Syphilis in HIV-infected mothers and infants: results from the NICHD/HPTN 040 study

Maternal Syphilis Leading to High Efficiency In Utero Transmission of Antiretroviral Resistant HIV: Intersection of Two Pandemics

BACKGROUND

Testing for syphilis and HIV is indicated in prenatal care in the United States. Effective antiretroviral therapy during pregnancy reduces mother-to-child HIV transmission (MTCT) to less than 1%. Syphilis infection in pregnant women with unsuppressed HIV increases the risk of MTCT, usually in utero. The incidences of syphilis in women of childbearing age and corresponding congenital syphilis are increasing in the United States.

METHODS

We report 3 cases of in utero HIV transmission associated with maternal syphilis that occurred during the ongoing syphilis epidemic.

RESULTS

All 3 women had untreated HIV infection and active syphilis with placentitis during late pregnancy. Their newborns were found to have symptomatic congenital syphilis and HIV infection from in utero transmission. The babies' antiretroviral resistance patterns were nearly identical to their mothers'.

CONCLUSIONS

When untreated syphilis and uncontrolled HIV coincide in pregnancy, there is a high likelihood of in utero mother-to-child HIV transmission. The current syphilis epidemic in the United States may lead to an increase in MTCT.

Benzathine penicillin G stockouts and other barriers to documented syphilis treatment in pregnancy in Zambia

OBJECTIVE

The prevalence of syphilis in Zambia remains high and is a critical public health concern. The Zambian Ministry of Health recommends universal screening and same-day treatment for syphilis in pregnancy, yet the syphilis screening rate is low, and treatment is poorly documented. The goal of this study was to document syphilis treatment rates and associated factors among pregnant women in care in Zambia.

METHODS

This retrospective cohort study included pregnant women diagnosed with syphilis according to rapid plasma reagin (RPR) screening during routine antenatal care (ANC) in Lusaka, Zambia in 2018-2019. The main outcome of interest was lack of documented BPG treatment during pregnancy. Additional information about pregnancy and neonatal outcomes, partner referral for therapy, and facility level stockout data were included. Patient characteristics were compared by treatment status using Pearson Chi-Square Test and logistic regression models were created to estimate the association between individual level-factors, facility type, and lack of BPG treatment. A Cochran-Mantel-Haenszel test was used to evaluate facility-level data with significance set at p<0.05.

RESULTS

Among 1,231 pregnant women who screened positive for syphilis at clinic, 643 (52%) lacked documented antibiotic treatment at the facility. BPG was the only antibiotic used to treat syphilis in the cohort and 8% of sex partners had evidence of referral for therapy. Preterm delivery rates were higher in women without documented BPG (43% vs 32%; p = 0.003). In adjusted models, only calendar year and hospital facility type were associated with lack of treatment. At the facility level, annual syphilis screening rates ranged from 37-65% and most (7/10) clinics reported at least one stockout of BPG.

CONCLUSION

Treatment rates for syphilis in pregnancy in Zambia were low and BPG medication stockouts at the facility level were common. A consistent supply of BPG at all ANC facilities is needed to facilitate timely treatment and improve birth outcomes.

Demographics of Youth With Newly Diagnosed Acute/Recent HIV Infection in Adolescent Trials Network 147: Early Treatment of Acute HIV Infection

PURPOSE

Gay, bisexual, and other cisgender men who have sex with men, and racial minority youth are at elevated risk of acquiring HIV infection. The Adolescent Trials Network 147 recruited youth with acute/recent HIV-infection for early antiretroviral treatment. The cohort make-up is described here.

METHODS

Treatment-naïve, recently identified HIV + youth, aged 12-24 years, from Los Angeles and New Orleans were recruited from community centers, clinics, social media, and a high-risk seronegative cohort (n = 1,727, the Adolescent Trials Network 149) using point-of-care assays. Acute HIV infection was determined by Fiebig staging. HIV RNA viral load (VL) and CD4 cell counts, along with demographic and behavioral data were assessed at enrollment.

RESULTS

Between July 2017 and July 2021, 103 newly diagnosed youth were enrolled, initiating antiretroviral treatment within a week. Mean age was 20.8 years (standard deviation: 2.4); 90.3% identified as cis male, 83.5% were single or in casual relationships, 71.8% were gay, bisexual, and other cisgender men who have sex with men; 60.2% were Black. One-fourth (24.3%) reported homelessness ever; 10.7% within last 4 months. At enrollment, median plasma VL was 37,313 HIV RNA copies/ml (interquartile range: 5,849-126,162) and median CD4 count 445.5 cells/mm3 (interquartile range: 357-613). 40% of youth reported acute retroviral symptoms before or at enrollment. Acutely infected, seroconverting youth had the highest VL. Sexually transmitted coinfections were present at enrollment in 56% of the cohort, with syphilis being most frequent (39%).

DISCUSSION

Early identification and treatment of HIV can increase positive HIV outcomes. A high sexually transmitted infection burden was present in recently HIV-infected youth. Acute retroviral symptoms were not reported by most participants, demonstrating that broad universal HIV screening is needed for identification of recent infection in youth.

Syphilis screening coverage and positivity by HIV treatment status among South African pregnant women enrolled in the 2019 antenatal HIV sentinel survey

We describe coverage of maternal syphilis screening, syphilis positivity, coverage of treatment and their association with maternal HIV infection and antiretroviral treatment (ART) status among pregnant women attending South African antenatal clinics. The 2019 antenatal care sentinel survey was a cross-sectional survey conducted from 1 October to 15 November 2019 at 1589 sentinel sites in all nine provinces of the country and aimed to enrol 36,000 pregnant women ages 15-49 years regardless of HIV, ART or syphilis status. Data collection procedures included obtaining written informed consent, a brief interview, medical record review and blood specimen collection. Completed data collection forms and specimens were sent to designated regional laboratories for data capture and HIV serology testing. Data analysis determined four outcomes i) syphilis screening coverage ii) syphilis positivity iii) coverage of any treatment and iv) with Benzathine penicillin G (BPG). Multivariable logistic regression models with or without interaction between HIV infection and ART status with province were used to determine factors associated with syphilis positivity. Of the 41 598 women enrolled, 35 900 were included in the analysis for syphilis screening coverage. The weighted syphilis screening coverage was 96.4% [95% Confidence Interval (CI) 95.9-96.7%] nationally and was lowest among HIV positive women not on ART at 93.5% (95% CI 92.2-94.5%). Syphilis positivity was 2.6% (95% CI 2.4-2.9%) nationally. Among those who were syphilis positive, 91.9% (95% CI 89.8-93.7%) had documentation of syphilis treatment status, of whom 92.0% (95% CI 89.8-93.9%) were treated, with the majority treated with one or more doses of BPG [92.2% (95% CI 89.8-94.3%)]. HIV-positive women, not on ART [adjusted odd ratio (aOR) 2.24 (95% 1.71-2.93)] and those on ART [aOR 2.25 (95% CI 1.91-2.64)] were more likely to be syphilis positive compared to those who were HIV negative. The national syphilis screening coverage met the global screening target of 95%. Syphilis positivity was higher among HIV positive women compared to negative women. Introduction of rapid syphilis testing and ensuring a universal supply of appropriate treatment for syphilis will reduce the likelihood of mother-to-child transmission of syphilis.

Sustained Virologic Suppression Reduces HIV-1 DNA Proviral Levels and HIV Antibodies in Perinatally HIV-Infected Children Followed from Birth

The extent to which perinatally HIV-infected children, following cART initiation, develop a low proviral reservoir burden over time, as measured by HIV DNA droplet-digital polymerase chain reaction (ddPCR) and the effect on HIV antibody is not well characterized. We measured proviral HIV DNA and plasma RNA virus load (VL) in 37 perinatally HIV-infected children at 6 months of age who initiated stable cART. At 6-11 years of age, HIV proviral DNA, HIV VL (RNA), and HIV antibody by Western Blot (WB) were assessed. CART was initiated before 6 months of age in 13 children and after 6 months in 24. At school age, the HIV DNA levels did not differ by the timing of cART, and the HIV DNA levels were lower in children with negative/indeterminate WB (p = 0.0256). Children with undetectable HIV RNA VL > 50% of the time since cART initiation had lower median DNA VL than children with undetectable VL < 50% of the time (p = 0.07). Long-term viral suppression in perinatally HIV-infected children is associated with a decrease in HIV antibodies and reduced HIV reservoirs.

Mother-to-Child HIV Transmission among Pregnant Women in a City with the Highest Rates of HIV in Brazil

OBJECTIVE

Most of the HIV pediatric infections are acquired through mother-to-child transmission (MTCT). Porto Alegre is a state capital of Brazil that had a HIV MTCT rate of 4.1% in 2013 and the highest rate of HIV-infected pregnant women in the country during 2018. Zidovudine and nevirapine have been used in Brazil for high-risk newborns since 2012. The aim of the study was to investigate HIV MTCT rate and the factors associated with HIV transmission at a hospital that is a reference center for HIV-infected mothers in Porto Alegre, after the introduction of this policy.

