpartum adherence to antiretroviral therapy in the Eastern Cape, South Africa. PLoS One 2020; 15:e0229592. [PMID: 32106255 PMCID: PMC7046212 DOI: 10.1371/journal.pone.0229592] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 02/10/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Adherence to antiretroviral therapy (ART), especially during the postpartum period, remains a major challenge in the efforts towards eliminating mother-to-child transmission of HIV. This study examined the levels and determinants of postpartum adherence to ART among mothers with HIV in the Eastern Cape, South Africa. METHODS In this cross-sectional analytical study, we interviewed 495 postpartum women with HIV between January and May 2018. We measured postpartum adherence using six questions probing participants' adherence behaviours since child birth. We categorised the adherence behaviours into complete adherence (mothers who reported no missed episode(s) of ART since child birth) and suboptimal adherence (mothers with any missed episode(s) of ART). Adjusted and unadjusted logistic regression models were used to examine the determinants of postpartum adherence to ART. RESULTS Overall, 63.9% reported complete adherence during the postpartum period but the rates varied by socio-demographic and behavioural characteristics. The adjusted logistic regression analysis showed that younger mothers were 70% less likely to report complete adherence to ART compared to mothers aged 40 and above. Likewise, mothers who currently use alcohol were 53% less likely to report complete postpartum adherence to ART compared to those who did not use alcohol. However, mothers who knew their partner's status were twice more likely to report complete postpartum adherence compared to those who did not. There was no statistically significant relationship between ART adherence and breastfeeding durations. CONCLUSION Postpartum adherence to ART is suboptimal in the study setting, and younger mothers and those who use alcohol have a lower odds of complete adherence. Knowing a partner's status improves adherence, but infant feeding practices did not influence postpartum adherence behaviours. It is critical to design and strengthen interventions which target young mothers and alcohol users. Also, HIV sero-status disclosure should be encouraged among mothers to facilitate partner support.
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28
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Freeman-Romilly N, Nyatsanza F, Namiba A, Lyall H. Moving closer to what women want? A review of breastfeeding and women living with HIV in the UK and high-income countries. HIV Med 2020; 21:1-8. [PMID: 31825556 DOI: 10.1111/hiv.12792] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | - F Nyatsanza
- ICASH Cambridgeshire, Cambridge Community Services NHS Trust, GUM/HIV, Cambridge, UK
| | | | - H Lyall
- Imperial College Healthcare NHS Trust, Children's Services, London, UK
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29
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Bansaccal N, Van der Linden D, Marot JC, Belkhir L. HIV-Infected Mothers Who Decide to Breastfeed Their Infants Under Close Supervision in Belgium: About Two Cases. Front Pediatr 2020; 8:248. [PMID: 32537442 PMCID: PMC7266974 DOI: 10.3389/fped.2020.00248] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/21/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: In most industrialized countries, human immunodeficiency virus (HIV) infection remains a formal contraindication to breastfeeding. However, for the past 9 years, the World Health Organization (WHO) has recommended, for developing countries, that mothers infected with HIV and treated by combined antiretroviral therapy (cART) should breastfeed their infants. HIV-infected women coming from developing countries and living in industrialized settings are increasingly expressing their natural desire to breastfeed. To avoid uncontrolled breastfeeding practices and reduce the risk of mother-to-child transmission of the virus, there is an urgent need to consider the wishes of these women. Discussion: We report two cases in which specific guidelines were implemented in order to support the mothers' choice to breastfeed in Belgium. As a result of different prophylactic measures including antiretrovirals in mothers and infants and close follow-up, none of the infants were infected. Conclusions: National or international recommendations for HIV-infected mothers who choose to breastfeed in industrialized countries remain unclear and discordant. There is an unmet need for experts to address this emerging issue and to develop an international consensus for the monitoring and prophylactic management of exposed-infants.
