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Sakyi KS, Hurley EA, Kanyangarara M, Owusu PG, Sowah LA, Lartey M, Jackson F, Sacks E. Over forty percent of women living with HIV report interruption in antiretroviral therapy during intrapartum and early postpartum inpatient stay: findings from five hospitals in Ghana. AIDS Care 2024; 36:139-145. [PMID: 37723120 DOI: 10.1080/09540121.2023.2254546] [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: 11/15/2022] [Accepted: 08/27/2023] [Indexed: 09/20/2023]
Abstract
Antiretroviral therapy (ART) adherence during and after pregnancy is essential to reduce perinatal transmission of HIV. However, little is known about adherence during the intrapartum and early postpartum inpatient hospital stay. Using secondary data from a hospital-based cohort study focused on the relationship between birthweight and engagement in HIV care, we examined the magnitude of, reasons for, and factors associated with incomplete intrapartum and early postpartum ART adherence among adult women (18 years or older) living with HIV who delivered within the previous two weeks at one of five hospitals in Accra, Ghana. Of the 142 enrolled participants who had complete adherence data and reported being on ART at the time of hospital admission, 43% (61/142) reported missing at least one ART dose during labor, delivery, and postpartum, including almost 20% (28/142) missing 2 or more consecutive doses. Women who reported frequently missing ART doses during pregnancy had higher odds of reporting missed doses during their intrapartum and postpartum hospital stays. Among those with inpatient ART interruption, the most frequently cited reasons were: forgetting medication at home (42%) and challenges of being in or recovering from labor (29%). Maternal perception of infant health at birth, hospital level of care, and frequency of missing HIV medications during pregnancy were associated with incomplete ART adherence during the intrapartum and early postpartum inpatient stay. An enabling clinical environment to facilitate access to ART during inpatient stays may have positive implications for ART adherence.
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Affiliation(s)
- Kwame S Sakyi
- School of Health Sciences, Oakland University, Rochester, MI, USA
- Center for Learning and Childhood Development, Accra, Ghana
| | - Emily A Hurley
- Center for Learning and Childhood Development, Accra, Ghana
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, USA
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Mufaro Kanyangarara
- Center for Learning and Childhood Development, Accra, Ghana
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, SC, USA
| | - Prince G Owusu
- Center for Learning and Childhood Development, Accra, Ghana
- Department of Human Development and Family Studies, Michigan State University, East Lansing, MI, USA
| | | | - Margaret Lartey
- Department of Medicine, University of Ghana Medical School, Accra, Ghana
| | | | - Emma Sacks
- Center for Learning and Childhood Development, Accra, Ghana
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
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Brittain K, Brown K, Phillips T, Zerbe A, Pellowski J, Remien RH, Mellins CA, Abrams EJ, Myer L. Why do Integrated Maternal HIV and Infant Healthcare Services work? A Secondary Analysis of a Randomised Controlled Trial in South Africa. AIDS Behav 2023; 27:3831-3843. [PMID: 37306847 PMCID: PMC10598190 DOI: 10.1007/s10461-023-04097-x] [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] [Accepted: 05/20/2023] [Indexed: 06/13/2023]
Abstract
In a randomised trial, we found that integrated maternal HIV and infant health services through the end of breastfeeding were significantly associated with the primary outcome of engagement in HIV care and viral suppression at 12 months postpartum, compared to the standard of care. Here, we quantitatively explore potential psychosocial modifiers and mediators of this association. Our findings suggest that the intervention was significantly more effective among women experiencing an unintended pregnancy but did not improve outcomes among women reporting risky alcohol use. Although not statistically significant, our results suggest that the intervention may also be more effective among women experiencing higher levels of poverty and HIV-related stigma. We observed no definitive mediator of the intervention effect, but women allocated to integrated services reported better relationships with their healthcare providers through 12 months postpartum. These findings point to high-risk groups that may benefit the most from integrated care, as well as groups for whom these benefits are hampered and that warrant further attention in intervention development and evaluation.
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Affiliation(s)
- Kirsty Brittain
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.
| | - Karryn Brown
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - Tamsin Phillips
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - Allison Zerbe
- Mailman School of Public Health, ICAP at Columbia University, Columbia University, New York, NY, USA
| | - Jennifer Pellowski
- Department of Behavioral & Social Sciences, Brown University School of Public Health, Providence, RI, USA
- International Health Institute, Brown University School of Public Health, Providence, RI, USA
| | - Robert H Remien
- New York State Psychiatric Institute, HIV Center for Clinical & Behavioral Studies, Columbia University, New York, NY, USA
| | - Claude A Mellins
- New York State Psychiatric Institute, HIV Center for Clinical & Behavioral Studies, Columbia University, New York, NY, USA
| | - Elaine J Abrams
- Mailman School of Public Health, ICAP at Columbia University, Columbia University, New York, NY, USA
- Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
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Improved virologic outcomes in postpartum women living with HIV referred to differentiated models of care. AIDS 2022; 36:2203-2211. [PMID: 36111547 DOI: 10.1097/qad.0000000000003385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Differentiated service delivery (DSD) models are used to deliver antiretroviral therapy (ART) but data are limited in postpartum women, who are at high risk of non-adherence and elevated viral load (VL) over the extended postpartum period. DESIGN Randomized controlled trial. METHODS We enrolled consecutive postpartum women who initiated ART during pregnancy and met local DSD eligibility (clinically stable, VL less than 400 copies/ml) at a large primary healthcare (PHC) clinic. Women were randomized to a community-based 'adherence club' (AC, the local DSD model: community health worker-led groups of 20-30 patients with ART dispensing at a community venue) or routine PHC clinics (local standard of care with nurse/doctor-led services). Follow-up visits with VL separate from routine care took place at 3, 6, 12, 18 and 24 months postpartum. Endpoints were time to VL of at least 1000 copies/ml (primary) and VL of at least 50 copies/ml (secondary) by intention-to-treat. RESULTS At enrolment ( n = 409), the median duration postpartum was 10 days, all women had a VL less than 1000 copies/ml and 88% had a VL less than 50 copies/ml; baseline characteristics did not differ by arm. Twenty-four-month retention was 89%. Sixteen and 29% of women in AC experienced a VL of at least 1000 copies/ml by 12 and 24 months, compared to 23 and 37% in PHC, respectively (hazard ratio [HR] = 0.71; 95% confidence interval [CI] = 0.50-1.01). Thirty-two and 44% of women in ACs had a VL of at least 50 copies/ml by 12 and 24 months, compared to 42 and 56% in PHC, respectively (HR = 0.68; 95% CI = 0.51-0.91). CONCLUSIONS Early DSD referral was associated with reduced viraemia through 24 months postpartum and may be an important strategy to improve maternal virologic outcomes.
