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Boisson-Walsh A, Ravelomanana NLR, Tabala M, Malongo F, Kawende B, Babakazo P, Yotebieng M. Association of comprehensiveness of antiretroviral care and detectable HIV viral load suppression among pregnant and postpartum women in the Democratic Republic of the Congo: a cross-sectional study. Front Glob Womens Health 2024; 5:1308019. [PMID: 38903153 PMCID: PMC11188341 DOI: 10.3389/fgwh.2024.1308019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 05/21/2024] [Indexed: 06/22/2024] Open
Abstract
Introduction Worldwide, over two-thirds of people living with HIV are on antiretroviral therapy (ART). Despite increased ART access, high virological suppression prevalence remains out of reach. Few studies consider the quality of ART services and their impact on recipients' viral suppression. We assessed the association between ART service readiness and HIV viral load suppression among pregnant and breastfeeding women living with HIV (WLH) receiving ART in maternal and child health (MCH) clinics in Kinshasa, Democratic Republic of Congo. Methods We performed a cross-sectional analysis leveraging data from a continuous quality improvement intervention on WLH's long-term ART outcomes. From November 2016 to May 2020, we enrolled WLH from the three largest clinics in each of Kinshasa'Łs 35 health zones. We measured clinic's readiness using three WHO-identified ART care quality indicators: relevant guidelines in ART service area, stocks of essential ART medicines, and relevant staff training in ≥24 months, scoring clinics 0-3 based on observed indicators. We defined viral load suppression as ≤1,000 cp/ml. Multilevel mixed-effect logistic models were used to estimate prevalence odds ratios (ORs) measuring the strength of the association between ART service readiness and viral suppression. Results Of 2,295 WLH, only 1.9% received care from a clinic with a score of 3, 24.1% received care from a 0-scoring clinic, and overall, 66.5% achieved virologically suppression. Suppression increased from 65% among WLH receiving care in 0-scoring clinics to 66.9% in 1-scoring clinics, 65.8% in 2-scoring clinics, and 76.1% in 3-scoring clinics. We did not observe a statistically significant association between ART service readiness score and increased viral suppression prevalence, however we did find associations between other factors, such as the location of the health center and pharmacist availability with suppressed viral load. Discussion A lack of comprehensive ART care underscores the need for enhanced structural and organizational support to improve virological suppression and overall health outcomes for women living with HIV..
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Affiliation(s)
- Alix Boisson-Walsh
- Department of Health Policy and Management, University of Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Martine Tabala
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Fathy Malongo
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Bienvenu Kawende
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Pélagie Babakazo
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Marcel Yotebieng
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, United States
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Jiang W, Ronen K, Osborn L, Drake AL, Unger JA, Matemo D, Richardson BA, Kinuthia J, John-Stewart G. HIV Viral Load Patterns and Risk Factors Among Women in Prevention of Mother-To-Child Transmission Programs to Inform Differentiated Service Delivery. J Acquir Immune Defic Syndr 2024; 95:246-254. [PMID: 37977207 PMCID: PMC10922247 DOI: 10.1097/qai.0000000000003352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Differentiated service delivery (DSD) approaches decrease frequency of clinic visits for individuals who are stable on antiretroviral therapy. It is unclear how to optimize DSD models for postpartum women living with HIV (PWLH). We evaluated longitudinal HIV viral load (VL) and cofactors, and modelled DSD eligibility with virologic failure (VF) among PWLH in prevention of mother-to-child transmission programs. METHODS This analysis used programmatic data from participants in the Mobile WAChX trial (NCT02400671). Women were assessed for DSD eligibility using the World Health Organization criteria among general people living with HIV (receiving antiretroviral therapy for ≥6 months and having at least 1 suppressed VL [<1000 copies/mL] within the past 6 months). Longitudinal VL patterns were summarized using group-based trajectory modelling. VF was defined as having a subsequent VL ≥1000 copies/mL after being assessed as DSD-eligible. Predictors of VF were determined using log-binomial models among DSD-eligible PWLH. RESULTS Among 761 women with 3359 VL results (median 5 VL per woman), a 3-trajectory model optimally summarized longitudinal VL, with most (80.8%) women having sustained low probability of unsuppressed VL. Among women who met DSD criteria at 6 months postpartum, most (83.8%) maintained viral suppression until 24 months. Residence in Western Kenya, depression, reported interpersonal abuse, unintended pregnancy, nevirapine-based antiretroviral therapy, low-level viremia (VL 200-1000 copies/mL), and drug resistance were associated with VF among DSD-eligible PWLH. CONCLUSIONS Most postpartum women maintained viral suppression from early postpartum to 24 months and may be suitable for DSD referral. Women with depression, drug resistance, and detectable VL need enhanced services.
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Affiliation(s)
- Wenwen Jiang
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Keshet Ronen
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Lusi Osborn
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Alison L. Drake
- Global Health, University of Washington, Seattle, Washington, USA
| | - Jennifer A. Unger
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA, Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Daniel Matemo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Barbra A. Richardson
- Departments of Biostatistics and Global Health, University of Washington, Division of Vaccine and Infectious Disease, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - John Kinuthia
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
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Endalamaw Alamneh D, Shiferaw MB, Getachew Demissie M, Emiru MA, Zemene Kassie T, Endaylalu Lakew K, Tadege TZ. Virological Outcomes Among Pregnant Women Receiving Antiretroviral Treatment in the Amhara Region, North West Ethiopia. HIV AIDS (Auckl) 2023; 15:209-216. [PMID: 37159581 PMCID: PMC10163878 DOI: 10.2147/hiv.s389506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 04/22/2023] [Indexed: 05/11/2023] Open
Abstract
Background Globally, approximately 35 million people are infected with HIV infection. Sub-Saharan countries contributed 71% of global burden. Women are the most affected groups accounting for 51% of global infection and 90% of HIV infections in children (<15 years) are a result of mother to child transmission. In the absence of any intervention, mother-to-child transmission has been estimated to 30-40% that could occur at various periods like during pregnancy, delivery, and post-partum, via breastfeeding. For future generations to be born HIV-free, evidences on the level of viremia and contributing factors in pregnant mothers is important. Objective The objective of this study is to determine the magnitude of viral non-suppression rate among pregnant women and identify the risk factors associated with viral non-suppression. Methods A cross-sectional study was conducted from July 01, 2021 to June 30, 2022, in pregnant women who are on antiretroviral treatment and attending HIV viral load testing in Amhara region viral load testing sites, North West Ethiopia. Socio-demographic, clinical, and HIV-1 RNA viral load data were collected from the excel database. The data were analyzed in SPSS 23.0 statistical software. Results Overall viral non-suppression rate was 9.1%. In other words, the viral suppression rate was 90.9%. Pregnant women being at AIDS stages III and IV and with fair treatment adherence and suspected testers were statistically associated with increased viral non-suppression rate. Conclusion Relatively low viral non-suppression rate among pregnant mothers that had almost met the third 90 of UNAIDS target. But, still, some mothers received a non-suppressed viral replication specifically the odds of having a non-suppressed viral load was higher in pregnant women with poor treatment adherence and WHO Stage III and IV and suspected testers.
