Assessing the effects of maternal HIV infection on pregnancy outcomes using cross-sectional data in Malawi

Impact of maternal HIV infection on perinatal outcomes: A systematic review

BACKGROUND

Maternal HIV infection remains a significant global health concern with potential repercussions on perinatal outcomes. Emphasis on early intervention to improve peri- and postnatal outcomes in infected mothers and infants is a valid therapeutic concern.

OBJECTIVES

To comprehensively analyze perinatal outcomes associated with maternal HIV infection and evaluate adverse effects associated with the HIV infection in the existing literature.

SEARCH STRATEGY

A comprehensive search of PubMed, MEDLINE, and Google Scholar was conducted from 2013 to September 2023, using relevant MeSH terms.

SELECTION CRITERIA

The included studies encompassed original studies, cross-sectional, prospective, retrospective studies and observational studies focused on perinatal outcomes in the context of maternal HIV infection.

DATA COLLECTION AND ANALYSIS

The selected studies underwent rigorous data collection and comprehensive quality checks and adhered to the PRISMA guidelines.

MAIN RESULTS

Nine eligible studies from Brazil, China, India, Malawi, Nigeria, Tanzania, the USA, and Canada were included. These studies have consistently demonstrated that maternal HIV infection is associated with adverse perinatal outcomes. The analysis revealed a higher risk of preterm birth (OR 1.57, 95% CI: 1.39-1.78), low birth weight (OR 1.33, 95% CI: 1.18-1.49), and small for gestational age (OR 1.38, 95% CI: 1.24-1.53) among infants born to mothers living with HIV. Notably, the impact of antiretroviral treatment (ART) on these outcomes varied, but maternal HIV infection remained a significant risk factor regardless of income level and geographic region.

CONCLUSION

Maternal HIV infection is consistently associated with adverse perinatal outcomes, emphasizing the need for targeted interventions and improved prenatal care in pregnant women with HIV infection.

Intermittent preventive treatment with sulphadoxine-pyrimethamine but not dihydroartemisinin-piperaquine modulates the relationship between inflammatory markers and adverse pregnancy outcomes in Malawi

Women in malaria-endemic areas receive sulphadoxine-pyrimethamine (SP) as Intermittent Preventive Treatment in Pregnancy (IPTp) to reduce malaria. While dihydroartemisinin-piperaquine (DP) has superior antimalarial properties as IPTp, SP is associated with superior fetal growth. As maternal inflammation influences fetal growth, we investigated whether SP alters the relationship between inflammation and birth outcomes. We measured C-reactive protein (CRP) and alpha-1-acid glycoprotein (AGP) at enrollment (16-28 gestation weeks (gw)), visit 3 (24-36 gw) and delivery in 1319 Malawian women randomized to receive monthly SP, DP, or DP and single-dose azithromycin (AZ) in the IMPROVE trial (NCT03208179). Logistic regression was used to assess the relationship between adverse outcomes, inflammation, and treatment arm. Elevated AGP at enrollment was associated with adverse birth outcome (aRR 1.40, 95% CI: 1.15, 1.70), with similar associations observed across treatment arms, exceptions being that elevated AGP was associated with low maternal weight gain in SP recipients (aRR 1.94, 95% CI: 1.36, 2.76) and with small for gestational age in DP+AZ recepients (aRR 1.49, 95% CI 1.02, 2.17). At visit 3 there were few associations between inflammation andoutcomes. At delivery, women with elevated AGP receiving either DP or DP+AZ had an increased risk of adverse birth outcomes (aRR 1.60, 95% CI: 1.28, 2.00), including low birth weight, pre-term birth and foetal loss, this was not seen in women receiving SP (aRR 0.82, 95% CI: 0.54, 1.26). The risk of an association between elevated AGP and adverse birth outcome was higher in those receiving DP or DP+AZ compared to those receiving SP (aRR 1.95, 95% CI: 1.21, 3.13). No clear associations between CRP and adverse outcomes were observed. AGP identified women at risk of adverse pregnancy outcomes. SP modifies the relationship between inflammatory biomarkers and adverse outcomes. Our findings provide insights into potential mechanisms by which SP may improve pregnancy outcomes.

Attitudes and perceptions towards developing a health educational video to enhance optimal uptake of malaria preventive therapy among pregnant women in Uganda: a qualitative study involving pregnant women, health workers, and Ministry of health officials

BACKGROUND

Malaria in pregnancy remains a major global public health problem. Intermittent prophylaxis treatment of malaria in pregnancy with Sulphadoxine-pyrimethamine and co-trimoxazole is efficacious for prevention of malaria in pregnancy HIV negative and positive women, respectively. However, uptake of the recommended doses of therapies has remained suboptimal in Uganda, majorly due to inadequate knowledge among pregnant women. Therefore, this study aimed to explore attitudes and perceptions towards developing an educational video for malaria preventive therapy.