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Brittain K, Teasdale CA, Ngeno B, Odondi J, Ochanda B, Brown K, Langat A, Modi S, Abrams EJ. Improving retention in antenatal and postnatal care: a systematic review of evidence to inform strategies for adolescents and young women living with HIV. J Int AIDS Soc 2021; 24:e25770. [PMID: 34449121 PMCID: PMC8395389 DOI: 10.1002/jia2.25770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/17/2021] [Accepted: 06/01/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Young pregnant and postpartum women living with HIV (WLHIV) are at high risk of poor outcomes in prevention of mother-to-child transmission services. The aim of this systematic review was to collate evidence on strategies to improve retention in antenatal and/or postpartum care in this population. We also conducted a secondary review of strategies to increase attendance at antenatal care (ANC) and/or facility delivery among pregnant adolescents, regardless of HIV status, to identify approaches that could be adapted for adolescents and young WLHIV. METHODS Selected databases were searched on 1 December 2020, for studies published between January 2006 and November 2020, with screening and data abstraction by two independent reviewers. We identified papers that reported age-disaggregated results for adolescents and young WLHIV aged <25 years at the full-text review stage. For the secondary search, we included studies among female adolescents aged 10 to 19 years. RESULTS AND DISCUSSION Of 37 papers examining approaches to increase retention among pregnant and postpartum WLHIV, only two reported age-disaggregated results: one showed that integrated care during the postpartum period increased retention in HIV care among women aged 18 to 24 years; and another showed that a lay counsellor-led combination intervention did not reduce attrition among women aged 16 to 24 years; one further study noted that age did not modify the effectiveness of a combination intervention. Mobile health technologies, enhanced support, active follow-up and tracing and integrated services were commonly examined as standalone interventions or as part of combination approaches, with mixed evidence for each strategy. Of 10 papers identified in the secondary search, adolescent-focused services and continuity of care with the same provider appeared to be effective in improving attendance at ANC and/or facility delivery, while home visits and group ANC had mixed results. CONCLUSIONS This review highlights the lack of evidence regarding effective strategies to improve retention in antenatal and/or postpartum care among adolescents and young WLHIV specifically, as well as a distinct lack of age-disaggregated results in studies examining retention interventions for pregnant WLHIV of all ages. Identifying and prioritizing approaches to improve retention of adolescents and young WLHIV are critical for improving maternal and child health.
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Affiliation(s)
- Kirsty Brittain
- Division of Epidemiology & BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Chloe A Teasdale
- Mailman School of Public HealthICAP‐Columbia UniversityNew YorkNYUSA
- Department of EpidemiologyMailman School of Public HealthNew YorkNYUSA
- Department of Epidemiology and BiostatisticsCUNY Graduate School of Public Health & Health PolicyNew YorkNYUSA
| | - Bernadette Ngeno
- Division of Global HIV and Tuberculosis (DGHT)US Centers for Disease Control and PreventionAtlantaGAUSA
| | - Judith Odondi
- Mailman School of Public HealthICAP‐Columbia UniversityNew YorkNYUSA
| | - Boniface Ochanda
- Division of Global HIV and Tuberculosis (DGHT)US Centers for Disease Control and PreventionNairobiKenya
| | - Karryn Brown
- Division of Epidemiology & BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Agnes Langat
- Division of Global HIV and Tuberculosis (DGHT)US Centers for Disease Control and PreventionNairobiKenya
| | - Surbhi Modi
- Division of Global HIV and Tuberculosis (DGHT)US Centers for Disease Control and PreventionAtlantaGAUSA
| | - Elaine J Abrams
- Mailman School of Public HealthICAP‐Columbia UniversityNew YorkNYUSA
- Department of EpidemiologyMailman School of Public HealthNew YorkNYUSA
- Department of PediatricsVagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
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Mdletshe N, Thobakgale C, Malaba TR, Madlala H, Myer L, Muema DM, Mogeni P, Gray CM, Altfeld M, Newell ML, Ndung'u T. Low immune activation in early pregnancy is associated with preterm but not small-for-gestational age delivery in HIV infected women initiating antiretroviral therapy in pregnancy: a PIMS case-control study in Cape Town, South Africa. Clin Infect Dis 2021; 73:2205-2216. [PMID: 33606024 PMCID: PMC8677566 DOI: 10.1093/cid/ciab151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Indexed: 12/24/2022] Open
Abstract
Background Mechanisms underlying an association between human immunodeficiency virus (HIV) or antiretroviral therapy (ART) during pregnancy with risk of preterm delivery (PTD) and small-for-gestational-age (SGA) remain unclear. We explored the association between cellular immune activation and PTD or SGA in women with HIV initiating ART during or before pregnancy. Methods Women with HIV enrolled at median 15 weeks’ gestation, were analyzed for immune markers, and matched on ART initiation timing (15 women initiated pre- and 15 during pregnancy). There were 30 PTD (delivery <37 weeks), 30 SGA (weight for age ≤10th percentile) cases, and 30 controls (term, weight for gestational age >25th percentile) as outcomes. Lymphocytes, monocytes, and dendritic cell populations and their activation status or functionality were enumerated by flow cytometry. Results PTD cases initiating ART in pregnancy showed decreased CD8+ T cell, monocyte, and dendritic cell activation; increased classical (CD14+CD16–) and intermediate (CD14+CD16+) monocyte frequencies; and decreased inflammatory monocytes (CD14dimCD16+) compared with SGA cases and term controls (all P < .05). Allowing for baseline viral load, the immune markers remained significantly associated with PTD but only in women initiating ART in pregnancy. Lower monocyte activation was predictive of PTD. TLR ligand-induced interferon-α and macrophage inflammatory protein-1β levels in monocytes were significantly lower in PTD women initiating ART in pregnancy. Conclusion Low immune activation, skewing toward anti-inflammatory monocytes, and lower monocyte cytokine production in response to TLR ligand stimulation were associated with PTD but not SGA among women initiating ART in, but not before, pregnancy, suggesting immune anergy to microbial stimulation as a possible underlying mechanism for PTD in women initiating ART in pregnancy.
