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van Vollenhoven H, Kalk E, Kroon SM, Maseko T, Phelanyane F, Euvrard J, Fourie L, le Roux N, Nongena P. Effects of the COVID-19 pandemic on early infant diagnosis of HIV in Cape Town, South Africa. South Afr J HIV Med 2024; 25:1542. [PMID: 38628908 PMCID: PMC11019036 DOI: 10.4102/sajhivmed.v25i1.1542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/19/2023] [Indexed: 04/19/2024] Open
Abstract
Background In South Africa, infants who are HIV-exposed are tested for HIV at birth and 10 weeks of age. The COVID-19 pandemic lockdown restrictions resulted in reduced access to healthcare services and uncertain impact on early infant HIV testing. Objectives To describe the effects of the COVID-19 pandemic lockdown restrictions on early infant HIV testing and diagnosis in Cape Town, South Africa. Method This retrospective cohort study compares HIV-exposed infants born during the first COVID-19 pandemic lockdown (2020) to those born in the same period the year before (2019). Laboratory and other data were abstracted from the Provincial Health Data Centre. Results A total of 2888 infants were included: 1474 born in 2020 and 1413 in 2019. Compared to 2019, there was an increase in the 10-week HIV polymerase chain reaction (PCR) uptake in 2020 (71% vs. 60%, P < 0.001). There was also an increase in the proportion of infants who demised without 10-week testing or were lost to follow-up in 2020 compared to 2019 (8% vs. 5%, P = 0.017). Differences detected in birth HIV PCR positivity rates between the two groups (1.1% vs. 0.5%, P = 0.17) did not reach statistical significance; however, a significant increase in vertical transmission of HIV by 10 weeks old was found in the 2020 cohort (1.2% vs. 0.5%. P = 0.046). Conclusion Vertical transmission of HIV at 10 weeks increased in the Cape Town Metropolitan during the initial COVID-19 lockdown. There was also an increase in the proportion of deaths without testing by 10 weeks in the 2020 group.
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Affiliation(s)
- Hendrike van Vollenhoven
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Emma Kalk
- School of Public Health, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
| | - Stuart M. Kroon
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Tafadzwa Maseko
- Family Medicine and Population Health (FAMPOP), Department of Epidemiology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Florence Phelanyane
- Health Intelligence Directorate, Western Cape Department of Health, Cape Town, South Africa
| | - Jonathan Euvrard
- Health Intelligence Directorate, Western Cape Department of Health, Cape Town, South Africa
| | - Lezanne Fourie
- Department of Neonatology, Mowbray Maternity Hospital, Cape Town, South Africa
| | - Nicolene le Roux
- HIV/AIDS, STI’s and Tuberculosis Directorate (HAST), New Somerset Hospital, Cape Town, South Africa
| | - Phumza Nongena
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Jiang W, Ronen K, Osborn L, Drake AL, Unger JA, Matemo D, Richardson BA, Kinuthia J, John-Stewart G. Programmatic Retention in Prevention of Mother-to-Child Transmission (PMTCT) Programs: Estimated Rates and Cofactors Using Different Nonretention Measures. J Acquir Immune Defic Syndr 2023; 92:106-114. [PMID: 36215980 PMCID: PMC9839514 DOI: 10.1097/qai.0000000000003117] [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: 04/05/2022] [Accepted: 09/13/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Prevention of mother-to-child transmission programs serve women continuing and initiating antiretroviral therapy (ART) in pregnancy, and follow-up schedules align to delivery rather than ART initiation, making conventional HIV retention measures (assessed from ART initiation) challenging to apply. We evaluated 3 measures of peripartum nonretention in Kenyan women living with HIV from pregnancy to 2 years postpartum. METHODS This longitudinal analysis used programmatic data from the Mobile WAChX trial (NCT02400671). Outcomes included loss to follow-up (LTFU) (no visit for ≥6 months), incomplete visit coverage (<80% of 3-month intervals with a visit), and late visits (>2 weeks after scheduled date). Predictors of nonretention were determined using Cox proportional hazards, log-binomial, and generalized estimating equation models. RESULTS Among 813 women enrolled at a median of 24 weeks gestation, incidence of LTFU was 13.6/100 person-years; cumulative incidence of LTFU by 6, 12, and 24 months postpartum was 16.7%, 20.9%, and 22.5%, respectively. Overall, 35.5% of women had incomplete visit coverage. Among 794 women with 12,437 scheduled visits, a median of 11.1% of visits per woman were late (interquartile range 4.3%-23.5%). Younger age, unsuppressed viral load, unemployment, ART initiation in pregnancy, and nondisclosure were associated with nonretention by all measures. Partner involvement was associated with better visit coverage and timely attendance. Women who became LTFU had higher frequency of previous late visits (16.7% vs. 7.7%, P < 0.0001). CONCLUSIONS Late visit attendance may be a sentinel indicator of LTFU. Identified cofactors of prevention of mother-to-child transmission programmatic retention may differ depending on retention measure assessed, highlighting the need for standardized measures.
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Affiliation(s)
- Wenwen Jiang
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Keshet Ronen
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Lusi Osborn
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Alison L. Drake
- Global Health, University of Washington, Seattle, Washington, USA
| | - Jennifer A. Unger
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA, Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Daniel Matemo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Barbra A. Richardson
- Departments of Biostatistics and Global Health, University of Washington, Division of Vaccine and Infectious Disease, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - John Kinuthia
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
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Vertical HIV transmission within 18 months post partum among women on lifelong antiretroviral therapy for HIV in Dar es Salaam, Tanzania: a prospective cohort study. Lancet HIV 2023; 10:e33-e41. [PMID: 36495896 DOI: 10.1016/s2352-3018(22)00289-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The UNAIDS estimate of vertical HIV transmission in Tanzania is high (11%), despite 84% uptake of antiretroviral therapy (ART) among pregnant women with HIV. We aimed to evaluate vertical transmission and its determinants by 18 months post partum among women on lifelong ART in routine health-care settings in Tanzania. METHODS We conducted a prospective cohort study in 226 health facitilies across Dar-es-Salaam, Tanzania. Eligible participants were pregnant women of any age with HIV, and later their infants, who enrolled in routine health-care services for the prevention of vertical transmission. We prospectively followed up mother-infant pairs at routine monthly visits until 18 months post partum and extracted data from the care and treatment clinic (CTC2) database, a national electronic database that stores patient-level HIV care and treatment clinic data. The primary outcome was time from birth to HIV diagnosis, defined as a positive infant HIV DNA PCR or antibody test from age 18 months. We used the Kaplan-Meier method to estimate cumulative risk of vertical transmission by 18 months post partum and Cox proportional hazards regression with shared frailties to account for potential clustering in health facilities to evaluate predictors of transmission. FINDINGS Between Jan 1, 2015, and Dec 31, 2017, 22 930 pregnant women with HIV (median age 30 years, IQR 25-34) enrolled on a care programme. After excluding 9140 (39·9%) women and 539 (2·4%) infants with missing outcome data, 13 251 (59·0%) mother-infant pairs were analysed, of whom 6072 (45·8%) women were already on ART before pregnancy. By 18 months post partum, 159 (1·2%) of 13 251 infants were diagnosed with HIV, equivalent to a risk of vertical transmission of 1·4% (95% CI 1·2-1·6). In the complete case analysis, the rates of vertical transmission were higher among women who enrolled in the third trimester of pregnancy than among those who enrolled in the first trimester (adjusted hazard ratio 3·01, 95% CI 1·59-5·70; p=0·0003), among women with advanced HIV disease than among those with early-stage disease (1·89, 1·22-2·93; p=0·0046), and among women who were on a second-line ART regimen than among those on a first-line regimen (3·58, 1·08-11·82; p=0·037). By contrast, the rate of vertical transmission was lower among women who were already on ART at enrolment than among those starting ART at enrolment (0·39, 0·25-0·60; p<0·0001) as well as among women in high-volume clinics than among those in low-volume clinics (0·46 (0·24-0·90; p<0·0097). INTERPRETATION Provision of ART for life (WHO's option B+ recommendation) has reduced the risk of vertical transmission to less than 2% among pregnant women with HIV in routine care settings in urban Tanzania. There is still a need to improve timely HIV diagnosis and ART uptake, and to optimise follow-up for the prevention of vertical transmission and the uptake of infant HIV testing. FUNDING Swedish International Development Cooperation Agency.
