HIV viraemia during pregnancy in women receiving preconception antiretroviral therapy in KwaDukuza, KwaZulu-Natal

Prevalence and predictors of persistent low-level HIV viraemia: a retrospective cohort study among people receiving dolutegravir-based antiretroviral therapy in Southern Nigeria

Background

Persistent low-level viraemia (PLLV) is a risk factor for virologic failure among people receiving antiretroviral therapy (ART).

Objectives

We assessed the prevalence and predictors of PLLV among individuals receiving Dolutegravir-based ART in southern Nigeria.

Design

This retrospective cohort study used routine program data from electronic medical records of persons receiving Dolutegravir-based first-line ART in 154 PEPFAR/USAID-supported health facilities in Akwa Ibom and Cross Rivers states, Nigeria.

Methods

Clients on first-line Dolutegravir-based ART ⩾6 months, who had a viral load result in the 12 months preceding October 2021 (baseline), and a second viral load result by September 2022 were included. Persons with low-level viraemia (LLV) (viral load 51-999 copies/ml) received additional adherence support. The outcome analysed was PLLV (two consecutive LLV results). Indices were summarized using descriptive statistics, and predictors of PLLV were determined using multivariate logistic regression.

Results

In total, 141,208 persons on ART were included, of which 63.3% (n = 89,944) were females. The median age was 36 [29-44] years, median ART duration was 19 [11-42] months. At the end of the study, 10.5% (14,759/141,208) had initial LLV, 90.1% (13,304/14,759) of which attained undetectable viral load (⩽50 copies/ml), and 1.1% (163/14,759) transitioned to virologic failure (⩾1000 copies/ml) by the end of the study. PLLV prevalence was 0.9% (1292/141,208). Increasing ART duration [adjusted odds ratio (aOR) = 1.0; 95% confidence interval (CI): 1.005-1.008; p < 0.001] and viral suppression (<1000 copies/ml) before initial LLV (aOR = 1.7; 95% CI: 1.50-2.00; p < 0.001) were positively associated with PLLV, while receipt of tuberculosis preventive therapy reduced the likelihood of PLLV (aOR = 0.3; 95% CI: 0.10-0.94; p = 0.039).

Conclusion

PLLV was uncommon among individuals receiving dolutegravir-based ART and was associated with longer ART duration, prior viral suppression, and non-receipt of tuberculosis preventive therapy. This strengthens recommendations for continuous adherence support and comprehensive health services with ART, to prevent treatment failure.

Paradoxical and Unmasking HIV Immune Reconstitution Inflammation Syndrome in Antiretroviral-Naïve Pregnant Women: A Prospective Cohort Study

BACKGROUND AND AIMS

Following antiretroviral therapy (ART) initiation, HIV-associated immune reconstitution inflammatory syndrome (IRIS), indicated by an array of opportunistic infections, may occur, presenting as either paradoxical, a worsening of a previously treated infection, or unmasking, a flare-up of an underlying, previously undiagnosed infection. The impact of ART as the backbone of HIV treatment and prevention has prolonged the survival of people living with HIV. In pregnancy, benefits have been shown by slowing HIV progression and preventing perinatal transmission; however, there have been risks of adverse reactions with ART, including immune responses to both the fetus and mother. This study sought to estimate the incidence of HIV-IRIS cumulatively and by type either paradoxical or unmasking IRIS, determine the baseline maternal and HIV clinical markers as predictors of, and analyze the log-rank test for survival time to IRIS outcome assessed by relying on an increase in CD4 count and/or a rapid decrease in viral load.

METHODS

An active records study was conducted between June 2019 and March 2020 among ART-naïve pregnant women attending the antenatal care units (ANCu) at the Kenyatta National and Mbagathi Hospitals, Nairobi, Kenya. Participants were aged between 20 and 49 years and had a confirmed HIV-positive test. To ascertain a true case of IRIS, the diagnosis was adjudicated for accuracy and consistency by an independent review committee. Plasma HIV viral load, CD4 counts, and routine laboratory evaluations (hemoglobin, white blood cell count (WBC)) were performed by each hospital's clinical laboratory. The IRIS incidence was assessed using the International Network for Studies Against HIV-Associated IRIS (INSHI) during the first three months after ART initiation. Multivariate Cox regression with IRIS as the outcome, using the SPSSSurvival package, examined the relationship between baseline maternal characteristics and HIV clinical markers before ART initiation and IRIS, and finally, decision-tree analysis for predicting IRIS was performed.

RESULTS

From a pool of 532 ART-naïve pregnant women, 133 (25%) developed IRIS, and 97 (72.9%) were in the unmasking category. The accumulated risk of experiencing IRIS symptoms increased from week two (hazard ratio (HR)=0.0287) to week 12 (HR=3.6158). Participants with a maternal BMI (MBMI) of 25-29.9 kg/m2 at baseline were at a higher risk of unmasking IRIS (HR=2.478; P=0.010). The WHO-HIV clinical stages 1 and 2 skewed towards paradoxical IRIS (regression coefficients =-0.111 and -0.276 (P<0.05)), while stage 4 skewed towards unmasking IRIS (regression coefficient=0.047, HR=1.048, P=0.941). A CD4 count > 500 cells/mm^3 skewed towards unmasking IRIS (regression coefficient=0.192, HR=1.211, P=0.416), while RNA-HIV viral loads >50 copies/ml towards paradoxical IRIS (regression coefficient=-0.199, HR=0.820, P=0.360. On decision tree analysis, 85% (P=0.001) of ART-naïve pregnant women with a baseline CD4 count below 500 copies/mm^3 presented with unmasking IRIS.

