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Fisher SA, Madden N, Espinal M, Garcia PM, Jao JK, Yee LM. Clinical Trials That Have Changed Clinical Practice and Care of Pregnant People With HIV. Clin Obstet Gynecol 2024; 67:381-398. [PMID: 38450526 DOI: 10.1097/grf.0000000000000860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Over the last 4 decades, significant advances in the care of HIV during pregnancy have successfully reduced, and nearly eliminated, the risk of perinatal HIV transmission. The baseline risk of transmission without intervention (25% to 30%) is now <1% to 2% in the United States with contemporary antepartum, intrapartum, and postnatal interventions. In this review, we discuss 3 landmark clinical trials that substantially altered obstetric practice for pregnant individuals with HIV and contributed to this extraordinary achievement: 1) the Pediatric AIDS Clinical Trials Group 076 Trial determined that antepartum and intrapartum administration of antiretroviral drug zidovudine to the pregnant individual, and postnatally to the newborn, could reduce the risk of perinatal transmission by approximately two-thirds; 2) the European Mode of Delivery Collaboration Trial demonstrated performance of a prelabor cesarean birth before rupture of membranes among pregnant people with viremia reduced the risk of perinatal transmission compared with vaginal birth; and 3) the International Maternal Pediatric Adolescent AIDS Clinical Trials Network 2010 Trial identified that dolutegravir-containing, compared with efavirenz-containing, antiretroviral regimens during pregnancy achieved a significantly higher rate of viral suppression at delivery with shorter time to viral suppression, with fewer adverse pregnancy outcomes. Collectively, these trials not only advanced obstetric practice but also advanced scientific understanding of the timing, mechanisms, and determinants of perinatal HIV transmission. For each trial, we will describe key aspects of the study protocol and outcomes, insights gleaned about the dynamics of perinatal transmission, how each study changed clinical practice, and relevant updates to current practice since the trial's publication.
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Affiliation(s)
- Stephanie A Fisher
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology
| | - Nigel Madden
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology
| | - Mariana Espinal
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology
| | - Patricia M Garcia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology
| | - Jennifer K Jao
- Division of Infectious Diseases, Departments of Medicine and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology
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2
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Atkinson A, Tulloch K, Boucoiran I, Money D. Directive clinique n o 450 : Prise en charge des femmes enceintes vivant avec le VIH et interventions pour réduire le risque de transmission périnatale. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024:102552. [PMID: 38729607 DOI: 10.1016/j.jogc.2024.102552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
OBJECTIFS La présente directive fournit une mise à jour sur les soins aux femmes enceintes vivant avec le VIH et sur la prévention de la transmission périnatale du VIH. La directive est une révision de la directive no 310, Lignes directrices pour ce qui est des soins à offrir aux femmes enceintes qui vivent avec le VIH et des interventions visant à atténuer la transmission périnatale, et comprend une revue actualisée de la littérature avec des recommandations à jour. POPULATION CIBLE Les femmes enceintes chez qui le VIH a été diagnostiqué lors d'un dépistage prénatal et les femmes vivant avec le VIH qui tombent enceintes. Cette ligne directrice ne contient pas de conseils spécifiques pour les filles et femmes en âge de procréer vivant avec le VIH, mais qui ne sont pas enceintes. RéSULTATS: La prévention de la transmission périnatale du VIH est un indicateur clé de la réussite d'un système de santé et nécessite une prise en charge multidisciplinaire des femmes enceintes vivant avec le VIH. Les résultats escomptés comprennent : des conseils à l'intention des prestataires de soins canadiens concernant les pratiques exemplaires de la prise en charge périnatale des femmes enceintes vivant avec le VIH; la réduction des cas de transmission périnatale du VIH en vue d'éradiquer la transmission périnatale; la prestation de soins optimaux pour les femmes enceintes afin d'assurer les meilleurs états de santé maternelle et la suppression du VIH; et un soutien et des recommandations fondés sur des données probantes pour les femmes enceintes vivant avec le VIH, en maintenant la conscience et la prise en compte des impacts psychosociaux complexes liés à la vie avec le VIH. BéNéFICES, RISQUES ET COûTS: La transmission périnatale du VIH implique d'importants risques de morbidité et mortalité pour l'enfant et est associée à des coûts de soins de santé pour toute sa vie. La grossesse est une période de vulnérabilité physique et émotionnelle, mais c'est aussi l'occasion d'impliquer la femme enceinte dans l'optimisation de sa santé. La présente directive n'inclut pas de recommandations entraînant des coûts supplémentaires pour les établissements de santé par comparaison à la directive précédente. L'application de ces recommandations vise à améliorer la santé de la mère et de l'enfant en optimisant la santé maternelle et en prévenant la transmission périnatale du VIH. DONNéES PROBANTES: La littérature publiée et non publiée a été examinée, en particulier pour la période après 2013. Les bases de données OVID-Medline, Embase, PubMed et la Cochrane Library ont été consultées afin de trouver les publications pertinentes disponibles en anglais ou en français pour chaque section de la directive. Les résultats étudiés proviennent d'études publiées entre 2012 et 2022, à savoir des revues systématiques, des essais cliniques randomisés et des études observationnelles. Les recherches ont été mises à jour sur une base régulière et intégrées à la directive clinique jusqu'en mai 2023. La littérature non publiée, les protocoles et les lignes directrices internationales ont été repérés par l'entremise de sites Web d'organismes de santé, de collections de directives cliniques et de sociétés de spécialité médicale nationales et internationales. MéTHODES DE VALIDATION: Les auteures ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe A (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles). PROFESSIONNELS CONCERNéS: Les utilisateurs visés par cette directive sont les prestataires de soins obstétricaux et les cliniciens spécialisés en maladies infectieuses qui prennent en charge des femmes enceintes vivant avec le VIH. RéSUMé DES MéDIAS SOCIAUX: Mise à jour de la directive canadienne sur le VIH pendant la grossesse, fondée sur des recherches de partout dans le monde et adaptée aux besoins et objectifs du système de santé canadien pour les femmes enceintes vivant avec le VIH et leur famille.
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Zangeneh SZ, Wilson EA, Ahluwalia S, Donnell DJ, Chen YQ, Grinsztejn B, Melo MG, Godbole SV, Hosseinipour MC, Taha T, Kumwenda J, McCauley M, Cohen MS, Nielsen-Saines K. Pregnancy rates and clinical outcomes among women living with HIV enrolled in HPTN 052. AIDS Care 2023; 35:824-832. [PMID: 36524872 PMCID: PMC10191867 DOI: 10.1080/09540121.2022.2141187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/21/2022] [Indexed: 12/23/2022]
Abstract
HPTN 052 was a multi-country clinical trial of cART for preventing heterosexual HIV-1 transmission. The study allowed participation of pregnant women and provided access to cART and contraceptives. We explored associations between pregnancy and clinical measures of HIV disease stage and progression. Of 869 women followed for 5.70 (SD = 1.62) years, 94.7% were married/cohabitating, 96% initiated cART, and 76.3% had >2 past pregnancies. Of 337 women who experienced pregnancy, 89.3% were from countries with lower contraceptive coverage, 56.1% first started cART with PI-based regimens and 57.6% were 25-34 years old. Mean cART duration and condom use were similar among pregnant and nonpregnant individuals. Adjusting for confounders, viral load suppression (VLS) was not (aHR(CI) = 0.82(0.61, 1.08)) and CD4 was slightly associated with decreased rates of first pregnancy over time (aHR(CI) = 0.9(0.84, 0.95)); baseline VLS was associated with increased (aRR(CI) = 2.48(1.71, 3.59)) and baseline CD4 was slightly associated with decreased number of pregnancies (aRR(CI) = 0.9(0.85,0.96)) over study duration. Partner seroconversion was univariably associated with higher rates of first pregnancy (HR(CI) = 2.02(1.32,3.07)). Despite a background of higher maternal morbidity and mortality rates, our findings suggest that becoming pregnant does not pose a threat to maternal health in women with HIV when there is access to medical care and antiretroviral treatment.
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Affiliation(s)
- Sahar Z. Zangeneh
- RTI International, Research Triangle Park, NC, USA
- Fred Hutchinson Cancer Research Center, Seattle WA, USA
- University of Washington, Seattle WA, USA
| | | | | | - Deborah J. Donnell
- Fred Hutchinson Cancer Research Center, Seattle WA, USA
- University of Washington, Seattle WA, USA
| | - Ying Q. Chen
- Stanford University School of Medicine, Stanford, CA, USA
| | - Beatriz Grinsztejn
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | | | | | - Mina C. Hosseinipour
- University of North Carolina Chapel Hill, Chapel Hill, NC USA
- UNC Project, Lilongwe, Malawi
| | - Taha Taha
- Center for Global Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore MD, USA
| | | | | | - Myron S. Cohen
- University of North Carolina Chapel Hill, Chapel Hill, NC USA
| | - Karin Nielsen-Saines
- David Geffen UCLA School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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4
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Dude AM, Jones M, Wilson T. Human Immunodeficiency Virus in Pregnancy. Obstet Gynecol Clin North Am 2023; 50:389-399. [PMID: 37149318 DOI: 10.1016/j.ogc.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Approximately 5000 people living with human immunodeficiency virus (HIV) give birth each year. Perinatal transmission of HIV will occur in about 15% to 45% of pregnancies without treatment. With appropriate antiretroviral therapy for pregnant people as well as appropriate intrapartum and postpartum interventions, the rate of perinatal transmission can be reduced to less than 1%. Antiretroviral therapy will also reduce health risks for pregnant patients living with HIV. All pregnant people should be offered the opportunity to learn their HIV status and access treatment as needed.
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Affiliation(s)
- Annie M Dude
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Maura Jones
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Tenisha Wilson
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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5
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Ruel T, Penazzato M, Zech JM, Archary M, Cressey TR, Goga A, Harwell J, Landovitz RJ, Lain MG, Lallemant M, Namusoke-Magongo E, Mukui I, Permar SR, Prendergast AJ, Shapiro R, Abrams EJ. Novel Approaches to Postnatal Prophylaxis to Eliminate Vertical Transmission of HIV. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2200401. [PMID: 37116934 PMCID: PMC10141432 DOI: 10.9745/ghsp-d-22-00401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/01/2023] [Indexed: 04/03/2023]
Abstract
Despite progress in providing antiretroviral therapy to pregnant women living with HIV, a substantial number of vertical transmissions continue to occur. Novel approaches leveraging modern potent, safe, and well-tolerated antiretroviral drugs are urgently needed.
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Affiliation(s)
- Theodore Ruel
- University of California, San Francisco, San Francisco, CA, USA
| | | | - Jennifer M. Zech
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, NY, USA
| | | | - Tim R. Cressey
- AMS-IRD Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Ameena Goga
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Pretoria, South Africa
| | | | - Raphael J. Landovitz
- UCLA Center for Clinical AIDS Research and Education, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Marc Lallemant
- AMS-PHPT Research Collaboration, Chiang Mai University, Chiang Mia, Thailand
- Penta Foundation Italy, Padova, Italy
| | | | - Irene Mukui
- Drugs for Neglected Diseases Initiative, Nairobi, Kenya
| | - Sallie R. Permar
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Andrew J. Prendergast
- Queen Mary University of London, London, United Kingdom
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Roger Shapiro
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Elaine J. Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, NY, USA
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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6
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Yang L, Cambou MC, Nielsen-Saines K. The End Is in Sight: Current Strategies for the Elimination of HIV Vertical Transmission. Curr HIV/AIDS Rep 2023; 20:121-130. [PMID: 36971951 DOI: 10.1007/s11904-023-00655-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE OF REVIEW The goal of this review is to highlight and interpret recent trends and developments in the diagnosis, treatment, and prevention of HIV vertical transmission from a clinical perspective. RECENT FINDINGS Universal third-trimester retesting and partner testing may better identify incident HIV among pregnant patients and result in early initiation of antiretroviral therapy to prevent vertical transmission. The proven safety and efficacy of integrase inhibitors such as dolutegravir may be particularly useful in suppressing viremia in pregnant persons who present late for ART treatment. Pre-exposure prophylaxis (PrEP) during pregnancy may play a role in preventing HIV acquisition; however, its role in preventing vertical transmission is difficult to elucidate. Substantial progress has been made in recent years to eliminate HIV perinatal transmission. Future research hinges upon a multipronged approach to improving HIV detection, risk-stratified treatment strategies, and prevention of primary HIV infection among pregnant persons.