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Affiliation(s)
- Demeke Endalamaw Alamneh
- Virology Department, Amhara Regional State Public Health Institute, Bahir Dar, Ethiopia
- Correspondence: Demeke Endalamaw Alamneh, Email
| | - Melashu Balew Shiferaw
- Infectious and Tropical diseases, Amhara Regional State Public Health Institute, Bahir Dar, Ethiopia
| | | | | | | | | | - Taye Zeru Tadege
- Neglected Tropical Diseases, Amhara Regional State Public Health Institute, Bahir Dar, Ethiopia
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Fernández-Luis S, Lain MG, Serna-Pascual M, Domínguez-Rodríguez S, Kuhn L, Liberty A, Barnabas S, Lopez-Varela E, Otwombe K, Danaviah S, Nastouli E, Palma P, Cotugno N, Spyer M, Giannuzzi V, Giaquinto C, Violari A, Cotton MF, Nhampossa T, Klein N, Ramsagar N, van Rensburg AJ, Behuhuma O, Vaz P, Maiga AI, Oletto A, Naniche D, Rossi P, Rojo P, Tagarro A. Optimizing the World Health Organization algorithm for HIV vertical transmission risk assessment by adding maternal self-reported antiretroviral therapy adherence. BMC Public Health 2022; 22:1312. [PMID: 35804333 PMCID: PMC9264598 DOI: 10.1186/s12889-022-13543-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 05/05/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) risk assessment algorithm for vertical transmission of HIV (VT) assumes the availability of maternal viral load (VL) result at delivery and early viral control 4 weeks after initiating antiretroviral treatment (ART). However, in many low-and-middle-income countries, VL is often unavailable and mothers' ART adherence may be suboptimal. We evaluate the inclusion of the mothers' self-reported adherence into the established WHO-algorithm to identify infants eligible for enhanced post-natal prophylaxis when mothers' VL result is not available at delivery. METHODS We used data from infants with perinatal HIV infection and their mothers enrolled from May-2018 to May-2020 in Mozambique, South Africa, and Mali. We retrospectively compared the performance of the WHO-algorithm with a modified algorithm which included mothers' adherence as an additional factor. Infants were considered at high risk if born from mothers without a VL result in the 4 weeks before delivery and with adherence <90%. RESULTS At delivery, 143/184(78%) women with HIV knew their status and were on ART. Only 17(12%) obtained a VL result within 4 weeks before delivery, and 13/17(76%) of them had VL ≥1000 copies/ml. From 126 women on ART without a recent VL result, 99(79%) had been on ART for over 4 weeks. 45/99(45%) women reported suboptimal (< 90%) adherence. A total of 81/184(44%) infants were classified as high risk of VT as per the WHO-algorithm. The modified algorithm including self-adherence disclosure identified 126/184(68%) high risk infants. CONCLUSIONS In the absence of a VL result, mothers' self-reported adherence at delivery increases the number of identified infants eligible to receive enhanced post-natal prophylaxis.
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Affiliation(s)
- Sheila Fernández-Luis
- Centro de Investigação em Saúde de Manhiça (CISM), Bairro Cambeve, Rua 12, Distrito da Manhiça, CP 1929, Maputo, Mozambique. .,ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.
| | | | - Miquel Serna-Pascual
- Pediatrics Department, Pediatric Research and Clinical Trials Unit (UPIC), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain
| | - Sara Domínguez-Rodríguez
- Pediatrics Department, Pediatric Research and Clinical Trials Unit (UPIC), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain
| | - Louise Kuhn
- Gertrude H. Sergievsky Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
| | - Afaaf Liberty
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shaun Barnabas
- Family Center for Research with Ubuntu, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elisa Lopez-Varela
- Centro de Investigação em Saúde de Manhiça (CISM), Bairro Cambeve, Rua 12, Distrito da Manhiça, CP 1929, Maputo, Mozambique.,ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Kennedy Otwombe
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Siva Danaviah
- Africa Health Research Institute (AHRI), Durban, KwaZulu-Natal, South Africa
| | - Eleni Nastouli
- Great Ormond Street Institute for Child Health (GOS ICH), University College London (UCL), London, UK
| | - Paolo Palma
- Research Unit in Clinical Immunology and Vaccinology, Bambino Gesu' Children's Hospital, 00165, Rome, Italy.,Chair of Pediatrics, Department of Systems Medicine, University of Rome "Tor Vergata", 00133, Rome, Italy
| | - Nicola Cotugno
- Research Unit in Clinical Immunology and Vaccinology, Bambino Gesu' Children's Hospital, 00165, Rome, Italy.,Chair of Pediatrics, Department of Systems Medicine, University of Rome "Tor Vergata", 00133, Rome, Italy
| | - Moira Spyer
- Great Ormond Street Institute for Child Health (GOS ICH), University College London (UCL), London, UK
| | - Viviana Giannuzzi
- Fondazione per la Ricerca Farmacologica Gianni Benzi onlus, Valenzano, Italy
| | - Carlo Giaquinto
- Department of Mother and Child Health, University of Padova, Padova, Italy
| | - Avy Violari
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark F Cotton
- Family Center for Research with Ubuntu, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Tacilta Nhampossa
- Centro de Investigação em Saúde de Manhiça (CISM), Bairro Cambeve, Rua 12, Distrito da Manhiça, CP 1929, Maputo, Mozambique.,Instituto Nacional de Saúde (INS), Mozambique, Maputo, Mozambique
| | - Nigel Klein
- Africa Health Research Institute (AHRI), Durban, KwaZulu-Natal, South Africa.,Great Ormond Street Institute for Child Health (GOS ICH), University College London (UCL), London, UK
| | - Nastassja Ramsagar
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Anita Janse van Rensburg
- Family Center for Research with Ubuntu, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Osee Behuhuma
- Africa Health Research Institute (AHRI), Durban, KwaZulu-Natal, South Africa
| | - Paula Vaz
- Fundação Ariel Glaser Contra o SIDA Pediátrico, Maputo, Mozambique
| | | | | | - Denise Naniche
- Centro de Investigação em Saúde de Manhiça (CISM), Bairro Cambeve, Rua 12, Distrito da Manhiça, CP 1929, Maputo, Mozambique.,ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Paolo Rossi
- Academic Department of Pediatrics, Children's Hospital Bambino Gesù, Rome, Italy
| | - Pablo Rojo
- Pediatrics Department, Pediatric Research and Clinical Trials Unit (UPIC), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain
| | - Alfredo Tagarro
- Pediatrics Department, Pediatric Research and Clinical Trials Unit (UPIC), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain.,Pediatrics Department, Hospital Universitario Infanta Sofía; Infanta Sofia University Hospital and Henares University Hospital Foundation for Biomedical Research and Innovation (FIIB HUIS HHEN), San Sebastián de los Reyes, Madrid, Spain.,Pediatrics Research Group, Universidad Europea de Madrid, Madrid, Spain
