Pregnancy outcomes in HIV-positive women: a retrospective cohort study

Factors Associated with the Uptake of Long-Acting Reversible Contraception and Contraceptive Use in Postpartum People with HIV at a Single Tertiary Care Center

OBJECTIVE

 This study aimed to elucidate factors contributing to uptake of highly effective contraception, including permanent contraception, and no contraceptive plan among postpartum people with HIV (PWHIV).

STUDY DESIGN

 A retrospective cohort analysis was conducted to correlate postpartum birth control (PPBC) with sociodemographic and biomedical variables among postpartum PWHIV who received care at The Ruth M. Rothstein CORE Center and delivered at John H. Stroger, Jr. Hospital of Cook County in Chicago, from 2012 to 2020.

RESULTS

 Earlier gestational age (GA) at initiation of prenatal care, having insurance, and increased parity are associated with uptake of highly effective contraception. Meanwhile, later GA at presentation increased odds of having no PPBC plan.

CONCLUSION

 Early prenatal care, adequate insurance coverage, and thorough PPBC counseling are important for pregnant PWHIV.

KEY POINTS

· Contraceptive use among PWHIV is poorly understood.. · Having insurance and increased parity are associated with long-acting reversible contraception use.. · Earlier GA at first prenatal care visit is associated with increased PPBC uptake..

Impact of maternal HIV infection on perinatal outcomes: A systematic review

BACKGROUND

Maternal HIV infection remains a significant global health concern with potential repercussions on perinatal outcomes. Emphasis on early intervention to improve peri- and postnatal outcomes in infected mothers and infants is a valid therapeutic concern.

OBJECTIVES

To comprehensively analyze perinatal outcomes associated with maternal HIV infection and evaluate adverse effects associated with the HIV infection in the existing literature.

SEARCH STRATEGY

A comprehensive search of PubMed, MEDLINE, and Google Scholar was conducted from 2013 to September 2023, using relevant MeSH terms.

SELECTION CRITERIA

The included studies encompassed original studies, cross-sectional, prospective, retrospective studies and observational studies focused on perinatal outcomes in the context of maternal HIV infection.

DATA COLLECTION AND ANALYSIS

The selected studies underwent rigorous data collection and comprehensive quality checks and adhered to the PRISMA guidelines.

MAIN RESULTS

Nine eligible studies from Brazil, China, India, Malawi, Nigeria, Tanzania, the USA, and Canada were included. These studies have consistently demonstrated that maternal HIV infection is associated with adverse perinatal outcomes. The analysis revealed a higher risk of preterm birth (OR 1.57, 95% CI: 1.39-1.78), low birth weight (OR 1.33, 95% CI: 1.18-1.49), and small for gestational age (OR 1.38, 95% CI: 1.24-1.53) among infants born to mothers living with HIV. Notably, the impact of antiretroviral treatment (ART) on these outcomes varied, but maternal HIV infection remained a significant risk factor regardless of income level and geographic region.

CONCLUSION

Maternal HIV infection is consistently associated with adverse perinatal outcomes, emphasizing the need for targeted interventions and improved prenatal care in pregnant women with HIV infection.

Association between tuberculosis and pregnancy outcomes: a retrospective cohort study of women in Cape Town, South Africa

BACKGROUND

Tuberculosis (TB) remains a leading cause of mortality among women of childbearing age and a significant contributor to maternal mortality. Pregnant women with TB are at high risk of adverse pregnancy outcomes. This study aimed to determine risk factors for an adverse pregnancy outcome among pregnant women diagnosed with TB.

METHODS

Using TB programmatic data, this retrospective cohort analysis included all women who were routinely diagnosed with TB in the public sector between October 2018 and March 2020 in two health subdistricts of Cape Town, and who were documented to be pregnant during their TB episode. Adverse pregnancy outcome was defined as either a live birth of an infant weighing <2500 g and/or with a gestation period <37 weeks or as stillbirth, miscarriage, termination of pregnancy, maternal or early neonatal death. Demographics, TB and pregnancy characteristics were described by HIV status. Logistic regression was used to determine risk factors for adverse pregnancy outcome.

RESULTS

Of 248 pregnant women, half (52%) were living with HIV; all were on antiretroviral therapy at the time of their TB diagnosis. Pregnancy outcomes were documented in 215 (87%) women, of whom 74 (34%) had an adverse pregnancy outcome. Being older (35-44 years vs 25-34 years (adjusted OR (aOR): 3.99; 95% CI: 1.37 to 11.57), living with HIV (aOR: 2.72; 95% CI: 0.99 to 4.63), having an unfavourable TB outcome (aOR: 2.29; 95% CI: 1.03 to 5.08) and having presented to antenatal services ≤1 month prior to delivery (aOR: 10.57; 95% CI: 4.01 to 27.89) were associated with higher odds of an adverse pregnancy outcome.

CONCLUSIONS

Pregnancy outcomes among women with TB were poor, irrespective of HIV status. Pregnant women with TB are a complex population who need additional support prior to, during and after TB treatment to improve TB treatment and pregnancy outcomes. Pregnancy status should be considered for inclusion in TB registries.

Does Maternal HIV Infection Affect Neonatal Outcomes?

BACKGROUND

Pregnancy among women infected with HIV is classified as a high-risk pregnancy. While previous research has indicated an elevated likelihood of preterm birth, low birth weight, and early gestational age in infants born to mothers with HIV, the correlation between maternal HIV infection and different neonatal results remains unclear.

OBJECTIVE

This study aims to investigate the impact of maternal HIV infection on after-birth neonatal outcomes using machine learning (ML) and statistical methods.

METHODS

A case-control study is conducted through a three-stage process: Initially, the outcomes among newborns from HIV-positive mothers are identified through a combination of literature review and expert survey. Subsequently, data are paired at a 1:2 ratio based on gestational age with infants from HIV-positive mothers (n=48) compared to HIV-negative mothers (n=96) as the control group. Finally, filter, wrapper and embedded based feature selection techniques are applied to identify outcomes that exhibit significant differences between the two groups. feature selection techniques are applied to identify outcomes that exhibit significant differences between the two groups.

OUTCOMES

RESULTS

The statistical analysis showed that the rate of addiction among HIV-positive mothers is higher than that of the HIV-negative group. The need for mechanical ventilation and duration of ventilator-assisted breathing in infants born to HIV-positive mothers are significantly higher than in infants born to HIV-negative mothers. Moreover, based on feature selection methods, increasing the need for mechanical ventilation and reducing surfactant administration were two important outcomes.

CONCLUSION

To investigate the impact of maternal HIV infection on neonatal outcomes, various statistical and machine learning-based feature selection techniques were implemented, and the results showed that the presented methods can be utilized to examine the potential impacts of different diseases contracted by the mother on the infant.

Association between maternal HIV infection and the risks of preterm birth and low birth weight in Chengdu, China: a propensity score matching approach

OBJECTIVES

To estimate the effect of HIV infection on the risk of preterm birth (PTB) and low birth weight (LBW) among Chinese pregnancy women.

DESIGN

A retrospective cohort study included HIV-positive pregnant women who gave birth to singletons in Chengdu between 2011 and 2020 and and HIV-negative pregnant women who delivered singletons at the Chengdu Women's and Children's Central Hospital in 2020.

