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Facha W, Tadesse T, Wolka E, Astatkie A. Viral load non-suppression status among women exposed to Dolutegravir-based versus Efavirenz-based regimens in Ethiopia: A before-and-after study. PLoS One 2024; 19:e0305331. [PMID: 38857273 PMCID: PMC11164349 DOI: 10.1371/journal.pone.0305331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/28/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND High viral load during pregnancy and breastfeeding period is the risk factor for vertical transmission of human immunodeficiency virus (HIV). Currently, Dolutegravir (DTG)-based regimens are recommended to attain adequate viral load suppression (VLS) among women. However, its effect on VLS has not been investigated among women in PMTCT care in Ethiopia. OBJECTIVE This study aimed to investigate the rate of viral load non-suppression among women exposed to DTG-based versus Efavirenz (EFV)-based regimens in Ethiopia. METHODS An uncontrolled before-and-after study design was conducted among 924 women (462 on EFV-based and 462 on DTG-based regimens) enrolled in PMTCT care from September 2015 to February 2023. The outcome variable was the viral load (VL) non-suppression among women on PMTCT care. A modified Poisson regression model was employed, and the proportion was computed to compare the rate of VL non-suppression in both groups. The risk ratio (RR) with a 95% confidence interval (CI) was calculated to assess viral load non-suppression among women on DTG-based and EFV-based regimens by adjusting for other variables. RESULTS The overall rate of non-suppressed VL was 16.2% (95% CI: 14.0-18.8%). Mothers on DTG-based regimens had approximately a 30% (adjusted risk ratio (aRR): 0.70; 95% CI: 0.52-0.94) lesser risk of developing non-suppressed VL than women on EFV-based regimens. Besides, older women were 1.38 times (aRR: 1.38; 95% CI: 1.04-1.83); mothers who did not disclose their HIV status to their partners were 2.54 times (aRR: 2.54; 95% CI: 1.91-3.38); and mothers who had poor or fair adherence to antiretroviral (ARV) drugs were 2.11 times (aRR: 2.11; 95% CI: 1.45-3.07) at higher risk of non-suppressed VL. CONCLUSION Women on DTG-based regimens had a significantly suppressed VL compared to those on EFV-based regimens. Thus, administering DTG-based first-line ART regimens should be strengthened to achieve global and national targets on VLS.
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Affiliation(s)
- Wolde Facha
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Takele Tadesse
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Eskinder Wolka
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Ayalew Astatkie
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
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Boisson-Walsh A, Ravelomanana NLR, Tabala M, Malongo F, Kawende B, Babakazo P, Yotebieng M. Association of comprehensiveness of antiretroviral care and detectable HIV viral load suppression among pregnant and postpartum women in the Democratic Republic of the Congo: a cross-sectional study. Front Glob Womens Health 2024; 5:1308019. [PMID: 38903153 PMCID: PMC11188341 DOI: 10.3389/fgwh.2024.1308019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 05/21/2024] [Indexed: 06/22/2024] Open
Abstract
Introduction Worldwide, over two-thirds of people living with HIV are on antiretroviral therapy (ART). Despite increased ART access, high virological suppression prevalence remains out of reach. Few studies consider the quality of ART services and their impact on recipients' viral suppression. We assessed the association between ART service readiness and HIV viral load suppression among pregnant and breastfeeding women living with HIV (WLH) receiving ART in maternal and child health (MCH) clinics in Kinshasa, Democratic Republic of Congo. Methods We performed a cross-sectional analysis leveraging data from a continuous quality improvement intervention on WLH's long-term ART outcomes. From November 2016 to May 2020, we enrolled WLH from the three largest clinics in each of Kinshasa'Łs 35 health zones. We measured clinic's readiness using three WHO-identified ART care quality indicators: relevant guidelines in ART service area, stocks of essential ART medicines, and relevant staff training in ≥24 months, scoring clinics 0-3 based on observed indicators. We defined viral load suppression as ≤1,000 cp/ml. Multilevel mixed-effect logistic models were used to estimate prevalence odds ratios (ORs) measuring the strength of the association between ART service readiness and viral suppression. Results Of 2,295 WLH, only 1.9% received care from a clinic with a score of 3, 24.1% received care from a 0-scoring clinic, and overall, 66.5% achieved virologically suppression. Suppression increased from 65% among WLH receiving care in 0-scoring clinics to 66.9% in 1-scoring clinics, 65.8% in 2-scoring clinics, and 76.1% in 3-scoring clinics. We did not observe a statistically significant association between ART service readiness score and increased viral suppression prevalence, however we did find associations between other factors, such as the location of the health center and pharmacist availability with suppressed viral load. Discussion A lack of comprehensive ART care underscores the need for enhanced structural and organizational support to improve virological suppression and overall health outcomes for women living with HIV..
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Affiliation(s)
- Alix Boisson-Walsh
- Department of Health Policy and Management, University of Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Martine Tabala
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Fathy Malongo
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Bienvenu Kawende
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Pélagie Babakazo
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Marcel Yotebieng
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, United States
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Azhali BA, Setiabudi D, Alam A. Evaluating the impact of triple elimination program for mother-to-child transmission of HIV, syphilis, and hepatitis B in Indonesia. NARRA J 2023; 3:e405. [PMID: 38455604 PMCID: PMC10919734 DOI: 10.52225/narra.v3i3.405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/13/2023] [Indexed: 03/09/2024]
Abstract
Indonesian government launched a triple elimination program to eliminate mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV), syphilis, and hepatitis B in 2018, aiming to increase screening uptake among pregnant women during antenatal visits and to reduce the rates of these infections in children less than 50 per 100,000 live births. Despite this initiative, a thorough assessment of its effectiveness, particularly in Bandung, the capital city of West Java, as one of the most densely populated cities in Indonesia with a high HIV incidence, has yet to be conducted. The aim of this study was to analyze the impact of this triple elimination program in Bandung by assessing the data between 2017 and 2020. Monthly data was obtained from the Health Office of Bandung for four years, including number of screenings done for HIV, syphilis, and hepatitis B, number of confirmed cases and number of pregnant women treated for those infections. Additionally, data on children under 24 months old afflicted by these infections were also collected. Our data indicated an increase in screening coverage for HIV, syphilis, and HBV among pregnant women; however, it remained below the national set benchmarks for screening coverage. Only 59.5% of HIV-positive pregnant women received anti-retroviral therapy in 2020, while merely 25% of syphilis-positive cases were administered benzathine penicillin G. Syphilis screening was correlated with an increase in positive cases among children, suggesting missed opportunities in managing syphilis-positive pregnant women. Furthermore, management of HIV- and syphilis-positive cases had suboptimal outcomes. Data on hepatitis B was not evaluated since it was not available. To achieve the triple elimination program goals, comprehensive coordination among all relevant stakeholders is required, as is continuous monitoring and evaluation.