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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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Cuco RM, Loquiha O, Juga A, Couto A, Meggi B, Vubil A, Sevene E, Osman N, Temermam M, Degomme O, Sidat M, Bhatt N. Nevirapine hair and plasma concentrations and HIV-1 viral suppression among HIV infected ante-partum and post-partum women attended in a mother and child prevention program in Maputo city, Mozambique. PLoS One 2022; 17:e0261522. [PMID: 35143515 PMCID: PMC8830619 DOI: 10.1371/journal.pone.0261522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 12/05/2021] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Prevention of mother to child transmission of HIV (PMTCT) is frequently challenged by irregular access to more effective anti-retroviral therapy. Nevirapine single dose (sdNVP), sdNVP+AZT+3TC for MTCT prophylaxis and NVP+ AZT+3TC for treatment and PMTCT were withdrawn due to low genetic resistance barrier and low efficacy. However current PMTCT lines in Mozambique include DTG+3TC+TDF, TDF+3TC+EFV, DTG +ABC+3TC, and AZT + NVP syrup prophylaxis for exposed babies. We assessed NVP hair and plasma concentrations and association with HIV-1RNA suppression among HIV+ ante-partum and post-partum women under PMTCT in Maputo, Mozambique. METHODS From December 2013 to November 2014, prospectively were enrolled 200 HIV+ ante-partum women on 200mg nevirapine and zidovudine 300 plus lamivudine 150mg twice daily at least with 3 months treatment and seen again at 24 weeks post-partum. Self-reported pill-taking adherence, NVP concentrations in hair, plasma, hemoglobin, CD4 cell count, HIV-1 RNA load was evaluated. NVP concentration in hair and plasma was analyzed as categorical quartile variable based on better data fit. NVP concentration was set between ≤3.77 ng/ml in plasma and ≤17,20 ng/mg in hair in quartile one to ≥5.36 ng/ml in plasma and ≥53.21 ng/mg in hair in quartile four. Logistic regression models for repeated measures were calculated. Following the World Health Organization (WHO) guidelines we set viral suppression at HIV-1RNA < 1000 c/mL. Outcome was HIV-1 RNA<1000 copies/ml. Predictor was NVP concentration in hair categorized in quartiles. RESULTS In total 369 person-visits (median of 1.85) were recorded. Self-reported adherence was 98% (IQR 97-100%) at ante-partum. In 25% person visits, NVP concentrations were within therapeutic levels (3.77 ng/ml to 5.35 ng/ml) in plasma and (17.20 ng/mg to 53.20 ng/mg) in hair. In 50% person visits NVP concentrations were above 5.36 ng/ml in plasm and 53.21 ng/mg in hair. HIV-1 RNA suppression was found in 34.7% of women with two viral loads, one at enrollment and another in post-partum. Odds of HIV-1 RNA suppression in quartile 4, was about 6 times higher than in quartile 1 (p-value = 0.006) for NVP hair concentration and 7 times for NVP plasma concentration (p-value = 0.012). CONCLUSIONS The study results alert for potential low efficacy of current PMTCT drug regimens in use in Mozambique. Affordable means for individual monitoring adherence, ART plasma and hair levels, drug resistant and HIV-1 RNA levels monitoring are recommended for prompt identification of inadequate drug regimens exposure patterns and adjust accordingly.
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Affiliation(s)
- Rosa Marlene Cuco
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
- National Directorate of Public Health, Ministry of Health, Maputo, Mozambique
- International Centre for Reproductive Health (ICRH), University of Gent, Gent, Belgium
| | - Osvaldo Loquiha
- Department of Mathematics and Informatics, Faculty of Sciences Eduardo Mondlane University, Maputo, Mozambique
| | - Adelino Juga
- Department of Mathematics and Informatics, Faculty of Sciences Eduardo Mondlane University, Maputo, Mozambique
| | - Aleny Couto
- National Directorate of Public Health, Ministry of Health, Maputo, Mozambique
| | - Bindiya Meggi
- Instituto Nacional de Saúde (INS), Marracuene, Mozambique
| | - Adolfo Vubil
- Instituto Nacional de Saúde (INS), Marracuene, Mozambique
| | - Esperança Sevene
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Nafissa Osman
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
- Department of Gynecology and Obstetrics at Maputo Central Hospital, Maputo, Mozambique
| | - Marleen Temermam
- International Centre for Reproductive Health (ICRH), University of Gent, Gent, Belgium
- Department of Gynecology and Obstetrics, Aga Khan University Hospital, Nairobi, Kenya
| | - Olivier Degomme
- International Centre for Reproductive Health (ICRH), University of Gent, Gent, Belgium
| | - Mohsin Sidat
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Nilesh Bhatt
- Instituto Nacional de Saúde (INS), Marracuene, Mozambique
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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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Chohan BH, Ronen K, Khasimwa B, Matemo D, Osborn L, Unger JA, Drake AL, Beck IA, Frenkel LM, Kinuthia J, John-Stewart G. Food insecurity, drug resistance and non-disclosure are associated with virologic non-suppression among HIV pregnant women on antiretroviral treatment. PLoS One 2021; 16:e0256249. [PMID: 34407133 PMCID: PMC8372899 DOI: 10.1371/journal.pone.0256249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 07/29/2021] [Indexed: 11/25/2022] Open
Abstract
We determined social and behavioral factors associated with virologic non-suppression among pregnant women receiving Option B+ antiretroviral treatment (ART). Baseline data was used from women in Mobile WAChX trial from 6 public maternal child health (MCH) clinics in Kenya. Virologic non-suppression was defined as HIV viral load (VL) ≥1000 copies/ml. Antiretroviral resistance testing was performed using oligonucleotide ligation (OLA) assay. ART adherence information, motivation and behavioral skills were assessed using Lifewindows IMB tool, depression using PHQ-9, and food insecurity with the Household Food Insecurity Access Scale. Correlates of virologic non-suppression were assessed using Poisson regression. Among 470 pregnant women on ART ≥4 months, 57 (12.1%) had virologic non-suppression, of whom 65% had HIV drug resistance mutations. In univariate analyses, risk of virologic non-suppression was associated with moderate-to-severe food insecurity (RR 1.80 [95% CI 1.06–3.05]), and varied significantly by clinic site (range 2%-22%, p <0.001). In contrast, disclosure (RR 0.36 [95% CI 0.17–0.78]) and having higher adherence skills (RR 0.70 [95% CI 0.58–0.85]) were associated with lower risk of virologic non-suppression. In multivariate analysis adjusting for clinic site, disclosure, depression symptoms, adherence behavior skills and food insecurity, disclosure and food insecurity remained associated with virologic non-suppression. Age, side-effects, social support, physical or emotional abuse, and distance were not associated with virologic non-suppression. Prevalence of virologic non-suppression among pregnant women on ART was appreciable and associated with food insecurity, disclosure and frequent drug resistance. HIV VL and resistance monitoring, and tailored counseling addressing food security and disclosure, may improve virologic suppression in pregnancy.
