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Navér L, Albert J, Carlander C, Gisslén M, Pettersson K, Soeria-Atmadja S, Sönnerborg A, Westling K, Yilmaz A, Pettersson K. Prophylaxis and treatment of HIV infection in pregnancy, Swedish guidelines 2024. Infect Dis (Lond) 2024; 56:657-668. [PMID: 38805265 DOI: 10.1080/23744235.2024.2360029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 05/21/2024] [Indexed: 05/30/2024] Open
Abstract
In May 2024, the Swedish Reference Group on Antiviral Therapy updated the guidelines on management of HIV infection in pregnancy. The most important recommendations and revisions were: (i) ART during pregnancy should be started as early as possible and continue after delivery; (ii) Suppressive ART should normally not be modified; (iii) The treatment target of HIV RNA <20 copies/ml remains; (iv) Dolutegravir/emtricitabine/tenofovir DF is the first-line drug combination also in pregnant women and women planning pregnancy; (v) There is no evidence of an increased risk of neural tube defects associated with dolutegravir; (vi) Mode of delivery for women with effective ART and HIV RNA <200 copies/ml should follow standard obstetric procedures; (vii) Caesarean section is recommended if HIV RNA ≥200 copies/ml; (viii) Scalp electrode, foetal blood sampling and/or vacuum delivery should be used on strict indications, but does not necessitate intensified infant prophylaxis; (ix) Management and mode of delivery in case of premature or full-term rupture of membranes should follow standard obstetric procedures; (x) Recommended infant antiretroviral prophylaxis has been updated; (xi) The duration of infant antiretroviral prophylaxis (gestational age ≥35 weeks and mother on effective ART and HIV RNA <200 copies/ml) has been changed from 4 to 2 weeks; (xii) Infants born to women with HIV RNA ≥200 copies/ml should receive 4 weeks of combination prophylaxis; (xiii) Fertility evaluation and assisted reproduction should be offered to women on suppressive ART according to the same principles as for other women; (xiv) Women living with HIV should still be advised against breastfeeding; (xv) Women who nevertheless opt to breastfeed should be offered intensified support and follow-up.
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Affiliation(s)
- Lars Navér
- Department of Pediatrics, Karolinska University Hospital, Stockholm, Sweden
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Jan Albert
- Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Christina Carlander
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Gisslén
- Department of Infectious Diseases, University of Göteborg, Göteborg, Sweden
- Department of Infectious, Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Göteborg, Sweden
- Public Health Agency of Sweden, Solna, Sweden
| | - Kristina Pettersson
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Sandra Soeria-Atmadja
- Department of Pediatrics, Karolinska University Hospital, Stockholm, Sweden
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Anders Sönnerborg
- Department of Clinical Virology, Karolinska University Hospital, Stockholm, Sweden
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Katarina Westling
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Aylin Yilmaz
- Department of Infectious Diseases, University of Göteborg, Göteborg, Sweden
- Department of Infectious, Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Karin Pettersson
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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2
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Young AM, Stoner MCD, Mathebula F, Mohuba R, Baez A, Seyama L, Mutero P, Etima J, Fabiano Z, Fairlie L, Mayo AJ, Balkus JE, Song M, Bunge K, Piper J, Balan IC, van der Straten A, Montgomery ET. Acceptability of the Dapivirine Vaginal Ring and Daily Oral Pre-exposure Prophylaxis (PrEP) during Pregnancy in Malawi, South Africa, Uganda, and Zimbabwe. AIDS Behav 2024:10.1007/s10461-024-04421-z. [PMID: 39052199 DOI: 10.1007/s10461-024-04421-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 07/27/2024]
Abstract
Pregnant and lactating persons in sub-Saharan Africa face a heightened risk of HIV acquisition, due to biological and behavioral factors, combined with limited access to prevention and treatment services. Oral pre-exposure prophylaxis (PrEP) and the dapivirine vaginal ring are promising tools for HIV prevention, and the ring's recent approval in multiple African countries represents a significant advancement in expanding access to HIV prevention. In a nested qualitative study within the MTN-042 trial, we explored the acceptability of study products among pregnant persons in the second and early third trimesters. Interviews were conducted privately, using a semi-structured guide with 77 participants, in participants' preferred language. Topics explored included product acceptability (using the theoretical framework of acceptability), user experience, satisfaction, disclosure, community attitudes, and sexual activity during pregnancy. Interview transcripts were analyzed using Dedoose software. We observed positive attitudes among participants towards the study products, which they found generally user-friendly, despite the added complexities of using them during pregnancy. Participants recognized that consistent and correct use would provide protection for both them and their unborn children. Although initial concerns existed, most of these worries dissipated over time, with study staff support and increased product use experience. These findings emphasize the importance of continued surveillance, support, and education to ensure the successful rollout of new HIV prevention measures during pregnancy.
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Affiliation(s)
- Alinda M Young
- Women's Global Health Imperative at RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA.
- Department of Maternal and Child Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Marie C D Stoner
- Women's Global Health Imperative at RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA
| | - Florence Mathebula
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rebone Mohuba
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alejandro Baez
- Women's Global Health Imperative at RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA
| | - Linly Seyama
- Johns Hopkins Project - Kamuzu University of Health Science, Blantyre, Malawi
| | - Prisca Mutero
- University of Zimbabwe - Clinical Trials Research Centre, 15 Phillips Road, Belgravia, Harare, Zimbabwe
| | - Juliane Etima
- Makerere University - Johns Hopkins University Research Collaboration, Upper Mulago Hill Road Kampala, Kampala, Uganda
| | - Zayithwa Fabiano
- Johns Hopkins Project - Kamuzu University of Health Science, Blantyre, Malawi
| | - Lee Fairlie
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ashley J Mayo
- FHI 360, 359 Blackwell St., Suite 200, Durham, NC, USA
| | - Jennifer E Balkus
- Department of Epidemiology, University of Washington School of Public Health, Seattle, USA
- Vaccine and Infectious Disease Division, Fred Hutch Cancer Center, Seattle, USA
| | - Mei Song
- Magee-Women's Hospital of UPMC, 300 Halket Street, Pittsburgh, PA, USA
| | | | | | - Ivan C Balan
- Department of Behavioral Science and Social Medicine, Florida State University College of Medicine, Tallahassee, FL, USA
| | - Ariane van der Straten
- ASTRA consulting, 256 Stanford Avenue, Kensington, CA, USA
- Center for AIDS Prevention Studies (CAPS) UCSF, San Franscico, CA, USA
| | - Elizabeth T Montgomery
- Women's Global Health Imperative at RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA
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3
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Goga A, Ramraj T, Naidoo L, Daniels B, Matlou M, Chetty T, Dassaye R, Ngandu NK, Galli L, Reddy T, Seocharan I, Ndlangamandla Q, September Q, Ngcobo N, Reddy M, Cafun-Naidoo T, Woeber K, Jeenarain N, Imamdin R, Maharajh K, Ramjeth A, Bhengu T, Clarence E, Van de Perre P, Tylleskär T, Nagot N, Moles JP, Moore PL, Mkhize NN, Gama L, Dispinseri S, Biswas P, Scarlatti G. Safety and pharmacokinetics of subcutaneous administration of broadly neutralizing anti-HIV-1 monoclonal antibodies (bNAbs), given to HIV-1 exposed, uninfected neonates and infants: study protocol for a phase I trial. BMC Infect Dis 2024; 24:712. [PMID: 39033300 PMCID: PMC11264722 DOI: 10.1186/s12879-024-09588-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 07/03/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND The ambitious goal to eliminate new pediatric HIV infections by 2030 requires accelerated prevention strategies in high-risk settings such as South Africa. One approach could be pre-exposure prophylaxis (PrEP) with broadly neutralizing anti-HIV-1 monoclonal antibodies (bNAbs). The aim of our study is to define the optimal dose(s), the ideal combination(s) of bNAbs in terms of potency and breadth, and timing of subcutaneous (SC) administration(s) to prevent breast milk transmission of HIV. METHODS Two bNAbs, CAP256V2LS and VRC07-523LS, will be assessed in a sequential and randomized phase I, single-site, single-blind, dose-finding trial. We aim to investigate the 28-day safety and pharmacokinetics (PK) profile of incrementally higher doses of these bNAbs in breastfeeding HIV-1 exposed born without HIV neonates alongside standard of care antiretroviral (ARV) medication to prevent (infants) or treat (mothers) HIV infection. The trial design includes 3 steps and 7 arms (1, 2, 3, 4, 5, 6 and 6b) with 8 infants in each arm. The first step will evaluate the safety and PK profile of the bNAbs when given alone as a single subcutaneous (SC) administration at increasing mg/kg body weight doses within 96 h of birth: arms 1, 2 and 3 at doses of 5, 10, and 20 mg/kg of CAP256V2LS, respectively; arms 4 and 5 at doses of 20 and 30 mg/kg of VRC07-523LS, respectively. Step two will evaluate the safety and PK profile of a combination of the two bNAbs administered SC at fixed doses within 96 h of birth. Step three will evaluate the safety and PK profile of the two bNAbs administered SC in combination at fixed doses, after 3 months. Arms 1 and 6 will follow sequential recruitment, whereas randomization will occur sequentially between arms (a) 2 & 4 and (b) 3 & 5. Before each randomization, a safety pause will allow review of safety data of the preceding arms. DISCUSSION The results of this trial will guide further studies on bNAbs to prevent breast milk transmission of HIV. PROTOCOL VERSION Version 4.0 dated 15 March 2024. TRIAL REGISTRATION Pan African Clinical Trial Registry (PACTR): PACTR202205715278722, 21 April 2022; South African National Clinical Trial Registry (SANCTR): DOH-27-062022-6058.
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Affiliation(s)
- Ameena Goga
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
- Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa
| | - Trisha Ramraj
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Logashvari Naidoo
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Brodie Daniels
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Masefetsane Matlou
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Terusha Chetty
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Reshmi Dassaye
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Nobubelo K Ngandu
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Laura Galli
- Viral Evolution and Transmission Unit, IRCCS Ospedale San Raffaele s.r.l., Milan, Italy
| | - Tarylee Reddy
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Ishen Seocharan
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Qondeni Ndlangamandla
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Qholokazi September
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Nokwanda Ngcobo
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Mayuri Reddy
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Tamon Cafun-Naidoo
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Kubashni Woeber
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Nitesha Jeenarain
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Rabia Imamdin
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Keshnee Maharajh
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Ashmintha Ramjeth
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Thobile Bhengu
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Emma Clarence
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Philippe Van de Perre
- Pathogenesis and Control of Chronic and Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang; CHU Montpellier, Montpellier, France
| | - Thorkild Tylleskär
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Nicolas Nagot
- Pathogenesis and Control of Chronic and Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang; CHU Montpellier, Montpellier, France
| | - Jean-Pierre Moles
- Pathogenesis and Control of Chronic and Emerging Infections, University of Montpellier, INSERM, Etablissement Français du Sang; CHU Montpellier, Montpellier, France
| | - Penny L Moore
- SA MRC Antibody Immunity Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Center for HIV and STIs, National Institute for Communicable Diseases a Division of the National Health Laboratory Service, Johannesburg, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Nonhlanhla N Mkhize
- SA MRC Antibody Immunity Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Center for HIV and STIs, National Institute for Communicable Diseases a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Lucio Gama
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institute of Health, Bethesda, USA
| | - Stefania Dispinseri
- Viral Evolution and Transmission Unit, IRCCS Ospedale San Raffaele s.r.l., Milan, Italy
| | - Priscilla Biswas
- Viral Evolution and Transmission Unit, IRCCS Ospedale San Raffaele s.r.l., Milan, Italy
| | - Gabriella Scarlatti
- Viral Evolution and Transmission Unit, IRCCS Ospedale San Raffaele s.r.l., Milan, Italy.
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Kuchukhidze S, Walters MK, Panagiotoglou D, Boily MC, Diabaté S, Russell WA, Stöckl H, Sardinha L, Mbofana F, Wanyenze RK, Imai-Eaton JW, Maheu-Giroux M. The contribution of intimate partner violence to vertical HIV transmission: a modelling analysis of 46 African countries. Lancet HIV 2024:S2352-3018(24)00148-6. [PMID: 39059403 DOI: 10.1016/s2352-3018(24)00148-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 05/16/2024] [Accepted: 05/17/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Addressing gender inequities could be key to the elimination of vertical transmission of HIV. Women experiencing intimate partner violence (IPV) might be at an increased risk of vertical transmission due to their vulnerability to HIV acquisition and barriers to access to and retention in care. Sub-Saharan Africa, where IPV burden is among the highest globally, accounts for most new paediatric HIV infections. We aimed to examine the proportion of excess vertical transmission attributable to IPV in this region. METHODS In this modelling analysis, we created a probability tree model of vertical HIV transmission among women aged 15-49 years in 46 African countries. We estimated the proportion of vertical transmission attributable to past-year physical or sexual IPV, or both, as an age-standardised population attributable fraction (PAF) and as excess vertical transmission risk per 1000 births among women experiencing IPV. We incorporated perinatal and postnatal vertical transmission among women who acquired HIV before pregnancy, during pregnancy, and during breastfeeding. Fertility, HIV prevalence, HIV incidence, antiretroviral therapy (ART) uptake, and ART retention varied in the model by women's IPV experience. The model was parameterised using UNAIDS' 2023 Spectrum model data, WHO's Global Database on Violence Against Women, and the peer-reviewed literature. Uncertainty intervals (95% UI) were calculated through 1000 Monte Carlo simulations. FINDINGS Across 46 countries 13% (95% UI 6-21) of paediatric HIV infections in 2022 were attributed to IPV, corresponding to over 22 000 paediatric infections. The PAF ranged from 4% (2-7) in Niger to 28% (13-43) in Uganda. The PAF was highest among girls aged 15-19 years (20%, 8-33) and lowest among women aged 45-49 years (6%, 3-9). In southern Africa, where women's HIV prevalence is highest (23%), IPV led to 11 (5-20) additional infections per 1000 births among women affected by IPV. INTERPRETATION IPV might be responsible for one in eight paediatric HIV infections in sub-Saharan Africa. Ending IPV could accelerate vertical transmission elimination, especially among young women who bear the highest burden of violence. FUNDING Canadian Institutes of Health Research, Canada Research Chair, and Fonds de recherche du Québec-Santé. TRANSLATIONS For the French, Georgian and Spanish translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Salome Kuchukhidze
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, QC, Canada
| | - Magdalene K Walters
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Dimitra Panagiotoglou
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, QC, Canada
| | - Marie-Claude Boily
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Souleymane Diabaté
- Département de Médecine Sociale et Préventive, Université Laval, Québec City, QC, Canada; Centre de Recherche du CHU de Québec-Université Laval, Québec City, QC, Canada
| | - W Alton Russell
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, QC, Canada
| | - Heidi Stöckl
- Institute for Medical Information Processing, Biometry, and Epidemiology, Medical Faculty, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Lynnmarie Sardinha
- The UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jeffrey W Imai-Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK; Center for Infectious Disease Dynamics, Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Mathieu Maheu-Giroux
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, QC, Canada.
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5
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Chhun N, Rothschild CW, Penumetsa M, Matemo D, Kithao P, Richardson BA, John-Stewart G, Kinuthia J, Drake AL. Evaluating the performance of a risk assessment score tool to predict HIV acquisition among pregnant and postpartum women in Kenya. PLoS One 2024; 19:e0306992. [PMID: 38985777 PMCID: PMC11236202 DOI: 10.1371/journal.pone.0306992] [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: 06/19/2023] [Accepted: 06/25/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Clinical risk score tools require validation in diverse settings and populations before they are widely implemented. We aimed to externally validate an HIV risk assessment tool for predicting HIV acquisition among pregnant and postpartum women. In the context of prevention of mother-to-child transmission programs, risk score tools could be used to prioritize retesting efforts and delivery of pre-exposure prophylaxis (PrEP) to pregnant and postpartum women most at risk for HIV acquisition while minimizing unnecessary perinatal exposure. METHODS Data from women enrolled in a cross-sectional study of programmatic HIV retesting and/or receiving maternal and child health care services at five facilities in Western Kenya were used to validate the predictive ability of a simplified risk score previously developed for pregnant/postpartum women. Incident HIV infections were defined as new HIV diagnoses following confirmed negative or unknown status during pregnancy. Predictive performance was assessed using the area under the receiver operating characteristic curve (AUC) and Brier score. RESULTS Among 1266 women with 35 incident HIV infections, we found an AUC for predicting HIV acquisition of 0.60 (95% CI, 0.51, 0.69), with a Brier score of 0.27. A risk score >6 was associated with a 2.9-fold increase in the odds of HIV acquisition (95% CI, 1.48, 5.70; p = 0.002) vs scores ≤6. Women with risk scores >6 were 27% (346/1266) of the population but accounted for 52% of HIV acquisitions. Syphilis, age at sexual debut, and unknown partner HIV status were significantly associated with increased risk of HIV in this cohort. CONCLUSION The simplified risk score performed moderately at predicting risk of HIV acquisition in this population of pregnant and postpartum women and may be useful to guide PrEP use or counseling.