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Affiliation(s)
- Buti A. Azhali
- Department of Child Health, Faculty of Medicine, Universitas Islam Bandung, Bandung, Indonesia
| | - Djatnika Setiabudi
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Anggraini Alam
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
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Chagomerana MB, Harrington BJ, DiPrete BL, Wallie S, Maliwichi M, Wesevich A, Phulusa JN, Kumwenda W, Jumbe A, Hosseinipour MC. Three-year outcomes for women newly initiated on lifelong antiretroviral therapy during pregnancy - Malawi option B. AIDS Res Ther 2023; 20:37. [PMID: 37308909 PMCID: PMC10258937 DOI: 10.1186/s12981-023-00523-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 05/02/2023] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION Antiretroviral therapy (ART) is very effective in preventing vertical transmission of HIV but some women on ART experience different virologic, immunologic, and safety profiles. While most pregnant women are closely monitored for short-term effects of ART during pregnancy, few women receive similar attention beyond pregnancy. We aimed to assess retention in care and clinical and laboratory-confirmed outcomes over 3 years after starting ART under Malawi's Option B + program. METHODS We conducted a prospective cohort study of pregnant women newly diagnosed with HIV who started tenofovir disoproxil fumarate/emtricitabine/efavirenz (TDF/3TC/EFV) for the first time at Bwaila Hospital in Lilongwe, Malawi between May 2015 and June 2016. Participants were followed for 3 years. We summarized demographic characteristics, pregnancy outcomes, and clinical and laboratory adverse events findings using proportions. Log-binomial regression models were used to estimate the overall risk ratios (RR) and the corresponding 95% confidence interval (CI) for the association between index pregnancy (i.e. index pregnancy vs. subsequent pregnancy) and preterm birth, and index pregnancy and low birthweight. RESULTS Of the 299 pregnant women who were enrolled in the study, 255 (85.3%) were retained in care. There were 340 total pregnancies with known outcomes during the 36-month study period, 280 index pregnancies, and 60 subsequent pregnancies. The risks of delivering preterm (9.5% for index pregnancy and13.5% for subsequent pregnancy: RR = 0.70; 95% CI: 0.32-1.54), or low birth weight infant (9.8% for index pregnancy and 4.2% for subsequent pregnancy: RR = 2.36; 95% CI: 0.58-9.66) were similar between index and subsequent pregnancies. Perinatally acquired HIV was diagnosed in 6 (2.3%) infants from index pregnancies and none from subsequent pregnancies. A total of 50 (16.7%) women had at least one new clinical adverse event and 109 (36.5%) women had at least one incident abnormal laboratory finding. Twenty-two (7.3%) women switched to second line ART: of these 64.7% (8/17) had suppressed viral load and 54.9% (6/17) had undetectable viral load at 36 months. CONCLUSION Most of the women who started TDF/3TC/EFV were retained in care and few infants were diagnosed with perinatally acquired HIV. Despite switching, women who switched to second line therapy continued to have higher viral loads suggesting that additional factors beyond TDF/3TC/EFV failure may have contributed to the switch. Ongoing support during the postpartum period is necessary to ensure retention in care and prevention of vertical transmission.
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Affiliation(s)
- Maganizo B Chagomerana
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi.
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Bryna J Harrington
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- Johns Hopkins Dept. of Gynecology & Obstetrics, Baltimore, MD, USA
| | - Bethany L DiPrete
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Austin Wesevich
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- Section of Hematology/Oncology, University of Chicago, Chicago, IL, USA
| | | | - Wiza Kumwenda
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Allan Jumbe
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Mina C Hosseinipour
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Tembo TA, Markham CM, Masiano SP, Sabelli R, Wetzel E, Ahmed S, Mphande M, Mkandawire AM, Chitani MJ, Khama I, Nyirenda R, Mazenga A, Abrams EJ, Kim MH. Intervention Fidelity to VITAL Start (Video Intervention to Inspire Treatment Adherence for Life) in a Randomized Controlled Trial Among Women Living With HIV in Malawi. Health Promot Pract 2023:15248399231177303. [PMID: 37282494 DOI: 10.1177/15248399231177303] [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] [Indexed: 06/08/2023]
Abstract
BACKGROUND Intervention effectiveness in a randomized controlled trial is attributed to intervention fidelity. Measuring fidelity has increasing significance to intervention research and validity. The purpose of this article is to describe a systematic assessment of intervention fidelity for VITAL Start (Video intervention to Inspire Treatment Adherence for Life)-a 27-minute video-based intervention designed to improve antiretroviral therapy adherence among pregnant and breastfeeding women. METHOD Research Assistants (RAs) delivered VITAL Start to participants after enrolment. The VITAL Start intervention had three components: a pre-video orientation, video viewing, and post-video counseling. Fidelity assessments using checklists comprised self (RA assessment) and observer (Research Officers, also known as ROs) assessment. Four fidelity domains (adherence, dose, quality of delivery, and participant responsiveness) were evaluated. Score scale ranges were 0 to 29 adherence, 0 to 3 dose, 0 to 48 quality of delivery and 0 to 8 participant responsiveness. Fidelity scores were calculated. Descriptive statistics summarizing the scores were performed. RESULTS In total, eight RAs delivered 379 VITAL Start sessions to 379 participants. Four ROs observed and assessed 43 (11%) intervention sessions. The mean scores were 28 (SD = 1.3) for adherence, 3 (SD = 0) for dose, 40 (SD = 8.6) for quality of delivery, and 10.4 (SD = 1.3) for participant responsiveness. CONCLUSION Overall, the RAs successfully delivered the VITAL Start intervention with high fidelity. Intervention fidelity monitoring should be an important element of randomized control trial design of specific interventions to ensure having reliable study results.
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Affiliation(s)
- Tapiwa A Tembo
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Christine M Markham
- Health Promotion and Behavioral Sciences, The University of Texas Health Center at Houston School of Public Health, Houston, TX, USA
| | - Steven P Masiano
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Rachael Sabelli
- Department of Public Health and Community Medicine, Tufts University, Medford, MA, USA
| | - Elizabeth Wetzel
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
- Baylor College of Medicine International Paediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA
| | - Saeed Ahmed
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
- Baylor College of Medicine International Paediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA
| | - Mtisunge Mphande
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | | | - Mike J Chitani
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Innocent Khama
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | | | - Alick Mazenga
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Elaine J Abrams
- ICAP at Columbia, Mailman School of Public Health and Vagelos College of Physicians & Surgeons, Columbia University, NY, USA
| | - Maria H Kim
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
- Baylor College of Medicine International Paediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA
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Ka’e AC, Nka AD, Yagai B, Domkam Kammogne I, Ngoufack Jagni Semengue E, Nanfack AJ, Nkenfou C, Tommo Tchouaket MC, Takou D, Sosso SM, Fainguem N, Abba A, Pabo W, Kamgaing N, Temgoua E, Tchounga B, Tchendjou P, Tetang S, Njom Nlend AE, Ceccherini-Silberstein F, Mercedes Santoro M, Fokam J. The mother-to-child transmission of HIV-1 and profile of viral reservoirs in pediatric population: A systematic review with meta-analysis of the Cameroonian studies. PLoS One 2023; 18:e0278670. [PMID: 36649370 PMCID: PMC9844886 DOI: 10.1371/journal.pone.0278670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/21/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The mother-to-child transmission of HIV-1 (MTCT) remains on the major route of HIV-transmission among pediatric populations in Africa. Though a prevention of MTCT (PMTCT) high-priority country, data on the MTCT burdens in Cameroon remains fragmented. OBJECTIVE We sought to assess the pooled MTCT rate, its risk-factors, and to characterize viral reservoirs of infected-children in Cameroon. METHODS All relevant observational cohort and cross-sectional studies conducted in Cameroon were searched from PubMed, African Journals Online, Google scholar, ScienceDirect and academic medical education databases. Heterogeneity and publication bias were respectively assessed by the I2 statistic and the Egger/funnel plot test. Meta-analysis was performed using the random effects model. MTCT rate >5% was considered as "high". This review was registered in the Prospero database, CRD42021224497. RESULTS We included a total of 29 studies and analyzed 46 684 children born from HIV-positive mothers. The overall rate of MTCT was 7.00% (95% CI = 6.07-8.51). According to regions, the highest burden was in Adamaoua-region (17.51% [95% CI:14.21-21.07]) with only one study found. PMTCT option-B+ resulted in about 25% reduction of MTCT (8.97% [95% CI: 8.71-9.24] without option-B+ versus 2.88% [95% CI: 5.03-9.34] with option-B+). Regarding risk-factors, MTCT was significantly associated with the absence of PMTCT-interventions both in children (OR:5.40 [95% CI: 2.58-11.27]) and mothers (OR: 3.59 [95% CI: 2.15-5.99]). Regarding viral reservoirs, a pro-viral DNA mean of 3.34±1.05 log10/mL was observed among 5/57 children and archived HIV drug resistance mutations were identified in pro-viral DNA marker among 21/79 infected-children. CONCLUSION In spite of the dropdown in MTCT following option-B+ implementation, MTCT remains high in Cameroon, with substantial disparities across regions. Thus, in this era of option-B+, achieving MTCT elimination requires interventions in northern-Cameroon. The variation in pro-viral load in infected-children underlines the relevance of characterizing viral reservoirs for possible infection control in tropical settings.