CONCLUSION

For ART-naïve pregnant women, unmasking IRIS is the most common type, and an MBMI of 25-29.9 kg/m2, advanced HIV infection, a CD4 count <500 cells/mm^3, and a higher parity at baseline may be clinically useful predictors. The higher proportion of ART-naïve pregnant women experiencing unmasking as compared to paradoxical IRIS supports the need for earlier assessment based on potential predictors.

Virological Outcomes Among Pregnant Women Receiving Antiretroviral Treatment in the Amhara Region, North West Ethiopia

Background

Globally, approximately 35 million people are infected with HIV infection. Sub-Saharan countries contributed 71% of global burden. Women are the most affected groups accounting for 51% of global infection and 90% of HIV infections in children (<15 years) are a result of mother to child transmission. In the absence of any intervention, mother-to-child transmission has been estimated to 30-40% that could occur at various periods like during pregnancy, delivery, and post-partum, via breastfeeding. For future generations to be born HIV-free, evidences on the level of viremia and contributing factors in pregnant mothers is important.

Objective

The objective of this study is to determine the magnitude of viral non-suppression rate among pregnant women and identify the risk factors associated with viral non-suppression.

Methods

A cross-sectional study was conducted from July 01, 2021 to June 30, 2022, in pregnant women who are on antiretroviral treatment and attending HIV viral load testing in Amhara region viral load testing sites, North West Ethiopia. Socio-demographic, clinical, and HIV-1 RNA viral load data were collected from the excel database. The data were analyzed in SPSS 23.0 statistical software.

Results

Overall viral non-suppression rate was 9.1%. In other words, the viral suppression rate was 90.9%. Pregnant women being at AIDS stages III and IV and with fair treatment adherence and suspected testers were statistically associated with increased viral non-suppression rate.

Conclusion

Relatively low viral non-suppression rate among pregnant mothers that had almost met the third 90 of UNAIDS target. But, still, some mothers received a non-suppressed viral replication specifically the odds of having a non-suppressed viral load was higher in pregnant women with poor treatment adherence and WHO Stage III and IV and suspected testers.

Viral load testing among pregnant women living with HIV in Mutare district of Manicaland province, Zimbabwe

BACKGROUND

Viral load (VL) monitoring of pregnant women living with HIV (PWLHIV) and antiretroviral therapy (ART) may contribute to lowering the risk of vertical transmission of HIV. The aims of this study were to assess the uptake of HIV VL testing among PWLHIV at entry to the prevention-of-mother-to-child transmission (PMTCT) services and identify facilitatory factors and barriers to HIV VL access.

METHODS

A retrospective, cross-sectional study was conducted at 15 health facilities in Mutare district, Manicaland Province, Zimbabwe from January to December 2018. This analysis was complemented by prospective interviews with PWLHIV and health care providers between October 2019 and March 2020. Quantitative data were analysed using descriptive and inferential statistical methods. Risk factors were evaluated using multivariate logistic regression. Open-ended questions were analysed and recurring and shared experiences and perceptions of PWLHIV and health care providers identified.

RESULTS

Among 383 PWLHIV, enrolled in antenatal care (ANC) and receiving ART, only 121 (31.6%) had a VL sample collected and 106 (88%) received their results. Among these 106 women, 93 (87.7%) had a VL < 1000 copies/mL and 77 (73%) a VL < 50 copies/mL. The overall median duration from ANC booking to VL sample collection was 87 (IQR, 7-215) days. The median time interval for the return of VL results from date of sample collection was 14 days (IQR, 7-30). There was no significant difference when this variable was stratified by time of ART initiation. VL samples were significantly less likely to be collected at local authority compared to government facilities (aOR = 0.28; 95% CI 0.16-0.48). Barriers to VL testing included staff shortages, non-availability of consumables and sub-optimal sample transportation. Turnaround time was prolonged by the manual results feedback system.

CONCLUSIONS AND RECOMMENDATION

The low rate of HIV VL testing among PWLHIV in Mutare district is a cause for concern. To reverse this situation, the Ministry of Health should consider interventions such as disseminating antiretroviral guidelines and policies electronically, conducting regular PMTCT mentorship for clinical staff members, and utilising point of care testing and telecommunication devices like mHealth to increase uptake of VL testing and improve results turnaround time.

Antibiotic use amongst pregnant women in a public hospital in KwaZulu-Natal

Background

Antibiotics are amongst the more frequently prescribed medicines in pregnant women and the use of antibiotics is increasing. However, with limited studies available in this population, the safe use of antibiotics in pregnancy remains a concern.

Aim

To evaluate the use of antibiotics amongst pregnant women attending a public health care facility. The main objective of this study was to quantify the types of antibiotics used in pregnant women.