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Kim E, Jonnalagadda S, Cuervo-Rojas J, Jahn A, Payne D, West C, Ogollah F, Maida A, Kayira D, Nyirenda R, Dobbs T, Patel H, Radin E, Voetsch A, Auld A. Toward elimination of mother-to-child transmission of HIV in Malawi: Findings from the Malawi Population-based HIV Impact Assessment (2015–2016). PLoS One 2022; 17:e0273639. [PMID: 36048781 PMCID: PMC9436140 DOI: 10.1371/journal.pone.0273639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/11/2022] [Indexed: 11/23/2022] Open
Abstract
Background Malawi spearheaded the development and implementation of Option B+ for prevention of mother-to-child transmission of HIV (PMTCT), providing life-long ART for all HIV-positive pregnant and breastfeeding women. We used data from the 2015–2016 Malawi Population-based HIV Impact Assessment (MPHIA) to estimate progress toward 90-90-90 targets (90% of those with HIV know their HIV-positive status; of these, 90% are receiving ART; and of these, 90% have viral load suppression [VLS]) for HIV-positive women reporting a live birth in the previous 3 years. Methods MPHIA was a nationally representative household survey; consenting eligible women aged 15–64 years were interviewed on pregnancies and outcomes, including HIV status during their most recent pregnancy, PMTCT uptake, and early infant diagnosis (EID) testing. Descriptive analyses were weighted to account for the complex survey design. Viral load (VL) results were categorized by VLS (<1,000 copies/mL) and undetectable VL (target not detected/below the limit of detection). Results Of the 3,153 women included in our analysis, 371 (10.1%, 95% confidence interval [CI]: 8.8%–11.3%) tested HIV positive in the survey. Most HIV-positive women (84.2%, 95% CI: 79.9%–88.6%) reported knowing their HIV-positive status; of these, 94.9% (95% CI: 91.7%–98.2%) were receiving ART; and of these, 91.2% (95% CI: 87.4%–95.0%) had VLS. Among the 371 HIV-positive women, 76.0% (95% CI: 70.4%–81.7%) had VLS and 66.5% (95% CI: 59.8%–73.2%) had undetectable VL. Among 262 HIV-exposed children, 50.8% (95% CI: 42.8%–58.8%) received EID testing within 2 months of birth, whereas 17.9% (95% CI: 11.9%–23.8%) did not receive EID testing. Of 190 HIV-exposed children with a reported HIV test result, 2.1% (95% CI: 0.0%–4.6%) had positive results. Conclusions MPHIA data demonstrate high PMTCT uptake at a population level. However, our results identify some gaps in VLS in postpartum women and EID testing.
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Affiliation(s)
- Evelyn Kim
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
- * E-mail:
| | - Sasi Jonnalagadda
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Juliana Cuervo-Rojas
- ICAP at Columbia University, New York, NY, United States of America
- Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Andreas Jahn
- Division of HIV and AIDS, Ministry of Health, Government of Malawi, Lilongwe, Malawi
| | - Danielle Payne
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Christine West
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Francis Ogollah
- ICAP at Columbia University, New York, NY, United States of America
| | - Alice Maida
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Dumbani Kayira
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Rose Nyirenda
- Division of HIV and AIDS, Ministry of Health, Government of Malawi, Lilongwe, Malawi
| | - Trudy Dobbs
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Hetal Patel
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Elizabeth Radin
- ICAP at Columbia University, New York, NY, United States of America
| | - Andrew Voetsch
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Andrew Auld
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
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Bhushan NL, Stockton MA, Harrington BJ, DiPrete BL, Maliwichi M, Jumbe AN, Kulisewa K, Chagomerana MB, Pence BW, Gaynes BN, Hosseinipour MC. Probable perinatal depression and social support among women enrolled in Malawi's Option B+ Program: A longitudinal analysis. J Affect Disord 2022; 306:200-207. [PMID: 35314248 PMCID: PMC9681029 DOI: 10.1016/j.jad.2022.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 11/19/2021] [Accepted: 03/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Malawi's PMTCT Option B+ program has expanded the reach of ART services among pregnant and breastfeeding women, but retention in lifelong HIV care remains challenging. Given that depression can undermine retention, it is important to understand how depression changes over the perinatal period, varies across treatment and retention groups, and could be buffered by social support. METHODS Data are from an observational study conducted among women enrolled in Malawi's PMTCT Option B+ program. We used multilevel generalized linear models to estimate the odds of probable depression by time, treatment and retention group, and social support. Probable depression was assessed with the Edinburgh Postnatal Depression Scale and Patient Health Questionnaire-9. RESULTS Of 468 women, 15% reported probable depression at antenatal enrollment and prevalence differed across newly diagnosed individuals, second line therapy users, and previous defaulters (18%, 21%, 5%, p = 0.001). Odds of probable perinatal depression decreased over time (OR per month: 0.87, 95% CI: 0.82-0.92) but were higher among those newly diagnosed (OR: 3.25, 95% CI: 1.59-6.65) and on second line therapy (OR: 3.39, 95% CI: 1.44-7.99) as compared to previous defaulters. Odds of probable postpartum depression were lower for participants with high social support (OR: 0.19, 95% CI: 0.09-0.39). LIMITATIONS Lack of diagnostic psychiatric evaluation precludes actual diagnosis of depression. CONCLUSIONS Probable depression varied across the perinatal period and across treatment and retention groups. Social support was protective for postpartum depression among all participants. Depression screening and provision of social support should be considered in PMTCT programs.
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Affiliation(s)
- Nivedita L. Bhushan
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | | | - Bethany L. DiPrete
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | | | | | | | - Brian W. Pence
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Bradley N. Gaynes
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Mina C. Hosseinipour
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,UNC Project, Lilongwe, Malawi
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Retention in care and viral suppression in the PMTCT continuum at a large referral facility in western Kenya. AIDS Behav 2022; 26:3494-3505. [PMID: 35467229 PMCID: PMC9550706 DOI: 10.1007/s10461-022-03666-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2022] [Indexed: 11/20/2022]
Abstract
Medical records of pregnant and postpartum women living with HIV and their infants attending a large referral facility in Kenya from 2015 to 2019 were analyzed to identify characteristics associated with retention in care and viral suppression. Women were stratified based on the timing of HIV care enrollment: known HIV-positive (KHP; enrolled pre-pregnancy) and newly HIV-positive (NHP; enrolled during pregnancy). Associations with retention at 18 months postpartum and viral suppression (< 1000 copies/mL) were determined. Among 856 women (20% NHP), retention was 83% for KHPs and 53% for NHPs. Viral suppression was 88% for KHPs and 93% for NHPs, but 19% of women were missing viral load results. In a competing risk model, viral suppression increased by 18% for each additional year of age but was not associated with other factors. Overall, 1.9% of 698 infants with ≥ 1 HIV test result were HIV-positive. Tailored interventions are needed to promote retention and viral load testing, particularly for NHPs, in the PMTCT continuum.