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Affiliation(s)
- Lanbo Yang
- Warren Alpert Medical School, Brown University, 222 Richmond Street, Providence, RI, 02903, USA.
| | - Mary Catherine Cambou
- Division of Infectious Diseases, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Karin Nielsen-Saines
- Division of Pediatric Infectious Diseases, Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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7
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Ter Schiphorst E, Hansen KC, Holm M, Hønge BL. Mother-to-child HIV-2 transmission: comparison with HIV-1 and evaluation of factors influencing the rate of transmission. A systematic review. Trans R Soc Trop Med Hyg 2021; 116:399-408. [PMID: 34791488 DOI: 10.1093/trstmh/trab165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/26/2021] [Accepted: 10/27/2021] [Indexed: 11/12/2022] Open
Abstract
A review and collection of data on HIV-2 mother-to-child transmission (MTCT) is absent in the literature. This systematic review and meta-analysis aims to provide a pooled estimate of the rate of HIV-2 MTCT and to identify factors influencing the rate of transmission. PubMed and EMBASE were used to identify eligible publications using a sensitive search strategy. All publications until February 2021 were considered; 146 full-text articles were assessed. Observational studies describing the rate of HIV-2 MTCT in a defined HIV-2 infected study population were included. Other publication types and studies describing HIV-1 or dually infected populations were excluded. Nine studies consisting of 901 mother-child pairs in West Africa, France and Portugal were included in the meta-analysis. The pooled rate estimate of HIV-2 MTCT for antiretroviral therapy-naïve women was 0.2% (95% CI 0.03 to 1.47%), considerably lower than that for HIV-1. The levels of maternal HIV RNA and CD4 cell count were positively related to the vertical transmission rate. Maternal HIV-2 infection did not significantly affect perinatal mortality. It was concluded that the vertical transmission of HIV-2 is lower than that of HIV-1. Maternal viral load and CD4 cell count appear to influence the rate of HIV-2 MTCT.
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Affiliation(s)
- Emelie Ter Schiphorst
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.,Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Kamille Carstens Hansen
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Mette Holm
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Bo Langhoff Hønge
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.,Department of Clinical Immunology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.,Bandim Health Project, Indepth Network, Apartado 861, 1004 Bissau Codex, Guinea-Bissau
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8
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Marichannegowda MH, Mengual M, Kumar A, Giorgi EE, Tu JJ, Martinez DR, Romero-Severson EO, Li X, Feng L, Permar SR, Gao F. Different evolutionary pathways of HIV-1 between fetus and mother perinatal transmission pairs indicate unique immune selection in fetuses. Cell Rep Med 2021; 2:100315. [PMID: 34337555 PMCID: PMC8324465 DOI: 10.1016/j.xcrm.2021.100315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/12/2021] [Accepted: 05/18/2021] [Indexed: 11/04/2022]
Abstract
Study of evolution and selection pressure on HIV-1 in fetuses will lead to a better understanding of the role of immune responses in shaping virus evolution and vertical transmission. Detailed genetic analyses of HIV-1 env gene from 12 in utero transmission pairs show that most infections (67%) occur within 2 months of childbirth. In addition, the env sequences from long-term-infected fetuses are highly divergent and form separate phylogenetic lineages from their cognate maternal viruses. Host-selection sites unique to neonate viruses are identified in regions frequently targeted by neutralizing antibodies and T cell immune responses. Identification of unique selection sites in the env gene of fetal viruses indicates that the immune system in fetuses is capable of exerting selection pressure on viral evolution. Studying selection and evolution of HIV-1 or other viruses in fetuses can be an alternative approach to investigate adaptive immunity in fetuses.
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Affiliation(s)
| | - Michael Mengual
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
| | - Amit Kumar
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC 27710, USA
| | - Elena E. Giorgi
- Theoretical Division, Los Alamos National Laboratory, Los Alamos, NM 87544, USA
| | - Joshua J. Tu
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC 27710, USA
| | - David R. Martinez
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC 27710, USA
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC 27710, USA
| | | | - Xiaojun Li
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
| | - Liping Feng
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC 27710, USA
| | - Sallie R. Permar
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC 27710, USA
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC 27710, USA
- Department of Pediatrics, Duke University Medical Center, Durham, NC 27710, USA
| | - Feng Gao
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
- School of Medicine, Jinan University, Guangzhou, Guangdong 510632, P.R. China
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9
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Ahmed B, Konje JC. Screening for infections in pregnancy - An overview of where we are today. Eur J Obstet Gynecol Reprod Biol 2021; 263:85-93. [PMID: 34171635 DOI: 10.1016/j.ejogrb.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 05/27/2021] [Accepted: 06/07/2021] [Indexed: 12/09/2022]
Abstract
Although most infections in pregnancy have very little impact, some affect either the mother or fetus or both. Screening must target those infections with consequences and furthermore, must be cost-beneficial. The introduction of any screening test for infections should take into consideration the prevalence of the condition, its consequences (health impact), the accuracy of the test and whether there are remedial steps including primary and secondary prevention to take with a positive or negative test. For some of these infections (for example syphilis and rubella) universal screening of all pregnant women has been the norm world-wide but as the epidemiology of these infections continue to change, a review of this practice must evolve. Furthermore, emerging infections line severe acute respiratory syndrome coronavirus-2 pose greater public health challenges. This article provides an overview of screening for infections in pregnancy, critically appraising screening for the common infections and arguing for abandoning of universal screening for rubella but advocating for universal screening for GBS and selective screening for CMV and toxoplasmosis.
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Affiliation(s)
- Badredeen Ahmed
- Feto Maternal Centre, Doha, Qatar; Weill Cornell Medicine, Doha, Qatar; Qatar University, Qatar
| | - Justin C Konje
- Department of Health Sciences, University of Leicester, UK.
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10
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Faure-Bardon V, Ville Y. Maternal infections: revisiting the need for screening in pregnancy. BJOG 2021; 128:304-315. [PMID: 32937015 DOI: 10.1111/1471-0528.16509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2020] [Indexed: 12/09/2022]
Abstract
The decision to implement screening for infections during pregnancy depends upon epidemiological, economic, therapeutic and test performance criteria. It therefore varies with public health priorities from country to country. When screening is implemented, the first trimester has become the best time slot to build individual care pathways in this field. This is most relevant for evaluating the risk of embryonic consequences, planning diagnostic testing, initiating primary or secondary prevention and optimising the accuracy of ultrasound follow-up. This article is a critical appraisal of epidemiological data and current international screening recommendations for infections in pregnancy. TWEETABLE ABSTRACT: Screening for infections in pregnancy: a critical review of current epidemiological evidence and international guidelines.
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Affiliation(s)
- V Faure-Bardon
- EA 73-28, Paris Descartes University, Sorbonne Paris Cité, Paris, France.,Maternity, AP-HP, Hôpital Necker-Enfants Malades, Paris, France
| | - Y Ville
- EA 73-28, Paris Descartes University, Sorbonne Paris Cité, Paris, France.,Maternity, AP-HP, Hôpital Necker-Enfants Malades, Paris, France
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11
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Holzmann APF, Silva CSDOE, Soares JAS, Vogt SE, Alves CDR, Taminato M, Barbosa DA. Preventing vertical HIV virus transmission: hospital care assessment. Rev Bras Enferm 2020; 73:e20190491. [PMID: 32321146 DOI: 10.1590/0034-7167-2019-0491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 10/30/2019] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES assess the implementation of actions to prevent vertical transmission of HIV. METHODS a retrospective cohort study conducted in two maternity hospitals in the city of Montes Claros, State of Minas Gerais. All women admitted for childbirth diagnosed with HIV and their respective newborns were included from 2014 to 2017. Data were collected from medical records and analyzed descriptively. RESULTS population consisted of 46 pairs of mothers and newborns. Management was considered inadequate in 30 cases of parturient/postpartum women (65.2%) and 14 cases of newborns (30.4%). The main reasons for inadequate maternal management were lack of pharmacological inhibition of lactation (53.3%) and counseling/consent for HIV testing (43.3%). For newborns, late onsetoffirst dose ofZidovudine (50.0%) and no prescriptionofNevirapine (28.6%). CONCLUSIONS important prevention opportunities were missed, pointing to the need for improved care.
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Affiliation(s)
| | | | | | | | | | - Mônica Taminato
- Universidade Federal de São Paulo. São Paulo, São Paulo, Brazil
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12
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Wei L, Mansoor N, Khan RA, Czejka M, Ahmad T, Ahmed M, Ali M, Yang DH. WB-PBPK approach in predicting zidovudine pharmacokinetics in preterm neonates. Biopharm Drug Dispos 2019; 40:341-349. [PMID: 31693190 DOI: 10.1002/bdd.2208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 10/07/2019] [Accepted: 10/09/2019] [Indexed: 01/17/2023]
Abstract
Antiretroviral therapy has been the mainstay of treatment for neonates born to HIV infected mothers. Neonates born prematurely to HIV positive mothers are underdeveloped not only in anatomical terms but also in their physiological systems. Zidovudine, the first antiretroviral drug in clinical therapy for the treatment of HIV has been approved for use in preterm neonates both prophylactically and therapeutically. The present work describes the whole body physiologically based pharmacokinetic (WB-PBPK) model development for zidovudine in preterm neonates of varying gestational ages, to observe the pharmacokinetic behavior of the drug in this vulnerable group of the population. Along with the height, weight, post-natal, and gestational ages of the preterm neonates, metabolic enzymes CYP2A6, CYP2C8, etc. were incorporated for each neonate. The composition of the different organs in terms of water and lipid components, blood flow rates, etc. were specified during simulations according to the gestational ages of these neonates. The following PK parameters were estimated for preterm neonates using simulated plasma profiles: AUC 2686.41 ± 123.49 μmol min/L, Cmax 6.46 ± 0.74 μmol/L, half-life 8.98 ± 2.36 hr, mean residence time 12.23 ± 3.43 hr, and total plasma clearance 1.48 ± 0.19 ml/min/kg in comparison with the observed PK parameters of a clinical study by Mirochknic et al. in preterm neonates with AUC 2020.04 μmol/min/L, Cmax 6.10 μmol/L, and total plasma clearance 1.62 ml/min/kg. PBPK simulations provide an opportunity to visualize the possible impact of physiological maturity levels at varying gestational ages on the pharmacokinetic behavior of zidovudine in preterm neonates.
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Affiliation(s)
- Liuya Wei
- School of Pharmacy, Weifang Medical University, Weifang, 261053, China.,Department of Pharmaceutical Sciences, St John's University, New York, 11439, USA
| | - Najia Mansoor
- Department of Pharmacology, Faculty of Pharmacy & Pharmaceutical Sciences, University of Karachi, Karachi, 75270, Pakistan
| | - Rafeeq Alam Khan
- Department of Pharmacology, Faculty of Pharmacy & Pharmaceutical Sciences, University of Karachi, Karachi, 75270, Pakistan
| | - Martin Czejka
- Department of Clinical Pharmacy and Diagnostics, University of Vienna, Vienna, A-1090, Austria
| | - Tasneem Ahmad
- Pharma Professional Services, Karachi, 75270, Pakistan
| | - Mansoor Ahmed
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy & Pharmaceutical Sciences, University of Karachi, Karachi, 75270, Pakistan
| | - Mohsin Ali
- Department of Chemistry, University of Karachi, Karachi, 75270, Pakistan
| | - Dong-Hua Yang
- Department of Pharmaceutical Sciences, St John's University, New York, 11439, USA
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Abstract
OBJECTIVE The purpose of this guideline is to provide recommendations to obstetric health care providers and to minimize practice variations for HIV screening, while taking provincial and territorial recommendations into account. OUTCOMES The risk of transmission of HIV from mother to fetus is significant if the mother is not treated. The primary outcome of screening for and treating HIV in pregnancy is a marked decrease in the rate of vertical transmission of HIV from mother to fetus. Secondary outcomes include confirmation of HIV infection in the woman, which allows optimization of her health and long-term management. EVIDENCE The Cochrane Library and Medline were searched for English-language articles published related to HIV screening and pregnancy. Additional articles were identified through the references of these articles. All study types were reviewed. RECOMMENDATIONS
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Chaka TE, Abebe TW, Kassa RT. Option B+ prevention of mother-to-child transmission of HIV/AIDS service intervention outcomes in selected health facilities, Adama town, Ethiopia. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2019; 11:77-82. [PMID: 31118825 PMCID: PMC6498145 DOI: 10.2147/hiv.s192556] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 03/04/2019] [Indexed: 11/23/2022]
Abstract
Background: Vertical HIV transmission from mother-to-child accounts for more than 90% of pediatric HIV/AIDS infection. Virtual elimination of mother-to-child transmission (MTCT) of HIV is possible by giving comprehensive prevention of HIV/AIDS mother-to-child transmission (PMTCT) care. The objective of this study was to assess Option B+ (initiation of antiretroviral therapy for all pregnant mothers) PMTCT service intervention and outcomes in selected health facilities of Adama town, Ethiopia. Methods: A retrospective study was employed. A total of 248 medical records of mother–infant cohorts were included. Data wer collected from logbooks and/or records and individual medical records using a data abstraction tool. Results: Mean±SD age of mothers was 26.8±4.3 years. Half (50.8%) of the mothers were enrolled in PMTCT at 13–24 weeks of gestational age. The majority (79.6%) of mothers’ CD4 counts were ≥351/mm3. Most of the mothers (71%) were on a tenofovir–lamivudine–evafrenz regimen. One-quarter of mothers were prescribed co-trimoxazole prophylactic therapy. Loss to follow-up from the Option B+ continuum was 10 (4.2%). Almost all (98.4%) of the infants were prescribed nevirapine prophylaxis. Nearly 90% (n=223) of the HIV-exposed infants were discharged as HIV negative. Conclusions: The Option B+ PMTCT service can minimize the chances of MTCT of HIV infection if used optimally. The magnitudes of loss to follow-up and death were lower than in comparable studies. Initiating all pregnant mothers on antiretroviral therapy irrespective of their clinical stage and CD4 count may have contributed to the optimal retention in care and near elimination of MTCT of HIV infection.