SETTING

Data of pregnant women living with HIV were extracted from China's Information System of Prevention of Mother-to-Child Transmission of HIV Management. Additionally, information for HIV-negative pregnant women was extracted from the electronic medical record system of the Chengdu Women's and Children's Central Hospital.

PARTICIPANTS

755 HIV-positive women and 15,094 HIV-negative pregnant women were included.

PRIMARY OUTCOME MEASURES

PTB and LBW rates, which were defined by gestational weeks and birth weight.

RESULTS

The incidences of PTB and LBW (13.51% and 14.17%, respectively) were significantly higher in the HIV-positive group compared with the HIV-negative group (6.82% and 4.65%). Propensity score matching was performed to improve comparability of the two groups, resulting in 1590 pregnancies with 558 HIV-positive and 1032 HIV-negative women in the final analysis. Conditional logistic regression was used to estimate the effect of maternal HIV status on adverse pregnancy outcomes. After propensity score matching and controlling the potential confounders, HIV infection was strongly associated with higher chances of LBW and PTB with adjusted odd ratios (95% confidence interval) of 2.53 (1.74 to 3.68) and 1.95 (1.33 to 2.85), respectively.

CONCLUSIONS

HIV infection was significantly associated with increased risks of PTB and LBW in Chinese pregnant women. Future studies should focus on investigating the mechanisms underlying the association between HIV infection and adverse birth outcomes, and on identifying strategies to reduce the incidence of PTB and LBW in pregnant women living with HIV.

Adverse Perinatal Outcomes among Adolescent Pregnant Women Living with HIV: A Propensity-Score-Matched Study

HIV infection and adolescent pregnancy are known to increase the risk of adverse perinatal outcomes. However, data are limited concerning the outcomes of pregnancies among adolescent girls living with HIV. This retrospective propensity-score matched study aimed to compare adverse perinatal outcomes in adolescent pregnant women living with HIV (APW-HIV-positive) with HIV-negative adolescent pregnant women (APW-HIV-negative) and adult pregnant women with HIV (PW-HIV). APW-HIV-positive were propensity-score matched with APW-HIV-negative and PW-HIV. The primary endpoint was a composite endpoint of adverse perinatal outcomes, comprising preterm birth and low birth weight. There were 15 APW-HIV-positive and 45 women in each control group. The APW-HIV-positive were aged 16 (13-17) years and had had HIV for 15.5 (4-17) years, with 86.7% having perinatally acquired HIV. The APW-HIV-positive had higher rates of perinatally acquired HIV infection (86.7 vs. 24.4%, p < 0.001), a longer HIV infection time (p = 0.021), and longer exposure to antiretroviral therapy (p = 0.034) compared with the PW-HIV controls. The APW-HIV-positive had an almost five-fold increased risk of adverse perinatal outcomes compared with healthy controls (42.9% vs. 13.3%, p = 0.026; OR 4.9, 95% CI 1.2-19.1). The APW-HIV-positive and APW-HIV-negative groups had similar perinatal outcomes.

Clinical risk factors of adverse outcomes among women with COVID-19 in the pregnancy and postpartum period: a sequential, prospective meta-analysis

OBJECTIVE

This sequential, prospective meta-analysis sought to identify risk factors among pregnant and postpartum women with COVID-19 for adverse outcomes related to disease severity, maternal morbidities, neonatal mortality and morbidity, and adverse birth outcomes.

DATA SOURCES

We prospectively invited study investigators to join the sequential, prospective meta-analysis via professional research networks beginning in March 2020.

STUDY ELIGIBILITY CRITERIA

Eligible studies included those recruiting at least 25 consecutive cases of COVID-19 in pregnancy within a defined catchment area.

METHODS

We included individual patient data from 21 participating studies. Data quality was assessed, and harmonized variables for risk factors and outcomes were constructed. Duplicate cases were removed. Pooled estimates for the absolute and relative risk of adverse outcomes comparing those with and without each risk factor were generated using a 2-stage meta-analysis.

RESULTS

We collected data from 33 countries and territories, including 21,977 cases of SARS-CoV-2 infection in pregnancy or postpartum. We found that women with comorbidities (preexisting diabetes mellitus, hypertension, cardiovascular disease) vs those without were at higher risk for COVID-19 severity and adverse pregnancy outcomes (fetal death, preterm birth, low birthweight). Participants with COVID-19 and HIV were 1.74 times (95% confidence interval, 1.12-2.71) more likely to be admitted to the intensive care unit. Pregnant women who were underweight before pregnancy were at higher risk of intensive care unit admission (relative risk, 5.53; 95% confidence interval, 2.27-13.44), ventilation (relative risk, 9.36; 95% confidence interval, 3.87-22.63), and pregnancy-related death (relative risk, 14.10; 95% confidence interval, 2.83-70.36). Prepregnancy obesity was also a risk factor for severe COVID-19 outcomes including intensive care unit admission (relative risk, 1.81; 95% confidence interval, 1.26-2.60), ventilation (relative risk, 2.05; 95% confidence interval, 1.20-3.51), any critical care (relative risk, 1.89; 95% confidence interval, 1.28-2.77), and pneumonia (relative risk, 1.66; 95% confidence interval, 1.18-2.33). Anemic pregnant women with COVID-19 also had increased risk of intensive care unit admission (relative risk, 1.63; 95% confidence interval, 1.25-2.11) and death (relative risk, 2.36; 95% confidence interval, 1.15-4.81).

CONCLUSION

We found that pregnant women with comorbidities including diabetes mellitus, hypertension, and cardiovascular disease were at increased risk for severe COVID-19-related outcomes, maternal morbidities, and adverse birth outcomes. We also identified several less commonly known risk factors, including HIV infection, prepregnancy underweight, and anemia. Although pregnant women are already considered a high-risk population, special priority for prevention and treatment should be given to pregnant women with these additional risk factors.

Type and timing of antiretroviral therapy during pregnancy: Impact on risk of preterm delivery and small-for-gestational age births in Canada, a retrospective cohort study

OBJECTIVE

To evaluate the impact of type and timing of antiretroviral therapy (ART) on the risk of preterm delivery (PTD) and small-for-gestational age (SGA) birth among pregnant women and people living with HIV in Canada.

METHODS

Data for this retrospective cohort study were analyzed from the Canadian Perinatal HIV Surveillance Program from 1990 to 2020. The association between ART and risk of PTD (<37 weeks) and SGA birth (<10th percentile) was explored using mixed effects logistic regression and time-dependent Cox proportional hazards models.

RESULTS

Overall, there were 14.9% (654 of 4379) PTD and 18.5% (732 of 3947) SGA cases. A higher risk of PTD was observed with nonnucleoside reverse transcriptase inhibitor-(adjusted hazard ratio [aHR], 1.73; P = 0.019) and boosted protease inhibitor- (aHR, 186; P = 0.007) based regimens compared with integrase strand transfer inhibitor (INSTI)-based regimens. ART initiation prior to conception was associated with a lower risk of SGA birth compared with ART initiation after conception at 1 to 14 weeks (adjusted odds ratio [aOR], 0.69; P = 0.024) and > 14 weeks (aOR, 0.70; P = 0.005).

CONCLUSION

INSTI-based ART regimens were associated with lower risk of PTD compared with other regimens, and ART initiation before conception was associated with a lower risk of SGA birth. These findings, with overall safety data, should be considered when providing pregnancy counseling to people living with HIV.

