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Fairlie L, Sawry S, Pals S, Sherman G, Williamson D, Le Roux J, Ngeno B, Berrie L, Diallo K, Cox MH, Mogashoa M, Chersich M, Modi S. More Frequent HIV Viral Load Testing With Point-Of-Care Tests Detects Elevated Viral Load Earlier in Postpartum HIV-Positive Women in a Randomized Controlled Trial in Two Clinics in Johannesburg, South Africa. J Acquir Immune Defic Syndr 2023; 94:412-420. [PMID: 37949444 DOI: 10.1097/qai.0000000000003295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 08/04/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Elevated maternal HIV viral load (VL) increases vertical transmission risk for breastfeeding children. This randomized controlled trial in Johannesburg primarily evaluated whether 3-monthly point-of-care testing, with laboratory-based standard-of-care testing (arm 2), compared with 6-monthly laboratory-based VL testing (arm 1) in postpartum women living with HIV receiving first-line tenofovir-emtricitabine-efavirenz antiretroviral treatment improved VL suppression, factors associated with nonsuppression, and drug resistance in those with virologic failure. METHODS Mother-child pairs were enrolled July 2018-April 2019 at the child's 6/10/14-week clinic visit. Women were randomized 1:1 to arm 1 or 2. Trained staff performed point-of-care VL testing using the Cepheid's Xpert HIV-1 VL assay. We fitted a generalized linear mixed model with VL suppression (<50 copies/mL (cps/mL) and <1000 cps/mL) at enrollment and 6, 12, and 18 months postpartum as the outcome and indicator variables for time, study site, study arm, and interaction variables. The final model tested for a difference by study arm, pooling across time points. RESULTS Of 405 women enrolled (204 arm 1 and 201 arm 2), 249 (61%) remained in follow-up through 18 months. There was no difference in VL suppression between arms at 6, 12, or 18 months. VL suppression rate (<50 cps/mL) at 18 months was 64.8% in arm 1 and 63.0% in arm 2 (P = 0.27). On bivariate analysis, there was an association with late antenatal booking and being in arm 2 for nonsuppressed VL, but no significant association with breastfeeding. HIV drug resistance was found in 12 of 23 participants (52.2%). CONCLUSION We found no significant difference in VL suppression with more frequent VL testing in postpartum women living with HIV receiving first-line efavirenz-based antiretroviral treatment.
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Affiliation(s)
- Lee Fairlie
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shobna Sawry
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sherri Pals
- Division of Global HIV & Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Gayle Sherman
- Paediatric HIV Surveillance in the Centre for HIV and STI, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
- Department of Paediatrics & Child Health, Faculty of Heath Sciences, University of the Witwatersrand, Johannesburg, South Africa; and
| | - Dhelia Williamson
- Division of Global HIV & Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Jean Le Roux
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bernadette Ngeno
- Division of Global HIV & Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Leigh Berrie
- Division of Global HIV and TB (DGHT), CDC South Africa, Pretoria, South Africa
| | - Karidia Diallo
- Division of Global HIV and TB (DGHT), CDC South Africa, Pretoria, South Africa
| | - Mackenzie Hurlston Cox
- Division of Global HIV & Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Mary Mogashoa
- Division of Global HIV and TB (DGHT), CDC South Africa, Pretoria, South Africa
| | - Matthew Chersich
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Surbhi Modi
- Division of Global HIV & Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Atlanta, GA
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Bwire GM, Aiko BG, Mosha IH, Kilapilo MS, Mangara A, Kazonda P, Swai JP, Swalehe O, Jordan MR, Vercauteren J, Sando D, Temba D, Shao A, Mauka W, Decouttere C, Vandaele N, Sangeda RZ, Killewo J, Vandamme AM. High viral suppression and detection of dolutegravir-resistance associated mutations in treatment-experienced Tanzanian adults living with HIV-1 in Dar es Salaam. Sci Rep 2023; 13:20493. [PMID: 37993493 PMCID: PMC10665358 DOI: 10.1038/s41598-023-47795-1] [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: 08/18/2023] [Accepted: 11/18/2023] [Indexed: 11/24/2023] Open
Abstract
To curb HIV infection rate in Tanzania, antiretroviral therapy (ART) has been scaled up since 2006, and in 2019, the country shifted to regimen including dolutegravir as a default first line. We assessed the success of ART and the contribution of HIV drug resistance (HIVDR) to unsuppressed viral loads. Between February and May 2023 a cross-sectional survey with random sampling was conducted in the six clinics in an urban cohort in Dar es Salaam. Patients with unsuppresed viral loads (local criteria viral load (VL) ≥ 1000 copies/mL) were tested for HIVDR mutations using the WHO adapted protocol for plasma samples. Mutations were interpreted using the Stanford HIVDR database. In total 600 individuals participated in this survey, the majority were female (76.83%), mean age ([Formula: see text] standard deviation) was 44.0 ([Formula: see text] 11.6) years. The median duration on ART (interquartile range) was 6.5 (3.9-10.2) years. Approximately 99% were receiving tenofovir + lamivudine + dolutegravir as a fixed dose combination. VL testing was successful in 99.67% (598/600) of survey patients and only 33 had VL ≥ 1000 copies/mL, resulting in a viral suppression level of 94.48% (565/598, 95% CI 92.34-96.17%). For 23 samples, protease and reverse transcriptase (RT) genotyping were successful, with 13 sequences containing RT inhibitor surveillance drug resistance mutations (SDRMs) (56.5%). No SDRM against protease inhibitors were detected. Thirty samples were successfully genotyped for integrase with 3 sequences (10.08%) containing integrase strand transfer inhibitor (INSTI) SDRMs. In samples successfully genotyped in the three genetic regions, 68.18% (16/22) had a genotypic susceptibility score (GSS) ≥ 2.5 for the concurrent regimen, implying factors beyond drug resistance caused the unsuppressed viral load. For five patients, GSS indicated that HIVDR may have caused the unsuppressed viral load. All three patients with INSTI resistance mutations were highly resistant to dolutegravir and accumulated nucleoside and non-nucleoside RT inhibitor HIVDR mutations. Although in this cohort the last 95 UNAIDS target was almost achieved, HIVDR mutations, including INSTIs resistance mutations were detected in HIV-positive individuals taking ART for at least one year. We recommend the design and implementation of high-impact interventions to prevent the increase of HIVDR, failure of dolutegravir and address the non-resistance factors in the study area.
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Affiliation(s)
- George M Bwire
- Laboratory of Clinical and Epidemiological Virology (Rega Institute), Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research Clinical and Epidemiological Virology, Institute for the Future, KU Leuven, Rega-Herestraat 49-Bus 1040, 3000, Leuven, Belgium.
- Department of Pharmaceutical Microbiology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, 65013, Tanzania.
| | - Beatrice Godwin Aiko
- Department of Pharmaceutics and Pharmacy Practice, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, 65013, Tanzania
- Faculty of Economics and Business, Access to Medicine Research Center, KU Leuven, 3000, Leuven, Belgium
| | - Idda H Mosha
- Department of Behavioural Sciences, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, 65015, Tanzania
| | - Mary S Kilapilo
- Department of Pharmaceutical Microbiology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, 65013, Tanzania
| | - Alli Mangara
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Dar es Salaam Urban Cohort Study, Dar es Salaam, 65013, Tanzania
| | - Patrick Kazonda
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Dar es Salaam Urban Cohort Study, Dar es Salaam, 65013, Tanzania
| | - Janeth P Swai
- Department of Business Studies, School of Business, Mzumbe University, Dar es Salaam, 20266, Tanzania
| | - Omary Swalehe
- Department of Business Studies, School of Business, Mzumbe University, Dar es Salaam, 20266, Tanzania
| | | | - Jurgen Vercauteren
- Laboratory of Clinical and Epidemiological Virology (Rega Institute), Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research Clinical and Epidemiological Virology, Institute for the Future, KU Leuven, Rega-Herestraat 49-Bus 1040, 3000, Leuven, Belgium
| | - David Sando
- Managament and Development for Health, Mwai Kibaki Road, Dar es Salaam, Tanzania
| | - David Temba
- Managament and Development for Health, Mwai Kibaki Road, Dar es Salaam, Tanzania
| | - Amani Shao
- Managament and Development for Health, Mwai Kibaki Road, Dar es Salaam, Tanzania
| | - Wilhellmuss Mauka
- Managament and Development for Health, Mwai Kibaki Road, Dar es Salaam, Tanzania
| | - Catherine Decouttere
- Faculty of Economics and Business, Access to Medicine Research Center, KU Leuven, 3000, Leuven, Belgium
| | - Nico Vandaele
- Faculty of Economics and Business, Access to Medicine Research Center, KU Leuven, 3000, Leuven, Belgium
| | - Raphael Z Sangeda
- Department of Pharmaceutical Microbiology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, 65013, Tanzania
| | - Japhet Killewo
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, 65015, Tanzania
| | - Anne-Mieke Vandamme
- Laboratory of Clinical and Epidemiological Virology (Rega Institute), Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research Clinical and Epidemiological Virology, Institute for the Future, KU Leuven, Rega-Herestraat 49-Bus 1040, 3000, Leuven, Belgium
- Center for Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
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Buzibye A, Wools-Kaloustian K, Olagunju A, Twinomuhwezi E, Yiannoutsos C, Owen A, Neary M, Matovu J, Banturaki G, Castelnuovo B, Lamorde M, Khoo S, Waitt C, Kiragga A. Relating CYP2B6 genotype and efavirenz resistance among post-partum women living with HIV with high viremia in Uganda: a nested cross-sectional study. AIDS Res Ther 2023; 20:20. [PMID: 37004096 PMCID: PMC10064798 DOI: 10.1186/s12981-023-00514-2] [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: 01/03/2023] [Accepted: 03/24/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND We investigated the association between CYP2B6 polymorphisms and efavirenz drug resistance among women living with HIV who started on antiretroviral therapy during pregnancy and with high viremia during post-partum. METHODS This was a cross-sectional study of women with viral loads greater than 1000 copies/ml who were at least 6 weeks postpartum. Sanger sequencing was used to detect resistant mutations, as well as host genotyping, and efavirenz resistance was compared among the metabolizer genotypes. RESULTS Over the course of one year (July 2017-July 2018), 322 women were screened, with 110 (34.2%) having viral loads of 1000 copies/ml and 62 having whole blood available for genotyping. Fifty-nine of these women had both viral resistance and human host genotypic results. Efavirenz resistance according to metabolizer genotype was; 47% in slow, 34% in extensive and 28% in intermediate metabolizers, but the difference was not statistically significant due to the small sample size. CONCLUSIONS There was no statistically significant difference in EFV resistance between EFV metabolizer genotypes in women who started antiretroviral therapy during pregnancy and had high viremia in the postpartum period. However, a numerical trend was discovered, which calls for confirmation in a large, well-designed, statistically powered study.
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Affiliation(s)
- Allan Buzibye
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O. Box 22418, Kampala, Uganda.
| | | | - Adeniyi Olagunju
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Ellon Twinomuhwezi
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O. Box 22418, Kampala, Uganda
| | | | - Andrew Owen
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Megan Neary
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Joshua Matovu
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O. Box 22418, Kampala, Uganda
| | - Grace Banturaki
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O. Box 22418, Kampala, Uganda
| | - Barbara Castelnuovo
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O. Box 22418, Kampala, Uganda
| | - Mohammed Lamorde
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O. Box 22418, Kampala, Uganda
| | - Saye Khoo
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Catriona Waitt
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Agnes Kiragga
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O. Box 22418, Kampala, Uganda
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Intimate partner violence and HIV treatment adherence in urban South Africa: Mediating role of perinatal common mental disorders. SSM - MENTAL HEALTH 2022; 2:100112. [PMID: 36688232 PMCID: PMC9792377 DOI: 10.1016/j.ssmmh.2022.100112] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/28/2022] [Accepted: 05/04/2022] [Indexed: 01/25/2023] Open
Abstract
Background Antiretroviral therapy (ART) has potential to eliminate perinatal HIV infections, but adherence to ART in late pregnancy and postpartum is often suboptimal. Intimate partner violence (IPV) may influence non-adherence among perinatal women living with HIV (WWH), but few quantitative studies have examined this over time or explored mechanisms for this association. Methods We used secondary data from a parent trial in Johannesburg comprising WWH from the control arm (n=63) and WWH ineligible for the trial (n=133). Trained nurse researchers administered questionnaires at first antenatal visit on past-year psychological, physical, and/or sexual IPV (WHO instrument), socio-demographics (age, food security, education), and perinatal common mental symptoms of depression (Hospital Anxiety and Depression Screener-d); anxiety (HADS-a); post-traumatic stress disorder (PTSD; Harvard Trauma Questionnaire). At endline visit 2-4 months postpartum, nurse researchers assessed self-reported ART adherence using a visual analog scale (with ≥95% considered "good"). We fitted structural equation models (SEM) in MPlus to explore direct and indirect effects of IPV on ART adherence. Results Of 196 perinatal WWH, 53.1% reported IPV exposure at baseline. The majority of participants (85.7%) had good perinatal ART adherence. In adjusted models, IPV at baseline was associated with halved odds of good adherence (aOR=0.51, 95%CI=0.20-0.96). IPV was associated with higher adjusted odds of probable depression (aOR=4.64), anxiety (aOR=2.85), and PTSD (aOR=3.42). In SEM, IPV had a direct (standardized coef=-0.22) and indirect effect (coef=-0.05) on ART via common mental disorders. The total effect of IPV on perinatal adherence was of moderate size (coef= -0.27) and the model had good fit (CFI=0.972; TLI=0.969; RMSEA=0.045; SRMR=0.076). Conclusion IPV was longitudinally associated with perinatal ART non-adherence in part due to its relationship with mental health symptomology. Addressing IPV within clinical care has potential to improve perinatal mental health, maternal HIV outcomes, and HIV-free infant survival.