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Affiliation(s)
- Nok Chhun
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Claire W. Rothschild
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Monalisa Penumetsa
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Daniel Matemo
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Peninah Kithao
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Barbra A. Richardson
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
- Department of Pediatrics, University of Washington, Seattle, WA, United States of America
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Alison L. Drake
- Department of Global Health, University of Washington, Seattle, WA, United States of America
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Stoner MCD, Mathebula F, Sedze N, Seyama L, Mohuba R, Fabiano Z, Etima J, Young A, Scheckter R, van der Straten A, Piper J, Noguchi L, Montgomery ET, Balán IC. Depression Among Pregnant and Breastfeeding Persons Participating in Two Randomized Trials of the Dapivirine Vaginal Ring and Oral Pre-Exposure Prophylaxis (PrEP) in Malawi, South Africa, Uganda, and Zimbabwe. AIDS Behav 2024; 28:2264-2275. [PMID: 38526641 DOI: 10.1007/s10461-024-04321-2] [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] [Accepted: 03/11/2024] [Indexed: 03/27/2024]
Abstract
Depression is associated with lower adherence to oral pre-exposure prophylaxis (PrEP) to prevent HIV, but data are not currently available on how depression may affect use of other HIV prevention methods including the dapivirine vaginal ring (DVR). We conducted a mixed methods study using data from the Microbicide Trials Network (MTN) 042/DELIVER (n = 558) and MTN-043/B-PROTECTED (n = 197) studies to describe the prevalence of depressive symptoms and explore how depressive symptoms may have influenced attitudes about use of the monthly DVR and once-daily oral PrEP tablet among pregnant and breastfeeding persons, respectively, in Malawi, South Africa, Uganda, and Zimbabwe. Eleven participants had high Edinburgh Postnatal Depression scores ≥ 10 in MTN-042/DELIVER (2%) and four participants (2%) in MTN-043/B-PROTECTED. In interviews with 9 participants who had high scores (6 DVR, 3 oral PrEP), those with depressive symptoms described overlapping stressors which were magnified by job loss and economic instability during the COVID-19 pandemic, and by experiences of pregnancy/postpartum. These participants experienced a lack of support from partners or family members, and conflict with partners related to trust, and infidelity. While we did not find evidence of a change in product adherence, there was a strong sense of commitment and motivation to use the study products for protection from HIV for participants themselves and their baby. Although lack of social support is usually an obstacle to adherence, in this study, the participants' lives and relationships seemed to have reinforced the need for HIV prevention and motivated women to protect themselves and their babies from HIV.
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Affiliation(s)
| | - Florence Mathebula
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Natasha Sedze
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Linly Seyama
- Johns Hopkins Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Rebone Mohuba
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Zayithwa Fabiano
- Johns Hopkins Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Juliane Etima
- Makerere University - Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | | | | | | | - Jeanna Piper
- National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, USA
| | - Lisa Noguchi
- Division of Reproductive, Maternal, Newborn, Child and Adolescent Health, Jhpiego/Johns Hopkins University, Washington, DC, USA
| | | | - Iván C Balán
- Florida State University College of Medicine, Tallahassee, FL, USA
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7
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Creisher PS, Klein SL. Pathogenesis of viral infections during pregnancy. Clin Microbiol Rev 2024; 37:e0007323. [PMID: 38421182 PMCID: PMC11237665 DOI: 10.1128/cmr.00073-23] [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] [Indexed: 03/02/2024] Open
Abstract
SUMMARYViral infections during pregnancy are associated with significant adverse perinatal and fetal outcomes. Pregnancy is a unique immunologic and physiologic state, which can influence control of virus replication, severity of disease, and vertical transmission. The placenta is the organ of the maternal-fetal interface and provides defense against microbial infection while supporting the semi-allogeneic fetus via tolerogenic immune responses. Some viruses, such as cytomegalovirus, Zika virus, and rubella virus, can breach these defenses, directly infecting the fetus and having long-lasting consequences. Even without direct placental infection, other viruses, including respiratory viruses like influenza viruses and severe acute respiratory syndrome coronavirus 2, still cause placental damage and inflammation. Concentrations of progesterone and estrogens rise during pregnancy and contribute to immunological adaptations, placentation, and placental development and play a pivotal role in creating a tolerogenic environment at the maternal-fetal interface. Animal models, including mice, nonhuman primates, rabbits, and guinea pigs, are instrumental for mechanistic insights into the pathogenesis of viral infections during pregnancy and identification of targetable treatments to improve health outcomes of pregnant individuals and offspring.
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Affiliation(s)
- Patrick S Creisher
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sabra L Klein
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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8
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Rosenthal M, Stolz A, Haskin L, Leung SYJ, Wong C, O'Grady T, Swain CA, Kaufman S. Prevalence of Repeat Prenatal HIV Screening in New York State. J Womens Health (Larchmt) 2024. [PMID: 38864110 DOI: 10.1089/jwh.2023.0835] [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: 06/13/2024] Open
Abstract
Description: New York State Department of Health (NYSDOH) recommends that all pregnant patients receive human immunodeficiency virus (HIV) screening during pregnancy. This study assessed the prevalence of repeat prenatal HIV testing and factors associated with receipt of the recommended tests. Methods: Data from the NYSDOH newborn screening program were used to randomly select pregnant persons without HIV who delivered a liveborn infant in 2017. Receipt of repeat testing was defined as an initial HIV test in the first or second trimesters and the final in the third trimester (relaxed); or an initial test in the first trimester and the final in the third trimester (strict). Relative risks (RRs) and 95% confidence intervals were calculated in bivariate analyses. Adjusted RRs were calculated to determine associations between demographic and clinical factors and receipt of repeat HIV testing. Results: The cohort included 2,225 individuals. Roughly one quarter (24%) received the recommended tests in the first or second and third trimesters and 17% received them in the first and third trimesters. Individuals who reported Hispanic or Asian race/ethnicities, had government-funded insurance, started prenatal care in the first trimester, delivered in New York City, or received prenatal hepatitis C virus screening were significantly more likely to receive repeat testing using either definition. Conclusions: Despite the benefits and cost-effectiveness, the prevalence of repeat prenatal HIV screening during the third trimester remains persistently low. Improved messaging and targeted education and resources to assist prenatal providers could reinforce the importance of repeat testing and reduce residual perinatal HIV transmission.
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Affiliation(s)
- Mark Rosenthal
- Division of HIV/STI Epidemiology, Evaluation, and Partner Services, New York State Department of Health, Albany, New York, USA
| | - Amanda Stolz
- Division of HIV/STI Epidemiology, Evaluation, and Partner Services, New York State Department of Health, Albany, New York, USA
| | - Lisa Haskin
- Division of HIV and Hepatitis Health care, New York State Department of Health, AIDS Institute, Albany, New York, USA
| | - Shu-Yin John Leung
- Office of Program Evaluation and Research, New York State Department of Health, AIDS Institute, Albany, New York, USA
| | - Calvin Wong
- Division of HIV/STI Epidemiology, Evaluation, and Partner Services, New York State Department of Health, Albany, New York, USA
| | - Thomas O'Grady
- Division of HIV/STI Epidemiology, Evaluation, and Partner Services, New York State Department of Health, Albany, New York, USA
- University at Albany School of Public Health, Albany, New York, USA
| | - Carol-Ann Swain
- Division of HIV/STI Epidemiology, Evaluation, and Partner Services, New York State Department of Health, Albany, New York, USA
| | - Suzanne Kaufman
- Division of HIV and Hepatitis Health care, New York State Department of Health, AIDS Institute, Albany, New York, USA
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Abuogi L, Noble L, Smith C. Infant Feeding for Persons Living With and at Risk for HIV in the United States: Clinical Report. Pediatrics 2024; 153:e2024066843. [PMID: 38766700 DOI: 10.1542/peds.2024-066843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 05/22/2024] Open
Abstract
Pediatricians and pediatric health care professionals caring for infants born to people living with and at risk for HIV infection are likely to be involved in providing guidance on recommended infant feeding practices. Care team members need to be aware of the HIV transmission risk from breastfeeding and the recommendations for feeding infants with perinatal HIV exposure in the United States. The risk of HIV transmission via breastfeeding from a parent with HIV who is receiving antiretroviral treatment (ART) and is virally suppressed is estimated to be less than 1%. The American Academy of Pediatrics recommends that for people with HIV in the United States, avoidance of breastfeeding is the only infant feeding option with 0% risk of HIV transmission. However, people with HIV may express a desire to breastfeed, and pediatricians should be prepared to offer a family-centered, nonjudgmental, harm reduction approach to support people with HIV on ART with sustained viral suppression below 50 copies per mL who desire to breastfeed. Pediatric health care professionals who counsel people with HIV who are not on ART or who are on ART but without viral suppression should recommend against breastfeeding. Pediatric health care professionals should recommend HIV testing for all pregnant persons and HIV preexposure prophylaxis to pregnant or breastfeeding persons who test negative for HIV but are at high risk of HIV acquisition.
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Affiliation(s)
- Lisa Abuogi
- Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Lawrence Noble
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York
| | - Christiana Smith
- Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
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Wu L, Saina M, Brown C, Chege D, Donnell D, Glidden DV, Ngure K, Mugo NR, Akelo N, Schaafsma T, Anderson PL, Mugwanya KK. Establishing adherence-concentration-efficacy thresholds of TDF-FTC pre-exposure prophylaxis for HIV prevention in African women: a protocol for the Women TDF-FTC Benchmark Study. FRONTIERS IN REPRODUCTIVE HEALTH 2024; 6:1325257. [PMID: 38860025 PMCID: PMC11163076 DOI: 10.3389/frph.2024.1325257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 05/06/2024] [Indexed: 06/12/2024] Open
Abstract
Background Oral pre-exposure prophylaxis (PrEP) using co-formulated emtricitabine (FTC) and tenofovir disoproxil fumarate (TDF) is a potent HIV prevention method for men and women, with its efficacy highly dependent on adherence. A pivotal HIV efficacy study combined with a directly observed pharmacological study defined the thresholds for HIV protection in men who have sex with men (MSM), which are the keys to PrEP promotion and development of new PrEP agents. For African women at risk for HIV and belonging to a priority group considered due to disproportionately high incident HIV infections, the variable adherence in PrEP clinical trials and the limited pharmacologic data have resulted in a lack of clarity about the PrEP adherence required for HIV protection. We propose a study to quantify the adherence-concentration-efficacy thresholds of TDF/FTC PrEP among African cisgender women to inform decisions about optimal PrEP dosing and adherence for HIV protection. Methods We randomized 45 low-risk HIV-uninfected African women, aged 18-30 years old, to directly observe the TDF/FTC PrEP of two, four, or seven doses per week for 8 weeks. A complementary age-matched pregnant women cohort at high risk of HIV, who will receive seven doses per week, was recruited (N = 15) with the primary aim of establishing benchmark concentrations in dried blood spots and peripheral blood mononuclear cells. Plasma, whole blood (WB), urine, hair, vaginal fluid, and vaginal tissue (non-pregnant women only) were archived for future testing. Drug concentrations were measured using methods validated for each biological matrix. Pharmacokinetic models were fitted to drug concentrations to quantify concentration-adherence thresholds. To define the drug concentrations associated with HIV protection, we applied the newly defined thresholds from the primary pharmacologic trial to the subset of women randomized to TDF/FTC or TDF in the Partners PrEP Study with the drug concentration assessed in plasma and WB samples. Multiple imputation was used to construct a data set with drug concentrations at each visit when an HIV test was performed for the entire cohort, replicating the work for MSM. Discussion The proposed study generated the first African women-specific TDF-PrEP adherence-concentration-efficacy thresholds essential for guiding the accurate interpretation of TDF/FTC PrEP programs and clinical trials of novel HIV prevention products using TDF/FTC as an active control. Clinical Trial Registration ClinicalTrials.gov, identifier (NCT05057858).
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Affiliation(s)
- Linxuan Wu
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Matilda Saina
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Clare Brown
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - David Chege
- Clinical Trials Research Laboratory, Kenyatta National Hospital, Nairobi, Kenya
| | - Deborah Donnell
- Department of Global Health, University of Washington, Seattle, WA, United States
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - David V. Glidden
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, United States
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, WA, United States
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Nelly R. Mugo
- Department of Global Health, University of Washington, Seattle, WA, United States
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nina Akelo
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Torin Schaafsma
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Peter L. Anderson
- Department of Pharmaceutical Science, University of Colorado Denver, Aurora, CO, United States
| | - Kenneth K. Mugwanya
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
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Sorato MM, Alemu T, Toma A, Paulos G, Mekonnen S. Effect of HIV and substance use disorder comorbidity on the placenta, fetal and maternal health outcomes: systematic review and meta-analysis protocol. BMJ Open 2024; 14:e083037. [PMID: 38772595 PMCID: PMC11110607 DOI: 10.1136/bmjopen-2023-083037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 05/09/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND Substance use disorders and HIV infection have a bidirectional relationship. People who use illicit drugs are at increased risk of contracting HIV/AIDS, and people living with HIV/AIDS are at increased risk of using substances due to disease-related complications like depression and HIV-associated dementia. There is no adequate evidence on the effect of HIV/AIDS and substance use disorder comorbidity-related effects on placental, fetal, maternal and neonatal outcomes globally. METHODS AND ANALYSIS We will search articles written in the English language until 30 January 2024, from PubMed/Medline, Cochrane Library, Embase, Scopus, Web of Sciences, SUMsearch2, Turning Research Into Practice database and Google Scholar. A systematic search strategy involving AND/OR Boolean Operators will retrieve information from these databases and search engines. Qualitative and quantitative analysis methods will be used to report the effect of HIV/AIDS and substance use disorders on placental, fetal and maternal composite outcomes. Descriptive statistics like pooled prevalence mean and SD will be used for qualitative analysis. However, quantitative analysis outcomes will be done by using Comprehensive Meta-Analysis Software for studies that are combinable. The individual study effects and the weighted mean difference will be reported in a forest plot. In addition to this, the presence of multiple morbidities like diabetes, chronic kidney disease and maternal haemoglobin level could affect placental growth, fetal growth and development, abortion, stillbirth, HIV transmission and composite maternal outcomes. Therefore, subgroup analysis will be done for pregnant women with multiple morbidities. ETHICS AND DISSEMINATION Since systematic review and meta-analysis will be conducted by using published literature, ethical approval is not required. The results will be presented in conferences and published in peer-reviewed journals. PROSPERO REGISTRATION NUMBER CRD42023478360.
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Affiliation(s)
- Mende Mensa Sorato
- Pharmacy, School of Medicine, Komar University of Science and Technology, Sulaymania, Iraq
| | - Tsegaye Alemu
- School of Public Health, Hawassa University College of Medicine and Health Sciences, Hawassa, Southern Nations, Ethiopia
| | - Alemayehu Toma
- Pharmacy, School of Medicine, Komar University of Science and Technology, Sulaymania, Iraq
| | - Getahun Paulos
- Pharmacy, School of Medicine, Komar University of Science and Technology, Sulaymania, Iraq
| | - Shewangizaw Mekonnen
- Nursing, School of Medicine, Komar University of Science and Technology, Sulaymania, Iraq
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Djiadeu P, Begum H, Archibald C, Ekmekjian T, Busa G, Dansoh J, Van Nguyen P, Merckx J, Fleurant A. Risk of transmission of HIV to infants during breast/chest feeding when mothers/birthing parents living with HIV are on antiretroviral therapy: a protocol for a rapid review. BMJ Open 2024; 14:e084436. [PMID: 38719325 PMCID: PMC11086518 DOI: 10.1136/bmjopen-2024-084436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 04/12/2024] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION HIV is a major public health issue affecting millions globally. Women and girls account for 46% of new HIV infections in 2022 and approximately 1.3 million females become pregnant every year. Vertical transmission of HIV from persons living with HIV (PLHIV) to infants may occur through different modalities, such as through breast/chest feeding. Notably, 82% of PLHIV who chose to breast/chest feed are on antiretroviral therapy (ART) when feeding their infants. Precise estimates of the risk of postpartum transmission to infants during breast/chest feeding at varying viral load levels remain a significant gap in the literature. METHODS AND ANALYSIS A rapid systematic search of electronic databases will be conducted from January 2005 to the present, including Medline, Embase and Global Health. The objective of this rapid review is to explore and assess the available evidence on the effect of varying viral load levels on the risk of HIV transmission to infants during breast/chest feeding when the birthing or gestational parent living with HIV is on ART. Study characteristics will be summarised and reported to support the narrative summary of the findings. The focus will be on the absolute risk of HIV transmission from birthing parent to infant during chest/breast feeding. The findings will also be stratified by month, including the risk of HIV transmission for 6 months and greater than 6 months postpartum. We will ascertain the risk of bias using A Measurement Tool to Assess Systematic Reviews 2, Quality of Prognosis Studies and Downs and Black checklist for the appropriate study type. A summary score will not be calculated, rather the strengths and limitations of the studies will be narratively described. ETHICS AND DISSEMINATION No human subjects will be involved in the research. The findings of this rapid review will inform a future systematic review and will be disseminated through peer-reviewed publications, presentations and conferences. PROSPERO REGISTRATION NUMBER CRD42024499393.
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Affiliation(s)
- Pascal Djiadeu
- Public Health Agency of Canada, Ottawa, Ontario, Canada
- STBBI Guidance, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Housne Begum
- Public Health Agency of Canada, Ottawa, Ontario, Canada
- STBBI Guidance, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Chris Archibald
- Public Health Agency of Canada, Ottawa, Ontario, Canada
- STBBI Guidance, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | | | - Giovanna Busa
- Public Health Agency of Canada, Ottawa, Ontario, Canada
- STBBI Guidance, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Jeffery Dansoh
- Public Health Agency of Canada, Ottawa, Ontario, Canada
- STBBI Guidance, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Phu Van Nguyen
- Public Health Agency of Canada, Ottawa, Ontario, Canada
- STBBI Guidance, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Joanna Merckx
- Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Annie Fleurant
- Public Health Agency of Canada, Ottawa, Ontario, Canada
- STBBI Guidance, Public Health Agency of Canada, Ottawa, Ontario, Canada
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Iordache MD, Meca DC, Cirstoiu MM. Fetal Clinical and Paraclinical Outcomes in HIV-Positive Pregnant Women. Cureus 2024; 16:e59568. [PMID: 38826912 PMCID: PMC11144293 DOI: 10.7759/cureus.59568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2024] [Indexed: 06/04/2024] Open
Abstract
Background Adverse pregnancy outcomes in women with human immunodeficiency virus (HIV) infection remain significantly increased. Untreated maternal infection primarily leads to fetal complications, such as intrauterine growth restriction, stillbirth, or preterm birth. Concerning both maternal and fetal complications that can appear in pregnancy associated with HIV infection, the purpose of the study was to determine fetal and maternal demographic characteristics and the correlation between blood count parameters and poor fetal prognosis. Methods We conducted a quantitative study utilizing document review as the data collection method. This study encompassed a cohort of nine HIV-positive pregnant women who delivered at the Obstetrics and Gynecology Department of the University Emergency Hospital in Bucharest from January 1, 2021, to December 31, 2023. A comparative cohort of nine healthy pregnant women who delivered during the same period in the same facility was selected using stratified random sampling. We examined maternal and fetal demographic parameters and neonatal outcomes, reporting them to paraclinical laboratory data. Results The incidence of pregnancy-related HIV infections was 0.16%. The mean age of patients in the selected group was 29.88 ± 5.53. There was no statistically significant correlation between maternal clinical and paraclinical parameters in the HIV-positive and HIV-negative groups. Although there was a slightly negative difference in the fetal weight at birth, the 1-min APGAR (appearance, pulse, grimace, activity, and respiration) score, and the intrauterine growth restriction between the two groups, there was a statistically significant association between admission to the neonatal intensive care unit (NICU) and the neonates from HIV-positive pregnancies. In our study, we observed preterm deliveries in 22.22% of cases, and we did not record any stillbirths. The 1-min APGAR score was correlated with the value of leukocytes in peripheral blood. Vertical transmission was established to be 11.11% independent of maternal blood count parameters. Conclusion HIV infection during pregnancy leads to a higher risk of admission to the NICU. Fetal leukocytosis is indicative of a lower 1-min APGAR score. The primary emphasis of therapeutic intervention during pregnancy should center on vigilant monitoring of maternal viral load and the timely administration of antiretroviral therapy to enhance fetal outcomes.
