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Perinatal Antiretroviral Intensification to Prevent Intrapartum HIV Transmission When Antenatal Antiretroviral Therapy Is Initiated Less Than 8 Weeks Before Delivery. J Acquir Immune Defic Syndr 2020; 84:313-322. [PMID: 32205720 PMCID: PMC9741956 DOI: 10.1097/qai.0000000000002350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Infants born to women living with HIV initiating combination antiretroviral therapy (cART) late in pregnancy are at high risk of intrapartum infection. Mother/infant perinatal antiretroviral intensification may substantially reduce this risk. METHODS In this single-arm Bayesian trial, pregnant women with HIV receiving standard of care antiretroviral prophylaxis in Thailand (maternal antenatal lopinavir-based cART; nonbreastfed infants 4 weeks' postnatal zidovudine) were offered "antiretroviral intensification" (labor single-dose nevirapine plus infant zidovudine-lamivudine-nevirapine for 2 weeks followed by zidovudine-lamivudine for 2 weeks) if their antenatal cART was initiated ≤8 weeks before delivery. A negative birth HIV-DNA polymerase chain reaction (PCR) followed by a confirmed positive PCR defined intrapartum transmission. Before study initiation, we modeled intrapartum transmission probabilities using data from 3738 mother/infant pairs enrolled in our previous trials in Thailand using a logistic model, with perinatal maternal/infant antiretroviral regimen and predicted viral load at delivery as main covariates. Using the characteristics of the women enrolled who received intensification, prior intrapartum transmission probabilities (credibility intervals) with/without intensification were estimated. After including the transmission data observed in the current study, the corresponding Bayesian posterior transmission probability was derived. RESULTS No intrapartum transmission of HIV was observed among the 88 mother/infant pairs receiving intensification. The estimated intrapartum transmission probability was 2·2% (95% credibility interval 0·5-6·1) without intensification versus 0·3% (0·0-1·6) with intensification. The probability of superiority of intensification over standard of care was 94·4%. Antiretroviral intensification appeared safe. CONCLUSION Mother/infant antiretroviral intensification was effective in preventing intrapartum transmission of HIV in pregnant women receiving ≤8 weeks antepartum cART.
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Beste S, Essajee S, Siberry G, Hannaford A, Dara J, Sugandhi N, Penazzato M. Optimal Antiretroviral Prophylaxis in Infants at High Risk of Acquiring HIV: A Systematic Review. Pediatr Infect Dis J 2018; 37:169-175. [PMID: 29319636 DOI: 10.1097/inf.0000000000001700] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION The risk of perinatal HIV infection can be dramatically reduced through maternal antiretroviral (ARV) therapy and infant ARV postnatal prophylaxis. The 2013 World Health Organization guidelines recommended 4-6 weeks of nevirapine or zidovudine as postnatal prophylaxis, with possible extension to 12 weeks for high-risk breastfed infants. A systematic review was undertaken to determine if there is evidence for the World Health Organization to recommend enhanced or extended prophylaxis for high-risk infants. METHODS Cochrane CENTRAL, EMBASE, PubMed databases from 2005 to 2015, as well as conference on retroviruses and opportunistic infections and international aids society abstracts were searched. Cohort studies and randomized controlled trials examining the use of combination or prolonged regimens in HIV-exposed infants were included. A total of 1185 studies were screened by title and abstract and 45 full-text articles were examined in further detail. RESULTS AND DISCUSSION Of the 4 included studies, 3 examined multidrug prophylaxis regimens in formula-fed, high-risk HIV-exposed infants. Multidrug regimens were shown to significantly reduce transmission rates, compared with single-drug regimens; however, there was no significant difference between 2- and 3-drug regimens. An randomized controlled trial examining prolonged ARV prophylaxis in a breastfed population showed that 6 months of nevirapine resulted in lower HIV transmission rates compared with a standard 6-week nevirapine regimen. CONCLUSIONS The limited available evidence suggests that using combination ARV regimens in high-risk infants reduces intrapartum transmission and that using prolonged prophylaxis in breastfed infants reduces breastfeeding transmission rates. However, the additional benefit of combination or prolonged regimens in the context of maternal ARV therapy remains unclear.