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Affiliation(s)
- Aude Christelle Ka’e
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
- University of Rome “Tor Vergata” (UTV-Rome), Rome, Italy
- * E-mail: (ACK); (JF)
| | - Alex Durand Nka
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
- University of Rome “Tor Vergata” (UTV-Rome), Rome, Italy
| | - Bouba Yagai
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
- University of Rome “Tor Vergata” (UTV-Rome), Rome, Italy
| | | | - Ezechiel Ngoufack Jagni Semengue
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
- University of Rome “Tor Vergata” (UTV-Rome), Rome, Italy
| | - Aubin Joseph Nanfack
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
| | - Celine Nkenfou
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
- Higher Teachers Training College, University of Yaounde I, Yaounde, Cameroon
| | - Michel Carlos Tommo Tchouaket
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
- Catholic University of Central Africa (UCAC), Yaounde, Cameroon
| | - Desire Takou
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
| | - Samuel Martin Sosso
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
| | - Nadine Fainguem
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
- University of Rome “Tor Vergata” (UTV-Rome), Rome, Italy
| | - Aissatou Abba
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
| | - Willy Pabo
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
- University of Buea, Buea, Cameroon
| | - Nelly Kamgaing
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
| | - Edith Temgoua
- National AIDS Control Committee (CNLS), Yaounde, Cameroun
| | - Boris Tchounga
- Elisabeth Glaser Pediatric AIDS Foundation (EGPAF), Douala, Cameroon
| | - Patrice Tchendjou
- Elisabeth Glaser Pediatric AIDS Foundation (EGPAF), Douala, Cameroon
| | - Suzie Tetang
- National Social Welfare Hospital (CHE), Yaounde, Cameroon
| | | | | | | | - Joseph Fokam
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
- University of Buea, Buea, Cameroon
- * E-mail: (ACK); (JF)
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Labisi TO, Podany AT, Fadul NA, Coleman JD, King KM. Factors associated with viral suppression among cisgender women living with human immunodeficiency virus in the United States: An integrative review. WOMEN'S HEALTH (LONDON, ENGLAND) 2022; 18:17455057221092267. [PMID: 35435055 PMCID: PMC9019389 DOI: 10.1177/17455057221092267] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Women account for 23% of new human immunodeficiency virus diagnoses in the United States, yet remain understudied. Adherence to antiretroviral therapy and consequent viral suppression are keys to preventing human immunodeficiency virus transmission, reducing risk of drug resistance, and improving health outcomes. OBJECTIVES This review identified and synthesized peer-reviewed studies in the United States describing factors associated with viral suppression among cisgender women living with human immunodeficiency virus. METHODS We searched five databases: Cumulative Index to Nursing and Allied Health (CINAHL), PubMed, Embase, Scopus, and PsycINFO, and reported the findings using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Eligible studies included: (1) peer-reviewed English-language articles published since 2010; (2) includes only cisgender women; (3) participants were at least 18 years of age; (4) reported metrics on viral loads; and (5) conducted in the United States. RESULTS Fourteen studies in total were reviewed. Eight studies had adult women living with human immunodeficiency virus, four recruited only pregnant women, and two included only racial minority women. The most commonly reported factors negatively associated with viral suppression were substance use (n = 4), followed by availability of health insurance, financial constraint, complexity of human immunodeficiency virus treatment regimen (n = 3), and intimate partner violence (n = 2). Other factors were depression, race, and age. In addition, all four studies that included only pregnant women reported early human immunodeficiency virus care engagement as a significant predictor of low viral loads pre- and post-partum. CONCLUSION Substance use, financial constraint, lack of health insurance, human immunodeficiency virus treatment regimen type, intimate partner violence, and late human immunodeficiency virus care pre-post pregnancy were the most common factors negatively associated with viral suppression. There is a paucity of data on viral suppression factors related to transgender and rural populations. More human immunodeficiency virus research is needed to explore factors associated with human immunodeficiency virus treatment outcomes in transgender women and cisgender women in rural U.S. regions.
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Affiliation(s)
- Titilola O Labisi
- Department of Health Promotion and Disease Prevention, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Anthony T Podany
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Nada A Fadul
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jason D Coleman
- School of Health and Kinesiology, University of Nebraska Omaha, Omaha, NE, USA
| | - Keyonna M King
- Department of Health Promotion and Disease Prevention, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
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Naburi HE, Mujinja P, Kilewo C, Biberfeld G, Bärnighausen T, Manji K, Lyatuu G, Urrio R, Zethraeus N, Orsini N, Ekström AM. Health care costs associated with clinic visits for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania. Medicine (Baltimore) 2021; 100:e27828. [PMID: 34797311 PMCID: PMC8601283 DOI: 10.1097/md.0000000000027828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/28/2021] [Indexed: 01/05/2023] Open
Abstract
Early and appropriate antenatal care (ANC) is key for the effectiveness of prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV). We evaluated the importance of ANC visits and related service costs for women receiving option B+ to prevent mother-to-child transmission (MTCT) of HIV in Tanzania.A cost analysis from a health care sector perspective was conducted using routine data of 2224 pregnant women newly diagnosed with HIV who gave birth between August 2014 and May 2016 in Dar es Salaam, Tanzania. We evaluated risk of infant HIV infection at 12 weeks postnatally in relation to ANC visits (<4 vs ≥4 visits). Costs for service utilisation were estimated through empirical observations and the World Health Organisation Global Price Reporting Mechanism.Mean gestational age at first ANC visit was 22 (±7) weeks. The average number of ANC/prevention of MTCT visits among the 2224 pregnant women in our sample was 3.6 (95% confidence interval [CI] 3.6-3.7), and 57.3% made ≥4 visits. At 12 weeks postnatally, 2.7% (95% CI 2.2-3.6) of HIV exposed infants had been infected. The risk of MTCT decreased with the number of ANC visits: 4.8% (95% CI 3.6-6.4) if the mother had <4 visits, and 1.0% (95% CI 0.5-1.7) at ≥4. The adjusted MTCT rates decreased by 51% (odds ratio 0.49, 95% CI 0.31-0.77) for each additional ANC visit made. The potential cost-saving was 2.2 US$ per woman at ≥4 visits (84.8 US$) compared to <4 visits (87.0 US$), mainly due to less defaulter tracing.Most pregnant women living with HIV in Dar es Salaam initiated ANC late and >40% failed to adhere to the recommended minimum of 4 visits. Improved ANC attendance would likely lead to fewer HIV-infected infants and reduce both short and long-term health care costs due to less spending on defaulter tracing and future treatment costs for the children.