Stress-Sensitive Regulators of Fetal Neurodevelopment in HIV and Preeclampsia: An Immunocytochemical Appraisal of Placental OGT and T4 Levels

Preeclampsia and HIV are a significant burden to maternal health globally, especially in low-middle income countries such as South Africa. In the KwaZulu-Natal province, SA antenatal HIV prevalence is 41.1%, while PE is 12%. PE and HIV infections are maternal stress and inflammation that impact placental function and fetal development. Therefore, this study investigated the impact of the comorbidity of PE and HIV on placental stress and neurodevelopment. Placentae were obtained from four cohorts of pregnant women: normotensive HIV negative, normotensive HIV positive, preeclamptic HIV negative, and preeclamptic HIV positive. The placental tissue sections were immunostained for OGT and T4. Our findings showed that the maternal weight, diastolic, and systolic blood pressures (BP) were higher in PE vs. the normotensive groups, irrespective of HIV status. In addition, significant changes were noticed in the placental weight, fetoplacental ratio, and placental efficiency coefficient. Our findings showed that the maternal weight, diastolic, and systolic blood pressures (BP) were statistically higher in the PE compared to the normotensive. No significant differences were observed between HIV positive and HIV negative groups. In addition, significant changes were noticed in the placental weight, fetoplacental ratio, and placental coefficient. Furthermore, considerable upregulation in the placental expression of OGT in both the conducting and exchange villi of PE and concomitant downregulation in HIV-positive patients compared with Normotensive and HIV-negative individuals, respectively. Our results provide inferential evidence on the dysregulation of OGT in the comorbidity of PE and HIV. This may mediate a compromised programmed outcome of an adverse maternal environment during pregnancy and consequently affect fetal development.

Effects of HIV Infection on Pregnancy Outcomes Among Women Attending Antenatal Care in Referral Hospitals of the Amhara Regional State, Ethiopia: A Prospective Cohort Study

Background

Human immunodeficiency virus (HIV) has remained to be a significant public health problem worldwide mainly affecting women. Despite a 2 to 3 times higher risk of adverse pregnancy outcomes, around 2 million HIV positive women give birth each year globally. However, there is a dearth of evidences in Ethiopia about the effect of maternal HIV infection on pregnancy outcomes where adverse birth outcomes are still a significant health problem. This study is, therefore, aimed to examine the effect of HIV on the risk of adverse pregnancy outcomes in Amhara Regional State, Ethiopia.

Methods

A prospective cohort study was conducted among 704 pregnant women (352 women with HIV and 352 women without HIV infection). Systematic random sampling technique was employed to select the study participants. Data on socio-demographic, obstetric, clinical, as well as behavioral and psychosocial characteristics were collected using a validated tool. Data on the outcome variables were also collected following delivery. Modified Poisson regression was employed to estimate the relative risk (RR) of HIV on low birth weight (LBW), preterm birth, and still birth at 95% confidence level. Attributable fraction (AF) was used to report the impact of HIV infection on pregnancy outcomes.

Results

Of the total 704 pregnant women enrolled for the study, 96.3% (678) completed the study. The mean age of the study participants was 30.8 (SD ± 5.4) for HIV positive and 27 (SD ± 5.4) for HIV negative women. The cumulative incidence of low birth weight, preterm birth, and stillbirth were 21.4%, 9.4%, and 4.1%, respectively. The incidence of LBW was 24.7% among HIV positive and 17.8% among HIV negative women. The incidence of preterm birth was 10.7% among HIV positive and 7.9% among HIV negative women. And the incidence of stillbirth was 3.7% and 4.6% among HIV positive and those HIV negative women. New-borns from women with HIV infection had a higher risk of low birth weight and preterm birth than those HIV negative women (Adjusted Relative Risk (ARR) = 1.47; 95% CI: 1.06-2.03) and (ARR = 1.74; 95% CI: 1.08-2.79), respectively. The attributable risk of HIV on low birth weight was 32% (Attributable Fraction (AF) = 32%, 95% CI: 23-46%), and 43% (AF = 43%, 95% CI: 23-46%) for preterm birth.

Conclusion

Maternal HIV infection increased the risk of low birth weight and preterm birth. This implies due attention is required while providing maternal health services primarily antenatal care and delivery services. These services should be aimed at reducing adverse pregnancy outcomes with more attention given to women with HIV infection. Moreover, reinforcement of HIV prevention intervention strategies should be considered at all levels.

Predictors of adverse pregnancy outcomes among Kenyan women with HIV on antiretroviral treatment in pregnancy

OBJECTIVE

The aim of this study was to understand predictors of adverse pregnancy outcomes (APOs) among women on antiretroviral treatment (ART).

DESIGN

A longitudinal cohort.

METHODS

Participants from the Mobile WAChX trial were evaluated for APOs, including stillbirth (fetal death at ≥20 weeks' gestation), preterm birth (PTB, livebirth at <37 weeks' gestation,) and neonatal death (NND, ≤28 days after live birth). Predictors were determined by univariable and multivariable Cox proportional hazards and log-binomial models.

RESULTS

Among 774 women included, median age was 27 years and 29.0% had unsuppressed HIV viral load (>1000 copies/ml) at enrollment. Half (55.1%) started ART prepregnancy, 89.1% on tenofovir-based regimens. Women with depression had a higher risk of stillbirth (adjusted hazard ratio [aHR] 2.93, 95% confidence interval (95% CI) 1.04-8.23), and women with lower social support score had higher risk of late stillbirth (aHR 11.74, 2.47-55.86). Among 740 livebirths, 201 (27.2%) were preterm and 22 (3.0%) experienced NND. PTB was associated with unsuppressed maternal viral load (adjusted prevalence ratio [aPR] 1.28, 95% CI 1.02-1.61), intimate partner violence (IPV) in pregnancy (aPR 1.94, 95% CI 1.28-2.94), and history of any sexually transmitted infection (STI) (aPR 1.63, 95% CI 1.06-2.51). NND was associated with PTB (aPR 2.53, 95% CI 1.10-5.78) and STI history (aPR 4.25, 95% CI 1.39-13.06). Most associations retained significance in the subgroup of women with viral suppression.

CONCLUSION

Maternal viremia during pregnancy predicted PTB as did IPV, lower education, and STI history, while psychosocial stressors predicted stillbirth. Implementing mental health services, ART adherence, partner support, and routine STI screening and treatment could reduce APOs among women with HIV in sub-Saharan Africa settings.