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Affiliation(s)
- Nordin Bansaccal
- Pediatric Infectious Diseases, Pediatric Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Dimitri Van der Linden
- Pediatric Infectious Diseases, Pediatric Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Jean-Christophe Marot
- Internal Medicine Department, Cliniques Saint-Pierre, Ottignies-Louvain-la-Neuve, Belgium
| | - Leïla Belkhir
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium.,Infectious Diseases, Internal Medicine Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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30
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Brief Report: No HIV Transmission From Virally Suppressed Mothers During Breastfeeding in Rural Tanzania. J Acquir Immune Defic Syndr 2019; 79:e17-e20. [PMID: 29781882 DOI: 10.1097/qai.0000000000001758] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To what extent antiretroviral therapy (ART) reduces mother-to-child HIV transmission (MTCT) during breastfeeding remains unclear. We assessed the MTCT risk from mothers on ART to their infants during breastfeeding. SETTING Ifakara, rural Tanzania. METHODS We included infants born between January 2013 and May 2016 to mothers who initiated ART before delivery, had a negative HIV DNA polymerase chain reaction at 4-12 weeks and exclusively breastfed for ≥6 months. Mothers' plasma HIV-RNA viral loads (VLs) were measured up to 11 months postdelivery. Infants were tested for HIV following national guidelines. RESULTS Among 214 women with 218 pregnancies and 228 infants (10 twins), the median age at delivery was 33 years (interquartile range 28-36 years), and the mean time on ART was 23 months (interquartile range, 4-52 months). VL was measured twice in 53% (113/218) of pregnancies. During breastfeeding, 91% of mothers (199/218) had VL of <1000 copies per milliliter, and 75% (164/218) had <100 copies per milliliter. To November 2017, 8% (19/228) of infants were lost to follow-up (LTFU), 2% (5/228) transferred, and 8% (18/228) died before the determination of final HIV serostatus. Among the remaining 186 infants, 2 (1%; 95% confidence interval: 0.3% to 4%) were HIV positive: 1 born from a mother with high VL 1-month postdelivery and 1 from a mother who interrupted ART. Assuming a 15% MTCT risk through breastfeeding among the 42 infants LTFU, transferred, or dead, the overall MTCT risk would be 4%. CONCLUSIONS We found no MTCT from mothers who were retained in care and had suppressed VL. Breastfeeding signifies a very low risk when mothers adhere to ART. Adherence counseling, VL monitoring, and strategies to trace back those LTFU should be a priority.
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Abstract
BACKGROUND Antiretroviral treatment (ART) adherence is often suboptimal in the perinatal period. We measured hair tenofovir (TFV) concentrations as a metric of adherence in postpartum women to understand patterns and predictors of adherence throughout this critical period. In addition, we examined the association between hair TFV concentrations and virologic outcomes. METHODS Between 12/2012 and 09/2016, hair samples were collected longitudinally from delivery through breastfeeding from women on ART in the Promoting Maternal and Infant Survival Everywhere study (NCT01061151) in sub-Saharan Africa. Hair TFV levels were measured using validated methods. Using generalized estimating equations, we estimated the association between hair TFV levels and virologic suppression (<400 copies/ml) over time and assessed predictors of hair TFV levels. RESULTS Hair TFV levels were measured at 370 visits in 71 women from delivery through a median of 14 months (interquartile range 12-15) of breastfeeding. Levels ranged from below detection (0.002) to 1.067 ng/mg (geometric mean: 0.047). After at least 90 days on ART, 69 women had at least one viral load measured (median 5 measures, range 1-9); 18 (26%) experienced viremia at least once. Each doubling of TFV level more than doubled odds of concurrent virologic suppression [odds ratio 2.35, 95% confidence interval (CI): 1.44-3.84, P = 0.0006] and was associated with 1.43 times the odds of future suppression (95% CI: 0.75-2.73, P = 0.28). Relative to the first 3 months after delivery, hair levels were highest in months 6-12 (1.42-fold higher, 95% CI: 1.09-1.85, P = 0.01). CONCLUSION Hair TFV levels strongly predicted concurrent virologic suppression among breastfeeding women. Objective adherence metrics can supplement virologic monitoring to optimize treatment outcomes in this important transition period.