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Affiliation(s)
- Helga Elineema Naburi
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Phares Mujinja
- Institute of Public health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Charles Kilewo
- Departments of Obstetrics and Gynaecology, MUHAS, Dar es Salaam, Tanzania
| | - Gunnel Biberfeld
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
- Africa Health Research Institute (AHRI), Mtubatuba, South Africa
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Karim Manji
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Goodluck Lyatuu
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Departments of Obstetrics and Gynaecology, MUHAS, Dar es Salaam, Tanzania
- Management and Development for Health (MDH), Dar es Salaam, Tanzania
| | - Roseline Urrio
- Departments of Obstetrics and Gynaecology, MUHAS, Dar es Salaam, Tanzania
- Management and Development for Health (MDH), Dar es Salaam, Tanzania
| | - Niklas Zethraeus
- Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | - Nicola Orsini
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Cioffi CC, Seeley JR. Voluntary Pregnancy Screening at Syringe Exchanges: A Feasibility Study. ACTA ACUST UNITED AC 2021; 2:57-80. [PMID: 34693283 DOI: 10.1177/2632077020973362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to explore the feasibility of offering voluntary pregnancy screening at syringe exchange programs using the National Implementation Research Network Hexagon Discussion and Analysis Tool. We conducted a survey among female syringe exchange clients that assessed perceived needs, values, and behavioral intentions for parenting and entering treatment if they received a positive pregnancy screen and surveys among staff and core volunteers to assess organizational fit, capacity, and needed supports. Participants and staff reported that pregnancy screening was needed at syringe exchange and that capacity needs to be expanded to provide services. Pregnancy screening at syringe exchanges holds the potential to lead to early detection of pregnancy. Early detection of pregnancy among women who inject drugs may result in improved prenatal care, including substance use treatment and treatment of infectious diseases, for women who would otherwise be unlikely to receive prenatal care.
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Saweri OPM, Batura N, Al Adawiyah R, Causer LM, Pomat WS, Vallely AJ, Wiseman V. Economic evaluation of point-of-care testing and treatment for sexually transmitted and genital infections in pregnancy in low- and middle-income countries: A systematic review. PLoS One 2021; 16:e0253135. [PMID: 34138932 PMCID: PMC8211269 DOI: 10.1371/journal.pone.0253135] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 05/30/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Sexually transmitted and genital infections in pregnancy are associated with adverse pregnancy and birth outcomes. Point-of-care tests for these infections facilitate testing and treatment in a single antenatal clinic visit and may reduce the risk of adverse outcomes. Successful implementation and scale-up depends on understanding comparative effectiveness of such programmes and their comparative costs and cost effectiveness. This systematic review synthesises and appraises evidence from economic evaluations of point-of-care testing and treatment for sexually transmitted and genital infections among pregnant women in low- and middle-income countries. METHODS Medline, Embase and Web of Science databases were comprehensively searched using pre-determined criteria. Additional literature was identified by searching Google Scholar and the bibliographies of all included studies. Economic evaluations were eligible if they were set in low- and middle-income countries and assessed antenatal point-of-care testing and treatment for syphilis, chlamydia, gonorrhoea, trichomoniasis, and/or bacterial vaginosis. Studies were analysed using narrative synthesis. Methodological and reporting standards were assessed using two published checklists. RESULTS Sixteen economic evaluations were included in this review; ten based in Africa, three in Latin and South America and three were cross-continent comparisons. Fifteen studies assessed point-of-care testing and treatment for syphilis, while one evaluated chlamydia. Key drivers of cost and cost-effectiveness included disease prevalence; test, treatment, and staff costs; test sensitivity and specificity; and screening and treatment coverage. All studies met 75% or more of the criteria of the Drummond Checklist and 60% of the Consolidated Health Economics Evaluation Reporting Standards. CONCLUSIONS Generally, point-of-care testing and treatment was cost-effective compared to no screening, syndromic management, and laboratory-based testing. Future economic evaluations should consider other common infections, and their lifetime impact on mothers and babies. Complementary affordability and equity analyses would strengthen the case for greater investment in antenatal point-of-care testing and treatment for sexually transmitted and genital infections.
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Affiliation(s)
- Olga P. M. Saweri
- The Kirby Institute, University of New South Wales, Sydney, Australia
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
- * E-mail:
| | - Neha Batura
- University College London, London, United Kingdom
| | | | - Louise M. Causer
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - William S. Pomat
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Andrew J. Vallely
- The Kirby Institute, University of New South Wales, Sydney, Australia
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Virginia Wiseman
- The Kirby Institute, University of New South Wales, Sydney, Australia
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Mafaune HW, Sacks E, Chadambuka A, Musarandega R, Tachiwenyika E, Simmonds FM, Nyamundaya T, Cohn J, Mahomva A, Mushavi A. Effectiveness of Maternal Transmission Risk Stratification in Identification of Infants for HIV Birth Testing: Lessons From Zimbabwe. J Acquir Immune Defic Syndr 2021; 84 Suppl 1:S28-S33. [PMID: 32520912 PMCID: PMC7302327 DOI: 10.1097/qai.0000000000002373] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In 2017, Zimbabwe adopted a modified version of the World Health Organization 2016 recommendation on HIV birth testing by offering HIV testing at birth only to infants at "high risk" of HIV transmission. There is limited evidence on the effectiveness of this approach. Our study assessed the sensitivity and specificity of birth testing "high risk" infants only. METHODS We conducted a cross-sectional study at 10 health facilities from November 2018 to July 2019. A nucleic acid test for HIV was performed on all HIV-exposed infants identified within 48 hours of life, irrespective of risk status. Univariate and bivariate analyses were used to estimate the performance of the risk screening tool. RESULTS HIV nucleic acid test was successfully performed on 1970 infants (95%), of whom 266 (13.5%) were classified as high-risk infants. HIV prevalence for all infants tested was 1.5% (95% CI: 1% to 2%), whereas prevalence among high-risk infants and low-risk infants was 6.8% (95% CI: 3.7% to 9.8%) and 0.6% (95% CI: 0.3% to 1%) respectively. Sensitivity and specificity of the maternal risk screening tool was at 62.1% (95% CI: 44.4% to 79.7%) and 87.2% (95% CI: 85.7% to 88.7%), respectively; positive and negative predictive values were 6.8% (95% CI: 3.7% to 9.8%) and 99.4% (95% CI: 99.0% to 99.7%) respectively. CONCLUSIONS Despite high negative predictive value, sensitivity was relatively low, with potential of missing 2 in every 5 HIV infected infants. Given the potential benefits of early ART initiation for all exposed infants, where feasible, universal testing for HIV-exposed infants at birth may be preferred to reduce missing infected infants.