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Nematadzira TG, Murnane PM, Odiase OJ, Bacchetti P, Okochi H, Tallerico R, Chanaiwa VM, Vhembo T, Mutambanengwe-Jacob MT, Louie A, Chipato T, Gandhi M, Stranix-Chibanda L. Antiretroviral Therapy Adherence During and Postbreastfeeding Cessation Measured by Tenofovir Levels in Hair. J Acquir Immune Defic Syndr 2022; 91:237-241. [PMID: 35952357 PMCID: PMC9561228 DOI: 10.1097/qai.0000000000003076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND We examined change in antiretroviral treatment (ART) adherence after breastfeeding (BF) cessation using hair tenofovir (TFV) concentrations as an objective metric of medication consumption. METHODS A subset of postpartum women in Zimbabwe randomized in IMPAACT PROMISE to take ART while BF and post-BF cessation had hair TFV measured longitudinally. Using linear mixed-effect models, we estimated differences in hair TFV levels after BF cessation, accounting for trends in levels over time regardless of BF status and change in slope after breastfeeding cessation. We also estimated the relative risk of viremia (>50 copies/mL) per doubling of hair TFV concentration. RESULTS Among 55 women (median age 26, interquartile range 24-29 years), hair TFV levels (n = 305) were available for a median of 9 visits per woman between 3 and 29 months postpartum. Hair TFV levels ranged from undetected to 0.25 ng/mg (median 0.04 ng/mg). Controlling for trends since delivery [decline of 2.2% per month, 95% confidence interval (CI): -5.3 to 1.0], TFV levels averaged 24.4% higher (95% CI: -5.1 to 63.1) post-BF cessation than during BF, with no change in slope (0.0% per month, 95% CI: -3.8 to 3.9). Postpartum, 42% of women were ever viremic. Higher TFV levels were strongly protective; relative risk of viremia per doubling of TFV was 0.52 (95% CI: 0.43 to 0.63; P < 0.0001). CONCLUSIONS Leveraging an objective metric of ART use, we observed modestly declining adherence across the postpartum period, but no additional decline associated with breastfeeding cessation. High viremia frequency and varying postpartum TFV levels observed highlight the importance of enhanced adherence support with viral load monitoring among postpartum women.
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Affiliation(s)
| | - Pamela M. Murnane
- Institute for Global Health Sciences, University of California-San Francisco, San Francisco, CA
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA
| | - Osamuedeme J. Odiase
- Hair Analytical Laboratory, University of California-San Francisco, San Francisco, CA; and
| | - Peter Bacchetti
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA
| | - Hideaki Okochi
- Hair Analytical Laboratory, University of California-San Francisco, San Francisco, CA; and
| | - Regina Tallerico
- Hair Analytical Laboratory, University of California-San Francisco, San Francisco, CA; and
| | - Vongai M. Chanaiwa
- University of Zimbabwe-Clinical Trials Research Centre, Harare, Zimbabwe
| | - Tichaona Vhembo
- University of Zimbabwe-Clinical Trials Research Centre, Harare, Zimbabwe
| | | | - Alexander Louie
- Hair Analytical Laboratory, University of California-San Francisco, San Francisco, CA; and
| | - Tsungai Chipato
- University of Zimbabwe-Clinical Trials Research Centre, Harare, Zimbabwe
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Monica Gandhi
- Hair Analytical Laboratory, University of California-San Francisco, San Francisco, CA; and
| | - Lynda Stranix-Chibanda
- University of Zimbabwe-Clinical Trials Research Centre, Harare, Zimbabwe
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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Mokua S, Maloba M, Wexler C, Goggin K, Staggs V, Mabachi N, Maosa N, Babu S, Hurley E, Finocchario-Kessler S. Evaluating the efficacy of the HITSystem 2.1 to improve PMTCT retention and maternal viral suppression in Kenya: Study protocol of a cluster-randomized trial. PLoS One 2022; 17:e0263988. [PMID: 35881649 PMCID: PMC9321364 DOI: 10.1371/journal.pone.0263988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/28/2022] [Indexed: 11/19/2022] Open
Abstract
Background Gaps in the provision of guideline-adherent prevention of mother-to-child transmission of HIV (PMTCT) services and maternal retention in care contribute to nearly 8000 Kenyan infants becoming infected with HIV annually. Interventions that routinize evidence-based PMTCT service delivery and foster consistent patient engagement are essential to eliminating mother-to-child transmission of HIV. The HITSystem 2.1 is an eHealth intervention that aims to improve retention in PMTCT services and viral load monitoring, using electronic alerts to providers and SMS to patients. This study will evaluate the impact, implementation, and cost-effectiveness of HITSystem 2.1. Method This cluster randomized trial will be conducted at 12 study hospital (6 intervention, 6 control). Pregnant women living with HIV who have initiated PMTCT care ≤36 weeks gestation are eligible. Women enrolled at control hospitals will receive standard-of-care PMTCT services. Women enrolled at intervention hospitals will receive standard-of-care PMTCT services plus enhanced HITSystem 2.1 tracking. Mixed logistic regression models will compare the arms on two primary outcomes: (1) completed guideline-adherence PMTCT services and (2) viral suppression at both delivery and 6 months postpartum. We will assess associations between provider and patient characteristics (disclosure status, partner status, depression, partner support), PMTCT knowledge, and motivation with retention outcomes. Using the RE-AIM model, we will also assess implementation factors to guide sustainable scale-up. Finally, a cost-effectiveness analysis will be conducted. Discussion This study will provide insights regarding the development and adaptation of eHealth strategies to meet the global goal of eliminating new HIV infections in children and optimizing maternal health through PMTCT services. If efficacious, implementation and cost-effectiveness data gathered in this study will guide scale-up across Kenyan health facilities. Trial registration This study was registered at clinicaltrials.gov (NCT04571684) on October 1, 2020.
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Affiliation(s)
- Sharon Mokua
- Kenya Medical Research Institute, Nairobi, Kenya
- * E-mail: ,
| | - May Maloba
- Global Health Innovations–Kenya, Nairobi, Kenya
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Missouri, United States of America
| | - Kathy Goggin
- Children’s Mercy Kansas City, Health Services and Outcomes Research, Kansas City, Missouri, United States of America
- University of Missouri-Kansas City, School of Medicine, Kansas City, Missouri, United States of America
| | - Vincent Staggs
- Children’s Mercy Kansas City, Health Services and Outcomes Research, Kansas City, Missouri, United States of America
| | - Natabhona Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Missouri, United States of America
| | | | | | - Emily Hurley
- Children’s Mercy Kansas City, Health Services and Outcomes Research, Kansas City, Missouri, United States of America
| | - Sarah Finocchario-Kessler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Missouri, United States of America
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7
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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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Ngandu NK, Lombard CJ, Mbira TE, Puren A, Waitt C, Prendergast AJ, Tylleskär T, Van de Perre P, Goga AE. HIV viral load non-suppression and associated factors among pregnant and postpartum women in rural northeastern South Africa: a cross-sectional survey. BMJ Open 2022; 12:e058347. [PMID: 35273061 PMCID: PMC8915310 DOI: 10.1136/bmjopen-2021-058347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES We aimed to measure the prevalence of maternal HIV viral load (VL) non-suppression and assess associated factors, to evaluate progress towards United Nations-AIDS (UNAIDS) targets. DESIGN Cross-sectional study. SETTING The eight largest community health centres of Ehlanzeni, a rural district in northeast South Africa. PARTICIPANTS Pregnant women living with HIV (WLHIV) in their third trimester and postpartum WLHIV and their biological infants, recruited equally across all stages of the first 24 months post partum, were included. A sample of 612 mothers participated from a target of 1000. PRIMARY OUTCOME MEASURES The primary outcome was maternal VL (mVL) non-suppression (defined here as mVL >1000 copies/mL). We collected information on antiretroviral use, healthcare visits and sociodemographics through interviews and measured plasma mVL. Descriptive statistics, χ2 tests and multivariable logistic regression analysis were conducted. RESULTS All mothers (median age: 30 years) were on antiretroviral therapy (ART) and 24.9% were on ART ≤12 months. The prevalence of mVL non-suppression was 14.7% (95% CI: 11.3% to 19.0%), while 13.8% had low-level viraemia (50-1000 copies/mL). Most (68.9%) women had initiated breast feeding and 37.6% were currently breast feeding their infants. Being younger than 25 years (adjusted odds ratio (AOR): 2.6 (95% CI: 1.1 to 6.4)), on first-line ART (AOR: 2.3 (95% CI: 1.1 to 4.6)) and married/cohabiting (AOR: 1.9 (95% CI: 1.0 to 3.7)) were significantly associated with increased odds of mVL non-suppression. CONCLUSIONS The prevalence of mVL ≤1000 copies/mL of 85.3% among pregnant and postpartum WLHIV and attending public healthcare centres in this rural district is below the 2020 90-90-90 and 2030 95-95-95 UNAIDS targets. Given that low-level viraemia may also increase the risk of vertical HIV transmission, we recommend strengthened implementation of the new guidelines which include better ART options, improved ART regimen switching and mVL monitoring schedules, and intensified psychosocial support for younger women, while exploring district-level complementary interventions, to sustain VLs below 50 copies/mL among all women.
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Affiliation(s)
- Nobubelo Kwanele Ngandu
- HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Carl J Lombard
- Division of Epidemiology and Biostatistics, University of Stellenbosch, Cape Town, South Africa
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Thandiwe Elsie Mbira
- HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Adrian Puren
- Centre for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Catriona Waitt
- Faculty of Health and Life Sciences, Department of Pharmacology, University of Liverpool, Liverpool, UK
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrew J Prendergast
- Blizard Institute, Queen Mary University of London, London, UK
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | | | - Philippe Van de Perre
- Pathogenesis and Control of Chronic and Emerging Infections, University of Montpellier INSERM, Montpellier, France
- CHU, Montpellier, Montpellier, France
- Etablissement Français du Sang, Antilles University, Paris, France
| | - Ameena Ebrahim Goga
- HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa
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9
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Rugemalila J, Kamori D, Maokola W, Mizinduko M, Barabona G, Masoud S, Mlunde LB, Mutagonda RF, Ruhago G, Mushi J, Sambu V, Ueno T, Mutayoba B, Njau P, Nagu T, Aboud S, Sunguya BF. Acquired HIV drug resistance among children and adults receiving antiretroviral therapy in Tanzania: a national representative survey protocol. BMJ Open 2021; 11:e054021. [PMID: 34921085 PMCID: PMC8689191 DOI: 10.1136/bmjopen-2021-054021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Tanzania is making an enormous effort in scaling-up of antiretroviral therapy (ART). However, people living with HIV (PLHIV) continue to succumb to the challenge of drug resistance. Evidence on drug resistance for a national survey is unavailable in Tanzania. Therefore, we sought to assess viral suppression (vs) rates and magnitude of acquired drug resistance (ADR) among PLHIV. METHODS AND ANALYSIS A national survey will be conducted from 26 July to 29 October 2021 in 22 regions, recruiting 2160 participants. These will include adults on ART for 9-15 months and ≥48 months and children on ART for 9-15 months and ≥36 months. A standardised questionnaire will capture participants' demographic and clinical data. Plasma and dried blood spot will be prepared for viral load testing and drug resistance genotyping. Statistical analyses to determine the burden of ADR, characteristics and factors associated therewith will be done using STATA V.15. ETHICS AND DISSEMINATION Ethical approval has been obtained from the National Health Research Ethics Committee of Tanzania (NIMR/HQ/R.8a/Vol.IX/3432). Appropriate participant informed consent or parental consent and assent will be obtained. Dissemination will include a survey report, conference presentations, policy briefs and peer-reviewed publications.
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Affiliation(s)
- Joan Rugemalila
- Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Doreen Kamori
- Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Werner Maokola
- Strategic Information Unit, National AIDS Control Program, Dodoma, Tanzania
| | - Mucho Mizinduko
- Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Godfrey Barabona
- Joint Research Center for Human Retrovirus Infection, Kumamoto University, Kumamoto-Shi, Kumamoto, Japan
| | - Salim Masoud
- Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Linda B Mlunde
- Department of Community Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ritah Francis Mutagonda
- Clinical Pharmacy and Pharmacology, Muhimbili University of Health and Allied Sciences, Dar-es-salaam, Tanzania, United Republic of Tanzania
| | - George Ruhago
- Department of Development Studies, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jeremiah Mushi
- Strategic Information Unit, National AIDS Control Program, Dodoma, Tanzania
| | - Veryeh Sambu
- Strategic Information Unit, National AIDS Control Program, Dodoma, Tanzania
| | - Takamasa Ueno
- Joint Research Center for Human Retrovirus Infection, Kumamoto University, Kumamoto-Shi, Kumamoto, Japan
| | - Beatrice Mutayoba
- Administration Department, National AIDS Control Program, Dodoma, Tanzania
| | - Prosper Njau
- Strategic Information Unit, National AIDS Control Program, Dodoma, Tanzania
| | - Tumaini Nagu
- Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Said Aboud
- Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Bruno F Sunguya
- Department of Community Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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10
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Naburi HE, Mujinja P, Kilewo C, Biberfeld G, Bärnighausen T, Manji K, Lyatuu G, Urrio R, Zethraeus N, Orsini N, Ekström AM. Health care costs associated with clinic visits for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania. Medicine (Baltimore) 2021; 100:e27828. [PMID: 34797311 PMCID: PMC8601283 DOI: 10.1097/md.0000000000027828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/28/2021] [Indexed: 01/05/2023] Open
Abstract
Early and appropriate antenatal care (ANC) is key for the effectiveness of prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV). We evaluated the importance of ANC visits and related service costs for women receiving option B+ to prevent mother-to-child transmission (MTCT) of HIV in Tanzania.A cost analysis from a health care sector perspective was conducted using routine data of 2224 pregnant women newly diagnosed with HIV who gave birth between August 2014 and May 2016 in Dar es Salaam, Tanzania. We evaluated risk of infant HIV infection at 12 weeks postnatally in relation to ANC visits (<4 vs ≥4 visits). Costs for service utilisation were estimated through empirical observations and the World Health Organisation Global Price Reporting Mechanism.Mean gestational age at first ANC visit was 22 (±7) weeks. The average number of ANC/prevention of MTCT visits among the 2224 pregnant women in our sample was 3.6 (95% confidence interval [CI] 3.6-3.7), and 57.3% made ≥4 visits. At 12 weeks postnatally, 2.7% (95% CI 2.2-3.6) of HIV exposed infants had been infected. The risk of MTCT decreased with the number of ANC visits: 4.8% (95% CI 3.6-6.4) if the mother had <4 visits, and 1.0% (95% CI 0.5-1.7) at ≥4. The adjusted MTCT rates decreased by 51% (odds ratio 0.49, 95% CI 0.31-0.77) for each additional ANC visit made. The potential cost-saving was 2.2 US$ per woman at ≥4 visits (84.8 US$) compared to <4 visits (87.0 US$), mainly due to less defaulter tracing.Most pregnant women living with HIV in Dar es Salaam initiated ANC late and >40% failed to adhere to the recommended minimum of 4 visits. Improved ANC attendance would likely lead to fewer HIV-infected infants and reduce both short and long-term health care costs due to less spending on defaulter tracing and future treatment costs for the children.