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Siraprapasiri T, Ongwangdee S, Benjarattanaporn P, Peerapatanapokin W, Sharma M. The impact of Thailand's public health response to the HIV epidemic 1984–2015: understanding the ingredients of success. J Virus Erad 2016. [DOI: 10.1016/s2055-6640(20)31093-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Disclosing in utero HIV/ARV exposure to the HIV-exposed uninfected adolescent: is it necessary? J Int AIDS Soc 2016; 19:21099. [PMID: 27741954 PMCID: PMC5065689 DOI: 10.7448/ias.19.1.21099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 09/06/2016] [Accepted: 09/14/2016] [Indexed: 01/04/2023] Open
Abstract
Introduction The tremendous success of antiretroviral therapy has resulted in a diminishing population of perinatally HIV-infected children on the one hand and a mounting number of HIV-exposed uninfected (HEU) children on the other. As the oldest of these HEU children are reaching adolescence, questions have emerged surrounding the implications of HEU status disclosure to these adolescents. This article outlines the arguments for and against disclosure of a child's HEU status. Discussion Disclosure of a child's HEU status, by definition, requires disclosure of maternal HIV status. It is necessary to weigh the benefits and harms which could occur with disclosure in each of the following domains: psychosocial impact, long-term physical health of the HEU individual and the public health impact. Does disclosure improve or worsen the psychological health of the HEU individual and extended family unit? Do present data on the long-term safety of in utero HIV/ARV exposure reveal potential health risks which merit disclosure to the HEU adolescent? What research and public health programmes or systems need to be in place to afford monitoring of HEU individuals and which, if any, of these require disclosure? Conclusions At present, it is not clear that there is sufficient evidence on whether long-term adverse effects are associated with in utero HIV/ARV exposures, making it difficult to mandate universal disclosure. However, as more countries adopt electronic medical record systems, the HEU status of an individual should be an important piece of the health record which follows the infant not only through childhood and adolescence but also adulthood. Clinicians and researchers should continue to approach the dialogue around mother–child disclosure with sensitivity and a cogent consideration of the evolving risks and benefits as new information becomes available while also working to maintain documentation of an individual's perinatal HIV/ARV exposures as a vital part of his/her medical records. As more long-term adult safety data on in utero HIV/ARV exposures become available these decisions may become clearer, but at this time, they remain complex and multi-faceted.
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Sirirungsi W, Khamduang W, Collins IJ, Pusamang A, Leechanachai P, Chaivooth S, Ngo-Giang-Huong N, Samleerat T. Early infant HIV diagnosis and entry to HIV care cascade in Thailand: an observational study. Lancet HIV 2016; 3:e259-65. [PMID: 27240788 PMCID: PMC6047735 DOI: 10.1016/s2352-3018(16)00045-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 02/15/2016] [Accepted: 03/10/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Early infant diagnosis of HIV is crucial for timely initiation of antiretroviral therapy (ART) in infected children who are at high risk of mortality. Early infant diagnosis with dried blood spot testing was provided by the National AIDS Programme in Thailand from 2007. We report ART initiation and vital status in children with HIV after 7 years of rollout in Thailand. METHODS Dried blood spot samples were collected from HIV-exposed children in hospitals in Thailand and mailed to the Faculty of Associated Medical Sciences, Chiang Mai University, where HIV DNA was assessed with real-time PCR to establish HIV infection. We linked data from children with an HIV infection to the National AIDS Programme database to ascertain ART and vital status. FINDINGS Between April 5, 2007, and Oct 1, 2014, 16 046 dried blood spot samples were sent from 8859 children in 364 hospitals in Thailand. Median age at first dried blood spot test was 2·1 (IQR 1·8-2·5) months. Of 7174 (81%) children with two or more samples, 223 (3%) were HIV positive (including five unconfirmed). Of 1685 (19%) children with one sample, 70 (4%) were unconfirmed positive. Of 293 (3%) children who were HIV positive, 220 (75%) registered for HIV care and 170 (58%) initiated ART. Median age at ART initiation decreased from 14·2 months (IQR 10·2-25·6) in 2007 to 6·1 months (4·2-9·2) in 2013, and the number of children initiating ART aged younger than 1 year increased from five (33%) of 15 children initiating ART in 2007 to ten (83%) of 12 initiating ART in 2013. 15 (9%) of 170 children who initiated ART died and 16 (32%) of 50 who had no ART record died. INTERPRETATION Early infant diagnosis with dried blood spot testing had high uptake in primary care settings. Further improvement of linkage to HIV care is needed to ensure timely treatment of all children with an HIV infection. FUNDING None.
