HIV seroprevalence and rapid testing in unbooked pregnant African women

Systematic review and meta-analysis of seroprevalence of human immunodeficiency virus serological markers among pregnant women in Africa, 1984-2020

BACKGROUND

Human immunodeficiency virus (HIV) is a major public health concern, particularly in Africa where HIV rates remain substantial. Pregnant women are at an increased risk of acquiring HIV, which has a significant impact on both maternal and child health.

AIM

To review summarizes HIV seroprevalence among pregnant women in Africa. It also identifies regional and clinical characteristics that contribute to study-specific estimates variation.

METHODS

The study included pregnant women from any African country or region, irrespective of their symptoms, and any study design conducted in any setting. Using electronic literature searches, articles published until February 2023 were reviewed. The quality of the included studies was evaluated. The DerSimonian and Laird random-effects model was applied to determine HIV pooled seroprevalence among pregnant women in Africa. Subgroup and sensitivity analyses were conducted to identify potential sources of heterogeneity. Heterogeneity was assessed with Cochran's Q test and I2 statistics, and publication bias was assessed with Egger's test.

RESULTS

A total of 248 studies conducted between 1984 and 2020 were included in the quantitative synthesis (meta-analysis). Out of the total studies, 146 (58.9%) had a low risk of bias and 102 (41.1%) had a moderate risk of bias. No HIV-positive pregnant women died in the included studies. The overall HIV seroprevalence in pregnant women was estimated to be 9.3% [95% confidence interval (CI): 8.3-10.3]. The subgroup analysis showed statistically significant heterogeneity across subgroups (P < 0.001), with the highest seroprevalence observed in Southern Africa (29.4%, 95%CI: 26.5-32.4) and the lowest seroprevalence observed in Northern Africa (0.7%, 95%CI: 0.3-1.3).

CONCLUSION

The review found that HIV seroprevalence among pregnant women in African countries remains significant, particularly in Southern African countries. This review can inform the development of targeted public health interventions to address high HIV seroprevalence in pregnant women in African countries.

Improved pregnancy outcomes with increasing antiretroviral coverage in South Africa

BACKGROUND

Universal multi drug antiretroviral treatment in pregnancy is a global priority in our bid to eliminate paediatric HIV infections although few studies have documented the impact of antiretroviral coverage on overall pregnancy outcomes.

METHODS

We conducted a maternity audit at a large regional hospital in South Africa during July-December 2011 and January-June 2014 with an aim to determine an association between pregnancy outcomes and the ARV treatment guidelines implemented during those specific periods. During 2011, women received either Zidovudine/sd Nevirapine or Stavudine/Lamivudine/Nevirapine if CD4+ count was < 350 cells/ml. During 2014, all HIV positive pregnant women were eligible for a fixed dose combination (FDC) of triple ARVs (Tenofovir/Emtracitabine/Efavirenz).

RESULTS

In 2011, 622 (35.9%) of 1732 HIV positive pregnant women received triple antiretrovirals (D4T/3TC/NVP) and in 2014, 2104 (94.8%) of 2219 HIV positive pregnant women received the fixed dose combination (TDF/FTC/EFV). We observed a reduction in the proportion of unregistered pregnancies, caesarean delivery rate, still birth rate, very low birth weight rate, and very premature delivery rate in 2014. In a bivariate analysis of all 9,847 deliveries, unregistered pregnancies (2.2%) and HIV infection (37.8%) remained significant risk factors for SB(OR 6.36 and 1.43 respectively), PTD(OR 4.23 and 1.26 respectively),LBW (OR 4.07 and 1.26 respectively) and SGA(OR 2.17 and 1.151 respectively). In a multivariable analysis of HIV positive women only, having received AZT/NVP or D4T/3TC/NVP or EFV/TDF/FTC as opposed to not receiving any ARV was significantly associated with reduced odds of a SB (OR 0.08, 0.21 and 0.18 respectively), PTD (OR 0.52, 0.68 and 0.56 respectively) and LBW(0.37, 0.61 and 0.52 respectively).

CONCLUSION

An improvement in birth outcomes is likely associated with the increased coverage of triple antiretroviral treatment for pregnant women. And untreated HIV infected women and women who do not seek antenatal care should be considered most at risk for poor birth outcomes.

Prevalence of HIV among women entering labor who accepted or declined voluntary counseling and testing

OBJECTIVE

To assess whether there was a difference in HIV seroprevalence between eligible women who declined and those who agreed to participate in a study of voluntary counseling and testing among women entering labor with unknown HIV status in South Africa.

