Adapting the preterm birth phenotyping framework to a low-resource, rural setting and applying it to births from Migori County in western Kenya

BACKGROUND

Preterm birth is the leading cause of neonatal and under-five mortality worldwide. It is a complex syndrome characterized by numerous etiologic pathways shaped by both maternal and fetal factors. To better understand preterm birth trends, the Global Alliance to Prevent Prematurity and Stillbirth published the preterm birth phenotyping framework in 2012 followed by an application of the model to a global dataset in 2015 by Barros, et al. Our objective was to adapt the preterm birth phenotyping framework to retrospective data from a low-resource, rural setting and then apply the adapted framework to a cohort of women from Migori, Kenya.

METHODS

This was a single centre, observational, retrospective chart review of eligible births from November 2015 - March 2017 at Migori County Referral Hospital. Adaptations were made to accommodate limited diagnostic capabilities and data accuracy concerns. Prevalence of the phenotyping conditions were calculated as well as odds of adverse outcomes.

RESULTS

Three hundred eighty-seven eligible births were included in our study. The largest phenotype group was none (no phenotype could be identified; 41.1%), followed by extrauterine infection (25.1%), and antepartum stillbirth (16.7%). Extrauterine infections included HIV (75.3%), urinary tract infections (24.7%), malaria (4.1%), syphilis (3.1%), and general infection (3.1%). Severe maternal condition was ranked fourth (15.6%) and included anaemia (69.5%), chronic respiratory distress (22.0%), chronic hypertension prior to pregnancy (5.1%), diabetes (3.4%), epilepsy (3.4%), and sickle cell disease (1.7%). Fetal anaemia cases were the most likely to transfer to the newborn unit (OR 5.1, 95% CI 0.8, 30.9) and fetal anomaly cases were the most likely to result in a pre-discharge mortality (OR 3.9, 95% CI 0.8, 19.2).

CONCLUSIONS

Using routine data sources allowed for a retrospective analysis of an existing dataset, requiring less time and fewer resources than a prospective study and demonstrating a feasible approach to preterm phenotyping for use in low-resource settings to inform local prevention strategies.

Growth and neurodevelopmental outcomes of preterm and low birth weight infants in rural Kenya: a cross-sectional study

OBJECTIVE

Data on long-term outcomes of preterm (PT) and low birth weight (LBW) infants in countries with high rates of neonatal mortality and childhood stunting are limited, especially from community settings. The current study sought to explore growth and neurodevelopmental outcomes of PT/LBW infants from a rural community-based setting of Kenya up to 18 months adjusted age.

DESIGN

Cross-sectional study.

SETTING

Migori County, Kenya.

PARTICIPANTS

Three hundred and eighty-two PT/LBW infants (50.2% of those identified as eligible) from a cluster randomised control trial evaluating a package of facility-based intrapartum quality of care interventions for newborn survival consented for follow-up.

OUTCOME MEASURES

Caregiver interviews and infant health, growth and neurodevelopmental assessments were completed at 6, 12 or 18 months±2 weeks. Data included sociodemographic information, medical history, growth measurements and neurodevelopmental assessment using the Ten Questions Questionnaire, Malawi Developmental Assessment Tool and Hammersmith Infant Neurological Examination. Analyses were descriptive and univariate regression models. No alterations were made to planned data collection.

RESULTS

The final sample included 362 PT/LBW infants, of which 56.6% were moderate to late PT infants and 64.4% were LBW. Fewer than 2% of parents identified their child as currently malnourished, but direct measurement revealed higher proportions of stunting and underweight than in national demographic and health survey reports. Overall, 22.7% of caregivers expressed concern about their child's neurodevelopmental status. Neurodevelopmental delays were identified in 8.6% of infants based on one or more standardised tools, and 1.9% showed neurological findings indicative of cerebral palsy.

CONCLUSIONS

Malnutrition and neurodevelopmental delays are common among PT/LBW infants in this setting. Close monitoring and access to early intervention programmes are needed to help these vulnerable infants thrive.

TRIAL REGISTRATION NUMBER

NCT03112018.

Defining and estimating effects in cluster randomized trials: A methods comparison

Across research disciplines, cluster randomized trials (CRTs) are commonly implemented to evaluate interventions delivered to groups of participants, such as communities and clinics. Despite advances in the design and analysis of CRTs, several challenges remain. First, there are many possible ways to specify the causal effect of interest (eg, at the individual-level or at the cluster-level). Second, the theoretical and practical performance of common methods for CRT analysis remain poorly understood. Here, we present a general framework to formally define an array of causal effects in terms of summary measures of counterfactual outcomes. Next, we provide a comprehensive overview of CRT estimators, including the t-test, generalized estimating equations (GEE), augmented-GEE, and targeted maximum likelihood estimation (TMLE). Using finite sample simulations, we illustrate the practical performance of these estimators for different causal effects and when, as commonly occurs, there are limited numbers of clusters of different sizes. Finally, our application to data from the Preterm Birth Initiative (PTBi) study demonstrates the real-world impact of varying cluster sizes and targeting effects at the cluster-level or at the individual-level. Specifically, the relative effect of the PTBi intervention was 0.81 at the cluster-level, corresponding to a 19% reduction in outcome incidence, and was 0.66 at the individual-level, corresponding to a 34% reduction in outcome risk. Given its flexibility to estimate a variety of user-specified effects and ability to adaptively adjust for covariates for precision gains while maintaining Type-I error control, we conclude TMLE is a promising tool for CRT analysis.

Cost analysis of an intrapartum quality improvement package for improving preterm survival and reinforcing best practices in Kenya and Uganda

INTRODUCTION

Preterm birth is a leading cause of under-5 mortality, with the greatest burden in lower-resource settings. Strategies to improve preterm survival have been tested, but strategy costs are less understood. We estimate costs of a highly effective Preterm Birth Initiative (PTBi) intrapartum intervention package (data strengthening, WHO Safe Childbirth Checklist, simulation and team training, quality improvement collaboratives) and active control (data strengthening, Safe Childbirth Checklist).

METHODS

In our analysis, we estimated costs incremental to current cost of intrapartum care (in 2020 $US) for the PTBi intervention package and active control in Kenya and Uganda. We costed the intervention package and control in two scenarios: 1) non-research implementation costs as observed in the PTBi study (Scenario 1, mix of public and private inputs), and 2) hypothetical costs for a model of implementation into Ministry of Health programming (Scenario 2, mostly public inputs). Using a healthcare system perspective, we employed micro-costing of personnel, supplies, physical space, and travel, including 3 sequential phases: program planning/adaptation (9 months); high-intensity implementation (15 months); lower-intensity maintenance (annual). One-way sensitivity analyses explored the effects of uncertainty in Scenario 2.

RESULTS

Scenario 1 PTBi package total costs were $1.11M in Kenya ($48.13/birth) and $0.74M in Uganda ($17.19/birtth). Scenario 2 total costs were $0.86M in Kenya ($23.91/birth) and $0.28M in Uganda ($5.47/birth); annual maintenance phase costs per birth were $16.36 in Kenya and $3.47 in Uganda. In each scenario and country, personnel made up at least 72% of total PTBi package costs. Total Scenario 2 costs in Uganda were consistently one-third those of Kenya, largely driven by differences in facility delivery volume and personnel salaries.