Estimated blood pressure trajectories and hypertension patterns among pregnant women living with HIV, Haiti, 2007-2017

Hypertension in pregnancy is a key driver of mortality and morbidity among Haitian women. HIV infection and treatment may worsen hypertension and increase cardiovascular disease risk. The authors examined blood pressure and hypertension patterns among 1965 women (2306 pregnancies ending in live births) in a prevention of maternal-to-child transmission (PMTCT) program in Port-au-Prince, Haiti, between 2007 and 2017. Hypertension was defined as blood pressure ≥140/90 mm Hg on two consecutive visits. Latent class analysis assessed trajectories of mean arterial pressure (MAP) and multinomial ordinal logistic regression examined factors associated with higher trajectories. Between 2007-2009 and 2013-2016, hypertension at PMTCT entry increased from 1.3% to 3.8% (p = .005), while incidence at any time during PMTCT follow-up increased from 5.0 to 16.1 per 100 person-years (p < .001). Hypertension detected ≤20 weeks and > 20 weeks of gestation (possible gestational hypertension) increased from 1.1% to 3.5% (p = .003) and from 2.3% to 6.9% (p < .001), respectively. Five MAP trajectories ranged from low-stable to high-increasing. In multivariable analysis controlling for history of antiretroviral therapy, age, parity, and weight, program entry in more recent years was associated with greater odds of higher MAP trajectory (adjusted odds ratio for 2013-2016 vs. 2007-2009 = 3.1, 95% confidence interval: 1.7-5.6). The increasing prevalence and incidence of hypertension highlight a need for screening and management prior to PMTCT entry and during follow-up. In a population with limited access to chronic disease care, and where many deliveries occur outside of a clinical setting, the period of PMTCT follow-up represents an opportunity to diagnose and initiate management of preexisting and pregnancy-related hypertension.

HIV-Positive and HIV-Negative Women with Medicaid Have Similar Rates of Stillbirth and Preterm Birth

Introduction: Women living with human immunodeficiency virus (WLHIV) may face additional challenges and differential birth outcomes when compared with women without human immunodeficiency virus (HIV). There is limited research to date studying birth outcomes among a nationally representative sample of WLHIV. This study compares stillbirth and prematurity rates between HIV-positive (HIV+) and HIV-negative (HIV-) mothers in the Medicaid program. Methods: We used 12 years (2001-2012) of Medicaid Analytic eXtract data. We included Medicaid claims from the 14 states with the highest prevalence of HIV: California, Florida, Georgia, Illinois, Louisiana, Massachusetts, Maryland, North Carolina, New Jersey, New York, Ohio, Pennsylvania, Texas, and Virginia. Primary outcomes were stillbirth and preterm birth. We used logistic regression models adjusting for age, race, Medicaid coverage, eligibility, substance use, rurality, comorbidities, and state fixed effects to compare differences in rates for women with and without HIV. Results: Our study included a total of 33,078 HIV+ and 7,663,758 HIV- pregnancies from Medicaid enrollees between 2001 and 2012. The proportions of stillbirths and preterm births were higher for HIV+ when compared with HIV- mothers (0.9% vs. 0.7% and 8.0% vs. 6.6%, p < 0.0001). After adjusting for covariates, being HIV+ was not significantly associated with both stillbirth (odds ratio [OR]: 1.05) or prematurity (OR: 1.01). Black race was a strong independent predictor of both stillbirth and prematurity (OR: 1.99 and 1.51, p < 0.01). Rurality and substance abuse were not associated with either outcome. Conclusions: After adjustment for relevant covariates, maternal HIV infection was not associated with increased rates of stillbirth or preterm birth in the Medicaid program in the United States. It is imperative that we understand and eliminate the clinical, social, and contextual factors that are responsible for the strong association between black race and poor perinatal outcomes that we observe.

Joint spatio-temporal modelling of adverse pregnancy outcomes sharing common risk factors at sub-county level in Kenya, 2016-2019

Background

Adverse pregnancy outcomes jointly account for a high proportion of mortality and morbidity among pregnant women and their infants. Furthermore, the burden attributed to adverse pregnancy outcomes remains high and inadequately characterised due to the intricate interplay of its etiology and shared set of important risk factors. This study sought to quantify and map the underlying risk of multiple adverse pregnancy outcomes in Kenya at sub-county level using a shared component space-time modelling framework.

Methods

Reported sub-county level adverse pregnancy outcomes count from January 2016 – December 2019 were obtained from the Kenyan District Health Information System. A Bayesian hierarchical spatio-temporal model was used to estimate the joint burden of adverse pregnancy outcomes in space (sub-county) and time (year). To improve the precision of our estimates over time and space, information across the outcomes were combined via the shared and the outcome-specific components using a shared component model with spatio-temporal interactions.

Results

Overall, the total number of adverse outcomes in pregnancy increased by 14.2% (95% UI: 14.0–14.5) from 88,816 cases in 2016 to 101,455 cases in 2019. Between 2016 and 2019, the estimated low birth weight rate and the pre-term birth rate were 4.5 (95% UI: 4.4–4.7) and 2.3 (95% UI: 2.2–2.5) per 100 live births. The stillbirth and neonatal death rates were estimated to be 18.7 (95% UI: 18.0–19.4) and 6.9 (95% UI: 6.4–7.4) per 1000 live births. The magnitude of the spatio-temporal variation attributed to shared risk was high for pre-term births, low birth weight, neonatal deaths, stillbirths and neonatal deaths, respectively. The shared risk patterns were dominant in sub-counties located along the Indian ocean coastline, central and western Kenya.

Conclusions

This study demonstrates the usefulness of a Bayesian joint spatio-temporal shared component model in exploiting specific and shared risk of adverse pregnancy outcomes sub-nationally. By identifying sub-counties with elevated risks and data gaps, our estimates not only assert the need for bolstering maternal health programs in the identified high-risk sub-counties but also provides a baseline against which to assess the progress towards the attainment of Sustainable Development Goals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12210-9.

Perinatal outcomes in women living with HIV-1 and receiving antiretroviral therapy-a systematic review and meta-analysis

INTRODUCTION

Antiretroviral therapy-naïve pregnant women living with HIV are at an increased risk for adverse pregnancy outcomes. It remains controversial whether this risk persists with antiretroviral therapy. We conducted a systematic review and meta-analysis to evaluate whether pregnant women living with HIV and receiving antiretroviral therapy antenatally, are at an increased risk of adverse outcomes compared with HIV-negative controls.

MATERIAL AND METHODS

We searched MEDLINE, Embase, International Pharmaceutical Abstracts, EBM Reviews, PubMed (non-MEDLINE records), EBSCO CINAHL Complete, Clarivate Web of Science, African Index Medicus, LILACS and Google Scholar for all observational studies comparing pregnant women living with HIV on antiretroviral therapy with HIV-negative controls from 1 January 1994 to 10 August 2021 with no language or geographic restrictions. Perinatal outcomes included preterm birth (PTB), low birthweight, small-for-gestational age and preeclampsia. Using a random-effects model we pooled raw data to generate odds ratio (OR) with 95% confidence intervals (CI) for each outcome. Sub-analyses for high and low resource countries and time of antiretroviral therapy initiation were performed. This systematic review and meta-analysis is registered with PROSPERO, number CRD42020182722.

RESULTS

Of the 7900 citations identified, 27 were eligible for analysis (12 636 pregnant women living with HIV on antiretroviral therapy and 7 812 115 HIV-negative controls). ORs (95% CI) of PTB (1.88 [1.63-2.17]), small-for-gestational age (1.60 [1.18-2.17]) and low birthweight (2.15 [1.58-2.92]) were significantly higher in pregnant women living with HIV than in HIV-negative women, while the risk of preeclampsia (0.86 [0.57-1.30]) was comparable. The risk of PTB and low birthweight was higher in both high resource and low resource countries, while the risk of small-for-gestational age was higher only in the former. Preconceptional antiretroviral therapy was associated with a higher risk of PTB compared with antenatal initiation.