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Chan M, Muriuki EM, Emery S, Kanthula R, Chohan V, Frenkel LM, Wald A, Chohan B, Overbaugh J, Roxby AC. Correlates of HIV detection among breastfeeding postpartum Kenyan women eligible under Option B. PLoS One 2019; 14:e0216252. [PMID: 31150396 PMCID: PMC6544340 DOI: 10.1371/journal.pone.0216252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 04/16/2019] [Indexed: 12/13/2022] Open
Abstract
Background The Option B+ strategy streamlines delivery of HIV antiretroviral therapy (ART) to pregnant women, but concerns remain about ART treatment adherence and long term outcomes. Methods We conducted a retrospective analysis of a cohort of HIV-positive, postpartum breastfeeding women receiving ART via Option B+ in Nairobi, Kenya. The primary outcome was virologic failure in plasma (HIV RNA >1000 copies/mL), and detection in breast milk (>150 copies/mL) and endocervical secretions (>100 copies/mL) at 2 postpartum timepoints. Correlates of virologic failure were assessed using univariate tests and multivariate logistic regression. Results Of 42 women at 6–14 weeks postpartum, 21.4% of women had HIV RNA detected in plasma; 14.3% in breast milk, and 23.7% in endocervical secretions. At 18–24 weeks postpartum, the percentages were 21.1%, 7.1%, and 14.3%, respectively. Younger maternal age, intent to breastfeed for longer, and later ART start in pregnancy were significantly associated with plasma virologic failure (p < 0.05 for each). Odds of plasma virologic failure at 6–14 weeks postpartum were 1.25 times higher (95% CI 1.04, 1.51) for each increase in week of gestation at ART initiation. Only 3 women had resistance mutations to their regimen. Conclusions Despite months of ART, nearly one-quarter of the women in our cohort did not achieve plasma virologic suppression in the postpartum period. After adjusting for time on ART, earlier ART initiation in pregnancy was significantly associated with plasma suppression. Our findings suggest that postpartum HIV RNA monitoring in Option B+ programs will be needed to achieve elimination of MTCT.
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Affiliation(s)
- Mary Chan
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Eric Munene Muriuki
- Institute for Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - Sandra Emery
- Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Ruth Kanthula
- Seattle Children’s Research Institute, Seattle, Washington, United States of America
| | - Vrasha Chohan
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Lisa M. Frenkel
- 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
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Anna Wald
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, United States of America
| | - Bhavna Chohan
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Julie Overbaugh
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Alison C. Roxby
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- * E-mail:
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Davis NL, Corbett A, Kaullen J, Nelson JAE, Chasela CS, Sichali D, Hudgens MG, Miller WC, Jamieson DJ, Kourtis AP. Antiretroviral Drug Concentrations in Breastmilk, Maternal HIV Viral Load, and HIV Transmission to the Infant: Results From the BAN Study. J Acquir Immune Defic Syndr 2019; 80:467-473. [PMID: 30570527 PMCID: PMC6391211 DOI: 10.1097/qai.0000000000001941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Concentration of antiretroviral (ARV) drug found in plasma, and amounts of drug excreted into breastmilk, may affect HIV viral load and potentially perinatal HIV transmission. METHODS In this cohort study with 2-phase sampling, we included mothers randomized to postpartum maternal ARVs or daily infant nevirapine during 28 weeks of breastfeeding in the Breastfeeding, Antiretrovirals, and Nutrition study. Among these, we included all mothers who transmitted HIV to their infants between 2 and 28 weeks and 15% of mothers who did not (n = 27 and 227, respectively). Spearman correlation coefficients (r) were used to assess the correlation between maternal plasma and breastmilk ARV concentration. Associations between the median effective drug concentration (EC50) and detectable maternal viral load (plasma: >40 copies per milliliter, breastmilk: >56 copies per milliliter) were assessed using mixed-effects models. Cox models were used to estimate the association between maternal or infant plasma drug concentration and breastmilk HIV transmission from 2 to 28 weeks. RESULTS All ARV compounds exhibited substantial correlations between maternal plasma and breastmilk concentrations (r: 0.85-0.98, P-value <0.0001). Having plasma drug concentration above the EC50 was associated with lower odds of having detectable HIV RNA [maternal plasma odds ratio (OR) 0.64, 95% confidence interval (CI): 0.45 to 0.91; breastmilk OR 0.22, 95% CI: 0.14 to 0.35] and a reduced rate of breastmilk HIV transmission (hazard ratio 0.40, 95% CI: 0.18 to 0.93). Having breastmilk drug concentration above the EC50 was also associated with lower odds of having detectable maternal HIV RNA (plasma OR 0.62, 95% CI: 0.45 to 0.85; breastmilk OR 0.42, 95% CI: 0.29 to 0.59). CONCLUSIONS Ensuring adequate drug concentration is important for viral suppression and preventing breastmilk HIV transmission.