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Affiliation(s)
- Nontlantla Mdletshe
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal (UKZN), Durban, South Africa
| | - Christina Thobakgale
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal (UKZN), Durban, South Africa.,School of Pathology, National Institute for Communicable Diseases and the University of the Witwatersrand, Johannesburg, South Africa
| | - Thokozile R Malaba
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Hlengiwe Madlala
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Polycarp Mogeni
- Africa Health Research Institute, Durban, South Africa.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,KwaZulu-Natal Innovation and Sequencing Platform (KRISP), University of KwaZulu-Natal, Durban, South Africa
| | - Clive M Gray
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Marcus Altfeld
- Department of Viral Immunology, Heinrich-Pette-Institute, Leibniz Institute for Experimental Virology, Hamburg, Germany
| | - Marie-Louise Newell
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Thumbi Ndung'u
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal (UKZN), Durban, South Africa.,Africa Health Research Institute, Durban, South Africa.,Max Planck Institute for Infection Biology, Berlin, Germany.,Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, Cambridge, Massachusetts, USA.,Division of Infection and Immunity, University College London, London, United Kingdom
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6
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Wessels J, Sherman G, Bamford L, Makua M, Ntloana M, Nuttall J, Pillay Y, Goga A, Feucht U. The updated South African National Guideline for the Prevention of Mother to Child Transmission of Communicable Infections (2019). South Afr J HIV Med 2020; 21:1079. [PMID: 32832113 PMCID: PMC7433286 DOI: 10.4102/sajhivmed.v21i1.1079] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/03/2020] [Indexed: 11/01/2022] Open
Affiliation(s)
- Jeannette Wessels
- Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Pretoria, South Africa
| | - Gayle Sherman
- Department of Paediatrics & Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Centre for HIV & STI, National Institute for Communicable Diseases, Division of the National Health Laboratory Services, Johannesburg, South Africa
| | - Lesley Bamford
- Child, Youth, and School Health Chief Directorate, National Department of Health, Pretoria, South Africa.,School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
| | - Manala Makua
- Communicable and Non-Communicable Diseases Branch, National Department of Health, Pretoria
| | - Mathilda Ntloana
- Communicable and Non-Communicable Diseases Branch, National Department of Health, Pretoria
| | - James Nuttall
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Yogan Pillay
- Communicable and Non-Communicable Diseases Branch, National Department of Health, Pretoria
| | - Ameena Goga
- Health Systems Research Unit, South African Research Council, Cape Town, South Africa.,Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa.,HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Ute Feucht
- Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Pretoria, South Africa.,Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa.,Tshwane District Health Services, Gauteng Department of Health, Tshwane, South Africa.,Maternal and Infant Health Care Strategies Research Unit, South African Medical Research Council, Pretoria, South Africa
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Brittain K, Mellins CA, Remien RH, Phillips TK, Zerbe A, Abrams EJ, Myer L. Impact of HIV-Status Disclosure on HIV Viral Load in Pregnant and Postpartum Women on Antiretroviral Therapy. J Acquir Immune Defic Syndr 2020; 81:379-386. [PMID: 30939530 DOI: 10.1097/qai.0000000000002036] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND HIV-status disclosure is widely encouraged by counseling services, in part because it is thought to improve antiretroviral therapy (ART) adherence and thus HIV viral suppression. However, few longitudinal studies have examined the impact of disclosure on HIV viral load (VL) during pregnancy and postpartum. METHODS We explored these associations among 1187 women living with HIV, enrolled between March 2013 and June 2014 in Cape Town, South Africa. RESULTS Among women who tested HIV-positive before pregnancy, we observed no association between disclosure and VL at entry into antenatal care among those already on ART, nor at delivery and 12 months postpartum among those initiating ART. Among women who tested HIV-positive during pregnancy and initiated ART subsequently, disclosure to a male partner was associated with a reduced risk of VL ≥50 copies/mL at delivery (adjusted risk ratio: 0.56; 95% confidence interval: 0.31 to 1.01). After stratification by relationship status, this association was only observed among women who were married and/or cohabiting. In addition, disclosure to ≥1 family/community member was associated with a reduced risk of VL ≥50 copies/mL at 12 months postpartum (adjusted risk ratio: 0.69; 95% confidence interval: 0.48 to 0.97) among newly-diagnosed women. CONCLUSIONS These findings suggest that the impact of disclosure on VL is modified by 3 factors: (1) timing of HIV diagnosis (before vs. during the pregnancy); (2) relationship to the person(s) to whom women disclose; and (3) in the case of disclosure to a male partner, relationship status. Counseling about disclosure may be most effective if tailored to individual women's circumstances.
