Rapid HIV testing, pregnancy, antiretroviral prophylaxis and infant abandonment in St Petersburg

The uptake of integrated perinatal prevention of mother-to-child HIV transmission programs in low- and middle-income countries: a systematic review

BACKGROUND

The objective of this review was to assess the uptake of WHO recommended integrated perinatal prevention of mother-to-child transmission (PMTCT) of HIV interventions in low- and middle-income countries.

METHODS AND FINDINGS

We searched 21 databases for observational studies presenting uptake of integrated PMTCT programs in low- and middle-income countries. Forty-one studies on programs implemented between 1997 and 2006, met inclusion criteria. The proportion of women attending antenatal care who were counseled and who were tested was high; 96% (range 30-100%) and 81% (range 26-100%), respectively. However, the overall median proportion of HIV positive women provided with antiretroviral prophylaxis in antenatal care and attending labor ward was 55% (range 22-99%) and 60% (range 19-100%), respectively. The proportion of women with unknown HIV status, tested for HIV at labor ward was 70%. Overall, 79% (range 44-100%) of infants were tested for HIV and 11% (range 3-18%) of them were HIV positive. We designed two PMTCT cascades using studies with outcomes for all perinatal PMTCT interventions which showed that an estimated 22% of all HIV positive women attending antenatal care and 11% of all HIV positive women delivering at labor ward were not notified about their HIV status and did not participate in PMTCT program. Only 17% of HIV positive antenatal care attendees and their infants are known to have taken antiretroviral prophylaxis.

CONCLUSION

The existing evidence provides information only about the initial PMTCT programs which were based on the old WHO PMTCT guidelines. The uptake of counseling and HIV testing among pregnant women attending antenatal care was high, but their retention in PMTCT programs was low. The majority of women in the included studies did not receive ARV prophylaxis in antenatal care; nor did they attend labor ward. More studies evaluating the uptake in current PMTCT programs are urgently needed.

Correlates of unprotected sexual intercourse among women who inject drugs or who have sexual partners who inject drugs in St Petersburg, Russia

OBJECTIVES

To assess risk for unintended pregnancy, this study describes the correlates of unprotected sexual intercourse (UPSI) among women who inject illicit drugs or who have sexual partners who inject drugs in St Petersburg, Russia.

METHODS

Data from a cross-sectional survey and biological test results collected between 2005 and 2008 from 202 Russian women (143 drug injectors and 59 non-drug injectors) were analysed. Multivariate regression was used to investigate the correlates of UPSI occurring at the women's last sexual act. Independent variables included socio-demographics, age at sexual debut, first sexual encounter perceived as involuntary, number of pregnancies and number of children for which the participant is the primary caretaker, heavy sporadic drinking (i.e. consuming more than five drinks in 2 hours at least twice a month), at-risk drinking per the Alcohol Use Disorder Identification Test (AUDIT-C) score, and sexually transmitted infections (HIV-1, syphilis serology, Chlamydia trachomatis and Neisseria gonorrheae).

RESULTS

Sixty-seven percent of women reported UPSI at last intercourse. UPSI was independently associated with heavy sporadic drinking [odds ratio (OR) 2.8, 95% CI 1.2-6.6] and having been pregnant (OR 2.25, 95% CI 1.1-4.6).

CONCLUSIONS

Despite the high risk for HIV acquisition or transmission and unintended pregnancy, condom use among the study population is low. Programmes to investigate and improve contraceptive use, including condom use, among this vulnerable group of women are needed. Such programmes may require identifying and targeting female reproductive health concerns and problem drinking, particularly heavy sporadic drinking, rather than conventional measures of alcohol misuse.

Prevention of mother-to-child transmission of human immunodeficiency virus among pregnant women using injecting drugs in Ukraine, 2000-10

AIMS

To compare clinical status, mother-to-child transmission (MTCT) rates, use of prevention of (PMTCT) interventions and pregnancy outcomes between HIV-infected injecting drug users (IDUs) and non-IDUs.

DESIGN AND SETTING

Prospective cohort study conducted in seven human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) Centres in Ukraine, 2000-10.