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van Lettow M, Tippett Barr BA, van Oosterhout JJ, Schouten E, Jahn A, Kalua T, Auld A, Nyirenda R, Wadonda N, Kim E, Landes M. The National Evaluation of Malawi's PMTCT Program (NEMAPP) study: 24-month HIV-exposed infant outcomes from a prospective cohort study. HIV Med 2021; 23:573-584. [PMID: 34970836 PMCID: PMC9303195 DOI: 10.1111/hiv.13209] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/21/2021] [Accepted: 11/09/2021] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Data on long-term HIV-free survival in breastfeeding, HIV-exposed infants (HEIs) are limited. The National Evaluation of Malawi's Prevention of Mother-to-Child Transmission (PMTCT) Program (NEMAPP), conducted between 2014 and 2018, evaluated mother-to-child transmission (MTCT) and infant outcomes up to 24 months postpartum. METHODS We enrolled a nationally representative cohort of HEIs at 54 health facilities across four regional strata in Malawi and used multivariable Cox regression analysis to investigate the risk of adverse outcomes (HIV transmission, infant death and loss to follow-up) to 24 months postpartum. Models, controlling for survey design, were fitted for the total cohort (n = 3462) and for a subcohort that received maternal viral load (VL) monitoring (n = 1282). RESULTS By 24 months, in 3462 HEIs, weighted cumulative MTCT was 4.9% [95% confidence interval (CI) 3.7-6.4%], 1.3% (95% CI 0.8-2.2%) of HEIs had died, 26.2% (95% CI 24.0-28.6%) had been lost to follow-up and 67.5% (95% CI 65.0-70.0%) were alive and HIV-free. Primiparity [weighted adjusted hazard ratio (aHR) 1.6; 95% CI 1.1-2.2; parity 2-3: weighted aHR 1.5; 95% CI 1.2-1.9], the mother not disclosing her HIV status to her partner (no disclosure: weighted aHR 1.3; 95% CI 1.1-1.6; no partner: weighted aHR 0.7; 95% CI 0.5-0.9), unknown maternal ART start (weighted aHR 2.0; 95% CI 1.0-3.9) and poor adherence (missed ≥ 2 days of ART in the last month: weighted aHR 1.7; 95% CI 1.2-2.2; not on ART: weighted aHR 1.7; 95% CI 1.0-2.7) were associated with adverse outcomes by 24 months. In the subcohort analysis, risk of HIV transmission or infant death was higher among HEIs whose mothers started ART post-conception (during pregnancy: weighted aHR 3.2; 95% CI 1.3-7.7; postpartum: weighted aHR 12.4; 95% CI 1.5-99.6) or when maternal viral load at enrolment was > 1000 HIV-1 RNA copies/mL (weighted aHR 15.7; 95% CI 7.8-31.3). CONCLUSIONS Infant positivity and infant mortality at 24 months were low for a breastfeeding population. Starting ART pre-conception had the greatest impact on HIV-free survival in HEIs. Further population-level reduction in MTCT may require additional intervention during breastfeeding for women new to PMTCT programmes. Pre-partum diagnosis and linkage to ART, followed by continuous engagement in care during breastfeeding can further reduce MTCT but are challenging to implement.
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Affiliation(s)
- Monique van Lettow
- Dignitas International, Zomba, Malawi.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Nyanja Health Research Institute, Salima, Malawi
| | - Beth A Tippett Barr
- Nyanja Health Research Institute, Salima, Malawi.,US Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi.,Department of Medicine, College of Medicine University of Malawi, Blantyre, Malawi
| | | | - Andreas Jahn
- Malawi Ministry of Health, Department of HIV and AIDS, Lilongwe, Malawi.,International Training Education and Community Health (ITECH), Lilongwe, Malawi
| | - Thokozani Kalua
- Malawi Ministry of Health, Department of HIV and AIDS, Lilongwe, Malawi
| | - Andrew Auld
- US Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Rose Nyirenda
- Malawi Ministry of Health, Department of HIV and AIDS, Lilongwe, Malawi
| | - Nellie Wadonda
- US Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Evelyn Kim
- US Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Megan Landes
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Nyanja Health Research Institute, Salima, Malawi.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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Outcomes of retained and disengaged pregnant women living with HIV in Uganda. PLoS One 2021; 16:e0251413. [PMID: 34019568 PMCID: PMC8139492 DOI: 10.1371/journal.pone.0251413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 04/26/2021] [Indexed: 02/03/2023] Open
Abstract
Introduction Loss-to-follow-up among women living with HIV (WLWHIV) may lead to unfavorable outcomes for both mother and exposed infant. This study traced WLWHIV disengaged from care and their infants and compared their outcomes with those retained in care. Methods The study included WLWHIV who initiated ART during pregnancy at six public clinics in Uganda. A woman was defined as disengaged (DW) if she had not attended her 6-week post-partum visit by 10 weeks after her estimated date of delivery. DW were matched with retained women (RW) by age and duration on ART. Nurse counselors traced all selected DW via telephone and community visits to assess vital status, infant HIV sero-status and maternal HIV viral load through blood draws. Results Between July 2017 and July 2018, 734 women (359 DW and 375 RW) were identified for the study. Tracing was attempted on 349 DW and 160 (44.6%) were successfully located and enrolled in the study. They were matched with 162 RW. Among DW, 52 (32.5%) transferred to another health facility. Very few DW, 39.0% were HIV virally suppressed (<1000 copies/ml) compared to RW 89.5%, P<0.001). Among 138 babies born to DW, 4.3% tested positive for HIV compared to 1.4% among babies born to RW (P = 0.163). Conclusion Pregnant and breastfeeding WLWHIV who disengage from care are difficult to find in urban environments. Many have detectable viral loads, leading to the potential for an increased risk of MTCT. Efforts to reduce disengagement from care are critical for the successful elimination of MTCT in resource-limited settings.
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Nydal SM, Munyaw Y, Bruun JN, Brantsæter AB. Achievements and Challenges in the Prevention of Mother-to-Child Transmission of HIV-A Retrospective Cohort Study from a Rural Hospital in Northern Tanzania. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18052751. [PMID: 33803114 PMCID: PMC7967482 DOI: 10.3390/ijerph18052751] [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] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/25/2021] [Accepted: 03/03/2021] [Indexed: 12/04/2022]
Abstract
Despite the goal of eliminating new human immunodeficiency virus (HIV) infections in children, mother-to-child transmission is still common in resource-poor countries. The aims of this study were to assess the occurrence of mother-to-child transmission of HIV (MTCT) by age 18 months, risk factors for transmission, and the implementation of the national prevention of MTCT (PMTCT) program in a rural hospital in Tanzania. Data were collated from various medical registers and records. We included 172 children and 167 HIV-infected mothers. Among 88 children (51%) with adequate information, 9 (10.2%) were infected. Increased risk of MTCT was associated with late testing of the child (>2 months) [OR = 9.5 (95% CI: 1.8–49.4)], absence of antiretroviral therapy during pregnancy [OR = 9.7 (95% CI: 2.1–46.1)], and maternal CD4 cell count <200 cells/mm3 [OR = 15.3 (95% CI: 2.1–111)]. We were unable to determine the occurrence of MTCT transmission in 84 children (49%). The results from this study highlight that there is an urgent need for enhanced efforts to improve follow-up of HIV-exposed children, to improve documentation in registries and records, and to facilitate ease of linkage between these.