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Affiliation(s)
| | - Emma Sacks
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC
| | | | | | | | | | | | - Jennifer Cohn
- Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland; and
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12
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Early post-partum viremia predicts long-term non-suppression of viral load in HIV-positive women on ART in Malawi: Implications for the elimination of infant transmission. PLoS One 2021; 16:e0248559. [PMID: 33711066 PMCID: PMC7954347 DOI: 10.1371/journal.pone.0248559] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/01/2021] [Indexed: 12/03/2022] Open
Abstract
Background Long-term viral load (VL) suppression among HIV-positive, reproductive-aged women on ART is key to eliminating mother-to-child transmission (MTCT) but few data exist from sub-Saharan Africa. We report trends in post-partum VL in Malawian women on ART and factors associated with detectable VL up to 24 months post-partum. Methods 1–6 months post-partum mothers, screened HIV-positive at outpatient clinics in Malawi, were enrolled (2014–2016) with their infants. At enrollment, 12- and 24-months post-partum socio-demographic and PMTCT indicators were collected. Venous samples were collected for determination of maternal VL (limit of detection 40 copies/ml). Results were returned to clinics for routine management. Results 596/1281 (46.5%) women were retained in the study to 24 months. Those retained were older (p<0.01), had higher parity (p = 0.03) and more likely to have undetectable VL at enrollment than those lost to follow-up (80.0% vs 70.2%, p<0.01). Of 590 women on ART (median 30.1 months; inter-quartile range 26.8–61.3), 442 (74.9%) with complete VL data at 3 visits were included in further analysis. Prevalence of detectable VL at 12 and 24 months was higher among women with detectable VL at enrollment than among those with undetectable VL (74 detectable VL results/66 women vs. 19/359; p<0.001). In multivariable analysis (adjusted for age, parity, education, partner disclosure, timing of ART start and self-reported adherence), detectable VL at 24 months was 9 times more likely among women with 1 prior detectable VL (aOR 9.0; 95%CI 3.5–23.0, p<0.001) and 226 times more likely for women with 2 prior detectable VLs (aOR 226.4; 95%CI 73.0–701.8, p<0.001). Conclusions Detectable virus early post-partum strongly increases risk of ongoing post-partum viremia. Due to high loss to follow-up, the true incidence of detectable VL over time is probably underestimated. These findings have implications for MTCT, as well as for the mothers, and call for intensified VL monitoring and targeted adherence support for women during pregnancy and post-partum.
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Chagomerana MB, Edwards JK, Zalla LC, Carbone NB, Banda GT, Mofolo IA, Hosseinipour MC, Herce ME. Timing of HIV testing among pregnant and breastfeeding women and risk of mother-to-child HIV transmission in Malawi: a sampling-based cohort study. J Int AIDS Soc 2021; 24:e25687. [PMID: 33749155 PMCID: PMC7982503 DOI: 10.1002/jia2.25687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 02/02/2021] [Accepted: 02/17/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Pregnant women living with HIV can achieve viral suppression and prevent HIV mother-to-child transmission (MTCT) with timely HIV testing and early ART initiation and maintenance. Although it is recommended that pregnant women undergo HIV testing early in antenatal care in Malawi, many women test positive during breastfeeding because they did not have their HIV status ascertained during pregnancy, or they tested negative during pregnancy but seroconverted postpartum. We sought to estimate the association between the timing of last positive HIV test (during pregnancy vs. breastfeeding) and outcomes of maternal viral suppression and MTCT in Malawi's PMTCT programme. METHODS We conducted a two-stage cohort study among mother-infant pairs in 30 randomly selected high-volume health facilities across five nationally representative districts of Malawi between 1 July 2016 and 30 June 2017. Log-binomial regression was used to estimate prevalence ratios (PR) and risk ratios (RR) for associations between timing of last positive HIV test (i.e. breastfeeding vs. pregnancy) and maternal viral suppression and MTCT, controlling for confounding using inverse probability weighting. RESULTS Of 822 mother-infant pairs who had available information on the timing of the last positive HIV test, 102 mothers (12.4%) had their last positive test during breastfeeding. Women who lived one to two hours (PR = 2.15; 95% CI: 1.29 to 3.58) or >2 hours (PR = 2.36; 95% CI: 1.37 to 4.10) travel time to the nearest health facility were more likely to have had their last positive HIV test during breastfeeding compared to women living <1 hour travel time to the nearest health facility. The risk of unsuppressed VL did not differ between women who had their last positive HIV test during breastfeeding versus pregnancy (adjusted RR [aRR] = 0.87; 95% CI: 0.48 to 1.57). MTCT risk was higher among women who had their last positive HIV test during breastfeeding compared to women who had it during pregnancy (aRR = 6.57; 95% CI: 3.37 to 12.81). CONCLUSIONS MTCT in Malawi occurred disproportionately among women with a last positive HIV test during breastfeeding. Testing delayed until the postpartum period may lead to higher MTCT. To optimize maternal and child health outcomes, PMTCT programmes should focus on early ART initiation and providing targeted testing, prevention, treatment and support to breastfeeding women.
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Affiliation(s)
- Maganizo B Chagomerana
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jessie K Edwards
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lauren C Zalla
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Godfrey T Banda
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | - Innocent A Mofolo
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Mina C Hosseinipour
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Michael E Herce
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Mubiana-Mbewe M, Bosomprah S, Kadota JL, Koyuncu A, Kusanathan T, Mweebo K, Musokotwane K, Mulenga PL, Chi BH, Vinikoor MJ. Effect of Enhanced Adherence Package on Early ART Uptake Among HIV-Positive Pregnant Women in Zambia: An Individual Randomized Controlled Trial. AIDS Behav 2021; 25:992-1000. [PMID: 33033996 PMCID: PMC10580733 DOI: 10.1007/s10461-020-03060-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2020] [Indexed: 10/23/2022]
Abstract
We evaluated the effect of an option B-plus Enhanced Adherence Package (BEAP), on early ART uptake in a randomized controlled trial. HIV-positive, ART naïve pregnant women in Lusaka, Zambia, were randomized to receive BEAP (phone calls/home visits, additional counseling, male partner engagement and missed-visit follow-up) versus standard of care (SOC). The primary outcome was initiating and remaining on ART at 30 days. Analysis was by intention to treat (ITT) using logistic regression. Additional per protocol analysis was done. We enrolled 454 women; 229 randomized to BEAP and 225 to SOC. Within 30 days of eligibility, 445 (98.2%) initiated ART. In ITT analysis, 82.5% BEAP versus 80.4% SOC participants reached primary outcome (crude relative risk [RR] 1.03; 95% confidence interval [CI] 0.91-1.16; Wald test statistic = 0.44; p-value = 0.66). In per protocol analysis, (92 participants (40.2%) excluded), 91.9% BEAP versus 80.4% SOC participants reached primary outcome (crude RR 1.14; 95% CI 1.02-1.29; Wald test statistic = 2.23; p-value = 0.03). Early ART initiation in pregnancy was nearly universal but there was early drop out suggesting need for additional adherence support.This trial was registered at ClinicalTrials.gov (trials number NCT02459678) on May 14, 2015.
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Affiliation(s)
- Mwangelwa Mubiana-Mbewe
- Centre for Infectious Disease Research in Zambia, Plot 34620 Off Alick Nkhata Road, P.O. Box 34681, Lusaka, Zambia.