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Affiliation(s)
- Nicole L Davis
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Amanda Corbett
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Josh Kaullen
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Julie A E Nelson
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Charles S Chasela
- Division of Epidemiology and Biostatistics, School of Public Health, University of Witwatersrand, Parktown, South Africa
| | | | - Michael G Hudgens
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Denise J Jamieson
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Athena P Kourtis
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
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Gross MS, Taylor HA, Tomori C, Coleman JS. Breastfeeding with HIV: An Evidence-Based Case for New Policy. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2019; 47:152-160. [PMID: 30994076 PMCID: PMC7053566 DOI: 10.1177/1073110519840495] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
To help eliminate perinatal HIV transmission, the US Department of Health and Human Services recommends against breastfeeding for women living with HIV, regardless of viral load or combined antiretroviral therapy (cART) status. However, cART radically improves HIV prognosis and virtually eliminates perinatal transmission, and breastfeeding's health benefits are well-established. In this setting, pregnancy is increasing among American women with HIV, and a harm reduction approach to those who breastfeed despite extensive counseling is suggested. We assess the evidence and ethical justification for current policy, with attention to pertinent racial and health disparities. We first review perinatal transmission and breastfeeding data relevant to US infants. We compare hypothetical risk of HIV transmission from breastmilk to increased mortality from sudden infant death syndrome, necrotizing enterocolitis and sepsis from avoiding breastfeeding, finding that benefits may outweigh risks if mothers maintain undetectable viral load on cART. We then review maternal health considerations. We conclude that avoidance of breastfeeding by women living with HIV may not maximize health outcomes and discuss our recommendation for revising national guidelines in light of autonomy, harm reduction and health inequities.
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Affiliation(s)
- Marielle S Gross
- Marielle S. Gross, M.D., M.B.E., is a Hecht-Levi postdoctoral research fellow in the Berman Institute of Bioethics at Johns Hopkins University where she recently completed residency training in Gynecology & Obstetrics. She attended medical school at the University of Florida, and previously completed degrees in Philosophy, Jewish Ethics and Bioethics at Columbia University, the Jewish Theological Seminary, and New York University, respectively. Holly A. Taylor, Ph.D., M.P.H., is a Core Faculty member of the Johns Hopkins Berman Institute of Bioethics and Associate Professor in the Department of Health Policy and Management (HPM), Bloomberg School of Public Health. Dr. Taylor received her B.A. from Stanford University, her M.P.H. from the School of Public Health at the University of Michigan and her Ph.D. in health policy with a concentration in bioethics from the Bloomberg School of Public Health, Johns Hopkins University. Cecilia Tomori, Ph.D., studied biology and education at Swarthmore College and obtained her Ph.D. in Anthropology from the University of Michigan in 2011. She completed a postdoctoral fellowship at Johns Hopkins School of Public Health and served as faculty there between 2013-2017. Jenell S. Coleman, M.D., M.P.H., is associate professor in the Johns Hopkins School of Medicine Department of Gynecology and Obstetrics with a joint appointment in the Department of Medicine and is the medical director of the John's Hopkins Women's Health Center. Dr. Coleman earned her M.D. from the University of Pennsylvania School of Medicine and completed Ob/Gyn residency at the University of California, Los Angeles. She completed a fellowship in reproductive infectious diseases at the University of California, San Francisco and received an M.P.H. from the University of California, Berkeley