CONCLUSIONS

If taken up and implemented, the PTBi package has the potential to save preterm lives, with potential steady-state (maintenance) costs that would be roughly 5-15% of total per-birth healthcare costs in Uganda and Kenya.

Effect of a quality improvement intervention for management of preterm births on outcomes of all births in Kenya and Uganda: A secondary analysis from a facility-based cluster randomized trial

Background

A large proportion of early neonatal deaths occur at the time or on the first day of birth. The Preterm Birth Initiative East Africa (PTBi EA) set out to decrease mortality among preterm births through improving quality of facility-based intrapartum care. The PTBi EA cluster randomized trial's primary analysis showed the package reduced intrapartum stillbirth and neonatal death among preterm infants. This secondary analysis examines the impact of the PTBi intervention package on stillbirth and predischarge newborn deaths combined, among all births in 20 participating facilities in Kenya and Uganda.

Methods

Eligible facilities were pair-matched and randomly assigned (1:1) into either the intervention or the control group. All facilities received support for data strengthening and a modified World Health Organization (WHO) Safe Childbirth Checklist; facilities in the intervention group additionally received provider mentoring using PRONTO simulation and team training as well as quality improvement collaboratives. We abstracted data from maternity registers.

Results

Of the total 29 442 births that were included, Kenya had 8468 and 6465 births and Uganda had 8719 and 5790 births, in the control and intervention arms, respectively. There were 935 stillbirths and predischarge newborn deaths in the control arm and 439 in the intervention arm. The adjusted odds ratio (aOR) for the effect of the intervention on the combined outcome, among all births, was 0.96 (95% confidence interval (CI) = 0.69-1.32), which was different by country: Kenya - 1.12 (95% CI = 0.72-1.73); Uganda - 0.65 (95% CI = 0.44-0.98); P_interaction  = 0.025. These trends were similar after excluding the PTBi primary cohort.

Conclusions

The intervention package improved survival among all births in Uganda but not in Kenya. These results suggest the importance of context and facility differences that were observed between the two countries.

Registration

This trial is registered with ClinicalTrials.gov, NCT03112018.

Prevalence of Substance Use and Its Association with Sociodemographic and Behavioral Factors among Women Who Conduct Sex Work in Kenya

Female sex workers (FSWs) in sub-Saharan Africa are a marginalized group with an increased morbidity risk. Psychoactive substance use among this group is common and increases the risk of adverse health consequences. The type of substance used, extent, and nature of use varies with different settings and regions. We examine the use of specific psychoactive substances among FSWs residing in an urban informal settlement in Nairobi. This cross-sectional study was conducted between April and August 2017. Structured questionnaires were administered in face-to-face interviews. Descriptive statistics and logistic regression were undertaken to examine prevalence, patterns, and factors associated with use of specific substances. Out of 301 FSWs, 98% reported current psychoactive substance use. The most used substance was alcohol with 95.6% of the study population reporting use in the past year. Of these, 151 (50.2%) met criteria for very high-risk drinkers. Reported current use was 61.5% for cannabis, 47.2% for khat, and 30.9% for tobacco. Factors independently associated with hazardous and harmful alcohol use included earning a higher monthly income (>USD50) and disclosure of sex work to close family and friends. There is an urgent need for preventive and curative interventions to address the high prevalence of substance use among FSW residing in high-risk urban informal settlements in Kenya.

Implementing the WHO Safe Childbirth Checklist modified for preterm birth: lessons learned and experiences from Kenya and Uganda

Background

The WHO Safe Childbirth Checklist (SCC) contains 29 evidence-based practices (EBPs) across four pause points spanning admission to discharge. It has been shown to increase EBP uptake and has been tailored to specific contexts. However, little research has been conducted in East Africa on use of the SCC to improve intrapartum care, particularly for preterm birth despite its burden. We describe checklist adaptation, user acceptability, implementation and lessons learned.

Methods

The East Africa Preterm Birth Initiative (PTBi EA) modified the SCC for use in 23 facilities in Western Kenya and Eastern Uganda as part of a cluster randomized controlled trial evaluating a package of facility-based interventions to improve preterm birth outcomes. The modified SCC (mSCC) for prematurity included: addition of a triage pause point before admission; focus on gestational age assessment, identification and management of preterm labour; and alignment with national guidelines. Following introduction, implementation lasted 24 and 34 months in Uganda and Kenya respectively and was supported through complementary mentoring and data strengthening at all sites. PRONTO® simulation training and quality improvement (QI) activities further supported mSCC use at intervention facilities only. A mixed methods approach, including checklist monitoring, provider surveys and in-depth interviews, was used in this analysis.

Results

A total of 19,443 and 2229 checklists were assessed in Kenya and Uganda, respectively. In both countries, triage and admission pause points had the highest rates of completion. Kenya’s completion was greater than 70% for all pause points; Uganda ranged from 39 to 75%. Intervention facilities exposed to PRONTO and QI had higher completion rates than control sites. Provider perceptions cited clinical utility of the checklist, particularly when integrated into patient charts. However, some felt it repeated information in other documentation tools. Completion was hindered by workload and staffing issues.

Conclusion

This study highlights the feasibility and importance of adaptation, iterative modification and complementary activities to reinforce SCC use. There are important opportunities to improve its clinical utility by the addition of prompts specific to the needs of different contexts. The trial assessing the PTBi EA intervention package was registered at ClinicalTrials.gov NCT03112018 Registered December 2016, retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07650-x.

Water Insecurity is Associated with Lack of Viral Suppression and Greater Odds of AIDS-Defining Illnesses Among Adults with HIV in Western Kenya

Reliable access to safe and acceptable water in sufficient quantities (i.e., water security) is important for medication adherence and limiting pathogen exposure, yet prior studies have only considered the role of food security as a social determinant of HIV-related health. Therefore, the objective of this analysis was to assess the relationships between household water insecurity and HIV-related outcomes among adults living with HIV in western Kenya (N = 716). We conducted a cross-sectional analysis of baseline data from Shamba Maisha (NCT02815579), a cluster randomized controlled trial of a multisectoral agricultural and asset loan intervention. Baseline data were collected from June 2016 to December 2017. We assessed associations between water insecurity and HIV-related outcomes, adjusting for clinical and behavioral confounders, including food insecurity. Each five-unit higher household water insecurity score (range: 0-51) was associated with 1.21 higher odds of having a viral load ≥ 1000 copies/mL (95% CI 1.07, 1.36) and 1.26 higher odds of AIDS-defining illness (95% CI 1.11, 1.42). Household water insecurity was not associated with CD4 cell count (B: 0.27; 95% CI -3.59, 13.05). HIV treatment and support programs should consider assessing and addressing water insecurity in addition to food insecurity to optimize HIV outcomes.

Household Water and Food Insecurity Are Positively Associated with Poor Mental and Physical Health among Adults Living with HIV in Western Kenya

BACKGROUND

Household food insecurity (FI) and water insecurity (WI) are prevalent public health issues that can co-occur. Few studies have concurrently assessed their associations with health outcomes, particularly among people living with HIV.