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Affiliation(s)
- Helga Elineema Naburi
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Phares Mujinja
- Institute of Public health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Charles Kilewo
- Departments of Obstetrics and Gynaecology, MUHAS, Dar es Salaam, Tanzania
| | - Gunnel Biberfeld
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
- Africa Health Research Institute (AHRI), Mtubatuba, South Africa
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Karim Manji
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Goodluck Lyatuu
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Departments of Obstetrics and Gynaecology, MUHAS, Dar es Salaam, Tanzania
- Management and Development for Health (MDH), Dar es Salaam, Tanzania
| | - Roseline Urrio
- Departments of Obstetrics and Gynaecology, MUHAS, Dar es Salaam, Tanzania
- Management and Development for Health (MDH), Dar es Salaam, Tanzania
| | - Niklas Zethraeus
- Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | - Nicola Orsini
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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11
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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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12
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Bintabara D, Lilungulu A, Jumanne S, Nassoro MM, Mpondo BC. Does facility readiness promote high-quality of provider-initiated HIV testing and counseling to pregnant women? A national survey for improving policy of prevention of mother-to-child transmission of HIV in Tanzania. AIDS Res Ther 2021; 18:38. [PMID: 34217319 PMCID: PMC8254244 DOI: 10.1186/s12981-021-00362-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/26/2021] [Indexed: 11/10/2022] Open
Abstract
Background Provider-initiated HIV testing and counseling (PITC) is a recommended approach to screen for HIV to all pregnant women during antenatal care (ANC) visits, and all with HIV positive results have to be enrolled into prevention of mother-to-child transmission of HIV (PMTCT) program. However, little is known about the relationship between facility readiness and the uptake of PITC to pregnant women attending ANC in Tanzania. Therefore, this study assessed whether the facility readiness promotes the uptake of PITC to the pregnant women attending ANC for the purpose of improving the PMTCT interventions in Tanzania. Methods This study analyzed data for health facilities obtained from the 2014–2015 Tanzania service provision assessment survey. The Primary outcome measure was a composite variable (with score of 0–5) in which its higher scores indicates provision of high-quality of PITC. Also, facilities scored higher in the PMTCT service readiness index were considered to have high readiness to provide PMTCT services. In Poisson regression analyses, a series of models were fitted to assess whether there is an association between provision of high-quality of PITC and facility readiness. In all statistical analysis, a P < 0.05 was considered significant. Results Out of 1853 included first-visit ANC consultations, only about one-third of pregnant women received all five components required for PITC. The mean percentage of PMTCT readiness score was moderate 63.96 [61.32–66.59]%. In adjusted model, we found that facility with high readiness to provide PMTCT services was significantly associated with the provision of high-quality of PITC (model 2: [β = 0.075, P = 0.00]). Conclusion In order to increase high-quality of PITC services, efforts should be made to improve the PMTCT facility readiness by increasing availability of trained staffs, diagnostic tools, and ARTs among health facilities in Tanzania. Supplementary Information The online version contains supplementary material available at 10.1186/s12981-021-00362-y.
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13
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Eke AC, Olagunju A, Momper J, Penazzato M, Abrams EJ, Best BM, Capparelli EV, Bekker A, Belew Y, Kiser JJ, Struble K, Taylor G, Waitt C, Mirochnick M, Cressey TR, Colbers A. Optimizing Pharmacology Studies in Pregnant and Lactating Women Using Lessons From HIV: A Consensus Statement. Clin Pharmacol Ther 2021; 110:36-48. [PMID: 32930408 PMCID: PMC8167886 DOI: 10.1002/cpt.2048] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/16/2020] [Indexed: 12/02/2022]
Abstract
Information on the extent of drug exposure to mothers and infants during pregnancy and lactation normally becomes available years after regulatory approval of a drug. Clinicians face knowledge gaps on drug selection and dosing in pregnancy and infant exposure during breastfeeding. Physiological changes during pregnancy often result in lower drug exposures of antiretrovirals, and in some cases a risk of reduced virologic efficacy. The International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) network and the World Health Organization (WHO)-convened Pediatric Antiretrovirals Working Group collaboratively organized a workshop of key stakeholders in June 2019 to define key standards to generate pharmacology data for antiretrovirals to be used among pregnant and lactating women; review the antiretroviral product pipeline; describe key gaps for use in low-income and middle-income countries; and identify opportunities to undertake optimal studies allowing for rapid implementation in the clinical field. We discussed ethical and regulatory principles, systemic approaches to obtaining data for pregnancy pharmacokinetic/pharmacodynamic (PK/PD) studies, control groups, optimal sampling times during pregnancy, and pharmacokinetic parameters to be considered as primary end points in pregnancy PK/PD studies. For lactation studies, the type of milk to collect, ascertainment of maternal adherence, and optimal PK methods to estimate exposure were discussed. Participants strongly recommended completion of preclinical reproductive toxicology studies prior to phase III, to allow study protocols to include pregnant women or to allow women who become pregnant after enrolment to continue in the trial. The meeting concluded by developing an algorithm for design and interpretation of results and noted that recruitment of pregnant and lactating women into clinical trials is critical.
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Affiliation(s)
- Ahizechukwu C. Eke
- Division of Maternal Fetal MedicineDepartment of Gynecology & ObstetricsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Adeniyi Olagunju
- Faculty of PharmacyObafemi Awolowo UniversityIle‐IfeNigeria
- Department of Molecular & Clinical PharmacologyUniversity of LiverpoolLiverpoolUK
| | - Jeremiah Momper
- Skaggs School of Pharmacy and Pharmaceutical SciencesUniversity of California San DiegoLa JollaCaliforniaUSA
| | - Martina Penazzato
- HIV, Hepatitis and STI DepartmentWorld Health OrganizationGenevaSwitzerland
| | - Elaine J. Abrams
- Mailman School of Public HealthICAP at Columbia UniversityNew YorkNew YorkUSA
- Department of PediatricsVagelos College of Physicians & SurgeonsColumbia UniversityNew YorkNew YorkUSA
| | - Brookie M. Best
- Skaggs School of Pharmacy and Pharmaceutical SciencesUniversity of California San DiegoLa JollaCaliforniaUSA
- Pediatrics DepartmentUniversity of California San Diego School of Medicine‐Rady Children’s Hospital San DiegoSan DiegoCaliforniaUSA
- University of LiverpoolLiverpoolUK
| | - Edmund V. Capparelli
- Skaggs School of Pharmacy and Pharmaceutical SciencesUniversity of California San DiegoLa JollaCaliforniaUSA
- Pediatrics DepartmentUniversity of California San Diego School of Medicine‐Rady Children’s Hospital San DiegoSan DiegoCaliforniaUSA
- University of LiverpoolLiverpoolUK
| | - Adrie Bekker
- Department of Paediatrics and Child HealthStellenbosch UniversityCape TownSouth Africa
| | - Yodit Belew
- Division of Antiviral Products, US Food and Drug Administration (FDA)Silver SpringMarylandUSA
| | - Jennifer J. Kiser
- Department of Pharmaceutical SciencesUniversity of Colorado Skaggs School of Pharmacy and Pharmaceutical SciencesAuroraColoradoUSA
| | - Kimberly Struble
- Division of Antiviral Products, US Food and Drug Administration (FDA)Silver SpringMarylandUSA
| | - Graham Taylor
- Department of Infectious DiseaseFaculty of MedicineImperial CollegeLondonUK
| | - Catriona Waitt
- Department of HIV PharmacologyUniversity of LiverpoolLiverpoolUK
| | | | - Tim R. Cressey
- Department of Molecular & Clinical PharmacologyUniversity of LiverpoolLiverpoolUK
- PHPT/IRD UMI 174Faculty of Associated Medical SciencesChiang Mai UniversityChiang MaiThailand
- Department of Immunology & Infectious DiseasesHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Angela Colbers
- Department of PharmacyRadboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
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14
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Rubio-Garrido M, Reina G, Ndarabu A, Rodriguez-Galet A, Valadés-Alcaraz A, Barquín D, Carlos S, Holguín Á. High drug resistance levels could compromise the control of HIV infection in paediatric and adolescent population in Kinshasa, the Democratic Republic of Congo. PLoS One 2021; 16:e0248835. [PMID: 33857166 PMCID: PMC8049233 DOI: 10.1371/journal.pone.0248835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 12/18/2020] [Indexed: 11/18/2022] Open
Abstract
Background The inadequacy of HIV viraemia and resistance monitoring in Africa leads to uncontrolled circulation of HIV strains with drug resistance mutations (DRM), compromising antiretroviral therapy (ART) effectiveness. This study describes the DRM prevalence and its therapeutic impact in HIV-infected pediatric patients from Kinshasa (Democratic Republic of Congo, DRC). Methods From 2016–2018, dried blood were collected from 71 HIV-infected children and adolescents under ART in two hospitals in Kinshasa for HIV-1 DRM pol analysis, predicted ARV-susceptibility by Stanford and phylogenetic characterization. Results HIV-1 sequences were recovered from 55 children/adolescents with 14 years of median-age. All had received nucleoside and non-nucleoside reverse transcriptase inhibitors (NRTI, NNRTI), 9.1% protease inhibitors (PI) and only one integrase inhibitor (INI). Despite the use of ART, 89.1% showed virological failure and 67.3% carried viruses with major-DRM to one (12.7%), two (47.3%), or three (5.5%) ARV-families. Most children/adolescents harbored DRM to NNRTI (73.5%) or NRTI (61.2%). Major-DRM to PI was present in 8.3% and minor-DRM to INI in 15%. Dual-class-NRTI+NNRTI resistance appeared in 53.1% of patients. Viruses presented high/intermediate resistance to nevirapine (72.9% patients), efavirenz (70.9%), emtricitabine/lamivudine (47.9%), rilpivirine (41.7%), etravirine (39.6%), doravidine (33.3%), zidovudine (22.9%), among others. Most participants were susceptible to INI and PI. Great diversity of variants was found, with a high rate (40%) of unique recombinants. Conclusion The high DRM prevalence observed among HIV-infected children and adolescents in Kinshasa could compromise the 95-95-95-UNAIDS targets in the DRC. It also reinforces the need for routine resistance monitoring for optimal rescue therapy election in this vulnerable population to control the spread of resistant HIV in the country.
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Affiliation(s)
- Marina Rubio-Garrido
- HIV-1 Molecular Epidemiology Laboratory, Microbiology and Parasitology Department, Hospital Ramón y Cajal-IRYCIS and CIBEREsp-RITIP-CoRISPe, Madrid, Spain
| | - Gabriel Reina
- Microbiology Department, Clínica Universidad de Navarra, Navarra Institute for Health Research, Institute of Tropical Health, Universidad de Navarra, Pamplona, Spain
| | | | - Ana Rodriguez-Galet
- HIV-1 Molecular Epidemiology Laboratory, Microbiology and Parasitology Department, Hospital Ramón y Cajal-IRYCIS and CIBEREsp-RITIP-CoRISPe, Madrid, Spain
| | - Ana Valadés-Alcaraz
- HIV-1 Molecular Epidemiology Laboratory, Microbiology and Parasitology Department, Hospital Ramón y Cajal-IRYCIS and CIBEREsp-RITIP-CoRISPe, Madrid, Spain
| | - David Barquín
- Microbiology Department, Clínica Universidad de Navarra, Navarra Institute for Health Research, Institute of Tropical Health, Universidad de Navarra, Pamplona, Spain
| | - Silvia Carlos
- Department of Preventive Medicine and Public Health, Universidad de Navarra, Navarra Institute for Health Research, Institute of Tropical Health, Universidad de Navarra, Pamplona, Spain
| | - África Holguín
- HIV-1 Molecular Epidemiology Laboratory, Microbiology and Parasitology Department, Hospital Ramón y Cajal-IRYCIS and CIBEREsp-RITIP-CoRISPe, Madrid, Spain
- * E-mail:
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15
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Early post-partum viremia predicts long-term non-suppression of viral load in HIV-positive women on ART in Malawi: Implications for the elimination of infant transmission. PLoS One 2021; 16:e0248559. [PMID: 33711066 PMCID: PMC7954347 DOI: 10.1371/journal.pone.0248559] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/01/2021] [Indexed: 12/03/2022] Open
Abstract
Background Long-term viral load (VL) suppression among HIV-positive, reproductive-aged women on ART is key to eliminating mother-to-child transmission (MTCT) but few data exist from sub-Saharan Africa. We report trends in post-partum VL in Malawian women on ART and factors associated with detectable VL up to 24 months post-partum. Methods 1–6 months post-partum mothers, screened HIV-positive at outpatient clinics in Malawi, were enrolled (2014–2016) with their infants. At enrollment, 12- and 24-months post-partum socio-demographic and PMTCT indicators were collected. Venous samples were collected for determination of maternal VL (limit of detection 40 copies/ml). Results were returned to clinics for routine management. Results 596/1281 (46.5%) women were retained in the study to 24 months. Those retained were older (p<0.01), had higher parity (p = 0.03) and more likely to have undetectable VL at enrollment than those lost to follow-up (80.0% vs 70.2%, p<0.01). Of 590 women on ART (median 30.1 months; inter-quartile range 26.8–61.3), 442 (74.9%) with complete VL data at 3 visits were included in further analysis. Prevalence of detectable VL at 12 and 24 months was higher among women with detectable VL at enrollment than among those with undetectable VL (74 detectable VL results/66 women vs. 19/359; p<0.001). In multivariable analysis (adjusted for age, parity, education, partner disclosure, timing of ART start and self-reported adherence), detectable VL at 24 months was 9 times more likely among women with 1 prior detectable VL (aOR 9.0; 95%CI 3.5–23.0, p<0.001) and 226 times more likely for women with 2 prior detectable VLs (aOR 226.4; 95%CI 73.0–701.8, p<0.001). Conclusions Detectable virus early post-partum strongly increases risk of ongoing post-partum viremia. Due to high loss to follow-up, the true incidence of detectable VL over time is probably underestimated. These findings have implications for MTCT, as well as for the mothers, and call for intensified VL monitoring and targeted adherence support for women during pregnancy and post-partum.