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Affiliation(s)
- Wasna Sirirungsi
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand.
| | - Woottichai Khamduang
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; Institut de Recherche pour le Développement, Unité Mixte Internationale 174-Program for HIV Prevention and Treatment, Chiang Mai, Thailand
| | - Intira Jeannie Collins
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Artit Pusamang
- HIV/AIDS and Tuberculosis Program, National Health Security Office, Bangkok, Thailand
| | - Pranee Leechanachai
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Suchada Chaivooth
- HIV/AIDS and Tuberculosis Program, National Health Security Office, Bangkok, Thailand
| | - Nicole Ngo-Giang-Huong
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; Institut de Recherche pour le Développement, Unité Mixte Internationale 174-Program for HIV Prevention and Treatment, Chiang Mai, Thailand; Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Tanawan Samleerat
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
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Munsakul W, Lolekha R, Kowadisaiburana B, Roongpisuthipong A, Jirajariyavej S, Asavapiriyanont S, Hancharoenkit U, Baipluthong B, Pattanasin S, Martin M. Dual contraceptive method use and pregnancy intention among people living with HIV receiving HIV care at six hospitals in Thailand. Reprod Health 2016; 13:8. [PMID: 26842976 PMCID: PMC4739396 DOI: 10.1186/s12978-016-0123-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 01/25/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Describe dual contraceptive method use and the intention to become pregnant of people living with HIV (PLHIV) and their partners in Thailand. METHODS From January 2008-March 2009, we systematically selected a cohort of PLHIV from PLHIV seeking care at five tertiary care hospitals and one community hospital to complete a questionnaire assessing sexual activity, intention to become pregnant, and contraceptive practices at baseline and 12 months after enrollment. Participants received short family planning messages every 2-3 months to promote the use of dual contraceptives and were offered family planning services. RESULTS A total of 1,388 PLHIV enrolled, their median age was 37 years (IQR 33-43), 898 (64.7%) had a steady partner, and 737 (53.1%) were male. Among those with a steady partner, 862 (96.0%) did not intend to become pregnant; 709 (82.3%) had sex during the previous 3 months, 683 (96.3%) used at least one contraceptive method, and 202 (29.6%) used dual contraceptive methods. Of the 317 PLHIV who used a single contraceptive method at baseline, 66 (20.8%) reported using dual methods at 12 months. Participants at two tertiary care hospitals where coordinators facilitated PLHIV referral between HIV and OB/GYN clinics were more likely than participants at the other hospitals to change from single method to dual method (p ≤ 0.03). CONCLUSION Few PLHIV in this study intended to become pregnant; however, only one-fourth used dual contraceptive methods. Integrating an assessment of the intention to become pregnant and strengthening the PLHIV referral systems in family planning services may contribute to higher rates of dual contraceptive use.
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Affiliation(s)
- Warangkana Munsakul
- Faculty of Medicine Vajira Hospital, Navamindharadhiraj University, Bangkok, Thailand
| | - Rangsima Lolekha
- Thailand Ministry of Public Health-U.S. Center for Disease Control and Prevention Collaboration, P.O. Box 139, Nonthaburi, 11000 Thailand
| | | | | | | | | | | | - Benjamas Baipluthong
- Thailand Ministry of Public Health-U.S. Center for Disease Control and Prevention Collaboration, P.O. Box 139, Nonthaburi, 11000 Thailand
| | - Sarika Pattanasin
- Thailand Ministry of Public Health-U.S. Center for Disease Control and Prevention Collaboration, P.O. Box 139, Nonthaburi, 11000 Thailand
| | - Michael Martin
- Thailand Ministry of Public Health-U.S. Center for Disease Control and Prevention Collaboration, P.O. Box 139, Nonthaburi, 11000 Thailand
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, USA
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Lallemant M, Le Coeur S, Sirirungsi W, Cressey TR, Ngo-Giang-Huong N, Traisathit P, Klinbuayaem V, Sabsanong P, Kanjanavikai P, Jourdain G, Mcintosh K, Koetsawang S. Randomized noninferiority trial of two maternal single-dose nevirapine-sparing regimens to prevent perinatal HIV in Thailand. AIDS 2015; 29:2497-507. [PMID: 26372485 PMCID: PMC4871947 DOI: 10.1097/qad.0000000000000865] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Perinatal single-dose nevirapine (sdNVP) selects for resistance mutations. The objective of this trial was to compare two maternal sdNVP-sparing regimens with standard zidovudine (ZDV)/sdNVP prophylaxis. DESIGN PHPT-5 was a randomized, partially double-blind placebo-controlled, noninferiority trial in Thailand (NCT00409591). Study participants were women with CD4 of at least 250 cells/μl and their infants. METHODS All women received ZDV from 28 weeks' gestation and their newborn infants for one week. Women were also randomized to receive NVP-NVP (reference): maternal intrapartum sdNVP with a 7-day 'tail' of ZDV along with lamivudine, and infant NVP (one dose immediately, another 48 h later); infant-only NVP: maternal placebos for sdNVP and the 'tail', with infant NVP; LPV/r: maternal LPV/r starting at 28 weeks. Infants were formula-fed. HIV-diagnosis was determined by DNA-PCR. RESULTS Four-hundred and thirty-five women were randomized between January 2009 and September 2010. Accrual was terminated prematurely following a change in Thai guidelines recommending antiretroviral combination therapy for all pregnant women. Data on 405 mothers and 407 live-born children were analyzed. Baseline characteristics were similar between arms. Intent-to-treat transmission rates were 3.8% (95% confidence interval: 1.2-8.6) in NVP-NVP, 1.6% (0.2-5.6) in infant-only NVP, and 1.4% (0.4-5.1) in LPV/r arms. As-treated rates were 2.2% (0.5-6.4), 3.2% (0.9-7.9), and 1.5% (0.2-5.2), respectively. Factors independently associated with transmission were prophylaxis duration less than 8 weeks (adjusted odds ratio 15.5; 3.6-66.1) and viral load at baseline at least 4 log10copies/ml (adjusted odds ratio 10.9; 1.3-91.5). Regimens appeared well tolerated. CONCLUSION Transmission rates in all arms were low but noninferiority was not proven. Antiretroviral prophylaxis for at least 8 weeks before delivery is necessary to minimize transmission risk.