OBJECTIVES

We aimed to investigate the associations between FI and WI and how they relate to physical and mental health.

METHODS

Food-insecure adult smallholder farmers living with HIV in western Kenya were recruited to participate in a cluster-randomized controlled trial of a multisectoral agricultural and asset loan intervention. We used baseline data on experiences of FI (using the Household Food Insecurity Access Scale, range: 0-27) and WI (using a modified scale developed for this region, range: 0-51) in the prior month (n = 716). Outcomes included probable depression (using the Hopkins Symptom Checklist), fatigue and diarrhea in the prior month, and overall mental and physical health (using the Medical Outcomes Study HIV Health Survey, range: 0-100). We first assessed Pearson correlations between FI, WI, and sociodemographic characteristics. We then developed 3 regressions for each health outcome (control variables and FI; control variables and WI; control variables, FI, and WI) and compared model fit indexes.

RESULTS

Correlations between household FI, WI, and wealth were low, meaning they measure distinct constructs. FI and WI were associated with numerous physical and mental health outcomes; accounting for both resource insecurities typically provided the best model fit. For instance, when controlling for FI, each 10-point higher WI score was associated with a 6.42-point lower physical health score (P < 0.001) and 2.92 times greater odds of probable depression (P < 0.001).

CONCLUSIONS

Assessing both FI and WI is important for correctly estimating their relation with health outcomes. Interventions that address food- and water-related issues among persons living with HIV concurrently will likely be more effective at improving health than those addressing a single resource insecurity. This trial was registered at clinicaltrials.gov as NCT02815579.

Environmental, Metabolic, and Inflammatory Factors Converge in the Pathogenesis of Moderate Acute Malnutrition in Children: An Observational Cohort Study

Acute malnutrition affects more than 50 million children worldwide. These children are at an increased risk of morbidity and mortality from infectious disease. However, the pathogenesis of acute malnutrition and mechanisms underlying the increased risk and poor outcomes from infection are not well understood. Our objective was to identify differences in inflammation and inflammatory responses between children with moderate acute malnutrition (MAM) and healthy controls (HCs), and search for environmental, pathophysiological, and metabolic factors that may influence this response. Sixteen children with MAM and 16 HCs aged 18-36 months were studied in Nairobi, Kenya. None of the children had symptoms of an infectious disease (fever, diarrhea, or cough) in the 2 weeks before enrollment and sample collection. Demographic and health data were provided by their primary caregivers. Blood samples were collected to measure various biomarkers and the response to an inflammatory stimulus. Children with MAM were more frequently from households with contaminated water, crowding, and unstable income sources. They also had increases in basal inflammation, circulating bacterial lipopolysaccharide (LPS), markers of intestinal damage, and an exaggerated whole blood inflammatory response to LPS. Metabolic changes in children with MAM led to increased plasma levels of long-chain fatty acids, which were found to contribute to the pro-inflammatory state. These exploratory findings suggest convergence of multiple factors to promote dysregulated inflammatory responses and prompt several mechanistic hypotheses that can be pursued to better understand the pathogenesis of MAM.

Implementing an intrapartum package of interventions to improve quality of care to reduce the burden of preterm birth in Kenya and Uganda

Background

Quality of care during the intrapartum and immediate postnatal period for maternal and newborn health remains a major challenge due to the multiple health system bottlenecks in low-income countries. Reports of complex interventions that have been effective in reducing maternal and newborn mortality in these settings are usually limited in description, which inhibits learning and replication. We present a detailed account of the Preterm Birth Initiative (PTBi) implementation process, experiences and lessons learnt to inform scale-up and replication.

Methods

Using the TiDieR framework, we detail how the PTBi implemented an integrated package of interventions through a pair-matched cluster randomized control trial in 20 health facilities in Migori County, Kenya, and the Busoga region in east central Uganda from 2016 to 2019. The package aimed to improve quality of care during the intrapartum and immediate postnatal period with a focus on preterm birth. The package included data strengthening (DS) and introduction of a modified WHO Safe Childbirth Checklist (mSCC), simulation-based training and mentoring (PRONTO), and a Quality Improvement (QI) Collaborative.

Results

In 2016, DS and mSCC were introduced to improve existing data processes and increase the quality of data for measures needed to evaluate study impact. PRONTO and QI interventions were then rolled out sequentially. While package components were implemented with fidelity, some implementation processes required contextual adaptation to allow alignment with national priorities and guidelines, and flexibility to optimize uptake.

Conclusion

Lessons learned included the importance of synergy between interventions, the need for local leadership engagement, and the value of strengthening local systems and resources. Adaptations of individual elements of the package to suit the local context were important for effective implementation, and the TIDieR framework provides the guidance needed in detailed description to replicate such a complex intervention in other settings. Detailed documentation of the implementation process of a complex intervention with mutually synergistic components can help contextualize trial results and potential for scale-up. The trial is registered at ClinicalTrials.govNCT03112018, registered December 2016, posted April 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00109-w.

Effect of a quality improvement package for intrapartum and immediate newborn care on fresh stillbirth and neonatal mortality among preterm and low-birthweight babies in Kenya and Uganda: a cluster-randomised facility-based trial

Background

Although gains in newborn survival have been achieved in many low-income and middle-income countries, reductions in stillbirth and neonatal mortality have been slow. Prematurity complications are a major driver of stillbirth and neonatal mortality. We aimed to assess the effect of a quality improvement package for intrapartum and immediate newborn care on stillbirth and preterm neonatal survival in Kenya and Uganda, where evidence-based practices are often underutilised.

Methods

This unblinded cluster-randomised controlled trial was done in western Kenya and eastern Uganda at facilities that provide 24-h maternity care with at least 200 births per year. The study assessed outcomes of low-birthweight and preterm babies. Eligible facilities were pair-matched and randomly assigned (1:1) into either the intervention group or the control group. All facilities received maternity register data strengthening and a modified WHO Safe Childbirth Checklist; facilities in the intervention group additionally received provider mentoring using PRONTO simulation and team training as well as quality improvement collaboratives. Liveborn or fresh stillborn babies who weighed between 1000 g and 2500 g, or less than 3000 g with a recorded gestational age of less than 37 weeks, were included in the analysis. We abstracted data from maternity registers for maternal and birth outcomes. Follow-up was done by phone or in person to identify the status of the infant at 28 days. The primary outcome was fresh stillbirth and 28-day neonatal mortality. This trial is registered with ClinicalTrials.gov, NCT03112018.

Findings

Between Oct 1, 2016, and April 30, 2019, 20 facilities were randomly assigned to either the intervention group (n=10) or the control group (n=10). Among 5343 eligible babies in these facilities, we assessed outcomes of 2938 newborn and fresh stillborn babies (1447 in the intervention and 1491 in the control group). 347 (23%) of 1491 infants in the control group were stillborn or died in the neonatal period compared with 221 (15%) of 1447 infants in the intervention group at 28 days (odds ratio 0·66, 95% CI 0·54–0·81). No harm or adverse effects were found.