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Affiliation(s)
- Madalina Daniela Iordache
- Department of Obstetrics and Gynaecology, University Emergency Hospital Bucharest, Doctoral School of Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Daniela Catalina Meca
- Department of Obstetrics and Gynaecology, University Emergency Hospital Bucharest, Doctoral School of Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Monica Mihaela Cirstoiu
- Department of Obstetrics and Gynaecology, University Emergency Hospital Bucharest, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
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Kabami J, Koss CA, Sunday H, Biira E, Nyabuti M, Balzer LB, Gupta S, Chamie G, Ayieko J, Kakande E, Bacon MC, Havlir D, Kamya MR, Petersen M. Randomized Trial of Dynamic Choice HIV Prevention at Antenatal and Postnatal Care Clinics in Rural Uganda and Kenya. J Acquir Immune Defic Syndr 2024; 95:447-455. [PMID: 38489493 PMCID: PMC10927304 DOI: 10.1097/qai.0000000000003383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 11/30/2023] [Indexed: 03/17/2024]
Abstract
BACKGROUND Pregnant and postpartum women in Sub-Saharan Africa are at high risk of HIV acquisition. We evaluated a person-centered dynamic choice intervention for HIV prevention (DCP) among women attending antenatal and postnatal care. SETTING Rural Kenya and Uganda. METHODS Women (aged 15 years or older) at risk of HIV acquisition seen at antenatal and postnatal care clinics were individually randomized to DCP vs. standard of care (SEARCH; NCT04810650). The DCP intervention included structured client choice of product (daily oral pre-exposure prophylaxis or postexposure prophylaxis), service location (clinic or out of facility), and HIV testing modality (self-test or provider-administered), with option to switch over time and person-centered care (phone access to clinician, structured barrier assessment and counseling, and provider training). The primary outcome was biomedical prevention coverage-proportion of 48-week follow-up with self-reported pre-exposure prophylaxis or postexposure prophylaxis use, compared between arms using targeted maximum likelihood estimation. RESULTS Between April and July 2021, we enrolled 400 women (203 intervention and 197 control); 38% were pregnant, 52% were aged 15-24 years, and 94% reported no pre-exposure prophylaxis or postexposure prophylaxis use for ≥6 months before baseline. Among 384/400 participants (96%) with outcome ascertained, DCP increased biomedical prevention coverage 40% (95% CI: 34% to 47%; P < 0.001); the coverage was 70% in intervention vs. 29% in control. DCP also increased coverage during months at risk of HIV (81% in intervention, 43% in control; 38% absolute increase; 95% CI: 31% to 45%; P < 0.001). CONCLUSION A person-centered dynamic choice intervention that provided flexibility in product, testing, and service location more than doubled biomedical HIV prevention coverage in a high-risk population already routinely offered access to biomedical prevention options.
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Affiliation(s)
- Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | | | - Helen Sunday
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Edith Biira
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Marilyn Nyabuti
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Laura B. Balzer
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA; and
| | - Shalika Gupta
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA; and
| | - Gabriel Chamie
- Department of Medicine, University of California, San Francisco, CA
| | - James Ayieko
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elijah Kakande
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Melanie C. Bacon
- Department of Health and Human Services, National Institute of Health, Bethesda, MD
| | - Diane Havlir
- Department of Medicine, University of California, San Francisco, CA
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Maya Petersen
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA; and
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Dessale DS, Gebremariam MB, Wolde AA. HIV seroconversion and associated factors among seronegative pregnant women attending ANC in Ethiopia: an institution-based cross-sectional study. FRONTIERS IN REPRODUCTIVE HEALTH 2024; 6:1246734. [PMID: 38660333 PMCID: PMC11039893 DOI: 10.3389/frph.2024.1246734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 03/25/2024] [Indexed: 04/26/2024] Open
Abstract
Background In countries with limited resources, including Ethiopia, HIV is diagnosed using a rapid serological test, which does not detect the infection during the window period. Pregnant women who test negative for HIV on the first test may seroconvert throughout pregnancy. Women who are seroconverted during pregnancy may not have received interventions, as they are considered HIV-negative unless they are retested for HIV at the end of their pregnancy. Due to limited data on HIV seroconversion, this study aimed to measure the extent of HIV seroconversion and to identify associated factors among seronegative pregnant women attending ANC in Ethiopia. Methods Institution-based cross-sectional study was conducted among HIV-negative pregnant women attending the ANC in Ethiopia between June and July 2020. Socio-demographic, clinical, and behavioral data were collected through face-to-face questionnaires and participants' records review. HIV retesting was performed to determine the current HIV status of pregnant women. The data collected were entered into Epi data version 4.4.1 and were exported and analyzed by SPSS version 25. A p-value < 0.25 in the bivariate analysis was entered into multivariable logistic regression analysis and a p-value of < 0.05 was considered statistically significant. Result Of the 494 pregnant women who tested negative for HIV on their first ANC test, six (1.2%) tested positive on repeat testing. Upon multivariable logistic regression, pregnant women who have had a reported history of sexually transmitted infections [AOR = 7.98; 95% CI (1.21, 52.82)], participants' partners reported travel history for work frequently [AOR = 6.00; 95% CI (1.09, 32.99)], and sexually abused pregnant women [AOR = 7.82; 95% CI (1.194, 51.24)] were significantly associated with HIV seroconversion. Conclusion The seroconversion rate in this study indicates that pregnant women who are HIV-negative in early pregnancy are at an ongoing risk of seroconversion throughout their pregnancy. Thus, this study highlights the benefit of a repeat HIV testing strategy in late pregnancy, particularly when the risk of seroconversion or new infection cannot be convincingly excluded. Therefore, repeated testing of HIV-negative pregnant women in late pregnancy provides an opportunity to detect seroconverted pregnant women to enable the timely use of ART to prevent mother-to-child transmission of HIV infection.
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Affiliation(s)
- Dawit Sisay Dessale
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Asrat Arja Wolde
- National Data Management and Analytics Center, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
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Erlwanger A, Rocroi I, Kirtley S, Hemelaar J. Perinatal outcomes associated with pre-exposure prophylaxis for HIV prevention during pregnancy: a systematic review and meta-analysis. EClinicalMedicine 2024; 70:102532. [PMID: 38685925 PMCID: PMC11056414 DOI: 10.1016/j.eclinm.2024.102532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 05/02/2024] Open
Abstract
Background The World Health Organization (WHO) recommends tenofovir disoproxil fumarate (TDF)-based oral pre-exposure prophylaxis (PrEP), the dapivirine vaginal ring, and long-acting intramuscular injectable cabotegravir (CAB-LA) for HIV prevention in populations at substantial risk of HIV infection. Pregnancy is a period of elevated risk of maternal HIV infection and transmission to the infant. This systematic review and meta-analysis assessed the risk of adverse perinatal outcomes among HIV-negative pregnant women with exposure to any PrEP modality. Methods We conducted a systematic review by searching Medline, EMBASE, CINAHL, Global Health, the Cochrane Library, WHO ICTR, ISRCTN, PACTR, and ClinicalTrials.gov for studies published between 1 January 2000 and 29 August 2023. We included studies reporting on the association of antenatal exposure to any PrEP modality with 13 perinatal outcomes: preterm birth (PTB), very PTB, spontaneous PTB, spontaneous very PTB, low birthweight (LBW), very LBW, term LBW, preterm LBW, small for gestational age (SGA), very SGA, miscarriage, stillbirth, or neonatal death (NND). Quality assessments of included studies were performed. Fixed-effect meta-analyses were conducted to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs). The protocol is registered with PROSPERO, CRD42022339825. Findings Of 18,598 citations identified, 13 studies (eight randomised controlled trials (RCTs) and five cohort studies), assessing 8712 pregnant women in Africa, were included. Oral PrEP, compared to no PrEP, was not associated with PTB in meta-analyses of six RCTs (OR 0.73, 95% CI 0.43-1.26; I2 = 0.0%) or five unadjusted cohort studies (OR 0.84, 95% CI 0.69-1.03; I2 = 0.0%), but was associated with a reduced risk of PTB in three adjusted cohort studies (aOR 0.67; 95% CI 0.52-0.88, I2 = 0.0%). There was no association of oral PrEP with LBW, vLBW, SGA, or NND, compared to no PrEP. There was no association with PTB when oral TDF/emtricitabine (FTC) PrEP, oral TDF PrEP, and tenofovir vaginal gel were compared to each other. There was no association of the dapivirine vaginal ring with PTB or NND, compared to placebo or oral TDF/FTC PrEP. We found no data on CAB-LA. Interpretation We found no evidence of adverse perinatal outcomes associated with PrEP exposure during pregnancy. Our findings support the WHO recommendation to provide oral PrEP to women of reproductive age and pregnant women. More data is needed to assess the safety of all PrEP modalities in pregnancy. Funding None.
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Affiliation(s)
- Alison Erlwanger
- National Perinatal Epidemiology Unit, Infectious Disease Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Isabelle Rocroi
- National Perinatal Epidemiology Unit, Infectious Disease Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joris Hemelaar
- National Perinatal Epidemiology Unit, Infectious Disease Epidemiology Unit, Oxford Population Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Drake AL, Jiang W, Kitao P, Farid S, Richardson BA, Katz DA, Wagner AD, Johnson CC, Matemo D, Stewart GJ, Kinuthia J. Preferences and uptake of home-based HIV self-testing for maternal retesting in Kenya. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.28.24305050. [PMID: 38585992 PMCID: PMC10996825 DOI: 10.1101/2024.03.28.24305050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Objective To compare preferences, uptake, and cofactors for unassisted home-based oral self-testing (HB-HIVST) versus clinic-based rapid diagnostic blood tests (CB-RDT) for maternal HIV retesting. Design Prospective cohort. Methods Between November 2017 and June 2019, HIV-negative pregnant Kenyan women receiving antenatal care were enrolled and given a choice to retest with HB-HIVST or CB-RDT. Women were asked to retest between 36 weeks gestation and 1 week post-delivery if the last HIV test was <24 weeks gestation or at 6 weeks postpartum if ≥24 weeks gestation, and self-report on retesting at a 14 week postpartum. Results Overall, 994 women enrolled and 33% (n=330) selected HB-HIVST. HB-HIVST was selected because it was private (68%), convenient (63%), and offered flexibility in timing of retesting (63%), whereas CB-RDT was selected due to trust of providers to administer the test (77%) and convenience of clinic testing (64%). Among 905 women who reported retesting at follow-up, 135 (15%) used HB-HIVST. Most (94%) who selected CB-RDT retested with this strategy, compared to 39% who selected HB-HIVST retesting with HB-HIVST. HB-HIVST retesting was more common among women with higher household income and those who may have been unable to test during pregnancy (both retested postpartum and delivered <37 weeks gestation) and less common among women who were depressed. Most women said they would retest in the future using the test selected at enrollment (99% HB-HIVST; 93% CB-RDT-RDT). Conclusions While most women preferred CB-RDT for maternal retesting, HB-HIVST was acceptable and feasible and may increase retesting coverage and partner testing.
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Affiliation(s)
- Alison L Drake
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Wenwen Jiang
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Peninah Kitao
- Research and Programmes, Kenyatta National Hospital, Nairobi, Kenya
| | - Shiza Farid
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Barbra A Richardson
- Department of Biostatistics, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - David A Katz
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Cheryl C Johnson
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Daniel Matemo
- Research and Programmes, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace-John Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - John Kinuthia
- Research and Programmes, Kenyatta National Hospital, Nairobi, Kenya
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Johnson LF, Myer L, Jamieson L, Meyer-Rath G, Delany-Moretlwe S, Joseph Davey D. The potential benefits of long-acting injectable cabotegravir in pregnant and breastfeeding women and their infants. AIDS 2024; 38:589-594. [PMID: 38016171 PMCID: PMC10906189 DOI: 10.1097/qad.0000000000003803] [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: 08/29/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Pregnant and breastfeeding women (PBW) in sub-Saharan Africa have high HIV incidence rates and associated risk of vertical transmission to their infants. Oral preexposure prophylaxis (PrEP) and injectable PrEP (long-acting cabotegravir, or CAB-LA) can potentially reduce this HIV transmission, but population-level impacts are uncertain. METHODS We extended a previously developed model of HIV and PrEP in South Africa to allow for variable PrEP duration and preference in PBW. We considered three potential scenarios for PrEP provision to PBW: oral PrEP only, CAB-LA only, and allowing oral/CAB-LA choice, with uptake and retention assumptions informed by South African data, each compared with a 'base' scenario without PrEP for PBW. RESULTS Without PrEP for PBW, the model estimates 1.31 million new infections will occur between 2025 and 2035 in South African adults and children, including 100 000 in PBW, 16 800 in infants at/before birth, and 35 200 in children through breastmilk. In the oral PrEP-only scenario, these numbers would reduce by 1.2% (95% CI: 0.7-1.7%), 8.6% (4.8-12.9%), 4.0% (2.1-5.8%), and 5.3% (3.0-8.2%) respectively. In the CAB-LA-only scenario, the corresponding reductions would be 6.1% (2.9-9.6%), 41.2% (19.8-65.0%), 12.6% (6.0-19.4%), and 29.5% (13.9-46.8%), respectively, and in the oral/CAB-LA choice scenario, similar reductions would be achieved [5.6% (3.4-8.0%), 39% (23.4-55.9%), 12.4% (7.4-16.8%) and 27.6% (16.5-39.9%) respectively]. CONCLUSION CAB-LA has the potential to be substantially more effective than oral PrEP in preventing HIV acquisition in PBW and vertical transmission, and can also modestly reduce HIV incidence at a population level.
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Affiliation(s)
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, Netherlands
- The South African Department of Science and Innovation/National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
- The South African Department of Science and Innovation/National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- Department of Global Health, Boston University, Boston, MA, USA
| | | | - Dvora Joseph Davey
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town
- Division of Infectious Diseases, Geffen School of Medicine, University of California Los Angeles, Los Angeles CA, USA
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19
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Ngumbau NM, Neary J, Wagner AD, Abuna F, Ochieng B, Dettinger JC, Gómez L, Marwa MM, Watoyi S, Nzove E, Pintye J, Baeten JM, Kinuthia J, John-Stewart G. Cofactors of Partner HIV Self-testing and Oral PrEP Acceptance Among Pregnant Women at High Risk of HIV in Kenya. J Acquir Immune Defic Syndr 2024; 95:238-245. [PMID: 38408215 PMCID: PMC10897494 DOI: 10.1097/qai.0000000000003355] [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: 02/28/2023] [Accepted: 11/06/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Oral pre-exposure prophylaxis (PrEP) and male partner HIV self-testing (HIVST) is being scaled up within antenatal clinics. Few data are available on how co-distribution influences acceptance of both interventions. METHODS We used data from the PrEP Implementation of Mothers in Antenatal Care (NCT03070600) trial in Kenya. Women included in this analysis were determined to be at high risk of HIV and offered oral PrEP and partner HIVST. Characteristics were compared between women who chose: (1) PrEP and HIVST, (2) HIVST-alone, (3) PrEP-alone, or (4) declined both (reference), excluding women who had partners known to be living with HIV. RESULTS Among 911 women, median age was 24 years, 87.3% were married, 43.9% perceived themselves to be at high risk of HIV and 13.0% had history of intimate partner violence (IPV). Overall, 68.9% accepted HIVST and 18.4% accepted PrEP, with 54.7% accepting HIVST-alone, 4.2% PrEP-alone, and 14.3% both HIVST and PrEP. Of women accepting HIVST, partner HIV testing increased from 20% to 82% and awareness of partner HIV status increased from 4.7% to 82.0% between pregnancy and 9 months postpartum (P < 0.001). Compared with women who accepted neither, choosing: (1) HIVST-alone was associated with being married, higher level of education, and residing with partner; (2) PrEP-alone was associated with lower social support, IPV, not residing with partner, longer time living with partner, and suspicion of other partners; and (3) PrEP and HIVST was associated with being married, IPV, and suspicion that partner had other partners. CONCLUSIONS Understanding factors associated with accepting HIVST and PrEP can inform HIV prevention programs for pregnant women. CLINICAL TRIAL NUMBER NCT03070600.