| | - Holly A Taylor
- Marielle S. Gross, M.D., M.B.E., is a Hecht-Levi postdoctoral research fellow in the Berman Institute of Bioethics at Johns Hopkins University where she recently completed residency training in Gynecology & Obstetrics. She attended medical school at the University of Florida, and previously completed degrees in Philosophy, Jewish Ethics and Bioethics at Columbia University, the Jewish Theological Seminary, and New York University, respectively. Holly A. Taylor, Ph.D., M.P.H., is a Core Faculty member of the Johns Hopkins Berman Institute of Bioethics and Associate Professor in the Department of Health Policy and Management (HPM), Bloomberg School of Public Health. Dr. Taylor received her B.A. from Stanford University, her M.P.H. from the School of Public Health at the University of Michigan and her Ph.D. in health policy with a concentration in bioethics from the Bloomberg School of Public Health, Johns Hopkins University. Cecilia Tomori, Ph.D., studied biology and education at Swarthmore College and obtained her Ph.D. in Anthropology from the University of Michigan in 2011. She completed a postdoctoral fellowship at Johns Hopkins School of Public Health and served as faculty there between 2013-2017. Jenell S. Coleman, M.D., M.P.H., is associate professor in the Johns Hopkins School of Medicine Department of Gynecology and Obstetrics with a joint appointment in the Department of Medicine and is the medical director of the John's Hopkins Women's Health Center. Dr. Coleman earned her M.D. from the University of Pennsylvania School of Medicine and completed Ob/Gyn residency at the University of California, Los Angeles. She completed a fellowship in reproductive infectious diseases at the University of California, San Francisco and received an M.P.H. from the University of California, Berkeley
| | - Cecilia Tomori
- Marielle S. Gross, M.D., M.B.E., is a Hecht-Levi postdoctoral research fellow in the Berman Institute of Bioethics at Johns Hopkins University where she recently completed residency training in Gynecology & Obstetrics. She attended medical school at the University of Florida, and previously completed degrees in Philosophy, Jewish Ethics and Bioethics at Columbia University, the Jewish Theological Seminary, and New York University, respectively. Holly A. Taylor, Ph.D., M.P.H., is a Core Faculty member of the Johns Hopkins Berman Institute of Bioethics and Associate Professor in the Department of Health Policy and Management (HPM), Bloomberg School of Public Health. Dr. Taylor received her B.A. from Stanford University, her M.P.H. from the School of Public Health at the University of Michigan and her Ph.D. in health policy with a concentration in bioethics from the Bloomberg School of Public Health, Johns Hopkins University. Cecilia Tomori, Ph.D., studied biology and education at Swarthmore College and obtained her Ph.D. in Anthropology from the University of Michigan in 2011. She completed a postdoctoral fellowship at Johns Hopkins School of Public Health and served as faculty there between 2013-2017. Jenell S. Coleman, M.D., M.P.H., is associate professor in the Johns Hopkins School of Medicine Department of Gynecology and Obstetrics with a joint appointment in the Department of Medicine and is the medical director of the John's Hopkins Women's Health Center. Dr. Coleman earned her M.D. from the University of Pennsylvania School of Medicine and completed Ob/Gyn residency at the University of California, Los Angeles. She completed a fellowship in reproductive infectious diseases at the University of California, San Francisco and received an M.P.H. from the University of California, Berkeley
| | - Jenell S Coleman