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Affiliation(s)
- Tolossa Eticha Chaka
- Department of Pediatrics & Child Health, Adama Hospital Medical College, Adama, Ethiopia
| | | | - Roza Teshome Kassa
- Department of Nursing & Midwifery, College of Health Sciences, Addis Ababa University, Ababa, Ethiopia
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Foreword. Clin Obstet Gynecol 2019; 61:90-94. [PMID: 29351150 DOI: 10.1097/grf.0000000000000347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Saraswat N, Chopra A, Kumar S, Agarwal R, Mitra D, Kamboj P. A Cross-sectional Study to Analyze the Social, Sexual, and Reproductive Challenges among Serodiscordant Couples. Indian J Dermatol 2019; 64:377-382. [PMID: 31543532 PMCID: PMC6749756 DOI: 10.4103/ijd.ijd_367_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction The term "serodiscordant couples" refers to an intimate partnership in which one partner is human immunodeficiency virus (HIV) positive and the other HIV negative. They form a special population which are constantly at risk of acquiring infection, require safer sexual and reproductive options, and are in constant psychological and emotional distress. Aims To describe the social, sexual, and reproductive issues and their impact on serodiscordant couples. Materials and Methods A cross-sectional study was conducted on HIV-serodiscordant couples, admitted or attending our outpatient department, where the couples had not separated. A detailed interview of the partners on social, sexual, and reproductive issues was conducted and the data were endorsed in the pro forma. Results Sixty-four serodiscordant couples were included in the study. Sixty-two (96.8%) males were seropositive compared to 2 (3.1%) females. Sixty-one (95.3%) patients were married and 3 (4.6%) were unmarried. Thirty-six (56.2%) patients were between the age group of 21 and 35 years, 21 (32.8%) between 36 and 55 years, and 7 (10.9%) between 56 and 70 years. Sixty-two (96.8%) patients had a heterosexual orientation compared to 2 (3.1%) patients who were homosexual. Twenty-one (32.8%) patients had a history of sexual encounter outside the relation while 27 (42.1%) were not aware of the source of infection. Fifty-one (79.6%) patients were on antiretroviral therapy (ART) compared to 13 (20.3%) patients who were not on ART. Thirty-one (48.4%) patients admitted to have a constant strain in relation while 16 (25%) were practicing safe sex. Thirty-nine (60.9%) patients had fear of disease transmission while 26 (40.6%) had fear of pregnancy. Forty-nine (76.5%) patients had children at the time of detection while 15 (23.4%) had no issue. Forty-one (64%) patients expressed desire to have children as compared to 23 (35.9%). Conclusion The unique requirements of serodiscordant couples in terms of providing them safer sexual and reproductive options to prevent the transmission of HIV to the seronegative partner or the child during pregnancy need to be addressed for better patient management.
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Affiliation(s)
| | - Ajay Chopra
- Department of Dermatology, Base Hospital, New Delhi, India
| | - Sushil Kumar
- Department of Dermatology, MLN Medical College, Allahabad, Uttar Pradesh, India
| | - Reetu Agarwal
- Department of Dermatology, Base Hospital, New Delhi, India
| | - Debdeep Mitra
- Department of Dermatology, Base Hospital, New Delhi, India
| | - Parul Kamboj
- Department of Dermatology, Military Hospital, Guwahati, Assam, India
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Kumar A, Smith CEP, Giorgi EE, Eudailey J, Martinez DR, Yusim K, Douglas AO, Stamper L, McGuire E, LaBranche CC, Montefiori DC, Fouda GG, Gao F, Permar SR. Infant transmitted/founder HIV-1 viruses from peripartum transmission are neutralization resistant to paired maternal plasma. PLoS Pathog 2018; 14:e1006944. [PMID: 29672607 PMCID: PMC5908066 DOI: 10.1371/journal.ppat.1006944] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 02/16/2018] [Indexed: 01/17/2023] Open
Abstract
Despite extensive genetic diversity of HIV-1 in chronic infection, a single or few maternal virus variants become the founders of an infant’s infection. These transmitted/founder (T/F) variants are of particular interest, as a maternal or infant HIV vaccine should raise envelope (Env) specific IgG responses capable of blocking this group of viruses. However, the maternal or infant factors that contribute to selection of infant T/F viruses are not well understood. In this study, we amplified HIV-1 env genes by single genome amplification from 16 mother-infant transmitting pairs from the U.S. pre-antiretroviral era Women Infant Transmission Study (WITS). Infant T/F and representative maternal non-transmitted Env variants from plasma were identified and used to generate pseudoviruses for paired maternal plasma neutralization sensitivity analysis. Eighteen out of 21 (85%) infant T/F Env pseudoviruses were neutralization resistant to paired maternal plasma. Yet, all infant T/F viruses were neutralization sensitive to a panel of HIV-1 broadly neutralizing antibodies and variably sensitive to heterologous plasma neutralizing antibodies. Also, these infant T/F pseudoviruses were overall more neutralization resistant to paired maternal plasma in comparison to pseudoviruses from maternal non-transmitted variants (p = 0.012). Altogether, our findings suggest that autologous neutralization of circulating viruses by maternal plasma antibodies select for neutralization-resistant viruses that initiate peripartum transmission, raising the speculation that enhancement of this response at the end of pregnancy could further reduce infant HIV-1 infection risk. Mother to child transmission (MTCT) of HIV-1 can occur during pregnancy (in utero), at the time of delivery (peripartum) or by breastfeeding (postpartum). With the availability of anti-retroviral therapy (ART), rate of MTCT of HIV-1 have been significantly lowered. However, significant implementation challenges remain in resource-poor areas, making it difficult to eliminate pediatric HIV. An improved understanding of the viral population (escape variants from autologous neutralizing antibodies) that lead to infection of infants at time of transmission will help in designing immune interventions to reduce perinatal HIV-1 transmission. Here, we selected 16 HIV-1-infected mother-infant pairs from WITS cohort (from pre anti-retroviral era), where infants became infected peripartum. HIV-1 env gene sequences were obtained by the single genome amplification (SGA) method. The sensitivity of these infant Env pseudoviruses against paired maternal plasma and a panel of broadly neutralizing monoclonal antibodies (bNAbs) was analyzed. We demonstrated that the infant T/F viruses were more resistant against maternal plasma than non-transmitted maternal variants, but sensitive to most (bNAbs). Signature sequence analysis of infant T/F and non-transmitted maternal variants revealed the potential importance of V3 and MPER region for resistance against paired maternal plasma. These findings provide insights for the design of maternal immunization strategies to enhance neutralizing antibodies that target V3 region of autologous virus populations, which could work synergistically with maternal ARVs to further reduce the rate of peripartum HIV-1 transmission.
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Affiliation(s)
- Amit Kumar
- Duke Human Vaccine Institute, Duke University Medical Centre, Durham, North Carolina, United States of America
| | - Claire E. P. Smith
- Duke Human Vaccine Institute, Duke University Medical Centre, Durham, North Carolina, United States of America
| | - Elena E. Giorgi
- Los Alamos National Laboratory, Los Alamos, New Mexico, United States of America
| | - Joshua Eudailey
- Duke Human Vaccine Institute, Duke University Medical Centre, Durham, North Carolina, United States of America
| | - David R. Martinez
- Duke Human Vaccine Institute, Duke University Medical Centre, Durham, North Carolina, United States of America
| | - Karina Yusim
- Los Alamos National Laboratory, Los Alamos, New Mexico, United States of America
| | - Ayooluwa O. Douglas
- Duke Human Vaccine Institute, Duke University Medical Centre, Durham, North Carolina, United States of America
| | - Lisa Stamper
- Duke Human Vaccine Institute, Duke University Medical Centre, Durham, North Carolina, United States of America
| | - Erin McGuire
- Duke Human Vaccine Institute, Duke University Medical Centre, Durham, North Carolina, United States of America
| | - Celia C. LaBranche
- Department of Surgery, Duke University Medical Centre, Durham, North Carolina, United States of America
| | - David C. Montefiori
- Department of Surgery, Duke University Medical Centre, Durham, North Carolina, United States of America
| | - Genevieve G. Fouda
- Duke Human Vaccine Institute, Duke University Medical Centre, Durham, North Carolina, United States of America
| | - Feng Gao
- Department of Medicine, Duke University Medical Centre, Durham, North Carolina, United States of America
- National Engineering Laboratory for AIDS Vaccine, College of Life Science, Jilin University, Changchun, Jilin, China
| | - Sallie R. Permar
- Duke Human Vaccine Institute, Duke University Medical Centre, Durham, North Carolina, United States of America
- * E-mail:
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Peltzer K, Weiss SM, Soni M, Lee TK, Rodriguez VJ, Cook R, Alcaide ML, Setswe G, Jones DL. A cluster randomized controlled trial of lay health worker support for prevention of mother to child transmission of HIV (PMTCT) in South Africa. AIDS Res Ther 2017; 14:61. [PMID: 29248014 PMCID: PMC5732507 DOI: 10.1186/s12981-017-0187-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 12/11/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We evaluate the impact of clinic-based PMTCT community support by trained lay health workers in addition to standard clinical care on PMTCT infant outcomes. METHODS In a cluster randomized controlled trial, twelve community health centers (CHCs) in Mpumalanga Province, South Africa, were randomized to have pregnant women living with HIV receive either: a standard care (SC) condition plus time-equivalent attention-control on disease prevention (SC; 6 CHCs; n = 357), or an enhanced intervention (EI) condition of SC PMTCT plus the "Protect Your Family" intervention (EI; 6 CHCs; n = 342). HIV-infected pregnant women in the SC attended four antenatal and two postnatal video sessions and those in the EI, four antenatal and two postnatal PMTCT plus "Protect Your Family" sessions led by trained lay health workers. Maternal PMTCT and HIV knowledge were assessed. Infant HIV status at 6 weeks postnatal was drawn from clinic PCR records; at 12 months, HIV status was assessed by study administered DNA PCR. Maternal adherence was assessed by dried blood spot at 32 weeks, and infant adherence was assessed by maternal report at 6 weeks. The impact of the EI was ascertained on primary outcomes (infant HIV status at 6 weeks and 12 months and ART adherence for mothers and infants), and secondary outcomes (HIV and PMTCT knowledge and HIV transmission related behaviours). A series of logistic regression and latent growth curve models were developed to test the impact of the intervention on study outcomes. RESULTS In all, 699 women living with HIV were recruited during pregnancy (8-24 weeks), and assessments were completed at baseline, at 32 weeks pregnant (61.7%), and at 6 weeks (47.6%), 6 months (50.6%) and 12 months (59.5%) postnatally. Infants were tested for HIV at 6 weeks and 12 months, 73.5% living infants were tested at 6 weeks and 56.7% at 12 months. There were no significant differences between SC and EI on infant HIV status at 6 weeks and at 12 months, and no differences in maternal adherence at 32 weeks, reported infant adherence at 6 weeks, or PMTCT and HIV knowledge by study condition over time. CONCLUSION The enhanced intervention administered by trained lay health workers did not have any salutary impact on HIV infant status, ART adherence, HIV and PMTCT knowledge. Trial registration clinicaltrials.gov: number NCT02085356.