STUDY DESIGN

This retrospective cohort study included all HIV-exposed infants born between February 2013 and December 2016 at the Hospital de Clínicas de Porto Alegre. Student's t-test or Fisher's exact test was used to compare variables between HIV-infected and uninfected groups of newborns. Poisson's regression with robust variance was used to determine the factors associated with HIV MTCT.

RESULTS

A total of 375 newborns were exposed to HIV, with an outpatient loss of 14.4% (n = 54). The HIV MTCT rate was 2.18% (n = 7), with four infected during the intrauterine period. The risk factors for MTCT were no prenatal care (relative risk [RR] = 9.4; 95% confidence interval [CI]: 2.0-44.3), late maternal HIV diagnosis in the peripartum period (RR = 16.3; 95% CI: 3.6-73.0), syphilis infection during pregnancy (RR = 9.3; 95% CI: 2.1-40.3), maternal viral load >1,000 copies/mL in the third trimester or peripartum period (RR = 9.5; 95% CI: 1.7-50.5), and lack of or inappropriate antiretroviral therapy during pregnancy (RR = 8.2; 95% CI: 1.6-41.4).

CONCLUSION

MTCT rate was 2.18%. With the institution of two-drug prophylaxis for high-risk newborns, persistent cases HIV MTCT were predominantly found among women with absence of antenatal care, late HIV diagnosis, syphilis coinfection, high viral load, and inadequate ARV therapy during pregnancy. Although zidovudine and nevirapine were administered postnatally to high-risk newborns, this regimen could not prevent transplacental transmission.

KEY POINTS

· Most of the HIV pediatric infections are acquired through mother-to-child transmission.. · The study investigated HIV MTCT rate and the factors associated with HIV transmission in Brazil.. · HIV MTCT rate was 2.18% and most of them were infected during the intrauterine period..

The Impact of Maternal Syphilis and Associated Factors on HIV Vertical Transmission

Maternal syphilis may increase HIV vertical transmission or it may be a marker of other risk factors. In a Brazilian historical series, HIV vertical transmission risk was higher in newborns exposed to maternal syphilis-HIV co-infection than in newborns exposed to maternal HIV infection alone. Maternal syphilis was a risk factor for HIV vertical transmission independent of education and prenatal visits but not independent of maternal elevated HIV viral loads or inadequate maternal antiretroviral treatment.

Sexually transmitted infection screening to prevent adverse birth and newborn outcomes: study protocol for a randomized-controlled hybrid-effectiveness trial

Background

Sexually transmitted infections (STIs) during pregnancy are associated with adverse birth outcomes, including preterm birth, low birth weight, perinatal death, and congenital infections such as increased mother-to-child HIV transmission. Prevalence of STIs among pregnant women in South Africa remains high, with most women being asymptomatic for their infection(s). Unfortunately, most STIs remain undetected and untreated due to standard practice syndromic management in accordance with World Health Organization (WHO) guidelines. Although lab-based and point-of-care molecular tests are available, optimal screening strategies during pregnancy, their health impact, and cost-effectiveness are unknown.

Methods

We will implement a 3-arm (1:1:1) type-1 hybrid effectiveness-implementation randomized-controlled trial (RCT). We will enroll 2500 pregnant women attending their first antenatal care (ANC) visit for their current pregnancy at participating health facilities in Buffalo City Metro District, Eastern Cape Province, South Africa. Participants allocated to arms 1 and 2 (intervention) will receive GeneXpert® point-of-care diagnostic testing for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis, with same-day treatment for detected infection(s). Arm 1 will additionally receive a test-of-cure 3 weeks post-treatment, while Arm 2 will receive a repeat test at 30–34 weeks’ gestation. Those allocated to Arm 3 will receive syndromic management (standard-of-care). The RE-AIM framework will be used to guide collection of implementation indicators to inform potential future scale up. Primary outcome measures include (1) frequency of adverse birth outcomes among study arms, defined by a composite measure of low birth weight and pre-term delivery, and (2) change in STI prevalence between baseline and birth outcome among intervention arms and compared to standard-of-care. Estimates and comparative costs of the different screening strategies relative to standard-of-care and the costs of managing adverse birth outcomes will be calculated. Cost-effectiveness will be assessed per STI and disability-adjusted life year averted.

Discussion

This trial is the first RCT designed to identify optimal, cost-effective screening strategies that decrease the burden of STIs during pregnancy and reduce adverse birth outcomes. Demonstrating the impact of diagnostic screening and treatment, compared to syndromic management, on birth outcomes will provide critical evidence to inform changes to WHO guidelines for syndromic management of STIs during pregnancy.

Trial registration

ClinicalTrials.gov NCT04446611. Registered on 25 June 2020.

Ineffective penicillin treatment and absence of partner treatment may drive the congenital syphilis epidemic in Brazil

BACKGROUND

Reducing congenital syphilis has been the focus of Brazilian health programs for decades, yet the cases continue to increase. Although health interventions have targeted HIV screening and treatment, syphilis management continues to be challenging. Syphilis during pregnancy may enhance the HIV maternal seroconversion risk. The potential factors fueling the syphilis epidemic were evaluated in south Brazil, an area of high HIV or syphilis endemicity.

OBJECTIVE

We hypothesized that ineffective treatment because of a lack of partner treatment, late presentation to care, and reinfection of previously treated mothers were potential drivers of syphilis mother-to-child transmission.

STUDY DESIGN

Data on women diagnosed with syphilis during pregnancy between January 1, 2008 and December 31, 2018 were obtained from a large urban hospital in Porto Alegre, Brazil. The patients were stratified into effective vs ineffective treatment groups according to the World Health Organization guidelines. Crude and adjusted risk ratios for the prediction of congenital syphilis and adverse fetal or neonatal outcomes were computed using Poisson regression.

RESULTS

Nearly 56,000 pregnant women delivered over the 11-year period; 1541 (2.8%) had confirmed syphilis during pregnancy, with 934 (61%) receiving ineffective syphilis treatment because of late presentation and diagnosis, delayed treatment initiation, and loss to follow-up with no treatment recorded. Ineffective treatment was associated with maternal education, prenatal care, timing of syphilis diagnosis, venereal diseases research laboratory titers, and maternal HIV coinfection. On multivariate regression analysis, ineffective treatment (adjusted risk ratio, 4.52; 95% confidence interval, 2.35–8.69), absence of prenatal care (adjusted risk ratio, 9.31; 95% confidence interval, 3.77–23.0), syphilis diagnosis at delivery (adjusted risk ratio, 3.08; 95% confidence interval, 2.07–4.58), and maternal nontreponemal titers ≥1:64 (1.09–1.93) were associated with an increased risk of fetal loss. Ineffective treatment (adjusted risk ratio, 1.71; 95% confidence interval, 1.59–1.84), year of diagnosis 2014 to 2016 (adjusted risk ratio, 1.07; 95% confidence interval, 1.02–1.13), absence of prenatal care (adjusted risk ratio, 1.44; 95% confidence interval, 1.17–1.76), and maternal nontreponemal titers >1:4 were associated with an increased risk of congenital syphilis. Although partner treatment reduced the congenital syphilis risk (adjusted risk ratio, 0.60; 95% confidence interval, 0.55–0.66), only 31.8% of partners received treatment. Maternal HIV coinfection was not associated with an increased risk of fetal loss, low birthweight, preterm birth, congenital syphilis, or symptomatic neonatal infection.

CONCLUSION

Public health initiatives promoting effective syphilis treatment in pregnancy, increased access to high-quality prenatal care, and partner treatment should be considered to reduce congenital syphilis.

Prevalence, incidence and seroconversion of HIV and Syphilis infections among pregnant women of South Africa

Background

Pregnant women in South Africa suffer from HIV and syphilis infections resulting in negative pregnancy outcomes. Little is known about the prevalence, incidence, seroconversion, and associated risk factors for those attending a midwife run obstetric unit.

Methods

A retrospective cohort study was undertaken among pregnant women attending antenatal clinic from January to December 2018. Logistic regression was conducted to determine the risk factors for HIV and syphilis.

Results

The prevalence of HIV and syphilis were 44.3% (95% confidence interval [CI]; 41.6:46.7) and 3.8% (95% CI; 3.1:4.1), respectively. The seroconversion and incidence for HIV were 4.0% (95% CI; 3.6:4.6) and 17.1 per 100 person-years, and for syphilis 2.6% (95% CI; 2.3:2.8) and 10.9 per 100 person-years, respectively. Significant predictors for HIV prevalence were ages: ages < 20 years, Odds ratio (OR) = 0.11 (p < 0.05), ages 20–24 years, OR = 0.19 (p < 0.05) and ages 25–29 years, OR = 0.38 (p < 0.05); gestational age: second trimester, OR = 0.68 (p < 0.05) and non-reactive syphilis, OR = 0.45 (p < 0.05). Age was the predictor for HIV incidence or seroconversion (age < 20 year, OR = 0.12, p = 0.01). Predictors for syphilis were ages < 20 years, OR = 0.11 (p < 0.05), ages 20–24 years and HIV status. Gestational age > 27 weeks were nine times (OR = 9.2, p = 0.03) more likely to seroconvert to syphilis.

Conclusions

The present study found high rates of seroprevalence, seroconversion and incidence of HIV and syphilis among pregnant women.