Interpretation

Fresh stillbirth and neonatal mortality among low-birthweight and preterm babies can be decreased using a package of interventions that reinforces evidence-based practices and invests in health system strengthening.

Funding

Bill & Melinda Gates Foundation.

Working with what you have: How the East Africa Preterm Birth Initiative used gestational age data from facility maternity registers

Objective

Preterm birth is the primary driver of neonatal mortality worldwide, but it is defined by gestational age (GA) which is challenging to accurately assess in low-resource settings. In a commitment to reducing preterm birth while reinforcing and strengthening facility data sources, the East Africa Preterm Birth Initiative (PTBi-EA) chose eligibility criteria that combined GA and birth weight. This analysis evaluated the quality of the GA data as recorded in maternity registers in PTBi-EA study facilities and the strength of the PTBi-EA eligibility criteria.

Methods

We conducted a retrospective analysis of maternity register data from March–September 2016. GA data from 23 study facilities in Migori, Kenya and the Busoga Region of Uganda were evaluated for completeness (variable present), consistency (recorded versus calculated GA), and plausibility (falling within the 3^rd and 97^th birth weight percentiles for GA of the INTERGROWTH-21^st Newborn Birth Weight Standards). Preterm birth rates were calculated using: 1) recorded GA <37 weeks, 2) recorded GA <37 weeks, excluding implausible GAs, 3) birth weight <2500g, and 4) PTBi-EA eligibility criteria of <2500g and between 2500g and 3000g if the recorded GA is <37 weeks.

Results

In both countries, GA was the least recorded variable in the maternity register (77.6%). Recorded and calculated GA (Kenya only) were consistent in 29.5% of births. Implausible GAs accounted for 11.7% of births. The four preterm birth rates were 1) 14.5%, 2) 10.6%, 3) 9.6%, 4) 13.4%.

Conclusions

Maternity register GA data presented quality concerns in PTBi-EA study sites. The PTBi-EA eligibility criteria of <2500g and between 2500g and 3000g if the recorded GA is <37 weeks accommodated these concerns by using both birth weight and GA, balancing issues of accuracy and completeness with practical applicability.

Agricultural and Finance Intervention Increased Dietary Intake and Weight of Children Living in HIV-Affected Households in Western Kenya

We tested whether a multisectoral household agricultural and finance intervention increased the dietary intake and improved the nutritional status of HIV-affected children. Two hospitals in rural Kenya were randomly assigned to be either the intervention or the control arm. The intervention comprised a human-powered water pump, microfinance loan for farm commodities, and training in sustainable farming practices and financial management. In each arm, 100 children (0-59 mo of age) were enrolled from households with HIV-infected adults 18-49 y old. Children were assessed beginning in April 2012 and every 3 mo for 1 y for dietary intake and anthropometry. Children in the intervention arm had a larger increase in weight (β: 0.025 kg/mo, P = 0.030), overall frequency of food consumption (β: 0.610 times · wk-1 · mo-1, P = 0.048), and intakes of staples (β: 0.222, P = 0.024), fruits and vegetables (β: 0.425, P = 0.005), meat (β: 0.074, P < 0.001), and fat (β: 0.057, P = 0.041). Livelihood interventions have potential to improve the nutrition of HIV-affected children. This trial was registered at clinicaltrials.gov as NCT01548599.

Prevalence of parental bereavement among female sex workers (FSW) in Kibra, Kenya

Female sex workers (FSW) residing in Kibra, Kenya experience elevated exposure to adverse events, yet the prevalence of parental bereavement is not well characterized. This cross-sectional pilot study on 301 FSWs residing in Kibra, Kenya found that 67.7% of these women were parentally bereaved. Significantly fewer parentally bereaved women reported historical use of condoms and emergency contraception compared to non-bereaved women, and older age of paternal bereavement was significantly associated with current contraceptive use. Prevalence rates of bereavement among this cohort are well over the national Kenyan average, and further research on the specific impact of bereavement is warranted.

An Agricultural and Finance Intervention Improved Dietary Intake and Nutritional Status of Children Living in HIV-affected Households in Western Kenya (P10-129-19)

Objectives

To test whether an intervention that was shown previously to have improved food security, dietary intake of adults, and HIV health outcomes also improved dietary intake and nutritional status of children living in HIV-affected households.

Methods

The study was conducted in the Nyanza Region, Kenya where two health facilities were randomly assigned as intervention or control arms. The intervention included a human-powered water pump, a microfinance loan to purchase farm commodities, and training in sustainable farming practices and financial management. One hundred children (6 to 60 months of age) were enrolled in each arm from households with HIV-infected adults 18 to 49 years old on antiretroviral therapy and with access to surface water and land. Children were assessed beginning in April 2012 and every three months for one year. Data were collected on dietary intake, height, weight, and mid-upper arm circumference (MUAC). The difference in differences from first visit and in linear trends over visits were tested using fixed-effects regression models.

Results

Compared to the control arm, children in the intervention arm had a larger increase in weight at the 12-month visit (β: 0.42, 95% CI: 0.08, 0.76) and increase in MUAC at the 6-month visit (β: 0.28, 95% CI: 0.08, 0.49), with no difference in changes in height over time. Compared to the control arm, the intervention arm had a larger increasing linear trend over time in intake of staples (β: 0.22, 95% CI: 0.02, 0.44), fruits and vegetables (β: 0.42, 95% CI: 0.10, 0.75), and meat (β: 0.07, 95% CI: 0.03, 0.12), and a larger decreasing linear trend in intake of condiments (β: -0.16, 95% CI: -0.23, -0.09) and tea (β: -0.12, 95% CI: -0.19, -0.05), with no differences in intake of eggs, dairy and fat over time.

Conclusions

This intervention that improved food security, dietary intake, and HIV health outcomes of HIV-infected adults also improved dietary intake and nutritional status of children living in those households. Multisectoral agricultural and financial interventions have the potential to improve the nutritional status of HIV-affected children in rural Kenya and should be further explored.

Funding Sources

National Institute of Mental Health.

Fortification of Carica papaya fruit seeds to school meal snacks may aid Africa mass deworming programs: a preliminary survey

BACKGROUND

Soil transmitted helminths (STHs) are among the world's neglected tropical diseases. Morbidity due to STHs is greatest in school-age children who typically have the highest burden of infection. In 2001, WHO passed a resolution for the use of large-scale mass drug administration (MDA) to deworm vulnerable children through school based programs. Though effective, there is concern that MDA might not be sustainable over extended periods. Additionally the current MDA strategy does not consider child malnutrition, a very common malady in resource limited countries. We report a pilot evaluation of an innovation that bundles school feeding and deworming.

METHODS

We designed a maize (corn) flour fortified with grounded dried papaya (Carica papaya) seeds and used it to prepare porridge as per the usual school meal recipe Children from three primary schools from Nandi County in Kenya were randomized into three arms: One school received 300 ml papaya fortified porridge daily (papaya group), the second school received similar serving of plain porridge without the pawpaw ingredient (control group) and the third school received plain porridge and the conventional MDA approach of one time 400 mg dosage of albendazole (albendazole arm). Prior to the randomization, an initial baseline stool microscopy analysis was done to determine presence and intensity of intestinal worms. Core indicators of nutrition-height, weight and hemoglobin counts were also assessed. The children were monitored daily for two months and final stool sample analysis and clinical monitoring done at the end of the study. Baseline and follow-up data were analyzed and compared through SAS version 9.1 statistical package.