PARTICIPANTS

Pregnant HIV-infected women, identified before/during pregnancy or intrapartum, and their live-born infants (n = 6200); 1028 women followed post-partum.

MEASUREMENTS

Maternal and delivery characteristics, PMTCT prophylaxis, MTCT rates, preterm delivery (PTD) and low birth weight (LBW).

FINDINGS

Of 6200 women, 1111 (18%) reported current/previous IDU. The proportion of IDUs diagnosed with HIV before conception increased from 31% in 2000/01 to 60% in 2008/09 (P < 0.01). Among women with undiagnosed HIV at conception, 20% of IDUs were diagnosed intrapartum versus 4% of non-IDUs (P < 0.01). At enrolment, 14% of IDUs had severe/advanced HIV symptoms versus 6% of non-IDUs (P < 0.001). IDUs had higher rates of PTD and LBW infants than non-IDUs, respectively, 16% versus 7% and 22% versus 10% (P < 0.001). IDUs were more likely to receive no neonatal or intrapartum PMTCT prophylaxis compared with non-IDUs (OR 2.81, p < 0.001). MTCT rates were 10.8% in IDUs versus 5.9% in non-IDUs; IDUs had increased MTCT risk (adjusted odds ratio 1.32, P = 0.049). Fewer IDUs with treatment indications received HAART compared with non-IDUs (58% versus 68%, P = 0.03).

CONCLUSIONS

Pregnant human immunodeficiency virus-infected injecting drug users in Ukraine have worse clinical status, poorer access to prevention of mother-to-child transmission prophylaxis and highly active antiretroviral therapy, more adverse pregnancy outcomes and higher risk of mother-to-child transmission than non-injecting drug user women.

Five-year trends in epidemiology and prevention of mother-to-child HIV transmission, St. Petersburg, Russia: results from perinatal HIV surveillance

Background

The HIV epidemic in Russia has increasingly involved reproductive-aged women, which may increase perinatal HIV transmission.

Methods

Standard HIV case-reporting and enhanced perinatal HIV surveillance systems were used for prospective assessment of HIV-infected women giving birth in St. Petersburg, Russia, during 2004-2008. Trends in social, perinatal, and clinical factors influencing mother-to-child HIV transmission stratified by history of injection drug use, and rates of perinatal HIV transmission were assessed using two-sided χ² or Cochran-Armitage tests.

Results

Among HIV-infected women who gave birth, the proportion of women who self-reported ever using injection drugs (IDUs) decreased from 62% in 2004 to 41% in 2008 (P < 0.0001). Programmatic improvements led to increased uptake of the following clinical services from 2004 to 2008 (all P < 0.01): initiation of antiretroviral prophylaxis at ≤28 weeks gestation (IDUs 44%-54%, non-IDUs 45%-72%), monitoring of immunologic (IDUs 48%-64%, non-IDUs 58%-80%) and virologic status (IDUs 8%-58%, non-IDUs 10%-75%), dual/triple antiretroviral prophylaxis (IDUs 9%-44%, non-IDUs 14%-59%). After initial increase from 5.3% (95% confidence interval [CI] 3.5%-7.8%) in 2004 to 8.5% (CI 6.1%-11.7%) in 2005 (P < 0.05), perinatal HIV transmission decreased to 5.3% (CI 3.4%-8.3%) in 2006, and 3.2% (CI 1.7%-5.8%) in 2007 (P for trend <0.05). However, the proportion of women without prenatal care and without HIV testing before labor and delivery remained unchanged.

Conclusions

Reduced proportion of IDUs and improved clinical services among HIV-infected women giving birth were accompanied by decreased perinatal HIV transmission, which can be further reduced by increasing outreach and HIV testing of women before and during pregnancy.