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Affiliation(s)
- Bhavna H Chohan
- Department of Global Health, University of Washington, Seattle, Washington, United States of America.,Center for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Keshet Ronen
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Brian Khasimwa
- Department of Pediatrics, University of Nairobi, Nairobi, Kenya
| | - Daniel Matemo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Lusi Osborn
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Jennifer A Unger
- Department of Global Health, University of Washington, Seattle, Washington, United States of America.,Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
| | - Alison L Drake
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Ingrid A Beck
- Center for Infectious Diseases Research, Seattle Children's Research Institute, Seattle, Washington, United States of America
| | - Lisa M Frenkel
- Department of Global Health, University of Washington, Seattle, Washington, United States of America.,Center for Infectious Diseases Research, Seattle Children's Research Institute, Seattle, Washington, United States of America.,Department of Medicine, University of Washington, Seattle, Washington, United States of America.,Department of Pediatrics, University of Washington, Seattle, Washington, United States of America.,Department of Laboratory Medicine, University of Washington, Seattle, Washington, United States of America
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, Washington, United States of America.,Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington, United States of America.,Department of Medicine, University of Washington, Seattle, Washington, United States of America.,Department of Pediatrics, University of Washington, Seattle, Washington, United States of America.,Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
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9
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HATCHER AM, BRITTAIN K, PHILLIPS TK, ZERBE A, ABRAMS EJ, MYER L. Longitudinal association between intimate partner violence and viral suppression during pregnancy and postpartum in South African women. AIDS 2021; 35:791-799. [PMID: 33587440 PMCID: PMC7969405 DOI: 10.1097/qad.0000000000002796] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We examined the longitudinal association between women's exposure to intimate partner violence (IPV) and HIV viral load during pregnancy and postpartum. DESIGN Secondary analysis of an HIV-positive cohort enrolled during pregnancy at a South African antenatal clinic. METHODS Viral load was assessed at 10 study visits and analyzed continuously as log10 copies/ml and suppression at less than 50 copies/ml. IPV was measured at three timepoints using behaviorally specific items. We used multivariate logistic regression to examine the association between IPV and viral suppression, and cross-lagged dynamic panel modeling (DPMs) to estimate the longitudinal association between IPV (lagged by 3-6 months) and log10 viral load. RESULTS Of 471 women, 84% were virally suppressed by 6 weeks postpartum and 67% at 12 months postpartum. One-third reported IPV exposure. IPV victimization was not associated with viral suppression at delivery, but was associated with a reduced odds of viral suppression at 12 months postpartum (aOR = 0.48, 95% CI = 0.27-0.85). Findings were robust to sensitivity analyses at different timepoints and clinical cut-points. In DPMs, lagged IPV exposure was associated with higher log10 viral load after controlling for past viral load, duration on ART, age, alcohol use, and gestation at study enrolment. Each standardized increase in IPV intensity was associated with higher log10 viral load (standardized coefficient = 0.12, 95% CI = 0.05-0.23). CONCLUSION Although viral suppression was widely achieved during pregnancy, suppression rates declined postpartum in this South African cohort. These data suggest IPV is longitudinally associated with elevated viral load postpartum. Interventions for reducing exposure to IPV are important for the health of women and may improve HIV care and treatment.
