Measurement of body composition in postpartum South African women living with and without HIV infection

Background

While several methodologies are available to measure adiposity, few have been validated in sub-Saharan African (SSA) and none in postpartum African women living with HIV (WLHIV). We compared bioelectrical impendence analysis (BIA) and air displacement plethysmography (ADP) against dual x-ray absorptiometry (DXA) in South African women and examined differences by HIV and body mass index (BMI) status.

Methods

Lin's concordance correlation coefficient (CCC) test was used to examine fat mass (FM), fat free mass (FFM), and total body fat percent (%BF) difference between BIA vs. DXA, and ADP vs. DXA in women living with HIV (n = 57) and without HIV (n = 25). The Bland Altman test was used to assess mean differences and the direction of bias.

Results

The median age was 31 years (IQR, 26-35) and months postpartum were 11 (IQR, 7-16), 44% of the women had obesity. Lin's CCC for BIA and ADP vs. DXA were both 0.80 for %BF and 0.97 for FM, and 0.86 and 0.80 for FFM, respectively. Mean differences (DXA-BIA and ADP estimates) were 0.22 ± 4.54% (p = 0.54) and 3.35 ± 3.27% (p < 0.01) for %BF, -0.82 ± 3.56 kg (p = 0.06) and 1.43 ± 2.68 kg (p = 0.01) for FM, -1.38 ± 3.61 kg (p = 0.01) and - 3.34 ± 2.37 kg (p < 0.01) for FFM, respectively. BIA overestimated %BF in WLHIV and underestimated it in women with obesity.

Conclusion

Body composition measurements using BIA and ADP correlated well with DXA, thereby providing alternative, safe tools for measuring postpartum FM and FFM in SSA women, including WLHIV.

Associations of HIV and antiretroviral therapy with gestational diabetes in South Africa

OBJECTIVE

To estimate associations of HIV status and antiretroviral (ART) regimen with gestational diabetes (GDM) and postpartum glucose metabolism.

DESIGN

Prospective cohort study.

METHODS

We enrolled pregnant persons with HIV (PWH) and without HIV in Cape Town, South Africa who were at least 18 years of age at 24-28 weeks' gestation and followed up to 26 months postpartum. Participants were tested for GDM in pregnancy and for diabetes postpartum using a 75 g 2 h oral glucose tolerance test (OGTT) and diagnosed via WHO criteria. We estimated associations of HIV status and ART regime [efavirenz (EFV) versus dolutegravir (DTG)] with GDM and postpartum impaired glucose metabolism using multivariable log binomial or linear regression models.

RESULTS

Among 397 participants [median age 30 (interquartile range (IQR) 25-34; n  = 198 without HIV, n  = 199 PWH], the prevalence of GDM was 6% (9 PWH versus 3% without HIV). In multivariable analyses, PWH were at higher risk of GDM [risk ratio (RR) 3.9, 95% confidence interval (CI) 1.4-10.7] after adjustment for prepregnancy BMI and other confounders. GDM risk did not differ by ART regimen (unadjusted prevalence 8.1% DTG versus 5.6% EFV, adjusted RR 1.1, 95% CI 0.2-6.6). Few participants had diabetes, impaired glucose tolerance (IGT), or impaired fasting glucose postpartum ( n  = 13, 6%) with no differences by HIV or ART status.

CONCLUSION

In a setting of universal GDM testing, PWH had an increased risk of impaired glucose metabolism during pregnancy but not postpartum. Among PWH, GDM risk was similar regardless of EFV or DTG use. Given concerns about DTG and weight gain, diabetes risk should continue to be monitored.

An Intervention to Improve Mental Health and HIV Care Engagement Among Perinatal Women in Malawi: A Pilot Randomized Controlled Trial

Perinatal depression (PND) is common and an important barrier to engagement in HIV care for women living with HIV (WLHIV). Accordingly, we adapted and enhanced The Friendship Bench, an evidence-based counseling intervention, for perinatal WLHIV. In a pilot randomized trial (NCT04143009), we evaluated the feasibility, acceptability, fidelity, and preliminary efficacy of the Enhanced Friendship Bench (EFB) intervention to improve PND and engagement in HIV care outcomes. Eighty pregnant WLHIV who screened positive for PND symptoms on the Self-Report Questionnaire (≥ 8) were enrolled, randomized 1:1 to EFB or usual care, and followed through 6 months postpartum. Overall, 100% of intervention participants were satisfied with the intervention and 93% found it beneficial to their overall health. Of 82 counseling sessions assessed for fidelity, 83% met or exceeded the fidelity threshold. At 6 months postpartum, intervention participants had improved depression remission (59% versus 36%, RD 23%, 95% CI 2%, 45%), retention in HIV care (82% versus 69%, RD 13%, -6%, 32%), and viral suppression (96% versus 90%, RD 7%, -7%, 20%) compared to usual care. Adverse events did not differ by arm. These results suggest that EFB intervention should be evaluated in a fully powered randomized trial to evaluate its efficacy to improve PND and engagement in HIV care outcomes for WLHIV.

Maternal weight trajectories and associations with infant growth in South African women

BACKGROUND

Despite the close relationship between pre-pregnancy body mass index (BMI), gestational weight gain (GWG) and postpartum weight (PPW), these factors are often studied separately. There are no data characterising longitudinal weight trajectories among pregnant and postpartum women in urban African populations. We examined maternal weight trajectories from pregnancy through to 12 months postpartum, factors associated with higher weight trajectory class membership and associations of weight trajectories with infant growth at 12 months.

METHODS

Data from 989 women were examined for weight trajectories from first antenatal care visit in pregnancy to 12 months postpartum using latent-class growth models. Baseline factors associated with class membership were assessed using multinomial logistic regression. Of the enrolled women, 613 of their infants were assessed for growth at 12 months. Anthropometry measurements for mothers and infants were conducted by a trained study nurse. Associations between maternal weight trajectory class and infant weight-for-age (WAZ), length-for-age (LAZ), weight-for-length (WLZ) at 12 months of age were analysed using linear regression.

RESULTS

Four distinct classes of maternal weight trajectories were identified. The classes included consistent low (29%), consistent medium (37%), medium-high (24%) and consistent high (10%) trajectories. Similar to trends observed with medium-high trajectory, baseline factors positively associated with consistent high class membership included age (OR 1.05, 95% CI 1.01-1.09), pre-pregnancy BMI (OR 2.24, 95% CI 1.97-2.56), stage 1 hypertension (OR 3.28, 95% CI 1.68-6.41), haemoglobin levels (OR 1.39, 95% CI 1.11-1.74) and parity (OR 1.39, 95% CI 1.15-1.67); living with HIV (OR 0.47, 95% CI 0.30-0.74) was inversely associated. In adjusted analyses, compared to consistent medium weight trajectory, consistent low weight trajectory (mean difference -0.41, 95% CI -0.71;-0.12) was associated with decreased, and consistent high weight trajectory (mean difference 1.21, 95% CI 0.59-1.83) with increased infant WAZ at 12 months of age.

CONCLUSION

Identification of unique longitudinal weight trajectory groupings might inform comprehensive efforts targeted at improving healthy maternal weight and infant outcomes.

Antiretroviral Therapy Use Was Not Associated with Stillbirth or Preterm Birth in an Analysis of U.S. Medicaid Pregnancies to Persons with HIV

Background

Using a U.S. based, nationally representative sample, this study compares stillbirth and preterm birth outcomes between women living with HIV (WWH) who did and did not use antiretroviral therapy (ART) during pregnancy, additionally assessing ART duration and regimen type.

Methods

Using 2001 to 2012 Medicaid Analytic eXtract (MAX) data from the 14 states with the highest prevalence of HIV. We estimated two, propensity score matched, multivariate logistic regression models for both outcomes of stillbirth and preterm birth: (1) any ART use and (2) the number of months on ART during pregnancy for ART users, adjusting for patient-level covariates.

Results

Only 34.6% of pregnancies among WWH had a history of ART use and among those, the proportions of stillbirth and preterm birth were 0.9% and 7.9%, respectively. Any ART use was not significantly associated with either outcome of stillbirth (marginal effects [MEs]: 0.06%, 95% confidence interval [CI]: -0.17 to 0.28) or preterm birth (ME: -0.12%, 95% CI: -0.79 to 0.55). For ART users, duration of ART was not significantly associated with either outcome. Black race was a strong independent predictor in both models (stillbirth: 0.80% and 0.84%, preterm birth: 4.19% and 3.76%). Neither protease inhibitor (PI) nor boosted PI regimens were more strongly associated with stillbirth or preterm birth than nucleoside reverse transcriptase inhibitor-based regimens.