Factors associated with abandonment of infants born to HIV-positive women: results from a Ukrainian birth cohort

Social marginalisation and other challenges facing HIV-positive pregnant women in Ukraine may put them at increased risk of relinquishing their infants to the state. We described rates of infant abandonment (exclusive non-parental care to most recent follow-up, censored at two years of age) and investigated associated factors using logistic regression models, in 4759 mother-infant pairs enrolled across six Ukrainian sites in the European Collaborative Study from 2000 to May 2009. Median maternal age was 26.0 years, 81.8% were married or cohabiting and 60.6% were nulliparous at enrolment. An injecting drug use (IDU) history was reported by 18.4%, 80.2% took antiretroviral therapy (ART) antenatally and most deliveries were vaginal. A small but significant proportion of infants had been cared for exclusively in institutions by their second birthday (2.1% overall), decreasing from 3.8% (15/393) in 2000-2002 to 1.6% (49/3136) in 2006-2009 (p<0.01), concurrent with prevention of mother-to-child transmission scale-up. A further 1% of infants spent some time in non-parental care. Antenatal ART was associated with an 88% reduced abandonment risk (adjusted odds ratio (AOR) 0.12), versus receipt of single dose nevirapine only, and this was reflected in HIV infection prevalence in the two groups (17.1% of abandoned infants versus 6.6% in parental care). Mothers without a cohabiting partner or husband were more likely to abandon (AOR 4.08), as were active IDUs (AOR 3.27) and those with ≥1 previous children (AOR 1.89 for second-born and AOR 2.56 for subsequent births). Women delivering by elective caesarean section were less likely to abandon (AOR 0.37 versus vaginal), as were those leaving full-time education later (AOR 0.61 for 17-18 years versus ≤16 years and AOR 0.23 for ≥19 years versus ≤16 years). Interventions to extend family planning and IDU harm reduction services along with non-stigmatising antenatal care to marginalised women are needed, and may reduce abandonment.

Antiretroviral prophylaxis to prevent perinatal HIV transmission in St. Petersburg, Russia: too little, too late

BACKGROUND

We evaluated the influence of type and timing of prophylaxis on perinatal HIV transmission in St. Petersburg, Russia.

METHODS

We linked surveillance data for 1498 HIV-infected mothers delivering from 2004 to 2007 with polymerase chain reaction data for 1159 infants to determine predictors of transmission.

RESULTS

The overall perinatal transmission rate was 6.3% [73 of 1159, 95% confidence interval (CI) 4.9% to 7.7%]. Among the 12.8% (n = 149) of mother-infant pairs receiving full course (antenatal, intrapartum, postnatal) dual/triple antiretroviral prophylaxis, the transmission rate was 2.7%. Among the 1010 receiving less complete regimens (full course zidovudine, single-dose nevirapine, or incomplete), transmission ranged from 4.1% to 12.2%. Among the 28.9% (330) of mothers initiating antiretroviral drugs <or=20 weeks gestation, perinatal transmission was 1.8%, compared with 4.0%, 8.6%, and 11.3% for those initiating antiretrovirals at 21-28 weeks, 29-42 weeks, or during labor and delivery, respectively (P for trend <0.0001). Compared with those initiating antepartum prophylaxis <or=20 weeks, those initiating antepartum prophylaxis >or=29 weeks (or not at all) had increased transmission odds (adjusted odds ratio: 4.9, 95% CI: 1.8 to 12.9; odds ratio: 5.1, 95% CI: 2.0 to 13.1, respectively).

CONCLUSIONS

In St. Petersburg, the potential for further reductions in perinatal transmission is evident, given low transmission among women receiving early combination prophylaxis.

HIV testing near the patient: changing the face of HIV testing

Virological, epidemiologic, and operational barriers have slowed the progress toward effective management and eradication of HIV infection, despite significant advances in diagnosis since the early 1980s. Because early diagnosis profoundly affects the health care and survival of infected/high-risk individuals, and because the time required for conventional testing remains a barrier in many settings, rapid HIV testing has been developed for use both in the clinical laboratory and at the point of care. Recent studies have identified applications, advantages, and limitations of these assays, which may influence the development of new and more effective public health testing and screening protocols. In the United States, the Food and Drug Administration has approved the use of six rapid HIV tests. This review summarizes these modern rapid point-of-care HIV tests and their role in preventing the spread of HIV and in detecting, managing, and treating patients affected by the HIV pandemic.

Abandoned babies and absent policies

OBJECT

Although infant abandonment is a historical problem, we know remarkably little about the conditions or effects of abandonment to guide evidence driven policies. This paper briefly reviews the existing international evidence base with reference to potential mental health considerations before mapping current UK guidelines and procedures, and available incidence data. Limitations arising from these findings are discussed with reference to international practice, and interpreted in terms of future pathways for UK policy.