CONCLUSIONS

Pregnant women living with HIV on antiretroviral therapy have an increased risk of PTB, low birthweight and small-for-gestational age in high resource countries, as well as PTB and low birthweight in low income countries compared with HIV-negative controls.

Preterm Birth and Antiretroviral Exposure in Infants HIV-exposed Uninfected

BACKGROUND

Infants HIV-exposed and uninfected (IHEU) who are born to women living with HIV are at an increased risk of preterm birth (PTB). Antenatal exposure to certain maternal antiretroviral therapy (ART) regimens has been associated with PTB, although existing studies in this domain are limited and report discordant findings. We determined odds of PTB among IHEU by antenatal ART regimens and timing of exposure, adjusting for maternal risk factors.

METHODS

We retrospectively studied IHEU born in British Columbia (BC), Canada between 1990 and 2012 utilizing provincial health administrative databases. We included data from a control group of infants HIV-unexposed and uninfected (IHUU) matched ~3:1 for each IHEU on age, sex and geocode.

RESULTS

A total of 411 IHEU and 1224 IHUU were included in univariable analysis. PTB was more frequent among IHEU (20%) compared with IHUU (7%). IHEU were more often antenatally exposed to alcohol, tobacco, as well as prescription, nonprescription, and illicit drugs (IHEU: 36%, 8% and 35%; vs. IHUU: 3%, 1% and 9%, respectively). After adjusting for maternal substance use and smoking exposure, IHEU remained at increased odds of PTB [adjusted odds ratio (aOR) (95% CI): 2.66; (1.73, 4.08)] compared with matched IHUU controls. ART-exposed IHEU (excluding those with NRTIs only ART) had lower adjusted odds of PTB compared with IHEU with no maternal ART exposure, regardless of regimen [aOR range: 0.16-0.29 (0.02-0.95)]. Odds of PTB between IHEU exposed to ART from conception compared with IHEU exposed to ART postconception did not differ [aOR: 0.91 (0.47, 1.76)]; however, both groups experienced lower odds of PTB compared with IHEU with no maternal ART [preconception: aOR: 0.28 (0.08, 0.89); postconception: aOR 0.30 (0.11, 0.83)].

CONCLUSIONS

BC IHEU were over twice as likely to be born preterm compared with demographically matched controls. Maternal substance use in pregnancy modulated this risk; however, we found no adverse associations of PTB with exposure to antenatal ART.

Does in utero HIV exposure and the early nutritional environment influence infant development and immune outcomes? Findings from a pilot study in Pretoria, South Africa

Background

As mother-to-child transmission of HIV decreases, and the population of infants who are born HIV-exposed, but uninfected (HEU) continues to rise, there is a growing need to understand the development and health outcomes of infants who are HEU to ensure that they have the healthiest start to life.

Methods

In a prospective cohort pilot study at Kalafong Hospital, Pretoria, South Africa, we aimed to determine if we could recruit new mothers living with HIV on antiretrovirals (ART; n = 20) and not on ART (n = 20) and new mothers without HIV (n = 20) through our clinics to study the effects of HEU on growth and immune- and neurodevelopment in infants in early life, and test the hypothesis that infants who were HEU would have poorer health outcomes compared to infants who were HIV-unexposed, uninfected (HUU). We also undertook exploratory analyses to investigate relationships between the early nutritional environment, food insecurity and infant development. Infant growth, neurodevelopment (Guide for Monitoring Child Development [GMCD]) and levels of monocyte subsets (CD14, CD16 and CCR2 expression [flow cytometry]) were measured in infants at birth and 12 weeks (range 8–16 weeks).

Results

We recruited 33 women living with HIV on ART and 22 women living without HIV within 4 days of delivery from June to December 2016. Twenty-one women living with HIV and 10 without HIV returned for a follow-up appointment at 12 weeks postpartum. The high mobility of this population presented major challenges to participant retention. Preliminary analyses revealed lower head circumference and elevated CCR2+ (% and median fluorescence intensity) on monocytes at birth among infants who were HEU compared to HUU. Maternal reports of food insecurity were associated with lower maternal nutrient intakes at 12 weeks postpartum and increased risk of stunting at birth for infants who were HEU, but not infants who were HUU.

Conclusions

Our small feasibility pilot study suggests that HEU may adversely affect infant development, and further, infants who are HEU may be even more vulnerable to the programming effects of suboptimal nutrition in utero and postnatally. This pilot and preliminary analyses have been used to inform our research questions and protocol in our ongoing, full-scale study.

Association of Adverse Neighborhood Exposures With HIV Viral Load in Pregnant Women at Delivery

IMPORTANCE

Racial disparities in maternal morbidity and mortality are in large part driven by poor control of chronic diseases. The association between adverse neighborhood exposures and HIV virologic control has not been well described for women with HIV during pregnancy.

OBJECTIVE

To evaluate the association between adverse neighborhood exposures and HIV viral load at delivery.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study assessed HIV surveillance data for pregnant women with HIV who had live deliveries in Philadelphia from January 1, 2005, through December 31, 2015. Data analyses were completed in August 2020.

EXPOSURES

Neighborhood exposures included extreme poverty, educational attainment, crime rates (using separate and composite measures), and social capital categorized above or below the median. Each neighborhood exposure was modeled separately to estimate its association with elevated HIV viral load.

MAIN OUTCOMES AND MEASURES

The main outcome was elevated HIV viral load of ≥200 copies/mL at delivery. We hypothesized that adverse neighborhood exposures would be associated with higher odds of having an elevated viral load at delivery. Confounders included birth year, age, race/ethnicity, previous birth while living with HIV, and prenatal HIV diagnosis. Prenatal care and substance use were considered potential mediators. We used logistic mixed effects models to estimate the association between neighborhood exposures and elevated viral load, adjusting for confounders in Model 1 and confounders and mediators in Model 2.

RESULTS

There were 905 births among 684 women with HIV, most of whom were aged 25 to 34 years (n = 463 [51.2%]) and were Black non-Hispanic (n = 743 [82.1%]). The proportion of women with elevated viral load decreased from 58.2% between 2005 and 2009 to 23.1% between 2010 and 2015. After adjusting for confounders in Model 1, higher neighborhood education was associated with lower odds of having an elevated viral load (adjusted odds ratio [AOR], 0.70; 95% CI, 0.50-0.96). More violent crime (AOR, 1.51; 95% CI, 1.10-2.07), prostitution crime (AOR, 1.46; 95% CI, 1.06-2.00), and a composite measure of crime (AOR, 1.44; 95% CI, 1.05-1.98) were positively associated with having a higher HIV viral load. These associations remained after adjusting for mediators in Model 2. In addition, the AOR for intermediate prenatal care varied between 1.93 (95% CI, 1.28-2.91) and 1.97 (95% CI, 1.31-2.96), whereas the AOR for inadequate prenatal care varied between 3.01 (95% CI, 2.05-4.43) and 3.06 (95% CI, 2.08-4.49) across regression models.

CONCLUSIONS AND RELEVANCE

In this cohort study, adverse neighborhood exposures during pregnancy and poor engagement in prenatal care were associated with poor virologic control at delivery. These findings suggest that interventions targeted at improving maternal health need to take the social environment into consideration.

Trends in Women With an HIV Diagnosis at Delivery Hospitalization in the United States, 2006-2014

OBJECTIVES

The risk of mother-to-child HIV transmission can be reduced to ≤0.5% if the mother's HIV status is known before delivery. This study describes 2006-2014 trends in diagnosed HIV infection documented on delivery discharge records and associated sociodemographic characteristics among women who gave birth in US hospitals.