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Affiliation(s)
- Marc Lallemant
- aUnité Mixte Internationale 174, Institut de Recherche pour le Développement (IRD)-PHPT, Chiang Mai, Thailand bDepartment of Immunology and Infectious, Diseases, Harvard School of Public Health, Boston, Massachusetts, USA cDepartment of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand dUnité Mixte de Recherche 196, Centre Français de la Population et du Développement, (INED-IRD-Paris V University), Paris, France eDepartment of Statistics, Faculty of Science, Chiang Mai University, Chiang Mai fSanpatong Hospital, Ministry of Public Health, Sanpatong gSamutprakarn Hospital, Ministry of Public Health, Samutprakarn hBanglamung Hospital, Ministry of Public Health, Chonburi, Thailand iChildren's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA jFamily Health Research Center, Mahidol University, Bangkok, Thailand
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Sripan P, Le Coeur S, Amzal B, Ingsrisawang L, Traisathit P, Ngo-Giang-Huong N, McIntosh K, Cressey TR, Sangsawang S, Rawangban B, Kanjanavikai P, Tréluyer JM, Jourdain G, Lallemant M, Urien S. Modeling of In-Utero and Intra-Partum Transmissions to Evaluate the Efficacy of Interventions for the Prevention of Perinatal HIV. PLoS One 2015; 10:e0126647. [PMID: 25992639 PMCID: PMC4438074 DOI: 10.1371/journal.pone.0126647] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 04/03/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Antiretroviral treatments decrease HIV mother-to-child transmission through pre/post exposure prophylaxis and reduction of maternal viral load. We modeled in-utero and intra-partum HIV transmissions to investigate the preventive role of various antiretroviral treatments interventions. METHODS We analysed data from 3,759 women-infant pairs enrolled in 3 randomized clinical trials evaluating (1) zidovudine monotherapy, (2) zidovudine plus perinatal single-dose nevirapine or (3) zidovudine plus lopinavir/ritonavir for the prevention of mother-to-child transmission of HIV in Thailand. All infants were formula-fed. Non-linear mixed effect modeling was used to express the viral load evolution under antiretroviral treatments and the probability of transmission. RESULTS Median viral load was 4 log10 copies/mL (Interquartile range: 3.36-4.56) before antiretroviral treatments initiation. An Emax model described the viral load time-course during pregnancy. Half of the maximum effect of zidovudine (28% decrease) and lopinavir/ritonavir (72% decrease) were achieved after 98 and 12 days, respectively. Adjusted on viral load at baseline (Odds ratio = 1.50 [95% confidence interval: 1.34, 1.68] per log10 copies/mL increment), antiretroviral treatments duration (OR = 0.80 [0.75, 0.84] per week increment) but not the nature of antiretroviral treatments were associated with in-utero transmission. Adjusted on gestational age at delivery (<37 weeks, OR = 2.37 [1.37, 4.10]), baseline CD4 (Odds ratio = 0.79 [0.72, 0.88] per 100 cells/mm3 increment) and predicted viral load at delivery (OR = 1.47 [1.25, 1.64] per log10 copies/mL increment), single-dose nevirapine considerably reduced intra-partum transmission (OR = 0.32 [0.2, 0.51]). CONCLUSION These models determined the respective contributions of various antiretroviral strategies on prevention of mother-to-child transmission. This can help predict the efficacy of new antiretroviral treatments and/or prevention of mother-to-child transmission strategies particularly for women with no or late antenatal care who are at high risk of transmitting HIV to their offspring. TRIAL REGISTRATION This analysis is based on secondary data obtained from three clinical trials. ClinicalTrials.gov. NCT00386230, NCT00398684, NCT00409591.