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Affiliation(s)
- Sunniva Marie Nydal
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, P.O. Box 1171, Blindern, 0318 Oslo, Norway; (S.M.N.); (J.N.B.)
| | - Yuda Munyaw
- Department of Obstetrics and Gynecology, Haydom Lutheran Hospital, P.O. Box 9000, Haydom, Mbulu Manyara, Tanzania;
| | - Johan N. Bruun
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, P.O. Box 1171, Blindern, 0318 Oslo, Norway; (S.M.N.); (J.N.B.)
| | - Arne Broch Brantsæter
- Department of Infectious Diseases, Ullevål Hospital, Oslo University Hospital, P.O. Box 4956, Nydalen, 0424 Oslo, Norway
- Department of Acute Medicine, Ullevål Hospital, Oslo University Hospital, P.O. Box 4956, Nydalen, 0424 Oslo, Norway
- Correspondence:
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Mbeya Munkhondya TE, Smyth RMD, Lavender T. Facilitators and barriers to retention in care under universal antiretroviral therapy (Option B+) for the Prevention of Mother to Child Transmission of HIV (PMTCT): A narrative review. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2021. [DOI: 10.1016/j.ijans.2021.100372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Haas AD, Technau KG, Pahad S, Braithwaite K, Madzivhandila M, Sorour G, Sawry S, Maxwell N, von Groote P, Tlali M, Davies MA, Egger M. Mental health, substance use and viral suppression in adolescents receiving ART at a paediatric HIV clinic in South Africa. J Int AIDS Soc 2020; 23:e25644. [PMID: 33283916 PMCID: PMC7720277 DOI: 10.1002/jia2.25644] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/23/2020] [Accepted: 11/02/2020] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Mental health problems are prevalent in adolescents living with HIV (ALHIV), often remain untreated, and may negatively affect antiretroviral therapy (ART) adherence and viral suppression. We implemented routine mental health screening at a paediatric ART clinic to improve the identification and management of mental health problems in ALHIV. In this report, we examine screening outcomes, associated patient characteristics and the odds of unsuppressed viral load in ALHIV screening positive for mental disorders. METHODS Adolescents aged 10 to 19 years attending Rahima Moosa Hospital in Johannesburg, South Africa between February 1, 2018, and January 1, 2020, were offered mental health screening at each routine HIV care visit. The screening included four pre-screening questions followed by full screening (conditional on positive pre-screening) for depression (Patient Health Questionnaire-9 [PHQ-9]), suicide (Adolescent Innovations Project [AIP]-handbook), anxiety (Generalized Anxiety Disorder-7 [GAD-7]), post-traumatic stress disorder (PTSD) (Primary Care PTSD Screen [PC-PTSD-5]) and substance use (CAGE Adapted to Include Drugs [CAGE-AID]). We assessed screening outcomes and calculated adjusted odds ratios for associations between positive screening tests at the first screen and unsuppressed viral load (>400 copies/mL) at the measurement taken closest to the date of screening, within hundred days before and one day after screening. RESULTS Out of 1203 adolescents who attended the clinic, 1088 (90.4%) were pre-screened of whom 381 (35.0%) underwent full screening, 48 (4.4%) screened positive for depression (PHQ-9 ≥10), 29 (2.8%) for suicidal concern, 24 (2.2%) for anxiety (GAD-7 ≥10), 38 (3.2%) for PTSD (PC-PTSD-5 ≥3), 18 (1.7%) for substance use (CAGE-AID ≥2) and 97 (8.9%) for any of these conditions. Positive screening for depression (aOR 2.39, 95% CI 1.02 to 5.62), PTSD (aOR 3.18, 95% CI 1.11 to 9.07), substance use (aOR 7.13, 95% CI 1.60 to 31.86), or any condition (aOR 2.17, 95% CI 1.17 to 4.02) were strongly associated with unsuppressed viral load. CONCLUSIONS ALHIV affected by mental health problems have increased rates of unsuppressed viral load and need specific clinical attention. The integration of routine mental health screening in paediatric ART programmes is a feasible approach for identifying and referring adolescents with mental health and adherence problems to counselling and psychosocial support services and if needed to psychiatric care.
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Affiliation(s)
- Andreas D Haas
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland
| | - Karl-Günter Technau
- Empilweni Services and Research Unit, Department of Paediatrics & Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shenaaz Pahad
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kate Braithwaite
- Empilweni Services and Research Unit, Department of Paediatrics & Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mampho Madzivhandila
- Empilweni Services and Research Unit, Department of Paediatrics & Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gillian Sorour
- Empilweni Services and Research Unit, Department of Paediatrics & Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shobna Sawry
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicola Maxwell
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Per von Groote
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mpho Tlali
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Matthias Egger
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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Awopegba OE, Kalu A, Ahinkorah BO, Seidu AA, Ajayi AI. Prenatal care coverage and correlates of HIV testing in sub-Saharan Africa: Insight from demographic and health surveys of 16 countries. PLoS One 2020; 15:e0242001. [PMID: 33166351 PMCID: PMC7652338 DOI: 10.1371/journal.pone.0242001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/26/2020] [Indexed: 11/19/2022] Open
Abstract
Background Prenatal screening of pregnant women for HIV is central to eliminating mother-to-child-transmission (MTCT) of HIV. While some countries in sub-Saharan Africa (SSA) have scaled up their prevention of MTCT programmes, ensuring a near-universal prenatal care HIV testing, and recording a significant reduction in new infection among children, several others have poor outcomes due to inadequate testing. We conducted a multi-country analysis of demographic and health surveys (DHS) to assess the coverage of HIV testing during pregnancy and also examine the factors associated with uptake. Methods We analysed data of 64,933 women from 16 SSA countries with recent DHS datasets (2015–2018) using Stata version 16. Adjusted and unadjusted logistic regression models were used to examine correlates of prenatal care uptake of HIV testing. Statistical significance was set at p<0.05. Results Progress in scaling up of prenatal care HIV testing was uneven across SSA, with only 6.1% of pregnant women tested in Chad compared to 98.1% in Rwanda. While inequality in access to HIV testing among pregnant women is pervasive in most SSA countries and particularly in West and Central Africa sub-regions, a few countries, including Rwanda, South Africa, Zimbabwe, Malawi and Zambia have managed to eliminate wealth and rural-urban inequalities in access to prenatal care HIV testing. Conclusion Our findings highlight the between countries and sub-regional disparities in prenatal care uptake of HIV testing in SSA. Even though no country has universal coverage of prenatal care HIV testing, East and Southern African regions have made remarkable progress towards ensuring no pregnant woman is left untested. However, the West and Central Africa regions had low coverage of prenatal care testing, with the rich and well educated having better access to testing, while the poor rarely tested. Addressing the inequitable access and coverage of HIV testing among pregnant women is vital in these sub-regions.