METHOD

A systematic approach was utilized to gather available data on policy information and statistics on abandoned babies in the UK.

RESULTS

A review of the limited literature indicates that baby abandonment continues to occur, with potentially wide-ranging mental health ramifications for those involved. However, research into such consequences is lacking, and evidence with which to understand risk factors or motives for abandonment is scarce. International approaches to the issue remain controversial with outcomes unclear. Our systematic search identified that no specific UK policy relating to baby abandonment exists, either nationally or institutionally. This is compounded by a lack of accurate of UK abandonment statistics. Data that does exist is not comprehensive and sources are incompatible, resulting in an ambiguous picture of UK baby abandonment.

CONCLUSIONS

Available literature indicates an absence of clear provision, policy and research on baby abandonment. Based on current understanding of maternal and child mental health issues likely to be involved in abandonment, existing UK strategy could be easily adapted to avoid the 'learning from scratch' approach. National policies on recording and handling of baby abandonments are urgently needed, and future efforts should be concentrated on establishing clear data collection frameworks to inform understanding, guide competent practice and enable successfully targeted interventions.

Abandoned babies in the UK - a review utilizing media reports

BACKGROUND

In the absence of national policy or comprehensive data, the phenomenon of abandoned babies is poorly understood in the UK. This study aims to use media reports as a resource to collate existing information on abandoned babies and to draw conclusions to inform future response.

METHODS

An exhaustive media search using electronic searches and media monitoring was undertaken to glean systematic information on all abandoned babies in the UK from 1998-2005. These were matched onto two databases - the UK Crime Statistics and the UK Abandoned Children Register in an attempt to align information on infant abandonment. Media reports were coded to list gender, survival, age, parental finding and circumstantial data.

RESULTS

Our figures suggest an average of 16 babies abandoned yearly, while official sources give conflicting indications because of incomplete data gathering and child over-inclusion. Through systematic coding of media reports, 124 babies were identified over a 7-year period. Of these, 96 (77.4%) were newborns (<1 week old) and 28 (22.6%) were older babies (>1 week old). Adjusted logistic regression analysis found the strongest predictors of survival were age at abandonment and 'findability'. Newborn babies were less likely to survive than older babies (33.7% newborns died vs. 0% older babies, P < 0.0001). Babies left in a non-findable location (34%) had a 5.19 (2.06, 13.11) higher odds of death compared with those to be found. Most babies (74%) were abandoned outdoors and only 9.7% were left with a memento. Few mothers, almost exclusively those of older babies, were found (37.1%). Of those found, 92% were located within 3 days of abandoning their baby. Media interest is transient - 44.8% cases have a single report - and are typified by negative headlines (81.5%).

CONCLUSIONS

This database currently represents the most accurate and comprehensive picture of the newborn abandonment phenomenon in the UK, a phenomenon that is rare but with high media and social interest. If the future well-being of mother and baby are to be catered for, clearer evidence-based policy and provision is vital.

Progress in prevention of mother-to-child transmission of HIV infection in Ukraine: results from a birth cohort study

Background

Ukraine was the epicentre of the HIV epidemic in Eastern Europe, which has the most rapidly accelerating HIV epidemic world-wide today; national HIV prevalence is currently estimated at 1.6%. Our objective was to evaluate the uptake and effectiveness of interventions for prevention of mother-to-child transmission (PMTCT) over an eight year period within operational settings in Ukraine, within the context of an ongoing birth cohort study.

Methods

The European Collaborative Study (ECS) is an ongoing birth cohort study in which HIV-infected pregnant women identified before or during pregnancy or at delivery were enrolled and their infants prospectively followed. Three centres in Ukraine started enrolling in 2000, with a further three joining in September 2006.