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Affiliation(s)
- Kirsty Brittain
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Claude A Mellins
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY
| | - Robert H Remien
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY
| | - Tamsin K Phillips
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Allison Zerbe
- Mailman School of Public Health, ICAP at Columbia University, New York, NY
| | - Elaine J Abrams
- Mailman School of Public Health, ICAP at Columbia University, New York, NY.,Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - 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 Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Kuhn L, Goga AE. Moving towards elimination: findings from the South Africa prevention of mother to child transmission evaluation (SAPMTCTE). BMC Infect Dis 2019; 19:782. [PMID: 31526365 PMCID: PMC6745774 DOI: 10.1186/s12879-019-4334-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Louise Kuhn
- Gertrude H. Sergievsky Center, College of Physicians and Surgeons, Columbia University Medical Center, 630 W 168th Street, New York, NY, 10032, USA. .,Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, 630 W 168th Street, New York, NY, 10032, USA.
| | - Ameena E Goga
- Health Systems Research Unit, South African Medical Research Council, Pretoria, 0001, South Africa.,Department of Paediatrics, University of Pretoria, Pretoria, 0001, South Africa
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Malaba TR, Phillips T, Le Roux S, Brittain K, Zerbe A, Petro G, Ronan A, McIntyre JA, Abrams EJ, Myer L. Antiretroviral therapy use during pregnancy and adverse birth outcomes in South African women. Int J Epidemiol 2017; 46:1678-1689. [PMID: 29040569 PMCID: PMC5837407 DOI: 10.1093/ije/dyx136] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/22/2017] [Accepted: 06/27/2017] [Indexed: 11/12/2022] Open
Abstract
Background Studies of antiretroviral therapy (ART) use during pregnancy in HIV-infected women have suggested that ART exposure may be associated with adverse birth outcomes. However, there are few data from sub-Saharan Africa where HIV is most common, and few studies involving the World Health Organization's (WHO's) recommended first-line regimens. Methods We enrolled consecutive HIV-infected pregnant women and a comparator cohort of uninfected women at a primary-level antenatal care facility in Cape Town, South Africa. Gestational assessment combined clinical history, examination and ultrasonography; outcomes included preterm (PTD), low birthweight (LBW) and small for gestational age (SGA) deliveries. In analysis we compared birth outcomes between HIV-infected and -uninfected women, and HIV-infected women who initiated ART before vs during pregnancy. Results In 1554 women (mean age 29 years) with live singleton births at time of analysis, 82% were HIV-infected, 92% of whom received a first-line regimen of tenofovir, emtricitabine and efavirenz. Overall, higher levels of PTD [22% vs 13%; odds ratio (OR) 1.94, 95% confidence interval (CI): 1.34, 2.82] and LBW (14% vs 9%; OR 1.62, 95% CI: 1.05, 2.29) were observed in HIV-infected vs uninfected women, although SGA deliveries were similar (9% vs 11%; OR 1.06, 95% CI: 0.71, 1.61). Adjusting for demographic characteristics and HIV disease measures, HIV-infected (vs HIV-uninfected) women had persistently increased odds of PTD [adjusted odds ratio (AOR) 2.03; CI 1.33, 3.10]; associations with LBW were attenuated (AOR 1.47; CI 0.90, 2.40). Among all HIV-infected women, there appeared to be no association between the timing of ART initiation (before or during pregnancy) and adverse birth outcomes. Conclusions These findings suggest that current WHO-recommended ART regimens appear relatively safe in pregnancy, although more data are required to understand the aetiology of preterm delivery in HIV-infected women using ART.
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Affiliation(s)
- Thokozile R Malaba
- Division of Epidemiology and Biostatistics
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Tamsin Phillips
- Division of Epidemiology and Biostatistics
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Stanzi Le Roux
- Division of Epidemiology and Biostatistics
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kirsty Brittain
- Division of Epidemiology and Biostatistics
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Allison Zerbe
- ICAP, Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Greg Petro
- Department of Obstetrics and Gynaecology, New Somerset Hospital, University of Cape Town, Cape Town, South Africa
| | - Agnes Ronan
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - James A McIntyre
- Division of Epidemiology and Biostatistics
- ANOVA Health Institute, Johannesburg, South Africa
| | - Elaine J Abrams
- ICAP, Columbia University, Mailman School of Public Health, New York, NY, USA
- College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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10
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Optimizing Antiretroviral Therapy (ART) for Maternal and Child Health (MCH): Rationale and Design of the MCH-ART Study. J Acquir Immune Defic Syndr 2017; 72 Suppl 2:S189-96. [PMID: 27355508 PMCID: PMC5113242 DOI: 10.1097/qai.0000000000001056] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background: Prevention of mother-to-child transmission of HIV implementation faces significant challenges globally, particularly in the context of universal lifelong antiretroviral therapy (ART) for all HIV-infected pregnant women. Methods: We describe the rationale and methods of the Maternal and Child Health-Antiretroviral Therapy (MCH-ART) study, an implementation science project examining strategies for providing HIV care and treatment to HIV-infected women who initiate ART during pregnancy and their HIV-exposed infants. Results: MCH-ART is composed of 3 interrelated study designs across the antenatal and postnatal periods. Phase 1 is a cross-sectional evaluation of consecutive HIV-infected pregnant women seeking antenatal care; phase 2 is an observational cohort of all women from phase 1 who are eligible for initiation of ART following local guidelines; and phase 3 is a randomized trial of strategies for delivering ART to breastfeeding women from phase 2 during the postpartum period. During each phase, a set of study measurement visits is carried out separately from antenatal care and ART services; a maximum of 9 visits takes place from the beginning of antenatal care through 12 months postpartum. In parallel, in-depth interviews are used to examine issues of ART adherence and retention qualitatively, and costs and cost-effectiveness of models of care are examined. Separate substudies examine health outcomes in HIV-uninfected women and their HIV-unexposed infants, and the role of the adherence club model for long-term adherence and retention. Discussion: Combining observational and experimental components, the MCH-ART study presents a novel approach to understand and optimize ART delivery for MCH.