| | - Samuel Bosomprah
- Centre for Infectious Disease Research in Zambia, Plot 34620 Off Alick Nkhata Road, P.O. Box 34681, Lusaka, Zambia
- Department of Biostatistics, School of Public Health, University of Ghana, Accra, Ghana
| | - Jillian L Kadota
- Centre for Infectious Disease Research in Zambia, Plot 34620 Off Alick Nkhata Road, P.O. Box 34681, Lusaka, Zambia
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, USA
| | - Aybüke Koyuncu
- Centre for Infectious Disease Research in Zambia, Plot 34620 Off Alick Nkhata Road, P.O. Box 34681, Lusaka, Zambia
| | | | - Keith Mweebo
- Prevention, Care and Treatment Branch, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Kebby Musokotwane
- Prevention, Care and Treatment Branch, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | | | - Benjamin H Chi
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - Michael J Vinikoor
- Centre for Infectious Disease Research in Zambia, Plot 34620 Off Alick Nkhata Road, P.O. Box 34681, Lusaka, Zambia
- Department of Medicine, University of Alabama at Birmingham, Birmingham, USA
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15
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Green D, Tordoff DM, Kharono B, Akullian A, Bershteyn A, Morrison M, Garnett G, Duerr A, Drain PK. Evidence of sociodemographic heterogeneity across the HIV treatment cascade and progress towards 90-90-90 in sub-Saharan Africa - a systematic review and meta-analysis. J Int AIDS Soc 2020; 23:e25470. [PMID: 32153117 PMCID: PMC7062634 DOI: 10.1002/jia2.25470] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 01/24/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction Heterogeneity of sociodemographics and risk behaviours across the HIV treatment cascade could influence the public health impact of universal ART in sub‐Saharan Africa if those not virologically suppressed are more likely to be part of a risk group contributing to onward infections. Sociodemographic and risk heterogeneity across the treatment cascade has not yet been comprehensively described or quantified and we seek to systematically review and synthesize research on this topic among adults in Africa. Methods We conducted a systematic review of peer‐reviewed literature in Embase and MEDLINE databases as well as grey literature sources published in English between 2014 and 2018. We included studies that included people living with HIV (PLHIV) aged ≥15 years, and reported a 90‐90‐90 outcome: awareness of HIV‐positive status, ART use among those diagnosed or viral suppression among those on ART. We summarized measures of association between sociodemographics, within each outcome, and as a composite measure of population‐wide viral suppression. Results and discussion From 3533 screened titles, we extracted data from 92 studies (50 peer‐reviewed, 42 grey sources). Of included studies, 32 reported on awareness, 53 on ART use, 32 on viral suppression and 23 on population‐wide viral suppression. The majority of studies were conducted in South Africa, Uganda, and Malawi and reported data for age and gender. When stratified, PLHIV ages 15 to 24 years had lower median achievement of the treatment cascade (60‐49‐81), as compared to PLHIV ≥25 years (70‐63‐91). Men also had lower median achievement of the treatment cascade (66‐72‐85), compared to women (79‐76‐89). For population‐wide viral suppression, women aged ≥45 years had achieved the 73% target, while the lowest medians were among 15‐ to 24‐year‐old men (37%) and women (49%). Conclusions Considerable heterogeneity exists by age and gender for achieving the HIV 90‐90‐90 treatment goals. These results may inform delivery of HIV testing and treatment in sub‐Saharan Africa, as targeting youth and men could be a strategic way to maximize the population‐level impact of ART.
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Affiliation(s)
- Dylan Green
- Department of Epidemiology, University of Washington, Seattle, WA, USA.,Strategic Analysis, Research & Training (START) Center, University of Washington, Seattle, WA, USA
| | - Diana M Tordoff
- Department of Epidemiology, University of Washington, Seattle, WA, USA.,Strategic Analysis, Research & Training (START) Center, University of Washington, Seattle, WA, USA
| | - Brenda Kharono
- Strategic Analysis, Research & Training (START) Center, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Adam Akullian
- Department of Epidemiology, University of Washington, Seattle, WA, USA.,Institute for Disease Modeling (IDM), Bellevue, WA, USA
| | | | | | | | - Ann Duerr
- Department of Epidemiology, University of Washington, Seattle, WA, USA.,Strategic Analysis, Research & Training (START) Center, University of Washington, Seattle, WA, USA.,Vaccine and Infectious Disease, Public Health Science Divisions, Fred Hutchinson Cancer Resesarch Center, HIV Vaccine Trials Network, Seattle, WA, USA
| | - Paul K Drain
- Department of Epidemiology, University of Washington, Seattle, WA, USA.,Strategic Analysis, Research & Training (START) Center, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA.,Division of Allergy and Infectious Diseases, Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
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16
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Opportunities and limits for dolutegravir in late pregnancy. Lancet HIV 2020; 7:e303-e304. [PMID: 32386717 DOI: 10.1016/s2352-3018(20)30071-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 02/21/2020] [Indexed: 11/23/2022]
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17
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Incidences and factors associated with viral suppression or rebound among HIV patients on combination antiretroviral therapy from three counties in Kenya. Int J Infect Dis 2020; 97:151-158. [PMID: 32497804 DOI: 10.1016/j.ijid.2020.05.097] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/18/2020] [Accepted: 05/24/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Limited data are available on the incidence and factors associated with viral rebound following viral suppression among HIV-infected individuals taking antiretroviral therapy (ART) in Kenya. Furthermore, the durability of viral suppression among HIV individuals taking ART is unknown. Information on incidence rates and factors associated with HIV viral load rebound and the durability of viral suppression (undetectable HIV copies in plasma) among HIV-infected individuals taking ART, will help improve the long-term management of HIV-infected individuals and explore approaches to long-term HIV remission or complete cure. OBJECTIVES The objectives of this study were to investigate the incidence rates of viral rebound following viral suppression, factors associated with viral rebound, and the durability of viral suppression among HIV-infected individuals on ART from Kilifi, Meru, and Nakuru counties in Kenya. METHODS This was a retrospective study involving 600 HIV-infected individuals taking combination ART (cART) and enrolled in comprehensive care centers (CCCs) at Malindi Sub-county Hospital, Nakuru Level 5 Hospital, and Meru Level 5 Hospital in Kenya. The medical files were inspected and medical history records abstracted for the selected participants. Participant laboratory data including HIV viral loads, types and history of ART, and treatment history of any opportunistic infections were abstracted using an abstraction checklist. Participants were grouped into those who achieved HIV viral suppression, with viral loads lower than the detection limit (LDL) (viral suppression), and those who experienced one or more detectable viral load measurements >40 copies/ml following the initial LDL (viral rebound). Durable viral suppression was defined as all viral load values at LDL over the 2-year period (2017-2019). Univariate and multivariate Poisson regression analyses were performed to assess the rates of viral rebound, as well as to investigate factors associated with it. RESULTS Out of 549 HIV-positive patients, 324/549 (59%) achieved HIV viral suppression (Meru 159/194 (82%), Nakuru 21/178 (12%), and Malindi 144/177 (81%)). The overall viral rebound rate was 41%, with site-specific viral rebound of 88.2%, 18.6%, and 18.0% in Nakuru, Malindi, and Meru, respectively. There was an overall rate of first viral rebound of 3.9 (95% confidence interval (CI) 6.9-14.4), 0.7 (95% CI 0.5-1.0), and 0.89 (95% CI 0.64-1.24) per 100 person-months in Nakuru, Malindi, and Meru, respectively. Good ART adherence (p = 0.0002), widow status (p = 0.0062), and World Health Organization (WHO) stage I (p = 0.0002) were associated with viral suppression, while poor ART adherence (p < 0.0001), WHO stage II (p = 0.0024), and duration on ART of 36 months (p = 0.0350) were associated with viral rebound. CONCLUSIONS The rate of viral suppression in patients on cART in the CCCs fell short of the WHO target. However, the study provides proof of evidence of undetectable viral load levels for more than 2 years, a sign that the United Nation's 2030 objective of controlling the risk of HIV transmission could be achieved.