RESULTS

A total of 326 children participated in the trial. The overall prevalence of Ascaris lumbricoides was 29.4% (96), Trichuris Trichura 5.2% (17) and hookworm 1 (0.3%). Papaya seed fortified porridge reduced the Ascaris lumbricoides egg count by 63.9% after the two month period (mean 209.7epg to 75.7 p < 0.002) as compared to the albendazole arm 78.8% (129.5 epg to 27.5, p value 0.006). The control group showed an increase in egg count (42.epg to 56.3) though it was not statistically significant. Hemoglobin counts in the papaya group increased from a mean of 2 g/dL (11.5 g/dL to 13.5 g/dL, p < 0.001), as compared to the albendazole arm that increased by 1 g/dL (12.8-13.9, p < 0.001). No significant change was observed in the placebo arm (13.2 to 13.1). Interestingly the papaya group showed a significant reduction of children with Tinea capitis (ringworms) (54.4 to 34%, p < 0.002) as compared to the albendazole arm that showed an increase in ringworm infestation though not statistically significant (39.7 to 64.7% p = 0.608).

CONCLUSION

Papaya seed fortified porridge had a significant effect on reduction of Ascaris lumbricoides burden. It had a better nutritional outcome and effect on child fungal infections than albendazole. Its application as a routine school meal may aid current national school based nutrition and deworming programs in Africa.

TRIAL REGISTRATION

This study was retrospectively registered at Clinicaltrials.gov Ref. NCT02725255 on 31st March 2016.

Clinical cascades as a novel way to assess physical readiness of facilities for the care of small and sick neonates in Kenya and Uganda

BACKGROUND

Globally, there were 2.7 million neonatal deaths in 2015. Significant mortality reduction could be achieved by improving care in low- and middle-income countries (LMIC), where the majority of deaths occur. Determining the physical readiness of facilities to identify and manage complications is an essential component of strategies to reduce neonatal mortality.

METHODS

We developed clinical cascades for 6 common neonatal conditions then utilized these to assess 23 health facilities in Kenya and Uganda at 2 time-points in 2016 and 2017. We calculated changes in resource availability over time by facility using McNemar's test. We estimated mean readiness and loss of readiness for the 6 conditions and 3 stages of care (identification, treatment, monitoring-modifying treatment). We estimated overall mean readiness and readiness loss across all conditions and stages. Finally, we compared readiness of facilities with a newborn special care unit (NSCU) to those without using the two-sample test of proportions.

RESULTS

The cascade model estimated mean readiness of 26.3-26.6% across the 3 stages for all conditions. Mean readiness ranged from 11.6% (respiratory distress-apnea) to 47.8% (essential newborn care) across both time-points. The model estimated overall mean readiness loss of 30.4-31.9%. There was mild to moderate variability in the timing of readiness loss, with the majority occurring in the identification stage. Overall mean readiness was higher among facilities with a NSCU (36.8%) compared to those without (20.0%).

CONCLUSION

The cascade model provides a novel approach to quantitatively assess physical readiness for neonatal care. Among 23 facilities in Kenya and Uganda, we identified a consistent pattern of 30-32% readiness loss across cascades and stages. This aggregate measure could be used to monitor and compare readiness at the facility-, health system-, or national-level. Estimates of readiness and loss of readiness may help guide strategies to improve care, prioritize resources, and promote neonatal survival in LMICs.

Demographic, psychosocial and clinical factors associated with postpartum depression in Kenyan women

BACKGROUND

Few longitudinal studies have examined associations between risk factors during pregnancy and mental health outcomes during the postpartum period. We used a cohort study design to estimate the prevalence, incidence and correlates of significant postpartum depressive symptoms in Kenyan women.

METHODS

We recruited adult women residing in an urban, resource-poor setting and attending maternal and child health clinics in two public hospitals in Nairobi, Kenya. A translated Kiswahili Edinburgh Postpartum Depression Scale was used to screen for depressive symptoms at baseline assessment in the 3rd trimester and follow up assessment at 6-10 weeks postpartum. Information was collected on potential demographic, psychosocial and clinical risk variables. Potential risk factors for postpartum depression were evaluated using multivariate logistic regression analysis.

RESULTS

Out of the 171 women who were followed up at 6-10 weeks postpartum, 18.7% (95% CI: 13.3-25.5) were found to have postpartum depression using an EPDS cut off of 10. In multivariate analyses, the odds of having postpartum depression was increased more than seven-fold in the presence of conflict with partner (OR = 7.52, 95% CI: 2.65-23.13). The association between antepartum and postpartum depression was quite strong but did not reach statistical significance (OR = 3.37, 95% CI: 0.98-11.64).

CONCLUSIONS

The high prevalence of significant postnatal depressive symptoms among Kenyan women underscores the need for addressing this public health burden. Depression screening and psychosocial support interventions that address partner conflict resolution should be offered as part of maternal health care.

Strengthening intrapartum and immediate newborn care to reduce morbidity and mortality of preterm infants born in health facilities in Migori County, Kenya and Busoga Region, Uganda: a study protocol for a randomized controlled trial

BACKGROUND

Preterm birth (birth before 37 weeks of gestation) and its complications are the leading contributors to neonatal and under-5 mortality. The majority of neonatal deaths in Kenya and Uganda occur during the intrapartum and immediate postnatal period. This paper describes our study protocol for implementing and evaluating a package of facility-based interventions to improve care during this critical window.

METHODS/DESIGN

This is a pair-matched, cluster randomized controlled trial across 20 facilities in Eastern Uganda and Western Kenya. The intervention facilities receive four components: (1) strengthening of routine data collection and data use activities; (2) implementation of the WHO Safe Childbirth Checklist modified for preterm birth; (3) PRONTO simulation training and mentoring to strengthen intrapartum and immediate newborn care; and (4) support of quality improvement teams. The control facilities receive both data strengthening and introduction of the modified checklist. The primary outcome for this study is 28-day mortality rate among preterm infants. The denominator will include all live births and fresh stillbirths weighing greater than 1000 g and less than 2500 g; all live births and fresh stillbirths weighing between 2501 and 3000 g with a documented gestational age less than 37 weeks.

DISCUSSION

The results of this study will inform interventions to improve personnel and facility capacity to respond to preterm labor and delivery, as well as care for the preterm infant.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03112018 . Registered on 13 April 2017.

Breastfeeding Is Associated with Decreased Risk of Hospitalization among HIV-Exposed, Uninfected Kenyan Infants

BACKGROUND

Human immunodeficiency virus (HIV)-exposed uninfected (HEU) infants are a growing population in sub-Saharan Africa, with higher morbidity and mortality than HIV-unexposed infants. HEU infants may experience increased morbidity due to breastfeeding avoidance.