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Fondoh VN, Mom NA. Mother-to-child transmission of HIV and its predictors among HIV-exposed infants at Bamenda Regional Hospital, Cameroon. Afr J Lab Med 2017; 6:589. [PMID: 29435421 PMCID: PMC5803518 DOI: 10.4102/ajlm.v6i1.589] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 05/27/2017] [Indexed: 11/22/2022] Open
Abstract
Background Mother-to-child transmission (MTCT) of HIV, has been a major global public health burden. Despite the use of antiretroviral prophylaxis by HIV-positive pregnant women and their infants, safe obstetric practice and safe infant feeding habits in the prevention of MTCT of HIV, the prevalence of HIV among HIV-exposed infants is still high in Cameroon. Objective Our objectives were to determine the prevalence, assess the predictors and determine the effect of combination antiretroviral therapy (cART) on MTCT of HIV at the regional hospital in Bamenda, Cameroon. Methods This was a retrospective study. Secondary data from 877 HIV-exposed infants aged ≤ 72 weeks were extracted from the records between January 2008 and December 2014. The predictors and effect of cART on MTCT of HIV were analysed using a multivariable logistic regression model and risk analysis, respectively. Results Out of 877 HIV-exposed infants, 62 were positive for HIV, giving a prevalence of 7.1%. Maternal antiretroviral intervention and infant age group were statistically significant predictors of MTCT of HIV. HIV-positive mothers who were on cART were 2.49 times less likely to transmit HIV than those who were not on cART. Conclusion In order to reduce the prevalence of HIV among HIV-exposed infants, maternal antiretroviral intervention should be targeted and the use of cART by HIV-positive pregnant women should be encouraged.
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Affiliation(s)
- Victor N Fondoh
- Bamenda Regional Hospital Laboratory, Bamenda, North-West Region, Cameroon
| | - Njong A Mom
- Faculty of Economics and Management Sciences, University of Bamenda, Bamenda, North-West Cameroon
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No 185-Dépistage du VIH au cours de la grossesse. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017. [DOI: 10.1016/j.jogc.2017.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Missed Opportunities for Prevention of Mother-to-Child Transmission of Human Immunodeficiency Virus. Obstet Gynecol 2017; 129:621-628. [PMID: 28277349 DOI: 10.1097/aog.0000000000001929] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify missed opportunities for prevention of mother-to-child transmission of human immunodeficiency virus (HIV). METHODS Data regarding HIV-infected children born between 2002 and 2009 to HIV-infected women enrolled in the U.S. International Maternal Pediatric Adolescent AIDS Clinical Trials prospective cohort study (protocol P1025) were reviewed. The characteristics of the HIV-infected infants and their mothers and the mothers' clinical management are described. RESULTS Twelve cases of mother-to-child transmission of HIV occurred among 1,857 liveborn neonates, for a prevalence of 0.65 per 100 live births to HIV-infected women (95% confidence interval 0.33-1.13). Four transmissions occurred in utero, three were peripartum transmissions, and the timing of transmission for five neonates was unable to be determined. None were breastfed. Seven women had plasma viral loads greater than 400 copies/mL near delivery. Six women had less than 11 weeks of antiretroviral therapy during pregnancy; three of these women had premature deliveries. One woman received no antiretroviral therapy during pregnancy because she was diagnosed with HIV postpartum. Six had poor to moderate adherence to antiretroviral therapy. Four of the five mothers with viral loads greater than 1,000 copies/mL delivered preterm neonates. There were five women who delivered by cesarean; four were nonelective cesarean deliveries and only one was an elective cesarean delivery for HIV prevention. CONCLUSION Despite access to high-level care and follow-up, a small proportion of HIV-infected women transmitted the virus to their neonates. This case series provides insight into factors contributing to HIV perinatal transmission and can inform the development of new strategies for prevention of mother-to-child transmission of HIV. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, https://clinicaltrials.gov, NCT00028145.
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Maternal Binding and Neutralizing IgG Responses Targeting the C-Terminal Region of the V3 Loop Are Predictive of Reduced Peripartum HIV-1 Transmission Risk. J Virol 2017; 91:JVI.02422-16. [PMID: 28202762 DOI: 10.1128/jvi.02422-16] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 02/08/2017] [Indexed: 01/07/2023] Open
Abstract
The development of an effective maternal HIV-1 vaccine that could synergize with antiretroviral therapy (ART) to eliminate pediatric HIV-1 infection will require the characterization of maternal immune responses capable of blocking transmission of autologous HIV to the infant. We previously determined that maternal plasma antibody binding to linear epitopes within the variable loop 3 (V3) region of HIV envelope (Env) and neutralizing responses against easy-to-neutralize tier 1 viruses were associated with reduced risk of peripartum HIV infection in the historic U.S. Woman and Infant Transmission Study (WITS) cohort. Here, we defined the fine specificity and function of the potentially protective maternal V3-specific IgG antibodies associated with reduced peripartum HIV transmission risk in this cohort. The V3-specific IgG binding that predicted low risk of mother-to-child-transmission (MTCT) was dependent on the C-terminal flank of the V3 crown and particularly on amino acid position 317, a residue that has also been associated with breakthrough transmission in the RV144 vaccine trial. Remarkably, the fine specificity of potentially protective maternal plasma V3-specific tier 1 virus-neutralizing responses was dependent on the same region in the V3 loop. Our findings suggest that MTCT risk is associated with neutralizing maternal IgG that targets amino acid residues in the C-terminal region of the V3 loop crown, suggesting the importance of the region in immunogen design for maternal vaccines to prevent MTCT.IMPORTANCE Efforts to curb HIV-1 transmission in pediatric populations by antiretroviral therapy (ART) have been highly successful in both developed and developing countries. However, more than 150,000 infants continue to be infected each year, likely due to a combination of late maternal HIV diagnosis, lack of ART access or adherence, and drug-resistant viral strains. Defining the fine specificity of maternal humoral responses that partially protect against MTCT of HIV is required to inform the development of a maternal HIV vaccine that will enhance these responses during pregnancy. In this study, we identified amino acid residues targeted by potentially protective maternal V3-specific IgG binding and neutralizing responses, localizing the potentially protective response in the C-terminal region of the V3 loop crown. Our findings have important implications for the design of maternal vaccination strategies that could synergize with ART during pregnancy to achieve the elimination of pediatric HIV infections.
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Haffejee F, Ports KA, Mosavel M. Knowledge and attitudes about HIV infection and prevention of mother to child transmission of HIV in an urban, low income community in Durban, South Africa: Perspectives of residents and health care volunteers. Health SA 2016. [DOI: 10.1016/j.hsag.2016.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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A meta-analysis assessing all-cause mortality in HIV-exposed uninfected compared with HIV-unexposed uninfected infants and children. AIDS 2016; 30:2351-60. [PMID: 27456985 DOI: 10.1097/qad.0000000000001211] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Conduct a meta-analysis examining differential all-cause mortality rates between HIV-exposed uninfected (HEU) infants and children as compared with their HIV-unexposed uninfected (HUU) counterparts. DESIGN Meta-analysis summarizing the difference in mortality between HEU and HUU infants and children. Reviewed studies comparing children in the two groups for all-cause mortality, in any setting, from 1994 to 2016 from six databases. METHODS Meta-analyses were done estimating overall mortality comparing the two groups, stratified by duration of follow-up time from birth (0-12, 12-24 and >24 months) and by year enrollment ended in each study: less than 2002 compared with at least 2002, when single-dose nevirapine for prevention of mother-to-child transmission (PMTCT) commenced in low-income and middle-income countries. RESULTS Included 22 studies, for a total of 29 212 study participants [n = 8840 (30.3%) HEU; n = 20 372 (37.7%) HUU]. Random effects models showed HEU had a more than 70% increased risk of mortality vs. HUU. Stratifying by age showed that HEU vs. HUU had a significant 60-70% increased risk of death at every age strata. There was a significant 70% increase in the risk of mortality between groups before the implementation of PMTCT, which remained after 2002 [risk ratio: 1.46; 95% confidence interval (CI): 1.14-1.87], when the availability of PMTCT services was widespread, suggesting that prenatal antiretroviral therapy, and healthier mothers, does not fully eliminate this increased risk in mortality. CONCLUSION We show a consistent increase risk of mortality for HEU vs. HUU infants and children. Longitudinal research is needed to elucidate underlying mechanisms, such as maternal and infant health status and breast feeding practices, which may help explain these differences in mortality.
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Thorne C, Newell ML. Managing Mother-to-Child Transmission of HIV Infection in Developed-Country Settings. WOMENS HEALTH 2016; 1:385-99. [DOI: 10.2217/17455057.1.3.385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This article reviews current understanding of the management of mother-to-child transmission of HIV-1 infection in the context of developed-country settings. The advent of highly active antiretroviral therapy has facilitated the virtual elimination of mother-to-child transmission of HIV infection in developed countries, reducing transmission rates to approximately 1–2%. This review describes the epidemiology of HIV infection among women of child-bearing age and the risk factors, timing and mechanisms of mother-to-child transmission, followed by a discussion of the identification of pregnant HIV-infected women and their therapeutic and obstetric management.
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Affiliation(s)
- Claire Thorne
- Institute of Child Health, Centre for Paediatric Epidemiology and Biostatistics, 30 Guilford Street London, WC1N 1EH, UK,
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Ogbonna K, Govender I, Tumbo J. Knowledge and practice of the prevention of mother-to-child transmission of HIV guidelines amongst doctors and nurses at Odi Hospital, Tshwane District. S Afr Fam Pract (2004) 2016. [DOI: 10.1080/20786190.2016.1228561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Buxmann H, Reitter A, Bapistella S, Stürmer M, Königs C, Ackermann H, Louwen F, Bader P, Schlößer RL, Willasch AM. Maternal CD4+ microchimerism in HIV-exposed newborns after spontaneous vaginal delivery or caesarean section. Early Hum Dev 2016; 98:49-55. [PMID: 27351353 DOI: 10.1016/j.earlhumdev.2016.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 05/24/2016] [Accepted: 06/14/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Maternal CD4+ cell microchimerism may be greater after caesarean section compared to spontaneous vaginal delivery and could cause mother-to-child transmission (MTCT) in HIV-exposed newborns. AIMS To evaluate maternal CD4+ cell microchimerism in HIV-exposed newborns after spontaneous vaginal delivery or caesarean section. STUDY DESIGN AND SUBJECTS In this prospective single-centre study, neonates whose mothers were infected with HIV and had normal MTCT risk according to the German Austrian Guidelines were considered for study enrolment. Maternal CD4+ cell microchimerism in the newborns' umbilical cord blood was measured and compared by mode of delivery. RESULTS Thirty-seven HIV-infected mothers and their 39 newborns were included in the study. None of the 17 (0.0%) newborns delivered vaginally had quantifiable maternal CD4+ cells (95% confidence interval (CI): 0.00-0.00) in their circulation at birth compared with four of 16 (25.0%) newborns delivered via planned caesarean section, who showed 0.01-0.66% maternal cells (95% CI: -0.06-0.16; P=0.02) in their circulation. The intention to treat analysis, which included six additional newborns delivered by unplanned caesarean section, showed quantifiable maternal CD4+ cells in one (0.05%; 95% CI: -0.02-0.04) of 23 (4.3%) newborn at birth compared to four of 16 (25.0%) born via planned caesarean section (95% CI: -0.06-0.16; P=0.04). There was no MTCT in any of the newborns. CONCLUSION In this small cohort, spontaneous vaginal delivery in HIV-infected women with normal MTCT risk was associated with lower maternal CD4+ cell transfer to newborns compared to planned caesarean section.