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16
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Sebastião CS, Morais J, Brito M. Factors Influencing HIV Drug Resistance among Pregnant Women in Luanda, Angola: Findings from a Cross-Sectional Study. Trop Med Infect Dis 2021; 6:tropicalmed6010029. [PMID: 33807796 PMCID: PMC8005960 DOI: 10.3390/tropicalmed6010029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 11/21/2022] Open
Abstract
The increase in HIV infection and drug-resistant strains is an important public health concern, especially in resource-limited settings. However, the identification of factors related to the propagation of infectious diseases represents a crucial target offering an opportunity to reduce health care costs as well as deepening the focus on preventing infection in high-risk groups. In this study, we investigate the factors related to drug resistance among HIV-infected pregnant women in Luanda, the capital city of Angola. This was a part of a cross-sectional study conducted with 42 HIV-positive pregnant women. A blood sample was collected, and HIV-1 genotyping was carried out using an in-house method. Multivariate analyses were performed to determine the interaction between sociodemographic characteristics and drug resistance. HIV drug resistance was detected in 44.1% of the studied population. High probabilities of drug resistance were observed for HIV-infected pregnant women living in rural areas (AOR: 2.73; 95% CI: 0.50–14.9) with high educational level (AOR: 6.27; 95% CI: 0.77–51.2) and comorbidities (AOR: 5.47; 95% CI: 0.28–106) and infected with a HIV-1 non-B subtype other than subtype C (AOR: 1.60; 95% CI: 0.25–10.3). The present study reports high HIV drug resistance. Furthermore, older-age, rural areas, high educational levels, unemployed status, having comorbidities, and HIV-1 subtypes were factors related to drug resistance. These factors impact on drug susceptibility and need to be urgently addressed in order to promote health education campaigns able to prevent the spread of drug-resistant HIV strains in Angola.
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Affiliation(s)
- Cruz S. Sebastião
- Centro de Investigação em Saúde de Angola, Caxito, Angola; (C.S.S.); (J.M.)
- Molecular Biology Laboratory, Instituto Nacional de Investigação em Saúde, Luanda, Angola
- Instituto Superior de Ciências da Saúde, Universidade Agostinho Neto, Luanda, Angola
| | - Joana Morais
- Centro de Investigação em Saúde de Angola, Caxito, Angola; (C.S.S.); (J.M.)
- Molecular Biology Laboratory, Instituto Nacional de Investigação em Saúde, Luanda, Angola
- Faculdade de Medicina, Universidade Agostinho Neto, Luanda, Angola
| | - Miguel Brito
- Centro de Investigação em Saúde de Angola, Caxito, Angola; (C.S.S.); (J.M.)
- Health and Technology Research Center, Escola Superior de Tecnologia da Saúde de Lisboa, Instituto Politécnico de Lisboa, 1990-096 Lisboa, Portugal
- Correspondence:
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Lyatuu GW, Mwashemele SZ, Urrio R, Naburi H, Kashmir N, Machumi L, Kibao A, Sellah Z, Ulenga N, Orsini N, Biberfeld G, Kilewo C, Ekström AM. Long-term virological outcomes in women who started option B+ care during pregnancy for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania: a cohort study. Lancet HIV 2021; 8:e256-e265. [PMID: 33581776 DOI: 10.1016/s2352-3018(20)30308-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 10/20/2020] [Accepted: 11/09/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Option B+ marked a milestone in prevention of mother-to-child transmission (PMTCT) of HIV by recommending lifelong antiretroviral therapy (ART) for all pregnant women with HIV. Nevertheless, concerns remain regarding long-term outcomes in settings with a high HIV burden. We analysed long-term virological outcomes in women enrolled on option B+ in Tanzania. METHODS In this prospective cohort study, we extracted data for pregnant women with HIV starting PMTCT care between Oct 1, 2014, and Sept 30, 2016, in routine health-care settings in Dar es Salaam, Tanzania, from national HIV and district health information system databases. We then excluded women who exited study sites before 6 months of ART follow-up and women who did not have a viral load test. Women were followed up until March 8, 2019. We used Poisson generalised estimating equations to examine trends in HIV viral suppression (<400 copies per mL) and virological failure (≥400 copies per mL), reporting relative risks (RRs) and 95% CIs adjusted for maternal age, gestational age, and several clinical characteristics. FINDINGS We identified 15 586 pregnant women with HIV, of whom 10 161 were eligible for follow-up. Women were followed up for a median of 37 months (IQR 31-45) and a maximum of 53 months. The median age at PMTCT initiation was 31 years (IQR 27-35). At PMTCT enrolment, 1245 (17·0%) of 7318 women with available data were in their third trimester, 4901 (48·2%) of 10 161 women started ART at least 1 month before PMTCT enrolment, and 3380 (33·4%) of 10 131 women with available data had advanced HIV. Overall, a viral suppression rate of 88·2% (95% CI 87·8-88·7) was observed over the entire follow-up period, ranging from 85·1% (84·3-85·9) in viral load tests done at 0-11 months to 90·6% (89·7-91·4) at 36 months or longer since PMTCT enrolment. In a complete-case analysis (ie, including patients with <30% missing data; n=7306), the risk of virological failure among women who remained in HIV care decreased over time (adjusted RR 0·87 [95% CI 0·80-0·95] at 12-23 months since PMTCT enrolment; 0·65 [0·59-0·72] at 24-35 months; and 0·63 [0·55-0·71] at ≥36 months vs at 0-11 months). Younger women (aged <20 years: 1·76 [1·40-2·23] vs aged 30-39 years) and those starting PMTCT late in pregnancy (third trimester: 1·28 [1·10-1·50] vs first trimester) or with advanced HIV (1·33 [1·16-1·51] vs without advanced HIV) had increased risk of virological failure. Women who attended an antenatal care facility where more than 50% of attendees received couples HIV testing had a decreased risk of virological failure (adjusted RR 0·81 [0·65-0·99] vs <50% having couples testing). INTERPRETATION High rates of viral suppression among women starting option B+ who remain in HIV care are sustainable, and might increase, at least up to 53 months. This rate might be further improved by addressing challenges of adolescent mothers, late presenters, and couples HIV testing at antenatal care. FUNDING Swedish International Development Agency.
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Affiliation(s)
- Goodluck W Lyatuu
- Management and Development for Health, Dar es Salaam, Tanzania; Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | | | - Roseline Urrio
- Management and Development for Health, Dar es Salaam, Tanzania; Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Helga Naburi
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Nassir Kashmir
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Lameck Machumi
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Ayoub Kibao
- Dar es Salaam Regional Administrative Secretary, Dar es Salaam, Tanzania
| | - Ziada Sellah
- Dar es Salaam Regional Administrative Secretary, Dar es Salaam, Tanzania
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Nicola Orsini
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Gunnel Biberfeld
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Charles Kilewo
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Kouamou V, Manasa J, Katzenstein D, McGregor AM, Ndhlovu CE, Makadzange T. Diagnostic Accuracy of Pan-Degenerate Amplification and Adaptation Assay for HIV-1 Drug Resistance Mutation Analysis in Low- and Middle-Income Countries. J Clin Microbiol 2020; 58:e01045-20. [PMID: 32522826 PMCID: PMC7448631 DOI: 10.1128/jcm.01045-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 06/07/2020] [Indexed: 11/20/2022] Open
Abstract
HIV drug resistance (HIVDR) is a barrier to sustained virologic suppression in low- and middle-income countries (LMICs). Point mutation assays targeting priority drug resistance mutations (DRMs) are being evaluated to improve access to HIVDR testing. In a cross-sectional study (June 2018 to September 2019), we evaluated the diagnostic accuracy of a simple and rapid HIVDR assay (the pan-degenerate amplification and adaptation [PANDAA] assay targeting the mutations K65R, K103NS, M184VI, Y181C, and G190A) compared to Sanger sequencing and next-generation sequencing (NGS). Plasma samples from adolescents and young adults (aged 10 to 24 years) failing antiretroviral therapy (viral load, >1,000 copies/ml on 2 consecutive occasions 1 month apart) were analyzed. Sensitivity and specificity of the PANDAA assay were determined by a proprietary application designed by Aldatu Biosciences. Agreement between genotyping methods was evaluated using Cohen's kappa coefficient. One hundred fifty samples previously characterized by Sanger sequencing were evaluated using PANDAA. For all DRMs detected, PANDAA showed a sensitivity and specificity of 98% and 94%, respectively. For nucleotide reverse transcriptase inhibitor DRMs, sensitivity and specificity were 98% (95% confidence interval [CI], 92% to 100%) and 100% (94% to 100%), respectively. For non-nucleotide reverse transcriptase inhibitor DRMs, sensitivity and specificity were 100% (97% to 100%) and 76% (61% to 87%), respectively. PANDAA showed strong agreement with Sanger sequencing for K65R, K103NS, M184VI, and G190A (kappa > 0.85) and substantial agreement for Y181C (kappa = 0.720). Of the 21 false-positive samples genotyped by PANDAA, only 6 (29%) were identified as low-abundance variants by NGS. With the high sensitivity and specificity to detect major DRMs, PANDAA could represent a simple and rapid alternative HIVDR assay in LMICs.
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Affiliation(s)
- Vinie Kouamou
- Department of Medicine, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Justen Manasa
- Department of Medical Microbiology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - David Katzenstein
- Department of Molecular Biology, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Alan M McGregor
- Department of Medicine, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Chiratidzo E Ndhlovu
- Department of Medicine, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Tariro Makadzange
- Department of Medicine, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
- Harvard Medical School, Boston, Massachusetts, USA
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Martin IB, Read S, Harrigan R, Gomez MP. Treatment Experience and Repeat Pregnancy Impact the Effectiveness of Non-Nucleoside Reverse Transcription Inhibitor-Highly Active Antiretroviral Therapy for the Prevention of Mother to Child Transmission of Human Immunodeficiency Virus. AIDS Res Hum Retroviruses 2020; 36:681-687. [PMID: 32408754 DOI: 10.1089/aid.2019.0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Non-nucleoside reverse transcription inhibitor (NNRTI)-containing antiretroviral therapy (ART) for the prevention of mother to child transmission (PMTCT) of human immunodeficiency virus (HIV) has led to dramatic reductions in perinatal HIV infection in resource-constrained settings. Nonetheless, PMTCT programs are complicated by repeat pregnancies, in which long-term or repeat exposures to PMTCT regimens over time may lead to the acquisition of HIV drug resistance mutations, and consequent treatment failure. In this study, we retrospectively assessed the effectiveness of the NNRTI-based PMTCT protocol from 2008 to 2010 in The Bahamas National HIV/AIDS Program. We show that women who had been in repeat pregnancies and those who were already prescribed ART at conception were at increased risk of virologic failure, relative to treatment-inexperienced women and primigravida, respectively (AOR 3.1, 95% CI: 1.3-7.1, p = .008 and AOR 5.0, 95% CI: 1.8-14.1, p = .002). In addition, women undergoing treatment at conception were more likely to possess HIVDR mutations relative to treatment-naive women (AOR 447.1, 95% CI: 17.9-11,173.5, p = .001). Therefore, individual treatment history is a key metric determining the effectiveness of current and future PMTCT interventions. The implications of this to PMTCT programmatic success in light of the most recent WHO guidelines are discussed.
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Affiliation(s)
| | - Stanley Read
- Department of Paediatrics, University of Toronto Hospital for Sick Kids, Toronto, Canada
| | - Richard Harrigan
- Research Laboratory, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - M. Perry Gomez
- Reference Lab, The Bahamas Ministry of Health, Nassau, Bahamas
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Matthews LT, Orrell C, Bwana MB, Tsai AC, Psaros C, Asiimwe S, Amanyire G, Musinguzi N, Bell K, Bangsberg DR, Haberer JE. Adherence to HIV antiretroviral therapy among pregnant and postpartum women during the Option B+ era: 12-month cohort study in urban South Africa and rural Uganda. J Int AIDS Soc 2020; 23:e25586. [PMID: 32820622 PMCID: PMC7441010 DOI: 10.1002/jia2.25586] [Citation(s) in RCA: 14] [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: 12/19/2019] [Revised: 06/18/2020] [Accepted: 07/01/2020] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION We conducted a cohort study to understand patterns of anti-retroviral therapy (ART) adherence during pregnancy, postpartum and non-pregnancy follow-up among women initiating ART in public clinics offering Option B+ in rural Uganda and urban South Africa. METHODS We collected survey data, continuously monitored ART adherence (Wisepill), HIV-RNA and pregnancy tests at zero, six and twelve months from women initiating ART in Uganda and South Africa, 2015 to 2017. The primary predictor of interest was follow-up time categorized as pregnant (pregnancy diagnosis to pregnancy end), postpartum (pregnancy end to study exit) or non-pregnancy-related (neither pregnant nor postpartum). Fractional regression models included demographics and socio-behavioural factors informed by the Behavioral Model for Vulnerable Populations. We evaluated HIV-RNA at 12 months by ever- versus never-pregnant status. RESULTS In Uganda, 247 women contributed 676, 900 and 1274 months of pregnancy, postpartum and non-pregnancy-related follow-up. Median ART adherence was consistently ≥90%: pregnancy, 94% (interquartile range [IQR] 78,98); postpartum, 90% (IQR 70,97) and non-pregnancy, 90% (IQR 80,98). Poorer adherence was associated with younger age (0.98% [95% CI 0.33%, 1.62%] average increase per year of age) and higher CD4 cell count (1.01% [0.08%, 1.94%] average decrease per 50 cells/mm3 ). HIV-RNA was suppressed among 91% (N = 135) ever-pregnant and 86% (N = 85) never-pregnant women. In South Africa, 190 women contributed 259, 624 and 1247 months of pregnancy, postpartum and non-pregnancy-related follow-up. Median adherence was low during pregnancy, 74% (IQR 31,96); postpartum, 40% (IQR 4,65) and non-pregnancy, 77% (IQR 47,92). Poorer adherence was associated with postpartum status (22.3% [95%CI 8.6%, 35.4%] average decrease compared to non-pregnancy-related follow-up) and less emotional support (1.4% [0.22%, 2.58%] average increase per unit increase). HIV-RNA was suppressed among 57% (N = 47) ever-pregnant and 86% (N = 93) never-pregnant women. CONCLUSIONS Women in rural Uganda maintained high adherence with 91% of ever-pregnant and 86% of never-pregnant women suppressing HIV-RNA at 12 months. Women in urban South Africa struggled with adherence, particularly during postpartum follow-up with median adherence of 40% and 57% of women with HIV-RNA suppression at one year, suggesting a crisis for postpartum women with HIV in South Africa. Findings suggest that effective interventions should promote emotional support.