METHODS

Anonymous cord blood specimens were collected-as dried blood spots-from all women approached for participation in a cluster-randomized trial. No patient identifiers were included on the cord blood specimens. The dried blood spots were analyzed for HIV antibody via enzyme immunoassay and western blotting.

RESULTS

Of 7238 women screened for study participation, 1041 (14.4%) had undocumented HIV status; of these women, 542 were eligible for inclusion and 343 enrolled. Based on 513 evaluable samples, the overall seroprevalence was 13.3% (95% confidence interval [CI], 10.4-16.5), which was similar to the 13.1% (95% CI, 9.7-17.2) seroprevalence among the 343 enrolled women.

CONCLUSION

Seroprevalence among eligible women was similar to that among enrolled women, which indicates that study participation did not select for a group with an HIV seroprevalence substantially different from that among women who declined to enroll.

Rapid intrapartum or postpartum HIV testing at a midwife obstetric unit and a district hospital in South Africa

OBJECTIVE

To compare the prepartum and postpartum feasibility and acceptance of voluntary counseling and rapid testing (VCT) among women with unknown HIV status in South Africa.

METHODS

Eligible women were randomized according to the calendar week of presentation to receive VCT either while in labor or after delivery.

RESULTS

Of 7238 women approached, 542 (7.5%) were eligible, 343 (63%) were enrolled, and 45 (13%) were found to be HIV infected. The proportions of eligible women who accepted VCT were 66.8% (161 of 241) in the intrapartum arm and 60.5% (182 of 301) in the postpartum arm, and the difference of 6.3% (95% CI, -1.8% to 14.5%) was not significant. The median times (44 and 45 minutes) required to conduct VCT were also similar in the 2 arms. In the intrapartum arm, all women in true labor received their test results before delivery and all those found to be HIV positive accepted prophylaxis with nevirapine before delivery.

CONCLUSIONS

Rapid testing in labor wards for women with an unknown HIV status is feasible and well accepted, and allows for a more timely antiretroviral prophylaxis than postpartum testing.

Post-evaluation of rapid HIV kits in the Korean market by an anti-HIV EQAS panel

This study aimed to provide evaluation information about rapid HIV kits by the anti-HIV External Quality Assessment Schemes (EQAS) panel of the Korea National Institute of Health (KNIH) and the rapid HIV test panel of the US Centers for Disease Control and Prevention (CDC). Each KNIH anti-HIV EQAS panel from 2003 to 2005 consisted of four or five samples of plasma obtained from blood donors with a strong positive or negative reaction to HIV. KNIH delivered each panel to public health centers for analysis of the HIV test results, and the reactivity of the five rapid HIV kits currently used in the Korean market were compared with that of a CDC reference. The analytic sensitivity and specificity of the rapid HIV kits for the KNIH anti-HIV EQAS in 2005 were 99.3 and 99.1%, respectively; in 2004, 98.8 and 97.1%; and in 2003, 94.8 and 95.9%. Five HIV kits from the CDC panel consistently showed positive reactivity for strong positive samples in all kits, but some showed erratic reactivity for weakly positive samples. This is the first report on post-evaluation of rapid HIV kits in the Korean market by an anti-HIV EQAS panel. It was found that the quality of performance of the rapid HIV tests had improved each year but should be interpreted with caution for weakly positive samples.

Rapid point-of-care HIV testing in pregnant women: a systematic review and meta-analysis

Rapid, point-of-care human immunodeficiency virus (HIV) testing has the potential to enhance strategies to prevent mother-to-child transmission (MTCT) of HIV infection. Rapid tests need minimal laboratory infrastructure and can be performed by health workers with minimal training. In our systematic review and meta-analysis, we aimed to summarize the overall diagnostic accuracy of rapid HIV tests in pregnancy, and outcomes such as acceptability, patient preference, feasibility and impact of rapid testing. We searched four major databases, identified and screened 1377 citations, and included 17 studies that met our eligibility criteria. Analyses of these studies suggested that the overall sensitivity and specificity of blood-based rapid tests was high compared with oral rapid tests. A two-step testing strategy, particularly parallel testing, was found to be superior to single-test strategy in labour and delivery settings. Acceptability of rapid tests and patient preference was variable across studies. Overall, rapid HIV testing was highly accurate compared with conventional tests and offer a clear advantage of enabling the implementation of timely interventions to reduce MTCT of HIV. To improve diagnostic accuracy and to reduce false-positive results, it may be necessary to use two rapid tests during labour and delivery.