An International Prospective Cohort Study of HIV and Zika in Infants and Pregnancy (HIV ZIP): Study Protocol

Zika virus (ZIKV) infection may adversely affect pregnancies of women living with HIV (WLHIV). Because no study to date has focused on maternal and child effects of HIV and ZIKV co-infection in pregnant women, we undertook the International Prospective Cohort Study of HIV and Zika in Infants and Pregnancy (HIV ZIP). The aims of this two-phase study of pregnant women and their infants are to compare the incidence of ZIKV infection among pregnant women with and without HIV infection and to determine the risk of adverse maternal and child outcomes associated with ZIKV/HIV co-infection at clinical sites in Brazil, Puerto Rico, and the continental United States. Phase I was designed to enroll pregnant women/infant pairs who were: (1) infected with HIV only, (2) infected with ZIKV only, (3) infected with HIV and ZIKV, and (4) not infected with either HIV or ZIKV. A key goal of this phase was to assess the feasibility of enrolling 200 women/infant pairs within a year, with a target of 150 WLHIV, 50 HIV-uninfected women, and a minimum of 20 who were co-infected with HIV and ZIKV. If the feasibility of Phase I proved successful, Phase II would enroll up to 1,800 additional pregnant women/infant pairs to the same four groups. Enrolled women in both phases were to be followed throughout their pregnancy and up to 6 weeks post-partum. Infants were also to be followed for 1 year after birth. To date, Phase 1 data collection and follow-up have been completed. Delineation of possible harmful effects of HIV/ZIKV co-infection will allow the formulation of standard-of-care recommendations to minimize adverse effects but enable the continuation of preventive HIV therapy. Furthermore, while the prospective HIV ZIP study was developed before the COVID pandemic, it is especially relevant today since it can be easily adapted to provide critically important information on the impact of COVID-19 infection or other still unrecognized new agents among pregnant women and their offspring worldwide.

Diagnosis and treatment of sexually transmitted infections in male partners of pregnant women in Brazil

Sexually transmitted infections (STIs) can adversely affect a woman's pregnancy and the health of the developing fetus. The source of these infections may be the male sexual partner who remains under-diagnosed and un-treated due to a combination of lack of symptoms, decreased access to health care, and poor health-seeking behaviors. From September 2018 to November 2019, we offered a cohort of pregnant women (gestational age range: 4.6-41 weeks) clinic-based STI testing for HIV and syphilis (via lateral flow assay rapid tests) and for Neisseria (N.) gonorrhoeae, Chlamydia (C.) trachomatis, and Trichomonas (T.) vaginalis (via PCR-based testing) at Santa Casa Hospital and 10 affiliated prenatal clinics in Porto Alegre, Brazil. 400 women between the ages of 18 and 46 years (mean age: 27 years) enrolled and 24% were diagnosed with an STI. Each woman enrolled agreed to invite their male partners to clinic for the same panel of STI testing, and 255 men (64%) between the ages of 18 and 64 years (mean age: 29 years) attended clinic and all accepted full intervention. In these male partners, 40 (16%) were diagnosed with an STI including 22 (8.7%) testing positive for C. trachomatis, 15 (6%) for treponemal antibody (syphilis), 7 (2.8%) for T. vaginalis, 3 (1.2%) for N. gonorrhoeae, and 1 (0.4%) for HIV antibody. In our multivariate analysis, having symptoms of an STI (AOR 4.5, 95% CI 1.3-15.2) and arguing about jealousy (AOR 3.1, 95% CI 1.2-8.2) remained significantly associated with male diagnosis of an STI. Sexually transmitted infections are common in sexual partners of pregnant women in Brazil and should be addressed to prevent reinfection of pregnant women.

Maternal HIV and syphilis are not syndemic in Brazil: Hot spot analysis of the two epidemics

While the annual incidence of HIV diagnosis in pregnancy in Brazil remains relatively stable, rates of maternal syphilis increased over six-fold in the past decade. We hypothesized that maternal HIV and syphilis are two distinct epidemics. Data on all cases of maternal HIV or syphilis detected in pregnancy between January 1, 2010 to December 31, 2018 were requested from the Brazilian Ministry of Health. In order to evaluate how the epidemics evolved over the time period, ArcGIS software was used to generate spatiotemporal maps of annual rates of detection of maternal HIV and syphilis in 2010 and 2018. We utilized Euclidean-distance hot spot analysis to identify state-specific clusters in 2010 and 2018. From 2010 to 2018, there were 66,631 cases of maternal HIV, 225,451 cases of maternal syphilis, and 150,414 cases of congenital syphilis in Brazil. The state of Rio Grande do Sul had the highest rate of maternal HIV detection in both 2010 and 2018. Hot spots of maternal HIV were identified in the three most Southern states in both 2010 and 2018 (99% confidence, z-score >2.58, p <0.01). While syphilis incidence >30 per 1,000 live births in 2018 in four states, only the two coastal states of Rio de Janeiro and Espirito Santo in Southeastern Brazil were significant hot spots (90% confidence, z-score 1.65-1.95, p <0.10). Contrary to the general assumption, HIV and syphilis epidemics in Brazil are not syndemic in pregnant women. There is a spatial cluster of maternal HIV in the South, while syphilis is increasing throughout the country, more recently on the coast. Focusing on maternal HIV hot spots in the Southern states is insufficient to curtail the maternal and congenital syphilis epidemics throughout the country. New strategies, including ongoing hot spot analysis, are urgently needed to monitor, identify and treat maternal syphilis.

Prospective cohort study of children exposed to hepatitis C virus through a pregnancy screening program

Objectives:

Porto Alegre, in south Brazil, has one of the highest Hepatitis C virus (HCV) infections rate in the country (84.4 cases/100,000 in 2018). Prenatal screening of HCV, however, has not been routinely offered.

Methods:

We conducted a longitudinal study of pregnant women with HCV and their infants between January 2014 to December 2018. Screening for HCV antibodies was offered to all women delivering at our tertiary institution. HCV RT-PCR was performed if seropositive. Infants were followed prospectively.

Results:

Among 18,953 pregnant women delivering, 17,810 were screened for HCV antibodies (93.9%) with 130 positive results. (HCV seroprevalence 0.7%). HCV RNA was detectable in 57/117 cases (48.7%). HCV viremia was associated with use of injectable drugs (p=0.03), inhaled/crack drug use (p=0.02), an HCV-seropositive partner, ≥3 lifetime sexual partners (p=<0.01). Genotype 1 was most prevalent (68%) during pregnancy. Among 43 children with follow-up, 6 (13%) were HCV infected (transmission rate 13.9%); genotype 3 infected 50%. Two infants (33%) cleared infection; mothers had genetic polymorphisms associated with clearance.

Conclusion:

HCV vertical transmission was high in our population, with HCV infection during pregnancy being vastly underdiagnosed. Public health efforts must focus on this vulnerable population for disease prevention and early treatment.

HIV, placental pathology and birth outcomes - a brief overview

The spectrum of placental pathology in human immunodeficiency virus (HIV) is vast. Features observed are not only limited to the effects of the virus itself but may include that of coinfections such as tuberculosis and syphilis. The presence of other comorbidities and changes as a result of antiretroviral therapy may further confound the histologic findings. There is a paucity of unbiased information of the effects of maternal HIV on the placenta and how these changes relate to birth outcomes. Antiretroviral therapy, now in widespread use, has altered the course of maternal HIV disease and it is unknown whether this has altered the pathophysiology of HIV on the placenta. HIV-associated placental findings that have been most well described include acute chorioamnionitis, low placental weight and maternal vascular malperfusion, with a tendency towards lower rates of chronic villitis.

Failure to recognize Low non-treponemal titer syphilis infections in pregnancy May lead to widespread under-treatment

OBJECTIVES

Rates of maternal syphilis have increased five-fold in Brazil in the past decade. While penicillin remains the only appropriate treatment for maternal syphilis, we hypothesized that low non-treponemal titers (<1:16) may lead to reduced penicillin treatment in Brazil.

METHODS

Using Brazilian Ministry of Health data on women diagnosed with maternal syphilis between January 1, 2010, and December 31, 2018, we conducted a random-effects logistic regression model with a cluster correction at the state level to evaluate predictive factors of penicillin treatment.

RESULTS

We observed yearly increases in cases of pregnant women with syphilis from 2010 to 2018. There was significant variation by state: 52,451 cases were reported in São Paulo, followed by 26,838 in Rio de Janeiro. Among 215,937 cases of maternal syphilis, 91·3% received penicillin. In the random-effects model, a non-treponemal titer ≥1:16 was associated with 1·44 higher odds of receiving penicillin (95% confidence interval [CI]: 1·391·48), and prenatal care was associated with a 2·12 increased odds of receiving penicillin (95% CI: 2·022·21). Although there is an association between the absence of prenatal care and inadequate treatment for syphilis, 83·2% of women in this cohort who did not receive penicillin were engaged in prenatal care.

CONCLUSIONS

Providers may inappropriately exclude low non-treponemal titers and thereby fail to use penicillin treatment in maternal syphilis. While the cause of the maternal syphilis epidemic in Brazil is multifactorial, we believe our findings can be used to develop targeted interventions throughout Brazil as well as shape public health initiatives globally.