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Viral suppression and factors associated with failure to achieve viral suppression among pregnant women in South Africa. AIDS 2020; 34:589-597. [PMID: 31821189 PMCID: PMC7050794 DOI: 10.1097/qad.0000000000002457] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Supplemental Digital Content is available in the text Objective: To describe viral load levels among pregnant women and factors associated with failure to achieve viral suppression (viral load ≤50 copies/ml) during pregnancy. Design: Between 1 October and 15 November 2017, a cross-sectional survey was conducted among 15–49-year-old pregnant women attending antenatal care (ANC) at 1595 nationally representative public facilities. Methods: Blood specimens were taken from each pregnant woman and tested for HIV. Viral load testing was done on all HIV-positive specimens. Demographic and clinical data were extracted from medical records or self-reported. Survey logistic regression examined factors associated with failure to achieve viral suppression. Result: Of 10 052 HIV-positive participants with viral load data, 56.2% were virally suppressed. Participants initiating antiretroviral therapy (ART) prior to pregnancy had higher viral suppression (71.0%) by their third trimester compared with participants initiating ART during pregnancy (59.3%). Booking for ANC during the third trimester vs. earlier: [adjusted odds ratio (AOR) 1.8, 95% confidence interval (CI):1.4–2.3], low frequency of ANC visits (AOR for 2 ANC visits vs. ≥4 ANC visits: 2.0, 95% CI:1.7–2.4), delayed initiation of ART (AOR for ART initiated at the second trimester vs. before pregnancy:2.2, 95% CI:1.8–2.7), and younger age (AOR for 15–24 vs. 35–49 years: 1.4, 95% CI:1.2–1.8) were associated with failure to achieve viral suppression during the third trimester. Conclusion: Failure to achieve viral suppression was primarily associated with late ANC booking and late initiation of ART. Efforts to improve early ANC booking and early ART initiation in the general population would help improve viral suppression rates among pregnant women. In addition, the study found, despite initiating ART prior to pregnancy, more than one quarter of participants did not achieve viral suppression in their third trimester. This highlights the need to closely monitor viral load and strengthen counselling and support services for ART adherence.
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Napyo A, Tumwine JK, Mukunya D, Tumuhamye J, Arach AAO, Ndeezi G, Waako P, Tylleskär T. Detectable HIV-RNA Viral Load Among HIV-Infected Pregnant Women on Treatment in Northern Uganda. Int J MCH AIDS 2020; 9:232-241. [PMID: 32704410 PMCID: PMC7370273 DOI: 10.21106/ijma.374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND / OBJECTIVES Detectable HIV viral load among HIV-infected pregnant women remains a public health threat. We aimed to determine factors associated with detectable viral load among HIV-infected pregnant women in Lira, Northern Uganda. METHODS We conducted a cross-sectional survey among 420 HIV-infected pregnant women attending Lira Regional Referral Hospital using a structured questionnaire and combined it with viral load tests from Uganda National Health Laboratories. We conducted multivariable logistic regression while adjusting for confounders to determine the factors associated with detectable viral load and we report adjusted odds ratios and proportion of women with viral load less than 50 copies/ml and above 1000 copies, respectively. RESULTS The prevalence of detectable viral load (>50 copies/ml) was 30.7% (95%CI: 26.3% - 35.4%) and >1000 copies/ml was 8.1% (95% CI: 5.7% - 11.1%). Factors associated with detectable viral load were not belonging to the Lango ethnicity (adjusted odds ratio = 1.92, 95%CI: 1.05 - 3.90) and taking a second-line (protease inhibitor-based) regimen (adjusted odds ratio = 4.41, 95%CI: 1.13 - 17.22). CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS HIV-infected pregnant women likely to have detectable viral load included those taking a protease inhibitor-based regimen and those who were not natives of Lira. We recommend intensified clinical and psychosocial monitoring for medication compliance among HIV-infected pregnant women that are likely to have a detectable viral load to significantly lower the risk of vertical transmission of HIV in Lira specifically those taking a protease inhibitor-based regimen and those who are non-natives to the study setting. Much as the third 90% of the global UNAIDS 90-90-90 target has been achieved, the national implementation of PMTCT guidelines should be tailored to its contextual needs.
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Affiliation(s)
- Agnes Napyo
- Department of Public Health, Faculty of Health Sciences, Busitema University, 236 Tororo, Uganda.,Centre for International Health, University of Bergen, 7804 Bergen, Norway.,Department of Pediatrics and Child Health, Makerere University, 7062 Kampala, Uganda
| | - James K Tumwine
- Department of Pediatrics and Child Health, Makerere University, 7062 Kampala, Uganda
| | - David Mukunya
- Centre for International Health, University of Bergen, 7804 Bergen, Norway
| | | | - Anna Agnes Ojok Arach
- Department of Pediatrics and Child Health, Makerere University, 7062 Kampala, Uganda.,Department of Nursing, Lira University, 1035 Lira, Uganda
| | - Grace Ndeezi
- Department of Pediatrics and Child Health, Makerere University, 7062 Kampala, Uganda
| | - Paul Waako
- Department of Pharmacology, Faculty of Health Sciences, Busitema University, 236 Tororo, Uganda
| | - Thorkild Tylleskär
- Centre for International Health, University of Bergen, 7804 Bergen, Norway
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20
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Yotebieng M, Mpody C, Ravelomanana NLR, Tabala M, Malongo F, Kawende B, Ntangu P, Behets F, Okitolonda E. HIV viral suppression among pregnant and breastfeeding women in routine care in the Kinshasa province: a baseline evaluation of participants in CQI-PMTCT study. J Int AIDS Soc 2019; 22:e25376. [PMID: 31496051 PMCID: PMC6732557 DOI: 10.1002/jia2.25376] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 07/21/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Published data on viral suppression among pregnant and breastfeeding women in routine care settings are scarce. Here, we report provincial estimates of undetectable and suppressed viral load among pregnant or breastfeeding women in HIV care in Kinshasa, Democratic Republic of Congo (DRC) and associated risk factors. METHODS This cross-sectional study was conducted as part of a baseline assessment for the CQI-PMTCT study: an ongoing cluster randomized trial to evaluate the effect of continuous quality interventions (CQI) on long-term ART outcomes among pregnant and breastfeeding women (NCT03048669). From November 2016 to June 2018, in each of the 35 Kinshasa provincial health zones (HZ), study teams visited the three busiest maternal and child health clinics, enrolled all HIV-positive pregnant or breastfeeding women (≤1 year post-delivery) receiving ART, and performed viral load testing. Log binomial models with generalized estimating equations to account for clustering at the HZ level, were used to estimate prevalence ratios comparing participants with undetected (<40 copies/mL) or suppressed (<1000 copies/mL) viral load across levels of individual and site characteristics. RESULTS Of the 1752 eligible women, 1623 had viral load results available, including 38% who had been on ART for <6 months and 74% were on tenofovir-lamivudine-efavirenz. Viral load was undetectable in 53% of women and suppressed in 62%. Among women who were on ART for ≥12 months, only 60% and 67% respectively, had undetectable or suppressed viral load. Viral load was undetectable in 53%, 48% and 58% of women testing during pregnancy, at delivery, and in postpartum respectively. In multivariable log binomial models, duration of ART >12 months, older age, being married, disclosure of HIV status, receiving care in an urban health zone or one supported by PEPFAR were all positively associated with viral suppression. CONCLUSIONS The observed high level of detectable viral load suggests that high ART coverage alone without substantial efforts to improve the quality of care for pregnant and breastfeeding women, will not be enough to achieve the goal of virtual elimination of vertical HIV transmission in high-burden and limited resources settings like DRC.