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Affiliation(s)
- Patumrat Sripan
- Department of Statistics, Kasetsart University, Bangkok, Thailand
- Institut de recherche pour le développement (IRD) UMI 174-PHPT, Marseille, France
- Ecole Doctorale de Santé Publique, Université Paris-Sud, Paris, France
| | - Sophie Le Coeur
- Institut de recherche pour le développement (IRD) UMI 174-PHPT, Marseille, France
- Department of Medical Technology, Chiang Mai University, Chiang Mai, Thailand
- Institut d'Etudes Démographiques, Paris, France
| | - Billy Amzal
- Institut de recherche pour le développement (IRD) UMI 174-PHPT, Marseille, France
- LASER Analytica, London, United Kingdom
| | | | | | - Nicole Ngo-Giang-Huong
- Institut de recherche pour le développement (IRD) UMI 174-PHPT, Marseille, France
- Department of Medical Technology, Chiang Mai University, Chiang Mai, Thailand
- Harvard School of Public Health, Boston, MA, United States of America
| | - Kenneth McIntosh
- Boston Children's Hospital, Boston, MA, United States of America
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States of America
| | - Tim R. Cressey
- Institut de recherche pour le développement (IRD) UMI 174-PHPT, Marseille, France
- Department of Medical Technology, Chiang Mai University, Chiang Mai, Thailand
- Harvard School of Public Health, Boston, MA, United States of America
| | | | | | | | - Jean-Marc Tréluyer
- EAU08 Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Unité de Recherche Clinique, AP-HP, Hôpital Tarnier, Paris, France
- CIC1419 INSERM, Cochin-Necker, Paris, France
| | - Gonzague Jourdain
- Institut de recherche pour le développement (IRD) UMI 174-PHPT, Marseille, France
- Department of Medical Technology, Chiang Mai University, Chiang Mai, Thailand
- Harvard School of Public Health, Boston, MA, United States of America
| | - Marc Lallemant
- Institut de recherche pour le développement (IRD) UMI 174-PHPT, Marseille, France
| | - Saïk Urien
- EAU08 Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Unité de Recherche Clinique, AP-HP, Hôpital Tarnier, Paris, France
- CIC1419 INSERM, Cochin-Necker, Paris, France
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Lolekha R, Kullerk N, Wolfe MI, Klumthanom K, Singhagowin T, Pattanasin S, Sombat P, Naiwatanakul T, Leartvanangkul C, Voramongkol N. Assessment of a couples HIV counseling and testing program for pregnant women and their partners in antenatal care (ANC) in 7 provinces, Thailand. BMC INTERNATIONAL HEALTH AND HUMAN RIGHTS 2014; 14:39. [PMID: 25539670 PMCID: PMC4301829 DOI: 10.1186/s12914-014-0039-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 12/15/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Couples HIV testing and counseling (CHTC) at antenatal care (ANC) settings allows pregnant women to learn the HIV status of themselves and their partners. Couples can make decisions together to prevent HIV transmission. In Thailand, men were tested at ANC settings only if their pregnant partners were HIV positive. A CHTC program based in ANC settings was developed and implemented at 16 pilot hospitals in 7 provinces during 2009-2010. METHODS Cross-sectional data were collected using standard data collection forms from all pregnant women and accompanying partners who presented at first ANC visit at 16 hospitals. CHTC data for women and partners were analyzed to determine service uptake and HIV test results among couples. In-depth interviews were conducted among hospital staff of participating hospitals during field supervision visits to assess feasibility and acceptability of CHTC services. RESULTS During October 2009-April 2010, 4,524 women initiating ANC were enrolled. Of these, 2,435 (54%) women came for ANC alone; 2,089 (46%) came with partners. Among men presenting with partners, 2,003 (96%) received couples counseling. Of these, 1,723 (86%) men and all pregnant women accepted HIV testing. Among 1,723 couples testing for HIV, 1,604 (93%) returned for test results. Of these, 1,567 (98%) were concordant negative, 6 (0.4%) were concordant positive and 17 (1%) were HIV discordant (7 male+/female- and 10 male-/female+). Nine of ten (90%) executive hospital staff reported high acceptability of CHTC services. CONCLUSIONS CHTC implemented in ANC settings helps identify more HIV-positive men whose partners were negative than previous practice, with high acceptability among hospital staff.