High Prevalence of Sexually Transmitted Infections in Pregnant Women Living in Southern Brazil

BACKGROUND

Porto Alegre, Brazil, has the highest rates of congenital syphilis and HIV in the country. Other treatable sexually transmitted infections (STIs) are associated with poor pregnancy and neonatal outcomes, but are only diagnosed by syndromic algorithms.

METHODS

Between September 2018 and November 2019, we offered all pregnant women clinic-based STI testing for HIV antibody and treponemal antibody (via lateral flow assay rapid tests provided by the Brazilian Government) and for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis (via polymerase chain reaction-based testing provided by Gene Xpert, Sunnyvale, CA) in 10 public prenatal health clinics in Porto Alegre. Participating women answered a brief survey via audio computer-assisted survey instrument regarding demographics, partnerships, and sexual behaviors. All infected individuals received appropriate treatment and referrals.

RESULTS

Of 400 pregnant women recruited, 94 (24%) were diagnosed with an STI, including 2% with HIV, 11% with syphilis, 9% with chlamydia, 1% with gonorrhea, 5% with trichomoniasis, and 3% with more than 1 STI. In our multivariate analysis, younger age (adjusted odds ratio [AOR], 1.1; 95% confidence interval [CI], 1-1.2), being non-White (AOR, 1.8; 95% CI, 1.1-3.1), having less education (AOR, 2; 95% CI, 1.2-3.4), and having a relationship <1 year (AOR, 2; 95% CI, 1.1-3.6) were all independent predictors of women having an STI. Endorsing symptoms of an STI (e.g., vaginal ulcers/lesions and vaginal discharge) was not predictive of having a laboratory-diagnosed STI (OR, 1.1; 95% CI, 0.7-1.7).

CONCLUSIONS

Etiologic-based screening for STIs was uniformly accepted by women attending both hospital-based and primary health clinics in the south of Brazil and can result in appropriate treatment of pregnant women.

Cost-effectiveness of dual maternal HIV and syphilis testing strategies in high and low HIV prevalence countries: a modelling study

BACKGROUND

Dual HIV and syphilis testing might help to prevent mother-to-child transmission (MTCT) of HIV and syphilis through increased case detection and treatment. We aimed to model and assess the cost-effectiveness of dual testing during antenatal care in four countries with varying HIV and syphilis prevalence.

METHODS

In this modelling study, we developed Markov models of HIV and syphilis in pregnant women to estimate costs and infant health outcomes of maternal testing at the first antenatal care visit with individual HIV and syphilis tests (base case) and at the first antenatal care visit with a dual rapid diagnostic test (scenario one). We additionally evaluated retesting during late antenatal care and at delivery with either individual tests (scenario two) or a dual rapid diagnosis test (scenario three). We modelled four countries: South Africa, Kenya, Colombia, and Ukraine. Strategies with an incremental cost-effectiveness ratio (ICER) less than the country-specific cost-effectiveness threshold (US$500 in Kenya, $750 in South Africa, $3000 in Colombia, and $1000 in Ukraine) per disability-adjusted life-year averted were considered cost-effective.

FINDINGS

Routinely offering testing at the first antenatal care visit with a dual rapid diagnosis test was cost-saving compared with the base case in all four countries (ICER: -$26 in Kenya,-$559 in South Africa, -$844 in Colombia, and -$454 in Ukraine). Retesting during late antenatal care with a dual rapid diagnostic test (scenario three) was cost-effective compared with scenario one in all four countries (ICER: $270 in Kenya, $260 in South Africa, $2207 in Colombia, and $205 in Ukraine).

INTERPRETATION

Incorporating dual rapid diagnostic tests in antenatal care can be cost-saving across countries with varying HIV prevalence. Countries should consider incorporating dual HIV and syphilis rapid diagnostic tests as the first test in antenatal care to support efforts to eliminate MTCT of HIV and syphilis.

FUNDING

WHO, US Agency for International Development, and the Bill & Melinda Gates Foundation.

Development and validation of a technology for obstetric intraoperative care safety

OBJECTIVES

to develop and validate an obstetric surgical safety checklist for intraoperative care.

METHODS

this is a methodological study with two phases: integrative review in databases, using selection criteria and descriptors to synthesize the evidence and develop the checklist; checklist content validation, with 37 judges, who answered a Likert-type questionnaire. For analysis, a >85% content validation index was applied.

RESULTS

the checklist's first moment reached a 96.1 content validation index; the second moment, 95.5; the third moment, 98.9. Thus, the validation index of all verifying sections present in the three surgical moments was 97.1. Cronbach's Alpha value was 95.57%.

CONCLUSIONS

the checklist items were validated by judges, with improvement of some items and insertion of others.

Highlighting a population-based re-emergence of Syphilis infection and assessing associated risk factors among pregnant women in Cameroon: Evidence from the 2009, 2012 and 2017 national sentinel surveillance surveys of HIV and syphilis

Background

Syphilis and HIV can be transmitted from pregnant women to their children and they remain a public health problem in Africa. Our study aimed to determine the trends of seroprevalence of HIV/syphilis co-infection and syphilis infection overtime through the national surveillance system in Cameroon and to explore associated risk factors.

Methods

We conducted cross-sectional studies of HIV and syphilis, targeting each year 7000 first antenatal care (ANC-1) attendees at the same sites during the 2009, 2012 and 2017 sentinel surveillance surveys. Pregnant women were enrolled at their ANC-1, sociodemographic and clinical information were collected. HIV and Syphilis test were performed by serial algorithm as per the national guidelines. Trends were assessed for HIV, syphilis and HIV/syphilis by estimating seroprevalence from cross-sectional studies. Associated risk factors were explored using multinomial logistic regression with 4 outcomes: HIV/syphilis co-infection, HIV infection only, syphilis infection only and no infection.

Results

Overall, 6 632, 6 521 and 6 859 pregnant women were enrolled in 2009, 2012 and 2017 respectively. In 2017, a total of 3 901 pregnant women enrolled were tested for syphilis. Almost half of them (47.9%) were living in urban area and were aged less than 25 years (44.7%). While HIV epidemic was on a decline (from 7.6% (95% CI: 6.99–8.28) in 2009 to 5.7% (95% CI: 4.93–6.4) in 2017), a huge significant increase of syphilis prevalence was observed (from 0.6% (95% CI:0.40–0.80) in 2009 to 5.7% (95% CI:4.93–6.40) in 2017). Pregnant women residing in rural areas were more likely to be infected with syphilis than those living in the urban area (aOR = 1.8 [95% CI: 1.3–2.4]). Unmarried pregnant women were three time more likely to be infected by HIV/Syphilis Co-infection than married, cohabiting, widow or divorced pregnant women (aOR = 2.8 [95% CI: 1.3–2.4]). Furthermore; living in Northern region was associated with a lower risk of being infected with HIV (aOR = 0.6 [95% CI: 0.5–0.9]) and Syphilis infection (aOR = 0.6 [95% CI: 0.4–0.9]).

Conclusion

The epidemiological dynamics of syphilis suggests a growing burden of syphilis infection in the general population of Cameroon. Our findings support the fact that while emphasizing strategies to fight HIV, huge efforts should also be made for strategies to prevent and fight syphilis infection especially among HIV positive women, in rural area, and southern regions.

Prevalence and associated factors of Treponema pallidum infection in a rural area of southwestern China

Background

Epidemiological data on Treponema pallidum infection are scarce from the southwestern region of China. The purpose of this study was to determine the distribution and determinants of T. pallidum infection in the region.

Methods

A community-based cross-sectional study of 2608 participants aged ≥14 years was conducted in a rural area of southwestern China in 2014–15. A pretested questionnaire was used to collect sociodemographic characteristics and other factors associated with T. pallidum infection. The diagnoses of T. pallidum, human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) infections were determined by commercial test kits. Logistic regression analysis was used to determine the correlates for T. pallidum infection, and adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated.

Results

The prevalence of T. pallidum infection was 1.2% (95% CI 0.8 to 1.7%). Risk factors varied by gender. In the male group, T. pallidum infection was significantly associated with ever injection drug use (aOR = 9.42, 95% CI 2.47 to 35.87) and HCV infection (aOR = 13.28, 95% CI 3.20 to 51.70). In the female group, correlates for T. pallidum infection included spouse having syphilis (aOR = 126.66, 95% CI 7.58 to 2122.94), ever having blood transfusion (aOR = 10.51, 95% CI 1.58 to 41.21) and HBV infection (aOR = 4.19, 95% CI 1.35 to 10.93).

Conclusions

The prevalence of T. pallidum infection was high in the rural area of southwestern China. Correlates for T. pallidum infection varied with sex specific. Intervention should be developed for the prevention and control of T. pallidum infection.

Clinical characteristics and outcomes for paediatric patients admitted with congenital or acquired syphilis: a population-based cohort study

OBJECTIVES

Paediatric congenital and acquired syphilis cases have been increasing since 2012 in the USA. Potential differences in associated hospitalisation trends and healthcare utilisation between the two syphilis entities have not yet been assessed. We sought to compare these entities and describe their clinical characteristics, distribution and impact in the USA.