METHODS

We conducted an exploratory study with qualitative methods among pregnant women attending antenatal care at Kisenyi Health Center IV (KHCIV), health workers from KHCIV, and officials from the Ministry of Health. The study was conducted at KHCIV from October 2022 to March 2023. Focus group discussions (FGD) were conducted among purposively selected pregnant women and key informant interviews (KII) among health workers and Ministry of Health officials. Data were analyzed using inductive and deductive thematic methods in atlas ti.8.

RESULTS

A total of five FGDs comprising of 7-10 pregnant women were conducted; and KIIs were conducted among four mid-wives, two obstetricians, and two Ministry of Health officials. Generally, all respondents mentioned a need for interventions to improve malaria preventive knowledge among pregnant women; were positive about developing an educative video for malaria preventive therapy in pregnancy; and suggested a short, concise, and edutaining video focusing both the benefits of taking and risks of not taking malaria preventive therapy. They proposed that women may be encouraged to view the video as soon as they conceive and throughout the pregnancy. It also was suggested that the video may be viewed on television sets in maternal and reproductive health clinics and homes, and on smart phones.

CONCLUSION

Pregnant women, health workers, and Ministry of Health officials were positive about the development of a short edutaining video on malaria preventive therapy that focuses on both benefits of taking and risks of not taking the malaria preventive therapy in pregnancy. This information guided the video development and therefore, in the development of health educative videos, client and stakeholder inputs may always be solicited.

Effects of Maternal HIV Infection and Alcohol Use in Pregnancy on Birth Outcomes in Uganda

Alcohol use and HIV infection are prevalent in sub-Saharan Africa (sSA), and both are associated with low birth weight. Yet, few studies have evaluated the combined effects of maternal HIV infection and alcohol use on birth outcomes. We analyzed data from a prospective cohort study of HIV-related placental changes in Ugandan women. We defined alcohol use as self-reported alcohol use within the last year, using the AUDIT questionnaire and used linear and logistic regression to measure associations between maternal alcohol use, HIV serostatus, and birth weight. In a subsample, we measured alcohol exposure using phosphatidylethanol (PEth) in neonatal heelstick dried blood spots to confirm maternal alcohol use. Of 352 participants, 176 (50%) were women with HIV (WHIV). Three of 176 (2%) HIVuninfected women and 17/176 (10%) of WHIV self-reported alcohol use (P = 0.002). Maternal HIV infection was associated with lower birth weight (β = -0.12, 95% CI [-0.20, -0.02], P = 0.02), but self-reported alcohol use was not (β = 0.06, 95% CI [-0.15, 0.26], P = 0.54), and the interaction between HIV serostatus and alcohol use was not significant (P = 0.13). Among the PEth subsample, neither HIV status nor PEthconfirmed alcohol use were associated with low birth weight. Maternal HIV infection was associated with lower birth weight, but alcohol use was not, and there was no significant interaction between maternal HIV infection and alcohol use. Alcohol use was more prevalent in WHIV and under-reporting was common. A larger study of the effects of laboratory-confirmed alcohol and HIV exposure on birth outcomes is warranted.

Determinants and outcomes of low birth weight among newborns at a tertiary hospital in Zambia: A retrospective cohort study

Context

Newborns' low birth weight (LBW) has been linked to early infant morbidity and mortality. However, our understanding of the determinants and outcomes of LBW in this population is still poor.

Aim

This study aimed to assess determinants and outcomes of LBW among newborns at a tertiary hospital.

Settings and Design

Retrospective cohort study at Women and Newborn Hospital in Lusaka Zambia.

Subjects and Methods

We reviewed delivery case records and neonatal files between January 1, 2018, and September 30, 2019, for newborns admitted to the neonatal intensive care unit.

Statistical Analysis Used

Logistic regression models were used to establish determinants of LBW and describe the outcomes.

Results

Women living with human immunodeficiency virus infection were more likely to deliver LBW infants (adjusted odds ratio [AOR] = 1.46; 95% confidence interval [CI]: 1.16-1.86). Other maternal determinants of LBW were; increased parity (AOR = 1.22; 95% CI: 1.05-1.43), preeclampsia (AOR = 6.91; 95% CI: 1.48-32.36), and gestational age <37 weeks compared to 37 weeks or more (AOR = 24.83; 95% CI: 13.27-46.44). LBW neonates were at higher odds of early mortality (AOR = 2.16; 95% CI: 1.85-2.52), developing respiratory distress syndrome (AOR = 2.96; 95% CI: 2.53-3.47), and necrotizing enterocolitis (AOR = 1.66; 95% CI: 1.16-2.38) than neonates with a birth weight of 2500 g or more.

Conclusions

These findings underscore the importance of effective maternal and neonatal interventions to reduce the risk of morbidity and mortality for neonates with LBW in Zambia and other similar settings.

Timing of Antiretroviral Therapy: Initiation and Birth Outcomes Among Pregnant Women With Human Immunodeficiency Virus in Tanzania

BACKGROUND

Combination antiretroviral therapy (cART) initiation during pregnancy reduces the risk of perinatal human immunodeficiency virus (HIV) transmission; however, studies have suggested that there may be unintended adverse consequences on birth outcomes for selected cART regimens.