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Affiliation(s)
- Abigail M HATCHER
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Kirsty BRITTAIN
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Tamsin K PHILLIPS
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Allison ZERBE
- ICAP, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Elaine J ABRAMS
- ICAP, Mailman School of Public Health, Columbia University, New York, New York, USA
- Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Landon MYER
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
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10
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Ruel TD, Capparelli EV, Tierney C, Nelson BS, Coletti A, Bryson Y, Cotton MF, Spector SA, Mirochnick M, LeBlanc R, Reding C, Zimmer B, Persaud D, Bwakura-Dangarembizi M, Naidoo KL, Hazra R, Jean-Philippe P, Chadwick EG. Pharmacokinetics and safety of early nevirapine-based antiretroviral therapy for neonates at high risk for perinatal HIV infection: a phase 1/2 proof of concept study. Lancet HIV 2021; 8:e149-e157. [PMID: 33242457 PMCID: PMC7933083 DOI: 10.1016/s2352-3018(20)30274-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 09/11/2020] [Accepted: 10/02/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND With increasing intention to treat HIV as early as possible, evidence to confirm the safety and therapeutic drug concentrations of a nevirapine-based antiretroviral regimen in the early neonatal period is needed. This study aims to establish dosing of nevirapine for very early treatment of HIV-exposed neonates at high risk of HIV acquisition. METHODS IMPAACT P1115 is a multinational phase 1/2 proof-of-concept study in which presumptive treatment for in-utero HIV infection is initiated within 48 h of birth in HIV-exposed neonates at high risk of HIV acquisition. Participants were neonates who were at least 34 weeks gestational age at birth and enrolled within 48 h of birth, born to women with presumed or confirmed HIV infection who had not received antiretrovirals during this pregnancy. The regimen consisted of two nucleoside reverse transcriptase inhibitors plus nevirapine dosed at 6 mg/kg twice daily for term neonates (≥37 weeks gestational age) or 4 mg/kg twice daily for 1 week and 6 mg/kg twice daily thereafter for preterm neonates (34 to <37 weeks gestational age). Here, we report the secondary outcomes of the study: nevirapine exposures in study weeks 1 and 2 and treatment-associated grade 3 or 4 adverse events at least possibly related to study treatment up to study week 4. A population pharmacokinetic model to assess nevirapine exposure was developed from dried blood spot and plasma nevirapine concentrations at study weeks 1 and 2. Nevirapine exposure was assessed in all patients with available blood samples and safety was assessed in all participants. This trial is registered at ClinicalTrials.gov (NCT02140255). FINDINGS Between Jan 23, 2015, and Sept 4, 2017, 438 neonates were enrolled and included in analyses; 36 had in-utero HIV infection and 389 (89%) were born at term. Neonates without confirmed in-utero HIV infection received nevirapine for a median of 13 days (IQR 7-14). Measured dried blood spot nevirapine concentrations were higher than the minimum HIV treatment target (3 μg/mL) in 314 (90%, 95% CI 86-93) of 349 neonates at week 1 and 174 (87%, 81-91) of 201 at week 2. In Monte-Carlo simulations, week 1 nevirapine concentrations exceeded 3 μg/mL in 80% of term neonates and 82% of preterm neonates. DAIDS grade 3 or 4 adverse events at least possibly related to antiretrovirals occurred in 30 (7%, 95% CI 5-10) of 438 infants but did not lead to nevirapine cessation in any neonates; neutropenia (25 [6%] neonates) and anaemia (six [1%]) were most common. INTERPRETATION Nevirapine at the dose studied was confirmed to be safe and provides therapeutic exposure concentrations. These data support nevirapine as a component of presumptive HIV treatment in high-risk neonates. FUNDING National Institute of Allergy and Infectious Diseases, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Institute of Mental Health.
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Affiliation(s)
- Theodore D Ruel
- University of California San Francisco, San Francisco, CA, USA.
| | | | - Camlin Tierney
- Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Bryan S Nelson
- Harvard TH Chan School of Public Health, Boston, MA, USA
| | | | | | | | | | | | - Rebecca LeBlanc
- Frontier Science and Technology Research Foundation, Amherst, NY, USA
| | - Christina Reding
- Frontier Science and Technology Research Foundation, Amherst, NY, USA
| | - Bonnie Zimmer
- Frontier Science and Technology Research Foundation, Amherst, NY, USA
| | - Deborah Persaud
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Rohan Hazra
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Patrick Jean-Philippe
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Ellen G Chadwick
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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11
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Moyo F, Mazanderani AH, Murray T, Sherman GG, Kufa T. Achieving maternal viral load suppression for elimination of mother-to-child transmission of HIV in South Africa. AIDS 2021; 35:307-316. [PMID: 33394673 DOI: 10.1097/qad.0000000000002733] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe changes in maternal viral control over time in South African women living with HIV (WLHIV) using surveillance data from the National Health Laboratory Service's Corporate Data Warehouse (NHLS CDW). DESIGN A retrospective cohort analysis of maternal viral load during pregnancy and up to 15 months postpartum was performed amongst WLHIV (15-49 years) within the public-health sector between 2016 and 2017. METHODS HIV and pregnancy-related test data were used to create a synthetic cohort of pregnant WLHIV from the NHLS CDW. Syphilis-screening, in association with ward type and/or postpregnancy cervical screening and/or birth HIV test and/or positive β-hCG, was used as a proxy for pregnancy. The syphilis-screening date marked the first antenatal care visit (fANC). Fractional polynomial models described viral load evolution from fANC up to 15 months postdelivery. Piecewise linear regression models determined factors associated with viral load decline. FINDINGS Among 178 319 pregnant WLHIV, 345 174 viral load tests were performed [median = 2 (IQR: 2-3) per woman]. At fANC, 85 545 (48%) women were antiretroviral therapy (ART) experienced; 88 877 (49.8%) were not and 3897 (2.2%) unknown. Proportions of viraemia (viral load ≥50 copies/ml) were 39 756 (53.6%) at first viral load performed during pregnancy, 14 780 (36.9%) at delivery and 24 328 (33.5%) postpartum. Maternal age at least 25 years, CD4+ cell count at least 500 cells/μl and viral load less than 50 copies/ml at baseline predicted sustained viral load suppression during follow-up. CONCLUSION Despite high-ART coverage among pregnant women in South Africa, only 63% of WLHIV achieved viral load less than 50 copies/ml at delivery. Maternal viral load monitoring requires prioritization for maternal health and eMTCT.
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Affiliation(s)
- Faith Moyo
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand
- Paediatric HIV Diagnostics Division, Wits Health Consortium, Johannesburg
| | - Ahmad Haeri Mazanderani
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service
- Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Pretoria
| | - Tanya Murray
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service
- Paediatric HIV Diagnostics Division, Wits Health Consortium, Johannesburg
| | - Gayle G Sherman
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service
- Paediatric HIV Diagnostics Division, Wits Health Consortium, Johannesburg
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tendesayi Kufa
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand
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12
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Bhengu BS, Tomita A, Mashaphu S, Paruk S. The Role of Adverse Childhood Experiences on Perinatal Substance Use Behaviour in KwaZulu-Natal Province, South Africa. AIDS Behav 2020; 24:1643-1652. [PMID: 31542877 DOI: 10.1007/s10461-019-02661-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The role of risky sexual behaviour has been widely investigated across the sub-Saharan African HIV hyperendemic setting, with few studies having focused on the behaviour attributed to the deep-rooted, neurodevelopmentally-driven adverse childhood experiences (ACE) that sustain the endemic. We investigated the role of ACE on perinatal substance use outcomes in KwaZulu-Natal Province, South Africa, with 223 women being interviewed within one-week post-partum at a general hospital. Our secondary outcome was the occurrence of preterm birth delivery, which is understood to be linked to ACE. Study results suggest that the most common perinatal substance use was alcohol (n = 27, 12.11%), followed by tobacco (n = 18, 8.07%), with the prevalence of preterm birth delivery being 8.97% (n = 20, 8.97%). Regression analyses indicated increased ACE being significantly associated with perinatal alcohol (aOR = 1.45, 95% CI 1.22-1.72), tobacco use (aOR = 1.56, 95% CI 1.23-1.97) and preterm birth delivery (aOR = 1.21, 95% CI 1.03-1.43), independent of socio-economic status. When the model was further adjusted by HIV status, suppressed viral load was more significantly associated with lower odds of preterm birth delivery (aOR = 0.06, 95% CI: 0.01-0.24) than an unsuppressed status. Risk-behaviour reduction strategies should address the role of ACE on substance use and viral load, and hence possibly ART adherence, in HIV hyperendemic settings.