Conclusion

ART use during pregnancy was low during this period. Our findings suggest that ART use and ART regimen are not associated, positively or negatively, with stillbirth or preterm birth for mothers with Medicaid. Additionally, our findings highlight a persisting need to address disparities in these outcomes for Black women.

The feasibility and acceptability of a task-shifted intervention for perinatal depression among women living with HIV in Malawi: a qualitative analysis

BACKGROUND

Perinatal depression (PND) is prevalent and negatively impacts HIV care among women living with HIV (WLHIV), yet PND remains under-identified in Malawian WLHIV. Accordingly, this formative study explored perceptions of the feasibility and acceptability of an integrated, task-shifted approach to PND screening and treatment in maternity clinics.

METHODS

We completed consecutive PND screenings of HIV+ women attending pre- or post-natal appointments at 5 clinics in Lilongwe district, Malawi. We conducted in-depth interviews with the first 4-5 women presenting with PND per site (n = 24 total) from July to August 2018. PND classification was based on a score ≥ 10 on the Edinburgh Postnatal Depression Scale (EPDS). We conducted 10 additional in-depth interviews with HIV and mental health providers at the 5 clinics.

RESULTS

Most participants endorsed the feasibility of integrated PND screening, as they believed that PND had potential for significant morbidity. Among providers, identified barriers to screening were negative staff attitudes toward additional work, inadequate staffing numbers and time constraints. Suggested solutions to barriers were health worker training, supervision, and a brief screening tool. Patient-centered counselling strategies were favored over medication by WLHIV as the acceptable treatment of choice, with providers supporting the role of medication to be restricted to severe depression. Providers identified nurses as the most suitable health workers to deliver task-shifted interventions and emphasized further training as a requirement to ensure successful task shifting.

CONCLUSION

Improving PND in a simple, task-shifted intervention is essential for supporting mental health among women with PND and HIV. Our results suggest that an effective PND intervention for this population should include a brief, streamlined PND screening questionnaire and individualized counselling for those who have PND, with supplemental support groups and depression medication readily available. These study results support the development of a PND intervention to address the gap in treatment of PND and HIV among WLHIV in Malawi.

Predicting Progression from Gestational Diabetes to Impaired Glucose Tolerance Using Peridelivery Data: An Observational Study

OBJECTIVE

 This article aimed to develop a predictive model to identify persons with recent gestational diabetes mellitus (GDM) most likely to progress to impaired glucose tolerance postpartum.

STUDY DESIGN

 We conducted an observational study among persons with GDM in their most recent pregnancy, defined by Carpenter-Coustan criteria. Participants were followed up from delivery through 1-year postpartum. We used lasso regression with k-fold cross validation to develop a multivariable model to predict progression to impaired glucose tolerance, defined as HbA1c≥5.7%, at 1-year postpartum. Predictive ability was assessed by the area under the curve (AUC), sensitivity, specificity, and positive and negative predictive values (PPV and NPV).

RESULTS

 Of 203 participants, 71 (35%) had impaired glucose tolerance at 1-year postpartum. The final model had an AUC of 0.79 (95% confidence interval [CI]: 0.72, 0.85) and included eight indicators of weight, body mass index, family history of type 2 diabetes, GDM in a prior pregnancy, GDM diagnosis<24 weeks' gestation, and fasting and 2-hour plasma glucose at 2 days postpartum. A cutoff point of ≥ 0.25 predicted probability had sensitivity of 80% (95% CI: 69, 89), specificity of 58% (95% CI: 49, 67), PPV of 51% (95% CI: 41, 61), and NPV of 85% (95% CI: 76, 91) to identify women with impaired glucose tolerance at 1-year postpartum.

CONCLUSION

 Our predictive model had reasonable ability to predict impaired glucose tolerance around delivery for persons with recent GDM.

KEY POINTS

· We developed a predictive model to identify persons with GDM most likely to develop IGT postpartum.. · The final model had an AUC of 0.79 (95% CI: 0.72, 0.85) and included eight clinical indicators.. · If validated, our model could help prioritize diabetes prevention efforts among persons with GDM..

Relationship between pre-pregnancy maternal body mass index and infant weight trajectories in HIV-exposed and HIV-unexposed infants

BACKGROUND

Maternal HIV and antiretroviral therapy (ART) exposure in utero may influence infant weight, but the contribution of maternal y body mass index (BMI) to early life overweight and obesity is not clear.

OBJECTIVE

To estimate associations between maternal BMI at entry to antenatal care (ANC) and infant weight through approximately 1 year of age and to evaluate whether associations were modified by maternal HIV status, maternal HIV and viral load, breastfeeding intensity through 6 months or timing of entry into ANC.

METHODS

We followed HIV-uninfected and -infected pregnant women initiating efavirenz-based ART from first antenatal visit through 12 months postpartum. Infant weight was assessed via World Health Organization BMI and weight-for-length z-scores (WLZ) at 6 weeks, 3, 6, 9 and 12 months. We used multivariable linear mixed-effects models to estimate associations between maternal BMI and infant z-scores over time.

RESULTS

In 861 HIV-uninfected infants (454 HIV-exposed; 407 HIV-unexposed), nearly 20% of infants were overweight or obese by 12 months of age, regardless of HIV exposure status. In multivariable analyses, increasing maternal BMI category was positively associated with higher infant BMIZ and WLZ scores between 6 weeks and 12 months of age and did not differ by HIV exposure status. However, HIV-exposed infants had slightly lower BMIZ and WLZ trajectories through 12 months of age, compared with HIV-unexposed infants across all maternal BMI categories. Differences in BMIZ and WLZ scores by HIV exposure were not explained by timing of entry into ANC or maternal viral load pre-ART initiation, but z-scores were slightly higher for HIV-exposed infants who were predominantly or exclusively versus partially breastfed.

CONCLUSIONS

These findings suggest maternal BMI influences early infant weight gain, regardless of infant HIV exposure status. Intervention to reduce maternal BMI may help to address growing concerns about obesity among HIV-uninfected children.

Cyclical Engagement in HIV Care: A Qualitative Study of Clinic Transfers to Re-enter HIV Care in Cape Town, South Africa

Long-term patient engagement and retention in HIV care is an ongoing challenge in South Africa's strained health system. However, some patients thought to be "lost to follow-up" (LTFU) may have "transferred" clinics to receive care elsewhere. Through semi-structured interviews, we explored the relationship between clinic transfer and long-term patient engagement among 19 treatment-experienced people living with HIV (PLWH) who self-identified as having engaged in a clinic transfer at least once since starting antiretroviral therapy (ART) in Gugulethu, Cape Town. Our findings suggest that patient engagement is often fluid, as PLWH cycle in and out of care multiple times during their lifetime. The linear nature of the HIV care cascade model poorly describes the lived realities of PLWH on established treatment. Further research is needed to explore strategies for reducing unplanned clinic transfers and offer more supportive care to new and returning patients.

Quantifying clinic transfers among people living with HIV in the Western Cape, South Africa: a retrospective spatial analysis

OBJECTIVES

For persons living with HIV (PLWH) in long-term care, clinic transfers are common and influence sustained engagement in HIV care, as they are associated with significant time out-of-care, low CD4 count, and unsuppressed viral load on re-entry. Despite the geospatial nature of clinic transfers, there exist limited data on the geospatial trends of clinic transfers to guide intervention development. In this study, we investigate the geospatial characteristics and trends of clinic transfers among PLWH on antiretroviral therapy (ART) in the Western Cape Province of South Africa.

DESIGN

Retrospective spatial analysis.

SETTING

PLWH who initiated ART treatment between 2012 and 2016 in South Africa's Western Cape Province were followed from ART initiation to their last visit prior to 2017. Deidentified electronic medical records from all public clinical, pharmacy, and laboratory visits in the Western Cape were linked across space and time using a unique patient identifier number.