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Affiliation(s)
- Oluwafemi Emmanuel Awopegba
- Economics and Business Policy Department, Nigerian Institute of Social and Economic Research, Ibadan, Nigeria
| | - Amarachi Kalu
- Department of Sociology, Faculty of the Social Sciences, University of Ibadan, Ibadan, Nigeria
| | - Bright Opoku Ahinkorah
- The Australian Centre for Public and Population Health Research (ACPPHR), Faculty of Health, University of Technology, Sydney, Australia
| | - Abdul-Aziz Seidu
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Anthony Idowu Ajayi
- Population Dynamics and Reproductive Health Unit, African Population and Health Research Centre, APHRC Campus, Nairobi, Kenya
- * E-mail:
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Mugglin C, Haas AD, van Oosterhout JJ, Msukwa M, Tenthani L, Estill J, Egger M, Keiser O. Long-term retention on antiretroviral therapy among infants, children, adolescents and adults in Malawi: A cohort study. PLoS One 2019; 14:e0224837. [PMID: 31725750 PMCID: PMC6855432 DOI: 10.1371/journal.pone.0224837] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 10/22/2019] [Indexed: 12/01/2022] Open
Abstract
Objectives We examine long-term retention of adults, adolescents and children on antiretroviral therapy under different HIV treatment guidelines in Malawi. Design Prospective cohort study. Setting and participants Adults and children starting ART between 2005 and 2015 in 21 health facilities in southern Malawi. Methods We used survival analysis to assess retention at clinic level, Cox regression to examine risk factors for loss to follow up, and competing risk analysis to assess long-term outcomes of people on antiretroviral therapy (ART). Results We included 132,274 individuals in our analysis, totalling 270,256 person years of follow up (PYFU; median per patient 1.3, interquartile range (IQR) 0.26–3.1), 62% were female and the median age was 32 years. Retention on ART was lower in the first year on ART compared to subsequent years for all guideline periods and age groups. Infants (0–3 years), adolescents and young adults (15–24 years) were at highest risk of LTFU. Comparing the different calendar periods of ART initiation we found that retention improved initially, but remained stable thereafter. Conclusion Even though the number of patients and the burden on health care system increased substantially during the study period of rapid ART expansion, retention on ART improved in the early years of ART provision, but gains in retention were not maintained over 5 years on ART. Reducing high attrition in the first year of ART should remain a priority for ART programs, and so should addressing poor retention among adolescents, young adults and men.
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Affiliation(s)
- Catrina Mugglin
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- * E-mail:
| | - Andreas D. Haas
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Joep J. van Oosterhout
- Dignitas International, Zomba, Malawi
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Malango Msukwa
- Baobab Health Trust, Lilongwe, Malawi
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Lyson Tenthani
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- I-TECH Malawi, Lilongwe, Malawi
| | - Janne Estill
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Olivia Keiser
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Institute of Global Health, University of Geneva, Geneva, Switzerland
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Reidy W, Nuwagaba-Biribonwoha H, Shongwe S, Sahabo R, Hartsough K, Wu Y, Gachuhi A, Mthethwa-Hleta S, Abrams EJ. Engagement in care among women and their infants lost to follow-up under Option B+ in eSwatini. PLoS One 2019; 14:e0222959. [PMID: 31665137 PMCID: PMC6821080 DOI: 10.1371/journal.pone.0222959] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 09/10/2019] [Indexed: 11/18/2022] Open
Abstract
Background Universal antiretroviral treatment (ART) for pregnant women with HIV, Option B+, has been adopted widely for prevention of mother-to-child HIV transmission (PMTCT). Some evidence shows high loss to follow-up (LTF) under this model. However, gaps in data systems limit this evidence. We collected additional information for women and infants LTF from Option B+ in Eswatini to assess more accurate outcomes. Methods LTF at 6-months postpartum was assessed using facility data. Additional data was gathered from: 1) the national ART database and paper records; 2) patient tracing; and 3) interviews and abstraction from patient-held records. Engagement in care was defined as any clinic visit within 91 days before or after 6-months postpartum or completion of a documented transfer; or, for those traced but not completing study interviews, visits at 6-months postpartum or later (for infants), or visits within 3-months of tracing (for women). Multivariable loglinear models were used to identify correlates of engagement. Results One-hundred-ninety-four (44.7%) of 434 LTF women had outcomes ascertained, including 122 (62.9%) women engaged in care. Among 510 LTF infants, 265 (52.0%) had ascertained outcomes, including 143 (54.0%) engaged in care, 47 (17.7%) pregnancy losses, and 18 (6.8%) deaths. Seventy-two of 189 live infants (38.1%) with ascertained outcomes had a 6-week early infant diagnostic (EID) test. Among women with ascertained outcomes, gestational age of 20+ weeks (vs. fewer than 20 weeks, aRR 0.80; 95% CI 0.68–0.94) and age 25–29 years (vs. 15–24 years, aRR 0.81; 95% CI 0.67–0.97), were associated with lower engagement; initiating ART after first ANC visit was associated with higher engagement (vs. at first ANC visit, aRR 1.12; 95% CI 1.04–1.21). Among infants with ascertained outcomes, mother not initiating ART was associated with lower engagement (vs. ART at first ANC visit, aRR 0.71; 95% CI 0.54–0.91). Conclusion Substantial numbers of women and infants classified as LTF under Option B+ were engaged in care, though a suboptimal level of 6-week EID testing was observed. These findings highlight a need to improve coverage of routine EID testing, and improve data systems to better capture PMTCT patient outcomes.
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Affiliation(s)
- William Reidy
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, New York, United States of America
- * E-mail:
| | - Harriet Nuwagaba-Biribonwoha
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, New York, United States of America
| | - Siphesihle Shongwe
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Ruben Sahabo
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Kieran Hartsough
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Yingfeng Wu
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Averie Gachuhi
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | | | - Elaine J. Abrams
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, New York, United States of America
- Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, United States of America
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Brief Report: No HIV Transmission From Virally Suppressed Mothers During Breastfeeding in Rural Tanzania. J Acquir Immune Defic Syndr 2019; 79:e17-e20. [PMID: 29781882 DOI: 10.1097/qai.0000000000001758] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To what extent antiretroviral therapy (ART) reduces mother-to-child HIV transmission (MTCT) during breastfeeding remains unclear. We assessed the MTCT risk from mothers on ART to their infants during breastfeeding. SETTING Ifakara, rural Tanzania. METHODS We included infants born between January 2013 and May 2016 to mothers who initiated ART before delivery, had a negative HIV DNA polymerase chain reaction at 4-12 weeks and exclusively breastfed for ≥6 months. Mothers' plasma HIV-RNA viral loads (VLs) were measured up to 11 months postdelivery. Infants were tested for HIV following national guidelines. RESULTS Among 214 women with 218 pregnancies and 228 infants (10 twins), the median age at delivery was 33 years (interquartile range 28-36 years), and the mean time on ART was 23 months (interquartile range, 4-52 months). VL was measured twice in 53% (113/218) of pregnancies. During breastfeeding, 91% of mothers (199/218) had VL of <1000 copies per milliliter, and 75% (164/218) had <100 copies per milliliter. To November 2017, 8% (19/228) of infants were lost to follow-up (LTFU), 2% (5/228) transferred, and 8% (18/228) died before the determination of final HIV serostatus. Among the remaining 186 infants, 2 (1%; 95% confidence interval: 0.3% to 4%) were HIV positive: 1 born from a mother with high VL 1-month postdelivery and 1 from a mother who interrupted ART. Assuming a 15% MTCT risk through breastfeeding among the 42 infants LTFU, transferred, or dead, the overall MTCT risk would be 4%. CONCLUSIONS We found no MTCT from mothers who were retained in care and had suppressed VL. Breastfeeding signifies a very low risk when mothers adhere to ART. Adherence counseling, VL monitoring, and strategies to trace back those LTFU should be a priority.