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Despite Access to Antiretrovirals for Prevention and Treatment, High Rates of Mortality Persist Among HIV-infected Infants and Young Children. Pediatr Infect Dis J 2017; 36:595-601. [PMID: 28027287 PMCID: PMC5432395 DOI: 10.1097/inf.0000000000001507] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Outcomes of HIV-infected children before widespread use of antiretroviral therapy (ART) for treatment and prevention of mother-to-child transmission (PMTCT) have been well characterized but less is known about children who acquire HIV infection in the context of good ART access. METHODS We enrolled newly diagnosed HIV-infected children ≤24 months of age at 3 hospitals and 2 clinics in Johannesburg, South Africa. We report ART initiation and mortality rates during 6 months from enrollment and factors associated with mortality. RESULTS Of 272 children enrolled, median age 6.1 months, 69.5% were diagnosed during hospitalization. By 6 months postenrollment, 53 (19.5%) died and 73 (26.8%) were lost-to-follow-up. Using Kaplan-Meier analysis, the probability of death by 6 months after enrollment was 23.5%. The median age of death was 9.1 months [95% confidence interval (CI): 8.6-12.0]. Overall, 226 (83%) children initiated ART which was associated with a 71% reduction in risk of death [hazard ratio (HR) = 0.29 (95% CI: 0.15-0.58)]. In multivariable analysis of infant factors, weight-for-age Z score < -2 standard deviation (SD) [HR = 2.43 (95% CI: 1.03-5.73)], CD4 <20% [HR = 3.29 (95% CI: 1.60-6.76)] and identification during hospitalization [HR = 2.89 (95% CI: 1.16-7.25)] were independently associated with mortality. In multivariable analysis of maternal factors, CD4 ≤350/no maternal ART was associated with increased mortality risk [HR = 2.57 (95% CI: 1.19-5.59)] versus CD4 >350/no maternal ART; exposure to maternal/infant antiretrovirals for PMTCT was associated with reduced mortality risk [HR = 0.53 (95% CI: 0.28-0.99)] versus no PMTCT. CONCLUSIONS ART initiation is highly protective against death in young children. However, despite improved access to ART, young children remain at risk for early death; innovative approaches to rapidly diagnose and initiate treatment as early in life as possible are needed.
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Myer L, Phillips TK, McIntyre JA, Hsiao NY, Petro G, Zerbe A, Ramjith J, Bekker LG, Abrams EJ. HIV viraemia and mother-to-child transmission risk after antiretroviral therapy initiation in pregnancy in Cape Town, South Africa. HIV Med 2016; 18:80-88. [PMID: 27353189 DOI: 10.1111/hiv.12397] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Maternal HIV viral load (VL) drives mother-to-child HIV transmission (MTCT) risk but there are few data from sub-Saharan Africa, where most MTCT occurs. We investigated VL changes during pregnancy and MTCT following antiretroviral therapy (ART) initiation in Cape Town, South Africa. METHODS We conducted a prospective study of HIV-infected women initiating ART within routine antenatal services in a primary care setting. VL measurements were taken before ART initiation and up to three more times within 7 days postpartum. Analyses examined VL changes over time, viral suppression (VS) at delivery, and early MTCT based on polymerase chain reaction (PCR) testing up to 8 weeks of age. RESULTS A total of 620 ART-eligible HIV-infected pregnant women initiated ART, with 2425 VL measurements by delivery (median gestation at initiation, 20 weeks; median pre-ART VL, 4.0 log10 HIV-1 RNA copies/mL; median time on ART before delivery, 118 days). At delivery, 91% and 73% of women had VL ≤ 1000 and ≤ 50 copies/mL, respectively. VS was strongly predicted by time on therapy and pre-ART VL. The risk of early MTCT was strongly associated with delivery VL, with risks of 0.25, 2.0 and 8.5% among women with VL < 50, 50-1000 and > 1000 copies/mL at delivery, respectively (P < 0.001). CONCLUSIONS High rates of VS at delivery and low rates of MTCT can be achieved in a routine care setting in sub-Saharan Africa, indicating the effectiveness of currently recommended ART regimens. Women initiating ART late in pregnancy and with high VL appear substantially less likely to achieve VS and require targeted research and programmatic attention.
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Affiliation(s)
- L Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - T K Phillips
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - J A McIntyre
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa.,Anova Health Institute, Johannesburg, South Africa
| | - N-Y Hsiao
- Division of Medical Virology, University of Cape Town & National Health Laboratory Services, Cape Town, South Africa
| | - G Petro
- Department of Obstetrics & Gynaecology, University of Cape Town, Cape Town, South Africa
| | - A Zerbe
- ICAP, Columbia University Mailman School of Public Health, New York, NY, USA
| | - J Ramjith
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - L-G Bekker
- Desmond Tutu HIV Centre, Institute of Infectious Diseases & Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - E J Abrams
- ICAP, Columbia University Mailman School of Public Health, New York, NY, USA.,College of Physicians & Surgeons, Columbia University, New York, NY, USA
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13
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Aebi-Popp K, Kouyos R, Bertisch B, Staehelin C, Rudin C, Hoesli I, Stoeckle M, Bernasconi E, Cavassini M, Grawe C, Lecompte TD, Rickenbach M, Thorne C, Martinez de Tejada B, Fehr J. Postnatal retention in HIV care: insight from the Swiss HIV Cohort Study over a 15-year observational period. HIV Med 2015; 17:280-8. [PMID: 26268702 DOI: 10.1111/hiv.12299] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this study was to quantify loss to follow-up (LTFU) in HIV care after delivery and to identify risk factors for LTFU, and implications for HIV disease progression and subsequent pregnancies. METHODS We used data on pregnancies within the Swiss HIV Cohort Study from 1996 to 2011. A delayed clinical visit was defined as > 180 days and LTFU as no visit for > 365 days after delivery. Logistic regression analysis was used to identify risk factors for LTFU. RESULTS A total of 695 pregnancies in 580 women were included in the study, of which 115 (17%) were subsequent pregnancies. Median maternal age was 32 years (IQR 28-36 years) and 104 (15%) women reported any history of injecting drug use (IDU). Overall, 233 of 695 (34%) women had a delayed visit in the year after delivery and 84 (12%) women were lost to follow-up. Being lost to follow-up was significantly associated with a history of IDU [adjusted odds ratio (aOR) 2.79; 95% confidence interval (CI) 1.32-5.88; P = 0.007] and not achieving an undetectable HIV viral load (VL) at delivery (aOR 2.42; 95% CI 1.21-4.85; P = 0.017) after adjusting for maternal age, ethnicity and being on antiretroviral therapy (ART) at conception. Forty-three of 84 (55%) women returned to care after LTFU. Half of them (20 of 41) with available CD4 had a CD4 count < 350 cells/μL and 15% (six of 41) a CD4 count < 200 cells/μL at their return. CONCLUSIONS A history of IDU and detectable HIV VL at delivery were associated with LTFU. Effective strategies are warranted to retain women in care beyond pregnancy and to avoid CD4 cell count decline. ART continuation should be advised especially if a subsequent pregnancy is planned.