METHODS

We conducted a population-based cohort study using the 2016 Kids' Inpatient Database (KID) to identify and characterise syphilis-associated hospitalisations among paediatric patients (age 0-21 years) in the USA during the year of 2016. Length of stay and hospitalisation costs for patients with congenital and acquired syphilis were compared in multivariable models.

RESULTS

A total of 1226 hospitalisations with the diagnosis of syphilis were identified. Of these patients, 958 had congenital syphilis and 268 were acquired cases. The mean cost of care for congenital syphilis was $23 644 (SD=1727), while the treatment of a patient with acquired syphilis on average cost $10 749 (SD=1966). Mean length of stay was 8 days greater and mean total costs were $12 895 (US dollars) higher in the congenital syphilis cohort compared with the acquired syphilis cohort. In congenital syphilis, there were greater frequency of cases in the Southern and Western regions of the USA (p<0.001).

CONCLUSION

Congenital syphilis was associated with greater healthcare-related expenditure than acquired syphilis in paediatric patients. In addition to improving patient outcomes, congenital syphilis prevention efforts may significantly reduce healthcare utilisation burden and cost.

Perinatal HIV as an infectious cause of developmental regression

Although many pathogens affect neurodevelopment, most do so by stalling or arresting developmental progress with damage to central nervous system (CNS) cells and circuits during fetal life, leaving lifelong sequelae after early neuronal infection. In utero infections with CNS repercussions generally result from direct infection of fetal neural cells, with varying degrees of CNS involvement depending on the stage of fetal development. Human Immunodeficiency Virus (HIV) is distinct from other conditions as it does not cause immediate repercussions to the CNS unless HIV perinatal infection is accompanied by other co-infections. Nevertheless, distinct from the other congenital infections which generally induce failure to attain developmental milestones, perinatal HIV infection causes developmental regression, with often indolent but progressive neurodevelopmental consequences. Loss of developmental milestones has long been recognized as an Acquired Immune Deficiency Syndrome defining condition, often with growth failure. HIV encephalopathy presents as developmental delay/loss of developmental milestones, with manifestations in motor, mental and expressive language functions. Perinatal HIV disease is herein reviewed, with focus on developmental outcomes, diagnosis and treatment.

Impact of Implementing Antenatal Syphilis Point-of-Care Testing on Maternal Mortality in KwaZulu-Natal, South Africa: An Interrupted Time Series Analysis

Background: Syphilis infection has been associated with an increased risk of HIV infection during pregnancy which poses greater risk for maternal mortality, and antenatal syphilis point-of-care (POC) testing has been introduced to improve maternal and child health outcomes. There is limited evidence on the impact of syphilis POC testing on maternal outcomes in high HIV prevalent settings. We used syphilis POC testing as a model to evaluate the impact of POC diagnostics on the improvement of maternal mortality in KwaZulu-Natal, South Africa. Methods: We extracted 132 monthly data points on the number of maternal deaths in facilities and number of live births in facilities for 12 tertiary healthcare facilities in KwaZulu-Natal (KZN), South Africa from 2004 to 2014 from District Health Information System (DHIS) health facility archived. We employed segmented Poisson regression analysis of interrupted time series to assess the impact of the exposure on maternal mortality ratio (MMR) before and after the implementation of antenatal syphilis POC testing. We processed and analyzed data using Stata Statistical Software: Release 13. (Stata, Corp LP, College Station, TX, USA). Results: The provincial average annual maternal mortality ratio (MMR) was estimated at 176.09 ± 43.92 ranging from a minimum of 68.48 to maximum of 225.49 per 100,000 live births. The data comprised 36 temporal points before the introduction of syphilis POC test exposure and 84 after the introduction in primary health care clinics in KZN. The average annual MMR for KZN from 2004 to 2014 was estimated at 176.09 ± 43.92. A decrease in MMR level was observed during 2008 after syphilis POC test implementation, followed by a rise during 2009. Analysis of the MMR trend estimates a significant 1.5% increase in MMR trends during the period before implementation and 1.3% increase after implementation of syphilis POC testing (p < 0.001). Conclusion: Although our finding suggests a brief reduction in the MMR trend after the implementation of antenatal syphilis POC testing, a continued increase in syphilis rates is seen in KwaZulu-Natal, South Africa. The study used one of the most powerful quasi-experimental research methods, segmented Poisson regression analysis of interrupted time series to model the impact of syphilis POC on maternal outcome. The study finding requires confirmation by use of more rigorous primary study design.

Brief Report: High Rates of Adverse Birth Outcomes in HIV and Syphilis Coinfected Women in Botswana

BACKGROUND

Little is known about the combined impact of HIV/syphilis coinfection on birth outcomes.

METHODS

Antenatal HIV and syphilis test results, obstetric history, and infant birth outcomes were collected from obstetric records in maternity wards in Botswana between 2008 and 2011 (5 sites) and 2014 and 2016 (8 sites). We used logistic regression to compare adverse birth outcomes by HIV and syphilis status. Outcomes included stillbirth, preterm delivery, low birth weight, and in-hospital neonatal death.

RESULTS

Of 76,466 women, 75,770 (99.1%) had HIV test results, and 20,520 (27.1%) were HIV positive. Syphilis test results were available for 67,290 (88.0%), and 697 (1.0%) had reactive rapid plasma reagin. Among 692 women with syphilis and an HIV test result, 261 (37.7%) were coinfected. HIV-infected women were more likely to be infected with syphilis than HIV-uninfected women [odds ratio (OR) = 1.68; 95% confidence interval (CI): 1.44 to 1.96]. From 2008-2011 to 2014-2016, the proportion of women with syphilis remained constant (1.1% vs. 1.0%, P = 0.41), but HIV/syphilis coinfection declined from 45% to 27% (P < 0.0001). Stillbirth occurred in 5.8% of coinfected women, compared with 1.9% with no HIV/syphilis (OR = 3.09; 95% CI: 1.83 to 5.23); 3.4% with HIV alone (OR = 1.75; 95% CI: 1.03 to 2.97), or 3.7% with syphilis alone (OR = 1.58; 95% CI: 0.77 to 3.25). Low birth weight occurred in 24.1% of coinfected women, compared with 12.1% with no HIV/syphilis (OR 2.31; 95% CI: 1.74 to 3.08; 20% with HIV alone (OR = 1.27; 95% CI: 0.96 to 1.69); or 14.6% with syphilis alone (OR = 1.85; 95% CI: 1.26 to 2.74).

CONCLUSIONS

Although HIV/syphilis coinfection in pregnancy has declined in the past decade, coinfection was associated with adverse birth outcomes.

HIV Status and Other Risk Factors for Prevalent and Incident Sexually Transmitted Infection during Pregnancy (2000-2014)

Background

Sexually transmitted infections (STIs) are associated with adverse birth outcomes. Current prenatal STI screening guidelines define "risk" without explicit consideration of HIV status. Our objective was to test the hypothesis that HIV status is associated with bacterial STI in pregnant women.

Methods

We designed a retrospective cohort study to identify pregnant women with HIV who delivered at our facility during 2000-2014. HIV+ women were compared to HIV- women with matching by year of delivery. Logistic regression was used to model adjusted odds of prevalent and incident STI. Prevalent STI was defined as chlamydia (CT), gonorrhea (GC), syphilis, or trichomoniasis detected on an initial prenatal screening test and incident STI as a newly positive result following a negative prenatal test.

Results

The cohort included 432 women, 210 HIV+ and 222 HIV-. Most pregnant women were screened for STI (92% of HIV+ women and 74% of HIV- women). STI rates were high and particularly elevated in HIV+ women: 29% vs 18% (p=0.02), for prevalent STI and 11% vs 2% (p<0.001) for incident STI. Risk factors for prevalent STI were as follows: HIV status (aOR 3.0, CI: 1.4-6.4), Black race (aOR 2.7, 95% CI: 1.1-6.6), and more recent delivery (2007-2014 compared to 2000-2006) (aOR 2.3, CI: 1.1-4.7). HIV status was an independent risk factor for incident STI (aOR 7.2, CI: 2.1-25.0).

Conclusion

Pregnant women who delivered in our center had high STI rates. Since HIV infection was independently associated with prevalent and incident STI, prenatal screening guidelines may need to incorporate HIV status as a high-risk group for repeat testing.

Infectious Morbidity, Mortality and Nutrition in HIV-exposed, Uninfected, Formula-fed Infants: Results From the HPTN 040/PACTG 1043 Trial

BACKGROUND

HIV-exposed uninfected (HEU) infants are a growing population with potentially poor health outcomes. We evaluated morbidity and mortality in HEU formula-fed infants enrolled in the NICHD HPTN 040/PACTG 1043 trial.

METHODS

Infectious morbidity, mortality and undernutrition were evaluated within a cohort of 1000 HEU infants enrolled between April 2004 and April 2010 in Brazil (n = 766) and South Africa (n = 234) as part of the NICHD/HPTN 040 trial of 3 different antiretroviral regimens to decrease intrapartum HIV vertical transmission.