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Affiliation(s)
- Rangsima Lolekha
- Global AIDS Program, Thailand MOPH-U.S. CDC Collaboration (TUC), Mail: P.O. Box 139, Nonthaburi, 11000, Thailand.
| | - Nareeluck Kullerk
- Department of Health (DOH), Ministry of Public Health, Nonthaburi, Thailand.
| | - Mitchell I Wolfe
- Global AIDS Program, Thailand MOPH-U.S. CDC Collaboration (TUC), Mail: P.O. Box 139, Nonthaburi, 11000, Thailand. .,U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Kanyarat Klumthanom
- Global AIDS Program, Thailand MOPH-U.S. CDC Collaboration (TUC), Mail: P.O. Box 139, Nonthaburi, 11000, Thailand.
| | | | - Sarika Pattanasin
- Global AIDS Program, Thailand MOPH-U.S. CDC Collaboration (TUC), Mail: P.O. Box 139, Nonthaburi, 11000, Thailand.
| | - Potjaman Sombat
- Global AIDS Program, Thailand MOPH-U.S. CDC Collaboration (TUC), Mail: P.O. Box 139, Nonthaburi, 11000, Thailand.
| | - Thananda Naiwatanakul
- Global AIDS Program, Thailand MOPH-U.S. CDC Collaboration (TUC), Mail: P.O. Box 139, Nonthaburi, 11000, Thailand.
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Cost-effectiveness of early infant HIV diagnosis of HIV-exposed infants and immediate antiretroviral therapy in HIV-infected children under 24 months in Thailand. PLoS One 2014; 9:e91004. [PMID: 24632750 PMCID: PMC3954590 DOI: 10.1371/journal.pone.0091004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 01/30/2014] [Indexed: 11/19/2022] Open
Abstract
Background HIV-infected infants have high risk of death in the first two years of life if untreated. WHO guidelines recommend early infant HIV diagnosis (EID) of all HIV-exposed infants and immediate antiretroviral therapy (ART) in HIV-infected children under 24-months. We assessed the cost-effectiveness of this strategy in HIV-exposed non-breastfed children in Thailand. Methods A decision analytic model of HIV diagnosis and disease progression compared: EID using DNA PCR with immediate ART (Early-Early); or EID with deferred ART based on immune/clinical criteria (Early-Late); vs. clinical/serology based diagnosis and deferred ART (Reference). The model was populated with survival and cost data from a Thai observational cohort and the literature. Incremental cost-effectiveness ratio per life-year gained (LYG) was compared against the Reference strategy. Costs and outcomes were discounted at 3%. Results Mean discounted life expectancy of HIV-infected children increased from 13.3 years in the Reference strategy to 14.3 in the Early-Late and 17.8 years in Early-Early strategies. The mean discounted lifetime cost was $17,335, $22,583 and $29,108, respectively. The cost-effectiveness ratio of Early-Late and Early-Early strategies was $5,149 and $2,615 per LYG, respectively as compared to the Reference strategy. The Early-Early strategy was most cost-effective at approximately half the domestic product per capita per LYG ($4,420 in Thailand 2011). The results were robust in deterministic and probabilistic sensitivity analyses including varying perinatal transmission rates. Conclusion In Thailand, EID and immediate ART would lead to major survival benefits and is cost- effective. These findings strongly support the adoption of WHO recommendations as routine care.