- Marielle S. Gross, M.D., M.B.E., is a Hecht-Levi postdoctoral research fellow in the Berman Institute of Bioethics at Johns Hopkins University where she recently completed residency training in Gynecology & Obstetrics. She attended medical school at the University of Florida, and previously completed degrees in Philosophy, Jewish Ethics and Bioethics at Columbia University, the Jewish Theological Seminary, and New York University, respectively. Holly A. Taylor, Ph.D., M.P.H., is a Core Faculty member of the Johns Hopkins Berman Institute of Bioethics and Associate Professor in the Department of Health Policy and Management (HPM), Bloomberg School of Public Health. Dr. Taylor received her B.A. from Stanford University, her M.P.H. from the School of Public Health at the University of Michigan and her Ph.D. in health policy with a concentration in bioethics from the Bloomberg School of Public Health, Johns Hopkins University. Cecilia Tomori, Ph.D., studied biology and education at Swarthmore College and obtained her Ph.D. in Anthropology from the University of Michigan in 2011. She completed a postdoctoral fellowship at Johns Hopkins School of Public Health and served as faculty there between 2013-2017. Jenell S. Coleman, M.D., M.P.H., is associate professor in the Johns Hopkins School of Medicine Department of Gynecology and Obstetrics with a joint appointment in the Department of Medicine and is the medical director of the John's Hopkins Women's Health Center. Dr. Coleman earned her M.D. from the University of Pennsylvania School of Medicine and completed Ob/Gyn residency at the University of California, Los Angeles. She completed a fellowship in reproductive infectious diseases at the University of California, San Francisco and received an M.P.H. from the University of California, Berkeley
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Adeniyi OV, Ajayi AI, Issah M, Owolabi EO, Goon DT, Avramovic G, Lambert J. Beyond health care providers' recommendations: understanding influences on infant feeding choices of women with HIV in the Eastern Cape, South Africa. Int Breastfeed J 2019; 14:7. [PMID: 30733819 PMCID: PMC6357465 DOI: 10.1186/s13006-019-0201-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 01/23/2019] [Indexed: 12/31/2022] Open
Abstract
Background Despite the array of studies on infant feeding practices of HIV-infected women, gaps still exist in the understanding of the underlying reasons for their infant feeding choices. Potential for behavioural change exists, especially in the light of the 2016 updated World Health Organization guideline on HIV and infant feeding. The aim of this paper is to determine the rate of adoption of exclusive breastfeeding in this cohort, examine the determinants of infant feeding choices of HIV-infected women and assess the underlying reasons for these choices. Methods This was a mixed methods study conducted between September 2015 and May 2016. It analyses the quantitative and qualitative data of 1662 peripartum women enrolled in the East London Prospective Cohort Study across three large maternity services in the Eastern Cape. Women with HIV reported their preferred choices of infant feeding. In addition, participants explained the underlying reasons for their choices. Descriptive and inferential statistics summarised the quantitative data, while thematic content analysis was performed on qualitative data. Results Of the 1662 women with complete responses, 80.3% opted to exclusively breastfeed their babies. In the adjusted model, up to grade 12 education level (AOR: 1.81; 95% CI: 1.14, 2.86), rural/peri-urban residence (AOR:1.44; 95% CI: 1.05, 1.96), alcohol use (AOR: 1.65; 95% CI: 1.25, 2.18), negative or unknown HIV status at booking (AOR:1.85; 95% CI:1.27, 2.70), currently married (AOR:1.43; 95% CI:1.01, 2.02) and WHO Clinical Stage 2-4 (AOR:1.77; 95% CI: 1.15, 2.72) were significantly associated with the decision to exclusively breastfeed. Health care providers' recommendations, perceived benefits of breastfeeding, unaffordability of formula feeding, and coercion were the underlying reasons for wanting to breastfeed; while work/school-related demands, breast-related issues, and fear of infecting the baby influenced their decision to formula feed. Conclusion The majority of HIV-infected women chose to breastfeed their babies in the Eastern Cape. Following up on these women to ensure they breastfeed exclusively, while also addressing their possible concerns, could be an important policy intervention. Future studies should focus on how early infant feeding decisions change over time, as well as the health outcomes for mother and child.