PARTICIPANTS

4176 ART initiators in South Africa (68% women).

METHODS

We defined a clinic transfer as any switch between health facilities that occurred on different days and measured the distance between facilities using geodesic distance. We constructed network flow maps to evaluate geospatial trends in clinic transfers over time, both for individuals' first transfer and overall.

RESULTS

Two-thirds of ART initiators transferred health facilities at least once during follow-up. Median distance between all clinic transfer origins and destinations among participants was 8.6 km. Participant transfers were heavily clustered around Cape Town. There was a positive association between time on ART and clinic transfer distance, both among participants' first transfers and overall.

CONCLUSION

This study is among the first to examine geospatial trends in clinic transfers over time among PLWH. Our results make clear that clinic transfers are common and can cluster in urban areas, necessitating better integrated health information systems and HIV care.

Patient Transfers and Their Impact on Gaps in Clinical Care: Differences by Gender in a Large Cohort of Adults Living with HIV on Antiretroviral Therapy in South Africa

For people living with HIV (PLWH), patient transfers may affect engagement in care. We followed a cohort of PLWH in Cape Town, South Africa who tested positive for HIV in 2012-2013 from ART initiation in 2012-2016 through December 2016. Patient transfers were defined as moving from one healthcare facility to another on a different day, considering all healthcare visits and recorded HIV-visits only. We estimated incidence rates (IR) for transfers by time since ART initiation, overall and by gender, and associations between transfers and gaps of > 180 days in clinical care. Overall, 4,176 PLWH were followed for a median of 32 months, and 8% (HIV visits)-17% (all healthcare visits) of visits were patient transfers. Including all healthcare visits, transfers were highest through 3 months on ART (IR 20.2 transfers per 100 visits, 95% CI 19.2-21.2), but increased through 36 months on ART when only HIV visits were included (IR 9.7, 95% CI 8.8-10.8). Overall, women were more likely to transfer than men, and transfers were associated with gaps in care (IR ratio [IRR] 3.06 95% CI 2.83-3.32; HIV visits only). In this cohort, patient transfers were frequent, more common among women, and associated with gaps in care.

Transportability From Randomized Trials to Clinical Care: On Initial HIV Treatment With Efavirenz and Suicidal Thoughts or Behaviors

In an analysis of randomized trials, use of efavirenz for treatment of human immunodeficiency virus (HIV) infection was associated with increased suicidal thoughts/behaviors. However, analyses of observational data have found no evidence of increased risk. To assess whether population differences might explain this divergence, we transported the effect of efavirenz use from these trials to a specific target population. Using inverse odds weights and multiple imputation, we transported the effect of efavirenz on suicidal thoughts/behaviors in these randomized trials (participants were enrolled in 2001-2007) to a trials-eligible cohort of US adults initiating antiretroviral therapy while receiving HIV clinical care at medical centers between 1999 and 2015. Overall, 8,291 cohort participants and 3,949 trial participants were eligible. Prescription of antidepressants (19% vs. 13%) and injection drug history (16% vs. 10%) were more frequent in the cohort than in the trial participants. Compared with the effect in trials, the estimated hazard ratio for efavirenz on suicidal thoughts/behaviors was attenuated in our target population (trials: hazard ratio (HR) = 2.3 (95% confidence interval (CI): 1.2, 4.4); transported: HR = 1.8 (95% CI: 0.9, 4.4)), whereas the incidence rate difference was similar (trials: HR = 5.1 (95% CI: 1.6, 8.7); transported: HR = 5.4 (95% CI: -0.4, 11.4)). In our target population, there was greater than 20% attenuation of the hazard ratio estimate as compared with the trials-only estimate. Transporting results from trials to a target population is informative for addressing external validity.

Obstetric fistula scoring tool for surgical trainees

OBJECTIVE

To examine the ability of a previously published risk score to predict incontinence at discharge in women with vesicovaginal fistulas (VVF) and to examine how the score correlates with an independent assessment of surgical skill.

METHODS

This is a retrospective cohort study including cases from January to June 2018. We evaluated operative records for factors associated with incontinence at hospital discharge, as well as relationships between a risk score cut-point of 20 or more and surgical skill level. All women with VVF undergoing vaginal repair were included.

RESULTS

A total of 176 individuals underwent repair; 23 were performed by beginner, 85 by intermediate, 47 by advanced, and 21 by expert surgeons. Factors found significantly associated with incontinence at hospital discharge included Goh classification, fistula size, circumferential fistula, and vaginal scarring. A score of 20 or more predicted residual incontinence with a negative predictive value of 92% (odds ratio 7.75, 95% confidence interval 2.95-22.34). Applying the score cut-point of 20 or more, we found an increased proportion of "high-risk" cases allocated to surgeons with an increasing level of expertise.

CONCLUSION

The correlation we observed between a risk score cut-point of 20 or more, continence status, and an independent assessment of surgical skill is promising. Although the risk score is not meant to replace clinical judgment, it may provide a surgical trainee with an objective method of determining whether to operate or refer for optimal outcomes.

Risk Factors for Progression From Gestational Diabetes to Postpartum Type 2 Diabetes: A Review

Gestational diabetes mellitus (GDM) complicates 6% to 8% of pregnancies and up to 50% of women with GDM progress to type 2 diabetes mellitus (DM) within 5 years postpartum. Clinicians have little guidance on which women are most at risk for DM progression or when evidence-based prevention strategies should be implemented in a woman's lifecycle. To help address this gap, the authors review identifiable determinants of progression from GDM to DM across the perinatal period, considering prepregnancy, pregnancy, and postpartum periods. The authors categorize evidence by pathways of risk including genetic, metabolic, and behavioral factors that influence progression to DM among women with GDM.

HIV and COVID-19: Intersecting Epidemics With Many Unknowns

As of July 2020, approximately 6 months into the pandemic of novel coronavirus disease 2019 (COVID-19), whether people living with human immunodeficiency virus (HIV; PLWH) are disproportionately affected remains an unanswered question. Thus far, risk of COVID-19 in people with and without HIV appears similar, but data are sometimes contradictory. Some uncertainty is due to the recency of the emergence of COVID-19 and sparsity of data; some is due to imprecision about what it means for HIV to be a "risk factor" for COVID-19. Forthcoming studies on the risk of COVID-19 to PLWH should differentiate between 1) the unadjusted, excess burden of disease among PLWH to inform surveillance efforts and 2) any excess risk of COVID-19 among PLWH due to biological effects of HIV, independent of comorbidities that confound rather than mediate this effect. PLWH bear a disproportionate burden of alcohol, other drug use, and mental health disorders, as well as other structural vulnerabilities, which might increase their risk of COVID-19. In addition to any direct effects of COVID-19 on the health of PLWH, we need to understand how physical distancing restrictions affect secondary health outcomes and the need for, accessibility of, and impact of alternative modalities of providing ongoing medical, mental health, and substance use treatment that comply with physical distancing restrictions (e.g., telemedicine).

High blood pressure at entry into antenatal care and birth outcomes among a cohort of HIV-uninfected women and women living with HIV initiating antiretroviral therapy in South Africa

OBJECTIVE

To examine associations between high blood pressure (BP) when entering antenatal care (ANC) and birth outcomes in a cohort of pregnant HIV- and women living with HIV (WLHIV) initiating antiretroviral treatment (ART).

STUDY DESIGN

Prospective cohort study.

MAIN OUTCOME MEASURES

Cesarean delivery, preterm birth (<37 weeks' gestation), low birthweight (LBW, <2500 g), small-for-gestational age (SGA, <10th percentile), and large-for-gestational age (LGA, >10th percentile for GA).

RESULTS

Of 1116 women (median GA 20 weeks; WLHIV 53%), 48% (53% WLHIV; 43% HIV-) entered ANC with high BP, defined as elevated (120-129 or < 80 mmHg), stage 1 (>130-139 or 80-89) or stage 2 hypertension (≥140 / or ≥ 90). WLHIV were more likely to have high BP (RR 1.32; 95%CI 1.12-1.57), controlling for pre-pregnancy body mass index and additional confounders. In multivariable analysis, there was no evidence that high BP increased the risk of cesarean delivery (RR 1.10, 95% CI 0.92-1.30), preterm birth (RR 1.15, 95% CI 0.81-1.62), LBW (RR 1.16, 95% CI 0.84-1.60) or SGA (RR 1.02, 0.72-1.44), overall or when stratified by HIV-status. High BP was associated with an increased risk of LGA (RR 1.43; 95% CI 1.00-2.03).