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Affiliation(s)
- H Buxmann
- Goethe University, Department for Children and Adolescents, Division for Neonatology, University Hospital Frankfurt/Main, Germany.
| | - A Reitter
- Department of Gynecology and Obstetrics, Division of Obstetrics and Prenatal Medicine, University Hospital Frankfurt/Main, Germany
| | - S Bapistella
- Goethe University, Department for Children and Adolescents, Division for Neonatology, University Hospital Frankfurt/Main, Germany
| | - M Stürmer
- Institute for Medical Virology, University Hospital Frankfurt/Main, Germany
| | - C Königs
- Department for Children and Adolescents, Division for Stem Cell Transplantation and Immunology, University Hospital Frankfurt/Main, Germany
| | - H Ackermann
- Institute of Biostatistics and Mathematical Modeling, University Hospital Frankfurt/Main, Germany
| | - F Louwen
- Department of Gynecology and Obstetrics, Division of Obstetrics and Prenatal Medicine, University Hospital Frankfurt/Main, Germany
| | - P Bader
- Department for Children and Adolescents, Division for Stem Cell Transplantation and Immunology, University Hospital Frankfurt/Main, Germany
| | - R L Schlößer
- Goethe University, Department for Children and Adolescents, Division for Neonatology, University Hospital Frankfurt/Main, Germany
| | - A M Willasch
- Department for Children and Adolescents, Division for Stem Cell Transplantation and Immunology, University Hospital Frankfurt/Main, Germany
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Blystad A, Moland KM. Technologies of hope? Motherhood, HIV and infant feeding in eastern Africa. Anthropol Med 2016; 16:105-18. [PMID: 27276404 DOI: 10.1080/13648470902940655] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A vast number of HIV positive mothers live with a known HIV positive status without an experienced ability to prevent the virus from spreading to their offspring. This article focuses on the dramatic effects on identity and sociality instigated by prevention of mother to child transmission of HIV (PMTCT) programmes, and discusses the potential for the development of HIV related activism linked to programme enrolment. Paying particular attention to the infant feeding options that are promoted through the programme - exclusive breastfeeding and replacement feeding - the article explores women's experiences struggling to secure an HIV free baby. At the heart of the findings lie devastating transformations in perceptions of body and self among HIV positive mothers enrolled in the PMTCT programmes, transformations highlighted by the shifting interpretations of mother's milk. The women suffer from extreme fear of feeding their babies HIV infected mother's milk. Very few mothers could afford formula products, and exclusive breastfeeding emerged as the option of the poor 'who have to breastfeed and let their babies die'. From being a prime symbol of nurture and love, mother's milk became a source of death in babies born to HIV positive mothers. The article argues that the incongruity between notions of maternal love and nurture on the one hand, and sexuality, HIV and death on the other, makes the PMTCT programme ill suited as a basis for activism. The material was collected through interviews and discussion with HIV positive mothers and nurse counsellors in Ethiopia and Tanzania, 2004-2006.
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Affiliation(s)
- Astrid Blystad
- a Department of Public Health and Primary Health Care , University of Bergen, Norway and Centre for International Health, University of Bergen , Norway
| | - Karen Marie Moland
- b Centre for International Health, University of Bergen, Norway and Department of Nursing , Bergen University College , Bergen , Norway
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Gantt S, Leister E, Jacobson DL, Boucoiran I, Huang ML, Jerome KR, Jourdain G, Ngo-Giang-Huong N, Burchett S, Frenkel L. Risk of congenital cytomegalovirus infection among HIV-exposed uninfected infants is not decreased by maternal nelfinavir use during pregnancy. J Med Virol 2016; 88:1051-8. [PMID: 26519647 PMCID: PMC4818099 DOI: 10.1002/jmv.24420] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Congenital cytomegalovirus (cCMV) infection is common among infants born to HIV-infected women. Nelfinavir (NFV), an antiretroviral drug that is safe during pregnancy, inhibits CMV replication in vitro at concentrations that standard doses achieve in plasma. We hypothesized that infants born to women receiving NFV for prevention of mother-to-child transmission of HIV (PMTCT) would have a reduced prevalence of cCMV infection. METHODS The prevalence of cCMV infection was compared among HIV-uninfected infants whose HIV-infected mothers either received NFV for >4 weeks during pregnancy (NFV-exposed) or did not receive any NFV in pregnancy (NFV-unexposed). CMV PCR was performed on infant blood samples collected at <3 weeks from birth. RESULTS Of the 1,255 women included, 314 received NFV for >4 weeks during pregnancy and 941 did not receive any NFV during pregnancy. The overall prevalence of cCMV infection in the infants was 2.2%, which did not differ by maternal NFV use. Maternal CD4 T cell counts were inversely correlated with risk of cCMV infection, independent of the time NFV was initiated during gestation. Infants with cCMV infection were born 0.7 weeks earlier (P = 0.010) and weighed 170 g less (P = 0.009) than uninfected infants. CONCLUSION Among HIV-exposed uninfected infants, cCMV infection was associated with adverse perinatal outcomes. NFV use in pregnancy was not associated with protection against cCMV. Safe and effective strategies to prevent cCMV infection are needed.
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Affiliation(s)
- Soren Gantt
- University of British Columbia and Child & Family Research Institute
- Fred Hutchinson Cancer Research Center
| | - Erin Leister
- Center for Biostatistics in AIDS Research, The Harvard T. H. Chan School of Public Health
| | - Denise L. Jacobson
- Center for Biostatistics in AIDS Research, The Harvard T. H. Chan School of Public Health
| | | | - Meei-Li Huang
- Fred Hutchinson Cancer Research Center
- University of Washington
| | - Keith R. Jerome
- Fred Hutchinson Cancer Research Center
- University of Washington
| | - Gonzague Jourdain
- Institut de Recherche pour le Développement
- The Harvard T. H. Chan School of Public Health
| | - Nicole Ngo-Giang-Huong
- Institut de Recherche pour le Développement
- The Harvard T. H. Chan School of Public Health
| | | | - Lisa Frenkel
- University of Washington
- Seattle Children’s Research Institute
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Read JS, Samuel NM, Parameshwari S, Dharmarajan S, Van Hook HM, Jacob SM, Junankar V, Bethel J, Xu J, Stoszek SK. Safety of HIV-1 Perinatal Transmission Prophylaxis With Zidovudine and Nevirapine in Rural South India. ACTA ACUST UNITED AC 2016; 6:125-36. [PMID: 17538004 DOI: 10.1177/1545109707301248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The authors assessed acceptance and safety of, and adherence to, perinatal HIV-1 transmission prophylaxis at 2 public hospitals in rural Tamil Nadu, India. METHODS Eligible HIV-1-infected women were offered zidovudine (ZDV) beginning at 28-weeks gestation until delivery. Their infants received ZDV for 6 weeks. A subsequent revision to the protocol added 1 dose of nevirapine (NVP) for mother and infant. RESULTS Sixty of 67 women (90%) met inclusion criteria for the cohort study. Thirty-four of 36 eligible women and all 19 eligible live born infants received prophylaxis on study. Infant, but not maternal, adherence to ZDV varied by antiretroviral prophylaxis group (those receiving combined prophylaxis with ZDV and NVP had lower median adherence) (P = .02). Neutropenia (usually transient) was the most common severe adverse event. Only 1 of 5 women with neutropenia possibly related to ZDV permanently discontinued ZDV. ZDV was not discontinued for any infant. CONCLUSION With the exception of neutropenia, usually transient and always without clinical consequences, long-term ZDV (with or without NVP prophylaxis) is well tolerated.
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Affiliation(s)
- Jennifer S Read
- Pediatric, Adolescent, and Maternal AIDS Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-7510, USA.
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Fleming TR, Ellenberg SS. Evaluating interventions for Ebola: The need for randomized trials. Clin Trials 2016; 13:6-9. [PMID: 26768563 DOI: 10.1177/1740774515616944] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Thomas R Fleming
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Susan S Ellenberg
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Haddad LB, Machen LK, Cordes S, Huylebroeck B, Delaney A, Ofotokun I, Nguyen ML, Jamieson DJ. Future desire for children among women living with HIV in Atlanta, Georgia. AIDS Care 2015; 28:455-9. [PMID: 26702869 DOI: 10.1080/09540121.2015.1114996] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Little is known regarding family planning desires among women living with HIV in the United States. This study aimed to identify factors influencing desire for children in the future among HIV-infected women in Atlanta, Georgia. HIV-infected women ages 18-45 completed an ACASI (audio computer-assisted self-interview) questionnaire. Chi-square, t-tests, and multivariate logistic regression evaluated factors associated with desire for future children. Of 181 participants, 62 (34.3%) expressed desire for children in the future, with increased desire among younger women (age <26) and those with seronegative partners. Concerns for horizontal and vertical HIV transmission were deterrents to future childbearing. Condom use and overall knowledge of transmission risk was low. Over a third of women desiring a child never discussed their desire with a physician. Misinformation regarding HIV transmission risks persists and is a notable concern influencing desire for children. Providers should reassess family planning desires regularly through integrated HIV care.
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Affiliation(s)
- Lisa B Haddad
- a Department of Gynecology and Obstetrics , Emory University School of Medicine , Atlanta , GA , USA
| | | | - Sarah Cordes
- a Department of Gynecology and Obstetrics , Emory University School of Medicine , Atlanta , GA , USA
| | - Brian Huylebroeck
- c Department of Epidemiology, Rollins School of Public Health , Emory University , Atlanta , GA , USA
| | | | - Igho Ofotokun
- e Department of Medicine, Infectious Disease Division and Grady Health Care System , Emory University School of Medicine , Atlanta , GA , USA
| | - Minh Ly Nguyen
- e Department of Medicine, Infectious Disease Division and Grady Health Care System , Emory University School of Medicine , Atlanta , GA , USA
| | - Denise J Jamieson
- a Department of Gynecology and Obstetrics , Emory University School of Medicine , Atlanta , GA , USA
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Meyers K, Qian H, Wu Y, Lao Y, Chen Q, Dong X, Li H, Yang Y, Jiang C, Zhou Z. Early Initiation of ARV During Pregnancy to Move towards Virtual Elimination of Mother-to-Child-Transmission of HIV-1 in Yunnan, China. PLoS One 2015; 10:e0138104. [PMID: 26407096 PMCID: PMC4583380 DOI: 10.1371/journal.pone.0138104] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 08/25/2015] [Indexed: 11/18/2022] Open
Abstract
Objective To identify factors associated with mother-to-child-transmission and late access to prevention of maternal to child transmission (PMTCT) services among HIV-infected women; and risk factors for infant mortality among HIV-exposed infants in order to assess the feasibility of virtual elimination of vertical transmission and pediatric HIV in this setting. Design Observational study evaluating the impact of a provincial PMTCT program. Methods The intervention was implemented in 26 counties of Yunnan Province, China at municipal and tertiary health care settings. Log linear regression models with generalized estimating equations were used to identify unadjusted and adjusted correlates for late ARV intervention and MTCT. Cox proportional hazard models with robust sandwich estimation were applied to examine correlates of infant mortality. Results Mother-to-child- transmission rate of HIV was controlled to 2%, with late initiation of maternal ARV showing a strong association with vertical transmission and infant mortality. Risk factors for late initiation of maternal ARV were age, ethnicity, education, and having a husband not tested for HIV. Mortality rate among HIV-exposed infants was 2.9/100 person-years. In addition to late initiation of maternal ARV, ethnicity, low birth weight and preterm birth were associated with infant mortality. Conclusions This PMTCT program in Yunnan achieved low rates of MTCT. However the infant mortality rate in this cohort of HIV-exposed children was almost three times the provincial rate. Virtual elimination of MTCT of HIV is an achievable goal in China, but more attention needs to be paid to HIV-free survival.