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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, East London, South Africa
| | - Moshood Issah
- Department of Sociology, Faculty of Social Sciences & Humanities, 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
| | - Daniel Ter Goon
- Department of Nursing Sciences, Faculty of Health Sciences, University of Fort Hare, East London, South Africa
| | - Gordana Avramovic
- Department of Infectious Diseases, Medicine and Sexual Health, Mater, Rotunda and University College, Dublin, Ireland
| | - John Lambert
- Department of Infectious Diseases, Medicine and Sexual Health, Mater, Rotunda and University College, Dublin, Ireland
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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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Waitt C, Low N, Van de Perre P, Lyons F, Loutfy M, Aebi-Popp K. Does U=U for breastfeeding mothers and infants? Breastfeeding by mothers on effective treatment for HIV infection in high-income settings. Lancet HIV 2018; 5:e531-e536. [PMID: 29960731 DOI: 10.1016/s2352-3018(18)30098-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 04/30/2018] [Accepted: 05/02/2018] [Indexed: 12/01/2022]
Abstract
Can the campaign Undetectable=Untransmittable (U=U), established for the sexual transmission of HIV, be applied to the transmission of HIV through breastfeeding? European AIDS Clinical Society and, to some extent, American guidelines now state that mothers with HIV who wish to breastfeed should be supported, with increased clinical and virological monitoring. This Viewpoint summarises existing evidence on transmission of HIV through breastfeeding, differences in HIV dynamics and viral load between breastmilk and plasma, and the effects of antiretroviral therapy on infants. At present, insufficient evidence exists to make clear recommendations for the required frequency of clinical and virological monitoring for mother and infant in a breastfeeding relationship or for the action to be taken in the event of viral rebound. We propose a roadmap for collaborative research to provide the missing evidence required to enable mothers who wish to breastfeed to make a fully informed choice.
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Affiliation(s)
- Catriona Waitt
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK; Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda; Royal Liverpool University Hospital, Liverpool, UK.
| | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Philippe Van de Perre
- Pathogenesis and Control of Chronic Infections, INSERM, University of Montpellier, Etablissement Français du Sang, CHU Montpellier, Montpellier, France
| | - Fiona Lyons
- Department of Genitourinary Medicine and Infectious Diseases, St James's Hospital, Dublin, Ireland
| | - Mona Loutfy
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Karoline Aebi-Popp
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
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HIV treatment in pregnancy. Lancet HIV 2018; 5:e457-e467. [PMID: 29958853 DOI: 10.1016/s2352-3018(18)30059-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/27/2018] [Accepted: 03/29/2018] [Indexed: 01/15/2023]
Abstract
Almost 25 years since antiretroviral therapy (ART) was first shown to prevent mother-to-child transmission of HIV, 76% of pregnant women living with HIV (over 1 million women) receive ART annually. This number is the result of successes in universal ART scale-up in low-income and middle-income countries. Despite unprecedented ART-related benefits to maternal and child health, challenges remain related to ART adherence, retention in care, and unequal access to ART. Implementation research is ongoing to understand and to address obstacles that lead to loss to follow-up. The biological mechanisms that underlie observed associations between antenatal ART and adverse outcomes in pregnancy and birth are not completely understood, with further research needed as well as strengthening of the systems to assess safety of antiretroviral drugs for the mother and HIV-exposed child. In the treat-all era, as duration of treatment and options for ART expand, pregnant women will remain a priority population for treatment optimisation to promote their health and that of their ART-exposed children.
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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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41
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McCarthy E, Joseph J, Foster G, Mangwiro AZ, Mwapasa V, Oyeledun B, Phiri S, Sam-Agudu NA, Essajee S. Modeling the Impact of Retention Interventions on Mother-to-Child Transmission of HIV: Results From INSPIRE Studies in Malawi, Nigeria, and Zimbabwe. J Acquir Immune Defic Syndr 2017; 75 Suppl 2:S233-S239. [PMID: 28498194 PMCID: PMC5432093 DOI: 10.1097/qai.0000000000001364] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Six implementation research studies in Malawi, Nigeria, and Zimbabwe tested approaches for improving retention in care among women living with HIV. We simulated the impact of their interventions on the probability of HIV transmission during pregnancy and breastfeeding. METHODS A computer-based state-transition model was developed to estimate the impact of the retention interventions. Patient-level data from the 6 studies were aggregated and analyzed, and weighted averages of mother-to-child transmission (MTCT) of HIV probabilities were presented. The average MTCT probability of the more successful interventions was applied to national estimates to calculate potential infections averted if these interventions were taken to scale. RESULTS Among the total cohort of 5742 HIV-positive women, almost 80% of all infant infections are attributed to the roughly 20% of HIV-positive pregnant and breastfeeding women not retained on antiretroviral therapy. Higher retention in the arms receiving interventions resulted in an overall lower estimated MTCT probability of 9.9% compared with 12.3% in the control arms. In the 2 studies that showed a statistically significant effect, Prevention of MTCT Uptake and Retention (PURE) and Mother Mentor (MoMent), the difference in transmission rates between intervention and control arms was 4.1% and 7.3%, respectively. Scaling up retention interventions nationally in the 3 countries could avert an average of almost 3000 infant infections annually. CONCLUSIONS Linking HIV-positive pregnant women to antiretroviral therapy and retaining them is essential for addressing the remaining gaps and challenges in HIV/AIDS care and the elimination of MTCT. At national level, even modest improvements in retention translates into large numbers of infant infections averted.