CONCLUSION

In this setting, half of women had high BP at entry into ANC, with WLHIV at increased risk of high BP. There was no strong evidence that high BP increased the risk of adverse birth outcomes overall, or by HIV-status, with the exception of LGA. WLHIV may be at high risk of high BP during pregnancy and should be monitored closely.

Does HIV infection modify the relationship between pre-pregnancy body mass index and adverse birth outcomes?

BACKGROUND

South Africa faces dual epidemics of HIV and obesity; however, little research has explored whether HIV status influences associations between pre-pregnancy body mass index (BMI) and adverse birth outcomes.

OBJECTIVES

To examine associations between pre-pregnancy body mass index (BMI) and adverse birth outcomes, and if they differ by HIV status.

METHODS

We followed HIV-uninfected and -infected pregnant women initiating antiretroviral therapy (ART) from first antenatal visit through delivery. HIV-infected women initiated ART (tenofovir-emtricitabine/lamivudine-efavirenz) in pregnancy. Estimated pre-pregnancy BMI (kg/m² ) was categorised as underweight (<18.5), normal (18.5-24.9), overweight (25.0-29.9), and obese (≥30.0). We used modified Poisson regression to estimate risk ratios (RR) for associations between pre-pregnancy BMI and adverse birth outcomes and explored modification by HIV status.

RESULTS

Among 1116 women (53% HIV-infected), 44% of HIV-uninfected women and 36% of HIV-infected women were classified as obese; 4% of women were underweight. Overall, 12% of infants were delivered preterm (<37 weeks), 10% small for gestational age (SGA, <10th percentile), and 9% large for gestational age (LGA, >90th percentile). Compared to HIV-uninfected women, HIV-infected women on ART had less LGA (5% vs 13%) but more SGA (12% vs 8%), and a similar proportion of preterm (13% vs 11%) infants. Pre-pregnancy BMI was not associated with preterm birth. Among HIV-uninfected women, obesity modestly increased the risk of LGA (RR 1.34, 95% confidence interval [CI] 0.82, 2.19), and underweight modestly elevated the risk of SGA (RR 1.66, 95% CI 0.79, 3.46). These associations were attenuated among HIV-infected women (RR 1.07, 95% CI 0.44, 2.64 for LGA, and RR 1.34, 95% CI 0.49, 3.64 for SGA).

CONCLUSIONS

In this urban African setting of high HIV prevalence, pre-pregnancy obesity was common and did not vary by HIV status. In HIV-uninfected women, obesity increased the risk of LGA and being underweight the risk of SGA, compared with among HIV-uninfected women.

Estimating retention in HIV care accounting for clinic transfers using electronic medical records: evidence from a large antiretroviral treatment programme in the Western Cape, South Africa

BACKGROUND

Estimates of retention in antiretroviral treatment (ART) programmes may be biased if patients who transfer to healthcare clinics are misclassified as lost to follow-up (LTFU) at their original clinic. In a large cohort, we estimated retention in care accounting for patient transfers using medical records.

METHODS

Using linked electronic medical records, we followed adults living with HIV (PLWH) in Cape Town, South Africa from ART initiation (2012-2016) through database closure at 36 months or 30 June 2016, whichever came first. Retention was defined as alive and with a healthcare visit in the 180 days between database closure and administrative censoring on 31 December 2016. Participants who died or did not have a healthcare visit in > 180 days were censored at their last healthcare visit. We estimated the cumulative incidence of retention using Kaplan-Meier methods considering (i) only records from a participant's ART initiation clinic (not accounting for transfers) and (ii) all records (accounting for transfers), over time and by gender. We estimated risk differences and bootstrapped 95% confidence intervals to quantify misclassification in retention estimates due to patient transfers.

RESULTS

We included 3406 PLWH initiating ART. Retention through 36 months on ART rose from 45.4% (95% CI 43.6%, 47.2%) to 54.3% (95% CI 52.4%, 56.1%) after accounting for patient transfers. Overall, 8.9% (95% CI 8.1%, 9.7%) of participants were misclassified as LTFU due to patient transfers.

CONCLUSIONS

Patient transfers can appreciably bias estimates of retention in HIV care. Electronic medical records can help quantify patient transfers and improve retention estimates.

Postpartum obesity and weight gain among human immunodeficiency virus-infected and human immunodeficiency virus-uninfected women in South Africa

In South Africa, up to 40% of pregnant women are living with human immunodeficiency virus (HIV), and 30-45% are obese. However, little is known about the dual burden of HIV and obesity in the postpartum period. In a cohort of HIV-uninfected and HIV-infected pregnant women initiating antiretroviral therapy in Cape Town, South Africa, we examined maternal anthropometry (weight and body mass index [BMI]) from 6 weeks through 12 months postpartum. Using multinomial logistic regression, we estimated associations between baseline sociodemographic, clinical, behavioural, and HIV factors and being overweight-obese I (BMI 25 to <35), or obese II-III (BMI >35), compared with being underweight or normal weight (BMI <25), at 12 months postpartum. Among 877 women, we estimated that 43% of HIV-infected women and 51% of HIV-uninfected women were obese I-III at enrollment into antenatal care, and 51% of women were obese I-III by 12 months postpartum. On average, both HIV-infected and HIV-uninfected women gained, rather than lost, weight between 6 weeks and 12 months postpartum, but HIV-uninfected women gained more weight (3.3 kg vs. 1.7 kg). Women who were obese I-III pre-pregnancy were more likely to gain weight postpartum. In multivariable analyses, HIV-infection status, being married/cohabitating, higher gravidity, and high blood pressure were independently associated with being obese II-III at 12 months postpartum. Obesity during pregnancy is a growing public health concern in low- and middle-income countries, including South Africa. Additional research to understand how obesity and HIV infection affect maternal and child health outcomes is urgently needed.

Beyond mobile phones: exploring using technology to support sustained engagement in care for HIV-infected women on antiretroviral therapy

Disengagement from HIV care has emerged as a challenge to the success of universal test and treat strategies for HIV-infected women. Technology may enhance efforts to monitor and support engagement in HIV care, but implementation barriers and facilitators need to be evaluated. We conducted a mixed-method study among HIV-infected, pregnant women and healthcare workers (HCWs) in Malawi to evaluate barriers and facilitators to three technologies to support monitoring HIV care: (1) text messaging, (2) SIM card scanning and (3) biometric fingerprint scanning. We included 123 HIV-infected, pregnant women and 85 HCWs in a survey, 8 focus group discussions and 5 in-depth interviews. Biometric fingerprint scanning emerged as the preferred strategy to monitor engagement in HIV care. Among HCWs, 70% felt biometrics were very feasible, while 48% thought text messaging and SIM card scanning were feasible. Nearly three quarters (72%) of surveyed women reported they would be very comfortable using biometrics to monitor HIV appointments. Barriers to using text messaging and SIM card scanning included low phone ownership (35%), illiteracy concerns, and frequent selling or changing of mobile phones. Future work is needed to explore the feasibly of implementing biometric fingerprint scanning or other technologies to monitor engagement in HIV care.

Depressive Symptoms and Engagement in Human Immunodeficiency Virus Care Following Antiretroviral Therapy Initiation

Background

The effect of depressive symptoms on progression through the human immunodeficiency virus (HIV) treatment cascade is poorly characterized.

Methods

We included participants from the Centers for AIDS Research Network of Integrated Clinic Systems cohort who were antiretroviral therapy (ART) naive, had at least 1 viral load and HIV appointment measure after ART initiation, and a depressive symptom measure within 6 months of ART initiation. Recent depressive symptoms were measured using the Patient Health Questionnaire-9 (PHQ-9) and categorized using a validated cut point (PHQ-9 ≥10). We followed participants from ART initiation through the first of the following events: loss to follow-up (>12 months with no HIV appointment), death, administrative censoring (2011-2014), or 5 years of follow-up. We used log binomial models with generalized estimating equations to estimate associations between recent depressive symptoms and having a detectable viral load (≥75 copies/mL) or missing an HIV visit over time.