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13
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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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14
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Rincón Franco S, Uriel M, Rodríguez LM, Romero Infante XC. Preventive measures to avoid vertical transmission in untreated pregnant women with HIV/AIDS. BMJ Case Rep 2020; 13:e233426. [PMID: 32213503 PMCID: PMC7167424 DOI: 10.1136/bcr-2019-233426] [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: 11/04/2022] Open
Abstract
The HIV/AIDS during pregnancy has high morbidity and mortality, without optimal prevention and treatment. The advanced stage cases are found in developing countries due to late detection, but, also in developed countries due to immigration; therefore, the professionals should know the management steps for these patients. The implementation of specific interventions can reduce vertical transmission incidence until 1%-8%. It is presented a case of a pregnant woman with AIDS detected during first hospitalisation, due to a ventilatory failure by opportunistic germs; at the delivery the specific interventions were implemented, being able to eliminate vertical transmission to the newborn. This article explains the four main aspects to be considered for reducing vertical transmission (detection of HIV, viral load levels-CD4 lymphocyte count, way and moment of childbirth and antiretroviral therapy) and shares experiences of the management of an advanced case, in order to help professionals to handle these cases and its complications.
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Affiliation(s)
- Sara Rincón Franco
- Faculty of Medicine, Universidad El Bosque Facultad de Medicina, Bogotá, Colombia
- Fetal Medicine Unit, Ecodiagnóstico El Bosque S.A.S, Bogotá, Colombia
| | - Montserrat Uriel
- Faculty of Medicine, Universidad El Bosque Facultad de Medicina, Bogotá, Colombia
- Fetal Medicine Unit, Ecodiagnóstico El Bosque S.A.S, Bogotá, Colombia
| | | | - Ximena Carolina Romero Infante
- Faculty of Medicine, Universidad El Bosque Facultad de Medicina, Bogotá, Colombia
- Fetal Medicine Unit, Ecodiagnóstico El Bosque S.A.S, Bogotá, Colombia
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15
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Viral suppression and factors associated with failure to achieve viral suppression among pregnant women in South Africa. AIDS 2020; 34:589-597. [PMID: 31821189 PMCID: PMC7050794 DOI: 10.1097/qad.0000000000002457] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Supplemental Digital Content is available in the text Objective: To describe viral load levels among pregnant women and factors associated with failure to achieve viral suppression (viral load ≤50 copies/ml) during pregnancy. Design: Between 1 October and 15 November 2017, a cross-sectional survey was conducted among 15–49-year-old pregnant women attending antenatal care (ANC) at 1595 nationally representative public facilities. Methods: Blood specimens were taken from each pregnant woman and tested for HIV. Viral load testing was done on all HIV-positive specimens. Demographic and clinical data were extracted from medical records or self-reported. Survey logistic regression examined factors associated with failure to achieve viral suppression. Result: Of 10 052 HIV-positive participants with viral load data, 56.2% were virally suppressed. Participants initiating antiretroviral therapy (ART) prior to pregnancy had higher viral suppression (71.0%) by their third trimester compared with participants initiating ART during pregnancy (59.3%). Booking for ANC during the third trimester vs. earlier: [adjusted odds ratio (AOR) 1.8, 95% confidence interval (CI):1.4–2.3], low frequency of ANC visits (AOR for 2 ANC visits vs. ≥4 ANC visits: 2.0, 95% CI:1.7–2.4), delayed initiation of ART (AOR for ART initiated at the second trimester vs. before pregnancy:2.2, 95% CI:1.8–2.7), and younger age (AOR for 15–24 vs. 35–49 years: 1.4, 95% CI:1.2–1.8) were associated with failure to achieve viral suppression during the third trimester. Conclusion: Failure to achieve viral suppression was primarily associated with late ANC booking and late initiation of ART. Efforts to improve early ANC booking and early ART initiation in the general population would help improve viral suppression rates among pregnant women. In addition, the study found, despite initiating ART prior to pregnancy, more than one quarter of participants did not achieve viral suppression in their third trimester. This highlights the need to closely monitor viral load and strengthen counselling and support services for ART adherence.
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16
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Nyakura J, Shewade HD, Ade S, Mushavi A, Mukungunugwa SH, Chimwaza A, Owiti P, Senkoro M, Mugurungi O. Viral load testing among women on 'option B+' in Mazowe, Zimbabwe: How well are we doing? PLoS One 2019; 14:e0225476. [PMID: 31794561 PMCID: PMC6890256 DOI: 10.1371/journal.pone.0225476] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 11/05/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Globally, ten percent of new HIV infections are among children and most of these children acquire infection through mother-to-child transmission. To prevent this, lifelong ART among pregnant and breast feeding (PBF) women living with HIV, irrespective of the WHO clinical stage, was adopted (option B+). There is limited cohort-wise assessment of VL testing among women on 'option B+'. OBJECTIVE Among a pregnancy cohort on antiretroviral therapy in public hospitals and clinics of Mazowe district, Zimbabwe (2017), to determine the i) proportion undergoing VL testing anytime up to six months post child birth and associated factors; ii) turnaround time (TAT) from sending the specimen to results receipt and VL suppression among those undergoing VL testing. METHODS This was a cohort study involving secondary programme data. Modified Poisson regression using robust variance estimates was used to determine the independent predictors of VL testing. RESULTS Of 1112 women, 354 (31.8%, 95% CI: 29.2-34.6) underwent VL testing: 113 (31.9%) during pregnancy, 124 (35%) within six months of child birth and for 117 (33.1%), testing period was unknown. Of 354, VL suppression was seen in 334 (94.4%) and 13 out of 20 with VL non-suppression underwent repeat VL testing. Among those with available dates (125/354), the median TAT was 93 days (IQR 19.3-255). Of 1112, VL results were available between 32 weeks and child birth in 31 (2.8%) women. When compared to hospitals, women registered for antenatal care in clinics were 36% less likely to undergo VL testing [aRR: 0.64 (95% CI: 0.53, 0.76)]. CONCLUSION Among women on option B+, the uptake of HIV VL testing was low with unacceptably long TAT. VL suppression among those tested was satisfactory. There is an urgent need to prioritize VL testing among PBF women and to consider use of point of care machines. There is a critical need to strengthen the recording and local utilisation of routine clinic data in order to successfully monitor progress of healthcare services provided.