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Affiliation(s)
- K Aebi-Popp
- Division of Infectious Diseases, University Hospital Bern, Bern, Switzerland
| | - R Kouyos
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - B Bertisch
- Division of Infectious Diseases, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - C Staehelin
- Division of Infectious Diseases, University Hospital Bern, Bern, Switzerland
| | - C Rudin
- University Children's Hospital Basel, Basel, Switzerland
| | - I Hoesli
- University Women's Hospital Basel, Basel, Switzerland
| | - M Stoeckle
- Division of Infectious Diseases, University Hospital Basel, Basel, Switzerland
| | - E Bernasconi
- Division of Infectious Diseases, Regional Hospital, Lugano, Switzerland
| | - M Cavassini
- Division of Infectious Diseases, University Hospital Lausanne, Lausanne, Switzerland
| | - C Grawe
- University Women's Hospital Zurich, Zurich, Switzerland
| | - T D Lecompte
- Division of Infectious Diseases, University Hospital Geneva, Geneva, Switzerland
| | - M Rickenbach
- Data Centre of the Swiss HIV Cohort Study, Institute for Social and Preventive Medicine, University of Lausanne, Lausanne, Switzerland
| | - C Thorne
- Population, Policy and Practice Programme, UCL Institute of Child Health, University College London, London, UK
| | - B Martinez de Tejada
- Department of Obstetrics and Gynaecology, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - J Fehr
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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14
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Eliminating mother-to-child transmission of the human immunodeficiency virus in sub-Saharan Africa: The journey so far and what remains to be done. J Infect Public Health 2015; 9:396-407. [PMID: 26194038 DOI: 10.1016/j.jiph.2015.06.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 06/10/2015] [Accepted: 06/12/2015] [Indexed: 11/21/2022] Open
Abstract
This review was carried out to provide a comprehensive overview of efforts toward elimination of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) with respect to progress, challenges, and recommendations in 21 sub-Saharan African priority countries. We reviewed literature published from 2011 to April 2015 using 3 databases; PubMed, Scopus, and Web of Science, as well as the 2014 Global Plan Progress Report. A total of 39 studies were included. Between 2009 and 2013, there was a 43% reduction in new HIV infections, the final MTCT rate was reduced from 28% to 18%, and antiretroviral therapy (ART) coverage increased from 11% to 24%. Challenges included poor adherence to antiretroviral therapy, poor linkage between mother-child pairs and post-natal healthcare services low early infant diagnosis coverage, low pediatric ART coverage, and high unmet needs for contraceptive services. Future recommendations include identification of key barriers, health system strengthening, strengthening community involvement, and international collaboration. There has been significant progress toward eliminating MTCT of HIV, but more effort is still needed.
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15
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Onono M, Kwena Z, Turan J, Bukusi EA, Cohen CR, Gray GE. "You Know You Are Sick, Why Do You Carry A Pregnancy Again?" Applying the Socio-Ecological Model to Understand Barriers to PMTCT Service Utilization in Western Kenya. JOURNAL OF AIDS & CLINICAL RESEARCH 2015; 6:467. [PMID: 26457229 PMCID: PMC4596237 DOI: 10.4172/2155-6113.1000467] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Throughout most of sub-Saharan Africa (SSA), prevention of mother-to-child transmission (PMTCT) services are readily available. However, PMTCT programs in SSA have had suboptimal performance compared to other regions of the world. The main objective of this study is to explore the socio-ecological and individual factors influencing the utilization of PMTCT services among HIV-positive pregnant women in western Kenya using a social ecological model as our analytical lens. METHODS Data were collected using in-depth interviews with 33 HIV-infected women attending government health facilities in rural western Kenya. Women with HIV-infected infants aged between 6 weeks to 6 months with a definitive diagnosis of HIV in the infant, as well as those with an HIV-negative test result in the infant were interviewed between November 2012 and June 2013. Coding and analysis of the transcripts followed grounded theory tenets. Coding reports were discussed in a series of meetings held among the authors. We then employed constant comparative analysis to discover dominant individual, family, society and structural determinants of PMTCT use. RESULTS Barriers to women's utilization of PMTCT services fell within the broad constructs of the socio-ecological model of individual, family, society and structural determinants. Several themes cut across the different steps of PMTCT cascade and relate to different constructs of the socio-ecological model. These themes include: self-motivation, confidence and resilience, family support, absence or reduced stigma, right provider attitude and quality of health services provided. We also found out that these factors ensured enhanced maternal health and HIV negative children. CONCLUSION The findings of this study suggest that a woman's social environment is an important determinant of MTCT. PMTCT Interventions must comprehensively address multiple factors across the different ecological levels. More research is however required for the development of multi-component interventions that combine strategies at different ecological levels.