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Affiliation(s)
- Lynn T Matthews
- Department of MedicineUniversity of Alabama at BirminghamBirminghamALUSA
- Department of MedicineMassachusetts General HospitalBostonMAUSA
| | | | | | - Alexander C Tsai
- Mbarara University of Science and TechnologyMbararaUganda
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
- Harvard Center for Population and Development StudiesBostonMAUSA
| | - Christina Psaros
- Department of PsychiatryMassachusetts General HospitalBostonMAUSA
| | - Stephen Asiimwe
- Mbarara University of Science and TechnologyMbararaUganda
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
- Kabwohe Clinical Research Center (KCRC)KabwoheUganda
| | - Gideon Amanyire
- Makerere‐Mbarara Universities Joint AIDS Program (MJAP)MbararaUganda
| | - Nicholas Musinguzi
- Mbarara University of Science and TechnologyMbararaUganda
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
| | - Kathleen Bell
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
| | - David R Bangsberg
- School of Public HealthOregon Health and Science University/Portland State UniversityPortlandORUSA
| | - Jessica E Haberer
- Department of MedicineMassachusetts General HospitalBostonMAUSA
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
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Abstract
Supplemental Digital Content is Available in the Text. HIV-infected, postpartum women on antiretroviral therapy (ART) have high rates of viremia. We examined predictors of postpartum viremia in the PROMISE study.
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Psaros C, Stanton AM, Bedoya CA, Mosery N, Evans S, Matthews LT, Haberer J, Vangel M, Safren S, Smit JA. Protocol for a prospective evaluation of postpartum engagement in HIV care among women living with HIV in South Africa. BMJ Open 2020; 10:e035465. [PMID: 31924641 PMCID: PMC6955573 DOI: 10.1136/bmjopen-2019-035465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION KwaZulu-Natal (KZN), South Africa (SA) has the highest prevalence of pregnant women living with HIV in the world. Pregnancy and the postpartum period offer opportunities to engage women in HIV care, to prevent perinatal transmission and to optimise maternal and infant well-being. However, research suggests that remaining engaged in HIV care during this time can be challenging. METHODS AND ANALYSIS We are conducting a 5-year prospective cohort study among pregnant women living with HIV in KZN to estimate the rates and factors associated with attrition from HIV care during this critical period. To determine who is most likely to fall out of care, we are examining a range of relevant variables informed by a socioecological model of HIV care, including individual, relational, community and healthcare system variables. We are enrolling 18-45-year-old women, at 28 weeks or more of pregnancy, who are living with HIV and currently taking antiretroviral therapies. Participants complete quantitative assessments at baseline (pregnancy) and at 6, 12, 18 and 24 months postpartum. A subset of women and their partners are invited to complete qualitative interviews to further explore their experiences in HIV care. The main study outcomes are suppressed HIV RNA and retention in care at each study assessment. Our understanding of the factors that drive postpartum attrition from HIV care will ultimately inform the development of interventions to facilitate continued engagement in postpartum HIV care. ETHICS AND DISSEMINATION This protocol has been approved by the Human Research Ethics Committee (Medical) at The University of the Witwatersrand (Johannesburg, SA) and the Partners Human Research Committee at Partners HealthCare (Boston, Massachusetts, USA). Site support and approval were obtained from the District Hospital and the KZN Provincial Department of Health. Results will be disseminated through peer-reviewed manuscripts, reports and both local and international presentations (Ethics Registration #170 212).
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Affiliation(s)
- Christina Psaros
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amelia M Stanton
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - C Andres Bedoya
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nzwakie Mosery
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
| | - Shannon Evans
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
| | - Lynn Turner Matthews
- Department of Medicine, Division of Infectious Diseases, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jessica Haberer
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Global Health, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mark Vangel
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Steven Safren
- Department of Psychology, University of Miami, Coral Gables, Florida, USA
| | - Jennifer A Smit
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
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Napyo A, Tumwine JK, Mukunya D, Tumuhamye J, Arach AAO, Ndeezi G, Waako P, Tylleskär T. Detectable HIV-RNA Viral Load Among HIV-Infected Pregnant Women on Treatment in Northern Uganda. Int J MCH AIDS 2020; 9:232-241. [PMID: 32704410 PMCID: PMC7370273 DOI: 10.21106/ijma.374] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND / OBJECTIVES Detectable HIV viral load among HIV-infected pregnant women remains a public health threat. We aimed to determine factors associated with detectable viral load among HIV-infected pregnant women in Lira, Northern Uganda. METHODS We conducted a cross-sectional survey among 420 HIV-infected pregnant women attending Lira Regional Referral Hospital using a structured questionnaire and combined it with viral load tests from Uganda National Health Laboratories. We conducted multivariable logistic regression while adjusting for confounders to determine the factors associated with detectable viral load and we report adjusted odds ratios and proportion of women with viral load less than 50 copies/ml and above 1000 copies, respectively. RESULTS The prevalence of detectable viral load (>50 copies/ml) was 30.7% (95%CI: 26.3% - 35.4%) and >1000 copies/ml was 8.1% (95% CI: 5.7% - 11.1%). Factors associated with detectable viral load were not belonging to the Lango ethnicity (adjusted odds ratio = 1.92, 95%CI: 1.05 - 3.90) and taking a second-line (protease inhibitor-based) regimen (adjusted odds ratio = 4.41, 95%CI: 1.13 - 17.22). CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS HIV-infected pregnant women likely to have detectable viral load included those taking a protease inhibitor-based regimen and those who were not natives of Lira. We recommend intensified clinical and psychosocial monitoring for medication compliance among HIV-infected pregnant women that are likely to have a detectable viral load to significantly lower the risk of vertical transmission of HIV in Lira specifically those taking a protease inhibitor-based regimen and those who are non-natives to the study setting. Much as the third 90% of the global UNAIDS 90-90-90 target has been achieved, the national implementation of PMTCT guidelines should be tailored to its contextual needs.
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Affiliation(s)
- Agnes Napyo
- Department of Public Health, Faculty of Health Sciences, Busitema University, 236 Tororo, Uganda.,Centre for International Health, University of Bergen, 7804 Bergen, Norway.,Department of Pediatrics and Child Health, Makerere University, 7062 Kampala, Uganda
| | - James K Tumwine
- Department of Pediatrics and Child Health, Makerere University, 7062 Kampala, Uganda
| | - David Mukunya
- Centre for International Health, University of Bergen, 7804 Bergen, Norway
| | | | - Anna Agnes Ojok Arach
- Department of Pediatrics and Child Health, Makerere University, 7062 Kampala, Uganda.,Department of Nursing, Lira University, 1035 Lira, Uganda
| | - Grace Ndeezi
- Department of Pediatrics and Child Health, Makerere University, 7062 Kampala, Uganda
| | - Paul Waako
- Department of Pharmacology, Faculty of Health Sciences, Busitema University, 236 Tororo, Uganda
| | - Thorkild Tylleskär
- Centre for International Health, University of Bergen, 7804 Bergen, Norway
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Chan M, Muriuki EM, Emery S, Kanthula R, Chohan V, Frenkel LM, Wald A, Chohan B, Overbaugh J, Roxby AC. Correlates of HIV detection among breastfeeding postpartum Kenyan women eligible under Option B. PLoS One 2019; 14:e0216252. [PMID: 31150396 PMCID: PMC6544340 DOI: 10.1371/journal.pone.0216252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 04/16/2019] [Indexed: 12/13/2022] Open
Abstract
Background The Option B+ strategy streamlines delivery of HIV antiretroviral therapy (ART) to pregnant women, but concerns remain about ART treatment adherence and long term outcomes. Methods We conducted a retrospective analysis of a cohort of HIV-positive, postpartum breastfeeding women receiving ART via Option B+ in Nairobi, Kenya. The primary outcome was virologic failure in plasma (HIV RNA >1000 copies/mL), and detection in breast milk (>150 copies/mL) and endocervical secretions (>100 copies/mL) at 2 postpartum timepoints. Correlates of virologic failure were assessed using univariate tests and multivariate logistic regression. Results Of 42 women at 6–14 weeks postpartum, 21.4% of women had HIV RNA detected in plasma; 14.3% in breast milk, and 23.7% in endocervical secretions. At 18–24 weeks postpartum, the percentages were 21.1%, 7.1%, and 14.3%, respectively. Younger maternal age, intent to breastfeed for longer, and later ART start in pregnancy were significantly associated with plasma virologic failure (p < 0.05 for each). Odds of plasma virologic failure at 6–14 weeks postpartum were 1.25 times higher (95% CI 1.04, 1.51) for each increase in week of gestation at ART initiation. Only 3 women had resistance mutations to their regimen. Conclusions Despite months of ART, nearly one-quarter of the women in our cohort did not achieve plasma virologic suppression in the postpartum period. After adjusting for time on ART, earlier ART initiation in pregnancy was significantly associated with plasma suppression. Our findings suggest that postpartum HIV RNA monitoring in Option B+ programs will be needed to achieve elimination of MTCT.
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Affiliation(s)
- Mary Chan
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Eric Munene Muriuki
- Institute for Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - Sandra Emery
- Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Ruth Kanthula
- Seattle Children’s Research Institute, Seattle, Washington, United States of America
| | - Vrasha Chohan
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Lisa M. Frenkel
- Seattle Children’s Research Institute, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Anna Wald
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, United States of America
| | - Bhavna Chohan
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Julie Overbaugh
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Alison C. Roxby
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- * E-mail:
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Zacharius KM, Basinda N, Marwa K, Mtui EH, Kalolo A, Kapesa A. Low adherence to Option B+ antiretroviral therapy among pregnant women and lactating mothers in eastern Tanzania. PLoS One 2019; 14:e0212587. [PMID: 30794633 PMCID: PMC6386496 DOI: 10.1371/journal.pone.0212587] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/05/2019] [Indexed: 11/18/2022] Open
Abstract
Background Adherence to option B+ antiretroviral treatment (ART) is vital to a successful implementation of Prevention of Mother to Child Transmission (PMTCT) program. Further studies show that optimal viral suppression is also crucial for a successful PMTCT program, however barriers to adherence exist and differ among populations and particularly within few years of its adoption in Tanzania. This study therefore aimed at investigating the level and predictors of adherence to ART option B+ among pregnant and lactating women in rural and urban settings of eastern Tanzania. Methodology A cross-sectional study was conducted among 305 pregnant women and lactating mothers on Option B+ regime from six health facilities located in rural and urban settings in Morogoro region in eastern Tanzania. Data were collected using a structured questionnaire. Data analysis was performed using descriptive statistics, as well as bivariate and multivariate logistic regression. Results Good adherence to option B+ PMTCT drugs was 26.3% and 61.1% among respondents residing in urban and rural areas respectively. The rural residents were 4.86 times more likely to adhere compared to their counterparts in an urban area (aOR = 4.86; 95% CI = 2.91–8.13). Similarly, women with male partners’ support in PMTCT were 3.51 times more likely to have good adherence than those without (aOR = 3.51, 95% CI = 1.21–10.15). Moreover, there was a significantly lower odds of adherence to option B+ among those who had been on treatment between one to two years as compared to those had less than one year of treatment (aOR = 0.45; 95%CI = 0.22–0.93). Conclusion Adherence to PMTCT option B+ antiretroviral drugs treatment among pregnant women and breastfeeding mothers was low and much lower among urban residents. Adherence was significantly predicted by rural residence, male partner support and short duration on ART. Efforts to improve adherence should focus on increasing male participation on PMTCT, tailored interventions to urban residents and those who have been on ART for a long duration.
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Affiliation(s)
| | - Namanya Basinda
- School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Karol Marwa
- Department of Pharmacology, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Emmanuel H. Mtui
- Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University, Moshi, Tanzania
| | - Albino Kalolo
- Department of Community Medicine, St. Francis University of Health and Allied Sciences, Ifakara, Tanzania
| | - Anthony Kapesa
- School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
- * E-mail:
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Lyatuu GW, Naburi H, Urrio R, Mwashemele SZ, Mdingi S, Panga R, Koda H, Chende Y, Tsere M, Mhalu A, Siril H, Lema IA, Aris E, Muya AN, Galanti MR, Biberfeld G, Kilewo C, Ekström AM. Engaging community leaders to improve male partner participation in the prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania. PLoS One 2018; 13:e0207986. [PMID: 30540794 PMCID: PMC6291081 DOI: 10.1371/journal.pone.0207986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 11/11/2018] [Indexed: 11/19/2022] Open
Abstract
Background Male partner participation improves uptake, retention and outcomes of prevention of mother-to-child transmission of HIV (PMTCT) services. However, in patriarchal settings few men accompany their partners to antenatal care (ANC) and PMTCT services. We explored whether community leaders can improve male partner participation in ANC and PMTCT. Methods We integrated initiatives to increase male partner participation in routine ANC care in six health facilities (attending about 4,500 new pregnant women per quarter) in Dar es Salaam, Tanzania in 2015/16. These initiatives were adapted from a best performing health facility, on male partner participation in ANC and PMTCT, referred to as the “best practice site”. At the six purposively selected intervention sites, we sensitized and garnered commitment from healthcare providers to provide couple friendly services. We then worked with the providers to sensitize and engage community leaders to integrate and promote male partner participation initiatives in their routine community activities. We assessed change in male partner participation in ANC and PMTCT using the proportion of women testing for HIV together with their partners (i.e. couple HIV testing) by quarter. We used 203 ANC facilities (attending about 31,000 new pregnant women per quarter) in the same area as control sites. Results After one year, couple HIV testing in the six intervention sites had tripled from 11.9% at baseline to 36.0% (p<0.001) while there was very little change (from 17.7% to 18.3%) in the 203 control sites (p = 0.07). Statistically significant improvements in couple testing were observed in four of the six intervention sites (6.7% to 19.1%; 9.3% to 74.6%; 46.2% to 95.2%; and 4.7% to 15.1% respectively. p<0.001 for all sites). Two of these four sites, located in the same administrative district as the best practice site, achieved remarkably high couple HIV testing (95.2% and 74.6%). This may be attributable to the greater engagement and active participation of the community leaders in these two sites compared to the other four. Conclusion Effective engagement and functional partnerships between healthcare providers and community leaders can contribute to improve male partner participation in ANC and PMTCT services. PMTCT programs should capitalize on community leaders, in addressing low male partner participation in ANC and PMTCT, in order to improve effective uptake, retention and outcomes of HIV prevention and treatment services among pregnant and breastfeeding women, their partners, infants and families.
