Outcome of pregnancy in HIV-positive women planned for vaginal delivery under effective antiretroviral therapy

The Cost-Effectiveness of HIV/STI Prevention in High-Income Countries with Concentrated Epidemic Settings: A Scoping Review

The purpose of this scoping review is to establish the state of the art on economic evaluations in the field of HIV/STI prevention in high-income countries with concentrated epidemic settings and to assess what we know about the cost-effectiveness of different measures. We reviewed economic evaluations of HIV/STI prevention measures published in the Web of Science and Cost-Effectiveness Registry databases. We included a total of 157 studies focusing on structural, behavioural, and biomedical interventions, covering a variety of contexts, target populations and approaches. The majority of studies are based on mathematical modelling and demonstrate that the preventive measures under scrutiny are cost-effective. Interventions targeted at high-risk populations yield the most favourable results. The generalisability and transferability of the study results are limited due to the heterogeneity of the populations, settings and methods involved. Furthermore, the results depend heavily on modelling assumptions. Since evidence is unequally distributed, we discuss implications for future research.

Pregnancy outcomes in HIV-positive women: a retrospective cohort study

PURPOSE

In the United States, an estimated 8500 HIV (human immunodeficiency virus) positive women gave birth in 2014. This rate appears to be increasing annually. Our objective is to examine obstetrical outcomes of pregnancy among HIV-positive women.

METHODS

A population-based cohort study was conducted using the Nationwide Inpatient Sample database (2003-2011) from the United States. Pregnant HIV-positive women were identified and compared to pregnant women without HIV. Multivariate logistic regression was used to estimate the adjusted effect of HIV status on obstetrical and neonatal outcomes.

RESULTS

Among 7,772,999 births over the study period, 1997 were in HIV-positive women (an incidence of 25.7/100,000 births). HIV-infected patients had greater frequency of pre-existing diabetes and chronic hypertension, and use of cigarettes, drugs, and alcohol during pregnancy (p < 0.001). Upon adjustment for baseline characteristics, HIV-infected women had greater likelihood of antenatal complications: preterm premature rupture of membranes (OR 1.35, 95% CI 1.14-1.60) and urinary tract infections (OR 3.02, 95% CI 2.40-3.81). Delivery and postpartum complications were also increased among HIV-infected women: cesarean delivery (OR 3.06, 95% CI 2.79-3.36), postpartum sepsis (OR 8.05, 95% CI 5.44-11.90), venous thromboembolism (OR 2.21, 95% CI 1.46-3.33), blood transfusions (OR 3.67, 95% CI 3.01-4.49), postpartum infection (OR 3.00, 95% CI 2.37-3.80), and maternal mortality (OR 21.52, 95% CI 12.96-35.72). Neonates born to these mothers were at higher risk of prematurity and intrauterine growth restriction.

CONCLUSION

Pregnancy in HIV-infected women is associated with adverse maternal and newborn complications. Pregnant HIV-positive women should be followed in high-risk healthcare centers.

The pregnancy decisions of HIV-positive women: the state of knowledge and way forward

Despite the growing number of women living with and affected by HIV, there is still insufficient attention to their pregnancy-related needs, rights, decisions and desires in research, policy and programs. We carried out a review of the literature to ascertain the current state of knowledge and highlight areas requiring further attention. We found that contraceptive options for pregnancy prevention by HIV-positive women are insufficient: condoms are not always available or acceptable, and other options are limited by affordability, availability or efficacy. Further, coerced sterilization of women living with HIV is widely reported. Information gaps persist in relation to effectiveness, safety and best practices regarding assisted reproductive technologies. Attention to neonatal outcomes generally outweighs attention to the health of women before, during and after pregnancy. Access to safe abortion and post-abortion care services, which are critical to women's ability to fulfill their sexual and reproductive rights, are often curtailed. There is inadequate attention to HIV-positive sex workers, injecting drug users and adolescents. The many challenges that women living with HIV encounter in their interactions with sexual and reproductive health services shape their pregnancy decisions. It is critical that HIV-positive women be more involved in the design and implementation of research, policies and programs related to their pregnancy-related needs and rights.

The National Institute for Health and Clinical Excellence (NICE) guidelines for caesarean section, 2011 update: implications for the anaesthetist

In 2004 the first National Institute for Health and Clinical Excellence guidelines on caesarean section were published with the aim of providing evidence-based recommendations for best practice. With the publication of new evidence, the guidelines have been revised with the second edition released in 2011. This review highlights the changes that have been made which are of specific relevance to obstetric anaesthetists including planned caesarean section compared with vaginal birth in healthy women with an uncomplicated pregnancy; management of the morbidly adherent placenta; mother-to-child transmission of maternal infections; maternal request for caesarean section; decision-to-delivery interval for emergency caesarean section; timing of antibiotic administration and childbirth after caesarean section.

Prevention of vertical transmission of HIV-1 in resource-limited settings

One of the most exciting areas of HIV research is that of prevention of vertical transmission from mother to child, since it accounts for 90% of childhood HIV infections, and therefore prevention in this context has an enormous potential impact on the spread of HIV among children. Focused research has yielded highly successful strategies for reducing infant infection rates, particularly in the developed world, and much work is underway to implement appropriate strategies in resource-limited settings, although this is not without challenges. Although transmission rates in some settings have been reduced to approximately 1%, scale-up and widespread implementation and application of strategic interventions for prevention of mother-to-child transmission of HIV during pregnancy, delivery and breastfeeding are needed in the developing world.