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Affiliation(s)
- Maricianah Onono
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Zachary Kwena
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Janet Turan
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, USA
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, USA
| | - Glenda E Gray
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, South Africa
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16
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Evolution of antiretroviral therapy services for HIV-infected pregnant women in Cape Town, South Africa. J Acquir Immune Defic Syndr 2015; 69:e57-e65. [PMID: 25723138 DOI: 10.1097/qai.0000000000000584] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Approaches to antiretroviral therapy (ART) in HIV-infected pregnant women have changed considerably in recent years, but there are few comparative data on the implementation of different models of service delivery. METHODS Using routine clinic records we examined ART initiation in pregnant women attending a large antenatal care (ANC) facility between January 2010 and December 2013 in Cape Town, South Africa. Over this time six different service delivery models were implemented sequentially to provide ART in pregnancy, including the integration of ART into ANC, use of point-of-care CD4 cell count testing, and universal ART initiation for all HIV-infected pregnant women. RESULTS During the study period 19,432 women sought ANC, levels of HIV testing were high (98%) and 30% of pregnant women tested HIV-positive. Integration of ART into ANC was associated with significant increases in the proportion of eligible women initiating treatment before delivery compared to referral to a separate ART clinic (p<0.001). When CD4 cell counts were used to determine ART eligibility, point-of-care testing was associated with decreased delays to ART initiation compared to laboratory-based testing (p<0.001). The strategy of universal ART led to the highest levels of ART initiation (with 92% of women starting before delivery) and the shortest delays, with 82% of women starting ART on the day of the first ANC visit. CONCLUSION Developments in service delivery models, most notably service integration and universal ART for pregnant women, have improved antenatal ART initiation dramatically in this setting. Further research is needed into how strategies for antenatal ART initiation impact maternal and child health over the long-term.
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17
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Clouse K, Schwartz S, Van Rie A, Bassett J, Yende N, Pettifor A. "What they wanted was to give birth; nothing else": barriers to retention in option B+ HIV care among postpartum women in South Africa. J Acquir Immune Defic Syndr 2015; 67:e12-8. [PMID: 24977376 DOI: 10.1097/qai.0000000000000263] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Women initiating antiretroviral therapy during pregnancy have high rates of dropout, particularly after delivery. We aimed to identify challenges to postpartum retention in care under Option B+, which expands antiretroviral therapy access to all HIV-positive pregnant women regardless of CD4 count. METHODOLOGY We performed 2 semi-structured interviews (SSI, n = 50) and 1 focus group discussion (n = 8) with HIV-positive women at Witkoppen Health and Welfare Centre, a primary care facility in Johannesburg, South Africa, that is one of the only clinics offering Option B+ in South Africa. RESULTS Fifty women completed the SSI before delivery, and 48 (96%) completed the second SSI within 3 months of delivery. Median age was 28 years (interquartile range: 26-34); most women worked (62%) or had worked in the previous year (18%). Postpartum women attending HIV care perceived that barriers to HIV care after delivery among other women included the belief that mothers care more about the baby's health than their own (29.2%, 14/48), women were "ignorant" or "irresponsible" (16.7%, 8/48), negative clinic staff treatment (12.5%, 6/48), and denial or lack of disclosure of HIV status (10.4% each, 5/48). Experienced barriers included lack of money (18.0%, 9/50), work conflict (6.0%, 3/50), and negative staff treatment (6.0%, 3/50). During the focus group discussion, 3 main themes emerged: conflict with work commitment, negative treatment from health-care workers, and lack of disclosure related to stigma. CONCLUSIONS We identified a complex set of interconnected barriers to retaining postpartum women in HIV care under Option B+, including structural, personal, and societal barriers. The importance of postpartum HIV care for the mother's own health must be embraced by health-care workers and public health programs.
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Affiliation(s)
- Kate Clouse
- *Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC; †Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC; and ‡Witkoppen Health and Welfare Centre, Johannesburg, South Africa
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18
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Kuhn L, Kim HY, Hsiao L, Nissan C, Kankasa C, Mwiya M, Thea DM, Aldrovandi GM, Bode L. Oligosaccharide composition of breast milk influences survival of uninfected children born to HIV-infected mothers in Lusaka, Zambia. J Nutr 2015; 145:66-72. [PMID: 25527660 PMCID: PMC4264023 DOI: 10.3945/jn.114.199794] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Human milk oligosaccharides (HMOs) have multiple immunomodulatory functions that influence child health. OBJECTIVE In this study we investigated whether HMO composition influences survival to 2 y of age in HIV-infected and HIV-exposed, uninfected (HEU) children during and after breastfeeding. METHODS In the context of an early weaning trial in 958 HIV-infected women in Lusaka, Zambia, we conducted a nested case-cohort analysis of mortality to 2 y of age among 103 HIV-infected and 143 HEU children. Breast-milk samples collected at 1 mo postpartum were analyzed for HMO content. Samples were selected to include mothers of all HIV-infected children detected by 6 wk of age, of whom 63 died at <2 y of age; mothers of all HEU children who died at <2 y of age (n = 66); and a random sample of 77 HEU survivors. Associations before and after weaning in HIV-infected and HEU infants separately were investigated by using Cox models. RESULTS Among HEU children, higher maternal breast-milk concentrations of 2-linked fucosylated HMOs [2'-fucosyllactose and lacto-N-fucopentaose (LNFP) I] (HR: 0.33; 95% CI: 0.14, 0.74) as well as non-2-linked fucosylated HMOs (3-fucosyllactose and LNFP II/III; HR: 0.28; 95% CI: 0.13, 0.67) were significantly associated with reduced mortality during, but not after, breastfeeding after adjustment for confounders. Breastfeeding was protective against mortality only in HEU children with high concentrations of fucosylated HMOs. Among HIV-infected children, no consistent associations between HMOs and mortality were observed, but breastfeeding was protective against mortality. CONCLUSIONS The oligosaccharide composition of breast milk may explain some of the benefits of breastfeeding in HEU children. HIV infection may modulate some of the consequences of HMOs on child survival.