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Affiliation(s)
- Nancy M Ngumbau
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | | | | | - Felix Abuna
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Ben Ochieng
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | | | | | - Mary M Marwa
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Salphine Watoyi
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | | | | | | | - John Kinuthia
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Epidemiology
- Department of Global Health
- Departments of Pediatrics and Medicine, University of Washington, Seattle, WA
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20
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Vogel JP, Jung J, Lavin T, Simpson G, Kluwgant D, Abalos E, Diaz V, Downe S, Filippi V, Gallos I, Galadanci H, Katageri G, Homer CSE, Hofmeyr GJ, Liabsuetrakul T, Morhason-Bello IO, Osoti A, Souza JP, Thakar R, Thangaratinam S, Oladapo OT. Neglected medium-term and long-term consequences of labour and childbirth: a systematic analysis of the burden, recommended practices, and a way forward. Lancet Glob Health 2024; 12:e317-e330. [PMID: 38070535 PMCID: PMC10805007 DOI: 10.1016/s2214-109x(23)00454-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 08/29/2023] [Accepted: 09/19/2023] [Indexed: 01/22/2024]
Abstract
Over the past three decades, substantial progress has been made in reducing maternal mortality worldwide. However, the historical focus on mortality reduction has been accompanied by comparative neglect of labour and birth complications that can emerge or persist months or years postnatally. This paper addresses these overlooked conditions, arguing that their absence from the global health agenda and national action plans has led to the misconception that they are uncommon or unimportant. The historical limitation of postnatal care services to the 6 weeks after birth is also a contributing factor. We reviewed epidemiological data on medium-term and long-term complications arising from labour and childbirth beyond 6 weeks, along with high-quality clinical guidelines for their prevention, identification, and treatment. We explore the complex interplay of human evolution, maternal physiology, and inherent predispositions that contribute to these complications. We offer actionable recommendations to change the current trajectories of these neglected conditions and help achieve the targets of Sustainable Development Goal 3. This paper is the third in a Series of four papers about maternal health in the perinatal period and beyond.
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Affiliation(s)
- Joshua P Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia.
| | - Jenny Jung
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - Tina Lavin
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Grace Simpson
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - Dvora Kluwgant
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - Edgardo Abalos
- Centro de Estudios de Estado y Sociedad (CEDES), Buenos Aires, Argentina
| | - Virginia Diaz
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
| | - Soo Downe
- School of Nursing and Midwifery, University of Central Lancashire, Preston, UK
| | - Veronique Filippi
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Ioannis Gallos
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Hadiza Galadanci
- Africa Center of Excellence for Population Health and Policy, Bayero University, Kano, Nigeria
| | - Geetanjali Katageri
- S Nijalingappa Medical College and HSK Hospital & Research Centre, Bagalkot, India
| | - Caroline S E Homer
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, University of Botswana, Gaborone, Botswana; University of the Witwatersrand and Walter Sisulu University, East London, South Africa
| | - Tippawan Liabsuetrakul
- Department of Epidemiology and Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Imran O Morhason-Bello
- Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences and Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Alfred Osoti
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - João Paulo Souza
- Department of Social Medicine, Ribeirao Preto Medical School, University of São Paulo, São Paulo, Brazil
| | | | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Olufemi T Oladapo
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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21
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Zewdie K, Kiweewa FM, Ssebuliba T, Morrison SA, Muwonge TR, Boyer J, Bambia F, Badaru J, Stein G, Mugwanya KK, Wyatt C, Yin MT, Mujugira A, Heffron R. The effect of daily oral PrEP use during pregnancy on bone mineral density among adolescent girls and young women in Uganda. FRONTIERS IN REPRODUCTIVE HEALTH 2024; 5:1240990. [PMID: 38260049 PMCID: PMC10801233 DOI: 10.3389/frph.2023.1240990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction Oral pre-exposure prophylaxis (PrEP) is recommended during pregnancy for at-risk cisgender women. Pregnancy is known to impede bone growth and tenofovir-based PrEP may also yield detrimental changes to bone health. Thus, we evaluated the effect of PrEP use during pregnancy on bone mineral density (BMD). Methods We used data from a cohort of women who were sexually active, HIV-negative, ages 16-25 years, initiating DMPA or choosing condoms for contraception and enrolled in the Kampala Women's Bone Study. Women were followed quarterly with rapid testing for HIV and pregnancy, PrEP dispensation, and adherence counseling. Those who became pregnant were counseled on PrEP use during pregnancy per national guidelines. BMD of the neck of the hip, total hip, and lumbar spine was measured using dual-energy x-ray absorptiometry at baseline and annually. We compared the mean percent change in BMD from baseline to month 24. Results Among 499 women enrolled in the study, 105 pregnancies occurred in 90 women. At enrollment, the median age was 20 years (IQR: 19-21) and 89% initiated PrEP. During pregnancy, 67% of women continued using PrEP and PrEP was dispensed in 64% of visits. BMD declined significantly in women using PrEP during pregnancy compared to women who were not pregnant nor used PrEP: relative BMD change was -2.26% (95% CI: -4.63 to 0.11, p = 0.06) in the femoral neck, -2.57% (95% CI: -4.48 to -0.66, p = 0.01) in total hip, -3.06% (95% CI: -5.49 to -0.63, p = 0.001) lumbar spine. There was no significant difference in BMD loss when comparing PrEP-exposed pregnant women to pregnant women who never used PrEP. Women who became pregnant were less likely to continue PrEP at subsequent study visits than women who did not become pregnant (adjOR: 0.25, 95% CI: 0.16-0.37, p < 0.001). Based on pill counts, there was a 62% reduction in the odds of high PrEP adherence during pregnancy (adjOR = 0.38, 95% CI: 0.27-0.58, p < 0.001). Conclusion Women who used PrEP during pregnancy experienced a similar reduction in BMD as pregnant women with no PrEP exposure, indicating that BMD loss in PrEP-using pregnant women is largely driven by pregnancy and not PrEP.
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Affiliation(s)
- Kidist Zewdie
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Flavia M. Kiweewa
- MakerereUniversity-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | | | - Susan A. Morrison
- Department of Global Health, University of Washington, Seattle, WA, United States
| | | | - Jade Boyer
- Department of Medicine, Division of Infectious Disease, Columbia University, New York, NY, United States
| | - Felix Bambia
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Josephine Badaru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Gabrielle Stein
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Kenneth K. Mugwanya
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Christina Wyatt
- Department of Medicine, Division of Nephrology, Duke University School of Medicine, Durham, NC, United States
| | - Michael T. Yin
- Department of Medicine, Division of Infectious Disease, Columbia University, New York, NY, United States
| | - Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, WA, United States
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
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22
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Chi BH, Saidi F, Graybill LA, Phanga T, Mollan KR, Amico KR, Freeborn K, Rosenberg NE, Hill LM, Hamoonga T, Richardson B, Kalua T, Phiri S, Mutale W. A Patient-Centered, Combination Intervention to Support Adherence to HIV Pre-exposure Prophylaxis During Pregnancy and Breastfeeding: A Randomized Pilot Study in Malawi. J Acquir Immune Defic Syndr 2024; 95:42-51. [PMID: 37757844 PMCID: PMC10873086 DOI: 10.1097/qai.0000000000003309] [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: 03/10/2023] [Accepted: 07/05/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Daily oral pre-exposure prophylaxis (PrEP) can reduce HIV incidence in pregnant and breastfeeding women, but adherence is essential. METHODS We conducted a pilot randomized trial to evaluate an intervention package to enhance antenatal and postnatal PrEP use in Lilongwe, Malawi. The intervention was based on patient-centered counseling adapted from previous PrEP studies, with the option of a participant-selected adherence supporter. Participants were locally eligible for PrEP and randomized 1:1 to intervention or standard counseling (ie, control) and followed for 6 months. Participants received the intervention package or standard counseling at enrollment, 1, 3, and 6 months. Adherence was measured through plasma and intracellular tenofovir concentrations and scored using a published algorithm. Our primary outcome was retention in care with concentrations consistent with 4-7 doses/week. RESULTS From June to November 2020, we enrolled 200 pregnant women with the median gestational age of 26 (interquartile range: 19-33) weeks. Study retention was high at 3 months (89.5%) and 6 months (85.5%). By contrast, across the 2 time points, 32.8% of participants retained in the study had adherence scores consistent with 2-5 doses/week while 10.3% had scores consistent with daily dosing. For the composite primary end point, no substantial differences were observed between the intervention and control groups at 3 months (28.3% vs. 29.0%, probability difference: -0.7%, 95% confidence interval: -13.3%, 11.8%) or at 6 months (22.0% vs. 26.3%, probability difference: -4.3%, 95% confidence interval: -16.1%, 7.6%). CONCLUSIONS In this randomized trial of PrEP adherence support, retention was high, but less than one-third of participants had pharmacologically confirmed adherence of ≥4 doses/week. Future research should focus on antenatal and postnatal HIV prevention needs and their alignment across the PrEP continuum, including uptake, persistence, and adherence.
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Affiliation(s)
- Benjamin H Chi
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Lauren A Graybill
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Katie R Mollan
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- UNC Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - K Rivet Amico
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI
| | - Kellie Freeborn
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Nora E Rosenberg
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lauren M Hill
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Twaambo Hamoonga
- Department of Population Studies and Global Health, University of Zambia, Lusaka, Zambia
| | - Brian Richardson
- UNC Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Thokozani Kalua
- Center for International Health, Education, and Biosecurity, Lilongwe, Malawi
| | - Sam Phiri
- Partners in Hope, Lilongwe, Malawi; and
| | - Wilbroad Mutale
- Department of Health Policy and Systems, University of Zambia, Lusaka, Zambia
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Borboa-Olivares H, Estrada-Gutierrez G, Martinez-Portilla RJ, Espino-y-Sosa S, Flores-Pliego A, Espejel-Nuñez A, Camacho-Arroyo I, Solis-Paredes JM, Villafan-Bernal JR, Torres-Torres J. Impact of Protease Inhibitor-Based Highly Active Antiretroviral Therapy on Fetal Subcutaneous Fat Tissue in HIV-Pregnant Women in a Middle-Income Country. Viruses 2023; 16:10. [PMID: 38275945 PMCID: PMC10818469 DOI: 10.3390/v16010010] [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: 11/14/2023] [Revised: 12/17/2023] [Accepted: 12/18/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND HIV infection continues to be a global public health challenge, affecting approximately 1.7 million reproductive-aged women. Protease inhibitor-based highly active antiretroviral therapy (PI-HAART) has significantly reduced the risk of vertical transmission of HIV from mother to child. Nevertheless, concerns linger regarding the long-term effects, particularly on body composition, notably subcutaneous fat tissue (SFT). Although HIV-associated lipodystrophy syndrome (LS) has been well documented in adults and older children, its impact on fetuses exposed to PI-HAART remains underexplored. This study aims to evaluate SFT in the fetuses of HIV-pregnant women exposed to PI-HAART, assessing the potential clinical implications. METHODS We conducted a comparative study between HIV-pregnant women receiving PI-HAART and an HIV-negative control group. Fetometry measurements were obtained via 3D ultrasound. SFT in the fetal arm and thigh segments was assessed. Data were analyzed using lineal multivariate regression and receiver-operating characteristics (ROC)-curve analysis. RESULTS Fetuses exposed to PI-HAART exhibited a significant reduction in subcutaneous fat, particularly in the proximal third-middle union of the femur (coefficient: -2.588, p = 0.042). This reduction was correlated with lower newborn serum glucose levels (65.7 vs. 56.1, p = 0.007; coefficient: -1.277, p = 0.045). CONCLUSIONS Our study sheds light on the connection between PI-HAART, fetal subcutaneous fat, and neonatal health. These findings might reveal the long-lasting effects of PI-HAART on newborns and children's well-being. Our results emphasize the need for a more balanced approach to managing pregnant women with HIV in developing countries and open new venues for research on the impact of intrauterine PI-HAART exposure on energy metabolism and fetal programming.
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Affiliation(s)
- Hector Borboa-Olivares
- Community Interventions Research Branch, Instituto Nacional de Perinatología, Mexico City 11000, Mexico
| | | | - Raigam Jafet Martinez-Portilla
- Clinical Research Branch, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Mexico City 11000, Mexico (S.E.-y.-S.); (J.M.S.-P.)
| | - Salvador Espino-y-Sosa
- Clinical Research Branch, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Mexico City 11000, Mexico (S.E.-y.-S.); (J.M.S.-P.)
| | - Arturo Flores-Pliego
- Department of Immunobiochemistry, Instituto Nacional de Perinatología, Mexico City 11000, Mexico; (A.F.-P.); (A.E.-N.)
| | - Aurora Espejel-Nuñez
- Department of Immunobiochemistry, Instituto Nacional de Perinatología, Mexico City 11000, Mexico; (A.F.-P.); (A.E.-N.)
| | - Ignacio Camacho-Arroyo
- Unidad de Investigación en Reproducción Humana, Instituto Nacional de Perinatología-Facultad de Química, Universidad Nacional Autónoma de México, Mexico City 11000, Mexico;
| | - Juan Mario Solis-Paredes
- Clinical Research Branch, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Mexico City 11000, Mexico (S.E.-y.-S.); (J.M.S.-P.)
| | - Jose Rafael Villafan-Bernal
- Laboratory of Immunogenomics and Metabolic Diseases, Instituto Nacional de Medicina Genomica, Mexico City 14610, Mexico;
| | - Johnatan Torres-Torres
- Clinical Research Branch, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Mexico City 11000, Mexico (S.E.-y.-S.); (J.M.S.-P.)
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24
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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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Ebogo-Belobo JT, Kenmoe S, Mbongue Mikangue CA, Tchatchouang S, Robertine LF, Takuissu GR, Ndzie Ondigui JL, Bowo-Ngandji A, Kenfack-Momo R, Kengne-Ndé C, Mbaga DS, Menkem EZ, Kame-Ngasse GI, Magoudjou-Pekam JN, Kenfack-Zanguim J, Esemu SN, Tagnouokam-Ngoupo PA, Ndip L, Njouom R. Systematic review and meta-analysis of seroprevalence of human immunodeficiency virus serological markers among pregnant women in Africa, 1984-2020. World J Crit Care Med 2023; 12:264-285. [PMID: 38188451 PMCID: PMC10768416 DOI: 10.5492/wjccm.v12.i5.264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 09/19/2023] [Accepted: 11/08/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV) is a major public health concern, particularly in Africa where HIV rates remain substantial. Pregnant women are at an increased risk of acquiring HIV, which has a significant impact on both maternal and child health. AIM To review summarizes HIV seroprevalence among pregnant women in Africa. It also identifies regional and clinical characteristics that contribute to study-specific estimates variation. METHODS The study included pregnant women from any African country or region, irrespective of their symptoms, and any study design conducted in any setting. Using electronic literature searches, articles published until February 2023 were reviewed. The quality of the included studies was evaluated. The DerSimonian and Laird random-effects model was applied to determine HIV pooled seroprevalence among pregnant women in Africa. Subgroup and sensitivity analyses were conducted to identify potential sources of heterogeneity. Heterogeneity was assessed with Cochran's Q test and I2 statistics, and publication bias was assessed with Egger's test. RESULTS A total of 248 studies conducted between 1984 and 2020 were included in the quantitative synthesis (meta-analysis). Out of the total studies, 146 (58.9%) had a low risk of bias and 102 (41.1%) had a moderate risk of bias. No HIV-positive pregnant women died in the included studies. The overall HIV seroprevalence in pregnant women was estimated to be 9.3% [95% confidence interval (CI): 8.3-10.3]. The subgroup analysis showed statistically significant heterogeneity across subgroups (P < 0.001), with the highest seroprevalence observed in Southern Africa (29.4%, 95%CI: 26.5-32.4) and the lowest seroprevalence observed in Northern Africa (0.7%, 95%CI: 0.3-1.3). CONCLUSION The review found that HIV seroprevalence among pregnant women in African countries remains significant, particularly in Southern African countries. This review can inform the development of targeted public health interventions to address high HIV seroprevalence in pregnant women in African countries.
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Affiliation(s)
- Jean Thierry Ebogo-Belobo
- Center for Research in Health and Priority Pathologies, Institute of Medical Research and Medicinal Plants Studies, Yaounde 00237, Cameroon
| | - Sebastien Kenmoe
- Department of Microbiology and Parasitology, University of Buea, Buea 00237, Cameroon
| | | | | | | | - Guy Roussel Takuissu
- Centre for Food, Food Security and Nutrition Research, Institute of Medical Research and Medicinal Plants Studies, Yaounde 00237, Cameroon
| | | | - Arnol Bowo-Ngandji
- Department of Microbiology, The University of Yaounde I, Yaounde 00237, Cameroon
| | - Raoul Kenfack-Momo
- Department of Biochemistry, The University of Yaounde I, Yaounde 00237, Cameroon
| | - Cyprien Kengne-Ndé
- Epidemiological Surveillance, Evaluation and Research Unit, National AIDS Control Committee, Douala 00237, Cameroon
| | - Donatien Serge Mbaga
- Department of Microbiology, The University of Yaounde I, Yaounde 00237, Cameroon
| | | | - Ginette Irma Kame-Ngasse
- Center for Research in Health and Priority Pathologies, Institute of Medical Research and Medicinal Plants Studies, Yaounde 00237, Cameroon
| | | | | | - Seraphine Nkie Esemu
- Department of Microbiology and Parasitology, University of Buea, Buea 00237, Cameroon
| | | | - Lucy Ndip
- Department of Microbiology and Parasitology, University of Buea, Buea 00237, Cameroon
| | - Richard Njouom
- Department of Virology, Centre Pasteur du Cameroun, Yaounde 00237, Cameroon
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Saidi F, Phanga T, Graybill LA, Mollan KR, Hill LM, Sibande W, Msowoya G, Thom A, Rosenberg NE, Freeborn K, Amico KR, Phiri S, Mutale W, Chi BH. Acceptability of a Combination Adherence Strategy to Support HIV Antiretroviral Therapy and Pre-exposure Prophylaxis Adherence During Pregnancy and Breastfeeding in Malawi. AIDS Behav 2023; 27:4022-4032. [PMID: 37392270 DOI: 10.1007/s10461-023-04116-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 07/03/2023]
Abstract
In two parallel pilot studies, we implemented a combination adherence intervention of patient-centered counselling and adherence supporter training, tailored to support HIV treatment (i.e., antiretroviral therapy) or prevention (i.e., pre-exposure prophylaxis, or PrEP) during pregnancy and breastfeeding. Using a mixed-methods approach, we evaluated the intervention's acceptability. We investigated engagement, satisfaction, and discussion content via survey to all 151 participants assigned to the intervention arm (51 women living with HIV, 100 PrEP-eligible women without HIV). We also conducted serial in-depth interviews with a subgroup (n = 40) at enrollment, three months, and six months. In the quantitative analysis, the vast majority reported high satisfaction with intervention components and expressed desire to receive it in the future, if made available. These findings were supported in the qualitative analysis, with favorable comments about counselor engagement, intervention content and types of support received from adherence supporters. Overall, these results demonstrate high acceptability and provide support for HIV status-neutral interventions for antiretroviral adherence.