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Affiliation(s)
- Kathrine Meyers
- Aaron Diamond AIDS Research Center, New York, New York, United States of America
| | - Haoyu Qian
- Aaron Diamond AIDS Research Center, New York, New York, United States of America
| | | | - Yunfei Lao
- Yunnan AIDS Care Center, Kunming, Yunnan, China
| | | | - Xingqi Dong
- Yunnan AIDS Care Center, Kunming, Yunnan, China
| | - Huiqin Li
- Yunnan AIDS Care Center, Kunming, Yunnan, China
| | - Yiqing Yang
- Linxiang Maternal and Child Hospital, Lincang, Yunnan, China
| | - Chengqin Jiang
- Mangshi Maternal and Child Hospital, Dehong, Yunnan, China
| | - Zengquan Zhou
- Yunnan AIDS Care Center, Kunming, Yunnan, China
- Yunnan AIDS Initiative, Kunming, Yunnan, China
- * E-mail:
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Camacho-Gonzalez AF, Kingbo MH, Boylan A, Eckard AR, Chahroudi A, Chakraborty R. Missed opportunities for prevention of mother-to-child transmission in the United States. AIDS 2015; 29:1511-5. [PMID: 26244391 PMCID: PMC4502985 DOI: 10.1097/qad.0000000000000710] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 03/27/2015] [Accepted: 04/07/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe system failures potentially contributing to perinatal HIV transmission in the state of Georgia, United States, between 2005 and 2012. DESIGN A retrospective chart review of antenatal and postnatal records of HIV-infected infants between 1 January 2005 and 31 December 2012. METHODS Study participants included all HIV-infected infants referred for specialized management to the Ponce Family and Youth Clinic within Grady Health Systems in Atlanta. Main outcomes included identification of maternal, perinatal, and neonatal risk factors associated with vertical transmission. RESULTS Twenty-seven cases were identified; 89% of mothers were African-American between 16 and 30 years of age. Seventy-four percent of women knew their HIV status prior to pregnancy, 44% had no prenatal care, and 52% did not receive combination antiretroviral therapy during pregnancy or intrapartum zidovudine. HIV-1 RNA near the time of delivery was available in only 10 of 27 mothers, and of those, only three had an undetectable HIV-1 RNA level. Caesarean section was performed in 70% of women. Of the 27 children, the mean gestational age was 37 (SD: 2.9) weeks, with 33% requiring neonatal ICU admission. Fifty-nine percent were men, and only 67% received postnatal zidovudine prophylaxis. CONCLUSION Mother-to-child transmission of HIV continues to occur in Georgia at unacceptable levels. Increased education with adherence to existing national guidelines, as well as coordinated efforts between healthcare and public health providers to improve linkage and retention in medical care are urgently needed to prevent further vertical transmission events in Georgia.
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Affiliation(s)
- Andres F. Camacho-Gonzalez
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Emory University School of Medicine; Children's Healthcare of Atlanta
- Ponce Family and Youth Clinic, Grady Infectious Diseases Program, Grady Health Systems
| | - Marie-Huguette Kingbo
- Department of Epidemiology and Biostatistics, Georgia State University, Atlanta, Georgia, USA
| | - Ashley Boylan
- Ponce Family and Youth Clinic, Grady Infectious Diseases Program, Grady Health Systems
| | - Allison Ross Eckard
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Emory University School of Medicine; Children's Healthcare of Atlanta
- Ponce Family and Youth Clinic, Grady Infectious Diseases Program, Grady Health Systems
| | - Ann Chahroudi
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Emory University School of Medicine; Children's Healthcare of Atlanta
- Ponce Family and Youth Clinic, Grady Infectious Diseases Program, Grady Health Systems
| | - Rana Chakraborty
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Emory University School of Medicine; Children's Healthcare of Atlanta
- Ponce Family and Youth Clinic, Grady Infectious Diseases Program, Grady Health Systems
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Cowan JF, Micek M, Cowan JFG, Napúa M, Hoek R, Gimbel S, Gloyd S, Sherr K, Pfeiffer JT, Chapman RR. Early ART initiation among HIV-positive pregnant women in central Mozambique: a stepped wedge randomized controlled trial of an optimized Option B+ approach. Implement Sci 2015; 10:61. [PMID: 25924668 PMCID: PMC4436140 DOI: 10.1186/s13012-015-0249-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 04/16/2015] [Indexed: 11/17/2022] Open
Abstract
Background Despite effective prevention strategies and increasing investments in global health, maternal to child transmission (MTCT) of HIV remains a significant problem globally, especially in sub-Saharan Africa. In 2012, there were 94,000 HIV-positive pregnant women in Mozambique. Approximately 15% of these women transmitted HIV to their newborn infants, resulting in nearly 14,000 new pediatric HIV infections that year. To address this issue, in 2013, the Mozambican Ministry of Health implemented the World Health Organization-recommended “Option B+” strategy in which all newly diagnosed HIV-positive pregnant women are counseled to initiate combination anti-retroviral therapy (ART) immediately upon diagnosis regardless of CD4 count and to continue treatment for life. Given the limited experience with Option B+ in sub-Saharan Africa, few rigorous pragmatic trials have studied this new treatment strategy. Methods This study utilizes an initial formative research process involving patient and health care provider interviews and focus groups, workforce assessments, value stream mapping, and commodity utilization assessments to understand the strengths and weaknesses in the current Option B+ care cascade. The formative research is intended to guide identification and prioritization of key workflow modifications and the development of an enhanced adherence and retention package. These two components are bundled into a defined intervention implemented and evaluated across six health facilities utilizing a stepped wedge randomized controlled trial study design. The overall objective of this trial is to develop and test a pilot intervention in central Mozambique to implement the new Option B+ guidelines with high fidelity and increase the proportion of HIV-positive pregnant women in target antenatal clinics (ANC) who start ART prior to delivery and are retained in care. Discussion This pragmatic study utilizes research strategies that have the potential to meaningfully improve the Option B+ care cascade in central Mozambique and to decrease the MTCT of HIV. This trial is designed to identify critical low-cost improvement strategies that can be bundled into a defined intervention. If this intervention has a measurable impact, it can be rapidly scaled up to other ANC in Mozambique and sub-Saharan Africa. Trial registration ClinicalTrials.gov: NCT02371265.
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Affiliation(s)
- James F Cowan
- Department of Global Health, University of Washington Schools of Medicine and Public Health, 1705 NE Pacific St.,, Seattle, WA, 98195, USA. .,Health Alliance International (HAI), 1107 NE 45th St., Suite 350, Seattle, WA, 98105, USA.
| | - Mark Micek
- Health Alliance International (HAI), 1107 NE 45th St., Suite 350, Seattle, WA, 98105, USA.
| | - Jessica F Greenberg Cowan
- Health Alliance International (HAI), 1107 NE 45th St., Suite 350, Seattle, WA, 98105, USA. .,Department of Family Medicine, University of Washington, Box 356390, Seattle, WA, 98195, USA.
| | - Manuel Napúa
- Beira Operations Research Center, Ministry of Health, Ponta Gea, Beira, Mozambique.
| | - Roxanne Hoek
- Health Alliance International (HAI), 1107 NE 45th St., Suite 350, Seattle, WA, 98105, USA.
| | - Sarah Gimbel
- Department of Global Health, University of Washington Schools of Medicine and Public Health, 1705 NE Pacific St.,, Seattle, WA, 98195, USA. .,Health Alliance International (HAI), 1107 NE 45th St., Suite 350, Seattle, WA, 98105, USA. .,Department of Family and Child Nursing, University of Washington, Box 355809, Seattle, WA, 98195, USA.
| | - Stephen Gloyd
- Department of Global Health, University of Washington Schools of Medicine and Public Health, 1705 NE Pacific St.,, Seattle, WA, 98195, USA. .,Health Alliance International (HAI), 1107 NE 45th St., Suite 350, Seattle, WA, 98105, USA.
| | - Kenneth Sherr
- Department of Global Health, University of Washington Schools of Medicine and Public Health, 1705 NE Pacific St.,, Seattle, WA, 98195, USA. .,Health Alliance International (HAI), 1107 NE 45th St., Suite 350, Seattle, WA, 98105, USA.
| | - James T Pfeiffer
- Department of Global Health, University of Washington Schools of Medicine and Public Health, 1705 NE Pacific St.,, Seattle, WA, 98195, USA. .,Health Alliance International (HAI), 1107 NE 45th St., Suite 350, Seattle, WA, 98105, USA. .,Department of Anthropology, University of Washington, Box 353100, Seattle, WA, 98195, USA.
| | - Rachel R Chapman
- Department of Global Health, University of Washington Schools of Medicine and Public Health, 1705 NE Pacific St.,, Seattle, WA, 98195, USA. .,Health Alliance International (HAI), 1107 NE 45th St., Suite 350, Seattle, WA, 98105, USA. .,Department of Anthropology, University of Washington, Box 353100, Seattle, WA, 98195, USA.
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Hardy E, Cu-Uvin S. Care of the HIV-infected pregnant woman in the developed world. Obstet Med 2015; 8:13-7. [PMID: 27512453 PMCID: PMC4934996 DOI: 10.1177/1753495x14531753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The reduction of human immunodeficiency virus (HIV) transmission from mother to child is one of the success stories of modern medicine and public health. In the developed world, with universal HIV counseling and testing, antiretroviral prophylaxis, scheduled Caesarean delivery if indicated, and avoidance of breastfeeding, HIV transmission from mother to infant can be <2%. Despite this, transmissions continue to occur, often due to lack of knowledge of HIV status. Missed opportunities for prevention and prevention challenges include late prenatal care, lack of HIV testing in pregnancy, lack of preconception counseling, unintended pregnancy, and substance abuse. We review preconception counseling including options for serodiscordant couples, and antepartum, peripartum and postpartum care of the HIV-infected woman in the developed world, and advocate for a comprehensive, collaborative, multidisciplinary approach.
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Affiliation(s)
- Erica Hardy
- Infectious Disease and Obstetric Medicine, Women & Infants Hospital, Providence, RI, USA
- The Alpert Medical School of Brown University, Providence, RI, USA
| | - Susan Cu-Uvin
- The Alpert Medical School of Brown University, Providence, RI, USA
- Infectious Disease, The Miriam Hospital, Providence, RI, USA
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Dryden-Peterson S, Bennett K, Hughes MD, Veres A, John O, Pradhananga R, Boyer M, Brown C, Sakyi B, van Widenfelt E, Keapoletswe K, Mine M, Moyo S, Asmelash A, Siedner M, Mmalane M, Shapiro RL, Lockman S. An augmented SMS intervention to improve access to antenatal CD4 testing and ART initiation in HIV-infected pregnant women: a cluster randomized trial. PLoS One 2015; 10:e0117181. [PMID: 25693050 PMCID: PMC4334487 DOI: 10.1371/journal.pone.0117181] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Less than one-third of HIV-infected pregnant women eligible for combination antiretroviral therapy (ART) globally initiate treatment prior to delivery, with lack of access to timely CD4 results being a principal barrier. We evaluated the effectiveness of an SMS-based intervention to improve access to timely antenatal ART. METHODS We conducted a stepped-wedge cluster randomized trial of a low-cost programmatic intervention in 20 antenatal clinics in Gaborone, Botswana. From July 2011-April 2012, 2 clinics were randomly selected every 4 weeks to receive an ongoing clinic-based educational intervention to improve CD4 collection and to receive CD4 results via an automated SMS platform with active patient tracing. CD4 testing before 26 weeks gestation and ART initiation before 30 weeks gestation were assessed. RESULTS Three-hundred-sixty-six ART-naïve women were included, 189 registering for antenatal care under Intervention and 177 under Usual Care periods. Of CD4-eligible women, 100 (59.2%) women under Intervention and 79 (50.6%) women under Usual Care completed CD4 phlebotomy before 26 weeks gestation, adjusted odds ratio (aOR, adjusted for time that a clinic initiated Intervention) 0.87 (95% confidence interval [CI]0.47-1.63, P = 0.67). The SMS-based platform reduced time to clinic receipt of CD4 test result from median of 16 to 6 days (P<0.001), was appreciated by clinic staff, and was associated with reduced operational cost. However, rates of ART initiation remained low, with 56 (36.4%) women registering under Intervention versus 37 (24.2%) women under Usual Care initiating ART prior to 30 weeks gestation, aOR 1.06 (95%CI 0.53-2.13, P = 0.87). CONCLUSIONS The augmented SMS-based intervention delivered CD4 results more rapidly and efficiently, and this type of SMS-based results delivery platform may be useful for a variety of tests and settings. However, the intervention did not appear to improve access to timely antenatal CD4 testing or ART initiation, as obstacles other than CD4 impeded ART initiation during pregnancy.