Results

We included 1057 HIV-infected adults who contributed 2424 person-years. At ART initiation, 30% of participants reported depressive symptoms. In multivariable analysis, recent depressive symptoms increased the risk of having a detectable viral load (risk ratio [RR], 1.28; 95% confidence interval [CI], 1.07, 1.53) over time. The association between depressive symptoms and missing an HIV visit (RR, 1.20; 95% CI, 1.05, 1.36) moved to the null after adjustment for preexisting mental health conditions (RR, 1.00; 95% CI, 0.85, 1.18).

Conclusions

Recent depressive symptoms are a risk factor for unsuppressed viral load, while preexisting mental health conditions may influence HIV appointment adherence.

Improving Monitoring of Engagement in HIV Care for Women in Option B+: A Pilot Test of Biometric Fingerprint Scanning in Lilongwe, Malawi

Sustained engagement in HIV care is critical to the success of Option B+ for HIV-infected pregnant women. However, monitoring women's engagement in care across clinics and over time is challenging due to migration and clinic transfers. Improved strategies to identify and monitor women's engagement in HIV care across a network of clinics are needed, but have not been pilot tested. We evaluated the feasibility and acceptability of biometric fingerprint scanning to identify women and monitor HIV visit attendance among women in Option B+. Over a 3-month period, we enrolled HIV-infected pregnant women receiving care at two antenatal clinics in Lilongwe, Malawi and monitored their engagement in care using biometric fingerprint scanning and the standard-of-care electronic medical record (EMR) monitoring system. Biometric data was collected by trained research assistants, who uploaded and synced data across study sites daily using wireless internet. We collected data weekly on the biometric scanner performance, reliability, and usability. We assessed the feasibility and acceptability of using biometric fingerprint scanning to record HIV visits during exit interviews with a sample of participants and healthcare workers and by comparing visit concordance between the biometric fingerprint scanning and EMR systems. We enrolled 314 HIV-infected pregnant women and 51 HCWs (n = 365 total participants). The majority of participants felt the biometric fingerprint scanning system was easy to use (64%), required no additional assistance (69%) and met their expectations (76%). No major issues with data security, privacy, or scanner functionality were reported by HIV-infected women or healthcare workers. Of the 542 HIV visits captured during the study period among women in Option B+, 80% were recorded in the biometric fingerprint system versus 51% in the EMR system (PR 1.57, 95% CI 1.43, 1.72, p-value < 0.05). Among HIV-infected pregnant women engaged in HIV care, biometric fingerprint scanning is a feasible and acceptable way to monitor HIV visits and may improve the ability to monitor women's engagement in HIV care over time and across clinics. Biometric fingerprint scanning should be scaled-up and evaluated as an implementation strategy to support sustained engagement in HIV care for women during the perinatal period.

Perinatal depression among mothers in a South African birth cohort study: Trajectories from pregnancy to 18 months postpartum

BACKGROUND

Perinatal depression affects 21-50% of women in South Africa and poses significant health risks to mothers and children. Trajectories of depressive symptoms change over time and have not been well characterized during the perinatal period in low and middle-income countries.

METHODS

Data from women enrolled in a population-based birth cohort study in Paarl, South Africa with at least 3 depression measures from pregnancy through 18 months postpartum (N = 831) were analyzed. Depressive symptoms were measured continuously using the Edinburgh Postnatal Depression Scale (EPDS). Group-based trajectory models were used to estimate trajectories of depressive symptoms during the perinatal period and multinomial multivariable models to identify predictors of trajectory group membership.

RESULTS

Five distinct trajectory patterns of depressive symptoms were identified: moderate levels of depressive symptoms during pregnancy but minimal postpartum (3.5%), minimal levels during pregnancy and increasing postpartum (3.7%), unstable levels peaking at 12 months postpartum (6.6%), mild levels with slight decrease postpartum (82.9%), and severe levels during pregnancy and postpartum (3.1%). Membership in the chronic severe symptom group was associated with stressful life events, sexual intimate partner violence and tobacco use.

LIMITATIONS

Modeling limitations prevented determining how changes in psychosocial predictors over time may influence depressive symptom trajectories.

CONCLUSIONS

Mild to severe depressive symptoms during pregnancy/postpartum were common among this South African cohort. Interventions to treat women with severe chronic depressive symptoms with co-occurring psychosocial issues are urgently needed.

Quantifying the HIV treatment cascade in a South African health sub-district by gender: retrospective cohort study

OBJECTIVES

To quantify the HIV care cascade in a Cape Town sub-district to understand rates of linkage to and engagement in HIV care.

METHODS

We used routinely collected data to reconstruct the treatment cascade for 8382 infected individuals who tested HIV + in 2012/2013. We obtained data on patient gender, year of initial HIV-positive test, age at testing and initial CD4 cell count and defined five stages of the HIV care cascade. We quantified attrition across cascade stages.

RESULTS

Two-thirds of the sample (5646) were women. Men were older at time of first testing (36.5 vs. 31.3 years) and had more advanced HIV disease at diagnosis (298 vs. 404 CD4 cells/µL for women). The median duration of follow-up was 818 days. Among women, 90.5% attended an initial HIV care visit, 54.6% became eligible for antiretroviral therapy under local guidelines during follow-up, 49.3% initiated ART and 45.6% achieved a therapeutic response. Among men, 88.0% attended an initial HIV care visit, 67.4% became ART eligible during follow-up, 48.0% initiated ART and 42.4% achieved a therapeutic response. Approximately 3% of women and 5% of men died during follow-up.

CONCLUSIONS

We were able to reconstruct the HIV treatment cascade using routinely collected data. In this setting, rates of engagement in care differ by gender in key stages of the cascade, with men faring worse than women at each cascade point. This highlights the need for interventions aimed at encouraging earlier testing, linkage, ART initiation and retention among men.

"A way of escaping": a qualitative study exploring reasons for clinic transferring and its impact on engagement in care among women in Option B

Clinic transfers among women in Option B+ are frequent, often undocumented, and may lead to suboptimal engagement in care and HIV outcomes. The reasons women move between HIV clinics are not well understood. We conducted four focus group discussions (FGD) among HIV-infected pregnant women in Option B+ and four FGDs and five in-depth interviews among healthcare workers (HCWs) at two large ART clinics in Lilongwe, Malawi. Mobility and fear of inadvertent HIV disclosure, particularly due to seeing neighbors or acquaintances at a clinic, were key drivers of transferring between HIV clinics. Women were aware of the need to obtain a formal transfer, but in practice this was often not feasible and led women to self-transfer clinics. Self-transferring to a new clinic frequently resulted to re-testing and re-initiating ART and concerns about disruptions in ART. Strategies to monitor women's engagement in HIV care without requiring a formal transfer are urgently needed.

The Depression Treatment Cascade: Disparities by Alcohol Use, Drug Use, and Panic Symptoms Among Patients in Routine HIV Care in the United States

Little is known about disparities in depression prevalence, treatment, and remission by psychiatric comorbidities and substance use among persons living with HIV (PLWH). We conducted a cross-sectional analysis in a large cohort of PLWH in routine care and analyzed conditional probabilities of having an indication for depression treatment, receiving treatment, receiving indicated treatment adjustments, and achieving remission, stratified by alcohol use, illicit drug use, and panic symptoms. Overall, 34.7% (95% CI 33.9-35.5%) of participants had an indication for depression treatment and of these, 55.3% (53.8-56.8%) were receiving antidepressants. Among patients receiving antidepressants, 33.0% (31.1-34.9%) had evidence of remitted depression. In a subsample of sites with antidepressant dosage data, only 8.8% (6.7-11.5%) of patients received an indicated treatment adjustment. Current drug users (45.8%, 95% CI 43.6-48.1%) and patients reporting full symptoms of panic disorder (75.0%, 95% CI 72.9-77.1%) were most likely to have an indication for antidepressant treatment, least likely to receive treatment given an indication (current drug use: 47.6%, 95% CI 44.3-51.0%; full panic symptoms: 50.8%, 95% CI 48.0-53.6%), or have evidence of remitted depression when treated (22.3%, 95% CI 18.5-26.6%; and 7.3%, 95% CI 5.5-9.6%, respectively). In a multivariable model, drug use and panic symptoms were independently associated with poorer outcomes along the depression treatment cascade. Few differences were evident by alcohol use. Current drug users were most likely to have an indication for depression treatment, but were least likely to be receiving treatment or to have remitted depression. These same disparities were even more starkly evident among patients with co-occurring symptoms of panic disorder compared to those without. Achieving improvements in the depression treatment cascade will likely require attention to substance use and psychiatric comorbidities.