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Kiertiburanakul S, Boettiger D, Lee MP, Omar SF, Tanuma J, Ng OT, Durier N, Phanuphak P, Ditangco R, Chaiwarith R, Kantipong P, Lee CK, Mustafa M, Saphonn V, Ratanasuwan W, Merati TP, Kumarasamy N, Wong WW, Zhang F, Pham TT, Pujari S, Choi JY, Yunihastuti E, Sungkanuparph S. Trends of CD4 cell count levels at the initiation of antiretroviral therapy over time and factors associated with late initiation of antiretroviral therapy among Asian HIV-positive patients. J Int AIDS Soc 2014; 17:18804. [PMID: 24598459 PMCID: PMC3944639 DOI: 10.7448/ias.17.1.18804] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 01/06/2014] [Accepted: 02/12/2014] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Although antiretroviral therapy (ART) has been rapidly scaled up in Asia, most HIV-positive patients in the region still present with late-stage HIV disease. We aimed to determine trends of pre-ART CD4 levels over time in Asian HIV-positive patients and to determine factors associated with late ART initiation. METHODS Data from two regional cohort observational databases were analyzed for trends in median CD4 cell counts at ART initiation and the proportion of late ART initiation (CD4 cell counts <200 cells/mm(3) or prior AIDS diagnosis). Predictors for late ART initiation and mortality were determined. RESULTS A total of 2737 HIV-positive ART-naïve patients from 22 sites in 13 Asian countries and territories were eligible. The overall median (IQR) CD4 cell count at ART initiation was 150 (46-241) cells/mm(3). Median CD4 cell counts at ART initiation increased over time, from a low point of 115 cells/mm(3) in 2008 to a peak of 302 cells/mm(3) after 2011 (p for trend 0.002). The proportion of patients with late ART initiation significantly decreased over time from 79.1% before 2007 to 36.3% after 2011 (p for trend <0.001). Factors associated with late ART initiation were year of ART initiation (e.g. 2010 vs. before 2007; OR 0.40, 95% CI 0.27-0.59; p<0.001), sex (male vs. female; OR 1.51, 95% CI 1.18-1.93; p=0.001) and HIV exposure risk (heterosexual vs. homosexual; OR 1.66, 95% CI 1.24-2.23; p=0.001 and intravenous drug use vs. homosexual; OR 3.03, 95% CI 1.77-5.21; p<0.001). Factors associated with mortality after ART initiation were late ART initiation (HR 2.13, 95% CI 1.19-3.79; p=0.010), sex (male vs. female; HR 2.12, 95% CI 1.31-3.43; p=0.002), age (≥51 vs. ≤30 years; HR 3.91, 95% CI 2.18-7.04; p<0.001) and hepatitis C serostatus (positive vs. negative; HR 2.48, 95% CI 1.-4.36; p=0.035). CONCLUSIONS Median CD4 cell count at ART initiation among Asian patients significantly increases over time but the proportion of patients with late ART initiation is still significant. ART initiation at higher CD4 cell counts remains a challenge. Strategic interventions to increase earlier diagnosis of HIV infection and prompt more rapid linkage to ART must be implemented.
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Affiliation(s)
| | - David Boettiger
- The Kirby Institute, University of New South Wales, Kensington, NSW, Australia
| | - Man Po Lee
- Queen Elizabeth Hospital, Hong Kong, China SAR
| | | | - Junko Tanuma
- National Center for Global Health and Medicine, Toyama Shinjuku-ku, Tokyo, Japan
| | | | - Nicolas Durier
- TREAT Asia, amfAR - The Foundation for AIDS Research, Bangkok, Thailand
| | | | | | - Romanee Chaiwarith
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | | | | | | | - Vonthanak Saphonn
- National Center for HIV/AIDS, Dermatology & STDs, Phnom Penh, Cambodia
| | - Winai Ratanasuwan
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Wing Wai Wong
- Taipei Veterans General Hospital and AIDS Prevention and Research Centre, National Yang-Ming University, Taipei, Taiwan
| | | | | | | | - Jun Yong Choi
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Evy Yunihastuti
- Working Group on AIDS Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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Alvarez-Uria G, Midde M, Pakam R, Bachu L, Naik PK. Effect of Formula Feeding and Breastfeeding on Child Growth, Infant Mortality, and HIV Transmission in Children Born to HIV-Infected Pregnant Women Who Received Triple Antiretroviral Therapy in a Resource-Limited Setting: Data from an HIV Cohort Study in India. ISRN PEDIATRICS 2012; 2012:763591. [PMID: 22701801 PMCID: PMC3371722 DOI: 10.5402/2012/763591] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Accepted: 04/04/2012] [Indexed: 11/23/2022]
Abstract
We describe a programme for the prevention of mother-to-child transmission (PMTCT) of HIV that provided universal antiretroviral therapy (ART) to all pregnant women regardless of the CD4 lymphocyte count and formula feeding for children with high risk of HIV transmission through breastfeeding in a district of India. The overall rate of HIV transmission was 3.7%. Although breastfeeding added a 3.1% additional risk of HIV acquisition, formula-fed infants had significantly higher risk of death compared to breastfed infants. The cumulative 12-month mortality was 9.6% for formula-fed infants versus 0.68% for breastfed infants. Anthropometric markers (weight, length/height, weight for length/height, body mass index, head circumference, mid-upper arm circumference, triceps skinfold, and subscapular skinfold) showed that formula-fed infants experience severe malnutrition during the first two months of life. We did not observe any death after rapid weaning at 5-6 months in breastfed infants. The higher-free-of HIV survival in breastfed infants and the low rate of HIV transmission found in this study support the implementation of PMTCT programmes with universal ART to all HIV-infected pregnant women and breastfeeding in order to reduce HIV transmission without increasing infant mortality in developing countries.