METHODS

We analyzed data from the 2006-2014 National Inpatient Sample and identified delivery discharges and women with diagnosed HIV infection by using International Classification of Diseases, Ninth Revision, Clinical Modification codes. We used a generalized linear model with log link and binomial distribution to assess trends and the association of sociodemographic characteristics with an HIV diagnosis on delivery discharge records.

RESULTS

During 2006-2014, an HIV diagnosis was documented on approximately 3900-4400 delivery discharge records annually. The probability of having an HIV diagnosis on delivery discharge records decreased 3% per year (adjusted relative risk [aRR] = 0.97; 95% CI, 0.94-0.99), with significant declines identified among white women aged 25-34 (aRR = 0.93; 95% CI, 0.88-0.97) or those using Medicaid (aRR = 0.93; 95% CI, 0.90-0.97); among black women aged 25-34 (aRR = 0.95; 95% CI, 0.92-0.99); and among privately insured women who were black (aRR = 0.96; 95% CI, 0.92-0.99), Hispanic (aRR = 0.92; 95% CI, 0.86-0.98), or aged 25-34 (aRR = 0.96; 95% CI, 0.92-0.99). The probability of having an HIV diagnosis on delivery discharge records was greater for women who were black (aRR = 8.45; 95% CI, 7.56-9.44) or Hispanic (aRR = 1.56; 95% CI, 1.33-1.83) than white; for women aged 25-34 (aRR = 2.33; 95% CI, 2.12-2.55) or aged ≥35 (aRR = 3.04; 95% CI, 2.79-3.31) than for women aged 13-24; and for Medicaid recipients (aRR = 2.70; 95% CI, 2.45-2.98) or the uninsured (aRR = 1.87; 95% CI, 1.60-2.19) than for privately insured patients.

CONCLUSION

During 2006-2014, the probability of having an HIV diagnosis declined among select sociodemographic groups of women delivering neonates. High-impact prevention efforts tailored to women remaining at higher risk for HIV infection can reduce the risk of mother-to-child HIV transmission.

Elevated Blood Mitochondrial DNA in Early Life Among Uninfected Children Exposed to Human Immunodeficiency Virus and Combination Antiretroviral Therapy in utero

BACKGROUND

Combination antiretroviral therapy (cART) during pregnancy prevents vertical transmission, but many antiretrovirals cross the placenta and several can affect mitochondria. Exposure to maternal human immunodeficiency virus (HIV) and/or cART could have long-term effects on children who are HIV exposed and uninfected (CHEU). Our objective was to compare blood mitochondrial DNA (mtDNA) content in CHEU and children who are HIV unexposed and uninfected (CHUU), at birth and in early life.

METHODS

Whole-blood mtDNA content at birth and in early life (age 0-3 years) was compared cross-sectionally between CHEU and CHUU. Longitudinal changes in mtDNA content among CHEU was also evaluated.

RESULTS

At birth, CHEU status and younger gestational age were associated with higher mtDNA content. These remained independently associated with mtDNA content in multivariable analyses, whether considering all infants, or only those born at term. Longitudinally, CHEU mtDNA levels remained unchanged during the first 6 months of life, and gradually declined thereafter. A separate age- and sex-matched cross-sectional analysis (in 214 CHEU and 214 CHUU) illustrates that the difference in mtDNA between the groups remains detectable throughout the first 3 years of life.

CONCLUSION

The persistently elevated blood mtDNA content observed among CHEU represents a long-term effect, possibly resulting from in utero stresses related to maternal HIV and/or cART. The clinical impact of altered mtDNA levels is unclear.

Sexual and reproductive health of women living with HIV in Muslim-majority countries: a systematic mixed studies review

Background

The number of women living with the human immunodeficiency virus (WLHIV) in Muslim-majority countries has increased significantly in the last decade. These women are often marginalized and face insecure sexual and reproductive health (SRH) needs and rights. However, little is known about the multi-faceted factors influencing these women’s fertility, contraceptive, and perinatal decisions and sexual life. This systematic mixed studies review aimed to synthesize the empirical evidence on social, cultural, and structural factors influencing the SRH of WLHIV in Muslim-majority countries.

Methods

This review provides a synthesis of quantitative, qualitative and mixed-method research findings searched from PubMed, EMBASE, Scopus, CINAHL and Cochrane databases. We screened 3452 SRH studies involving WLHIV. The studies, published in English between 2008 and 2017, were from 20 Muslim-majority countries with increased numbers of WLHIV. The quality of eligible studies was appraised using a mixed-methods appraisal tool (MMAT) version 2011. Findings were thematically analysed by a hybrid deductive-inductive approach. Two independent reviewers were involved in the study selection, data extraction, quality appraisal, and data synthesis.

Results

We included 13 SRH-related studies involving 1748 WLHIV in eight Muslim-majority countries. Most of these studies explored fertility desire and sexual health, while only a small proportion related to contraceptive use and the perinatal-care experience. We identified that WLHIV faced neglect of their SRH rights. These rights were predominantly affected by the socio-cultural, religious and health-services context of the women’s lives, which directed them to unsafe sex practices and stressful perinatal experiences.

Conclusions

This study points to the need for SRH laws, policies, and interventions which stop WLHIV experiencing SRH discrimination violence and achieving their SRH rights.

Impact of human immunodeficiency virus, malaria, and tuberculosis on adverse pregnancy outcomes in the United States

OBJECTIVE

To compare rates of adverse pregnancy outcomes for HIV, tuberculosis, and malaria-infected patients in the United States with those of uninfected patients.

STUDY DESIGN

A nationally representative sample of 24,149,664 singleton live births were identified using pregnancy hospitalizations that resulted in delivery between 1998-2000 and 2009-2011 in this retrospective cohort study. Maternal and fetal outcomes were evaluated.

RESULTS

There were 7204 HIV cases, 1450 TB cases, and 296 malaria cases over the two time periods, and the average age of infected subjects was 28.3. The HIV group was more likely to have almost all adverse pregnancy outcomes than the control group in both time periods. The 2009-2011 HIV group was more likely to undergo cesarean delivery than the 1998-2000 HIV group [1959 versus 1649, p < 0.0001].

CONCLUSION

Out of pregnant women infected with HIV, malaria, or tuberculosis, those infected with HIV are more likely to experience several adverse pregnancy outcomes than uninfected women.