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Affiliation(s)
- Friday Saidi
- University of North Carolina (UNC) Project Malawi, Bag A-104, Lilongwe, Malawi.
- Department of Obstetrics and Gynecology, Kamuzu University of Health Sciences, Lilongwe, Malawi.
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Twambilile Phanga
- University of North Carolina (UNC) Project Malawi, Bag A-104, Lilongwe, Malawi
| | - Lauren A Graybill
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Katie R Mollan
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Lauren M Hill
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Watson Sibande
- University of North Carolina (UNC) Project Malawi, Bag A-104, Lilongwe, Malawi
| | - Getrude Msowoya
- University of North Carolina (UNC) Project Malawi, Bag A-104, Lilongwe, Malawi
| | - Annie Thom
- University of North Carolina (UNC) Project Malawi, Bag A-104, Lilongwe, Malawi
| | - Nora E Rosenberg
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kellie Freeborn
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - K Rivet Amico
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | | - Wilbroad Mutale
- Department of Health Policy, University of Zambia School of Public Health, Lusaka, Zambia
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Stoner MCD, Hawley I, Mathebula F, Horne E, Etima J, Kemigisha D, Mutero P, Dandadzi A, Seyama L, Fabiano Z, Scheckter R, Noguchi L, Owor M, Balkus JE, Montgomery ET. Acceptability and Use of the Dapivirine Vaginal Ring and Daily Oral Pre-exposure Prophylaxis (PrEP) During Breastfeeding in South Africa, Malawi, Zimbabwe, and Uganda. AIDS Behav 2023; 27:4114-4123. [PMID: 37432541 PMCID: PMC10615878 DOI: 10.1007/s10461-023-04125-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2023] [Indexed: 07/12/2023]
Abstract
This study examines qualitative acceptability of the dapivirine vaginal ring (DVR) and oral daily pre-exposure prophylaxis (PrEP) among breastfeeding persons participating in Microbicide Trials Network 043/B-PROTECTED, a phase 3B safety and drug detectability study of DVR and oral PrEP in breastfeeding. A subsample of 52 participants were purposively sampled to participate in an in-depth interview (IDI). Breastfeeding participants found both study products to be acceptable, and easy to use. A common motivation for product use was to protect the baby from HIV, although participants' understanding of how the study drug would work to protect their babies was often unclear. While most participants did not report experiencing side effects, fears about side effects were common as both initial worries about how the study products would affect their health and the health of their baby, and increased anxiety that health issues experienced by them, or their baby were from the products.
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Affiliation(s)
- Marie C D Stoner
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA.
| | - Imogen Hawley
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA
| | - Florence Mathebula
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Elizea Horne
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Juliane Etima
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Doreen Kemigisha
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Prisca Mutero
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Adlight Dandadzi
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Linly Seyama
- Johns Hopkins Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Zayithwa Fabiano
- Johns Hopkins Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Lisa Noguchi
- Division of Reproductive, Maternal, Newborn, Child and Adolescent Health, Jhpiego/Johns Hopkins University, Washington, DC, USA
| | - Maxensia Owor
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Jennifer E Balkus
- Department of Epidemiology, University of Washington School of Public Health, Seattle, USA
- Vaccine and Infectious Disease Division, Fred Hutch Cancer Center, Seattle, USA
| | - Elizabeth T Montgomery
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Berkeley, CA, 94104, USA
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28
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Sila J, Wagner AD, Abuna F, Dettinger JC, Odhiambo B, Ngumbau N, Oketch G, Sifuna E, Gómez L, Hicks S, John-Stewart G, Kinuthia J. An implementation strategy package (video education, HIV self-testing, and co-location) improves PrEP implementation for pregnant women in antenatal care clinics in western Kenya. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1205503. [PMID: 38045529 PMCID: PMC10690761 DOI: 10.3389/frph.2023.1205503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 10/20/2023] [Indexed: 12/05/2023] Open
Abstract
Background Pre-exposure prophylaxis (PrEP) is recommended by the World Health Organization and the Kenyan Ministry of Health for HIV prevention in pregnancy and postpartum for women at risk for HIV. Integration of PrEP into antenatal care is promising, but delivery gaps exist in the face of healthcare provider shortages in resource-limited settings. Methods Between May and November 2021, we conducted a difference-in-differences study (3 months pre-intervention data collection and 3 months post-intervention data collection) analyzing four intervention facilities, where the strategies were implemented, and four comparison facilities, where no strategies were implemented. We tested a combination of three implementation strategies-video-based PrEP information in the waiting bay, HIV self-testing, and dispensing of PrEP in the antenatal care rooms-to improve PrEP delivery. We compared absolute changes in the proportion of antenatal attendees screened for PrEP (PrEP penetration), the proportion receiving all PrEP-specific steps in a visit (HIV testing, risk screening, and PrEP counseling) (PrEP fidelity), and client PrEP knowledge, client satisfaction, and waiting time and service time (a priori outcomes); post hoc, we compared the proportion offered PrEP (PrEP offer) and completing HIV testing. We measured provider perceptions of the acceptability and appropriateness of the implementation strategies. Results We observed significant improvements in PrEP penetration, PrEP offer, satisfaction, and knowledge (p < 0.05) and improvements in fidelity that trended towards significance (p = 0.057). PrEP penetration increased 5 percentage points (p = 0.008), PrEP fidelity increased 8 percentage points (p = 0.057), and PrEP offer increased 4 percentage points (p = 0.003) in intervention vs. comparison facilities. Client PrEP knowledge increased by 1.7 out of 6 total points (p < 0.001) and client satisfaction increased by 0.7 out of 24 total points (p = 0.003) in intervention vs. comparison facilities. We observed no changes in service time (0.09-min decrease; p = 0.435) and a small increase in waiting time (0.33-min increase; p = 0.005). HIV testing among those eligible did not change (1.5 percentage point decrease, p = 0.800). Providers felt the implementation strategies were acceptable and appropriate (median acceptability: 20/20; median appropriateness: 19.5/20). However, absolute levels of each step of the PrEP cascade remained suboptimal. Conclusions An implementation strategy package with video information, HIV self-testing, and co-location of medication dispensing enhanced PrEP delivery across several implementation outcomes and client satisfaction, while not substantially increasing wait time or decreasing provider-client contact time. Clinical trial registration ClinicalTrials.gov , identifier, NCT04712994.
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Affiliation(s)
- Joseph Sila
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Felix Abuna
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Julia C. Dettinger
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Ben Odhiambo
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Nancy Ngumbau
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - George Oketch
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Enock Sifuna
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Laurén Gómez
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Sarah Hicks
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Departments of Pediatrics & Medicine, University of Washington, Seattle, WA, United States
| | - John Kinuthia
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
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Govender V, Moodley D, Naidoo M, Connoly C, Ngcapu S, Abdool Karim Q. High incidence of asymptomatic genital tract infections in pregnancy in adolescent girls and young women: need for repeat aetiological screening. Sex Transm Infect 2023; 99:482-488. [PMID: 37208192 DOI: 10.1136/sextrans-2022-055658] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 04/10/2023] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION Sexually transmitted infection (STI) prevalence and incidence estimates for pregnant adolescents are under-reported. We estimated prevalence and incidence of STIs in pregnant adolescents (15-19 years) in comparison with pregnant women 20-24 and >25 years. METHODS Pregnant women registering at primary care clinics in Umlazi, a periurban subdistrict in KwaZulu-Natal, South Africa, were enrolled in an HIV incidence cohort study during February 2017-March 2018. Women were examined for abnormal vaginal discharge, received empirical treatment, tested for HIV-1 and had vaginal swabs taken at their first and a subsequent visit in the third trimester. Vaginal swabs were stored for STI testing at completion of study and tested for Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium using PCR. RESULTS A total of 752 HIV-negative pregnant women were enrolled at a median gestational age of 17 weeks: 180 (23.9%), 291 (38.7%) and 281 (37.4%) in the 15-19, 20-24 and >25 years age groups. Pregnant adolescents had an STI prevalence of 26.7% at baseline, not significantly lower than the 20-24 (34.7%, OR 1.4; 95% CI 1.0 to 2.1, p=0.09) and >25 years (33.8%, OR 1.4; 95% CI 0.9 to 2.1, p=0.12) age groups. T. vaginalis (11.1%), C. trachomatis (7.8%) and N. gonorrhoeae (4.4%) were most prevalent in adolescents, a trend similar to the other age groups. Overall, 43.4% were symptomatic and treated at baseline. Overall, 40.7% (118 of 290) of women who tested negative for an STI at baseline tested positive at the repeat visit (incidence 19.5/100 person years). STI incidence in pregnant adolescents was 23.9/100 person years and comparable with older age groups (20.5/100 person years and 16.2/100 person years). At the repeat visit, 19.0% of all women with an STI were symptomatic and treated. Performance of syndromic management was poor at baseline (negative predictive value (NPV) 68.6%, positive predictive value (PPV) 34.0%) and at repeat visit (NPV 58.4%, PPV 34.3%). CONCLUSIONS Prevalence of asymptomatic curable STIs in pregnant adolescents is high and comparable with women >20 years old. Adolescents remain at substantial risk of asymptomatic incident STIs during pregnancy.
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Affiliation(s)
- Vani Govender
- Centre for the AIDS Program of Research in South Africa, CAPRISA, Durban, KwaZulu-Natal, South Africa
- Obstetrics and Gynaecology, University of KwaZulu-Natal College of Health Sciences, Durban, KwaZulu-Natal, South Africa
| | - Dhayendre Moodley
- Centre for the AIDS Program of Research in South Africa, CAPRISA, Durban, KwaZulu-Natal, South Africa
- Obstetrics and Gynaecology, University of KwaZulu-Natal College of Health Sciences, Durban, KwaZulu-Natal, South Africa
| | - Megeshinee Naidoo
- Centre for the AIDS Program of Research in South Africa, CAPRISA, Durban, KwaZulu-Natal, South Africa
| | - Cathy Connoly
- Department of Biostatistics, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Sinaye Ngcapu
- Centre for the AIDS Program of Research in South Africa, CAPRISA, Durban, KwaZulu-Natal, South Africa
- Department of Medical Microbiology, University of KwaZulu-Natal College of Health Sciences, Durban, KwaZulu-Natal, South Africa
| | - Quarraisha Abdool Karim
- Centre for the AIDS Program of Research in South Africa, CAPRISA, Durban, KwaZulu-Natal, South Africa
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Mancuso N, Mathebula F, Chitukuta M, Matambanadzo KV, Tenza S, Reddy K, Nobula L, Kemigisha D, Stoner MCD. The impact of COVID-19 on sexual behavior, HIV prevention interest, general healthcare access, and other HIV risk factors among trial participants in Malawi, South Africa, Uganda, and Zimbabwe. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1270419. [PMID: 37965588 PMCID: PMC10642282 DOI: 10.3389/frph.2023.1270419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/03/2023] [Indexed: 11/16/2023] Open
Abstract
Introduction The COVID-19 pandemic greatly impacted HIV prevention and care globally. The pandemic also had disproportionate impacts on the financial, emotional, and physical wellbeing of women and girls in East and Southern Africa, who were already at increased HIV vulnerability. This study aimed to understand how the COVID-19 pandemic and its response efforts impacted the sexual behavior, HIV prevention interest, general healthcare access, and other HIV risk factors of women and girls in HIV prevention studies. Methods Using the socio-ecological model (SEM), an explanatory sequential mixed-methods analysis was performed with data from four Microbicide Trial Network (MTN) studies on different populations-adolescent girls and young women (AGYW), pregnant persons, breastfeeding persons, and couples-in Malawi, South Africa, Uganda, and Zimbabwe. Descriptive statistics for outcomes of interest were calculated within each study separately and Chi-squared tests of independence were performed to evaluate associations between study population and outcomes. Excerpts from study qualitative interviews were stratified into code reports which were then summarized into memos with key themes and considerations of the SEM framework to provide context to quantitative findings. Results Few participants (8/731) had known or suspected COVID-19 infection. Sexual frequency and alcohol use decreased most often among AGYW compared to pregnant or breastfeeding women and couples (p-value < 0.001). The pandemic had little impact on changes in reported HIV prevention interest or access to HIV prevention study products. Healthcare access was impacted for everyone, with couples most likely to report decreases in access (p-value < 0.001). From qualitative interviews, economic instability, adverse mental health, and increased violence due to COVID-19 caused increased strain on other factors related to HIV vulnerability. Conclusions While interest in HIV prevention did not change and a few HIV risks decreased for most women and girls, other vulnerabilities to HIV increased due to the COVID-19 pandemic, highlighting the importance of continued access to HIV prevention for women and girls. More research is needed to better understand the long-term impact of COVID-19 on HIV prevention and vulnerability in community populations.
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Affiliation(s)
- Noah Mancuso
- Women's Global Health Imperative, RTI International, Atlanta, GA, United States
| | | | - Miria Chitukuta
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | | | - Siyanda Tenza
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Krishnaveni Reddy
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Lumka Nobula
- Desmond Tutu HIV Foundation, Cape Town, South Africa
| | - Doreen Kemigisha
- Makerere University—Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Marie C. D. Stoner
- Women's Global Health Impeative, RTI International, Berkeley, CA, United States
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Wang R, Fruhauf TF, Sao SS, Gingher EL, Martin SJ, Coleman JS. Clinic-based interventions to increase preexposure prophylaxis awareness and uptake among United States patients attending an obstetrics and gynecology clinic in Baltimore, Maryland. Am J Obstet Gynecol 2023; 229:423.e1-423.e8. [PMID: 37531988 DOI: 10.1016/j.ajog.2023.07.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Cisgender women account for 1 of every 5 new US HIV diagnoses, with most cases (85%) attributed to heterosexual contact. HIV preexposure prophylaxis is an effective prevention strategy; however, preexposure prophylaxis awareness and prescriptions among women are low. OBJECTIVE This study aimed to increase preexposure prophylaxis counseling and uptake among cisgender women attending obstetrics and gynecology clinics. STUDY DESIGN The study included 3 obstetrics and gynecology clinics within a single health system in a high HIV prevalence region. There were 3 phases: baseline (the 3-month period before the clinical trial that included provider education and training of a registered nurse about preexposure prophylaxis), clinical trial (the 3-month period during which eligible patients were randomized to an active control or preexposure prophylaxis registered nurse intervention), and maintenance (the 3-month period after the trial ended). Electronic medical record clinical decision support tools were available to both arms during the clinical trial, which included best practice alerts, order sets, progress note templates, and written and video preexposure prophylaxis educational materials for patients. In the intervention arm, a preexposure prophylaxis nurse contacted and counseled patients and was equipped to prescribe preexposure prophylaxis. Moreover, this study evaluated the phases through the "reach, effectiveness, adoption, implementation, and maintenance" framework. The primary outcome of the study was effectiveness (eg, percentage of eligible patients with documented HIV prevention counseling in the electronic medical record or preexposure prophylaxis prescriptions). The secondary outcomes included reach (eg, percentage of best practice alerts that providers acted on or the percentage of eligible patients who spoke with the preexposure prophylaxis registered nurse), adoption (eg, percentage of eligible patients with a best practice alert that triggered or the percentage of eligible patients the preexposure prophylaxis registered nurse attempted to contact), and maintenance (eg, percentage of patients with documented HIV prevention counseling or preexposure prophylaxis prescriptions during the maintenance phase). RESULTS There were 904 unique patients in all phases with a mean age of 28.8±7.7 years, and 416 patients (46%) were pregnant; moreover, 436 patients were randomized in the clinical trial phase. Concerning reach and adoption, best practice alerts were triggered for 100% of eligible encounters; however, the providers acted on 52% of them. The preexposure prophylaxis nurse attempted to contact every patient and successfully spoke with 81.2% of them in the preexposure prophylaxis registered nurse arm. Concerning effectiveness, there were significantly more patients counseled about preexposure prophylaxis in the preexposure prophylaxis registered nurse group than in the active control group (66.5% vs 12.3%, respectively; P<.001), although preexposure prophylaxis prescriptions were equivalent (P=1.0). Among the subgroup of patients who were counseled about preexposure prophylaxis, 18.5% of patients in the active control arm and 3.4% in the preexposure prophylaxis registered nurse arm were prescribed preexposure prophylaxis (P=.02). Concerning maintenance, clinical decision support tools alone resulted in preexposure prophylaxis counseling of 1.0% of patients during the maintenance phase vs 0.6% of patients during the baseline phase and 11.2% of patients during the clinical trial phase (P<.001). Preexposure prophylaxis prescriptions were not statistically different among the 3 phases (P=.096). CONCLUSION A preexposure prophylaxis nurse effectively increased HIV prevention discussions but did not lead to more preexposure prophylaxis prescriptions than the preexposure prophylaxis-focused clinical decision support tools used by providers. The decrease in preexposure prophylaxis counseling after the trial phase suggests that persistent interventions are needed to maintain effects.