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Affiliation(s)
- Louise Kuhn
- Gertrude H Sergievsky Center and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Hae-Young Kim
- Gertrude H Sergievsky Center and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Lauren Hsiao
- Division of Neonatal Medicine and Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of California, San Diego, San Diego, CA
| | - Caroline Nissan
- Division of Neonatal Medicine and Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of California, San Diego, San Diego, CA
| | - Chipepo Kankasa
- University Teaching Hospital, University of Zambia, Lusaka, Zambia
| | - Mwiya Mwiya
- University Teaching Hospital, University of Zambia, Lusaka, Zambia
| | - Donald M Thea
- Center for International Health and Development, Boston University School of Public Health, Boston, MA; and
| | - Grace M Aldrovandi
- Department of Pediatrics, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | - Lars Bode
- Division of Neonatal Medicine and Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of California, San Diego, San Diego, CA;
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Mutevedzi PC, Newell ML. Review: [corrected] The changing face of the HIV epidemic in sub-Saharan Africa. Trop Med Int Health 2014; 19:1015-28. [PMID: 24976370 DOI: 10.1111/tmi.12344] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The widespread roll-out of antiretroviral therapy (ART) has substantially changed the face of human immunodeficiency virus (HIV). Timely initiation of ART in HIV-infected individuals dramatically reduces mortality and improves employment rates to levels prior to HIV infection. Recent findings from several studies have shown that ART reduces HIV transmission risk even with modest ART coverage of the HIV-infected population and imperfect ART adherence. While condoms are highly effective in the prevention of HIV acquisition, they are compromised by low and inconsistent usage; male medical circumcision substantially reduces HIV transmission but uptake remains relatively low; ART during pregnancy, delivery and breastfeeding can virtually eliminate mother-to-child transmission but implementation is challenging, especially in resource-limited settings. The current HIV prevention recommendations focus on a combination of preventions approach, including ART as treatment or pre- or post-exposure prophylaxis together with condoms, circumcision and sexual behaviour modification. Improved survival in HIV-infected individuals and reduced HIV transmission risk is beginning to result in limited HIV incidence decline at population level and substantial increases in HIV prevalence. However, achievements in HIV treatment and prevention are threatened by the challenges of lifelong adherence to preventive and therapeutic methods and by the ageing of the HIV-infected cohorts potentially complicating HIV management. Although current thinking suggests prevention of HIV transmission through early detection of infection immediately followed by ART could eventually result in elimination of the HIV epidemic, controversies remain as to whether we can treat our way out of the HIV epidemic.
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Affiliation(s)
- Portia C Mutevedzi
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
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Higgs ES, Goldberg AB, Labrique AB, Cook SH, Schmid C, Cole CF, Obregón RA. Understanding the role of mHealth and other media interventions for behavior change to enhance child survival and development in low- and middle-income countries: an evidence review. JOURNAL OF HEALTH COMMUNICATION 2014; 19 Suppl 1:164-89. [PMID: 25207452 PMCID: PMC4255285 DOI: 10.1080/10810730.2014.929763] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Given the high morbidity and mortality among children in low- and middle-income countries as a result of preventable causes, the U.S. government and the United Nations Children's Fund convened an Evidence Summit on Enhancing Child Survival and Development in Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change on June 3-4, 2013, in Washington, D.C. This article summarizes evidence for technological advances associated with population-level behavior changes necessary to advance child survival and healthy development in children under 5 years of age in low- and middle-income countries. After a rigorous evidence selection process, the authors assessed science, technology, and innovation papers that used mHealth, social/transmedia, multiplatform media, health literacy, and devices for behavior changes supporting child survival and development. Because of an insufficient number of studies on health literacy and devices that supported causal attribution of interventions to outcomes, the review focused on mHealth, social/transmedia, and multiplatform media. Overall, this review found that some mHealth interventions have sufficient evidence to make topic-specific recommendations for broader implementation, scaling, and next research steps (e.g., adherence to HIV/AIDS antiretroviral therapy, uptake and demand of maternal health service, and compliance with malaria treatment guidelines). While some media evidence demonstrates effectiveness in changing cognitive abilities, knowledge, and attitudes, evidence is minimal on behavioral endpoints linked to child survival. Population level behavior change is necessary to end preventable child deaths. Donors and low- and middle-income countries are encouraged to implement recommendations for informing practice, policy, and research decisions to fully maximize the impact potential of mHealth and multimedia for child survival and development.
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Affiliation(s)
- Elizabeth S. Higgs
- Division of Clinical Research
, National Institute for Allergy and Infectious Diseases
,
Bethesda
,
Maryland
,
USA
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases, 6700B Rockledge Drive,
Bethesda
,
MD
,
20892
,
USA
E-mail:
| | - Allison B. Goldberg
- Columbia University Mailman School of Public Health
,
New York
,
New York
,
USA
| | - Alain B. Labrique
- The John Hopkins Bloomberg School of Public Health
,
Baltimore
,
Maryland
,
USA
| | - Stephanie H. Cook
- Health Behavior Health Education Department, School of Public Health
, University of Michigan
,
Ann Arbor
,
Michigan
,
USA
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Women and Children First: The Impact of Sexually Transmitted Infections on Maternal and Child Health. JOURNAL OF SEXUALLY TRANSMITTED DISEASES 2014; 2014:671085. [PMID: 26316975 PMCID: PMC4437399 DOI: 10.1155/2014/671085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Accepted: 01/05/2014] [Indexed: 11/18/2022]
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