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Kabami J, Koss CA, Sunday H, Biira E, Nyabuti M, Balzer LB, Gupta S, Chamie G, Ayieko J, Kakande E, Bacon MC, Havlir D, Kamya MR, Petersen M. Randomized Trial of Dynamic Choice HIV Prevention at Antenatal and Postnatal Care Clinics in Rural Uganda and Kenya. J Acquir Immune Defic Syndr 2024; 95:447-455. [PMID: 38489493 PMCID: PMC10927304 DOI: 10.1097/qai.0000000000003383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 11/30/2023] [Indexed: 03/17/2024]
Abstract
BACKGROUND Pregnant and postpartum women in Sub-Saharan Africa are at high risk of HIV acquisition. We evaluated a person-centered dynamic choice intervention for HIV prevention (DCP) among women attending antenatal and postnatal care. SETTING Rural Kenya and Uganda. METHODS Women (aged 15 years or older) at risk of HIV acquisition seen at antenatal and postnatal care clinics were individually randomized to DCP vs. standard of care (SEARCH; NCT04810650). The DCP intervention included structured client choice of product (daily oral pre-exposure prophylaxis or postexposure prophylaxis), service location (clinic or out of facility), and HIV testing modality (self-test or provider-administered), with option to switch over time and person-centered care (phone access to clinician, structured barrier assessment and counseling, and provider training). The primary outcome was biomedical prevention coverage-proportion of 48-week follow-up with self-reported pre-exposure prophylaxis or postexposure prophylaxis use, compared between arms using targeted maximum likelihood estimation. RESULTS Between April and July 2021, we enrolled 400 women (203 intervention and 197 control); 38% were pregnant, 52% were aged 15-24 years, and 94% reported no pre-exposure prophylaxis or postexposure prophylaxis use for ≥6 months before baseline. Among 384/400 participants (96%) with outcome ascertained, DCP increased biomedical prevention coverage 40% (95% CI: 34% to 47%; P < 0.001); the coverage was 70% in intervention vs. 29% in control. DCP also increased coverage during months at risk of HIV (81% in intervention, 43% in control; 38% absolute increase; 95% CI: 31% to 45%; P < 0.001). CONCLUSION A person-centered dynamic choice intervention that provided flexibility in product, testing, and service location more than doubled biomedical HIV prevention coverage in a high-risk population already routinely offered access to biomedical prevention options.
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Affiliation(s)
- Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | | | - Helen Sunday
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Edith Biira
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Marilyn Nyabuti
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Laura B. Balzer
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA; and
| | - Shalika Gupta
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA; and
| | - Gabriel Chamie
- Department of Medicine, University of California, San Francisco, CA
| | - James Ayieko
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elijah Kakande
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Melanie C. Bacon
- Department of Health and Human Services, National Institute of Health, Bethesda, MD
| | - Diane Havlir
- Department of Medicine, University of California, San Francisco, CA
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Maya Petersen
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA; and
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Dessale DS, Gebremariam MB, Wolde AA. HIV seroconversion and associated factors among seronegative pregnant women attending ANC in Ethiopia: an institution-based cross-sectional study. FRONTIERS IN REPRODUCTIVE HEALTH 2024; 6:1246734. [PMID: 38660333 PMCID: PMC11039893 DOI: 10.3389/frph.2024.1246734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 03/25/2024] [Indexed: 04/26/2024] Open
Abstract
Background In countries with limited resources, including Ethiopia, HIV is diagnosed using a rapid serological test, which does not detect the infection during the window period. Pregnant women who test negative for HIV on the first test may seroconvert throughout pregnancy. Women who are seroconverted during pregnancy may not have received interventions, as they are considered HIV-negative unless they are retested for HIV at the end of their pregnancy. Due to limited data on HIV seroconversion, this study aimed to measure the extent of HIV seroconversion and to identify associated factors among seronegative pregnant women attending ANC in Ethiopia. Methods Institution-based cross-sectional study was conducted among HIV-negative pregnant women attending the ANC in Ethiopia between June and July 2020. Socio-demographic, clinical, and behavioral data were collected through face-to-face questionnaires and participants' records review. HIV retesting was performed to determine the current HIV status of pregnant women. The data collected were entered into Epi data version 4.4.1 and were exported and analyzed by SPSS version 25. A p-value < 0.25 in the bivariate analysis was entered into multivariable logistic regression analysis and a p-value of < 0.05 was considered statistically significant. Result Of the 494 pregnant women who tested negative for HIV on their first ANC test, six (1.2%) tested positive on repeat testing. Upon multivariable logistic regression, pregnant women who have had a reported history of sexually transmitted infections [AOR = 7.98; 95% CI (1.21, 52.82)], participants' partners reported travel history for work frequently [AOR = 6.00; 95% CI (1.09, 32.99)], and sexually abused pregnant women [AOR = 7.82; 95% CI (1.194, 51.24)] were significantly associated with HIV seroconversion. Conclusion The seroconversion rate in this study indicates that pregnant women who are HIV-negative in early pregnancy are at an ongoing risk of seroconversion throughout their pregnancy. Thus, this study highlights the benefit of a repeat HIV testing strategy in late pregnancy, particularly when the risk of seroconversion or new infection cannot be convincingly excluded. Therefore, repeated testing of HIV-negative pregnant women in late pregnancy provides an opportunity to detect seroconverted pregnant women to enable the timely use of ART to prevent mother-to-child transmission of HIV infection.