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Affiliation(s)
- Runzhi Wang
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Timothee F Fruhauf
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Saumya S Sao
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Erin L Gingher
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephen J Martin
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jenell S Coleman
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
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Fairlie L, Lavies D, Kalk E, Mhlongo O, Patel F, Technau KG, Mahtab S, Moodley D, Subedar H, Mullick S, Sawry S, Mehta U. Safety surveillance for PrEP in pregnant and breastfeeding women. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1221101. [PMID: 37854936 PMCID: PMC10581206 DOI: 10.3389/frph.2023.1221101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/14/2023] [Indexed: 10/20/2023] Open
Abstract
The risk of HIV acquisition is higher during pregnancy and postpartum than other times. Newly acquired maternal HIV infection associated with high primary viraemia, substantially increases the risk of vertical HIV transmission. Pre-exposure prophylaxis (PrEP) reduces the risk of HIV acquisition. Currently available products include oral tenofovir/emtricitabine (TDF/FTC) and tenofovir alafenamide (TAF)/FTC), long-acting cabotegravir (CAB-LA) and the dapivirine ring (DVR). All except oral TDF/FTC have limited safety data available for use in pregnant and breastfeeding women. The safety of new PrEP agents for pregnant women and the fetus, infant and child, either exposed in utero or during breastfeeding is an ongoing concern for health care workers and pregnant and breastfeeding women, particularly as the safety risk appetite for antiretroviral (ARV) agents used as PrEP is lower in pregnant and breastfeeding women who are HIV-uninfected, compared to women living with HIV taking ARVs as treatment. With the widespread rollout of TDF/FTC among pregnant women in South Africa and other low-middle income countries (LMIC) and the potential introduction of new PrEP agents for pregnant women, there is a need for safety surveillance systems to identify potential signals of risk to either the mother or fetus, measure the burden of such a risk, and where appropriate, provide specific reassurance to PrEP users. Safety data needs to be collected across the continuum of the product life cycle from pre-licensure into the post-marketing period, building a safety profile through both passive and active surveillance systems, recognising the strengths and limitations of each, and the potential for bias and confounding. Pharmacovigilance systems that aim to assess the risk of adverse birth outcomes in pregnant women exposed to PrEP and other agents need to consider the special requirements of pregnancy epidemiology to ensure that the data derived from surveillance are sufficiently robust to inform treatment policies. Here we review the known safety profiles of currently available PrEP candidates in women of child-bearing potential, pregnancy and breastfeeding and discuss pragmatic approaches for such surveillance in HIV-endemic LMICs.
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Affiliation(s)
- Lee Fairlie
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Diane Lavies
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Emma Kalk
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Faeezah Patel
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karl-Günter Technau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Sana Mahtab
- Wits Vaccines & Infectious Diseases Analytics (VIDA) Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Dhayendre Moodley
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | | | - Saiqa Mullick
- 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
| | - Ushma Mehta
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Scott RK, Yu Y, Marzinke MA, Coleman JS, Hendrix CW, Bies R. Clinical trial simulation to evaluate tenofovir disoproxil fumarate/emtricitabine HIV pre-exposure prophylaxis dosing during pregnancy. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1224580. [PMID: 37830105 PMCID: PMC10565828 DOI: 10.3389/frph.2023.1224580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 09/04/2023] [Indexed: 10/14/2023] Open
Abstract
Objective To evaluate upward-adjustment of tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) pre-exposure prophylaxis (PrEP) dosing during pregnancy in order to maintain target plasma concentrations associated with HIV protection. Design Population pharmacokinetic (PK) modeling and clinical trial simulation (CTS). Material and methods We developed population pharmacokinetic models for TFV and FTC using data from the Partners Demonstration Project and a PK study of TDF/FTC among cisgender women by Coleman et al., and performed an in-silico simulation. Pregnancy-trimester was identified as a significant covariate on apparent clearance in the optimized final model. We simulated 1,000 pregnant individuals starting standard daily oral TDF/FTC (300 mg/200 mg) prior to pregnancy. Upon becoming pregnant, simulated patients were split into two study arms: one continuing standard-dose and the other receiving double standard-dose throughout pregnancy. Results Standard-dose trough TFV concentrations were significantly lower in pregnancy compared to pre-pregnancy, with 34.0%, 43.8%, and 65.1% of trough plasma concentrations below the lower bound of expected trough concentrations presumed to be the protective threshold in the 1st, 2nd, and 3rd trimesters, respectively. By comparison, in the simulated double-dose group, 10.7%, 14.4%, and 27.8% of trough concentrations fell below the estimated protective thresholds in the 1st, 2nd, and 3rd trimesters, respectively. The FTC trough plasma concentration during pregnancy was also lower than pre-pregnancy, with 45.2% of the steady-state trough concentrations below the estimated protective trough concentrations of FTC. In the pregnancy-adjusted double-dose group, 24.1% of trough plasma concentrations were lower than protective levels. Conclusions Our simulation shows >50% of research participants on standard dosing would have 3rd trimester trough plasma TFV concentrations below levels associated with protection. This simulation provides the quantitative basis for the design of prospective TDF/FTC studies during pregnancy to evaluate the safety and appropriateness of pregnancy-adjusted dosing.
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Affiliation(s)
- Rachel K. Scott
- Women’s Health Research, MedStar Health Research Institute, Washington, DC, United States
| | - Yifan Yu
- Department of Pharmaceutical Sciences, University of Buffalo, Buffalo, NY, United States
| | - Mark A. Marzinke
- Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jenell S. Coleman
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Craig W. Hendrix
- Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Robert Bies
- Department of Pharmaceutical Sciences, University of Buffalo, Buffalo, NY, United States
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Pintye J, Kinuthia J, Abuna F, Anderson PL, Dettinger JC, Gomez L, Haberer JE, Marwa MM, Ngumbau N, Omondi P, Odhiambo B, Stern J, Watoyi S, Baeten JM, John-Stewart G. HIV pre-exposure prophylaxis initiation, persistence, and adherence during pregnancy through the postpartum period. AIDS 2023; 37:1725-1737. [PMID: 37289583 PMCID: PMC10527305 DOI: 10.1097/qad.0000000000003617] [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] [Indexed: 06/10/2023]
Abstract
OBJECTIVE We evaluated pre-exposure prophylaxis (PrEP) initiation, persistence, and adherence measured via tenofovir-diphosphate (TFV-DP) concentrations in dried blood spots (DBS) among women offered PrEP during pregnancy. METHODS We prospectively analyzed data from participants in the PrIMA Study (NCT03070600) who were offered PrEP during the second trimester and followed through 9 months postpartum. At follow-up visits (monthly in pregnancy; 6 weeks, 6 months, 9 months postpartum), self-reported PrEP use was assessed, and DBS were collected for quantifying TFV-DP concentrations. RESULTS In total, 2949 participants were included in the analysis. At enrollment, median age was 24 years [interquartile range IQR) 21-29], gestational age 24 weeks (IQR 20-28), and 4% had a known partner living with HIV. Overall, 405 (14%) participants initiated PrEP in pregnancy with higher frequency among those with risk factors for HIV acquisition, including >2 lifetime sexual partners, syphilis during pregnancy, forced sex, and intimate partner violence ( P < 0.05). At 9 months postpartum, 58% of PrEP initiators persisted with PrEP use, of which 54% self-reported not missing any PrEP pills in the last 30 days. Among DBS randomly selected from visits where participants persisted with PrEP ( n = 427), 50% had quantifiable TFV-DP. Quantifiable TFV-DP was twice as likely in pregnancy than postpartum [adjusted risk ratio (aRR) = 1.90, 95% confidence interval (CI) 1.40-2.57, P < 0.001]. Having a partner known to be living with HIV was the strongest predictor of PrEP initiation, persistence, and quantifiable TFV-DP ( P < 0.001). CONCLUSIONS PrEP persistence and adherence waned postpartum, though over half of PrEP initiators persisted through 9-months postpartum. Interventions should prioritize increasing knowledge of partner HIV status and sustaining adherence in the postpartum period.
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Affiliation(s)
| | - John Kinuthia
- University of Washington, Seattle, Washington, USA
- Kenyatta National Hospital, Nairobi, Kenya
| | | | | | | | - Laurén Gomez
- University of Washington, Seattle, Washington, USA
| | | | | | | | | | | | - Joshua Stern
- University of Washington, Seattle, Washington, USA
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Sabo MC, Lokken EM, Srinivasan S, Kinuthia J, Richardson BA, Fiedler TL, Munch M, Proll S, Salano C, John-Stewart G, Jaoko W, Fredricks DN, McClelland RS. Changes in Vaginal Bacteria and Inflammatory Mediators From Periconception Through the Early Postpartum Period in a Cohort of Kenyan Women Without HIV. J Infect Dis 2023; 228:487-499. [PMID: 37207618 PMCID: PMC10428199 DOI: 10.1093/infdis/jiad168] [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: 12/27/2022] [Revised: 05/04/2023] [Accepted: 05/18/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Women's increased risk of HIV acquisition during pregnancy and postpartum may be mediated by changes in vaginal microbiota and/or cytokines. METHODS A cohort of 80 Kenyan women who were HIV-1 seronegative contributed 409 vaginal samples at 6 pregnancy time points: periconception, positive pregnancy test result, first trimester, second trimester, third trimester, and postpartum. Concentrations of vaginal bacteria linked with HIV risk and Lactobacillus spp were measured using quantitative polymerase chain reaction. Cytokines were measured by immunoassay. RESULTS Based on Tobit regression, later pregnancy time points were associated with lower concentrations of Sneathia spp (P = .01), Eggerthella sp type 1 (P = .002), and Parvimonas sp type 2 (P = .02) and higher concentrations of Lactobacillus iners (P < .001), Lactobacillus crispatus (P < .001), Lactobacillus vaginalis (P < .001), interleukin 6 (P < .001), TNF (P = .004), C-X-C motif chemokine ligand 10 (CXCL10; P < .001), C-C motif ligand 3 (P = .009), C-C motif ligand 4 (P < .001), C-C motif ligand 5 (P = .002), interleukin 1β (P = .02), and interleukin 8 (P = .002). Most cervicovaginal cytokines and vaginal bacteria clustered separately in principal component analysis, except for CXCL10, which did not group with either cytokines or bacteria. The shift toward a Lactobacillus-dominated microbiota during pregnancy mediated the relationship between pregnancy time point and CXCL10. CONCLUSIONS Increases in proinflammatory cytokines, but not vaginal bacterial taxa linked with higher HIV risk, could provide an explanation for increased HIV susceptibility during pregnancy and postpartum.
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Affiliation(s)
- Michelle C Sabo
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Erica M Lokken
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Sujatha Srinivasan
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - John Kinuthia
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Tina L Fiedler
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Matthew Munch
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Sean Proll
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Clayton Salano
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Walter Jaoko
- Department of Medical Microbiology and Immunology, University of Nairobi, Nairobi, Kenya
| | - David N Fredricks
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - R Scott McClelland
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Medical Microbiology and Immunology, University of Nairobi, Nairobi, Kenya
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Hicks S, Odhiambo B, Abuna F, Dettinger JC, Ngumbau N, Gómez L, Sila J, Oketch G, Sifuna E, Weiner BJ, John-Stewart G, Kinuthia J, Wagner AD. Selecting implementation strategies to improve implementation of integrated PrEP for pregnant and postpartum populations in Kenya: a sequential explanatory mixed methods analysis. Implement Sci Commun 2023; 4:93. [PMID: 37580795 PMCID: PMC10424426 DOI: 10.1186/s43058-023-00481-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 07/29/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND There is a higher risk for HIV acquisition during pregnancy and postpartum. Pre-exposure prophylaxis (PrEP) is recommended during this period for those at high risk of infection; integrated delivery in maternal and child health (MCH) clinics is feasible and acceptable but requires implementation optimization. METHODS The PrEP in Pregnancy, Accelerating Reach and Efficiency study (PrEPARE; NCT04712994) engaged stakeholders to prioritize determinants of PrEP delivery (using Likert scores) and prioritize PrEP delivery implementation strategies. Using a sequential explanatory mixed methods design, we conducted quantitative surveys with healthcare workers at 55 facilities in Western Kenya and a stakeholder workshop (including nurses, pharmacists, counselors, and county and national policymakers), yielding visual plots of stakeholders' perceived feasibility and effectiveness of the strategies. A stepwise elimination process was used to identify seven strategies for empirical testing. Facilitator debriefing reports from the workshop were used to qualitatively assess the decision-making process. RESULTS Among 146 healthcare workers, the strongest reported barriers to PrEP delivery were insufficient providers and inadequate training, insufficient space, and high volume of patients. Sixteen strategies were assessed, 14 of which were included in the final analysis. Among rankings from 182 healthcare workers and 44 PrEP policymakers and implementers, seven strategies were eliminated based on low post-workshop ranking scores (bottom 50th percentile) or being perceived as low feasibility or low effectiveness for at least 50% of the workshop groups. The top seven strategies included delivering PrEP within MCH clinics instead of pharmacies, fast-tracking PrEP clients to reduce waiting time, delivering PrEP-related health talks in waiting bays, task shifting PrEP counseling, task shifting PrEP risk assessments, training different providers to deliver PrEP, and retraining providers on PrEP delivery. All top seven ranked strategies were grouped into bundles for subsequent testing. Facilitator debriefing reports generally aligned with rankings but noted how stakeholders' decision-making changed when considering the impact of strategies on facility staff and non-PrEP clients. CONCLUSIONS The most impactful barriers to integrated PrEP delivery in MCH clinics were insufficient staffing and space. Implementation strategies prioritized through multiple methods of stakeholder input focused on co-location of services and increasing clinic efficiency. Future testing of these stakeholder-prioritized strategy bundles will be conducted to assess the effectiveness and implementation outcomes.
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Affiliation(s)
- Sarah Hicks
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | | | | | - Julia C Dettinger
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Laurén Gómez
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | | | | | - Bryan J Weiner
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Grace John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Departments of Medicine, University of Washington, Seattle, WA, USA
- Departments of Pediatrics, University of Washington, Seattle, WA, USA
| | | | - Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, WA, USA
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Young AM, Saidi F, Phanga T, Tseka J, Bula A, Mmodzi P, Pearce LD, Maman S, Golin CE, Mutale W, Chi BH, Hill LM. Male partners' support and influence on pregnant women's oral PrEP use and adherence in Malawi. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1206075. [PMID: 37614700 PMCID: PMC10442580 DOI: 10.3389/frph.2023.1206075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/24/2023] [Indexed: 08/25/2023] Open
Abstract
Introduction Daily oral pre-exposure prophylaxis (PrEP) is a safe and effective HIV prevention method for pregnant and postpartum women, but adherence barriers exist. Understanding the role of male partners in supporting PrEP use may inform strategies to support PrEP adherence among pregnant and breastfeeding women. Methods To understand male partners' involvement in women's use of PrEP, we conducted in-depth interviews with pregnant women in Lilongwe, Malawi who had recently decided to use PrEP (n = 30) and their male partners (n = 20) in the context of a PrEP adherence trial. Women were purposively recruited to ensure variation in their partners' HIV status. Interviews were conducted in Chichewa using a semistructured guide. We followed a thematic approach to analyze the interview data. Results Most male partners were receptive to women using PrEP during pregnancy because it eased their fears of the woman and baby acquiring HIV. Men often played a key role in women's PrEP adherence by providing daily reminders and encouragement to adhere to their medication. The majority of women appreciated this support from the men as it lessened the burden of remembering to take their medications daily on their own and aided their adherence. However, several women who lacked male partner support spoke of wanting their partners to be more involved. Many men living with HIV found the mutual support beneficial for their antiretroviral therapy adherence, while men without HIV or with status unknown appreciated knowing that the family was protected. While most men were open to women continuing PrEP beyond the current study, some would only support it if women were still at risk for acquiring HIV. Conclusion In this study, male partners were strongly motivated to support the PrEP adherence of their female partners as a way of ensuring that the pregnant women and unborn babies were protected against HIV. Promoting disclosure and tangible support that arises organically among men may be helpful, but programs to enhance this support and identify ways to support women who do not receive support from their partners or do not wish to disclose their PrEP use to partners may be needed.
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Affiliation(s)
- Alinda M Young
- Department of Maternal and Child Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Women's Global Health Imperative at RTI International, Berkeley, CA, United States
| | - Friday Saidi
- UNC Project-Malawi, Lilongwe, Malawi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | | | | | | | - Lisa D Pearce
- Department of Sociology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Suzanne Maman
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Carol E Golin
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Wilbroad Mutale
- Department of Health Policy, University of Zambia School of Public Health, Lusaka, Zambia
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lauren M Hill
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Masenyetse LJ, Greenberg L, Samonyane F, Sekepe B, Mokone M, Mokone MJ, Tukei VJ, Beres LK. Oral HIV pre-exposure prophylaxis use among pregnant and postpartum women: results from real-world implementation in Lesotho. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1221752. [PMID: 37583546 PMCID: PMC10425268 DOI: 10.3389/frph.2023.1221752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/07/2023] [Indexed: 08/17/2023] Open
Abstract
Introduction Lesotho has reached epidemic control, PrEP is an important component in maintaining that and in reaching the goal of eliminating mother-to-child transmission. Methods We conducted a retrospective review of existing, routine PrEP health records in 26 health facilities in Lesotho. PrEP visit data were collected for pregnant and postpartum women screened for PrEP and/or enrolled in PrEP programs from 1 January 2019 through 30 June 2021 with follow-up data collected up to the date of data abstraction per site between October 2021 and May 2022. Poisson regression with robust variance was used to evaluate the association between patient characteristics and continuation of PrEP. Results Indications for starting PrEP were significantly associated with continuation in PrEP use. Women starting PrEP due to having a partner known to be living with HIV were the most likely to return for follow-up. In all age groups, the most common reason for starting PrEP was being in a serodiscordant relationship, though the proportion varies by age. Conclusion As Lesotho is now in the process of optimizing PrEP use among pregnant and postpartum women, it is critical to revise data sources to capture information that will link PrEP records and ANC/PNC records and document pregnancy/postpartum status in order to better understand PrEP use and gaps in this population.