Maternal HIV infection and risk of adverse pregnancy outcomes in Hunan province, China: A prospective cohort study

This study described the prevalence of adverse pregnancy outcomes (APOs) in Chinese HIV-infected pregnant women, and examined the relationship between maternal HIV infection /HIV-related factors and APOs.This prospective cohort study was carried out among 483 HIV-infected pregnant women and 966 HIV-uninfected pregnant women. The HIV-infected and HIV-uninfected women were enrolled from midwifery hospitals in Hunan province between October 2014 and September 2017. All data were extracted in a standard structured form, including maternal characteristics, HIV infection status, HIV-related factors and their pregnancy outcomes. APOs were assessed by maternal HIV infection status and HIV-related factors using logistic regression analysis.The incidences of stillbirth (3.9% vs 1.1%), preterm birth (PTB) (8.9% vs 3.7%), low birth weight (LBW) (12.2% vs 3.1%) and small for gestational age (SGA) (21.3% vs 7.0%) were higher in HIV-infected women than HIV-uninfected women, with adjusted ORs of 2.77 (95%CI: 1.24-6.17), 2.37 (95%CI: 1.44-3.89), 4.20 (95%CI: 2.59-6.82) and 3.26 (95%CI: 3.26-4.64), respectively. No differences were found in neonatal asphyxia or birth defects between HIV-infected and HIV-uninfected groups, with adjusted ORs of 1.12 (95%CI: 0.37-3.43) and 1.10 (95%CI: 0.51-2.39), respectively. Among HIV-infected pregnant women, different antiretroviral (ARV) regimens were significantly associated with stillbirths, but not PTB, LBW or SGA. Compared with untreated HIV infection (10.1%), both mono/dual therapy and HAART were associated with a reduced risk of stillbirths (2.0% and 3.2%, respectively), with an AOR of 0.19 (95%CI: 0.04-0.92) and 0.31 (95%CI: 0.11-0.85), respectively. Initial time of ARV drugs use and HIV infection status of the sexual partner were not associated with maternal APOs.The findings of this study indicated that maternal HIV infection was associated with significantly increased risks of stillbirth, PTB, LBW and SGA, but not neonatal asphyxia or birth defects. On the condition that most HIV-infected pregnant women started ARV therapy in or after the second trimester, both mono/dual therapy and HAART had a protective effect on stillbirth compared with untreated HIV infection. As some important confounders were not effectively controlled and the specific regimens of HAART were not analyzed, the above findings may have certain bias.

Comparison of two combined antiretroviral treatment regimens in the management of HIV in pregnancy: an observational study

Objective: Combined antiretroviral therapy (cART) in pregnancy traditionally included two nucleoside reverse transcriptase inhibitors plus 1 protease inhibitor (PI). Recently, integrase strand transfer inhibitors (INSTI) have been approved for use in pregnancy. We sought to compare the rate of undetectable VL near delivery in pregnant HIV-infected women receiving INSTI-based versus PI-based cART.Material and methods: Prospective cohort study (January 2010-March 2017) of pregnant HIV-infected pregnancies receiving care in a single obstetric infectious disease clinic. Included pregnancies (total = 171; INSTI - group = 111, PI - group = 60) had at least 2 VL (before and after intervention) during pregnancy. The primary outcome was the rate of undetectable VL near delivery.Results: We found comparable rates of undetectable HIV VL near delivery in pregnancies treated with INSTI-cART (74/111, 66.7%) compared to PI-cART (34/60, 56.7%; [adjusted p = .116, RR 1.26, 95% CI 0.92-2.59]). Compared to the PI-group, pregnancies in the INSTI-group showed lower median HIV VL near delivery (20 versus 50 copies/mL; adjusted p = .0454) and greater VL reduction (adjusted p = .0185). There were 3/171 (1.75%) infants diagnosed with HIV, 1 in the INSTI-group and 2 in the PI-group (p = .5635, RR 0.51, 95% CI 0.10-2.53).Conclusion: Pregnant HIV-infected women receiving either INSTI- or PI-based cART achieved comparable rates of undetectable HIV VL near delivery with similar perinatal transmission.

Perinatal outcomes of twenty-five human immunodeficiency virus-infected pregnant women: Hacettepe University experience

Objective:

To evaluate perinatal outcomes in human immunodeficiency virus (HIV) infected pregnant women in Turkey.

Material and Methods:

Maternal characteristics, pregnancy complications, laboratory findings including HIV load, CD4 cell count, CD4/CD8 ratio, neonatal features and final HIV status of the baby were retrospectively analyzed.

Results:

The sample included 26 singleton pregnancies, from 25 HIV-infected women. The ethnicities were Turkish (n=18), East European (n=4), Asian (n=2) and African (n=2). The majority (76.9%) was aware of their HIV status before becoming pregnant. Four cases (15.3%) were diagnosed during pregnancy and two (7.8%) at the onset of labor. The results for median HIV viral load, CD4 count, and CD4/CD8 ratio at birth were 20 copies/mL (0-34 587), 577/mm³ (115-977), and 0.7 (0.1-1.9), respectively. The HIV viral load rate was 5.5% in eighteen women taking anti-retroviral treatment. The rates of gestational diabetes mellitus, gestational hypertension, intrauterine growth restriction, and preterm delivery were 3.8%, 3.8%, 7.6%, and 8% (numbers are 1;1;2;2), respectively. The mean gestational week at birth was 38 weeks and mean birthweight is 2972±329 g. Two babies were congenitally infected with HIV (infection rate of 8.3%). There was one needle-related accident during surgery.

Conclusion:

Timely diagnosis of HIV infection during pregnancy is important for preventing mother to child transmission. HIV infected women may give birth to HIV negative babies with the help of a multidisciplinary team, composed of perinatology, infectious diseases, and pediatrics specialists.

Gestational diabetes mellitus in HIV-infected pregnant women: A systematic review and meta-analysis

BACKGROUND

Impaired glucose metabolism during pregnancy can result in a significant adverse pregnancy-outcomes. Previous studies have reported the contribution of ART to the impaired glucose tolerance and gestational diabetes mellitus (GDM) in HIV-infected pregnant women.

METHODS

PRISMA guideline was followed for this systematic review and meta-analysis. The STATA version 11 was employed to compute the pooled prevalence of GDM using the random effect model and 95% confidence interval. Subgroup analysis was conducted by geographical regions. Visual inspection of the funnel plot and Egger's regression test statistic were used to show the publication bias.

RESULTS

A total of 13,517 articles were identified, of which 21 publications met the inclusion criteria. The pooled prevalence of GDM among HIV-infected pregnant women was 4.42% (95% CI: 3.48; 5.35). According to the subgroup analysis, the pooled prevalence of GDM among HIV-infected pregnant women was 7.1% (95%CI: 3.38; 10.76) in Asia, 5.83% (95% CI: 2.61; 9.04) in Europe, 3.58% (95% CI: 2.67; 4.50) in America and 3.19% (95% CI: -2.89; 9.27) in Africa.

CONCLUSION

The pooled prevalence of GDM among HIV-infected pregnant women is expectedly high. Therefore, early screening of HIV-infected pregnant women for GDM is vital to reduce its complications related to pregnancy.

PROTOCOL REGISTRATION NUMBER

International Prospective Register of Systematic Reviews CRD42018090735.

Safety and Immunogenicity of Early Bacillus Calmette-Guérin Vaccination in Infants Who Are Preterm and/or Have Low Birth Weights: A Systematic Review and Meta-analysis

IMPORTANCE

Bacillus Calmette-Guérin (BCG) vaccination is commonly delayed in infants who are preterm and have low birth weights (LBW) despite the association of early vaccination with better vaccination coverage and potentially nonspecific benefits for survival.

OBJECTIVE

To determine the safety, immunogenicity, and protective efficacy against tuberculosis (TB) of BCG vaccination given at or before 7 days after birth vs vaccination more than 7 days after birth among infants who are preterm and/or had LBW.

DATA SOURCES

Searches of Medline, Embase, and Global Health databases were conducted from inception until August 8, 2017.