RESULTS

Twenty-three percent of infants had at least 1 infectious serious adverse effect. Infants born to mothers with <12 years of education [adjusted odds ratio (AOR), 2.6; 95% confidence interval [CI], 1.2-5.9), with maternal viral load of >1,000,000 copies/mL at delivery (AOR, 9.9; 95% CI, 1.6-63.1) were more likely to have infectious serious adverse effects. At 6 months, the infant mortality rate per 1000 live births overall was 22 ± 2.6, 9.1 ± 1.8 in Brazil and 64.1 ± 3 in South Africa. Undernutrition and stunting peaked at 1 month of age with 18% having a weight-for-age Z score ≤-2, and 22% with height for Z score ≤-2. The likelihood of infant mortality was greater among infants born in South Africa compared with Brazil (AOR, 6.2; 95% CI, 2.5-15.8), high maternal viral load (AOR, 1.7; 95% CI, 1.01-2.9) and birth weight-for-age Z score ≤-2 (AOR, 5.2; 95% CI, 1.8-14.8).

CONCLUSIONS

There were high rates of undernutrition, stunting and infectious serious adverse effect in this study's formula-fed HEU population. Suppressing maternal HIV viral load during the peripartum period may be a modifiable risk factor to decrease infant mortality.

Minimizing the Risk of Perinatal Human Immunodeficiency Virus Transmission

Importance

There are approximately 284,500 adolescent and adult women living with human immunodeficiency virus (HIV) in the United States. It is estimated that approximately 8500 of these women give birth annually. While the rate of perinatal transmission in the United States has decreased by more than 90% since the early 1990s, potentially preventable HIV transmission events still occur and cause significant morbidity and mortality.

Objective

The aim of this review was to summarize the current data regarding perinatal HIV transmission timing and risk factors, current management recommendations, and implications of timing of transmission on patient management.

Evidence Acquisition

Literature review.

Results

This review reiterates that the risk of perinatal HIV transmission can be reduced to very low levels by following current recommendations for screening for HIV in all pregnant women and properly treating HIV-infected mothers, as well as using evidence-based labor management practices.

Conclusions and Relevance

Familiarity with the pathogenesis of HIV transmission is important for obstetric care providers to appropriately manage HIV-infected women in pregnancy, intrapartum, and the postpartum period.

Sexually Transmitted Infection Prevalence in Women With HIV: Is There a Role for Targeted Screening?

BACKGROUND

Rates of sexually transmitted infections (STIs) and HIV are highest in the southern United States but vary widely by sex, age, and risk behavior. Current guidelines recommend annual screening for chlamydia, gonorrhea, syphilis, and trichomoniasis in all sexually active women with HIV.

METHODS

Screening rates and test positivity for chlamydia, gonorrhea, syphilis, and trichomoniasis were determined per calendar year in this retrospective cohort study of women in care at an urban HIV clinic in Birmingham, Alabama, from 2013 to 2015. Chlamydia, gonorrhea, and trichomonas infections were detected by molecular diagnostics and syphilis by serology. A combined end point for chlamydia/gonorrhea/syphilis (STI-3) was created based on similar test positivity and predictors. Predictors of STI-3 were identified using logistic regression and generalized estimating equations.

RESULTS

Among 745 women with HIV, median age was 46.8 years, 78.8% were black, and 61% were sexually active. In 2015, 83.7% of women were tested for STI. Test positivity was 1.0% for chlamydia, 0.5% for gonorrhea, 1.6% for syphilis, and 13.3% for trichomoniasis. Independent predictors of STI-3 were recent chlamydia or gonorrhea (odds ratio [OR], 3.7; 95% confidence interval [CI], 1-13.4; P = 0.047), public insurance compared with private (OR, 3.5; CI, 1-11.8; P = 0.048), and sex after drugs/alcohol (OR, 3.0; CI, 1.2-8.0; P = 0.025). Women 50 years or older were less likely to have STI (OR, 0.3; CI, 0.1-1; P = 0.040).

CONCLUSIONS

In a cohort of women engaged in HIV care in the southern United States, detection of chlamydia, gonorrhea, and syphilis was infrequent but trichomoniasis was common. Many women screened for STI were low risk and universal testing strategies warrant evaluation.

Congenital Cytomegalovirus and HIV Perinatal Transmission

BACKGROUND

Congenital cytomegalovirus (CMV) infection (cCMV) is an important cause of hearing loss and cognitive impairment. Prior studies suggest that HIV-exposed children are at higher risk of acquiring cCMV. We assessed the presence, magnitude and risk factors associated with cCMV among infants born to HIV-infected women, who were not receiving antiretrovirals during pregnancy.

METHODS

cCMV and urinary CMV load were determined in a cohort of infants born to HIV-infected women not receiving antiretrovirals during pregnancy. Neonatal urines obtained at birth were tested for CMV DNA by qualitative and reflex quantitative real-time polymerase chain reaction.

RESULTS

Urine specimens were available for 992 (58.9%) of 1684 infants; 64 (6.5%) were CMV-positive. Mean CMV load (VL) was 470,276 copies/ml (range: < 200-2,000,000 copies/ml). Among 89 HIV-infected infants, 16 (18%) had cCMV versus 42 (4.9%) of 858 HIV-exposed, uninfected infants (P < 0.0001). cCMV was present in 23.2% of infants with in utero and 9.1% infants with intrapartum HIV infection (P < 0.0001). Rates of cCMV among HIV-infected infants were 4-fold greater (adjusted OR, 4.4; 95% CI: 2.3-8.2) and 6-fold greater among HIV in utero-infected infants (adjusted OR, 6; 95% CI: 3-12.1) compared with HIV-exposed, uninfected infants. cCMV was not associated with mode of delivery, gestational age, Apgar scores, 6-month infant mortality, maternal age, race/ethnicity, HIV viral load or CD4 count. Primary cCMV risk factors included infant HIV-infection, particularly in utero infection.

CONCLUSION

High rates of cCMV with high urinary CMV VL were observed in HIV-exposed infants. In utero HIV infection appears to be a major risk factor for cCMV in infants whose mothers have not received combination antiretroviral therapy in pregnancy.

Factors Associated with Lower Respiratory Tract Infections in HIV-Exposed Uninfected Infants

To identify factors that predispose human immunodeficiency virus (HIV)-exposed uninfected infants (HEUs) to higher incidence of severe infections, hospitalization, and death in the first 6-24 months of life compared with HEUs with and without lower respiratory tract infection (LRTI) in the first 6 months of life. Nested case-control study of 107 LRTI+ infants enrolled in the International Site Development Initiative (NISDI) Perinatal and Longitudinal Study in Latin American Countries (LILAC) studies with and 140 LRTI- in the first 6 months, matched by date and place of birth. Infants and mothers had plasma antibodies measured against respiratory syncytial virus (RSV), parainfluenza (PIV) 1, 2, 3, influenza, and pneumococcus 1, 5, 6B, and 14. Compared with LRTI-, mothers of LRTI+ HEUs had lower years of education, lower CD4⁺ cells, and higher HIV plasma viral load at delivery, but similar use of antiretrovirals and cotrimoxazole and other sociodemographic characteristics. LRTI+ and LRTI- HEUs had similar demographic and hematological characteristics and antibody concentrations against respiratory pathogens at birth. At 6 months, the rates of seroconversions to respiratory pathogens and antibody responses to tetanus vaccine were also similar. However, antibody concentrations to RSV were significantly higher in LRTI+ compared with LRTI- HEUs and marginally higher to PIV1. Maternal factors associated with advanced HIV disease, but unrelated to the use of antiretrovirals, cotrimoxazole, or the level of maternal antibodies against respiratory pathogens, contribute to the increased risk of LRTI in HEUs. In HEUs, antiretroviral and cotrimoxazole use, exposure to respiratory pathogens and humoral immune responses were not associated with the incidence of LRTI.

Maternal Syphilis: An Independent Risk Factor for Mother to Infant Human Immunodeficiency Virus Transmission

A study of human immunodeficiency virus–infected pregnant women in India identified maternal syphilis co-infection as an independent risk factor for human immunodeficiency virus mother-to-child transmission by age 6 months with nearly 2.5-fold increased risk.

Syphilis is associated with increased human immunodeficiency virus acquisition and sexual transmission; we examined impact on human immunodeficiency virus mother-to-child transmission among mother-infant pairs enrolled in the India Six-Week Extended-Dose Nevirapine study. Maternal syphilis, diagnosed serologically using Venereal Disease Research Laboratory titer plus Treponema Pallidum Hemagglutination Assay, was associated with 2.5-fold greater risk.

Combined evaluation of sexually transmitted infections in HIV-infected pregnant women and infant HIV transmission

Background

Sexually transmitted infections (STIs) including Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Treponema pallidum (TP), and cytomegalovirus (CMV) may lead to adverse pregnancy and infant outcomes. The role of combined maternal STIs in HIV mother-to-child transmission (MTCT) was evaluated in mother-infant pairs from NICHD HPTN 040.

Methodology

Urine samples from HIV-infected pregnant women during labor were tested by polymerase chain reaction (PCR) for CT, NG, and CMV. Infant HIV infection was determined by serial HIV DNA PCR testing. Maternal syphilis was tested by VDRL and confirmatory treponemal antibodies.