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Affiliation(s)
| | - Lauren Greenberg
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States
| | | | - Bokang Sekepe
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | | | | | - Vincent J. Tukei
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
- Elizabeth Glaser Pediatric AIDS Foundation, Mbabane, Eswatini
| | - Laura K. Beres
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
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Naidoo K, Hoque M, Buckus S, Hoque M, Jagernath K. Prevention-of-mother-to-child-transmission (PMTCT) program outcomes in South Africa in the pre-COVID and COVID eras. BMC Public Health 2023; 23:1395. [PMID: 37474920 PMCID: PMC10357590 DOI: 10.1186/s12889-023-16214-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/28/2023] [Indexed: 07/22/2023] Open
Abstract
INTRODUCTION Two decades after implementing the Prevention of Mother to Child transmission (PMTCT) program, South Africa has still not managed to eliminate intrauterine mother-to-child (MTCT) HIV transmission. During the COVID pandemic access to maternal health services was reduced, potentially compromising the PMTCT program. METHOD A retrospective record review was conducted at a midwife-run obstetric unit in a high HIV prevalence setting. Data on pregnant women who delivered between January 2019 and December 2020 were analysed to evaluate predictors for MTCT, and compare pre-COVID and COVID-era changes in maternal and infant HIV incidence and prevalence. RESULTS A total of 1660 women delivered at the facility over a 24-month period (Jan 2019-Dec 2020), of whom 92.8% enrolled for antenatal care in 2019 and 94.6% in 2020. A significantly greater proportion of women were aware of their HIV status before enrolling for antenatal care in the pre-COVID (2019) than COVID (2020) period (88% vs 40.2%; p < 0.05). There was a significant increase in new HIV infection after enrolling for antenatal care during the COVID period compared to pre-COVID period (120 vs 62 women, p < 0.05). There was also a significant increase in the HIV prevalence among women who delivered during the COVID period than in the pre-COVID era (43.5% compared to 35.8%, p < 0.05). However, more than 95% of HIV-positive women initiated ART in both periods. Overall, a total of thirteen infants tested HIV positive (2.1% MTCT rate), with no difference in MTCT between 2019 and 2020. Infants born to women on antiretroviral therapy (ART) were 93% less likely to have a positive PCR test than those whose mothers who were not on ART. (OR = 0.07, 95% CI 0.031:0.178, p < 0.05). CONCLUSION The increase in maternal HIV incidence and prevalence during the COVID era suggest a lapse in HIV prevention strategies during the COVID pandemic. There is an urgent need to improve community test-and-treat campaigns among women of reproductive age in the community and increase access to HIV pre-exposure prophylaxis for pregnant women, especially during periods of health crises.
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Affiliation(s)
- Keshena Naidoo
- Department of Family Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - Monjurul Hoque
- Kwadabeka Community Health Centre, KwaDabeka, South Africa
| | - Somaya Buckus
- Kwadabeka Community Health Centre, KwaDabeka, South Africa
| | - Maariyah Hoque
- South African College of Applied Psychology, Pretoria, South Africa
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Farooq HZ, Apea V, Kasadha B, Ullah S, Hilton-Smith G, Haley A, Scherzer J, Hand J, Paparini S, Phillips R, Orkin CM. Study protocol: the ILANA study - exploring optimal implementation strategies for long-acting antiretroviral therapy to ensure equity in clinical care and policy for women, racially minoritised people and older people living with HIV in the UK - a qualitative multiphase longitudinal study design. BMJ Open 2023; 13:e070666. [PMID: 37423623 DOI: 10.1136/bmjopen-2022-070666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023] Open
Abstract
INTRODUCTION Cabotegravir and rilpivirine (CAB+RPV long-acting (LA)) is recommended as a treatment for HIV-1 allowing people living with HIV to receive 2 monthly injectable treatment, rather than daily pills. Providing injectable therapy in a system designed to provide and manage study participants on oral treatments poses logistical challenges namely how resources are used to accommodate patient preference within constrained health economies with capacity limitations. In this pragmatic multicentre study, we aim to understand the implementation of CAB-RPV-LA administration in two settings via mixed methods to explore perspectives of participants and the clinical team delivering CAB+RPV LA. METHODS AND ANALYSIS Women, racially minoritised people and older people are chronically under-represented in HIV clinical trials so the ILANA trial has set recruitment caps to ensure recruitment of 50% women, 50% ethnically diverse people and 30% over 50 years of age to include a more representative study population. Using a mixed-methods approach, the primary objective is to identify and evaluate the critical implementation strategies for CAB+RPV LA in both hospital and community settings. Secondary objectives include evaluating feasibility and acceptability of CAB+RPV LA administration at UK clinics and community settings from the perspective of HIV care providers, nurses and representatives at community sites, evaluating barriers to implementation, the utility of implementation strategies and adherence. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Health Research Authority Research Ethics Committee (REC reference: 22/PR/0318). The dissemination strategy has been formulated with the SHARE Collaborative Community Advisory Board to maximise the impact of this work on clinical care and policy. This strategy draws on and leverages existing resources within the participating organisations, such as their academic infrastructure, professional relationships and community networks. The strategy will leverage the Public Engagement Team and press office to support dissemination of findings. TRIAL REGISTRATION NUMBER NCT05294159.
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Affiliation(s)
- Hamzah Z Farooq
- Blizard Institute, Queen Mary University, London, UK
- SHARE Collaborative, Queen Mary University, London, UK
- Department of Infection and Immunity, Barts Health NHS Trust, London, UK
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Vanessa Apea
- Blizard Institute, Queen Mary University, London, UK
- SHARE Collaborative, Queen Mary University, London, UK
- Department of Infection and Immunity, Barts Health NHS Trust, London, UK
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Bakita Kasadha
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sadna Ullah
- Blizard Institute, Queen Mary University, London, UK
- SHARE Collaborative, Queen Mary University, London, UK
- Department of Infection and Immunity, Barts Health NHS Trust, London, UK
| | | | | | | | - James Hand
- SHARE Collaborative, Queen Mary University, London, UK
- Department of Infection and Immunity, Barts Health NHS Trust, London, UK
| | - Sara Paparini
- SHARE Collaborative, Queen Mary University, London, UK
- Centre for Public Health and Policy, Wolfson Institute of Population Health, Queen Mary University, London, UK
| | - Rachel Phillips
- Pragmatic Clinical Trials Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Chloe M Orkin
- Blizard Institute, Queen Mary University, London, UK
- SHARE Collaborative, Queen Mary University, London, UK
- Department of Infection and Immunity, Barts Health NHS Trust, London, UK
- Barts and The London School of Medicine and Dentistry, London, UK
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Kabaghe AN, Stephens R, Payne D, Theu J, Luhanga M, Chalira D, Arons MM, O'Malley G, Thomson KA, Nyangulu M, Nyirenda R, Patel P, Wadonda-Kabondo N. HIV Recent Infection and Past HIV Testing History Among Newly HIV-Diagnosed 15-24-Year-Olds in Malawi: An Analysis of 2019-2022 HIV Recent Infection Surveillance Data. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2023; 35:4-19. [PMID: 37406145 DOI: 10.1521/aeap.2023.35.suppa.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
Awareness of HIV status in Malawi is 88.3% and lowest among 15-24-year-olds (76.2%). There is a need to understand HIV testing history and transmission in this age group. We analyzed pooled HIV surveillance data to describe testing history and HIV recent infection among 8,389 HIV-positive 15-24-year-olds from 251 sites in Malawi between 2019 and 2022. Most HIV-positive 15-24-year-olds were female; aged 23-24 years; rural residents; and diagnosed at voluntary counseling and testing. No prior HIV testing was reported in 43.5% and 32.9% of 15-19-year-olds and males, respectively. Overall, 4.9% of HIV-positive diagnoses were classified as recent HIV infections, with the highest proportions among breastfeeding women (8.2%); persons tested at sexually transmitted infection clinics (9.0%); persons with a prior negative test within 6 months (13.0%); and 17-18-year-olds (7.3%). Tailored and innovative HIV prevention and testing strategies for young adolescents, young males, and pregnant and breastfeeding women are needed for HIV epidemic control.
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Affiliation(s)
| | - Reno Stephens
- U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Danielle Payne
- U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Joe Theu
- International Training and Education Center for Health (I-TECH), University of Washington, Lilongwe, Malawi
| | - Misheck Luhanga
- U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Davie Chalira
- International Training and Education Center for Health (I-TECH), University of Washington, Lilongwe, Malawi
| | - Melissa M Arons
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gabrielle O'Malley
- International Training and Education Center for Health (I-TECH), University of Washington, Seattle, Washington
| | - Kerry A Thomson
- International Training and Education Center for Health (I-TECH), University of Washington, Seattle, Washington
| | - Mtemwa Nyangulu
- U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | | | - Pragna Patel
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
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Bershteyn A, Resar D, Kim HY, Platais I, Mullick S. Optimizing the pipeline of multipurpose prevention technologies: opportunities across women's reproductive lifespans. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1169110. [PMID: 37325241 PMCID: PMC10266103 DOI: 10.3389/frph.2023.1169110] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
HIV/AIDS and maternal mortality are the two leading causes of death among women of reproductive age in sub-Saharan Africa. A growing body of research investigates opportunities for multipurpose prevention technologies (MPTs) that prevent unintended pregnancy, HIV, and/or other sexually transmitted infections (STIs) with a single product. More than two dozen MPTs are currently in development, most of them combining contraception with HIV pre-exposure prophylaxis, with or without protection from other STIs. If successful, such MPTs could offer women benefits at multiple levels: greater motivation for effective use; lower product administration burden; accelerated integration of HIV, STI, and reproductive health services; and opportunities to circumvent stigma by using contraception as a "fig leaf" for HIV and/or STI prevention. However, even if women find respite from product burden, lack of motivation, and/or stigma in contraceptive-containing MPTs, their use of MPTs will be interrupted, often multiple times, over the reproductive lifecourse due to desire for pregnancy, pregnancy and breastfeeding, menopause, and changes in risk. Interruptions to the benefits of MPTs could be avoided by combining HIV/STI prevention with other life-stage-appropriate reproductive health products. New product concepts could include combining prenatal supplements with HIV and STI prevention, emergency contraception with HIV post-exposure prophylaxis, or hormone replacement therapies for menopause with HIV and STI prevention. Research is needed to optimize the MPT pipeline based on the populations underserved by available options and the capacity of resource-constrained health systems to deliver novel preventative healthcare products.
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Affiliation(s)
- Anna Bershteyn
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Danielle Resar
- Clinton Health Access Initiative, Boston, MA, United States
| | - Hae-Young Kim
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Ingrida Platais
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Saiqa Mullick
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
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Haribhai S, Khadka N, Mvududu R, Mashele N, Bekker LG, Gorbach P, Coates TJ, Myer L, Joseph Davey DL. Psychosocial determinants of pre-exposure prophylaxis use among pregnant adolescent girls and young women in Cape Town, South Africa: A qualitative study. Int J STD AIDS 2023:9564624231152776. [PMID: 36947792 DOI: 10.1177/09564624231152776] [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: 03/24/2023]
Abstract
BACKGROUND In South Africa, at least 7.5 million people (age ≥15 years) are living with Human Immunodeficiency Virus (HIV). In 2020, 220,000 new infections occurred, approximately one-third of which were among cisgender adolescent girls and women (age ≥15 years). The perspectives of pregnant adolescent girls and young women (AGYW) as key, targeted end-users of pre-exposure prophylaxis (PrEP) in this setting are not well known. METHODS We purposively recruited participants enrolled in an ongoing cohort study at an urban antenatal clinic in Cape Town, South Africa for in-depth interviews between July-September 2020. We restricted our analysis to pregnant AGYW (age: 16-25 years) who initiated daily oral PrEP (Tenofovir/Emtricitabine) antenatally and self-reported either high PrEP persistence (≥25 days in the past 30 days and no missed PrEP collection), or low PrEP persistence and/or discontinuation (missing >5 days in the last 30 days or missed PrEP collection). The findings were organized thematically, per the adapted Health Behavior Model (2000), using Nvivo-v.1.5. RESULTS We interviewed 18 AGYW (mean age = 22 years), at a mean of 14 weeks postpartum. Higher self-esteem and high-quality study provider-client relationships, including empathic psychosocial support, facilitated PrEP continuation. Reported barriers included unstable social structure characteristics (i.e., financial hardship) and individual factors (i.e., unintended pregnancy, parental rejection, and inadequate peer- and [non-cohabiting] partner support). Participants self-perceived a need for PrEP, feeling susceptible to non-consensual, forced sex, or considering partners' (presumed) sexual risk-taking. Limited community awareness regarding PrEP availability and/or perceived complexity in navigating health system access to PrEP, impede continuation. CONCLUSIONS PrEP-focused healthcare access pathways for pregnant and postpartum AGYW need to be simplified. Further research is needed on health system determinants (i.e., structural barriers, provider-client interactions, and related outcomes) of oral PrEP utilization. In 2022, South Africa announced regulatory approval of long-acting PrEP options (i.e., the dapivirine ring for non-pregnant women and injectable cabotegravir, respectively); these may mitigate implementation barriers reported in this study. However, the safety and efficacy of long-acting PrEP (e.g., injectables, implants) among pregnant or breastfeeding women, specifically, remains to be confirmed in this setting.
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Affiliation(s)
- Sonia Haribhai
- Desmond Tutu Health Foundation/International AIDS Vaccine Initiative Fellowship, 108181Desmond Tutu Health Foundation, Cape Town, South Africa
| | - Nehaa Khadka
- Department of Epidemiology, Fielding School of Public Health, 8783University of California Los Angeles, Los Angeles, CA, USA
| | - Rufaro Mvududu
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, 37716University of Cape Town, Cape Town, South Africa
| | - Nyiko Mashele
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, 37716University of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, 37716University of Cape Town, Cape Town, South Africa
| | - Pamina Gorbach
- Department of Epidemiology, Fielding School of Public Health, 8783University of California Los Angeles, Los Angeles, CA, USA
| | - Thomas J Coates
- Division of Infectious Diseases, David Geffen School of Medicine, 8783University of California Los Angeles, Los Angeles, CA, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, 37716University of Cape Town, Cape Town, South Africa
| | - Dvora Leah Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, 8783University of California Los Angeles, Los Angeles, CA, USA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, 37716University of Cape Town, Cape Town, South Africa
- Division of Infectious Diseases, David Geffen School of Medicine, 8783University of California Los Angeles, Los Angeles, CA, USA
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Moodley D, Lombard C, Govender V, Naidoo M, Desmond AC, Naidoo K, Mhlongo O, Sebitloane M, Newell ML, Clark R, Rooney JF, Gray G, Lombard C, Govender V, Naidoo M, Desmond AC, Naidoo KL, Mhlongo O, Sebitloane M, Newell ML, Clark R, Rooney JF, Gray GE, Ngaleka L, Pillay N, Booi S, Samsunder N, Pillay L, Gray R, Gazu R, Nkosi T. Pregnancy and neonatal safety outcomes of timing of initiation of daily oral tenofovir disoproxil fumarate and emtricitabine pre-exposure prophylaxis for HIV prevention (CAP016): an open-label, randomised, non-inferiority trial. Lancet HIV 2023; 10:e154-e163. [PMID: 36746169 DOI: 10.1016/s2352-3018(22)00369-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 11/26/2022] [Accepted: 11/29/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND The safety of tenofovir disoproxil fumarate and emtricitabine as pre-exposure prophylaxis (PrEP) in pregnant women not living with HIV is uncertain. We aimed to compare pregnancy and neonatal outcomes in women exposed and not exposed to PrEP during pregnancy. METHODS In this single-site, open-label, randomised, non-inferiority trial in Durban, South Africa, we evaluated pregnancy and neonatal outcomes in pregnant women aged 18 years or older, not living with HIV, and at 14-28 weeks' gestation at the time of enrolment. Eligible participants were randomly assigned (1:1) using a computer-generated permuted block (block size of ten) randomisation list to immediate initiation or deferred initiation of PrEP until breastfeeding cessation. Participants in the immediate PrEP group received a monthly supply of once daily oral tenofovir disoproxil fumarate 300 mg and emtricitabine 200 mg. Participants in the deferred PrEP group received standard of care for HIV prevention. The primary outcomes were the occurrence of preterm live birth (<37 weeks gestational age) and very preterm birth (<34 weeks gestational age) determined by menstrual dating, low birthweight (<2500 g), very low birthweight (<1500 g), stillbirth (≥20 weeks gestational age), and small for gestational age (birthweight less than the tenth percentile). Post-natal safety outcomes will be reported elsewhere. We used binomial regression models to estimate risk differences and two-sided 90% CIs. Immediate PrEP was non-inferior to deferred PrEP if the upper bound of the 90% CI of the risk difference was less than the upper predefined non-inferiority margin for preterm birth (7·5%), very preterm birth (2·6%), low birthweight (5·5%), very low birthweight (1·2%), stillbirth (1·0%), and small for gestational age (3·7%). All outcomes were analysed in the intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT3227731. FINDINGS Between Sept 25, 2017, and Dec 6, 2019, we screened 693 women, of whom 540 were randomly assigned to immediate PrEP (n=271) or deferred PrEP (n=269). The median gestational age was 19 weeks (IQR 15-23 for immediate PrEP and 16-23 for deferred PrEP). The risk difference between the immediate PrEP group and the deferred PrEP group for preterm birth was -4·7% (90% CI -10·7 to 1·2; immediate PrEP was non-inferior), for very preterm birth was 0·6% (-3·4 to 4·6; upper limit exceeded the non-inferiority margin), for low birthweight was 2·5% (-1·6 to 6·6; upper limit exceeded the non-inferiority margin), for very low birthweight was 0% (-1·4 to 1·4; upper limit exceeded the non-inferiority margin), for stillbirth was 1·2% (-1·5 to 3·8; upper limit exceeded the non-inferiority margin), and for small for gestational age was 0·9% (-1·2 to 2·9; immediate PrEP was non-inferior). INTERPRETATION In our study, PrEP was not associated with preterm birth or small for gestational age infants. Our data support the use of tenofovir disoproxil fumarate and emtricitabine in pregnancy and our reassuring findings can be used to allay safety concerns among pregnant women. FUNDING South African Medical Research Council and Gilead Sciences.