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Affiliation(s)
- Scott Dryden-Peterson
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kara Bennett
- Bennett Statistical Consulting, Inc., Ballston Lake, New York, United States of America
| | - Michael D. Hughes
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Adrian Veres
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Oaitse John
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Rosina Pradhananga
- Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Matthew Boyer
- Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, United States of America
| | - Carolyn Brown
- John’s Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | | | | | | | - Sikhulile Moyo
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Aida Asmelash
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mark Siedner
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Mompati Mmalane
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Roger L. Shapiro
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Shahin Lockman
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
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Hurst SA, Appelgren KE, Kourtis AP. Prevention of mother-to-child transmission of HIV type 1: the role of neonatal and infant prophylaxis. Expert Rev Anti Infect Ther 2015; 13:169-81. [PMID: 25578882 PMCID: PMC4470389 DOI: 10.1586/14787210.2015.999667] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The prevention of mother-to-child transmission (PMTCT) of HIV is one of the great public health successes of the past 20 years. Much concerted research efforts and dedicated work have led to the achievement of very low rates of PMTCT of HIV in settings that can implement optimal prophylaxis. Though several implementation challenges remain, global elimination of pediatric HIV infection seems now more than ever to be an attainable goal. Often overlooked, the role of prophylaxis of the newborn is nevertheless a very important component of PMTCT. In this paper, we focus on the role of neonatal and infant prophylaxis, discuss mechanisms of protection, and present the clinical trial-generated evidence that led to the current recommendations for preventing infections in breastfed and non-breastfed infants. PMTCT of HIV should not end at birth; a continuum of care extending postpartum and postnatally is required to minimize the risk of new pediatric HIV infections.
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Affiliation(s)
- Stacey A. Hurst
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
| | - Kristie E. Appelgren
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
| | - Athena P. Kourtis
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
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Kumar A, Singh B, Kusuma YS. Counselling services in prevention of mother-to-child transmission (PMTCT) in Delhi, India: an assessment through a modified version of UNICEF-PPTCT tool. J Epidemiol Glob Health 2015; 5:3-13. [PMID: 25700918 PMCID: PMC7320346 DOI: 10.1016/j.jegh.2014.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 12/05/2014] [Accepted: 12/08/2014] [Indexed: 11/24/2022] Open
Abstract
The study aims to assess the counselling services provided to prevent mother to child transmission of HIV (PMTCT) under the Indian programme of prevention of parent-to-child transmission of HIV (PPTCT). Five hospitals in Delhi providing PMTCT services were randomly selected. A total of 201 post-test counselled women were interviewed using a modified version of the UNICEF-PPTCT evaluation tool. Knowledge about HIV transmission from mother-to-child was low. Post-test counselling mainly helped in increasing the knowledge of HIV transmission; yet 20%–30% of the clients missed this opportunity. Discussion on window period, other sexually transmitted diseases and danger signs of pregnancy were grossly neglected. The PMTCT services during the antenatal period are feasible and agreeable to be provided; however, certain aspects, like lack of privacy, confidentiality of HIV status of the client, counsellor’s ‘hurried’ attitude, communication skills and discriminant behaviour towards HIV-positive clients, and disinterest of clients in the counselling, remain as gaps. These issues may be addressed through refresher training to counsellors with an emphasis on social and behaviour change communication strategies. Addressing attitudinal aspects of the counsellors towards HIV positives is crucial to improve the quality of the services to prevent mother-to-child transmission of HIV.
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Affiliation(s)
- Arvind Kumar
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Bir Singh
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Yadlapalli S Kusuma
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi 110029, India.
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Nutritional Care of the Child with Human Immunodeficiency Virus Infection in the United States. HEALTH OF HIV INFECTED PEOPLE 2015. [PMCID: PMC7149620 DOI: 10.1016/b978-0-12-800769-3.00009-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In well-resourced settings, early infant diagnosis and administration of life-saving antiretrovirals (ARVs) have significantly improved clinical outcomes in pediatric human immunodeficiency virus (HIV) infection. The dramatic increase in survival rates is associated with enhancements in overall quality of life, which reflect a multidisciplinary, holistic approach to care. Current optimism starkly contrasts with the outlook and prognosis two decades ago, when failure to thrive and wasting syndrome from uncontrolled pediatric HIV infection resulted from poor oral intake, malabsorption, chronic diarrhea, and a persistently catabolic state. The tenets of care developed from that era still hold true in that all infants, children, and adolescents with HIV require comprehensive nutritional services in addition to effective combination antiretroviral therapy (cART). This chapter will review the principles of nutrition in the pre- and post-cART eras and discuss the etiologic factors associated with malnutrition, with an emphasis on interventions that have favorably impacted the growth and body composition of infants, children and adolescents with HIV.
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Iveli P, Noguera-Julian A, Soler-Palacín P, Martín-Nalda A, Rovira-Girabal N, Fortuny-Guasch C, Figueras-Nadal C. [Hepatotoxicity in healthy infants exposed to nevirapine during pregnancy]. Enferm Infecc Microbiol Clin 2014; 34:39-44. [PMID: 25487604 DOI: 10.1016/j.eimc.2014.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 08/22/2014] [Accepted: 10/17/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The use of nevirapine in HIV-infected pregnant women is discouraged due to its potential to cause hepatotoxicity. There is limited information available on the toxicity in non-HIV infected newborn exposed to this drug during pregnancy. The aim of the study is to determine the extent of hepatotoxicity in the newborn exposed to nevirapine and HIV during pregnancy. METHODS A cross-sectional, observational, multicenter study was conducted on a cohort of healthy infants born to HIV-infected mothers, in whom the first determination of alanine aminotransferase (ALT), before 6weeks of age, was collected. Patients were allocated to 2groups according to exposure to nevirapine during pregnancy. Hepatotoxicity was rated according to the AIDS Table for Grading the Severity of Adult and Pediatric Adverse Events (DAIDS). RESULTS This study included 160newborns from 159pregnancies (88exposed to nevirapine-based regimens and 71 exposed to protease inhibitors-based therapies). No cases of hepatotoxicity were observed according to the DAIDS Table for Grading. Two cases of ALT above normal values (2.8%; 95%CI: 0.3-9.8%) were observed in patients not exposed to nevirapine, and one case (1.1%; 95%CI: 0.0-6.1%) in the group exposed to nevirapine (P=.585). CONCLUSION The lack of differences between groups suggests that highly active antiretroviral treatment regimens including nevirapine administered during pregnancy do not involve a higher risk of liver disease compared to other treatment combinations.
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Affiliation(s)
- Pablo Iveli
- Unitat de Patologia Infecciosa i Immunodeficiències Pediàtriques, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - Antoni Noguera-Julian
- Unitat d'Infeccions, Servei de Pediatria, Hospital Universitari Sant Joan de Déu, Universitat de Barcelona, Barcelona, España
| | - Pere Soler-Palacín
- Unitat de Patologia Infecciosa i Immunodeficiències Pediàtriques, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España.
| | - Andrea Martín-Nalda
- Unitat de Patologia Infecciosa i Immunodeficiències Pediàtriques, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - Núria Rovira-Girabal
- Servei de Pediatria, Hospital Sant Joan de Déu, Xarxa Assistencial Althaia Sant Joan de Déu, Manresa, Barcelona, España
| | - Clàudia Fortuny-Guasch
- Unitat d'Infeccions, Servei de Pediatria, Hospital Universitari Sant Joan de Déu, Universitat de Barcelona, Barcelona, España
| | - Concepció Figueras-Nadal
- Unitat de Patologia Infecciosa i Immunodeficiències Pediàtriques, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
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Renet S, Closon A, Brochet MS, Bussières JF, Boucher M. Increase in transaminase levels following the use of raltegravir in a woman with a high HIV viral load at 35 weeks of pregnancy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 35:68-72. [PMID: 23343800 DOI: 10.1016/s1701-2163(15)31051-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Despite the efficacy of raltegravir in reducing viral load in HIV-infected patients, evidence for its safety in late pregnancy is lacking. A high rate of placental transfer was recently demonstrated. CASE A treatment-naïve 34-year-old HIV-1-positive woman of African origin began treatment with zidovudine/lamivudine, lopinavir/ritonavir, and raltegravir at 35 weeks of pregnancy. After 11 days of treatment with raltegravir, a substantial reduction in viral load was achieved. Concurrently, she had a 23-fold increase in serum alanine aminotransferase and a 10-fold increase in serum aspartate aminotransferase, both of which returned to normal when raltegravir treatment was discontinued. A healthy boy was delivered at term. The infant's tests for HIV were negative at five months, and he had no health problems at eight months. CONCLUSION This is the first case report, to our knowledge, of increased maternal serum transaminase levels following the use of raltegravir in a woman at a late stage of pregnancy.
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Affiliation(s)
- Sophie Renet
- Pharmacy Practice Research Unit (PPRU), CHU Sainte-Justine, Montreal QC, Pharmacy Department, Paris-Descartes University, Paris, France
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Gutin SA, Cummings B, Jaiantilal P, Johnson K, Mbofana F, Dawson Rose C. Qualitative evaluation of a Positive Prevention training for health care providers in Mozambique. EVALUATION AND PROGRAM PLANNING 2014; 43:38-47. [PMID: 24291214 PMCID: PMC4552037 DOI: 10.1016/j.evalprogplan.2013.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Revised: 10/19/2013] [Accepted: 10/29/2013] [Indexed: 06/02/2023]
Abstract
The rapid scale-up of HIV care and treatment in Mozambique has provided an opportunity to reach people living with HIV (PLHIV) with prevention interventions in HIV care and treatment settings. A three-day Positive Prevention (PP) training intervention for health care providers that focused on pressing issues for PLHIV in Mozambique was adapted and delivered at sites in three provinces. In-depth interviews were conducted with 31 providers trained in the PP curriculum. Qualitative data were used to assess the appropriateness of the training materials and approach, which lessons providers learned and were able to implement and which PP messages were still difficult to deliver. Providers reported gaining numerous insights from the training, including how to conduct a risk assessment and client-centered counseling, negotiating disclosure, partner testing, condom use, PMTCT, treatment adherence and approaches for positive living. Training topics not commonly mentioned included discordance counseling, STIs, family planning, alcohol and drug use, and frank sexual risk discussions. While areas for improvement exist, the PP training was useful in transferring skills to providers and is a viable component of HIV care. This evaluation helps identify areas where future PP trainings and specific strategies and messages can be refined for the Mozambican context.
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Affiliation(s)
- Sarah A Gutin
- UCSF, Department of Community Health Systems, School of Nursing, United States.
| | - Beverley Cummings
- Global AIDS Program, Centers for Disease Control and Prevention, Mozambique
| | | | - Kelly Johnson
- UCSF, Prevention and Public Health Group, Global Health Sciences, United States
| | | | - Carol Dawson Rose
- UCSF, Department of Community Health Systems, School of Nursing, United States
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Buchanan AM, Dow DE, Massambu CG, Nyombi B, Shayo A, Musoke R, Feng S, Bartlett JA, Cunningham CK, Schimana W. Progress in the prevention of mother to child transmission of HIV in three regions of Tanzania: a retrospective analysis. PLoS One 2014; 9:e88679. [PMID: 24551134 PMCID: PMC3923804 DOI: 10.1371/journal.pone.0088679] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 01/10/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Mother to child transmission (MTCT) of HIV-1 remains an important problem in sub-Saharan Africa where most new pediatric HIV-1 infections occur. Early infant diagnosis of HIV-1 using dried blood spot (DBS) PCR among exposed infants provides an opportunity to assess current MTCT rates. METHODS We conducted a retrospective data analysis on mother-infant pairs from all PMTCT programs in three regions of northern Tanzania to determine MTCT rates from 2008-2010. Records of 3,016 mother-infant pairs were assessed to determine early transmission among HIV-exposed infants in the first 75 days of life. RESULTS Of 2,266 evaluable infants in our cohort, 143 had a positive DBS PCR result at ≤ 75 days of life, for an overall transmission rate of 6.3%. Transmission decreased substantially over the period of study as more effective regimens became available. Transmission rates were tightly correlated to maternal regimen: 14.9% (9.5, 20.3) of infants became infected when women received no therapy; 8.8% (6.9, 10.7) and 3.6% (2.4, 4.8) became infected when women received single-dose nevirapine (sdNVP) or combination prophylaxis, respectively; the lowest MTCT rates occurred when women were on HAART, with 2.1% transmission (0.3, 3.9). Treatment regimens changed dramatically over the study period, with an increase in combination prophylaxis and a decrease in the use of sdNVP. Uptake of DBS PCR more than tripled over the period of study for the three regions surveyed. CONCLUSIONS Our study demonstrates significant reductions in MTCT of HIV-1 in three regions of Tanzania coincident with increased use of more effective PMTCT interventions. The changes we demonstrate for the period of 2008-2010 occurred prior to major changes in WHO PMTCT guidelines.