Results

Of the 3356 women enrolled, 21% (689) reported current or past injecting drug use (IDU). Most women were diagnosed antenatally and of those, the proportion diagnosed in the first/second trimester increased from 47% in 2000/01 (83/178) to 73% (776/1060) in 2006/07 (p < 0.001); intrapartum diagnosis was associated with IDU (Adjusted odds ratio 4.38; 95%CI 3.19–6.02). The percentage of women not receiving any antiretroviral prophylaxis declined from 18% (36/205) in 2001 to 7% in 2007 (61/843) (p < 0.001). Use of sdNVP alone substantially declined after 2003, with a concomitant increase in zidovudine prophylaxis. Median antenatal zidovudine prophylaxis duration increased from 24 to 72 days between 2000 and 2007. Elective caesarean section (CS) rates were relatively stable over time and 34% overall. Mother-to-child transmission (MTCT) rates decreased from 15.2% in 2001 (95%CI 10.2–21.4) to 7.0% in 2006 (95%CI 2.6–14.6). In adjusted analysis, MTCT risk was reduced by 43% with elective CS versus vaginal delivery and by 75% with zidovudine versus no prophylaxis.

Conclusion

There have been substantial improvements in use of PMTCT interventions in Ukraine, including earlier diagnosis of HIV-infected pregnant women and increasing coverage with antiretroviral prophylaxis and the initial MTCT rate has more than halved. Future research should focus on hard-to-reach populations such as IDU and on missed opportunities for further reducing the MTCT rate.

Rapid HIV testing and prevention of perinatal HIV transmission in high-risk maternity hospitals in St. Petersburg, Russia

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of a human immunodeficiency virus (HIV) rapid testing (RT) program.

STUDY DESIGN

From April 13, 2004, to April 13, 2005, pregnant women at 2 high-risk maternity hospitals with no or incomplete HIV testing results (negative tests at <34 weeks, none thereafter) were offered point-of-care RT, with antiretroviral prophylaxis for RT-positive women and their infants.

RESULTS

Overall, 89.2% of eligible women (3671/4117) underwent RT, of whom 90.4% received results before delivery. HIV seroprevalence among all women who underwent RT was 2.7% (100/3671 women); among previously untested women, seroprevalence was 6.5% (90/1375 women); the incidence of HIV seroconversion among women with previous negative tests during pregnancy was 0.4% (10/2296 women). After adjustment, the main predictor of receiving RT results after delivery was late admission. Among HIV-exposed infants, 97.9% (92/94) received prophylaxis; 61.7% (58/94) had available follow-up data, and 8.6% (5/58) met criteria for definitive or presumptive HIV infection.

CONCLUSION

The RT program achieved timely detection of HIV-infected women in labor with unknown HIV status and effectively prevented perinatal HIV transmission.

HIV seroprevalence in street youth, St. Petersburg, Russia

BACKGROUND

Reliable data on HIV infection among Russian street youth are unavailable. The purpose of this study was to assess HIV seroprevalence among street youth in St Petersburg and to describe social, sexual, and behavioral characteristics associated with HIV infection.

METHODS

A cross-sectional assessment conducted during January-May 2006 included city-wide mapping of 41 street youth locations, random selection of 22 sites, rapid HIV testing for all consenting 15-19-year-old male and female street youth at these sites, and an interviewer-administered survey. Adjusted odds ratios (AOR) were calculated using logistic regression, accounting for intracluster homogeneity.

RESULTS

Of 313 participants, 117 (37.4%, 95% confidence interval 26.1-50.2%) were HIV infected. Subgroups with the highest seroprevalences included double orphans (64.3%), those with no place to live (68.1%), those previously diagnosed with a sexually transmitted infection (STI; 70.5%), those currently sharing needles (86.4%), and those currently using inhalants (60.5%) or injection drugs (78.6%), including Stadol (82.3%) or heroin (78.1%). Characteristics independently associated with HIV infection included injecting drugs (AOR 23.0), sharing needles (AOR 13.3), being a double or single orphan (AOR 3.3 and 1.8), having no place to live (AOR 2.4), and being diagnosed with a STI (AOR 2.1). Most HIV-infected street youth were sexually active (96.6%), had multiple partners (65.0%), and used condoms inconsistently (80.3%).

DISCUSSION

Street youth aged 15-19 years in St Petersburg, Russia, have an extraordinarily high HIV seroprevalence. In street youth who are injection drug users, HIV seroprevalence is the highest ever reported for eastern Europe and is among the highest in the world.