METHODS

We analyzed adverse birth outcomes among a prospective cohort of 1307 pregnant women with HIV in Dar es Salaam who initiated cART during the first or second trimester of a singleton pregnancy. Our primary analysis compared birth outcomes by gestational age at cART initiation among these women initiating cART in pregnancy.

RESULTS

Among women who initiated cART in pregnancy, there was no relationship of gestational age at cART initiation with the risk of fetal death or stillbirth. However, women who initiated cART before 20 weeks of gestation compared with after 20 weeks had increased risk of preterm birth (risk ratio [RR], 1.30; 95% confidence interval [CI], 1.03-1.67) but decreased risk of small-for-gestational age birth (RR, 0.71; 95% CI, .55-.93).

CONCLUSIONS

With increasing use of cART preconception and early in pregnancy, clinicians should be aware of the benefits and potential risks of cART regimens to optimize birth outcomes.

Evaluating the Effect of Appropriate Complementary Feeding Practices on Child Growth in Malawi Using Cross-Sectional Data: An Application of Propensity Score Matching

Introduction: Appropriate complementary foods have been found to provide infants and young children with nutritional needs for their growth and development. In the absence of a randomized control trial (RCT), this study used observational data to evaluate the effect of appropriate complementary feeding practices on the nutritional status of children aged 6–23 months in Malawi using a propensity score matching statistical technique.

Methods: Data on 4,722 children aged 6 to 23 months from the 2015–16 Malawi Demographic and Health Survey (MDHS) were analyzed. Appropriate complementary feeding practices were assessed using the core indicators recommended by the World Health Organization (WHO)/United Nations Children's Fund (UNICEF), and consist of the introduction of complementary feeding, minimum dietary diversity, minimum meal frequency and minimum acceptable diet based on a dietary intake during a most recent 24-h period.

Results: The prevalence of stunting (height-for-age z-score < −2 SD) was 31.9% (95% CI: 29.3%, 34.6%), wasting (weight-for-height z-score < −2 SD) 3.5% (95% CI: 2.6%, 4.7%) and underweight (weight-for-age z-score < −2 SD) 9.9% (95% CI: 8.4%, 11.8%). Of the 4,722 children, 7.7% (95% CI: 6.9%, 8.5%) were provided appropriate complementary foods. Appropriate complementary feeding practices were found to result in significant decrease in stunting (OR = 0.7, 95% CI: 0.4, 0.95). They also resulted in the decrease of wasting (OR = 0.4, 95% CI: 0.1, 1.7) and underweight (OR = 0.6, 95% CI: 0.2, 1.7).

Conclusion: Appropriate complementary feeding practices resulted in a reduction of stunting, wasting, and underweight among children 6 to 23 months of age in Malawi. We recommend the continued provision of appropriate complementary foods to infants and young children to ensure that the diet has adequate nutritional needs for their healthy growth.

Adolescent, Pregnant, and HIV-Infected: Risk of Adverse Pregnancy and Perinatal Outcomes in Young Women from Southern Mozambique

Sub-Saharan Africa concentrates the burden of HIV and the highest adolescent fertility rates. However, there is limited information about the impact of the interaction between adolescence and HIV infection on maternal health in the region. Data collected prospectively from three clinical trials conducted between 2003 and 2014 were analysed to evaluate the association between age, HIV infection, and their interaction, with the risk of maternal morbidity and adverse pregnancy and perinatal outcomes in women from southern Mozambique. Logistic regression and negative binomial models were used. A total of 2352 women were included in the analyses; 31% were adolescents (≤19 years) and 29% HIV-infected women. The effect of age on maternal morbidity and pregnancy and perinatal adverse outcomes was not modified by HIV status. Adolescence was associated with an increased incidence of hospital admissions (IRR 0.55, 95%CI 0.37–0.80 for women 20–24 years; IRR 0.60, 95%CI 0.42–0.85 for women >25 years compared to adolescents; p-value < 0.01) and outpatient visits (IRR 0.86, 95%CI 0.71–1.04; IRR 0.76, 95%CI 0.63–0.92; p-value = 0.02), and an increased likelihood of having a small-for-gestational age newborn (OR 0.50, 95%CI 0.38–0.65; OR 0.43, 95%CI 0.34–0.56; p-value < 0.001), a low birthweight (OR 0.40, 95%CI 0.27–0.59; OR 0.37, 95%CI 0.26–0.53; p-value <0.001) and a premature birth (OR 0.42, 95%CI 0.24–0.72; OR 0.51, 95%CI 0.32–0.82; p-value < 0.01). Adolescence was associated with an increased risk of poor morbidity, pregnancy and perinatal outcomes, irrespective of HIV infection. In addition to provision of a specific maternity care package for this vulnerable group interventions are imperative to prevent adolescent pregnancy.