Results

A total of 899 mother-infant pairs were evaluated. Over 30% had at least one of the following infections (TP, CT, NG, and/or CMV) detected at the time of delivery. High rates of TP (8.7%), CT (17.8%), NG (4%), and CMV (6.3%) were observed. HIV MTCT was 9.1% (n = 82 infants). HIV MTCT was 12.5%, 10.3%, 11.1%, and 26.3% among infants born to women with CT, TP, NG or CMV respectively. Forty-two percent of HIV-infected infants were born to women with at least one of these 4 infections. Women with these infections were nearly twice as likely to have an HIV-infected infant (aOR 1.9, 95% CI 1.1–3.0), particularly those with 2 STIs (aOR 3.4, 95% CI 1.5–7.7). Individually, maternal CMV (aOR 4.4 1.5–13.0) and infant congenital CMV (OR 4.1, 95% CI 2.2–7.8) but not other STIs (TP, CT, or NG) were associated with an increased risk of HIV MTCT.

Conclusion

HIV-infected pregnant women identified during labor are at high risk for STIs. Co-infection with STIs including CMV nearly doubles HIV MTCT risk. CMV infection appears to confer the largest risk of HIV MTCT.

Trial registration

NCT00099359.

Prevalence of Curable Sexually Transmitted Infections in Pregnant Women in Low- and Middle-Income Countries From 2010 to 2015: A Systematic Review

BACKGROUND

Current literature comparing the prevalence rates of curable sexually transmitted infections (STIs) in pregnant women in various global regions is limited. As a result, antenatal screening practices for curable STIs in pregnant women, specifically Treponema pallidum (syphilis), Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), and Trichomonas vaginalis (TV) vary around the world, differing by country and particular STI.

METHODS

We conducted a systematic review of publications on STI prevalence among pregnant women in 30 different low- and middle-income countries. We searched PubMed for studies reporting prevalence of syphilis, CT, NG, and TV in pregnant women. English language studies published between January 1, 2010, and March 1, 2015, were included. The adjusted mean STI prevalence by region was calculated via multivariable linear regression adjusting for health care setting, women's mean age, study sample size, and sensitivity of diagnostic test.

RESULTS

We identified 75 studies that met inclusion criteria, providing 116 point prevalence estimates for curable STIs among 3,489,621 pregnant women. Adjusted mean prevalence for NG ranged from 1.2% (95% confidence interval [CI], 1.0-1.3) in Latin America to 4.6% (95% CI, 4.0-5.2) in Southern Africa; syphilis prevalence ranged from 1.1% (95% CI, 0.5-1.6) in Asia to 6.5% (95% CI, 4.7-6.3) in Southern Africa; CT ranged from 0.8% (95% CI, 0.4-1.1) in Asia to 11.2% (95% CI, 6.0-16.4) in Latin America; and TV ranged from 3.9% (95% CI, 2.2-5.6) in Latin America to 24.6% (95% CI, 17.9-31.4) in Southern Africa.

CONCLUSIONS

Although we observed a wide variation in STI burden in pregnancy after adjusting for age, test, and health care setting, further valid comparison may depend on adjustment for access to care and screening practices.

Cytomegalovirus Urinary Shedding in HIV-infected Pregnant Women and Congenital Cytomegalovirus Infection

BACKGROUND

Cytomegalovirus (CMV) urinary shedding in pregnant women infected with human immunodeficiency virus (HIV) was evaluated to determine whether it poses an increased risk for congenital CMV infection (cCMV).

METHODS

A subset of mother-infant pairs enrolled in the perinatal NICHD HPTN 040 study (distinguished by no antiretroviral use before labor) was evaluated. Maternal and infant urines were tested by qualitative real-time polymerase chain reaction (RT-PCR) for CMV DNA with quantitative RT-PCR performed on positive specimens.

RESULTS

Urine specimens were available for 260 women with 85.4% from the Americas and 14.6% from South Africa. Twenty-four women (9.2%) had detectable CMV viruria by qualitative PCR. Maternal CMV viruria was not associated with mean CD4 cell counts or HIV viral load but was associated with younger maternal age (P = .02). Overall, 10 of 260 infants (3.8%) had cCMV. Women with detectable peripartum CMV viruria were more likely to have infants with cCMV than those without: 20.8% (5/24) versus 2.1% (5/236), (P = .0001). Women with CMV viruria had significantly higher rates of HIV perinatal transmission (29.2% vs. 8.1%, P = .002). They were 5 times (adjusted odds ratio [aOR] = 5.6, 95% confidence interval [CI] 1.9-16.8) and nearly 30 times (aOR, 29.7; 95% CI, 5.4-164.2) more likely to transmit HIV and CMV to their infants, respectively. Maternal gonorrhea (aOR, 19.5; 95% CI, 2.5-151.3) and higher maternal HIV log10 viral load (OR, 2.8; 95% CI, 1.3-6.3) were also significant risk factors for cCMV.

CONCLUSION

In this cohort of HIV-infected pregnant women not on antiretrovirals, urinary CMV shedding was a significant risk factor for CMV and HIV transmission to infants.

CLINICAL TRIALS REGISTRATION NUMBER

NCT00099359.

[Incidence of congenital syphilis and factors associated with vertical transmission: data from the Birth in Brazil study]

The objectives were to estimate incidence of congenital syphilis and verify factors associated with vertical transmission. A national hospital-based study was performed in 2011-2012 with 23,894 postpartum women using an in-hospital interview and data from patient charts and prenatal cards. Univariate logistic regression was performed to verify factors associated with congenital syphilis. Estimated incidence of congenital syphilis was 3.51 per 1,000 live births (95%CI: 2.29-5.37) and vertical transmission rate was 34.3% (95%CI: 24.7-45.4). Congenital syphilis was associated with lower maternal schooling, black skin color, higher rate of risk factors for prematurity, late initiation of prenatal care, fewer prenatal visits, and lower rate of prenatal serological testing. Fetal mortality was six times higher in congenital syphilis, and newborns with congenital syphilis showed higher hospital admission rates. Congenital syphilis is a persistent public health problem in Brazil and is associated with greater social vulnerability and gaps in prenatal care.

Barriers and facilitators for men to attend prenatal care and obtain HIV voluntary counseling and testing in Brazil

Background

Providing HIV voluntary counseling and testing (VCT) to men who attend their partner's prenatal care is an intervention with potential to reduce HIV transmission to women and infants during the vulnerable period of pregnancy. Little is known about the acceptability of this intervention in global settings outside of Africa.

Methods

We conducted in-depth qualitative interviews to evaluate potential barriers and facilitators to prenatal care attendance for HIV VCT with 20 men who did and 15 men who did not attend prenatal care with their partners at Hospital Conceiçao in Porto Alegre, Brazil. Men were recruited at the labor and delivery unit at Hospital Conceiçao via a scripted invitation while visiting their newborn infant. Interviews lasted from 35–55 minutes and were conducted in Portuguese by a local resident trained extensively in qualitative methods. All interviews were transcribed verbatim, translated, and then analyzed using Atlast.ti software. An analysis of themes was then conducted using direct quotes and statements. We applied and adapted the AIDS Risk Reduction Theoretical Model and HIV Testing Decisions Model to the qualitative data to identify themes in the 35 interviews.

Results

If offered HIV testing during prenatal care, all men in both groups stated they would accept this intervention. Yet, individual, relationship and systemic factors were identified that affect these Brazilian men's decision to attend prenatal care, informing our final conceptual model. The men interviewed had a general understanding of the value of HIV prevention of mother to child transmission. They also described open and communicative relationships with their significant others and displayed a high level of enthusiasm towards optimizing the health of their expanding family. The major barriers to attending prenatal care included perceived stigma against HIV infected individuals, men’s lack of involvement in planning of the pregnancy as well as inconvenient scheduling of prenatal care, due to conflicting work schedules.

Conclusions

Brazilian men displayed high levels of HIV-related knowledge as well as open communication about HIV testing; especially when compared to findings from African studies. Future efforts should reorient prenatal care towards providing care to the entire family with a clear focus on protecting the infant from preventable diseases. Formally inviting men to prenatal care and providing them an acceptable medical excuse from work may enhance male involvement.

Molecular epidemiological survey of Treponema pallidum in pregnant women in the Zhabei District of Shanghai

PURPOSE

To evaluate the epidemiological characteristics of syphilis, such as incidence, vertical transmission and genotypes, in pregnant women in the Zhabei District of Shanghai. In addition, the changes in genotypes and the efficiency of genotyping were evaluated.

METHODOLOGY

We screened 3022 pregnant women for syphilis in the Shanghai Zhabei Central Hospital. Whole blood, plasma, earlobe blood and specimens from genital ulcers or skin/mucosal lesions were collected from syphilis-positive patients. Samples were genotyped by analysing a combination of three genes: tpr, arp and tp0548 (the tpr/arp/tp0548 genotype). Clinical data were further collected to evaluate disease incidence, maternal-neonatal transmission and social factors.