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Affiliation(s)
- Goodluck Willey Lyatuu
- Management and Development for Health, Dar es Salaam, Tanzania
- Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Helga Naburi
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Roseline Urrio
- Management and Development for Health, Dar es Salaam, Tanzania
- Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Sarah Mdingi
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Rehema Panga
- Ubungo Municipal Council, Dar es Salaam, Tanzania
| | - Happiness Koda
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Yusuph Chende
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Martha Tsere
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Aisa Mhalu
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Helen Siril
- Management and Development for Health, Dar es Salaam, Tanzania
| | | | - Eric Aris
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Aisa Nkya Muya
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Maria Rosaria Galanti
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
| | - Gunnel Biberfeld
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
| | - Charles Kilewo
- Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Anna Mia Ekström
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Disease, Karolinska university hospital, Stockholm, Sweden
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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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Atanga PN, Ndetan HT, Fon PN, Meriki HD, Muffih TP, Achidi EA, Hoelscher M, Kroidl A. Using a composite adherence tool to assess ART response and risk factors of poor adherence in pregnant and breastfeeding HIV-positive Cameroonian women at 6 and 12 months after initiating option B. BMC Pregnancy Childbirth 2018; 18:418. [PMID: 30359239 PMCID: PMC6202832 DOI: 10.1186/s12884-018-2058-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 10/15/2018] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) adherence in preventing HIV mother-to-child transmission in association with virological suppression and risk factors of low adherence in the Cameroon's Option B+ programme are poorly understood. We used a composite adherence score (CAS) to determine adherence and risk factors of poor adherence in association with virological treatment response in HIV-positive pregnant and breastfeeding women who remained in care at 6 and 12 months after initiating ART. METHODS We prospectively enrolled 268 women after ART initiation between October 2013 and December 2015 from five facilities within the Kumba health district. Adherence at 6 and 12 months were measured using a CAS comprising of a 6-month medication refill record review, a four-item self-reported questionnaires and a 30-day visual analogue scale. Adherence was defined as the sum scores of the three measures and classified as high, moderate and low. Measured adherence levels were compared to virological suppression rates at month 12 and risk factors of poor adherence were determined. RESULTS At 6 and 12 months, 217 (81.0%) and 185 (69.0%) women were available for adherence evaluation. Respectively. Of those, 128 (59.0%) and 68 (31.4%) had high or moderate adherence as per the CAS tool at month 6, and 116 (62.7%) and 48 (24.9%) at month 12, respectively. Viral loads were assessed in 165 women at months 12, and 92.7% had viral suppression (< 1000 copies/mL). Viral suppression was seen in 100% of women with high, 89.5% with moderate, and 52.9% with low adherence using the CAS tool. Virological treatment failure was significantly associated with low adherence [OR 7.6, (95%CI, 1.8-30.8)]. Risk factors for low adherence were younger age [aOR 3.8, (95%CI, 1.4-10.6)], primary as compared to higher levels of education [aOR 2.7, (95%CI, 1.4-5.2)] and employment in the informal sector compared to unemployment [aOR 1.9, (95%CI,1.0-3.6)]. CONCLUSIONS During the first year of Option B+ implementation in Cameroon our novel CAS adherence tool was feasible, and useful to discriminate ART adherence levels which correlated with viral suppression. Younger age, less educated and informal sector employed women may need more attention for optimal adherence to reduce the risk of virological failure.
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Affiliation(s)
- Pascal N Atanga
- Cameroon Baptist Convention Health Service (CBCHS), P. O. Box 152, Tiko, Health Services Complex, Mutengene, South West Region, Cameroon. .,Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, P.O. Box 63, Buea, Cameroon. .,Centre for International Health (CIH), University of Munich (LMU), Munich, Germany.
| | - Harrison T Ndetan
- Department of Epidemiology and Biostatistics, University Texas Health Northeast, School of Community and Rural Health, Tyler, USA.,Department of Biostatistics and Epidemiology, School of Public Health, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Peter N Fon
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, P.O. Box 63, Buea, Cameroon
| | - Henry D Meriki
- Department of Microbiology and Parasitology, Faculty of Sciences, University of Buea, P.O. Box 63, Buea, Cameroon.,Laboratory Department, Regional Hospital Buea, Buea, Cameroon
| | - Tih P Muffih
- Cameroon Baptist Convention Health Service (CBCHS), P. O. Box 152, Tiko, Health Services Complex, Mutengene, South West Region, Cameroon
| | - Eric A Achidi
- Faculty of Science, University of Buea, P.O. Box 63, Buea, Cameroon
| | - Michael Hoelscher
- Centre for International Health (CIH), University of Munich (LMU), Munich, Germany.,Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Munich, Germany.,German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Arne Kroidl
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Munich, Germany.,German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
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Phillips TK, Clouse K, Zerbe A, Orrell C, Abrams EJ, Myer L. Linkage to care, mobility and retention of HIV-positive postpartum women in antiretroviral therapy services in South Africa. J Int AIDS Soc 2018; 21 Suppl 4:e25114. [PMID: 30027583 PMCID: PMC6053482 DOI: 10.1002/jia2.25114] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/08/2018] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Linkage to care and mobility postpartum present challenges to long-term retention after initiating antiretroviral therapy (ART) in pregnancy, but there are few insights from sub-Saharan Africa. We aimed to describe postpartum linkage to care, mobility, retention and viral suppression after ART initiation in pregnancy. METHODS Using routine electronic data we assessed HIV-specific health contacts and clinic movements among women initiating ART in an integrated antenatal care (ANC) and ART clinic in Cape Town, South Africa. The local care model includes mandatory transfer to general ART clinics postpartum. We investigated linkage to care after leaving the integrated clinic and mobility to new clinics until 30 months on ART. We used Poisson regression to explore predictors of linkage, retention (accessing care at least once at both 12 [6 to <18] and 24 [18 to <30] months on ART), and viral suppression (HIV viral load [VL] ≤50 and ≤1000 copies/mL after 12 months on ART). RESULTS Among 617 women, 23% never linked to care; 71% and 65% were retained at 12 and 24 months on ART respectively, with 59% retained in care at both times. Those who linked (n = 485) accessed HIV care at 98 different clinics and 21% attended ≥2 clinics. Women >25 years, married/cohabiting or presenting early for ANC were more likely to link. Younger and unemployed women were more likely to attend ≥2 clinics (adjusted risk ratio [aRR] 1.10 95% confidence interval [CI] 1.02 to 1.18 and aRR 1.06 95% CI 0.99 to 1.12 respectively). Age >25 years (aRR 1.17 95% CI 1.02 to 1.33) and planned pregnancy (aRR 1.20 95% CI 1.09 to 1.33) were associated with being retained. Among 338 retained women with VL available, attending ≥2 clinics reduced the likelihood of viral suppression when defined as ≤50 copies/mL (aRR 0.81 95% CI 0.69 to 0.95). Distance moved was not associated with VL. CONCLUSIONS These data show that a substantial proportion of women do not link to postpartum ART care in this setting and, among those that do, long-term retention remains a challenge. Women move to a variety of clinics and young women appear particularly vulnerable to attrition. Interventions promoting linkage and continued retention for women initiating ART during pregnancy warrant urgent consideration.
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Affiliation(s)
- Tamsin K Phillips
- Division of Epidemiology & BiostatisticsCentre for Infectious Disease Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
- The South African Department of Science and Technology/National Research Foundation (DST‐NRF)Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA)Stellenbosch UniversityStellenboschSouth Africa
| | - Kate Clouse
- Vanderbilt Institute for Global HealthVanderbilt UniversityNashvilleTNUSA
- Department of MedicineDivision of Infectious DiseasesVanderbilt UniversityNashvilleTNUSA
| | - Allison Zerbe
- ICAPColumbia UniversityMailman School of Public HealthNew YorkNYUSA
| | - Catherine Orrell
- Desmond Tutu HIV CentreInstitute of Infectious Disease and Molecular Medicine and Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Elaine J Abrams
- ICAPColumbia UniversityMailman School of Public HealthNew YorkNYUSA
- College of Physicians & SurgeonsColumbia UniversityNew YorkNYUSA
| | - Landon Myer
- Division of Epidemiology & BiostatisticsCentre for Infectious Disease Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
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Patient-Initiated Repackaging of Antiretroviral Therapy, Viral Suppression and Drug Resistance. AIDS Behav 2018; 22:1671-1678. [PMID: 28185021 DOI: 10.1007/s10461-017-1721-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Patient-initiated repackaging of antiretroviral therapy (ART) refers to removal of ART medications from their original manufacturer's containers, and putting them into alternative containers. This behavior may be triggered by stigma associated with HIV infection, and may impact patient outcomes. We assessed association between patient initiated repackaging of ART and failure to achieve viral suppression (FVS) in a sample of 450 HIV-infected adults (≥8 years) on first line ART for ≥6 months. FVS was defined as a plasma HIV RNA level ≥400 copies/mL. A total of 197 (43.7%) patients reported repackaging their ART medications. One hundred ninety-one patients (42.4%) failed to suppress and FVS was associated with medication repackaging [adjusted odds ratio (aOR), 2.2; 95% CI 1.4-3.3.] Adherence to ART was also associated with FVS (aOR; 0.4; 95% CI 0.2-0.6.). Benefits of retaining drugs in their original packaging along with adherence to ART should be emphasized to reduce the risk of FVS.
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Ntamatungiro AJ, Muri L, Glass TR, Erb S, Battegay M, Furrer H, Hatz C, Tanner M, Felger I, Klimkait T, Letang E. Strengthening HIV therapy and care in rural Tanzania affects rates of viral suppression. J Antimicrob Chemother 2018; 72:2069-2074. [PMID: 28387865 DOI: 10.1093/jac/dkx095] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 02/28/2017] [Indexed: 12/19/2022] Open
Abstract
Objectives To assess viral suppression rates, to assess prevalence of acquired HIV drug resistance and to characterize the spectrum of HIV-1 drug resistance mutations (HIV-DRM) in HIV-1-infected patients in a rural Tanzanian HIV cohort. Methods This was a cross-sectional study nested within the Kilombero and Ulanga Antiretroviral Cohort. Virological failure was defined as HIV-1 RNA ≥50 copies/mL. Risk factors associated with virological failure and with the development of HIV-DRM were assessed using logistic regression. Results This study included 304 participants with a median time on ART of 3.5 years (IQR = 1.7-5.3 years); 91% were on an NNRTI-based regimen and 9% were on a boosted PI-based regimen. Viral suppression was observed in 277/304 patients (91%). Of the remaining 27 patients, 21 were successfully genotyped and 17/21 (81%) harboured ≥1 clinically relevant HIV-DRM. Of these, 13/17 (76.5%) had HIV-1 plasma viral loads of >1000 copies/mL. CD4 cell count <200 cells/mm(3) at the time of recruitment was independently associated with a close to 8-fold increased odds of virological failure [adjusted OR (aOR) = 7.71, 95% CI = 2.86-20.78, P < 0.001] and with a >8-fold increased odds of developing HIV-DRM (aOR = 8.46, 95% CI = 2.48-28.93, P = 0.001). Conclusions High levels of viral suppression can be achieved in rural sub-Saharan Africa when treatment and care programmes are well managed. In the absence of routine HIV sequencing, the WHO-recommended threshold of 1000 viral RNA copies/mL largely discriminates virological failure secondary to HIV-DRM.
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Affiliation(s)
| | - Lukas Muri
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Tracy R Glass
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Stefan Erb
- University of Basel, Basel, Switzerland.,Division of Infectious Diseases and Hospital Epidemiology, Department of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Manuel Battegay
- University of Basel, Basel, Switzerland.,Division of Infectious Diseases and Hospital Epidemiology, Department of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Hatz
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Marcel Tanner
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Ingrid Felger
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Thomas Klimkait
- Molecular Virology, Department Biomedicine Petersplatz, University of Basel, Basel, Switzerland
| | - Emilio Letang
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe recent clinical trial, laboratory and observational findings that highlight both the progress that can be achieved in elimination of new pediatric infections in international clinical trial settings among HIV-infected breastfeeding women while also describing recent safety concerns related to currently used antiretroviral regimens. The article will also address the ongoing adherence challenges for HIV-infected mothers in taking their antiretroviral drugs. This information is timely and relevant as new regimens are being considered for both prevention of mother-to-child transmission (PMTCT) of HIV and HIV treatment options worldwide. RECENT FINDINGS The main themes described in this article include both efficacy of different antiretroviral therapy (ART) regimens currently being rolled out internationally for PMTCT as well as safety findings from recent research including a large multisite international trial, PROMISE. SUMMARY The findings from the IMPAACT PROMISE trial as well as other recent trial and observational findings suggest that while progress has been steady in reducing PMTCT worldwide, the goal of virtual elimination of pediatric HIV worldwide will require careful attention to optimizing safety of new regimens which are less dependent on maternal daily ART adherence and safer in preventing certain toxicities.
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Affiliation(s)
- Mary G Fowler
- Department of Pathology, Johns Hopkins U. School of Medicine, Baltimore, Maryland
| | - Patricia Flynn
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Jim Aizire
- Department of Epidemiology, Johns Hopkins U. Bloomberg School of Public Health, Baltimore, Maryland, USA
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Chetty T, Newell ML, Thorne C, Coutsoudis A. Viraemia before, during and after pregnancy in HIV-infected women on antiretroviral therapy in rural KwaZulu-Natal, South Africa, 2010-2015. Trop Med Int Health 2017; 23:79-91. [PMID: 29121445 DOI: 10.1111/tmi.13001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Pregnancy and post-partum viral load suppression is critical to prevent mother-to-child HIV transmission and ensure maternal health. We measured viraemia risk before, during and after pregnancy in HIV-infected women. METHODS Between 2010 and 2015, 1425 HIV-infected pregnant women on lifelong antiretroviral therapy (ART) for at least six months pre-pregnancy were enrolled in a cohort study in rural KwaZulu-Natal, South Africa. Odds ratios were estimated in multilevel logistic regression, with pregnancy period time-varying. RESULTS Over half of 1425 women received tenofovir-based regimens (n = 791). Median pre-pregnancy ART duration was 2.1 years. Of 988 women (69.3%) with pre-pregnancy viral loads, 82.0%, 6.8% and 11.2% had VL <50, 50-999 and ≥1000 copies/ml, respectively. During pregnancy and at six, 12 and 24 months, viral load was ≥1000 copies/ml in 15.2%, 15.7%, 17.8% and 16.6% respectively; viral load <50 was 76.9%, 77%, 75.5% and 75.8%, respectively. Adjusting for age, clinical and pregnancy factors, viraemia risk (viral load ≥50 copies/ml) was not significantly associated with pregnancy [adjusted OR (aOR) 1.31; 95% CI 0.90-1.92], six months (aOR 1.30; 95% CI 0.83-2.04), 12 months (aOR 0.96; 95% CI 0.58-1.58) and 24 months (aOR 1.40; 95% CI 0.89-2.22) post-partum. Adjusting for ART duration-pregnancy period interaction, viraemia risk was 1.8 during pregnancy and twofold higher post-partum. CONCLUSIONS While undetectable viral load before pregnancy through post-partum was common, the UNAIDS goal to suppress viraemia in 90% of women was not met. Women on preconception ART remain vulnerable to viraemia; additional support is required to prevent mother-to-child HIV transmission and maintain maternal health.