Continence, quality of life and depression following surgical repair of obstetric vesicovaginal fistula: a cohort study

OBJECTIVE

We evaluated residual incontinence, depression, and quality of life among Malawian women who had undergone vesicovaginal fistula (VVF) repair 12 or more months previously.

DESIGN

Prospective cohort study.

SETTING

Fistula Care Centre in Lilongwe, Malawi.

POPULATION

Women who had undergone VVF repair in Lilongwe, Malawi at least 12 months prior to enrolment.

METHODS

Self-report of urinary leakage was used to evaluate for residual urinary incontinence; depression was evaluated with the Patient Health Questionnaire-9; quality of life was evaluated with the King's Health Questionnaire.

MAIN OUTCOME MEASURES

Prevalence and predictors of residual incontinence, quality of life scores, and prevalence of depression and suicidal ideation.

RESULTS

Fifty-six women (19.3%) reported residual urinary incontinence. In multivariable analyses, predictors of residual urinary incontinence included: pre-operative Goh type 3 [adjusted risk ratio (aRR) 2.82; 95% confidence interval (CI) 1.61-5.27) or Goh type 4 1.08-2.78), positive postoperative cough stress test (aRR = 2.42; 95% CI 1.24-4.71) and the positive 1-hour postoperative pad test (aRR = 2.20; 95% CI 1.08-4.48). Women with Goh types 3 and 4 VVF reported lower quality of life scores. Depressive symptoms were reported in 3.5% of women; all reported residual urinary incontinence.

CONCLUSIONS

While the majority of women reported improved outcomes in the years following surgical VVF repair, those with residual urinary incontinence had a poorer quality of life. Services are needed to identify and treat this at-risk group.

TWEETABLE ABSTRACT

Nearly one in five women reported residual urinary incontinence at follow up, 12 or months after vesicovaginal fistula repair.

Maternal immunisation to improve the health of HIV-exposed infants

HIV-exposed but uninfected (HEU) infants are at an increased risk of many infectious diseases that can contribute to the high mortality seen among HEU children. Maternal immunisation could be a promising strategy to reduce infections in HEU infants. However, very little research has explored the effect of HIV on the immunogenicity and effectiveness of vaccines given during pregnancy. We review the available evidence on maternal immunisation among women living with HIV (WLWH) for all vaccines recommended, considered, or being investigated for routine or risk-based use during pregnancy. Of the 11 vaccines included, only three have been investigated in WLWH. Available evidence suggests that maternal HIV infection limits the immunogenicity of several vaccines, leaving HEU infants more susceptible to infection during their first few months of life. Whether maternal immunisation reduces the infectious morbidity and mortality associated with infectious diseases in HEU children remains unknown. We conclude the Review by identifying future research priorities.

Cumulative Burden of Depression and All-Cause Mortality in Women Living With Human Immunodeficiency Virus

Background

Research linking depression to mortality among people living with human immunodeficiency virus (PLWH) has largely focused on binary "always vs never" characterizations of depression. However, depression is chronic and is likely to have cumulative effects on mortality over time. Quantifying depression as a cumulative exposure may provide a better indication of the clinical benefit of enhanced depression treatment protocols delivered in HIV care settings.

Methods

Women living with HIV (WLWH), naive to antiretroviral therapy, from the Women's Interagency HIV Study were followed from their first visit in or after 1998 for up to 10 semiannual visits (5 years). Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. An area-under-the-curve approach was used to translate CES-D scores into a time-updated measure of cumulative days with depression (CDWD). We estimated the effect of CDWD on all-cause mortality using marginal structural Cox proportional hazards models.

Results

Overall, 818 women contributed 3292 woman-years over a median of 4.8 years of follow-up, during which the median (interquartile range) CDWD was 366 (97-853). Ninety-four women died during follow-up (2.9 deaths/100 woman-years). A dose-response relationship was observed between CDWD and mortality. Each additional 365 days spent with depression increased mortality risk by 72% (hazard ratio, 1.72; 95% confidence interval, 1.34-2.20).

Conclusions

In this sample of WLWH, increased CDWD elevated mortality rates in a dose-response fashion. More frequent monitoring and enhanced depression treatment protocols designed to reduce CDWD may interrupt the accumulation of mortality risk among WLWH.

Early, regular breast-milk pumping may lead to early breast-milk feeding cessation

OBJECTIVE

To estimate the effect of early, regular breast-milk pumping on time to breast-milk feeding (BMF) and exclusive BMF cessation, for working and non-working women.

DESIGN

Using the Infant Feeding Practices Survey II (IFPS II), we estimated weighted hazard ratios (HR) for the effect of regular pumping (participant defined) compared with non-regular/not pumping, reported at month 2, on both time to BMF cessation (to 12 months) and time to exclusive BMF cessation (to 6 months), using inverse probability weights to control confounding.

SETTING

USA, 2005-2007.

SUBJECTS

BMF (n 1624) and exclusively BMF (n 971) IFPS II participants at month 2.

RESULTS

The weighted HR for time to BMF cessation was 1·62 (95 % CI 1·47, 1·78) and for time to exclusive BMF cessation was 1·14 (95 % CI 1·03, 1·25). Among non-working women, the weighted HR for time to BMF cessation was 2·05 (95 % CI 1·84, 2·28) and for time to exclusive BMF cessation was 1·10 (95 % CI 0·98, 1·22). Among working women, the weighted HR for time to BMF cessation was 0·90 (95 % CI 0·75, 1·07) and for time to exclusive BMF cessation was 1·14 (95 % CI 0·96, 1·36).

CONCLUSIONS

Overall, regular pumpers were more likely to stop BMF and exclusive BMF than non-regular/non-pumpers. Non-working regular pumpers were more likely than non-regular/non-pumpers to stop BMF. There was no effect among working women. Early, regular pumpers may need specialized support to maintain BMF.

Association of Increased Chronicity of Depression With HIV Appointment Attendance, Treatment Failure, and Mortality Among HIV-Infected Adults in the United States

IMPORTANCE

Depression commonly affects adults with HIV and complicates the management of HIV. Depression among individuals with HIV tends to be chronic and cyclical, but the association of this chronicity with HIV outcomes (and the related potential for screening and intervention to shorten depressive episodes) has received little attention.

OBJECTIVE

To examine the association between increased chronicity of depression and multiple HIV care continuum indicators (HIV appointment attendance, treatment failure, and mortality).

DESIGN, SETTING, AND PARTICIPANTS

The study comprised an observational clinical cohort of 5927 patients with 2 or more assessments of depressive severity who were receiving HIV primary care at 6 geographically dispersed US academic medical centers from September 22, 2005, to August 6, 2015.

MAIN OUTCOMES AND MEASURES

Missing a scheduled HIV primary care visit, detectable HIV RNA viral load (≥75 copies/mL), and all-cause mortality. Consecutive depressive severity measures were converted into a time-updated measure: percentage of days with depression (PDD), following established methods for determining depression-free days.

RESULTS

During 10 767 person-years of follow-up, the 5927 participants (5000 men, 926 women, and 1 intersex individual; median age, 44 years [range, 35-50 years]) had a median PDD of 14% (interquartile range, 0%-48%). During follow-up, 10 361 of 55 040 scheduled visits (18.8%) were missed, 6191 of 28 455 viral loads (21.8%) were detectable, and the mortality rate was 1.5 deaths per 100 person-years. Percentage of days with depression showed a dose-response relationship with each outcome. Each 25% increase in PDD led to an 8% increase in the risk of missing a scheduled appointment (risk ratio, 1.08; 95% CI, 1.05-1.11), a 5% increase in the risk of a detectable viral load (risk ratio, 1.05; 95% CI, 1.01-1.09), and a 19% increase in the mortality hazard (hazard ratio, 1.19; 95% CI, 1.05-1.36). These estimates imply that, compared with patients who spent no follow-up time with depression (PDD, 0%), those who spent the entire follow-up time with depression (PDD, 100%) faced a 37% increased risk of missing appointments (risk ratio, 1.37; 95% CI, 1.22-1.53), a 23% increased risk of a detectable viral load (risk ratio, 1.23; 95% CI, 1.06-1.43), and a doubled mortality rate (hazard ratio, 2.02; 95% CI, 1.20-3.42).