RESULTS

Out of 3022 pregnant women screened for syphilis, 41 were syphilis-positive. Of these, 43.9 % showed vertical transmission (18/41). The prevalence of syphilis in pregnant women was 1.32 %, higher than that in other districts in Shanghai in 2014. Genotyping was performed in 10/11 (90.9 %) samples of syphilis lesions, 8/41 (19.5 %) blood samples, 12/41 (29.3 %) plasma samples, and 20/39 (48.7 %) earlobe blood samples. The predominant genotype was 14d/f, followed by 15d/f, 13a/f, 13d/f and 9o/c. Genotype 13a/f was reported for the first time in the Shanghai area since 2010.

CONCLUSION

The prevalence of syphilis in pregnant women in the Zhabei District was higher than that in other areas in Shanghai and the genotype is variable.

Maternal HIV infection alters the immune balance in the mother and fetus; implications for pregnancy outcome and infant health

PURPOSE OF REVIEW

With the rapid roll-out of combination antiretroviral therapy to prevent mother-to-child transmission of HIV, there is an annual increase in the number of uninfected infants born to HIV-infected women. Although the introduction of combination antiretroviral therapy has vastly improved pregnancy outcome and the health of infants born to HIV-infected women, concerns remain regarding the impact the maternal HIV infection on the pregnancy outcome and the health of HIV-exposed uninfected infants.

RECENT FINDINGS

Maternal HIV infection is associated with negative pregnancy outcomes such as low birth weight. In addition, an increased susceptibility to infections is reported in HIV-exposed uninfected infants compared with infants born to uninfected women. Studies have shown that HIV-exposure affects the maternal/fetal unit, with increase of proinflammatory cytokine produced by placental cells, as well as altered infant immune responses. These changes could provide the underlying conditions for negative pregnancy outcomes and facilitate mother-to-child transmission of HIV in the infant. Further studies are required to understand the underlying mechanisms and investigate whether these altered infant immune responses persist and have clinical consequences beyond childhood.

SUMMARY

HIV infection in pregnant women is associated with altered immune responses in HIV-infected women and their offspring with clinical consequences for pregnancy outcome and the HIV-exposed uninfected infant. Further studies are required to address the origin and long-term consequences of prenatal HIV-exposure and subsequent immune activation for infant health.

Laboratory evaluation of the Chembio Dual Path Platform HIV-Syphilis Assay

Background

Use of rapid diagnostic tests for HIV and syphilis has increased remarkably in the last decade. As new rapid diagnostic tests become available, there is a continuous need to assess their performance and operational characteristics prior to use in clinical settings.

Objectives

In this study, we evaluated the performance of the Chembio Dual Path Platform (DPP^®) HIV–Syphilis Assay to accurately diagnose HIV, syphilis, and HIV/syphilis co-infection.

Method

In 2013, 990 serum samples from the Georgia Public Health Laboratory in Atlanta, Georgia, United States were characterised for HIV and syphilis and used to evaluate the platform. HIV reference testing combined third-generation Enzyme Immunoassay and Western Blot, whereas reference testing for syphilis was conducted by the Treponema pallidum passive particle agglutination method and the TrepSure assay. We assessed the sensitivity and specificity of the DPP assay on this panel by comparing results with the HIV and syphilis reference testing algorithms.

Results

For HIV, sensitivity was 99.8% and specificity was 98.4%; for syphilis, sensitivity was 98.8% and specificity was 99.4%. Of the 348 co-infected sera, 344 (98.9%) were detected accurately by the DPP assay, but 11 specimens had false-positive results (9 HIV and 2 syphilis) due to weak reactivity.

Conclusion

In this evaluation, the Chembio DPP HIV–Syphilis Assay had high sensitivity and specificity for detecting both HIV and treponemal antibodies. Our results indicate that this assay could have a significant impact on the simultaneous screening of HIV and syphilis using a single test device for high-risk populations or pregnant women needing timely care and treatment.

Hepatitis B, HIV, and Syphilis Seroprevalence in Pregnant Women and Blood Donors in Cameroon

Objectives. We estimated seroprevalence and correlates of selected infections in pregnant women and blood donors in a resource-limited setting. Methods. We performed a cross-sectional analysis of laboratory seroprevalence data from pregnant women and voluntary blood donors from facilities in Cameroon in 2014. Rapid tests were performed to detect hepatitis B surface antigen, syphilis treponemal antibodies, and HIV-1/2 antibodies. Blood donations were also tested for hepatitis C and malaria. Results. The seroprevalence rates and ranges among 7069 pregnant women were hepatitis B 4.4% (1.1–9.6%), HIV 6% (3.0–10.2%), and syphilis 1.7% (1.3–3.8%) with significant variability among the sites. Correlates of infection in pregnancy in adjusted regression models included urban residence for hepatitis B (aOR 2.9, CI 1.6–5.4) and HIV (aOR 3.5, CI 1.9–6.7). Blood donor seroprevalence rates and ranges were hepatitis B 6.8% (5.0–8.8%), HIV 2.2% (1.4–2.8%), syphilis 4% (3.3–4.5%), malaria 1.9%, and hepatitis C 1.7% (0.5–2.5%). Conclusions. Hepatitis B, HIV, and syphilis infections are common among pregnant women and blood donors in Cameroon with higher rates in urban areas. Future interventions to reduce vertical transmission should include universal screening for these infections early in pregnancy and provision of effective prevention tools including the birth dose of univalent hepatitis B vaccine.

Chlamydia trachomatis and Neisseria gonorrhoeae in HIV-infected Pregnant Women and Adverse Infant Outcomes

BACKGROUND

Sexually transmitted infections (STIs) in pregnancy such as Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) may lead to adverse infant outcomes.

METHODS

Individual urine specimens from HIV-infected pregnant women diagnosed with HIV during labor were collected at the time of infant birth and tested by polymerase chain reaction for CT and NG. Infant HIV infection was determined at 3 months with morbidity/mortality assessed through 6 months.

RESULTS

Of 1373 maternal urine samples, 277 (20.2%) were positive for CT and/or NG; 249 (18.1%) for CT, 63 (4.6%) for NG and 35 (2.5%) for both CT and NG. HIV infection was diagnosed in 117 (8.5%) infants. Highest rates of adverse outcomes (sepsis, pneumonia, congenital syphilis, septic arthritis, conjunctivitis, low birth weight, preterm delivery and death) were noted in infants of women with CT and NG (23/35, 65.7%) compared with NG (16/28, 57.1%), CT (84/214, 39.3%) and no STI (405/1096, 37%, P = 0.001). Death (11.4% vs. 3%, P = 0.02), low birth weight (42.9% vs. 16.9%, P = 0.001) and preterm delivery (28.6% vs. 10.2%, P = 0.008) were higher among infants of CT and NG-coinfected women. Infants who had any adverse outcome and were born to women with CT and/or NG were 3.5 times more likely to be HIV infected after controlling for maternal syphilis (odds ratio: 3.5, 95% confidence interval: 1.4-8.3). By adjusted multivariate logistic regression, infants born to mothers with any CT and/or NG were 1.35 times more likely to have an adverse outcome (odds ratio, 1.35; 95% confidence interval, 1.03-1.76).

CONCLUSIONS

STIs in HIV-infected pregnant women are associated with adverse outcomes in HIV-exposed infected and uninfected infants.

Chlamydia and Gonorrhea in HIV-Infected Pregnant Women and Infant HIV Transmission

BACKGROUND

Sexually transmitted infections (STIs) such as Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) can lead to adverse pregnancy and neonatal outcomes. The prevalence of STIs and its association with HIV mother-to-child transmission (MTCT) were evaluated in a substudy analysis from a randomized, multicenter clinical trial.

METHODOLOGY

Urine samples from HIV-infected pregnant women collected at the time of labor and delivery were tested using polymerase chain reaction testing for the detection of CT and NG (Xpert CT/NG; Cepheid, Sunnyvale, CA). Infant HIV infection was determined by HIV DNA polymerase chain reaction at 3 months.

RESULTS

Of the 1373 urine specimens, 249 (18.1%) were positive for CT and 63 (4.6%) for NG; 35 (2.5%) had both CT and NG detected. Among 117 cases of HIV MTCT (8.5% transmission), the lowest transmission rate occurred among infants born to CT- and NG-uninfected mothers (8.1%) as compared with those infected with only CT (10.7%) and both CT and NG (14.3%; P = 0.04). Infants born to CT-infected mothers had almost a 1.5-fold increased risk for HIV acquisition (odds ratio, 1.47; 95% confidence interval, 0.9-2.3; P = 0.09).

CONCLUSIONS

This cohort of HIV-infected pregnant women is at high risk for infection with CT and NG. Analysis suggests that STIs may predispose to an increased HIV MTCT risk in this high-risk cohort of HIV-infected women.

Impact of HIV-1 infection on the feto-maternal crosstalk and consequences for pregnancy outcome and infant health

Adaptation of the maternal immune system to establish maternal/fetal equilibrium is required for a successful pregnancy. Viral infections, including HIV-1 infection, can alter this maternal/fetal equilibrium, with significant consequences for pregnancy outcome, including miscarriages, impaired fetal growth, and premature delivery. Furthermore, maternal HIV-1 infection has been shown to have a long-term impact on the developing fetal immune system also when the infant is not infected with the virus. In this review, we discuss the consequences of maternal HIV-1 infection and antiretroviral therapy on pregnancy outcome and the health of the uninfected HIV-1-exposed infant.