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Affiliation(s)
- Terusha Chetty
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Marie-Louise Newell
- Faculty of Medicine, Institute for Developmental Sciences, University of Southampton, Southampton, UK
| | - Claire Thorne
- UCL Institute of Child Health, University College London, London, UK
| | - Anna Coutsoudis
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
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Swannet S, Decroo T, de Castro SMTL, Rose C, Giuliani R, Molfino L, Torrens AW, Macueia WSED, Perry S, Reid T. Journey towards universal viral load monitoring in Maputo, Mozambique: many gaps, but encouraging signs. Int Health 2017; 9:206-214. [PMID: 28810670 PMCID: PMC5881256 DOI: 10.1093/inthealth/ihx021] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 07/04/2017] [Indexed: 11/25/2022] Open
Abstract
Introduction Viral load (VL) monitoring for people on antiretroviral therapy (ART) is extremely challenging in resource-limited settings. We assessed the VL testing scale-up in six Médecins Sans Frontières supported health centres in Maputo, Mozambique, during 2014–15. Methods In a retrospective cohort study, routine programme data were used to describe VL testing uptake and results, and multi-variate logistical regression to estimate predictors of VL testing uptake and suppression. Results Uptake of a first VL test was 40% (17 236/43 579). Uptake of a follow-up VL test for patients with a high first VL result was 35% (1095/3100). Factors associated with a higher uptake included: age below 15 years, longer time on ART and attending tailored service delivery platforms. Virological suppression was higher in pregnant/breastfeeding women and in community ART Group members. Patients with a high first VL result (18%; 3100/17 236) were mostly younger, had been on ART longer or had tuberculosis. Out of 1095 attending for a follow-up VL test, 678 (62%) had virological failure. Of those, less than one-third had started second line ART. Conclusion This was the first study describing the uptake and results of VL testing scale-up in Mozambique. Identified gaps show patient and programmatic challenges. Where service delivery was customized to patient needs, VL monitoring was more successful.
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Affiliation(s)
- Sarah Swannet
- Operational Centres Geneva and Brussels, Médecins sans Frontières, Maputo, Mozambique
| | - Tom Decroo
- Operational Research Unit, Médecins sans Frontières, Luxembourg, Luxembourg
| | | | - Caroline Rose
- Operational Centres Geneva and Brussels, Médecins sans Frontières, Maputo, Mozambique
| | - Ruggero Giuliani
- Operational Centres Geneva and Brussels, Médecins sans Frontières, Maputo, Mozambique
| | - Lucas Molfino
- Operational Centres Geneva and Brussels, Médecins sans Frontières, Maputo, Mozambique
| | - Ana W Torrens
- Operational Centres Geneva and Brussels, Médecins sans Frontières, Maputo, Mozambique
| | - Walter S E D Macueia
- Operational Centres Geneva and Brussels, Médecins sans Frontières, Maputo, Mozambique
| | - Sharon Perry
- Southern Africa Medical Unit, Médecins sans Frontières, Cape Town, South Africa
| | - Tony Reid
- Operational Research Unit, Médecins sans Frontières, Luxembourg, Luxembourg
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Machnowska P, Hauser A, Meixenberger K, Altmann B, Bannert N, Rempis E, Schnack A, Decker S, Braun V, Busingye P, Rubaihayo J, Harms G, Theuring S. Decreased emergence of HIV-1 drug resistance mutations in a cohort of Ugandan women initiating option B+ for PMTCT. PLoS One 2017; 12:e0178297. [PMID: 28562612 PMCID: PMC5451067 DOI: 10.1371/journal.pone.0178297] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 05/10/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Since 2012, WHO guidelines for the prevention of mother-to-child transmission (PMTCT) of HIV-1 in resource-limited settings recommend the initiation of lifelong antiretroviral combination therapy (cART) for all pregnant HIV-1 positive women independent of CD4 count and WHO clinical stage (Option B+). However, long-term outcomes regarding development of drug resistance are lacking until now. Therefore, we analysed the emergence of drug resistance mutations (DRMs) in women initiating Option B+ in Fort Portal, Uganda, at 12 and 18 months postpartum (ppm). METHODS AND FINDINGS 124 HIV-1 positive pregnant women were enrolled within antenatal care services in Fort Portal, Uganda. Blood samples were collected at the first visit prior starting Option B+ and postpartum at week six, month six, 12 and 18. Viral load was determined by real-time RT-PCR. An RT-PCR covering resistance associated positions in the protease and reverse transcriptase HIV-1 genomic region was performed. PCR-positive samples at 12/18 ppm and respective baseline samples were analysed by next generation sequencing regarding HIV-1 drug resistant variants including low-frequency variants. Furthermore, vertical transmission of HIV-1 was analysed. 49/124 (39.5%) women were included into the DRM analysis. Virological failure, defined as >1000 copies HIV-1 RNA/ml, was observed in three and seven women at 12 and 18 ppm, respectively. Sequences were obtained for three and six of these. In total, DRMs were detected in 3/49 (6.1%) women. Two women displayed dual-class resistance against all recommended first-line regimen drugs. Of 49 mother-infant-pairs no infant was HIV-1 positive at 12 or 18 ppm. CONCLUSION Our findings suggest that the WHO-recommended Option B+ for PMTCT is effective in a cohort of Ugandan HIV-1 positive pregnant women with regard to the low selection rate of DRMs and vertical transmission. Therefore, these results are encouraging for other countries considering the implementation of lifelong cART for all pregnant HIV-1 positive women.
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Affiliation(s)
- Patrycja Machnowska
- Institute of Tropical Medicine and International Health, Charité—Universitätsmedizin Berlin, Berlin, Germany
- Division of HIV and Other Retroviruses, Robert Koch-Institute, Berlin, Germany
| | - Andrea Hauser
- Division of HIV and Other Retroviruses, Robert Koch-Institute, Berlin, Germany
| | | | - Britta Altmann
- Division of HIV and Other Retroviruses, Robert Koch-Institute, Berlin, Germany
| | - Norbert Bannert
- Division of HIV and Other Retroviruses, Robert Koch-Institute, Berlin, Germany
| | - Eva Rempis
- Institute of Tropical Medicine and International Health, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Alexandra Schnack
- Institute of Tropical Medicine and International Health, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Sarah Decker
- Institute of Tropical Medicine and International Health, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Vera Braun
- Institute of Tropical Medicine and International Health, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | | | - John Rubaihayo
- Department of Public Health, Mountains of the Moon University, Fort Portal, Uganda
| | - Gundel Harms
- Institute of Tropical Medicine and International Health, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Stefanie Theuring
- Institute of Tropical Medicine and International Health, Charité—Universitätsmedizin Berlin, Berlin, Germany
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Gill MM, Umutoni A, Hoffman HJ, Ndatimana D, Ndayisaba GF, Kibitenga S, Mugwaneza P, Asiimwe A, Bobrow EA. Understanding Antiretroviral Treatment Adherence Among HIV-Positive Women at Four Postpartum Time Intervals: Qualitative Results from the Kabeho Study in Rwanda. AIDS Patient Care STDS 2017; 31:153-166. [PMID: 28358624 DOI: 10.1089/apc.2016.0234] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
As lifelong antiretroviral therapy (ART) for pregnant women is implemented, it is important to understand the attitudes and norms affecting women's postpartum ART adherence. This is a qualitative cross-sectional study of HIV-positive postpartum women (n = 112) enrolled in a 2-year observational prospective cohort in Rwanda. Informed by the Theory of Reasoned Action (TRA), we conducted in-depth interviews with women whose children were 0-6, 7-12, 13-18, or 21-24 months of age to describe factors contributing to adherence and changes over time. Positive ART attitudes reported by women included mothers' health promotion, prevention of infant HIV infection, higher CD4 count, and improved physical appearance. Negative attitudes were few, but included side effects and the lifelong nature of treatment. Learning from people living with HIV (PLHIV) was identified as a norm facilitating adherence; ART adherence was inhibited by fear of disclosure or stigmatization in communities and clinics. Poor adherence behaviors were common immediately after HIV diagnosis, not necessarily during prevention of mother-to-child transmission (PMTCT). Women with older children, most of whom stopped breastfeeding by 13-18 months, reported more barriers and missed doses than women with younger children. The TRA was useful in identifying the collective influence of attitudes, norms, and intentions on behavior. Findings suggest that HIV-positive women are vulnerable to poor adherence following HIV diagnosis and around the time of breastfeeding cessation. Lifelong treatment adherence can be supported through PLHIV exemplifying long-term ART use, fewer and less stigmatizing clinic visits, and counseling messages highlighting the benefits of drugs on appearance and illness prevention and incorporating biological feedback.
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Affiliation(s)
- Michelle M. Gill
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia
| | - Aline Umutoni
- Elizabeth Glaser Pediatric AIDS Foundation, Kigali, Rwanda
| | - Heather J. Hoffman
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia
| | | | | | | | | | - Anita Asiimwe
- Rwanda University Teaching Hospitals (CHU), Kigali, Rwanda
| | - Emily A. Bobrow
- MEASURE Evaluation, University of North Carolina, Chapel Hill, North Carolina
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Fouda GG, Eudailey J, Kunz EL, Amos JD, Liebl BE, Himes J, Boakye-Agyeman F, Beck K, Michaels AJ, Cohen-Wolkowiez M, Haynes BF, Reimann KA, Permar SR. Systemic administration of an HIV-1 broadly neutralizing dimeric IgA yields mucosal secretory IgA and virus neutralization. Mucosal Immunol 2017; 10:228-237. [PMID: 27072605 PMCID: PMC5063654 DOI: 10.1038/mi.2016.32] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 02/22/2016] [Indexed: 02/07/2023]
Abstract
We investigated the mucosal distribution and neutralization potency of rhesus recombinant versions of the HIV-specific, broadly neutralizing antibody b12 (RhB12) following intravenous administration to lactating rhesus monkeys. IgG and dimeric IgA (dIgA) administration resulted in high plasma concentrations of broadly neutralizing antibody (bnAb), but the monomeric IgA (mIgA) was rapidly cleared from the systemic compartment. Interestingly, differences in the distribution of the RhB12 isoform were observed between the mucosal compartments. The peak concentration of RhB12 IgG was higher than dIgA in saliva, rectal, and vaginal secretions, but the bnAb concentration in milk was one to two logs higher after dIgA administration than with IgG or mIgA infusion. Neutralization was observed in plasma of all animals, but only those infused with RhB12 dIgA showed moderate levels of virus neutralization in milk. Remarkably, virus-specific secretory IgA was detected in mucosal compartments following dIgA administration. The high milk RhB12 dIgA concentration suggests that passive immunization with dIgA could be more effective than IgG to inhibit virus in breast milk.
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Affiliation(s)
- Genevieve G. Fouda
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC
| | - Joshua Eudailey
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC
| | - Erika L. Kunz
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC
| | - Joshua D. Amos
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC
| | - Brooke E. Liebl
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC
| | - Jonathan Himes
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC
| | | | - Krista Beck
- Division of Laboratory Animal Resources, Duke University Medical Center, Durham, NC
| | | | | | - Barton F. Haynes
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC
| | - Keith A. Reimann
- MassBiologics, University of Massachusetts Medical School, Boston, MA
| | - Sallie R. Permar
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC
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Zash RM, Souda S, Leidner J, Binda K, Hick C, Powis K, Makhema J, Mmalane M, Essex M, Lockman S, Shapiro RL. High Proportion of Deaths Attributable to HIV Among Postpartum Women in Botswana Despite Widespread Uptake of Antiretroviral Therapy. AIDS Patient Care STDS 2017; 31:14-19. [PMID: 28051898 DOI: 10.1089/apc.2016.0154] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Mortality in the postpartum period may be impacted by antiretroviral therapy (ART) received in pregnancy, and whether ART is continued in the postpartum period. HIV-infected and HIV-uninfected mothers were enrolled within 48 h of delivery at five public hospital maternity wards throughout Botswana and followed for 24 months. Maternal deaths were reported by one of the approved contacts given by the mother at enrollment. Detailed information on the cause of death was not available. Risk factors for 24-month mortality were assessed using Cox proportional hazard models. From February 2012 to March 2013, 3000 mothers (1499 HIV infected and 1501 HIV uninfected) were enrolled, and 2985 (99.5%) were followed to 24 months or death, or until the death of their child. There were 26 total maternal deaths through 24 months postpartum [439 per 100,000 person-years (p-y)], 22 among HIV-infected women (758 per 100,000 p-y) and 4 among HIV-uninfected women (132 per 100,000 p-y). Maternal HIV-infection (aHR 5.0, 95% CI 1.6-15.2) and infant birth injury (aHR 3.8, 95% CI 1.3-11.4) were independent risk factors for maternal death. Universal ART in pregnancy became the standard-of-care after June 2012, and 978 (65%) women received ART in pregnancy; by 24 months postpartum or end of follow-up, 1148 (79%) had started ART overall. There was no significant difference in 24-month mortality among HIV-infected women who took ART in pregnancy and continued throughout the follow-up period compared with HIV-infected women who took ART or zidovudine in pregnancy and stopped postpartum (aHR 0.6, 95% CI 0.2-1.7). Despite high uptake of ART in pregnancy and postpartum, women with HIV infection in Botswana are five times more likely to die than HIV-uninfected women in the 24 months postpartum.