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Affiliation(s)
- Marcel Yotebieng
- Division of EpidemiologyCollege of Public HealthThe Ohio State UniversityColumbusOHUSA
| | - Christian Mpody
- Division of EpidemiologyCollege of Public HealthThe Ohio State UniversityColumbusOHUSA
| | - Noro LR Ravelomanana
- Division of EpidemiologyCollege of Public HealthThe Ohio State UniversityColumbusOHUSA
| | - Martine Tabala
- School of Public HealthThe University of KinshasaKinshasaDemocratic Republic of Congo
| | - Fathy Malongo
- School of Public HealthThe University of KinshasaKinshasaDemocratic Republic of Congo
| | - Bienvenu Kawende
- School of Public HealthThe University of KinshasaKinshasaDemocratic Republic of Congo
| | - Paul Ntangu
- National AIDS Control Program (PNLS)Provincial CoordinationKinshasaDemocratic Republic of Congo
| | - Frieda Behets
- Department of EpidemiologyGillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNCUSA
- Department of Social MedicineThe University of North Carolina at Chapel HillChapel HillNCUSA
| | - Emile Okitolonda
- School of Public HealthThe University of KinshasaKinshasaDemocratic Republic of Congo
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21
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Phillips TK, Myer L. Shifting to the long view: engagement of pregnant and postpartum women living with HIV in lifelong antiretroviral therapy services. Expert Rev Anti Infect Ther 2019; 17:349-361. [PMID: 30978126 DOI: 10.1080/14787210.2019.1607296] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: The advent of policies promoting lifelong antiretroviral therapy (ART) for all pregnant and postpartum women living with HIV has shifted focus from short-term prevention of mother-to-child transmission (PMTCT) to lifelong engagement in ART services. However, disengagement from care threatens the long-term treatment and prevention benefits of lifelong ART. Areas covered: A framework for considering the unique aspects of ART for pregnant and postpartum women is presented along with a review of the literature on maternal engagement in care in sub-Saharan Africa and a discussion of potential interventions to sustain engagement in lifelong ART. Expert opinion: Engaging women and mothers in ART services for life is critical for maternal health, PMTCT, and prevention of sexual transmission. Evidence-based interventions exist to support engagement in care but most focus on periods of mother-to-child transmission risk. In the long term, life transitions and health-care transfers are inevitable. Thus, interventions that can reach beyond a single facility or provide a bridge between health services should be prioritized. Multicomponent interventions will also be essential to address the numerous intersecting barriers to sustained engagement in ART services.
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Affiliation(s)
- Tamsin K Phillips
- a Division of Epidemiology & Biostatistics and Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa
| | - Landon Myer
- a Division of Epidemiology & Biostatistics and Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa
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22
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Zacharius KM, Basinda N, Marwa K, Mtui EH, Kalolo A, Kapesa A. Low adherence to Option B+ antiretroviral therapy among pregnant women and lactating mothers in eastern Tanzania. PLoS One 2019; 14:e0212587. [PMID: 30794633 PMCID: PMC6386496 DOI: 10.1371/journal.pone.0212587] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/05/2019] [Indexed: 11/18/2022] Open
Abstract
Background Adherence to option B+ antiretroviral treatment (ART) is vital to a successful implementation of Prevention of Mother to Child Transmission (PMTCT) program. Further studies show that optimal viral suppression is also crucial for a successful PMTCT program, however barriers to adherence exist and differ among populations and particularly within few years of its adoption in Tanzania. This study therefore aimed at investigating the level and predictors of adherence to ART option B+ among pregnant and lactating women in rural and urban settings of eastern Tanzania. Methodology A cross-sectional study was conducted among 305 pregnant women and lactating mothers on Option B+ regime from six health facilities located in rural and urban settings in Morogoro region in eastern Tanzania. Data were collected using a structured questionnaire. Data analysis was performed using descriptive statistics, as well as bivariate and multivariate logistic regression. Results Good adherence to option B+ PMTCT drugs was 26.3% and 61.1% among respondents residing in urban and rural areas respectively. The rural residents were 4.86 times more likely to adhere compared to their counterparts in an urban area (aOR = 4.86; 95% CI = 2.91–8.13). Similarly, women with male partners’ support in PMTCT were 3.51 times more likely to have good adherence than those without (aOR = 3.51, 95% CI = 1.21–10.15). Moreover, there was a significantly lower odds of adherence to option B+ among those who had been on treatment between one to two years as compared to those had less than one year of treatment (aOR = 0.45; 95%CI = 0.22–0.93). Conclusion Adherence to PMTCT option B+ antiretroviral drugs treatment among pregnant women and breastfeeding mothers was low and much lower among urban residents. Adherence was significantly predicted by rural residence, male partner support and short duration on ART. Efforts to improve adherence should focus on increasing male participation on PMTCT, tailored interventions to urban residents and those who have been on ART for a long duration.
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Affiliation(s)
| | - Namanya Basinda
- School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Karol Marwa
- Department of Pharmacology, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Emmanuel H. Mtui
- Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University, Moshi, Tanzania
| | - Albino Kalolo
- Department of Community Medicine, St. Francis University of Health and Allied Sciences, Ifakara, Tanzania
| | - Anthony Kapesa
- School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
- * E-mail:
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23
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Abuogi LL, Humphrey JM, Mpody C, Yotebieng M, Murnane PM, Clouse K, Otieno L, Cohen CR, Wools-Kaloustian K. Achieving UNAIDS 90-90-90 targets for pregnant and postpartum women in sub-Saharan Africa: progress, gaps and research needs. J Virus Erad 2018; 4:33-39. [PMID: 30515312 PMCID: PMC6248851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The implementation of the 2013 World Health Organization Option B+ recommendations for HIV treatment during pregnancy has helped drive significant progress in achieving universal treatment for pregnant and postpartum women in sub-Saharan Africa (SSA). Yet, critical research and implementation gaps exist in achieving the UNAIDS 90-90-90 targets. To help guide researchers, programmers and policymakers in prioritising these areas, we undertook a comprehensive review of the progress, gaps and research needs to achieve the 90-90-90 targets for this population in the Option B+ era, including early infant HIV diagnosis (EID) for HIV-exposed infants. Salient areas where progress has been achieved or where gaps remain include: (1) knowledge of HIV status is higher among people with HIV in southern and eastern Africa compared to western and central Africa (81% versus 48%, UNAIDS); (2) access to antiretroviral therapy (ART) for pregnant women has doubled in 22 of 42 SSA countries, but only six have achieved the second 90, and nearly a quarter of pregnant women initiating ART become lost to follow-up; (3) viral suppression data for this population are sparse (estimates range from 30% to 98% peripartum), with only half of women maintaining suppression through 12 months postpartum; and (4) EID rates range from 15% to 62%, with only three of 21 high-burden SSA countries testing >50% HIV-exposed infants within the first 2 months of life. We have identified and outlined promising innovations and research designed to address these gaps and improve the health of pregnant and postpartum women living with HIV and their infants.
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Affiliation(s)
- Lisa L Abuogi
- Department of Pediatrics, University of Colorado,
Denver, Aurora, CO,
USA,Corresponding author:
Lisa Abuogi, Department of Pediatrics, University of Colorado,
Denver, Aurora,
CO,
USA
| | - John M Humphrey
- Department of Medicine, Indiana University School of Medicine,
Indianapolis, IN,
USA
| | - Christian Mpody
- Division of Epidemiology, Ohio State University,
Columbus, OH,
USA
| | - Marcel Yotebieng
- Division of Epidemiology, Ohio State University,
Columbus, OH,
USA
| | - Pamela M Murnane
- Center for AIDS Prevention Studies, University of California San Francisco,
San Francisco, CA,
USA
| | - Kate Clouse
- Vanderbilt Institute for Global Health, Vanderbilt University,
Nashville, TN,
USA
| | - Lindah Otieno
- Center for Microbial Research, Research Care and Training Program, Kenya Medical Research Institute,
Nairobi,
Kenya
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences,
University of California San Francisco, CA,
USA
| | - Kara Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine,
Indianapolis, IN,
USA
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24
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Achieving UNAIDS 90-90-90 targets for pregnant and postpartum women in sub-Saharan Africa: progress, gaps and research needs. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30343-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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