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Affiliation(s)
- Dhayendre Moodley
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa; Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa.
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Tygerberg, South Africa; Division of Epidemiology and Biostatistics, Department of Global Health, University of Stellenbosch, Tygerberg, South Africa
| | - Vani Govender
- Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa
| | - Megeshinee Naidoo
- Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa
| | - Alicia C Desmond
- Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa
| | - Kimesh Naidoo
- Department of Paediatrics and Child Health, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Ottacia Mhlongo
- KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa
| | - Motshedisi Sebitloane
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Marie-Louise Newell
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Human Health and Development, Faculty of Medicine, University of Southampton, Southampton, UK
| | | | | | - Glenda Gray
- South African Medical Research Council, Cape Town, South Africa
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Rosenberg NE, Shook-Sa BE, Liu M, Stranix-Chibanda L, Yotebieng M, Sam-Agudu NA, Hudgens MG, Phiri SJ, Mutale W, Bekker LG, Moyo S, Zuma K, Charurat ME, Justman J, Chi BH. Adult HIV-1 incidence across 15 high-burden countries in sub-Saharan Africa from 2015 to 2019: a pooled analysis of nationally representative data. Lancet HIV 2023; 10:e175-e185. [PMID: 36702151 PMCID: PMC10126805 DOI: 10.1016/s2352-3018(22)00328-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 10/13/2022] [Accepted: 10/27/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Harmonised population-based surveys with recent HIV-1 infection testing algorithms permit pooled cross-sectional estimation of HIV incidence across multiple countries. We aimed to estimate adult HIV-1 incidence rates and number of new infections by sex, age, and subregion in sub-Saharan Africa. METHODS We analysed data from 13 Population-Based HIV Impact Assessment (PHIA) surveys and two additional population-based surveys done between 2015 and 2019 in 15 sub-Saharan African countries. HIV-seropositive samples from adults aged 15-59 years were tested for recent HIV-1 infection by use of an algorithm consisting of the HIV-1 limiting antigen avidity enzyme immunoassay, HIV-1 viral load, and qualitative detection of antiretroviral agents. Data were pooled across countries; sampling weights were incorporated to represent all adults in the 15 national populations. Analyses accounted for the complex sample designs. HIV incidence rates, incidence rate differences, and number of new annual infections were estimated. FINDINGS Among 445 979 adults sampled, 382 had recent HIV-1 infection. The estimated HIV-1 incidence rate was 3·3 per 1000 person-years (95% CI 2·6-4·0) among women and 2·0 per 1000 person-years (1·2-2·7) among men (incidence rate difference 1·3 per 1000 person-years, 95% CI 0·3-2·3). Among adults aged 15-24 years, the incidence rate was higher for women (3·5 per 1000 person-years) than men (1·2 per 1000 person-years; difference 2·3, 95% CI 0·8-3·8), but infection rates were similar between sexes in all other age groups. The HIV-1 incidence rate was 7·4 per 1000 person-years (95% CI 5·0-9·7) in southern sub-Saharan Africa, 2·3 per 1000 person-years (1·7-2·9) in the eastern subregion, and 0·9 per 1000 person-years (0·6-1·2) in the western and central subregion. 689 000 (95% CI 546 000-833 000) new HIV cases were estimated annually among the 265 million susceptible adults (61·6% in women). INTERPRETATION HIV-1 incidence and number of new infections differed by age, sex, and subregion. Approaches for risk stratification are needed to guide comprehensive HIV-1 prevention. FUNDING National Institutes of Health.
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Affiliation(s)
- Nora E Rosenberg
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Bonnie E Shook-Sa
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mincen Liu
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lynda Stranix-Chibanda
- Child and Adolescent Health Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe; University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Marcel Yotebieng
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Nadia A Sam-Agudu
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA; International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Michael G Hudgens
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sam J Phiri
- Partners in Hope, Lilongwe, Malawi; Department of Public Health and Family Medicine, Kamuzu University of Health Sciences, Lilongwe, Malawi
| | | | | | - Sizulu Moyo
- University of Cape Town, Cape Town, South Africa; Human Sciences Research Council, Pretoria, South Africa
| | | | - Manhattan E Charurat
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jessica Justman
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Kinuthia J, Dettinger JC, Stern J, Ngumbau N, Ochieng B, Gómez L, Abuna F, Watoyi S, Marwa M, Odinga D, Wagner AD, Richardson BA, Pintye J, Baeten JM, John‐Stewart G. Risk-based versus universal PrEP delivery during pregnancy: a cluster randomized trial in Western Kenya from 2018 to 2019. J Int AIDS Soc 2023; 26:e26061. [PMID: 36807505 PMCID: PMC9939942 DOI: 10.1002/jia2.26061] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/19/2023] [Indexed: 02/22/2023] Open
Abstract
INTRODUCTION Integrating pre-exposure prophylaxis (PrEP) delivery for pregnant and postpartum women within maternal and child health (MCH) clinics is feasible and acceptable. It is unknown whether a risk-guided model would facilitate appropriate PrEP use among MCH attendees better than universally offering PrEP. METHODS The PrEP Implementation for Mothers in Antenatal Care (PrIMA) study was a cluster randomized trial to assess two models for PrEP delivery among pregnant women seeking routine MCH care at 20 public clinics in Kenya between January 2018 and July 2019 (NCT03070600). In the Universal arm, all participants received PrEP counselling and self-selected whether to initiate PrEP. In the Targeted arm, participants underwent an HIV risk assessment, including an objective risk-scoring tool and an offer of HIV self-tests for at-home partner testing; those determined to be at high risk received a PrEP offer. Participants were followed through 9 months postpartum. Primary outcomes included incident HIV and appropriate PrEP use (defined as PrEP uptake among those at high risk and no PrEP uptake for those not at risk). Outcomes were compared using intention-to-treat analyses, adjusting for baseline HIV risk and marital status. RESULTS Among 4447 women enrolled, the median age was 24.0 years (interquartile range [IQR]: 20.9, 28.3), and most were married (84.8%). The median gestational age at enrolment was 24 weeks (IQR: 20, 30). Women in the Targeted arm were more likely to be at high risk for HIV acquisition at baseline (51.6% vs. 33.3%). During 4638 person-years (p-yr) of follow-up, there were 16 maternal HIV infections with no difference in maternal HIV incidence between arms: 0.31/100 p-yr (95% CI: 0.15, 0.65) Targeted and 0.38/100p-yr (95% CI: 0.20, 0.73) Universal (adjusted relative risk [aRR]: 0.85 [CI: 0.28, 2.55]). There was no significant difference in the frequency of appropriate PrEP use between the arms (68.2% vs. 59.1% in Targeted vs. Universal, respectively) (aRR: 1.03 [CI: 0.96, 1.10]). CONCLUSIONS Given comparable maternal HIV incidence and PrEP uptake in Universal and Targeted approaches, and the simplicity that universal PrEP offers, our findings suggest that universal PrEP counselling is optimal for integrating PrEP in MCH systems.
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Affiliation(s)
- John Kinuthia
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | | | - Joshua Stern
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Nancy Ngumbau
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Ben Ochieng
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Laurén Gómez
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Felix Abuna
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Salphine Watoyi
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Mary Marwa
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Daniel Odinga
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Anjuli D. Wagner
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Barbra A. Richardson
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA,Department of BiostatisticsUniversity of WashingtonSeattleWashingtonUSA,Division of Allergy and Infectious DiseasesUniversity of WashingtonSeattleWashingtonUSA,Vaccine and Infectious Disease DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA
| | - Jillian Pintye
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA,Department of Behavioral Nursing & Health InformaticsUniversity of WashingtonSeattleWashingtonUSA
| | - Jared M. Baeten
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA,Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA,Gilead SciencesFoster CityCaliforniaUSA
| | - Grace John‐Stewart
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA,Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA,Department of PediatricsUniversity of WashingtonSeattleWashingtonUSA
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McKinney J, Mirani G, Levison J. Providers Have a Responsibility to Discuss Options for Infant Feeding With Pregnant People With Human Immunodeficiency Virus in High-Income Countries. Clin Infect Dis 2023; 76:535-539. [PMID: 36097892 DOI: 10.1093/cid/ciac761] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/29/2022] [Accepted: 09/08/2022] [Indexed: 11/12/2022] Open
Abstract
Guidelines in high-income countries generally recommend against breastfeeding for a pregnant person with HIV due to the historical risk of transmission to the infant and generally acceptable, safe, and sustainable access to formula. Maternal antiretroviral therapy and infant prophylaxis have been shown to significantly decrease the risk of transmission during breastfeeding. In addition, formula may not be acceptable to patients for a variety of cultural, social, or personal reasons, and its sustainability is called into question in the setting of the current nationwide formula shortage. Providers caring for pregnant people with HIV have a responsibility to discuss infant feeding with their patients, and help them weigh the risks and benefits within the limits of the current body of evidence. We outline a process, including a written agreement, that can be used to discuss infant feeding with all patients and help them make the best decision for their family.
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Affiliation(s)
- Jennifer McKinney
- Department of Maternal Fetal Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Gayatri Mirani
- Division of Allergy, Immunology, and Retrovirology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Judy Levison
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
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Mogaka JN, Otieno FA, Akim E, Beima-Sofie K, Dettinger J, Gomez L, Marwa M, Odhiambo B, Ngure K, Ronen K, Sharma M, John-Stewart G, Richardson B, Stern J, Unger J, Udren J, Watoyi S, Pintye J, Kinuthia J. A Text Messaging-Based Support Intervention to Enhance Pre-exposure Prophylaxis for HIV Prevention Adherence During Pregnancy and Breastfeeding: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e41170. [PMID: 36716092 PMCID: PMC9926344 DOI: 10.2196/41170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/22/2022] [Accepted: 12/06/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Cisgender women in Kenya are at elevated risk of HIV acquisition during pregnancy and post partum. Acute HIV infection during pregnancy and breastfeeding accounts for approximately one-third of all vertical HIV transmissions. The World Health Organization recommends offering oral tenofovir-based pre-exposure prophylaxis (PrEP) to pregnant and postpartum women who are HIV negative but at substantial and ongoing risk for HIV acquisition. PrEP delivery for pregnant and postpartum women is expanding within routine maternal child health clinics in Kenya. However, approximately half of pregnant women discontinue PrEP within 30 days of initiation. Therefore, it is crucial to develop PrEP adherence strategies that enhance support for adherence when peripartum events and health issues pose challenges to sustaining PrEP adherence. OBJECTIVE We are conducting a randomized controlled trial to determine the effect of a bidirectional communication platform named Mobile Solutions for Women's and Children's Health (mWACh), which utilizes two-way SMS text messaging between patients and remote nurses to support PrEP adherence and address maternal health concerns in real time during the peripartum period. METHODS The mWACh-PrEP study is a randomized trial designed to support PrEP adherence during the peripartum period by comparing mWACh-PrEP to the standard of care (ie, in-clinic adherence counseling) among women who are HIV negative and initiating PrEP. Purposive sampling was used to select 5 facilities offering PrEP in antenatal clinics in Kisumu and Siaya Counties, and block randomization will be used to divide participants into groups. Participants in the intervention arm will receive a customized messaging curriculum via SMS text messages targeted toward their particular perinatal stage. The primary outcome, PrEP adherence at 6 months post partum, will be evaluated using a log-binomial regression model, adjusting for imbalanced baseline characteristics. Based on a previous study of directly observed dosing conditions, we will use a hair tenofovir concentration cutoff of 0.038 ng/mg (corresponding to 7 doses/week) as the primary adherence outcome measured at 6 months post partum (binary outcome). Qualitative interviews and cost-effective analyses will be conducted to understand the feasibility, acceptability, and economic impact of the intervention. RESULTS Enrollment began in March 2022 and is projected to continue until July 2023, with follow-up through March 2024. The study results are expected to be reported in 2025. CONCLUSIONS This trial will provide insights into using mobile health to enhance PrEP adherence among pregnant and postpartum mothers. Additionally, the findings will have implications for the use of mobile health technology to improve adherence to other daily medications during the peripartum period. TRIAL REGISTRATION ClinicalTrials.gov NCT04472884; https://clinicaltrials.gov/ct2/show/NCT04472884. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/41170.
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Affiliation(s)
| | | | | | - Kristin Beima-Sofie
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Julia Dettinger
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Lauren Gomez
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Mary Marwa
- Kenyatta National Hospital, Nairobi, Kenya
| | | | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, WA, United States
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Keshet Ronen
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Barbra Richardson
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Joshua Stern
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Jennifer Unger
- Department of Global Health, University of Washington, Seattle, WA, United States
- Women and Infants Hospital, Providence, RI, United States
| | - Jenna Udren
- Department of Global Health, University of Washington, Seattle, WA, United States
| | | | - Jillian Pintye
- School of Nursing, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - John Kinuthia
- Kenyatta National Hospital, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, WA, United States
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Akinwaare MO, Okanlawon FA, Popoola MA, Adetunji OO. Birth Preparedness Plans and Status Disclosure Among Pregnant Women Living with HIV Who are Receiving Antiretroviral Therapy in Ibadan, Southwest, Nigeria. Int J MCH AIDS 2023; 12:e613. [PMID: 37065709 PMCID: PMC10102698 DOI: 10.21106/ijma.613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
Background Promoting the maternal health of pregnant women who are living with human immunodeficiency virus (HIV; [PWLH]) is key to reducing maternal mortality and morbidity. Thus, inadequate birth preparedness plans, non-institutional delivery, and status concealment among PWLH contribute to the spread of HIV infection and threaten the prevention of mother-to-child transmission (PMTCT). Therefore, this study aimed to assess the birth preparedness plan and status disclosure among PWLH, as well as the prevalence of HIV infection among pregnant women. Methods The study adopted a descriptive cross-sectional research design; a quantitative approach was used for data collection. Three healthcare facilities that represented the three levels of healthcare institutions and referral centers for the care of PWLH in the Ibadan metropolis were selected for the recruitment process. A validated questionnaire was used to collect data from 77 participants within the targeted population. Ethical approval was obtained prior to the commencement of data collection. Results The prevalence rate of HIV infection among the participants was 3.7%. Only 37.1% of the participants had a birth preparedness plan. A total of 40% of the participants tested for HIV, because testing was compulsory for antenatal registration. Only 7.1% of the participants had their status disclosed to their partners. Although 90% of the participants proposed delivering their babies in a hospital, only 80% of these participants had their status known in their proposed place of birth. Conclusion and Global Health Implications The prevalence of HIV infection among pregnant women is very low, which is an indication of improved maternal health. However, the level of birth preparedness plan and status disclosure to partners are equally low, and these factors can hinder PMTCT. Institutional delivery should be encouraged among all PWLH, and their HIV status must be disclosed at their place of birth.
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Affiliation(s)
- Margaret O. Akinwaare
- Department of Nursing, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Corresponding author
| | | | - Monisola A. Popoola
- Department of Clinical Nursing, University College Hospital, Ibadan, Nigeria
| | - Omotayo O. Adetunji
- Department of Clinical Nursing, University College Hospital, Ibadan, Nigeria
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Mussa A, Mayondi GK, Diseko M, Mabuta J, Mmalane M, Makhema J, Lockman S, Morroni C, Shapiro R, Zash R. Incident HIV acquisition among pregnant women in Botswana: findings from the Tsepamo birth outcomes surveillance study. J Int AIDS Soc 2023; 26:e26008. [PMID: 36691796 PMCID: PMC9871722 DOI: 10.1002/jia2.26008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 08/24/2022] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION In Botswana, where almost all pregnant women known to have HIV receive antiretroviral therapy, a large proportion of vertical HIV transmission may occur among women with incident undiagnosed HIV infection during pregnancy. Botswana guidelines recommend repeat HIV testing every 3 months in pregnancy, with at least one test in the third trimester. We evaluated the rate of repeat HIV testing, calculated HIV incidence during pregnancy and estimated missed seroconversions. METHODS In the Botswana Tsepamo Study, we abstracted HIV test dates and results from obstetric records of all women who delivered at maternity wards in 18 communities between 7th May 2017 and 20th August 2021. We defined seroconversion as an initial negative/indeterminate HIV test in pregnancy followed by a positive test during pregnancy/at delivery. The incidence rate (IR) of seroconversion was calculated among women with > = 2 known test dates. Missed seroconversions were estimated among women without a test in the third trimester by applying the IR to the time after the last HIV test until delivery. RESULTS Among 103,529 women delivering in the study period testing negative at the first test and with known conception and HIV test dates, 29,085 (28%) were tested in one trimester of pregnancy, 73,156 (71%) were tested in ≥ 2 trimesters of pregnancy and 9628 (9%) had a test in all trimesters. A total of 78,162 (75%) women had a third-trimester test. There were 223 seroconversions (2.58/1000 pregnancies, 0.26%) among those with ≥ 2 known HIV test dates, yielding an IR of 0.69/100 person-years. Among 25,289 women who did not have a test in the third trimester, we estimate approximately 58 seroconversions may have been missed during pregnancy due to a lack of repeat testing. Factors associated with seroconversion during pregnancy included younger age, less education and not being married. CONCLUSIONS More than two-thirds of women had repeat HIV testing in pregnancy and HIV incidence was low. However, an estimated 21% of seroconversions in pregnancy were likely missed due to a lack of re-testing. To reach the goal of zero new paediatric HIV infections, Botswana will need to intensify repeat HIV testing in the third trimester of pregnancy.
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Affiliation(s)
- Aamirah Mussa
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Usher InstituteUniversity of EdinburghEdinburghUK
| | | | - Modiegi Diseko
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Judith Mabuta
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | | | - Joseph Makhema
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Shahin Lockman
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Brigham and Women's HospitalBostonMassachusettsUSA
- Harvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Chelsea Morroni
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- MRC Centre for Reproductive Health and Centre for Global HealthUniversity of EdinburghEdinburghUK
| | - Roger Shapiro
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Harvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Rebecca Zash
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Beth Israel Deaconess Medical CenterBostonMassachusettsUSA
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