OBJECTIVES

We sought to describe the burden and identify predictors of hospitalization among HEU infants in the first year of life.

METHODS

Using a retrospective cohort of HIV-infected mothers and their HEU infants in Nairobi, Kenya, we identified infants who were HIV-uninfected at birth and were followed monthly until their last negative HIV test, death, loss to follow-up, or study exit at 1 year of age. Incidence, timing, and reason for hospitalization was assessed overall as well as stratified by feeding method. Predictors of first infectious disease hospitalization were identified using competing risk regression, with HIV acquisition and death as competing risks.

RESULTS

Among 388 infants, 113 hospitalizations were reported (35/100 infant-years [the combined years of observation contributed by all infants in the study]; 95% confidence interval [CI], 29-42). Ninety hospitalizations were due to 1 or more infectious diseases (26/100 infant-years; 95% CI, 21-32)-primarily pneumonia (n = 40), gastroenteritis (n = 17), and sepsis (n = 14). Breastfeeding was associated with decreased risk of infectious disease hospitalization (subhazard ratio = 0.39; 95% CI, 0.24-0.64), as was time-updated nutrition status (subhazard ratio = 0.73; 95% CI, 0.61-0.89). Incidence of infectious disease hospitalization among formula-fed infants was 51/100 infant-years (95% CI, 37-70) compared to 19/100 infant-years (95% CI, 14-25) among breastfed infants.

CONCLUSION

Among HEU infants, breastfeeding and nutrition status were associated with reduced hospitalization during the first year of life.

Incidence and correlates of tuberculosis IGRA conversion among HIV-infected postpartum women

SETTING

Prevention of maternal-to-child transmission program at a tertiary care hospital in Nairobi, Kenya. The risk of acquiring Mycobacterium tuberculosis infection among peripartum human immunodeficiency virus (HIV) infected women is poorly defined.

OBJECTIVE

To determine the incidence of and co-factors for interferon-gamma release assay (IGRA) conversion among postpartum HIV-infected women using T-SPOT.TB.

DESIGN

We used data and cryopreserved peripheral blood mononuclear cells from a historical cohort of HIV-infected women enrolled at 32 weeks' gestation and followed for 1 year postpartum between 1999 and 2005.

RESULTS

Of 89 women initially IGRA-negative during pregnancy, 11 (12.4%) became positive, 53 (59.5%) remained negative and 25 (28.1%) were indeterminate at 1 year postpartum. Mean interferon-gamma (IFN-γ) response among converters increased from ~1 to >50 spot-forming cells/well (P = 0.015). IGRA conversion was significantly associated with partner HIV infection, flush toilets, maternal illness and cough during follow-up, but not maternal CD4 count or HIV viral load.

CONCLUSION

The high rates of IGRA conversion seen among HIV-infected postpartum women in our study are similar to those of other groups at high risk for M. tuberculosis infection. This has important implications for M. tuberculosis infection screening strategies and provision of preventive therapy for the health of women and their infants.

In the shadowlands of global health: observations from health workers in Kenya

During the past decade, donor funding for health interventions in Kenya and other African countries has risen sharply. Focused on high-profile diseases such as HIV/AIDS, these funds create islands of intervention in a sea of under-resourced public health services. This paper draws on ethnographic research conducted in HIV clinics and in a public hospital to examine how health workers experience and reflect upon the juxtaposition of ‘global’ medicine with ‘local’ medicine. We show that health workers face an uneven playing field. High-prestige jobs are available in HIV research and treatment, funded by donors, while other diseases and health issues receive less attention. Outside HIV clinics, patient's access to medicines and laboratory tests is expensive, and diagnostic equipment is unreliable. Clinicians must tailor their decisions about treatment to the available medical technologies, medicines and resources. How do health workers reflect on working in these environments and how do their experiences influence professional ambitions and commitments?

Shamba Maisha: Pilot agricultural intervention for food security and HIV health outcomes in Kenya: design, methods, baseline results and process evaluation of a cluster-randomized controlled trial

BACKGROUND

Despite advances in treatment of people living with HIV, morbidity and mortality remains unacceptably high in sub-Saharan Africa, largely due to parallel epidemics of poverty and food insecurity.

METHODS/DESIGN

We conducted a pilot cluster randomized controlled trial (RCT) of a multisectoral agricultural and microfinance intervention (entitled Shamba Maisha) designed to improve food security, household wealth, HIV clinical outcomes and women's empowerment. The intervention was carried out at two HIV clinics in Kenya, one randomized to the intervention arm and one to the control arm. HIV-infected patients >18 years, on antiretroviral therapy, with moderate/severe food insecurity and/or body mass index (BMI) <18.5, and access to land and surface water were eligible for enrollment. The intervention included: 1) a microfinance loan (~$150) to purchase the farming commodities, 2) a micro-irrigation pump, seeds, and fertilizer, and 3) trainings in sustainable agricultural practices and financial literacy. Enrollment of 140 participants took four months, and the screening-to-enrollment ratio was similar between arms. We followed participants for 12 months and conducted structured questionnaires. We also conducted a process evaluation with participants and stakeholders 3-5 months after study start and at study end.

DISCUSSION

Baseline results revealed that participants at the two sites were similar in age, gender and marital status. A greater proportion of participants at the intervention site had a low BMI in comparison to participants at the control site (18% vs. 7%, p = 0.054). While median CD4 count was similar between arms, a greater proportion of participants enrolled at the intervention arm had a detectable HIV viral load compared with control participants (49% vs. 28%, respectively, p < 0.010). Process evaluation findings suggested that Shamba Maisha had high acceptability in recruitment, delivered strong agricultural and financial training, and led to labor saving due to use of the water pump. Implementation challenges included participant concerns about repaying loans, agricultural challenges due to weather patterns, and a challenging partnership with the microfinance institution. We expect the results from this pilot study to provide useful data on the impacts of livelihood interventions and will help in the design of a definitive cluster RCT.

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov, NCT01548599.

Humoral immune responses to Plasmodium falciparum among HIV-1-infected Kenyan adults

INTRODUCTION

Humoral immune responses play a pivotal role in naturally acquired immunity to malaria. Understanding which humoral responses are impaired among individuals at higher risk for malaria may improve our understanding of malaria immune control and contribute to vaccine development.

METHODS

We compared humoral responses with 483 Plasmodium falciparum antigens between adults in, Kisumu (high, year-long malaria transmission leading to partial immunity), and adults in Kisii (low, seasonal malaria transmission). Then within each site, we compared malaria-specific humoral responses between those at higher risk for malaria (CD4(+) ≤500) and those at lower risk for malaria (CD4(+) >500). A protein microarray chip containing 483 P. falciparum antigens and 71 HIV antigens was used. Benjamini-Hochberg adjustments were made to control for multiple comparisons.

RESULTS

Fifty-seven antigens including CSP, MSP1, LSA1 and AMA1 were identified as significantly more reactive in Kisumu than in Kisii. Ten of these antigens had been identified as protective in an earlier study. CD4(+) T-cell count did not significantly impact humoral responses.

CONCLUSION

Protein microarrays are a useful method to screen multiple humoral responses simultaneously. This study provides useful clues for potential vaccine candidates. Modest decreases in CD4 counts may not significantly impact malaria-specific humoral immunity.