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Affiliation(s)
- Justice Nyakura
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Hemant Deepak Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- The Union South-East Asia, New Delhi, India
- Karuna Trust, Bengaluru, Karnataka, India
| | - Serge Ade
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- Faculté de Médecine, Université de Parakou, Parakou, Benin
| | - Angela Mushavi
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | | | - Anesu Chimwaza
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Philip Owiti
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- National Tuberculosis, Leprosy and Lung Disease Programme, Nairobi, Kenya
| | - Mbazi Senkoro
- National Institute for Medical Research- Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Owen Mugurungi
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
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17
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Dugdale CM, Phillips TK, Myer L, Hyle EP, Brittain K, Freedberg KA, Cunnama L, Walensky RP, Zerbe A, Weinstein MC, Abrams EJ, Ciaranello AL. Cost-effectiveness of integrating postpartum antiretroviral therapy and infant care into maternal & child health services in South Africa. PLoS One 2019; 14:e0225104. [PMID: 31730630 PMCID: PMC6857940 DOI: 10.1371/journal.pone.0225104] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 10/29/2019] [Indexed: 11/29/2022] Open
Abstract
Background Poor engagement in postpartum maternal HIV care is a challenge worldwide and contributes to adverse maternal outcomes and vertical transmission. Our objective was to project the clinical and economic impact of integrated postpartum maternal antiretroviral therapy (ART) and pediatric care in South Africa. Methods Using the CEPAC computer simulation models, parameterized with data from the Maternal and Child Health–Antiretroviral Therapy (MCH-ART) randomized controlled trial, we evaluated the cost-effectiveness of integrated postpartum care for women initiating ART in pregnancy and their children. We compared two strategies: 1) standard of care (SOC) referral to local clinics after delivery for separate standard ART services for women and pediatric care for infants, and 2) the MCH-ART intervention (MCH-ART) of co-located maternal/pediatric care integrated in Maternal and Child Health (MCH) services throughout breastfeeding. Trial-derived inputs included: 12-month maternal retention in care and virologic suppression (SOC: 49%, MCH-ART: 67%), breastfeeding duration (SOC: 6 months, MCH-ART: 8 months), and postpartum healthcare costs for mother-infant pairs (SOC: $50, MCH-ART: $69). Outcomes included pediatric HIV infections, maternal and infant life expectancy (LE), lifetime HIV-related per-person costs, and incremental cost-effectiveness ratios (ICERs; ICER <US$903/YLS considered “cost-effective”). Results Compared to SOC, MCH-ART increased maternal LE (SOC: 25.26 years, MCH-ART: 26.20 years) and lifetime costs (SOC: $9,912, MCH-ART: $10,207; discounted). Projected pediatric outcomes for all HIV-exposed children were similar between arms, although undiscounted LE for HIV-infected children was shorter in SOC (SOC: 23.13 years, MCH-ART: 23.40 years). Combining discounted maternal and pediatric outcomes, the ICER was $599/YLS. Conclusion Co-located maternal HIV and pediatric care, integrated in MCH services throughout breastfeeding, is a cost-effective strategy to improve maternal and pediatric outcomes and should be implemented in South Africa.
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Affiliation(s)
- Caitlin M. Dugdale
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- * E-mail:
| | - Tamsin K. Phillips
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Emily P. Hyle
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Kirsty Brittain
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kenneth A. Freedberg
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Lucy Cunnama
- Health Economics Unit, School of Public Health & Family Medicine, University of Cape Town, South Africa
| | - Rochelle P. Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Allison Zerbe
- ICAP at Columbia and the Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Milton C. Weinstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Elaine J. Abrams
- ICAP at Columbia and the Mailman School of Public Health, Columbia University, New York, NY, United States of America
- College of Physicians & Surgeons, Columbia University, New York, NY, United States of America
| | - Andrea L. Ciaranello
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
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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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19
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Ntlantsana V, Hift RJ, Mphatswe WP. HIV viraemia during pregnancy in women receiving preconception antiretroviral therapy in KwaDukuza, KwaZulu-Natal. South Afr J HIV Med 2019; 20:847. [PMID: 31061722 PMCID: PMC6494933 DOI: 10.4102/sajhivmed.v20i1.847] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 02/05/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Preconception antiretroviral therapy (PCART) followed by sustained viral suppression is effective in preventing mother-to-child transmission of HIV. The rates of persistent and transient viraemia in such patients have not been prospectively assessed in South Africa. OBJECTIVES We determined the prevalence of transient and persistent viraemia in HIV-positive women entering antenatal care on PCART and studied variables associated with viraemia. METHODS We performed a prospective cross-sectional observational study of HIV-positive pregnant women presenting to a primary healthcare facility in KwaZulu-Natal. All had received at least 6 months of first-line PCART. Viral load (VL) was measured, patients were interviewed, adherence estimated using a visual analogue scale and adherence counselling provided. Viral load was repeated after 4 weeks where baseline VL exceeded 50 copies/mL. RESULTS We enrolled 82 participants. Of them, 59 (72%) pregnancies were unplanned. Fifteen participants (18.3%) were viraemic at presentation with VL > 50 copies/mL. Of these, seven (8.5%) had viral suppression (VL < 50 copies/mL), and eight remained viraemic at the second visit. Adherence correlated significantly with viraemia at baseline. Level of knowledge correlated with adherence but not with lack of viral suppression at baseline. Socio-economic indicators did not correlate with viraemia. No instances of vertical transmission were observed at birth. CONCLUSIONS Approximately 20% of women receiving PCART may demonstrate viraemia. Half of these may be transient. Poor adherence is associated with viraemia, and efforts to encourage and monitor adherence are essential. The rate of unplanned pregnancies is high, and antiretroviral therapy programmes should focus on family planning needs of women in the reproductive age group to prevent viral non-suppression prior to pregnancy. KEYWORDS Preconception Antiretroviral Therapy; HIV; Viraemia; Antenatal Care; Adherence.