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Beyond Early Infant Diagnosis: Changing the Approach to HIV-Exposed Infants. J Acquir Immune Defic Syndr 2019; 78 Suppl 2:S107-S114. [PMID: 29994832 DOI: 10.1097/qai.0000000000001736] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Despite dramatic global progress with implementing prevention of mother-to-child HIV transmission (PMTCT) programs, there were 160,000 new pediatric HIV infections in 2016. More than 50% of infant HIV infections now occur in the postpartum period, reflecting the relatively high coverage of interventions in the antenatal period and the need for greater attention to the breastfeeding mother and her HIV-exposed infant (HEI). Early diagnosis and treatment are critical to prevent morbidity and mortality in HIV-infected children; however, early infant HIV testing rates remain low in most high HIV-burden countries. Furthermore, systematic retention and follow-up of HEI in the postpartum period and ascertainment of final HIV status remain major program gaps. Despite multiple calls to action to improve infant HIV testing rates, progress has been marginal due to a lack of focus on the critical health care needs of HEI coupled with health system barriers that result in fragmented services for HIV-infected mothers and their families. In this paper, we describe the available evidence on the health outcomes of HEI, define a comprehensive care package for HEI that extends beyond early HIV testing, and describe successful examples of integrated services for HEI.
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"I do all I can but I still fail them": Health system barriers to providing Option B+ to pregnant and lactating women in Malawi. PLoS One 2019; 14:e0222138. [PMID: 31513684 PMCID: PMC6742345 DOI: 10.1371/journal.pone.0222138] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 08/22/2019] [Indexed: 11/30/2022] Open
Abstract
Malawi’s Option B+ program is based on a ‘test and treat’ strategy that places all HIV-positive pregnant and lactating women on lifelong antiretroviral therapy. The steep increase in patient load placed severe pressure on a health system that has struggled for decades with inadequate supply of health care workers (HCWs) and poor infrastructure. We set out to explore health system barriers to Option B+ by asking HCWs in Malawi about their experiences treating pregnant and lactating women. We observed and conducted semi-structured interviews (SSIs) with 34 HCWs including nine expert clients (ECs) at 14 health facilities across Malawi, then coded and analyzed the data. We found that HCWs implementing Option B+ are so overburdened in Malawi that it reduces their ability to provide quality care to patients, who receive less counseling than they should, wait longer than is reasonable, and have very little privacy. Interventions that increase the number of HCWs and upgrade infrastructure to protect the privacy of HIV-infected pregnant and lactating women and their husbands could increase retention, but facilities will need to be improved to support men who accompany their partners on clinic visits.
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Flax VL, Chapola J, Mokiwa L, Mofolo I, Swira H, Hosseinipour MC, Maman S. Infant and young child feeding learning sessions during savings groups are feasible and acceptable for HIV-positive and HIV-negative women in Malawi. MATERNAL & CHILD NUTRITION 2019; 15:e12765. [PMID: 30516880 PMCID: PMC7198955 DOI: 10.1111/mcn.12765] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 11/11/2018] [Accepted: 11/20/2018] [Indexed: 11/30/2022]
Abstract
Based on formative research, HIV-positive women in Lilongwe District, Malawi receive little infant and young child feeding (IYCF) counselling postpartum and want more support for IYCF from their husbands. To address these gaps, we implemented a behaviour change communication intervention promoting IYCF in village savings and loan associations (VSLAs) that included HIV-positive and HIV-negative women. The intervention consisted of 15 IYCF learning sessions facilitated by VSLA volunteers during regular VSLA meetings and included four sessions to which husbands were invited. We assessed the feasibility and acceptability of the intervention through learning session participation logs, structured observations of learning sessions, and in-depth interviews with HIV-positive and HIV-negative VSLA members, husbands of members, and VSLA volunteers. Nine VSLA volunteers conducted learning sessions with approximately 300-400 women, about one quarter of whom were lactating, and 25-35 men. VSLA volunteers consistently communicated technical information correctly, followed the learning session steps, and used visual aids. Sessions averaged 46 min, with <20% of observed sessions completed within the recommended time (20-25 min). Key themes from interviews were the following: (a) learning sessions were useful; (b) including HIV-positive and HIV-negative women in the sessions was acceptable; (c) information learned during sessions encouraged families to change IYCF practices; (d) IYCF messages were shared with others in the community; and (e) male participation was low because men considered VSLAs and IYCF to be women's activities. In conclusion, integrating IYCF learning sessions into VLSAs was feasible and acceptable for mixed groups of HIV-positive and HIV-negative women. Future research should test other strategies for involving men in IYCF.
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Affiliation(s)
- Valerie L. Flax
- Food, Nutrition, and Obesity Policy Research Program, RTI International, Research Triangle ParkNorth CarolinaUSA
| | | | - Lemekeza Mokiwa
- Food and Nutrition Security Department, CARE MalawiLilongweMalawi
| | | | - Henry Swira
- Food and Nutrition Security Team, CARE USAAtlantaGeorgiaUSA
| | - Mina C. Hosseinipour
- UNC Project‐MalawiLilongweMalawi
- Department of Medicine, School of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Suzanne Maman
- Department of Health Behavior, Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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Msukwa MT, Keiser O, Jahn A, Van Oosterhout JJ, Edmonds A, Phiri N, Manjomo R, Davies MA, Estill J. Timing of combination antiretroviral therapy (cART) initiation is not associated with stillbirth among HIV-infected pregnant women in Malawi. Trop Med Int Health 2019; 24:727-735. [PMID: 30891866 PMCID: PMC7137352 DOI: 10.1111/tmi.13233] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To assess the association between timing of maternal combination ART (cART) initiation and stillbirth among HIV-infected pregnant women in Malawi's Option B+ programme. METHODS Cohort study of HIV-infected pregnant women delivering singleton live or stillborn babies at ≥28 weeks of gestation using routine data from maternity registers between 1 January 2012 and 30 June 2015. We defined stillbirth as death of a foetus at ≥28 weeks of gestation. We report proportions of stillbirth according to timing of maternal cART initiation (before pregnancy, 1st or 2nd trimester, or 3rd trimester or labour). We used logistic regression, with robust standard errors to account for clustering of women within health facilities, to investigate the association between timing of cART initiation and stillbirth. RESULTS Of 10 558 mother-infant pairs abstracted from registers, 8380 (79.4%) met inclusion criteria. The overall rate of stillbirth was 25 per 1000 deliveries (95% confidence interval 22-29). We found no significant association between timing of maternal cART initiation and stillbirth. In multivariable models, older maternal age, male sex of the infant, breech vaginal delivery, delivery at < 34 weeks of gestation and experience of any maternal obstetric complication were associated with higher odds of stillbirth. Deliveries managed by a mission hospital or health centre were associated with lower odds of stillbirth. CONCLUSION Pregnant women's exposure to cART, regardless of time of its initiation, was not associated with increased odds of stillbirth.