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Affiliation(s)
- Rebecca Marie Zash
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Immunology and Infectious Diseases, TH Chan Harvard School of Public Health, Boston, Massachusetts
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Sajini Souda
- Department of Pathology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | | | | | - Chazha Hick
- Care Quality Commission, London, United Kingdom
| | - Kathleen Powis
- Immunology and Infectious Diseases, TH Chan Harvard School of Public Health, Boston, Massachusetts
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Medicine and Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Joseph Makhema
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mompati Mmalane
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Max Essex
- Immunology and Infectious Diseases, TH Chan Harvard School of Public Health, Boston, Massachusetts
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Shahin Lockman
- Immunology and Infectious Diseases, TH Chan Harvard School of Public Health, Boston, Massachusetts
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts
| | - Roger L. Shapiro
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Immunology and Infectious Diseases, TH Chan Harvard School of Public Health, Boston, Massachusetts
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
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Gill MM, Hoffman HJ, Bobrow EA, Mugwaneza P, Ndatimana D, Ndayisaba GF, Baribwira C, Guay L, Asiimwe A. Detectable Viral Load in Late Pregnancy among Women in the Rwanda Option B+ PMTCT Program: Enrollment Results from the Kabeho Study. PLoS One 2016; 11:e0168671. [PMID: 28006001 PMCID: PMC5179044 DOI: 10.1371/journal.pone.0168671] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 12/05/2016] [Indexed: 12/13/2022] Open
Abstract
There are limited viral load (VL) data available from programs implementing “Option B+,” lifelong antiretroviral treatment (ART) to all HIV-positive pregnant and postpartum women, in resource-limited settings. Extent of viral suppression from a prevention of mother-to-child transmission of HIV program in Rwanda was assessed among women enrolled in the Kigali Antiretroviral and Breastfeeding Assessment for the Elimination of HIV (Kabeho) Study. ARV drug resistance testing was conducted on women with VL>2000 copies/ml. In April 2013-January 2014, 608 pregnant or early postpartum HIV-positive women were enrolled in 14 facilities. Factors associated with detectable enrollment VL (>20 copies/ml) were examined using generalized estimating equations. The most common antiretroviral regimen (56.7%, 344/607) was tenofovir/lamivudine/efavirenz. Median ART duration was 13.5 months (IQR 3.0–48.8); 76.1% of women were on ART at first antenatal visit. Half of women (315/603) had undetectable RNA-PCR VL and 84.6% (510) had <1,000 copies/ml. Detectable VL increased among those on ART > 36 months compared to those on ART 4–36 months (72/191, 37.7% versus 56/187, 29.9%), though the difference was not significant. The odds of having detectable enrollment VL decreased significantly as duration on ART at enrollment increased (AOR = 0.99, 95% CI: 0.9857, 0.9998, p = 0.043). There was a higher likelihood of detectable VL for women with lower gravidity (AOR = 0.90, 95% CI: 0.84, 0.97, p = 0.0039), no education (AOR = 2.25, (95% CI: 1.37, 3.70, p = 0.0004), nondisclosure to partner (AOR = 1.97, 95% CI: 1.21, 3.21, p = 0.0063) and side effects (AOR = 2.63, 95% CI: 1.72, 4.03, p<0.0001). ARV drug resistance mutations were detected in all of the eleven women on ART > 36 months with genotyping available. Most women were receiving ART at first antenatal visit, with relatively high viral suppression rates. Shorter ART duration was associated with higher VL, with a concerning increasing trend for higher viremia and drug resistance among women on ART for >3 years.
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Affiliation(s)
- Michelle M. Gill
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, United States of America
- * E-mail:
| | - Heather J. Hoffman
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, United States of America
| | - Emily A. Bobrow
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, United States of America
| | | | | | | | - Cyprien Baribwira
- University of Maryland, Baltimore, Maryland, United States of America
| | - Laura Guay
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, United States of America
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, United States of America
| | - Anita Asiimwe
- Rwanda University Teaching Hospitals, Kigali, Rwanda
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40
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Mancinelli S, Galluzzo CM, Andreotti M, Liotta G, Jere H, Sagno JB, Amici R, Pirillo MF, Scarcella P, Marazzi MC, Vella S, Palombi L, Giuliano M. Virological Response and Drug Resistance 1 and 2 Years Post-Partum in HIV-Infected Women Initiated on Life-Long Antiretroviral Therapy in Malawi. AIDS Res Hum Retroviruses 2016; 32:737-42. [PMID: 27067142 DOI: 10.1089/aid.2015.0366] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The objective of this study was to determine the virological response and the possible emergence of drug resistance at 1 and 2 years postpartum in HIV-positive pregnant women enrolled under the Option B approach and meeting the criteria for treatment. In the study, women with baseline CD4(+) <350/mm(3) received a combination of stavudine, lamivudine, and nevirapine during pregnancy (from week 25 of gestation) and continued it indefinitely after delivery. HIV-RNA was measured at 12 and 24 months postpartum. Drug resistance mutations were assessed in those with HIV-RNA >50 copies/ml. Baseline resistance mutations were assessed in the entire cohort. A total of 107 women were studied. At baseline, resistance mutations were seen in 6.6% of the women. At 12 months, 26.7% of the women had >50 copies/ml and among them 12.9% had virological failure (HIV-RNA >1,000 copies/ml). At 24 months, detectable HIV-RNA was seen in 28.3% of the women and virological failure in 10.1% of the women. Resistance mutations (mainly non-nucleoside reverse transcriptase inhibitors mutations) were seen in 40% of the women with detectable HIV-RNA. Baseline mutations did not correlate with virological failure or the emergence of resistance at later time points. Virological failure 2 years postpartum and emergence of resistance were rare in this cohort of HIV-infected women. These findings are reassuring in the light of the new strategies for the prevention of mother-to-child HIV transmission, recommending life-long antiretroviral therapy administration.
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Affiliation(s)
- Sandro Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Clementina Maria Galluzzo
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Mauro Andreotti
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Giuseppe Liotta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Haswel Jere
- DREAM Program, Community of S. Egidio, Blantyre, Malawi
| | | | - Roberta Amici
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Maria Franca Pirillo
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Paola Scarcella
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - Stefano Vella
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Marina Giuliano
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
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Balagopal A, Gupte N, Shivakoti R, Cox AL, Yang WT, Berendes S, Mwelase N, Kanyama C, Pillay S, Samaneka W, Santos B, Poongulali S, Tripathy S, Riviere C, Lama JR, Cardoso SW, Sugandhavesa P, Semba RD, Hakim J, Hosseinipour MC, Kumarasamy N, Sanne I, Asmuth D, Campbell T, Bollinger RC, Gupta A. Continued Elevation of Interleukin-18 and Interferon-γ After Initiation of Antiretroviral Therapy and Clinical Failure in a Diverse Multicountry Human Immunodeficiency Virus Cohort. Open Forum Infect Dis 2016; 3:ofw118. [PMID: 27800521 PMCID: PMC5084713 DOI: 10.1093/ofid/ofw118] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 04/19/2016] [Indexed: 01/04/2023] Open
Abstract
Background. We assessed immune activation after antiretroviral therapy (ART) initiation to understand clinical failure in diverse settings. Methods. We performed a case-control study in ACTG Prospective Evaluation of Antiretrovirals in Resource-Limited Settings (PEARLS). Cases were defined as incident World Health Organization Stage 3 or 4 human immunodeficiency virus (HIV) disease or death, analyzed from ART weeks 24 (ART24) to 96. Controls were randomly selected. Interleukin (IL)-6, interferon (IFN)-γ-inducible protein-10, IL-18, tumor necrosis factor-α, IFN-γ, and soluble CD14 (sCD14) were measured pre-ART and at ART24 in plasma. Continued elevation was defined by thresholds set by highest pre-ART quartiles (>Q3). Incident risk ratios (IRRs) for clinical progression were estimated by Poisson regression, adjusting for age, sex, treatment, country, time-updated CD4+ T-cell count, HIV ribonucleic acid (RNA), and prevalent tuberculosis. Results. Among 99 cases and 234 controls, median baseline CD4+ T-cell count was 181 cells/µL, and HIV RNA was 5.05 log10 cp/mL. Clinical failure was independently associated with continued elevations of IL-18 (IRR, 3.03; 95% confidence interval [CI], 1.27–7.20), sCD14 (IRR, 2.17; 95% CI, 1.02–4.62), and IFN-γ (IRR, 0.08; 95% CI, 0.01–0.61). Among 276 of 333 (83%) who were virologically suppressed at ART24, IFN-γ was associated with protection from failure, but the association with sCD14 was attenuated. Conclusions. Continued IL-18 and sCD14 elevations were associated with clinical ART failure. Interferon-γ levels may reflect preserved immune function.
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Affiliation(s)
- Ashwin Balagopal
- Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Nikhil Gupte
- Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Rupak Shivakoti
- Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Andrea L Cox
- Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Wei-Teng Yang
- Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Sima Berendes
- Malawi College of Medicine-Johns Hopkins University Research Project , Blantyre , Malawi
| | | | - Cecilia Kanyama
- University of North Carolina Project, Kamuzu Central Hospital , Lilongwe , Malawi
| | - Sandy Pillay
- Nelson Mandela School of Medicine , University of KwaZulu-Natal , Durban , South Africa
| | | | - Breno Santos
- Hospital Nossa Senhora de Conceição , Porto Alegre , Brazil
| | | | | | | | - Javier R Lama
- Asociación Civil Impacta Salud y Educación (IMPACTA) Peru Clinical Trials Unit , Lima
| | - Sandra W Cardoso
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz , Rio de Janeiro , Brazil
| | | | - Richard D Semba
- Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - James Hakim
- University of Zimbabwe, College of Health Sciences , Harare
| | - Mina C Hosseinipour
- University of North Carolina Project, Kamuzu Central Hospital, Lilongwe, Malawi; University of North Carolina, Chapel Hill
| | | | - Ian Sanne
- University of Witwatersrand , Johannesburg , South Africa
| | | | | | | | - Amita Gupta
- Johns Hopkins University School of Medicine , Baltimore, Maryland
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Hawkins C, Ulenga N, Liu E, Aboud S, Mugusi F, Chalamilla G, Sando D, Aris E, Carpenter D, Fawzi W. HIV virological failure and drug resistance in a cohort of Tanzanian HIV-infected adults. J Antimicrob Chemother 2016; 71:1966-74. [PMID: 27076106 DOI: 10.1093/jac/dkw051] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 02/05/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES There are few data on ART failure rates and drug resistance from Tanzania, where there is a wide diversity of non-B HIV subtypes. We assessed rates and predictors of virological failure in HIV-infected Tanzanians and describe drug resistance patterns in a subgroup of these patients. METHODS ART-naive, HIV-1-infected adults enrolled in a randomized controlled trial between November 2006 and 2008 and on ≥24 weeks of first-line NNRTI-containing ART were included. Population-based genotyping of HIV-1 protease and reverse transcriptase was performed on stored plasma from patients with virological failure (viral load >1000 copies/mL at ≥24 weeks of ART) and at baseline, where available. RESULTS A total of 2403 patients [median (IQR) age 37 (32-43) years; 70% female] were studied. The median (IQR) baseline CD4+ T cell count was 128 (62-190) cells/μL. Predominant HIV subtypes were A, C and D (92.2%). The overall rate of virological failure was 14.9% (95% CI 13.2%-16.1%). In adjusted analyses, significant predictors of virological failure were lower CD4+ T cell count (P = 0.01) and non-adherence to ART (P < 0.01). Drug resistance mutations were present in 87/115 samples (75.7%); the most common were M184V/I (52.2%) and K103N (35%). Thymidine analogue mutations were uncommon (5.2%). The prevalence of mutations in 45 samples pre-ART was 22%. CONCLUSIONS High levels of early ART failure and drug resistance were observed among Tanzanian HIV-1-infected adults enrolled in a well-monitored study. Initiating treatment early and ensuring optimal adherence are vital for the success and durability of first-line ART in these settings.
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Affiliation(s)
- Claudia Hawkins
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA, USA
| | - Enju Liu
- Departments of Nutrition, Epidemiology, Biostatistics, and Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | - Said Aboud
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ferdinand Mugusi
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - David Sando
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Eric Aris
- Management and Development for Health, Dar es Salaam, Tanzania
| | | | - Wafaie Fawzi
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
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Matthews LT, Ribaudo HB, Kaida A, Bennett K, Musinguzi N, Siedner MJ, Kabakyenga J, Hunt PW, Martin JN, Boum Y, Haberer JE, Bangsberg DR. HIV-Infected Ugandan Women on Antiretroviral Therapy Maintain HIV-1 RNA Suppression Across Periconception, Pregnancy, and Postpartum Periods. J Acquir Immune Defic Syndr 2016; 71:399-406. [PMID: 26495883 PMCID: PMC4943862 DOI: 10.1097/qai.0000000000000874] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND HIV-infected women risk sexual and perinatal HIV transmission during conception, pregnancy, childbirth, and breastfeeding. We compared HIV-1 RNA suppression and medication adherence across periconception, pregnancy, and postpartum periods, among women on antiretroviral therapy (ART) in Uganda. METHODS We analyzed data from women in a prospective cohort study, aged 18-49 years, enrolled at ART initiation and with ≥1 pregnancy between 2005 and 2011. Participants were seen quarterly. The primary exposure of interest was pregnancy period, including periconception (3 quarters before pregnancy), pregnancy, postpartum (6 months after pregnancy outcome), or nonpregnancy related. Regression models using generalized estimating equations compared the likelihood of HIV-1 RNA ≤400 copies per milliliter, <80% average adherence based on electronic pill caps (medication event monitoring system), and likelihood of 72-hour medication gaps across each period. RESULTS One hundred eleven women contributed 486 person-years of follow-up. Viral suppression was present at 89% of nonpregnancy, 97% of periconception, 93% of pregnancy, and 89% of postpartum visits, and was more likely during periconception (adjusted odds ratio, 2.15) compared with nonpregnant periods. Average ART adherence was 90% [interquartile range (IQR), 70%-98%], 93% (IQR, 82%-98%), 92% (IQR, 72%-98%), and 88% (IQR, 63%-97%) during nonpregnant, periconception, pregnant, and postpartum periods, respectively. Average adherence <80% was less likely during periconception (adjusted odds ratio, 0.68), and 72-hour gaps per 90 days were less frequent during periconception (adjusted relative risk, 0.72) and more frequent during postpartum (adjusted relative risk, 1.40). CONCLUSIONS Women with pregnancy were virologically suppressed at most visits, with an increased likelihood of suppression and high adherence during periconception follow-up. Increased frequency of 72-hour gaps suggests a need for increased adherence support during postpartum periods.
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Affiliation(s)
- Lynn T Matthews
- *Division of Infectious Disease, Center for Global Health, Massachusetts General Hospital, Boston, MA; †Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA; ‡Faculty of Health Sciences, Simon Fraser University, Burnaby BC, Canada; §Bennett Statistical Consulting, Ballston Lake, NY; ‖Mbarara University of Science and Technology, Mbarara, Uganda; Departments of ¶Medicine, and #Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA; **Epicentre Mbarara, Mbarara, Uganda; ††Department of General Medicine, Center for Global Health, Massachusetts General Hospital, Boston, MA
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