CONCLUSIONS AND RELEVANCE

Greater chronicity of depression increased the likelihood of failure at multiple points along the HIV care continuum. Even modest increases in the proportion of time spent with depression led to clinically meaningful increases in negative outcomes. Clinic-level trials of protocols to promptly identify and appropriately treat depression among adults living with HIV should be conducted to understand the effect of such protocols on shortening the course and preventing the recurrence of depressive illness and improving clinical outcomes.

Patterns of efavirenz use as first-line antiretroviral therapy in the United States: 1999-2015

BACKGROUND

Efavirenz has been a mainstay of antiretroviral therapy (ART) for over 15 years in the US. Its association with neuropsychiatric side effects may influence clinical prescribing and management.

METHODS

We included HIV-infected adults enrolled in care at seven sites across the US, who initiated combination ART between 1999 and 2015. We examined the proportion initiating and continuing on efavirenz, overall and by mental health status. Log binomial and Cox models were used to estimate associations between mental health, clinical and sociodemographic characteristics and initiating or switching from efavirenz as first-line ART.

RESULTS

Of the 8,230 participants included, 3,710 (45%) initiated efavirenz. In multivariable analyses, prior mono- or dual-ART, ART initiation after 2006, being female, intravenous drug use, antidepressant prescription, previous mental health diagnosis and baseline CD4+ T-cell count >350 cells/mm3 were inversely associated with initiating efavirenz. Participants initiating efavirenz had a faster time to a regimen switch, compared with those initiating an efavirenz-free regimen (P-value <0.01). Among efavirenz initiators, starting efavirenz in more recent time periods and a previous mental health diagnosis were associated with faster time to switching from efavirenz. Despite this, 40-50% of participants with a previous mental health diagnosis initiated and continued on efavirenz for much of the follow-up period.

CONCLUSIONS

Multiple clinical factors, including mental health diagnoses, appeared to influence efavirenz use. While mental health diagnosis status and more recent treatment starts were associated with shorter duration of efavirenz therapy, a previous mental health diagnosis did not preclude efavirenz initiation or continuation in many participants.

Do black lives matter in public health research and training?

Objective

To examine whether investments made in public health research align with the health burdens experienced by white and black Americans.

Methods

In this cross-sectional study of all deaths in the United States in 2015, we compared the distribution of potential years of life lost (PYLL) across 39 causes of death by race and identified key differences. We examined the relationship between cause-of-death-specific PYLL and key indicators of public health investment (federal funding and number of publications) by race using linear spline models. We also compared the number of courses available at the top schools of public health relevant to the top causes of death contributor to PYLL for black and white Americans.

Results

Homicide was the number one contributor to PYLL among black Americans, while ischemic heart disease was the number one contributor to PYLL among white Americans. Firearm-related violence accounted for 88% of black PYLL attributed to homicide and 71% of white PYLL attributed to homicide. Despite the high burden of PYLL, homicide research was the focus of few federal grants or publications. In comparison, ischemic heart disease garnered 341 grants and 594 publications. The number of public health courses available relevant to homicide (n = 9) was similar to those relevant to ischemic heart disease (n = 10).

Conclusions

Black Americans are disproportionately affected by homicide, compared to white Americans. For both black and white Americans, the majority of PYLL due to homicide are firearm-related. Yet, homicide research is dramatically underrepresented in public health research investments in terms of grant funding and publications, despite available public health training opportunities. If left unchecked, the observed disproportionate distribution of investments in public health resources threatens to perpetuate a system that disadvantages black Americans.

Comparative effectiveness of dual-action versus single-action antidepressants for the treatment of depression in people living with HIV/AIDS

BACKGROUND

Depression is the most common psychiatric comorbidity among people living with HIV/AIDS (PLWHA). Little is known about the comparative effectiveness between different types of antidepressants used to treat depression in this population. We compared the effectiveness of dual-action and single-action antidepressants in PLWHA for achieving remission from depression.

METHODS

We used data from the Centers for AIDS Research Network of Integrated Clinic Systems to identify 1175 new user dual-action or single-action antidepressant treatment episodes occurring from 2005 to 2014 for PLWHA diagnosed with depression. The primary outcome was remission from depression defined as a Patient Health Questionnaire-9 (PHQ-9) score <5. Mean difference in PHQ-9 depressive symptom severity was a secondary outcome. The main approach was an intent-to-treat (ITT) evaluation complemented with a per protocol (PP) sensitivity analysis. Generalized linear models were fitted to estimate treatment effects.

RESULTS

In ITT analysis, 32% of the episodes ended in remission for both dual-action and single-action antidepressants. The odds ratio (OR) of remission was 1.02 (95%CI=0.63,1.67). In PP analysis, 40% of dual-action episodes ended in remission compared to 32% in single-action episodes. Dual-action episodes had 1.33 times the odds of remission (95%CI=0.55,3.21), however the result was not statistically significant. Non-significant differences were also observed for depressive symptom severity.

LIMITATIONS

Missing data was common but was addressed with inverse probability weights.

CONCLUSIONS

Results suggest that single-action and dual-action antidepressants are equally effective in PLWHA. Remission was uncommon highlighting the need to identify health service delivery strategies that aid HIV providers in achieving full remission of their patients' depression.

Use of a postoperative pad test to identify continence status in women after obstetric vesicovaginal fistula repair: a prospective cohort study

OBJECTIVE

Determine whether a 1-hour pad test at discharge can identify continence status within 120 days of obstetric vesicovaginal fistula (VVF) repair.

DESIGN

Prospective cohort study.

SETTING

Fistula Care Centre in Lilongwe, Malawi.

POPULATION

Women with VVF who underwent repair between January 2012 and December 2014.

METHODS

Data on demographics, obstetric history, physical exam findings, operative management, postoperative findings, and follow up evaluations were collected on women with VVF repair.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and a receiver operating curve (ROC) were calculated to assess the utility of using a discharge pad test at three thresholds to identify women likely to be continent at follow up.

RESULTS

After VVF repair, 346 women had a 1-hour pad test performed at the time of hospital discharge and completed follow up within 120 days of repair. Of these, 79.8% (n = 276) were completely continent, whereas 20.2% (n = 70) had some degree of incontinence. The sensitivity and specificity of a negative 1-hour pad test at predicting continence is 68.1% and 82.9%, respectively. With this prevalence, a negative pad test at a 1.5-g threshold demonstrates a high predictive value (PPV = 94.0%, 95% CI 90.0-96.9) in detecting women with continence after repair.

CONCLUSIONS

At the 1.5-g threshold, a negative pad test at discharge identifies 94% of women who will remain continent after VVF repair. Adding the pad test to fistula care can identify women who are likely to remain continent and may not need further therapies in settings where resources are limited and follow up after repair is difficult.

TWEETABLE ABSTRACT

A negative pad test after repair is associated with continued continence at follow up.

Mind the Gap: Gaps in Antidepressant Treatment, Treatment Adjustments, and Outcomes among Patients in Routine HIV Care in a Multisite U.S. Clinical Cohort

BACKGROUND

Depression affects 20-30% of HIV-infected patients and is associated with worse HIV outcomes. Although effective depression treatment is available, depression is largely untreated or undertreated in this population.

METHODS

We quantified gaps in antidepressant treatment, treatment adjustments, and outcomes among US patients in routine HIV care in the nationally distributed CNICS observational clinical cohort. This cohort combines detailed clinical data with regular, self-reported depressive severity assessments (Patient Health Questionnaire-9, PHQ-9). We considered whether participants with likely depression received antidepressants, whether participants on antidepressants with persistently high depressive symptoms received timely dose adjustments, and whether participants achieved depression remission. We considered a cross-sectional analysis (6,219 participants in care in 2011-2012) and a prospective analysis (2,936 participants newly initiating CNICS care when PHQ-9 screening was active).

RESULTS

The cross-sectional sample was 87% male, 53% Caucasian, 25% African American, and 18% Hispanic; the prospective sample was similar. In both samples, 39-44% had likely depression, with 44-60% of those receiving antidepressants. Of participants receiving antidepressants, 20-26% experienced persistently high depressive symptoms; only a small minority of those received antidepressant dose adjustments. Overall, 35-40% of participants on antidepressants achieved full depression remission. Remission among participants with persistently high depressive symptoms was rare regardless of dose adjustments.