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Affiliation(s)
- Malango T. Msukwa
- Institute of Global Health, University of Geneva, Geneva, Switzerland
- Baobab Health Trust, Lilongwe, Malawi
| | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Andreas Jahn
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Joep J. Van Oosterhout
- Dignitas International, Zomba, Malawi
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Andrew Edmonds
- The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Nozgechi Phiri
- Institute of Global Health, University of Geneva, Geneva, Switzerland
- Baobab Health Trust, Lilongwe, Malawi
| | | | - Mary-Ann Davies
- Centre of Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Janne Estill
- Institute of Global Health, University of Geneva, Geneva, Switzerland
- Institute of Mathematical Statistics and Actuarial Science, University of Bern, Switzerland
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Apangu P, Izudi J, Bajunirwe F, Mulogo E, Batwala V. Retention of HIV exposed infants in care at Arua regional referral hospital, Uganda: a retrospective cohort study. BMC Public Health 2019; 19:436. [PMID: 31023290 PMCID: PMC6485049 DOI: 10.1186/s12889-019-6754-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 04/08/2019] [Indexed: 11/21/2022] Open
Abstract
Background Retention of HIV Exposed Infants (HEIs) in care ensures adequate care. Data on retention of HEIs at large referral hospitals in Uganda is limited. We investigated the retention level of HEIs and associated factors. Methods We conducted a retrospective cohort study on 352 HEIs in care (January 2014 and April 2015) at Arua Regional Referral Hospital, North-western Uganda. Electronic medical data were retrieved and analyzed with Stata. Chi-square, Fisher’s exact, and Students t-tests were used for bivariate analysis. Logistic regression was performed to determine factors independently associated with retention. Results 236 (67.0%) HEIs were delivered in a health facility and 306 (86.9%) received Nevirapine prophylaxis from birth until 6-weeks. Of mothers, 270 (76.7%) were 25–46 years, 202 (57.4%) attended antenatal care (ANC) at recent pregnancy, and 328 (93.2%) were on life-long anti-retroviral therapy. At 18-months, 277 (78.7%) HEIs were retained in care. Maternal age (25–46 years) (Adjusted Odds Ratio (AOR), 2.32; 95% CI, 1.32–4.06), ANC attendance during recent pregnancy (AOR, 2.01; 95% CI, 1.19–4.3.41) and Nevirapine prophylaxis initiation from birth until 6-weeks (AOR, 3.07; 95% CI, 1.50–6.26) were associated with retention. Conclusion Retention was suboptimal. Older maternal age, ANC visits at last pregnancy, and timely NVP initiation increased retention.
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Affiliation(s)
- Pontius Apangu
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Box 1410, Mbarara, Uganda
| | - Jonathan Izudi
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Box 1410, Mbarara, Uganda. .,Institute of Public Health and Management, Clarke International University, Box 7782, Kampala, Uganda.
| | - Francis Bajunirwe
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Box 1410, Mbarara, Uganda
| | - Edgar Mulogo
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Box 1410, Mbarara, Uganda
| | - Vincent Batwala
- Directorate of Research and Graduate Training, Mbarara University of Science and Technology, Box 1410, Mbarara, Uganda
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Singh J, Filteau S, Todd J, Gumede-Moyo S. Progress in the performance of HIV early infant diagnosis services in Zambia using routinely collected data from 2006 to 2016. BMC Public Health 2018; 18:1297. [PMID: 30477465 PMCID: PMC6258281 DOI: 10.1186/s12889-018-6222-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 11/14/2018] [Indexed: 11/22/2022] Open
Abstract
Background Early diagnosis and treatment initiation of HIV-infected infants can greatly reduce the risk of infant mortality. The WHO recommends testing HIV-exposed infants at 6 weeks of age and immediate initiation of antiretroviral therapy if positive. This study aimed to determine the feasibility of using an electronic health records system to evaluate the performance of Zambia’s HIV Early Infant Diagnosis services. Methods A retrospective analysis of routinely collected data from the Zambian SmartCare database was performed for the period January 2006 to December 2016. The study population includes all HIV-infected infants (n = 32,593) registered during this period on treatment for HIV. Univariable logistic regression was conducted to identify factors associated with later infant testing and treatment initiation. Results The mean age at infant HIV test decreased from 10.10 months in 2006 to 3.49 months in 2016. Infants born in 2015 were almost 4 times more likely to be tested under 2 months of age compared to infants born in 2006 (OR: 3.72, p-value: < 0.001). The mean time from diagnosis to treatment initiation decreased from 220 days in 2006 to 9 days in 2015. There was substantial regional variability with infants in the provinces of Copperbelt, Luapula and Southern performing best in outcomes and Eastern, Lusaka and Western performing the worst. Conclusions HIV-exposed infants born more recently have significantly better outcomes than infants born a decade ago in Zambia, which could be as a result of increased attention and funding for HIV programmes.
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Affiliation(s)
- Jasleen Singh
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Suzanne Filteau
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Jim Todd
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Sehlulekile Gumede-Moyo
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. .,School of Public Health, University of Zambia, Lusaka, Zambia.
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Weight gain of HIV-exposed, uninfected children born before and after introduction of the 'Option B+' programme in Malawi. AIDS 2018; 32:2201-2208. [PMID: 30005013 DOI: 10.1097/qad.0000000000001942] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare birth weight and weight gain in HIV-exposed, uninfected (HEU) infants up to 24 months old, who enrolled in the Malawian national HIV care clinic (HCC) programme either before or after Option B+ (OB+) was implemented. DESIGN, SETTING AND PARTICIPANTS HIV-exposed infants enrol in the HCC programme as soon as possible after birth and are followed up to at least 24 months old. This analysis includes HEU infants with recorded birth weight, date of birth, gender and at least one follow-up weight measurement from 21 health facilities in central and southern Malawi (January 2010-December 2014). Weight-for-age z scores (WAZ) were derived and compared by birth period using linear regression at birth and mixed effects models for postnatal weight gain up to 24 months old. RESULTS Of 6845 HEU infants included in this study, 88.5% were born after OB+. The proportion of infants exposed in utero to combination antiretroviral therapy (ART) significantly increased after OB+ was implemented, and infants were exposed to ART for a longer time. There was no significant difference in WAZ at birth (P = 0.654) among HEU infants by birth period, but postnatal weight gain was faster among HEU infants born in the Option B+ period than infants born pre-Option B+. CONCLUSION Birth weight was not affected by longer exposure to ART during pregnancy after OB+ was introduced, when weight gain in HEU infants was faster, possibly because their mothers were in better health.
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Steiniche D, Jespersen S, Medina C, Sanha FC, Wejse C, Hønge BL. Excessive mortality and loss to follow-up among HIV-infected children in Guinea-Bissau, West Africa: a retrospective follow-up study. Trop Med Int Health 2018; 23:1148-1156. [PMID: 30099816 DOI: 10.1111/tmi.13136] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To estimate the magnitude of mortality and loss to follow-up and describe predictors of mortality among HIV-infected children in Guinea-Bissau. METHODS Retrospective follow-up study among HIV-infected children under 15 years of age at the largest HIV-clinic in Guinea-Bissau from 2006-2016. A multivariate Cox proportional hazards model was used to identify predictors of mortality. RESULTS Of 525 children were included in the analysis: 371 (70.7%) with HIV-1, 17 (3.2%) with HIV-2, 25 (4.8%) with HIV-1/2, and 112 (21.3%) with HIV of unknown type. At diagnosis, the median age was 3.5 years, 44.7% met the WHO criteria for severe immunodeficiency by age based on CD4 cell count, and 59.4% were underweight. The median follow-up time was 6 months. Despite the availability of antiretroviral treatment, the mortality rate was 10.4 deaths per 100 person-years of follow-up. Within the first year of follow-up, 11.0% died, 3.1% were transferred and 38.8% were lost to follow-up, leaving 47.1% in follow-up. Severe immunodeficiency (adjusted hazard ratio (aHR) = 2.52, 95% CI: 1.22-5.21) and underweight (aHR = 3.14, 95% CI: 1.40-7.02) were independent predictors of mortality. CONCLUSIONS This study reveals a high rate of early mortality and loss to follow-up among HIV-infected children in Guinea-Bissau. Initiatives to improve patient retention are urgently needed.