Diagnosis of sexually transmitted infections and bacterial vaginosis among HIV-1-infected pregnant women in Nairobi

HIV-infected women with sexually transmitted infections (STIs) or bacterial vaginosis (BV) during pregnancy are at increased risk for poor obstetric outcomes. In resource-limited settings, diagnostic testing for STIs and BV is often not available and most pregnant women are managed using syndromic algorithms. As part of a Nairobi perinatal cohort, HIV-1-infected pregnant women were interviewed and samples were collected for STIs and BV testing. Diagnostic accuracy of STIs and BV by syndromic algorithms was evaluated with comparison to the reference standard. Among 441 women, prevalence of BV was 37%, trichomoniasis 16%, chlamydia 4%, syphilis 3% and gonorrhoea 2%. Significantly more women with STIs were aged 21-years-old, had not attended secondary school and had a history of STIs. Syndromic diagnosis of STIs and BV demonstrated a sensitivity of 45% and 57%, and positive predictive value of 30% and 42%, respectively. Among these HIV-infected, pregnant women, STIs and vaginal infections were common and syndromic diagnosis was insensitive, resulting in missed opportunities to intervene and improve infant and maternal health.

Latent tuberculosis detection by interferon γ release assay during pregnancy predicts active tuberculosis and mortality in human immunodeficiency virus type 1-infected women and their children

BACKGROUND

We evaluated the prognostic usefulness of interferon γ release assays (IGRAs) for active tuberculosis and mortality in Kenyan human immunodeficiency virus type 1 (HIV-1)-infected women and their infants.

METHODS

Prevalence and correlates of Mycobacterium tuberculosis-specific T-SPOT.TB IGRA positivity were determined during pregnancy in a historical cohort of HIV-1-infected women. Hazard ratios, adjusted for baseline maternal CD4 cell count (aHR(CD4)), were calculated for associations between IGRA positivity and risk of active tuberculosis and mortality over 2-year postpartum follow-up among women and their infants.

RESULTS

Of 333 women tested, 52 (15.6%) had indeterminate IGRA results. Of the remaining 281 women, 120 (42.7%) had positive IGRA results, which were associated with a 4.5-fold increased risk of active tuberculosis (aHR(CD4), 4.5; 95% confidence interval [CI], 1.1-18.0; P = .030). For immunosuppressed women (CD4 cell count, <250 cells/μL), positive IGRA results were associated with increased risk of maternal mortality (aHR(CD4), 3.5; 95% CI, 1.02-12.1;), maternal active tuberculosis or mortality (aHR(CD4), 5.2; 95% CI, 1.7-15.6; P = .004), and infant active tuberculosis or mortality overall (aHR(CD4), 3.0; 95% CI, 1.0-8.9; P = .05) and among HIV-1-exposed uninfected infants (aHR(CD4), 7.3; 95% CI, 1.6-33.5; P = .01).

CONCLUSIONS

Positive IGRA results for HIV-1-infected pregnant women were associated with postpartum active tuberculosis and mortality among mothers and their infants.

Risk factors for neonatal conjunctivitis in babies of HIV-1 infected mothers

PURPOSE

To determine the prevalence and correlates of neonatal conjunctivitis in infants born to human immunodeficiency virus type 1 (HIV-1) infected mothers.

METHODS

This was a nested case-control study within a perinatal HIV-1 cohort. HIV-1 seropositive mothers were enrolled during pregnancy and mother-infant pairs followed after delivery with assessment for neonatal conjunctivitis at 48 hours and up to 4 weeks after birth. Genital infections (chlamydia, gonorrhea, syphilis, trichomonas, bacterial vaginosis, and candida) were screened for at 32 weeks gestation. Mothers received treatment for genital infections diagnosed during pregnancy and short-course zidovudine. Newborns did not receive ocular prophylaxis at hospital deliveries. Multivariate logistic regression models were used to determine cofactors for neonatal conjunctivitis overall and stratified for infant HIV-1 status.

RESULTS

Four hundred and fifty-two infants were assessed and 101 (22.3%) had neonatal conjunctivitis during the first month postpartum. In multivariate analyses using odds ratios (OR) and confidence intervals (CI), neonatal conjunctivitis was associated with neonatal sepsis (adjusted OR 21.95, 95% CI 1.76, 274.61), birth before arrival to hospital (adjusted OR 13.91, 95% CI 1.39, 138.78) and birth weight (median 3.4 versus 3.3 kilograms, p=0.016, OR 1.79, 95% CI 1.01, 3.15). Infant HIV-1 infection was not associated with conjunctivitis.

CONCLUSIONS

Despite detection and treatment of genital infections during pregnancy, neonatal conjunctivitis was frequently diagnosed in infants born to HIV-1 infected mothers suggesting a need for increased vigilance and prophylaxis for conjunctivitis in these infants. Neonatal sepsis, birth before arrival to hospital, and higher birthweight are factors that may predict higher risk of neonatal conjunctivitis in this population.

Comparison of CD4 cell count, viral load, and other markers for the prediction of mortality among HIV-1-infected Kenyan pregnant women

BACKGROUND

There are limited data regarding the relative merits of biomarkers as predictors of mortality or time to initiation of antiretroviral therapy (ART).

METHODS

We evaluated the usefulness of the CD4 cell count, CD4 cell percentage (CD4%), human immunodeficiency virus type 1 (HIV-1) load, total lymphocyte count (TLC), body mass index (BMI), and hemoglobin measured at 32 weeks' gestation as predictors of mortality in a cohort of HIV-1-infected women in Nairobi, Kenya. Sensitivity, specificity, positive predictive value (PPV), and area under the receiver operating characteristic (ROC) curve (AUC) were determined for each biomarker separately, as well as for the CD4 cell count and the HIV-1 load combined.

RESULTS

Among 489 women with 10,150 person-months of follow-up, mortality rates at 1 and 2 years postpartum were 2.1% (95% confidence interval [CI], 0.7%-3.4%) and 5.5% (95% CI, 3.0%-8.0%), respectively. CD4 cell count and CD4% had the highest AUC value (>0.9). BMI, TLC, and hemoglobin were each associated with but poorly predictive of mortality (PPV, <7%). The HIV-1 load did not predict mortality beyond the CD4 cell count.

CONCLUSIONS

The CD4 cell count and CD4% measured during pregnancy were both useful predictors of mortality among pregnant women. TLC, BMI, and hemoglobin had a limited predictive value, and the HIV-1 load did not predict mortality any better than did the CD4 cell count alone.

HV-1-specific cytotoxic T lymphocytes and breast milk HIV-1 transmission

BACKGROUND

Breast-feeding by infants exposed to human immunodeficiency virus type 1 (HIV-1) provides an opportunity to assess the role played by repeated HIV-1 exposure in eliciting HIV-1-specific immunity and in defining whether immune responses correlate with protection from infection.