CONCLUSIONS

In this large, diverse cohort of US patients engaged in routine HIV care, we observed large gaps in antidepressant treatment, timely dose adjustment to address persistently high depressive symptoms, and antidepressant treatment outcomes. These results highlight the importance of more effective pharmacologic depression treatment models for HIV-infected patients.

Disparities in Depressive Symptoms and Antidepressant Treatment by Gender and Race/Ethnicity among People Living with HIV in the United States

Objective

To describe disparities along the depression treatment cascade, from indication for antidepressant treatment to effective treatment, in HIV-infected individuals by gender and race/ethnicity.

Methods

The Center for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) cohort includes 31,000 HIV-infected adults in routine clinical care at 8 sites. Individuals were included in the analysis if they had a depressive symptoms measure within one month of establishing HIV care at a CNICS site. Depressive symptoms were measured using the validated Patient Health Questionnaire-9 (PHQ-9). Indication for antidepressant treatment was defined as PHQ-9 ≥ 10 or a current antidepressant prescription. Antidepressant treatment was defined as a current antidepressant prescription. Evidence-based antidepressant treatment was considered treatment changes based on a person’s most recent PHQ-9, in accordance with clinical guidelines. We calculated the cumulative probability of moving through the depression treatment cascade within 24 months of entering CNICS HIV care. We used multivariable Cox proportional hazards models to estimate associations between gender, race/ethnicity, and a range of depression outcomes.

Results

In our cohort of HIV-infected adults in routine care, 47% had an indication for antidepressant treatment. Significant drop-offs along the depression treatment cascade were seen for the entire study sample. However, important disparities existed. Women were more likely to have an indication for antidepressant treatment (HR 1.54; 95% CI 1.34, 1.78), receive antidepressant treatment (HR 2.03; 95% CI 1.53, 2.69) and receive evidence-based antidepressant treatment (HR 1.67; 95% CI 1.03, 2.74), even after accounting for race/ethnicity. Black non-Hispanics (HR 0.47, 95% CI 0.35, 0.65), Hispanics (HR 0.63, 95% CI 0.44, 0.89) and other race/ethnicities (HR 0.35, 95% CI 0.17, 0.73) were less likely to initiate antidepressant treatment, compared to white non-Hispanics.

Conclusions

In our cohort of HIV-infected adults depressive symptoms were common. Important disparities in the prevalence of depressive symptoms and receipt of antidepressant treatment existed by gender and race/ethnicity.

Duration of cART Before Delivery and Low Infant Birthweight Among HIV-Infected Women in Lusaka, Zambia

OBJECTIVE

To estimate the association between duration of combination antiretroviral therapy (cART) during pregnancy and low infant birthweight (LBW), among women ≥37 weeks of gestation.

DESIGN

We conducted a retrospective cohort study of HIV-infected women who met eligibility criteria based on CD4 count ≤350 but had not started cART at entry into antenatal care. Our cohort was restricted to births that occurred ≥37 weeks of gestation.

METHODS

We used Poisson models with robust variance estimators to estimate risk ratios (RRs) and 95% confidence intervals (CIs).

RESULTS

Of 50,765 HIV-infected women with antenatal visits between January 2009 and September 2013, 4474 women met the inclusion criteria. LBW occurred in 302 pregnancies (7%). Nearly two-thirds of women (62%) eligible to initiate cART never started treatment. Overall, 14% were on cART for ≤8 weeks, 22% for 9-20 weeks, and 2% for 21-36 weeks. There was no evidence of an increased risk of LBW for women receiving cART for ≤8 weeks (RR = 1.22; 95% CI: 0.77 to 1.91), 9-20 weeks (RR = 1.23; 95% CI: 0.82 to 1.83), or 21-36 weeks (RR = 0.87; 95% CI: 0.22 to 3.46), compared with women who never initiated treatment. These findings were consistent across several sensitivity analyses.

CONCLUSIONS

Longer duration of cART was not associated with poor fetal growth among term pregnancies in our cohort. However, the relationship between cART and adverse pregnancy outcomes remains complicated. Continued work is required to investigate causality. An understanding cART's impact on adverse pregnancy outcomes is essential as cART becomes the cornerstone of preventing mother-to-child transmission programs globally.

A risk score to identify HIV-infected women most likely to become lost to follow-up in the postpartum period

Access to lifelong combination antiretroviral therapy (cART) is expanding among HIV-infected pregnant and breastfeeding women throughout sub-Saharan Africa (SSA). For this strategy to meaningfully improve maternal HIV outcomes, retention in HIV care is essential. We developed a risk score to identify women with high likelihood of loss to follow-up (LTFU) at 6 months postpartum from HIV care, using data from public health facilities in Lusaka, Zambia. LTFU was defined as not presenting for HIV care within 60 days of the last scheduled appointment. We used logistic regression to assess demographic, obstetric and HIV predictors of LTFU and to develop a simple risk score. Sensitivity and specificity were assessed at each risk score cut-point. Among 2029 pregnant women initiating cART between 2009 and 2011, 507 (25%) were LTFU by 6 months postpartum. Parity, education, employment status, WHO clinical stage, duration of cART during pregnancy and number of antenatal care visits were associated with LTFU (p-value < .10). A risk score cut-point of 11 (42nd percentile) had 85% sensitivity (95% CI 82%, 88%) and 22% specificity (95% CI 20%, 24%) to detect women LTFU and would exclude 20% of women from a retention intervention. A risk score cut-point of 18 (69th percentile) identified the 23% of women with the highest probability of LTFU and had sensitivity 32% (95% CI 28%, 36%) and specificity 80% (95% CI 78%, 82%). A risk score approach may be useful to triage a subset of women most likely to be LTFU for targeted retention interventions.

Improvements in depression and changes in quality of life among HIV-infected adults

Improving quality of life (QOL) for HIV-infected individuals is an important objective of HIV care, given the considerable physical and emotional burden associated with living with HIV. Although worse QOL has been associated with depression, no research has quantified the potential of improvement in depression to prospectively improve QOL among HIV-infected adults. We analyzed data from 115 HIV-infected adults with depression enrolled in a randomized controlled trial to evaluate the effectiveness of improved depression care on antiretroviral drug adherence. Improvement in depression, the exposure of interest, was defined as the relative change in depression at six months compared to baseline and categorized as full response (≥50% improvement), partial response (25-49% improvement), and no response (<25% improvement). Multivariable linear regression was used to investigate the relationship between improvement in depression and four continuous measures of QOL at six months: physical QOL, mental QOL, HIV symptoms, and fatigue intensity. In multivariable analyses, physical QOL was higher among partial responders (mean difference [MD] = 2.51, 95% CI: -1.51, 6.54) and full responders (MD = 3.68, 95% CI: -0.36, 7.72) compared to individuals who did not respond. Mental QOL was an average of 4.01 points higher (95% CI: -1.01, 9.03) among partial responders and 14.34 points higher (95% CI: 9.42, 19.25) among full responders. HIV symptoms were lower for partial responders (MD = -0.69; 95% CI: -1.69, 0.30) and full responders (MD = -1.51; 95% CI: -2.50, -0.53). Fatigue intensity was also lower for partial responders (MD = -0.94; 95% CI: -1.94, 0.07) and full responders (MD = -3.00; 95% CI: -3.98, -2.02). Among HIV-infected adults with depression, improving access to high-quality depression treatment may also improve important QOL outcomes.

Levels of alcohol use and history of HIV testing among female sex workers in Mombasa, Kenya

HIV testing is a critical first step to accessing HIV care and treatment, particularly for high-risk groups such as female sex workers (FSWs). Alcohol use may be a barrier to accessing HIV services, including HIV testing. We analyzed data from a cross-sectional survey of 818 FSWs in Mombasa, Kenya, and estimated the association between different levels of alcohol use and having never tested for HIV. In multivariable analyses, higher levels of alcohol consumption were associated with having never tested for HIV (PR 1.60; 95% CI: 1.07, 2.40). Future interventions should explore whether reducing harmful drinking improves HIV testing among FSWs.