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Affiliation(s)
- Ditte Steiniche
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Sanne Jespersen
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Candida Medina
- National HIV Programme, Ministry of Health, Bissau, Guinea-Bissau
| | | | - Christian Wejse
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark.,Center for Global Health AU, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Bo Langhoff Hønge
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
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Phiri N, Haas AD, Msukwa MT, Tenthani L, Keiser O, Tal K. "I found that I was well and strong": Women's motivations for remaining on ART under Option B+ in Malawi. PLoS One 2018; 13:e0197854. [PMID: 29874247 PMCID: PMC5991368 DOI: 10.1371/journal.pone.0197854] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 05/09/2018] [Indexed: 12/24/2022] Open
Abstract
Most Malawian women who start ART under Option B+ are still in care three years later, a higher than average adherence rate for life-threatening chronic disease treatments, worldwide (50%). We asked 75 Malawian on ART their motivations for remaining in treatment, and what barriers they overcame. Focus groups and interviews included 75 women on ART for 6+ months, at 12 health facilities. Four main motivations for continuing ART emerged: 1) evidence that ART improved their own and their children's health; 2) strong desire to be healthy and keep their children healthy; 3) treatment was socially supported; 4) HIV/ART counselling effectively showed benefits of ART and told women what to expect. Women surmounted the following barriers: 1) stigma; 2) health care system; 3) economic; 4) side effects. Women stayed on ART because they believed it works. Future interventions should focus on emphasizing ART's effectiveness, along with other services they provide.
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Affiliation(s)
- Nozgechi Phiri
- Institute of Global Health, University of Geneva, Geneva, Switzerland
- Institute for Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Baobab Health Trust, Lilongwe, Malawi
| | - Andreas D. Haas
- Institute for Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Malango T. Msukwa
- Institute of Global Health, University of Geneva, Geneva, Switzerland
- Institute for Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Baobab Health Trust, Lilongwe, Malawi
| | - Lyson Tenthani
- Institute for Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Baobab Health Trust, Lilongwe, Malawi
- International Training & Education Center for Health, Lilongwe, Malawi
| | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland
- Institute for Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Kali Tal
- Institute of Global Health, University of Geneva, Geneva, Switzerland
- Institute for Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Institute for Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
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Tenthani L, van Oosterhout JJ, Haas AD, Msukwa M, Phiri N, Chimbwandira F, Tal K, Aebi-Popp K, Estill J, Keiser O. Patterns of caesarean section in HIV infected and non-infected women in Malawi: is caesarean section used for PMTCT? BMC Pregnancy Childbirth 2018; 18:95. [PMID: 29649980 PMCID: PMC5897999 DOI: 10.1186/s12884-018-1722-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 03/28/2018] [Indexed: 11/15/2022] Open
Abstract
Background Caesarean section (CS) is not recommended for PMTCT in Malawi HIV Guidelines, contrary to most high-income countries where CS is indicated if viral suppression is sub-optimal pre-delivery. We describe patterns of CS in HIV-infected and uninfected women in Malawi and explored if insight into the use of Elective CS (ECS) for PMTCT could be obtained. Methods We used routinely collected data from individual medical records from 17 large health facilities in the central and southern regions of Malawi, from January 2010 to December 2013. We included data from maternity registers from all HIV-positive women, and randomly selected around every fourth woman with negative or unknown HIV status. We used multivariable logistic regressions and cluster-based robust standard errors to examine independent associations of patient- and facility characteristics with CS and ECS. Results We included 62,033 women in the analysis. The weighted percentage of women who had a spontaneous vaginal delivery was 80.0% (CI 95% 79.5–80.4%); 2.4% (95% CI 2.3–2.6%) had a vacuum extraction; 2.3% (95% CI 2.2–2.5%) had a vaginal breech delivery; 14.0% (95% CI 13.6–14.4%) had a CS while for 1.3% (95% CI 1.2–1.4%) the mode of delivery was not recorded. Prevalence of CS without recorded medical or obstetric indication (ECS) was 5.1%, (n = 3152). Presence of maternal and infant complications and older age were independently associated with CS delivery. HIV-positive women were less likely to have ECS than HIV negative women (aOR 0.65; 95%-CI 0.57–0.74). Among HIV-positive women, those on antiretrovirals (ARV’s) for ≥4 weeks prior to delivery were less likely to have ECS than HIV-positive women who had not received ARVs during pregnancy (aOR 0.81; 95% CI 0.68–0.96). Conclusions The pattern of CS’s in Malawi is largely determined by maternal and infant complications. Positive HIV status was negatively associated with CS delivery, possibly because health care workers were concerned about the risk of occupational HIV transmission and the known increased risk of post-operative complications. Our results leave open the possibility that CS is practiced to prevent MTCT given that ECS was more common among women at high risk of MTCT due to no or short exposure to ARV’s. Electronic supplementary material The online version of this article (10.1186/s12884-018-1722-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lyson Tenthani
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi. .,Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland. .,International Training and Education Center for Health, P.O Box 30369, Lilongwe 3, Malawi.
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi.,Department of Medicine, College of Medicine, Blantyre, Malawi
| | - Andreas D Haas
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Malango Msukwa
- The Baobab Health Trust, Lilongwe, Malawi.,Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Nozgechi Phiri
- The Baobab Health Trust, Lilongwe, Malawi.,Institute of Global Health, University of Geneva, Geneva, Switzerland
| | | | - Kali Tal
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Karoline Aebi-Popp
- Department of Infectious Diseases, University Hospital Bern, Bern, Switzerland
| | - Janne Estill
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Institute of Global Health, University of Geneva, Geneva, Switzerland.,Institute of Mathematical Statistics and Actuarial Science, University of Bern, Bern, Switzerland
| | - Olivia Keiser
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Institute of Global Health, University of Geneva, Geneva, Switzerland
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Vrazo AC, Firth J, Amzel A, Sedillo R, Ryan J, Phelps BR. Interventions to significantly improve service uptake and retention of HIV-positive pregnant women and HIV-exposed infants along the prevention of mother-to-child transmission continuum of care: systematic review. Trop Med Int Health 2017; 23:136-148. [PMID: 29164754 DOI: 10.1111/tmi.13014] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Despite the success of Prevention of Mother-to-Child Transmission of HIV (PMTCT) programmes, low uptake of services and poor retention pose a formidable challenge to achieving the elimination of vertical HIV transmission in low- and middle-income countries. This systematic review summarises interventions that demonstrate statistically significant improvements in service uptake and retention of HIV-positive pregnant and breastfeeding women and their infants along the PMTCT cascade. METHODS Databases were systematically searched for peer-reviewed studies. Outcomes of interest included uptake of services, such as antiretroviral therapy (ART) such as initiation, early infant diagnostic testing, and retention of HIV-positive pregnant and breastfeeding women and their infants. Interventions that led to statistically significant outcomes were included and mapped to the PMTCT cascade. An eight-item assessment tool assessed study rigour. PROSPERO ID CRD42017063816. RESULTS Of 686 citations reviewed, 11 articles met inclusion criteria. Ten studies detailed maternal outcomes and seven studies detailed infant outcomes in PMTCT programmes. Interventions to increase access to antenatal care (ANC) and ART services (n = 4) and those using lay cadres (n = 3) were most common. Other interventions included quality improvement (n = 2), mHealth (n = 1), and counselling (n = 1). One study described interventions in an Option B+ programme. Limitations included lack of HIV testing and counselling and viral load monitoring outcomes, small sample size, geographical location, and non-randomized assignment and selection of participants. CONCLUSIONS Interventions including ANC/ART integration, family-centred approaches, and the use of lay healthcare providers are demonstrably effective in increasing service uptake and retention of HIV-positive mothers and their infants in PMTCT programmes. Future studies should include control groups and assess whether interventions developed in the context of earlier 'Options' are effective in improving outcomes in Option B+ programmes.
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Affiliation(s)
- Alexandra C Vrazo
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Jacqueline Firth
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Anouk Amzel
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Rebecca Sedillo
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Julia Ryan
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - B Ryan Phelps
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
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