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Affiliation(s)
- Vuyokazi Ntlantsana
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Richard J. Hift
- School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Wendy P. Mphatswe
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
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20
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Abdi F, Alimoradi Z, Alidost F. Pregnancy outcomes and effects of antiretroviral drugs in HIV-positive pregnant women: a systematic review. Future Virol 2019. [DOI: 10.2217/fvl-2018-0213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim: Despite the clear morbidity, mortality and vertical transmission rates in women infected with HIV, there is still controversy surrounding the relationship between maternal infection and adverse neonatal outcomes. Antiretroviral therapy during pregnancy is considered the main and most effective method for reducing the vertical transmission of infection. However, there is no consensus over potential associations between antiretroviral therapy and adverse pregnancy outcomes. This systematic review focuses on the effects of antiretroviral drugs on pregnancy outcomes in HIV-positive women. Methods: After searching MEDLINE, the Cochrane Database of Systematic Reviews, the ISI Web of Sciences and EMBASE, 570 potentially eligible papers were identified. Only 32 papers were selected based on the inclusion criteria. Results: The most prevalent adverse pregnancy outcomes were low birth weight, preterm birth and stillbirth. Conclusion: Considering the higher prevalence of adverse pregnancy outcomes in HIV-infected women, HIV screening methods should be administered in all pregnant women. Appropriate treatment modalities should also be selected to minimize adverse pregnancy outcomes.
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Affiliation(s)
- Fatemeh Abdi
- Student Research Committee, Nursing & Midwifery Faculty, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zainab Alimoradi
- Department of Midwifery, Nursing & Midwifery Faculty, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Farzane Alidost
- Department of Reproductive Health, Nursing & Midwifery Faculty, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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21
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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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22
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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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23
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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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Langwenya N, Phillips TK, Brittain K, Zerbe A, Abrams EJ, Myer L. Same-day antiretroviral therapy (ART) initiation in pregnancy is not associated with viral suppression or engagement in care: A cohort study. J Int AIDS Soc 2018; 21:e25133. [PMID: 29939483 PMCID: PMC6016637 DOI: 10.1002/jia2.25133] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 05/04/2018] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Many prevention of mother-to-child HIV transmission programmes across Africa initiate HIV-infected (HIV positive) pregnant women on lifelong antiretroviral therapy (ART) on the first day of antenatal care ("same-day" initiation). However, there are concerns that same-day initiation may limit patient preparation before starting ART and contribute to subsequent non-adherence, disengagement from care and raised viral load. We examined if same-day initiation was associated with viral suppression and engagement in care during pregnancy. METHODS Consecutive ART-eligible pregnant women making their first antenatal care (ANC) visit at a primary care facility in Cape Town, South Africa were enrolled into a prospective cohort between March 2013 and June 2014. Before July 2013, ART eligibility was based on CD4 cell count ≤350 cells/μL ("Option A"), with a 1 to 2 week delay from the first ANC visit to ART initiation for patient preparation; thereafter all women were eligible regardless of CD4 cell count ("Option B+") and offered ART on the same day as first ANC visit. Women were followed with viral load testing conducted separately from routine ART services, and engagement in ART services was measured using routinely collected clinic, pharmacy and laboratory records through 12 months postpartum. RESULTS Among 628 HIV-positive women (median age, 28 years; median gestation at ART start, 21 weeks; 55% newly diagnosed with HIV), 73% initiated ART same-day; this proportion was higher under Option B+ versus Option A (85% vs. 20%). Levels of viral suppression (viral load <50 copies/mL) at delivery (74% vs. 82%) and 12 months postpartum (74% vs. 71%) were similar under same-day versus delayed initiation respectively. Findings were consistent when viral suppression was defined at <1000 copies/mL, after adjustment for demographic/clinical measures and across subgroups of age, CD4 and timing of HIV diagnosis. Time to first viral rebound following initial suppression did not differ by timing of ART initiation nor did engagement in care through 12 months postpartum (same-day = 73%, delayed = 73%, p = 0.910). CONCLUSIONS These data suggest that same-day ART initiation during pregnancy is not associated with lower levels of engagement in care or viral suppression through 12 months post-delivery in this setting, providing reassurance to ART programmes implementing Option B+.
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Affiliation(s)
- Nontokozo Langwenya
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Centre for Infectious Diseases Epidemiology & ResearchUniversity of Cape TownCape TownSouth Africa
| | - Tamsin K Phillips
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Centre for Infectious Diseases Epidemiology & ResearchUniversity of Cape TownCape TownSouth Africa
| | - Kirsty Brittain
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Centre for Infectious Diseases Epidemiology & ResearchUniversity of Cape TownCape TownSouth Africa
| | - Allison Zerbe
- ICAP at Columbia UniversityMailman School of Public HealthNew YorkNew York
| | - Elaine J Abrams
- ICAP at Columbia UniversityMailman School of Public HealthNew YorkNew York
- Columbia UniversityCollege of Physicians & SurgeonsNew YorkNew York
| | - Landon Myer
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Centre for Infectious Diseases Epidemiology & ResearchUniversity of Cape TownCape TownSouth Africa
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25
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Nachega JB, Sam-Agudu NA, Mofenson LM, Schechter M, Mellors JW. Achieving Viral Suppression in 90% of People Living With Human Immunodeficiency Virus on Antiretroviral Therapy in Low- and Middle-Income Countries: Progress, Challenges, and Opportunities. Clin Infect Dis 2018; 66:1487-1491. [PMID: 29324994 PMCID: PMC7190938 DOI: 10.1093/cid/ciy008] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 01/06/2018] [Indexed: 12/15/2022] Open
Abstract
Although significant progress has been made, the latest data from low- and middle-income countries show substantial gaps in reaching the third "90%" (viral suppression) of the UNAIDS 90-90-90 goals, especially among vulnerable and key populations. This article discusses critical gaps and promising, evidence-based solutions. There is no simple and/or single approach to achieve the last 90%. This will require multifaceted, scalable strategies that engage people living with human immunodeficiency virus, motivate long-term treatment adherence, and are community-entrenched and ‑supported, cost-effective, and tailored to a wide range of global communities.
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Affiliation(s)
- Jean B Nachega
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pennsylvania
- Department of Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pennsylvania
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Medicine and Centre for Infectious Diseases, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Nadia A Sam-Agudu
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja
- Department of Paediatrics, University of Cape Coast School of Medical Sciences, Ghana
| | | | - Mauro Schechter
- Projeto Praça Onze, Universidade Federal do Rio de Janeiro, Brazil
| | - John W Mellors
- Division of Infectious Diseases, University of Pittsburgh, School of Medicine, Pennsylvania
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