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Affiliation(s)
- Gerardo Alvarez-Uria
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, Kadiri Road, Bathalapalli 515661, India
| | - Manoranjan Midde
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, Kadiri Road, Bathalapalli 515661, India
| | - Raghavakalyan Pakam
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, Kadiri Road, Bathalapalli 515661, India
| | - Lakshminarayana Bachu
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, Kadiri Road, Bathalapalli 515661, India
| | - Praveen Kumar Naik
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, Kadiri Road, Bathalapalli 515661, India
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Landolt NK, Phanuphak N, Pinyakorn S, Lakhonphon S, Khongpetch C, Chaithongwongwatthana S, Ananworanich J. Sexual life, options for contraception and intention for conception in HIV-positive people on successful antiretroviral therapy in Thailand. AIDS Care 2012; 24:897-904. [PMID: 22292980 DOI: 10.1080/09540121.2011.648161] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
This article reports on the sexual life of HIV-positive heterosexual men and women in a stable relationship and on successful antiretroviral therapy in Thailand. We focused on one side on their sexual practices and options for contraception, and on the other on their intention for conception and factors influencing it, in the time of highly active antiretroviral therapy. In a cross-sectional study, 200 participants completed a questionnaire. Eleven female participants took part in focus group discussions (FGD), based on their intention for conception. We used descriptive statistics, logistic regression, and Chi-square exact test to present the results from the questionnaire, and a narrative approach for the FGD results. The median age of the participants was 37 years. Almost all were sexually active (88%) and rarely engaged in risky sexual behavior. The most common method of contraception for women was the male condom (95%), followed by female sterilization (40%). Almost all men reported consistent condom use. One-third of the main sexual partners were HIV-negative. The intention for conception was significantly less after being diagnosed with HIV (29% intended pregnancies after HIV diagnosis vs. 72% before HIV diagnosis). Nevertheless, 25% of the participants expressed a desire to have a child. We found a significant positive association between the intention for conception and less years of being married, the lower number of children and the higher levels of education. Therefore, we conclude that HIV-positive men and women are sexually active and in need of comprehensive reproductive health care services including counseling on safe ways to conceive and offering a diverse choice of contraceptive methods to those who do not wish to have children.
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Affiliation(s)
- Nadia K Landolt
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Bangkok, Thailand.
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Thai HIV-1-infected women do not require a dose increase of lopinavir/ritonavir during the third trimester of pregnancy. AIDS 2011; 25:1299-303. [PMID: 21516029 DOI: 10.1097/qad.0b013e328347f7e9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate whether Thai HIV-1-infected pregnant women require a dose increase of lopinavir/ritonavir (LPV/r) and to assess the safety and efficacy of the generic tablets during pregnancy. DESIGN Prospective, single-center pharmacokinetic study. METHODS HIV-infected pregnant, antiretroviral therapy-naive or experienced women started HAART containing generic LPV/r 400/100 mg tablets twice daily. The 12-h pharmacokinetic curves were recorded at gestational age 20 weeks (GA20, optional), 33 weeks (GA33) and 12 weeks postpartum (12PP, optional). RESULTS Twenty women were included. Median [interquartile range (IQR)] age was 28 (25-33) years and mean (SD) weight at GA33 was 59.9 (4.2) kg. Mean (SD) values for LPV area under the curve(0-12 h), C(max), C(min), and T(half) were 72.9 (19.2) mg/l h, 9.3 (2.2) mg/l, 3.2 (1.3) mg/l and 4.8 (2.4) h, respectively, on GA33 and 98.0 (24.1) mg/l h, 11.7 (2.2) mg/l, 4.7 (2.2) mg/l and 5.9 (2.7) h, respectively on 12PP. Twelve women recorded both GA33 and 12PP curves; mean LPV AUC(0-12) was significantly lower at GA33 [-24.1 (95% confidence interval -44.4 to -3.7) mg/l h]. At GA33, 19 of 20 women had sufficient LPV trough concentrations (>1.0 mg/l) and at 12PP, all had sufficient LPV trough concentrations. None of the women stopped LPV/r before planned discontinuation due to side-effects. At delivery, 19 of 20 women had a viral load below 50 copies/ml. One woman had a viral load of 60 copies/ml, but was undetectable at 12PP. CONCLUSION Standard dose generic LPV/r (400/100 mg twice daily) in Thai HIV-1-infected pregnant women leads to adequate plasma concentrations during the third trimester. The generic LPV/r tablet is well tolerated and effective for use during pregnancy.
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