METHODS

Breast-feeding infants born to HIV-1-seropositive women were assessed for HLA-selected HIV-1 peptide-specific cytotoxic T lymphocyte interferon (IFN)-gamma responses by means of enzyme-linked immunospot (ELISpot) assays at 1, 3, 6, 9, and 12 months of age. Responses were deemed to be positive when they reached > or = 50 HIV-1-specific sfu/1 x 10(6) peripheral blood mononuclear cells (PBMCs) and were at least twice those of negative controls.

RESULTS

A total of 807 ELISpot assays were performed for 217 infants who remained uninfected with HIV-1 at approximately 12 months of age; 101 infants (47%) had at least 1 positive ELISpot result (median, 78-170 sfu/1 x 10(6) PBMCs). The prevalence and magnitude of responses increased with age (P = .01 and P = .007, respectively); the median log(10) value for HIV-1-specific IFN-gamma responses increased by 1.0 sfu/1 x 10(6) PBMCs/month (P < .001) between 1 and 12 months of age. Of 141 HIV-1-uninfected infants with 1-month ELISpot results, 10 (7%) acquired HIV-1 infection (0/16 with positive vs. 10/125 [8%] with negative ELISpot results; P = .6). Higher values for log(10) HIV-1-specific spot-forming units at 1 month of age were associated with a decreased risk of HIV-1 infection, adjusted for maternal HIV-1 RNA level (adjusted hazard ratio, 0.09 [95% confidence interval, 0.01-0.72]).

CONCLUSION

. Breast-feeding HIV-1-exposed uninfected infants frequently had HIV-1-specific IFN-gamma responses. Greater early HIV-1-specific IFN-gamma responses were associated with decreased HIV-1 acquisition.

Salivary human immunodeficiency virus (HIV)-1-specific immunoglobulin A in HIV-1-exposed infants in Kenya

Humoral immunity, and specifically immunoglobulin A (IgA) that is directed against human immunodeficiency virus (HIV)-1, may contribute to protection against HIV-1 acquisition at mucosal surfaces. HIV-1-specific IgA has been detected in genital tract secretions of HIV-1-uninfected commercial sex workers with HIV-1 exposure, and may be produced in parotid saliva by infants exposed orally to HIV-1 during delivery and breastfeeding. To explore this hypothesis, we collected saliva from 145 infants aged < or = 6 months enrolled in a perinatal HIV-1 transmission study in Nairobi and from 55 control infants without HIV-1 exposure who were born to HIV-1-seronegative mothers. Among the 145 infants, 115 (79%) remained uninfected during the 12-month study period and 30 (21%) became HIV-1-infected during follow-up. Nine (8%) of the 115 HIV-1-exposed, uninfected infants had detectable levels of HIV-1 gp160-specific IgA compared with four (13%) of 30 infected infants and none of 55 control infants (P = 0.47 and P = 0.03 respectively). Among the nine HIV-1-exposed, uninfected infants with positive assays, median age was 1 month and none acquired HIV-1 during follow-up. We conclude that HIV-1-specific salivary IgA responses may be generated by very young infants exposed perinatally to maternal HIV-1. Mucosal responses would be an appropriate target for paediatric vaccines against breast milk HIV-1 transmission.

Predictors of mortality in HIV-1 exposed uninfected post-neonatal infants at the Kenyatta National Hospital, Nairobi

OBJECTIVES

To identify potential predictors of mortality, to determine mortality rate and to identify prevalent causes of death in a cohort of HIV-1 exposed uninfected infants.

DESIGN

Prospective cohort study.

SETTING

Kenyatta National Hospital, Nairobi, Kenya.

SUBJECTS

Three hundred and fifty one HIV-1 exposed uninfected post-neonatal infants who survived to one year of age.

RESULTS

Sixteen infants died (post-neonatal mortality rate of 47/1000 live births), 14 (88%) before six months of age. The most frequently identified medical conditions at death included bronchopneumonia, diarrhoea and failure to thrive. In multivariate analysis, prematurity (RR=10.5, 95%CI 3.8-29.1, p<0.001), teenage motherhood (RR=3.6, Cl 1.0-13.2, p=0.05) and symptomatic maternal HIV-1 disease (RR=2.7, CI 0.9-7.7, p=0.06) were associated with infant mortality.

CONCLUSION

Prematurity, teenage motherhood and symptomatic HIV-1 maternal disease were important predictors for post-neonatal mortality in this cohort of HIV-1 exposed uninfected infants. These factors should be considered in monitoring and follow up in prevention of mother-to-child HIV-1 transmission (PMTCT) programs.

Human leukocyte antigen (HLA) B*18 and protection against mother-to-child HIV type 1 transmission

Human leukocyte antigen (HLA) molecules regulate the cellular immune system and may be determinants of infant susceptibility to human immunodeficiency virus type 1 (HIV-1) infection. Molecular HLA typing for class I alleles was performed on infants followed in a Kenyan perinatal cohort. Early HIV-1 infection status was defined as infection occurring at birth or month 1, while late infection via breast milk was defined as first detection of HIV-1 after 1 month of age. Likelihood ratio tests based on a proportional hazards model adjusting for maternal CD4 T cell count and HIV-1 viral load at 32 weeks of gestation were used to test associations between infant allelic variation and incident HIV-1 infection. Among 433 infants, 76 (18%) were HIV-1 infected during 12 months of follow-up. HLA B*18 was associated with a significantly lower risk of early HIV-1 transmission [relative risk (RR) = 0.26; 95% confidence interval (CI) 0.04-0.82], and none of the 24 breastfeeding infants expressing HLA B*18 who were uninfected at month 1 acquired HIV-1 late via breast milk. We observed a trend toward increased early HIV-1 acquisition for infants presenting HLA A*29 (RR = 2.0; 95% CI 1.0-3.8) and increased late HIV-1 acquisition via breast milk for both Cw*07 and Cw*08 (RR = 4.0; 95% CI 1.0-17.8 and RR = 7.2; 95% CI 1.2-37.3, respectively). HLA B*18 may protect breast-feeding infants against both early and late HIV-1 acquisition, a finding that could have implications for the design and monitoring of HIV-1 vaccines targeting cellular immune responses against HIV-1.

Prevalence and magnitude of human immunodeficiency virus (HIV) type 1-specific lymphocyte responses in breast milk from HIV-1-seropositive women

Human immunodeficiency virus (HIV) type 1-specific cell-mediated immunity of breast milk may influence the likelihood of mother-to-child transmission of HIV-1 via breast-feeding. In breast-milk specimens collected during the first month postpartum from HIV-1-seropositive women in Nairobi, HIV-1 gag-specific cellular responses were detected in 17 (47%) of 36, and env-specific cellular responses were present in 20 (40%) of 50. Peripheral blood lymphocyte responses against either gag or env were detected in 35 (66%) of the 53 subjects, 18 (51%) of whom had positive gag or env responses in their breast milk. In paired analyses of blood and breast milk, the mean magnitude of responses to env or gag stimulation in breast milk was significantly higher than that in blood and remained higher in breast milk after normalization of responses according to CD8+ lymphocyte count. These results suggest that CD8+ lymphocytes present in breast milk have the capacity to recognize HIV-1-infected cells and may be selectively transported to breast milk to reduce either viral replication or transmission in breast milk.