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Affiliation(s)
- Ann M. Buchanan
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Division of Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Dorothy E. Dow
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Division of Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, United States of America
| | | | - Balthazar Nyombi
- Kilimanjaro Christian Medical Centre Clinical Laboratory, Moshi, Tanzania
| | - Aisa Shayo
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Rahma Musoke
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Sheng Feng
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, United States of America
| | - John A. Bartlett
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | | | - Werner Schimana
- Elizabeth Glaser Pediatric AIDS Foundation, Dar es Salaam, Tanzania
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Lee King PA, Pate DJ. Perinatal HIV testing among African American, Caucasian, Hmong and Latina women: exploring the role of health-care services, information sources and perceptions of HIV/AIDS. HEALTH EDUCATION RESEARCH 2014; 29:109-121. [PMID: 24150728 DOI: 10.1093/her/cyt101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Perinatal HIV transmission disproportionately affects African American, Latina and potentially Hmong women in the United States. Understanding racially and ethnically diverse women's perceptions of and experiences with perinatal health care, HIV testing and HIV/AIDS may inform effective health communications to reduce the risk of perinatal HIV transmission among disproportionate risk groups. We used a qualitative descriptive research design with content analysis of five focus groups of African American, Caucasian, Hmong and Latina women of reproductive age with low socioeconomic status distinguished by their race/ethnicity or HIV status. A purposive stratified sample of 37 women shared their health-care experiences, health information sources and perceptions of HIV testing and HIV/AIDS. Women's responses highlighted the importance of developing and leveraging trusted provider and community-based relationships and assessing a woman's beliefs and values in her sociocultural context, to ensure clear, consistent and relevant communications. Perinatal health communications that are culturally sensitive and based on an assessment of women's knowledge and understanding of perinatal health and HIV/AIDS may be an effective tool for health educators addressing racial and ethnic disparities in perinatal HIV transmission.
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Affiliation(s)
- Patricia A Lee King
- School of Social Work, University of Southern California, Los Angeles, CA 90089, USA and School of Social Welfare, University of Wisconsin-Milwaukee, Milwaukee, WI 53211, USA
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[Consensus statement on monitoring of HIV: pregnancy, birth, and prevention of mother-to-child transmission]. Enferm Infecc Microbiol Clin 2014; 32:310.e1-310.e33. [PMID: 24484733 DOI: 10.1016/j.eimc.2013.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 12/02/2013] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The main objective in the management of HIV-infected pregnant women is prevention of mother-to-child transmission; therefore, it is essential to provide universal antiretroviral treatment, regardless of CD4 count. All pregnant women must receive adequate information and undergo HIV serology testing at the first visit. METHODS We assembled a panel of experts appointed by the Secretariat of the National AIDS Plan (SPNS) and the other participating Scientific Societies, which included internal medicine physicians with expertise in the field of HIV infection, gynecologists, pediatricians and psychologists. Four panel members acted as coordinators. Scientific information was reviewed in publications and conference reports up to November 2012. In keeping with the criteria of the Infectious Diseases Society of America, 2levels of evidence were applied to support the proposed recommendations: the strength of the recommendation according to expert opinion (A, B, C), and the level of empirical evidence (I, II, III). This approach has already been used in previous documents from SPNS. RESULTS AND CONCLUSIONS The aim of this paper was to review current scientific knowledge, and, accordingly, develop a set of recommendations regarding antiretroviral therapy (ART), regarding the health of the mother, and from the perspective of minimizing mother-to-child transmission (MTCT), also taking into account the rest of the health care of pregnant women with HIV infection. We also discuss and evaluate other strategies to reduce the MTCT (elective Cesarean, child's treatment…), and different aspects of the topic (ARV regimens, their toxicity, monitoring during pregnancy and postpartum, etc.).
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Ngemu EK, Khayeka-Wandabwa C, Kweka EJ, Choge JK, Anino E, Oyoo-Okoth E. Effectiveness of option B highly active antiretroviral therapy (HAART) prevention of mother-to-child transmission (PMTCT) in pregnant HIV women. BMC Res Notes 2014; 7:52. [PMID: 24447387 PMCID: PMC3898637 DOI: 10.1186/1756-0500-7-52] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 01/15/2014] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Ensuring that no baby is born with HIV is an essential step towards achieving an AIDS-free generation. To achieve this, strategies that decouple links between childbirth and HIV transmission are necessary. Traditional forms of prevention of mother-to-child transmission of HIV (PMTCT), has been recommended. Recognizing the importance and challenges of combination of methods to achieve rapid PMTCT, the World Health Organization (WHO) recommended option B Highly Active Antiretroviral Therapy (HAART) for all HIV-positive pregnant women. This study aimed to evaluate the effectiveness of the HAART in PMTCT. A cohort of HIV-infected pregnant women in Kenya were obtained from the DREAM Center, Nairobi. The study participants underwent adherence counselling and Option B of HAART [Nevirapine(NVP) + Lamivudine + Zidovudine] at the fourth week of gestation followed by an intravenous NVP administration intrapartum and postpartum NVP syrup to the respective infants for six weeks. Absolute pre-HAART and post-HAART CD4 counts and viral loads counts were determined. Comparison of the CD4 counts and viral loads before and after administration of HAART were done using Wilcoxon's Matched Pairs Signed-Ranks Test. FINDINGS The mean absolute CD4 cell counts in mothers after administration of HAART was significantly higher (Z = 15.664, p < 0.001) than before the administration of HAART). Also the viral load of the mothers significantly (Z = 11.324, p < 0.001) reduced following HAART treatment. Following the HAART administration in mothers, up to 90% of children were confirmed to be HIV negative. CONCLUSION Administration of HAART to mothers and children demonstrated an effective mechanism of PMTCT. However, other aspects of HAART such as adherence, costs, mothers behaviour during HAART, and the child feeding programme during the therapy should further be evaluated and ascertained how they can affect the overall efficacy of option B HAART in PMTCT.
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Affiliation(s)
- Erastus K Ngemu
- School of Science, Department of Biochemistry, University of Eldoret, PO Box 1125, Eldoret, Kenya
| | - Christopher Khayeka-Wandabwa
- Institute of Tropical Medicine and Infectious Diseases (ITROMID), Jomo Kenyatta University of Agriculture and Technology (JKUAT), Nairobi, Kenya
| | - Eliningaya J Kweka
- Tropical Pesticides Research Institute, Division of Livestock and Human Diseases Vector Control, Mosquito Section, Ngaramtoni, Off Nairobi road, PO Box 3024, Arusha, Tanzania
| | - Joseph K Choge
- School of Health Sciences, University of Eastern Africa, Baraton, PO Box 2500-30100, Eldoret, Kenya
| | - Edward Anino
- School of Science, Department of Biochemistry, University of Eldoret, PO Box 1125, Eldoret, Kenya
| | - Elijah Oyoo-Okoth
- School Natural Resources and Environmental Studies, Karatina University, PO Box 1957-10101, Karatina, Kenya
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Newell ML, Thorne C. Antiretroviral therapy and mother-to-child transmission of HIV-1. Expert Rev Anti Infect Ther 2014; 2:717-32. [PMID: 15482235 DOI: 10.1586/14789072.2.5.717] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The advent of highly active antiretroviral therapy has facilitated the virtual elimination of mother-to-child transmission of HIV infection in developed countries, reducing transmission rates to approximately 1 to 2%. In these settings, highly active antiretroviral therapy has also transformed pediatric HIV infection into a chronic disease; although there are associated costs in terms of side effects and the heavy pill burden. In less developed settings, easier-to-use adaptations of antiretroviral therapy regimens, such as short-course and single-dose antiretroviral strategies or neonatal postexposure prophylaxis can also substantially prevent mother-to-child transmission, although to a lesser degree than highly active antiretroviral therapy. However, postnatal transmission of infection through breastfeeding significantly reduces the longer-term efficacy of these strategies. Ongoing research is focusing on the use of antiretroviral therapy in the breastfeeding period.
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Affiliation(s)
- Marie-Louise Newell
- University College London, Centre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
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Ngwende S, Gombe NT, Midzi S, Tshimanga M, Shambira G, Chadambuka A. Factors associated with HIV infection among children born to mothers on the prevention of mother to child transmission programme at Chitungwiza Hospital, Zimbabwe, 2008. BMC Public Health 2013; 13:1181. [PMID: 24330311 PMCID: PMC3878665 DOI: 10.1186/1471-2458-13-1181] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Accepted: 12/10/2013] [Indexed: 11/10/2022] Open
Abstract
Background Zimbabwe is one of the five countries worst affected by the HIV/AIDS pandemic with HIV infection contributing increasingly to childhood morbidity and mortality. Among the children born to HIV positive mothers participating in the PMTCT programme, 25% tested positive to HIV. We investigated factors associated with HIV infection among children born to mothers on the PMTCT programme. Methods A 1:1 unmatched case–control study was conducted at Chitungwiza Hospital, Zimbabwe, 2008. A case was defined as a child who tested HIV positive, born to a mother who had been on PMTCT programme. A control was a HIV negative child born to a mother who had been on PMTCT programme. An interviewer-administered questionnaire was used to collect data on demographic characteristics, risk factors associated with HIV infection and immunization status. Results A total of 120 mothers were interviewed. Independent risk factors associated with HIV infection among children included maternal CD4 count of less than 200 during pregnancy [aOR = 7.1, 95% CI (2.6-17)], mixed feeding [aOR = 29, 95% CI (4.2-208)], being hospitalized since birth [aOR = 2.9, 95% CI (1.2-4.8)] whilst being exclusively breast fed for less than 6 months [aOR = 0.1 (95% CI 0.03-0.4)] was protective. Conclusions HIV infection among children increased if the mother’s CD4 count was ≤200 cells/μL and if the child was exposed to mixed feeding. Breastfeeding exclusively for less than six months was protective. We recommended exclusive breast feeding period for the first six months and stop breast feeding after 6 months if affordable, sustainable and safe.
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Affiliation(s)
| | - Notion T Gombe
- Department of Community Medicine, University of Zimbabwe, Harare, Zimbabwe.
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Frequency and factors associated with adherence to and completion of combination antiretroviral therapy for prevention of mother to child transmission in western Kenya. J Int AIDS Soc 2013; 16:17994. [PMID: 23336727 PMCID: PMC3536941 DOI: 10.7448/ias.16.1.17994] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2012] [Accepted: 12/05/2012] [Indexed: 12/21/2022] Open
Abstract
Introduction The objective of this analysis was to identify points of disruption within the prevention of mother-to-child transmission (PMTCT) continuum from combination antiretroviral therapy (CART) initiation until delivery. Methods To address this objective, the electronic medical records of all antiretroviral-naïve adult pregnant women who were initiating CART for PMTCT between January 2006 and February 2009 within the Academic Model Providing Access To Healthcare (AMPATH), western Kenya, were reviewed. Outcomes of interest were clinician-initiated change or stop in regimen, disengagement from programme (any, early, late) and self-reported medication adherence. Disengagement was categorized as early disengagement (any interval of greater than 30 days between visits but returning to care prior to delivery) or late disengagement (no visit within 30 days prior to the date of delivery). The association between covariates and the outcomes of interest were assessed using bivariate (Kruskal-Wallis test for continuous variables and the Chi-square test for categorical variables) and multivariate logistic regression analysis. Results A total of 4284 antiretroviral-naïve pregnant women initiated CART between January 2006 and February 2009. The majority of women (89%) reported taking all of their medication at every visit. There were 18 (0.4%) deaths reported. Clinicians discontinued CART in 10 patients (0.7%) while 1367 (31.9%) women disengaged from care. Of those disengaging, 404 (29.6%) disengaged early and 963 (70.4%) late. In the multivariate model, the odds of disengagement decreased with increasing age (odds ratio [OR] 0.982; confidence interval [CI] 0.966–0.998) and increasing gestational age at CART initiation (OR 0.925; CI 0.909–0.941). Women receiving care at a district hospital (OR 0.794; CI 0.644–0.980) or tuberculosis medication (OR 0.457; CI 0.202–0.935) were less likely to disengage. The odds of disengagement were higher in married women (OR 1.277; CI 1.034–1.584). The odds of early disengagement decreased with increasing age at CART initiation (OR 0.902; CI 0.881–0.924). The odds of late disengagement decreased with increasing age at CART initiation (OR 0.936; CI 0.917–0.956). While they increased with higher CD4 counts at CART-initiation (OR 1.001; CI 1.000–1001) and in married women (OR 1.297; CI 1.000–1.695) Conclusions In a PMTCT programme embedded in an antiretroviral treatment programme with an active outreach department, the majority (67.4%) of women remained engaged and received uninterrupted prenatal CART.
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