Management of human immunodeficiency virus infection in pregnancy

The HIV global epidemic is having a devastating effect on women of reproductive age; women aged 15-24 years are 2.5 times more likely to be infected than young men in the same age group. Further, mother-to-child transmission (MTCT) accounts for almost two-thirds of the new infections that occur in children world-wide, annually. MTCT of HIV-1 varies widely and is dependent on obstetric practices, mode of delivery, breastfeeding, and the level of the viral load in the mother. Antiretroviral therapy (ARV) in pregnancy is prescribed for two main reasons: (i) women who need ARV medication for their own health; (ii) women who do not need treatment, or do not have access to treatment are offered prophylaxis to prevent MTCT, using one of a number of ARV regimens known to be effective. HIV infection is also associated with significant maternal morbidity and mortality. Clinicians caring for HIV-infected women need to update their knowledge continuously to provide optimal care.

Maternal mortality associated with tuberculosis-HIV-1 co-infection in Durban, South Africa

OBJECTIVES

To document the impact of tuberculosis and HIV-1 on maternal mortality.

DESIGN

Prospective study, 1997 and 1998; retrospective analysis, 1996.

PARTICIPANTS

Known maternal deaths, defined as the death of a mother within a year post-delivery, were studied in Durban, KwaZulu Natal. The HIV-1 status, presence of tuberculosis, maternal clinical features and perinatal outcomes were documented. The overall as well as HIV-1 and tuberculosis-specific maternal mortality rates for the hospital were calculated. The attributable fraction of deaths as a result of HIV-1 was calculated in the overall group and in those with tuberculosis co-infection.

RESULTS

A total of 50 518 deliveries and 101 maternal deaths were recorded. Of the deaths, 29.7% (30/101) were HIV-1 infected. The overall mortality rate was 200/100 000; for HIV-1-infected women this was 323.3/100 000, HIV-1-negative mothers, 148.6/100 000 live births. The attributable fraction of overall deaths as a result of HIV-1 was 15.9% Fourteen of the 15 mothers with tuberculosis were HIV-1 co-infected. The mortality rate for tuberculosis and HIV-1 co-infection was 121.7/1000; for tuberculosis without HIV-1 co-infection, 38.5/1000. Fifty-four per cent of maternal deaths caused by tuberculosis were attributable to HIV-1 infection. Thirty-five per cent of maternal deaths were associated with stillbirths; perinatal outcomes were no different between groups of mothers with tuberculosis, HIV-1 or neither infection.

CONCLUSION

Tuberculosis and HIV-1 are emerging as significant contributors to maternal mortality in KwaZulu Natal. Any attempt to improve maternal health must also include careful screening and investigation for tuberculosis in high-risk pregnant women.

Severe, rapidly progressive human immunodeficiency virus type 1 disease in newborns with coinfections

AIM

To describe a severe form of rapidly progressive HIV-1 infection manifesting in the neonatal period.

METHOD

Prospective cohort study, King Edward VIII Hospital, Durban, South Africa. HIV-1-exposed neonates with hepatosplenomegaly, lymphadenopathy or persistent pneumonia within the first 28 days of life were investigated for perinatal infections. Confirmation of neonatal HIV-1 infection, HIV-1 subtype and clinical outcomes were studied.

RESULTS

Twenty-three (72%) of 32 symptomatic HIV-1-exposed neonates recruited at a mean of 15.2 days were HIV-1-infected. HIV-1 infection was detected in 5 patients who were tested within 48 h of birth, confirming congenital infection. Congenital infection was not excluded in any case. Median neonatal viral load at recruitment was 471,932 copies/ml and median CD4 was 777 cells/mm3. The predominant clinical presentation was growth retardation and prematurity. Perinatal infections detected included: tuberculosis (8), syphilis (6) and cytomegalovirus (10). All of the neonates with perinatal tuberculosis were HIV-1-coinfected. Maternal and neonatal viral load and CD4 at recruitment were not statistically different between the groups with tuberculosis vs. other coinfections. Gag gene sequence analysis confirmed closely aligned HIV-1 subtype C in mothers and neonates. Nineteen (83%) died by 9 months, with a mean age at death of 3.5 months.

CONCLUSIONS

A distinct group of HIV-1-infected babies may clinically manifest in the neonatal period with perinatal coinfections, subsequent rapidly progressive HIV-1 and early death.