Setting

A public hospital classified as a referral hospital located in Durban, KwaZulu-Natal.

Methods

Demographic and treatment information of women were collected retrospectively from January 2019 to July 2019. A total of 184 pregnant patients, who received antibiotic therapy, were included in this study. Descriptive and analytical measures were used to analyse both patient demographics and treatment variables.

Results

A total of 416 antibiotic prescriptions, issued to 184 patients, were reviewed. Penicillins (39.7%), macrolides (13.0%) and combination penicillin- and beta-lactam inhibitors (12.3%) were reported as the most commonly prescribed antibiotics. Rifamycin (2.9%), hydrazides (2.2%) and aminoglycosides (1.9%) were less frequently prescribed. Most antibiotics were prescribed for diseases of the circulatory system (36.1%).

Conclusion

Several classes of antibiotics were used in pregnancy despite the lack of available safety data and clinical evidence. Informing women of the potential side effects and keeping abreast with new information played an important role in the safe, rational and effective use of medicines that contributed to improving maternal health.

Achieving maternal viral load suppression for elimination of mother-to-child transmission of HIV in South Africa

OBJECTIVE

To describe changes in maternal viral control over time in South African women living with HIV (WLHIV) using surveillance data from the National Health Laboratory Service's Corporate Data Warehouse (NHLS CDW).

DESIGN

A retrospective cohort analysis of maternal viral load during pregnancy and up to 15 months postpartum was performed amongst WLHIV (15-49 years) within the public-health sector between 2016 and 2017.

METHODS

HIV and pregnancy-related test data were used to create a synthetic cohort of pregnant WLHIV from the NHLS CDW. Syphilis-screening, in association with ward type and/or postpregnancy cervical screening and/or birth HIV test and/or positive β-hCG, was used as a proxy for pregnancy. The syphilis-screening date marked the first antenatal care visit (fANC). Fractional polynomial models described viral load evolution from fANC up to 15 months postdelivery. Piecewise linear regression models determined factors associated with viral load decline.

FINDINGS

Among 178 319 pregnant WLHIV, 345 174 viral load tests were performed [median = 2 (IQR: 2-3) per woman]. At fANC, 85 545 (48%) women were antiretroviral therapy (ART) experienced; 88 877 (49.8%) were not and 3897 (2.2%) unknown. Proportions of viraemia (viral load ≥50 copies/ml) were 39 756 (53.6%) at first viral load performed during pregnancy, 14 780 (36.9%) at delivery and 24 328 (33.5%) postpartum. Maternal age at least 25 years, CD4+ cell count at least 500 cells/μl and viral load less than 50 copies/ml at baseline predicted sustained viral load suppression during follow-up.

CONCLUSION

Despite high-ART coverage among pregnant women in South Africa, only 63% of WLHIV achieved viral load less than 50 copies/ml at delivery. Maternal viral load monitoring requires prioritization for maternal health and eMTCT.

Hospitalization and Predictors of Inpatient Mortality among HIV-Infected Patients in Jimma University Specialized Hospital, Jimma, Ethiopia: Prospective Observational Study

Despite the number of patients enrolled in ART is increased, HIV/AIDS continues to constitute a significant proportion of medical admissions and risk of mortality in low- and middle-income countries. As one of these countries, the case in Ethiopia is not different. The aim of this study was thus to assess reasons for hospitalization, discharge outcomes, and predictors of inpatient mortality among people living with HIV (PLWH) in Jimma University Specialized Hospital (JUSH), Jimma, Southwest Ethiopia. Prospective observational study was conducted in medical wards of JUSH from February 17^th to August 17^th, 2017. In this study, 101 PLWH admitted during the study period were included. To identify the predictors of mortality, multiple logistic regression analysis was employed. Of the 101 hospitalized PLWH, 62 (61.4%) of them were females and most of them (52.5%) were between 25 and 34 years of age. A majority (79.2%) of the study participants were known HIV patients, before their admission. Tuberculosis (24.8%), infections of the nervous system (18.8%), and pneumonia (9.9%) comprised more than half of the reasons for hospitalization. Moreover, drug-related toxicity was a reason for hospitalization of 6 (5.9%) patients. Outcomes of hospitalization indicated that the overall inpatient mortality was 18 (17.8%). The median CD4 cell counts for survivors and deceased patients were 202 cells/μL (IQR, 121–295 cells/μL) and 70 cells/μL (IQR, 42–100 cells/μL), respectively. Neurologic complications (AOR = 13.97; 95% CI: 2.32–84.17, P = 0.004), CD4 count ≤ 100 cells/μl (AOR = 16.40; 95% CI: 2.88–93.42, P = 0.002), and short hospital stay (AOR = 12.98, 95% CI: 2.13–78.97, P = 0.005) were found to be significant predictors of inpatient mortality. In conclusion, opportunistic infections are the main reason of hospitalization in PLWH.

Viral suppression and factors associated with failure to achieve viral suppression among pregnant women in South Africa

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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.

Detectable HIV-RNA Viral Load Among HIV-Infected Pregnant Women on Treatment in Northern Uganda

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.