STUDY SELECTION

Clinical trials, cohort studies, and case-control studies that included infants who were preterm and/or had LBW and reported safety, mortality, immunogenicity, proxies of vaccine take, and/or efficacy against TB.

DATA EXTRACTION AND SYNTHESIS

Two authors independently extracted data and assessed the quality of the studies. Data extracted included demographics, covariates, sources of bias, and effect estimates. Meta-analysis was performed using a random-effects model.

MAIN OUTCOMES AND MEASURES

Safety, mortality, immunogenicity, or other proxies of vaccine take, such as tuberculin skin test (TST) conversion and efficacy against tuberculosis.

RESULTS

Forty studies were included in a qualitative synthesis; infants who were preterm (born at 26-37 weeks' gestational age) and/or had LBW (0.69-2.5 kg at birth) were included. The BCG vaccine was administered at or before 7 days to 10 568 clinically stable infants who were preterm and/or had LBW; vaccination was administered to 4310 infants at varying times between 8 days and 12 months after birth. Twenty-one studies reporting safety found no cases of BCG-associated death or systemic disease in 8243 infants. Four studies reported no increase in all-cause mortality for infants who had LBW and who received early BCG vaccination compared with infants who had LBW with later vaccination or BCG-vaccinated infants of normal birth weight. Four studies reported lymphadenitis incidence; combined, these reported 0% to 2.9% incidence of vaccination within 7 days and 0% to 4.2% of vaccination after 7 days. Meta-analysis of 7 studies revealed no differences between early and delayed BCG vaccination for scar formation (n = 515; relative risk [RR], 1.01 [95% CI, 0.95-1.07]) or TST conversion (n = 397; RR, 0.97 [95% CI, 0.84-1.13]). Published data were insufficient to assess immunogenicity or protective efficacy against TB disease.

CONCLUSIONS AND RELEVANCE

Early BCG vaccination in healthy infants who are preterm and/or had LBW has a similar safety profile, reactogenicity, and TST conversion rate as delayed vaccination. Based on current evidence, early BCG vaccination in stable infants who are preterm and/or have LBW to optimize uptake is warranted.

Seroprevalence of Malaria and Hepatitis B Coinfection among Pregnant Women in Tamale Metropolis of Ghana: A Cross-Sectional Study

Background

Coinfections are becoming common risk factors that may contribute to the increased burden of morbidity in pregnancy. The aim of this study was to assess the seroprevalence of coinfections of malaria, hepatitis B (HBV), human immunodeficiency virus (HIV), and syphilis among pregnant women attending antenatal clinics (ANC) in the Tamale Metropolis.

Methods

By means of rapid diagnostic tests (RDTs), pregnant women attending the Tamale Teaching Hospital (TTH) were screened for malaria, HBV infection, HIV infection, and syphilis from March 2013 to February 2015. Haemoglobin (Hb) values, sickling, and glucose-6-phosphate dehydrogenase deficiency (G6PDd) statuses were also assessed using full blood count (FBC), sodium metabisulphite, and methaemoglobin reduction tests, respectively. Logistic regression analysis was performed to estimate the risks/odds ratios (ORs) for the coinfections and other variables (age, gravidity, and time of the first ANC visit) with 95% confidence intervals (CIs) and set p values for accepting any differences at <0.05.

Results

Within the two-year study period, data were collected from 3,127 pregnant women. The mean age (SD) of the pregnant women was 28.5 (±5.0) years. Of the total number, seroprevalence was high for malaria (11.6%) and HBV infection (4.2%) and low for HIV infection (1.0%) and syphilis (0.4%) monoinfections. Mal/HBV coinfection was higher (0.7%) when compared with Mal/HIV (0.1%), Mal/syphilis (0.0%), HBV/HIV (0.0%), HBV/syphilis (0.1%), and HIV/syphilis (0.0%) coinfections. The mean Hb (g/dl) for the women with the four monoinfections was significantly different from one another (p=0.009). Pregnant women with malaria infection were about 2 times more likely to be coinfected with HBV even after adjusting for potential confounders (adjusted odds ratio (AOR) = 1.66, 95% CI = 1.04-2.65, p=0.031). Those in their third trimester and visiting the ANC for the first time were significantly less likely to be infected with HBV (AOR = 0.45, 95% CI = 0.28-0.73, p=0.001), with malaria/HBV coinfection (AOR = 0.09, 95% CI = 0.01-0.68, p=0.020), and with any coinfection (AOR = 0.19, 95% CI = 0.06-0.63, p=0.007).

Conclusion

A comparatively high seroprevalence of malaria and its coinfection with HBV in pregnant women was observed in this study. Considering the effects that both malaria and HBV have on the liver, it would be expedient to conduct further studies to assess liver function among malaria/HBV-infected individuals, while interventions to prevent coinfections among pregnant women are intensified.

Leukocyte Telomere Length at Birth and During the Early Life of Children Exposed to but Uninfected With HIV After In Utero Exposure to Antiretrovirals

Background

Maternal combination antiretroviral therapy (cART) during pregnancy could impact the health of human immunodeficiency virus (HIV)-exposed, HIV-uninfected (HEU) children, because some antiretrovirals cross the placenta and can inhibit telomerase. Our objective was to compare leukocyte telomere length (LTL) in HEU children and HIV-unexposed, HIV-uninfected (HUU) children at birth and in early life and to investigate any relationship with cART exposure.

Methods

HEU and HUU children's blood LTL was compared cross-sectionally at birth, and during the first three years of life. Longitudinal HEU LTL dynamics was evaluated over that same period.

Results

At birth, the LTL in HEU children (n = 114) was not shorter than that in HUU children (n = 86), but female infants had longer LTL than male infants. Maternal cART (duration or type) showed no association with shorter infant LTL. Among 214 HEU children age- and sex-matched at a 1:1 ratio to HUU children, LTL declined similarly in both groups. In a longitudinal analysis, LTL attrition in HEU children was rapid from birth to 1 year of age and gradual thereafter. Zidovudine prophylaxis did not significantly alter LTL.

Conclusions

Our results indicate that from birth to 3 years of age, the LTL in HEU children is not negatively affected by exposure to maternal HIV infection and cART, at least not to the regimens used within this Canadian cohort, a reassuring finding.

Improving postpartum retention in care for women living with HIV in the United States

: Research findings have consistently demonstrated that women living with HIV in the United States and globally experience declines in medication adherence and retention in care after giving birth. A number of studies have identified factors associated with postpartum retention in care, but the evidence base for interventions to address the problem and close this gap in the HIV care continuum is limited. Furthermore, the majority of studies have been conducted in low-resource or moderate-resource countries and may be less applicable or require adaptation for use in high resource countries. In the United States, up to two-thirds of women drop out of care after delivery and are unable to maintain or achieve viral suppression postpartum, at a time when maternal and pediatric health are closely linked. We conducted a critical review of the literature to identify existing gaps regarding maternal retention in the United States and conceptualize the problem through the lens of the integrated and ecological models of health behavior. This review describes existing barriers and facilitators to retention in HIV care postpartum from published studies and suggests steps that can be taken, using a multilevel approach, to improve maternal retention. We propose five core action steps related to increasing awareness of the problem of poor postpartum retention, addressing needs for improved care coordination and case management, and using novel approaches to adapt and implement peer support and technology-based interventions to improve postpartum retention and clinical outcomes of women living with HIV.