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Affiliation(s)
- Elizabeth McCarthy
- Applied Analytics Team, Clinton Health Access Initiative, Lusaka, Zambia
| | - Jessica Joseph
- Applied Analytics Team, Clinton Health Access Initiative, Boston, MA
| | - Geoff Foster
- Ministry of Health and Child Care, Mutare, Zimbabwe
- Family AIDS Caring Trust, Mutare, Zimbabwe
| | | | - Victor Mwapasa
- Department of Public Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Sam Phiri
- Lighthouse Trust, Lilongwe, Malawi
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Lilongwe, Malawi
| | - 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, University of Maryland School of Medicine, Baltimore, MD; and
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42
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Myer L, Dunning L, Lesosky M, Hsiao NY, Phillips T, Petro G, Zerbe A, McIntyre JA, Abrams EJ. Frequency of Viremic Episodes in HIV-Infected Women Initiating Antiretroviral Therapy During Pregnancy: A Cohort Study. Clin Infect Dis 2017; 64:422-427. [PMID: 27927852 DOI: 10.1093/cid/ciw792] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 11/22/2016] [Indexed: 11/13/2022] Open
Abstract
Background The numbers of human immunodeficiency virus (HIV)-infected women initiating antiretroviral therapy (ART) in pregnancy are increasing rapidly with global policy changes. There are widespread concerns about ART adherence during pregnancy and postpartum but few data on viral suppression (VS) over time in these populations. Methods We followed a cohort of 523 women in Cape Town, South Africa, initiating ART in pregnancy (once-daily tenofovir 300 mg, emtricitabine 200 mg, and efavirenz 600 mg) and achieving VS (<50 copies/mL). Participants provided specimens through 12 months postpartum for batched viral load (VL) testing separate from routine care. Analyses described the incidence of major (>1000 copies/mL) and minor (50-1000 copies/mL) viremic episodes (VEs) and factors associated with major VEs. Results In the cohort (median age, 28 years; median pre-ART VL, 3.99 copies/mL; 3% previously defaulted ART; 24% with previous exposure to short-course antiretrovirals), the median time of follow-up from VS was 322 days. Overall, 70% maintained VS throughout follow-up, 8% experienced minor VEs only, and at least 1 major VE was documented in 22% of women. In women with VEs, peak viremia (median, 3.79 log10 copies/mL) was linearly related to pre-ART VL. The incidence of major VEs after initial VS was independently associated with younger age, ART initiation during the third trimester, previous defaulting on ART, and postpartum follow-up. Conclusions Viremia appears to occur frequently, particularly postpartum, among HIV-infected women after initial VS in this setting. More intensive VL monitoring is warranted in this population; the immediate causes and long-term implications of VE require investigation.
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Affiliation(s)
- Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Diseases Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Lorna Dunning
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Maia Lesosky
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nei-Yuan Hsiao
- National Health Laboratory Services and Division of Medical Virology, University of Cape Town, Cape Town, South Africa
| | - Tamsin Phillips
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Diseases Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Greg Petro
- Division of Obstetrics and Gynaecology, University of Cape Town, South Africa
| | - Allison Zerbe
- ICAP, Columbia University Mailman School of Public Health, New York, USA
| | - James A McIntyre
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Anova Health Institute, Johannesburg, South Africa
| | - Elaine J Abrams
- ICAP, Columbia University Mailman School of Public Health, New York, USA.,College of Physicians and Surgeons, Columbia University, New York, USA
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