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Affiliation(s)
- Dawit Sisay Dessale
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Asrat Arja Wolde
- National Data Management and Analytics Center, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
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Anderson K, Kalk E, Heekes A, Phelanyane F, Jacob N, Boulle A, Mehta U, Kassanjee R, Sridhar G, Ragone L, Vannappagari V, Davies M. Factors associated with vertical transmission of HIV in the Western Cape, South Africa: a retrospective cohort analysis. J Int AIDS Soc 2024; 27:e26235. [PMID: 38528395 PMCID: PMC10963590 DOI: 10.1002/jia2.26235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 03/07/2024] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION Monitoring mother-infant pairs with HIV exposure is needed to assess the effectiveness of vertical transmission (VT) prevention programmes and progress towards VT elimination. METHODS We used routinely collected data on infants with HIV exposure, born May 2018-April 2021 in the Western Cape, South Africa, with follow-up through mid-2022. We assessed the proportion of infants diagnosed with HIV at birth (≤7 days), 10 weeks (>1 to 14 weeks) and >14 weeks as proxies for intrauterine, intrapartum/early breastfeeding and late breastfeeding transmission, respectively. We used mixed-effects Poisson regression to assess factors associated with VT in mothers known with HIV by delivery. RESULTS We included 50,461 infants born to mothers known with HIV by delivery. HIV was diagnosed in 894 (1.8%) infants. Among mothers, 51% started antiretroviral treatment (ART) before and 27% during pregnancy; 17% restarted during pregnancy after ≥6 months interruption; and 6% had no recorded ART during pregnancy. Most pregnancy ART regimens included non-nucleoside reverse transcriptase inhibitors (83%). Of mothers with available results (90% with viral load [VL]; 70% with CD4), VL nearest delivery was <100 copies/ml in 78% and CD4 count ≥350 cells/μl in 62%. HIV-PCR results were available for 86%, 67% and 48% of eligible infants at birth, 10 weeks and >14 weeks. Among these infants, 0.9%, 0.4% and 1.5% were diagnosed positive at birth, 10 weeks and >14 weeks, respectively. Among infants diagnosed with HIV, 43%, 16% and 41% were diagnosed at these respective time periods. Among mothers with VL<100, 100-999, 1000-99,000 and ≥100,000 copies/ml nearest delivery, infant HIV diagnosis incidence was 0.4%, 2.3%, 6.6% and 18.4%, respectively. Increased VT was strongly associated with recent elevated maternal VL with a seven-fold increased rate with even modestly elevated VL (100-999 vs. <100 copies/ml). VT was also associated with unknown/low maternal CD4, maternal age <20 years, no antenatal ART, later maternal ART start/restart in pregnancy and ART gaps. CONCLUSIONS Despite high maternal ART coverage and routine postnatal prophylaxis, ongoing VT remains a concern. Timing of infant HIV diagnoses suggests intrapartum and/or breastfeeding transmission in nearly 60%. Interventions to ensure retention on ART and sustained maternal viral suppression are needed to reduce VT.
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Affiliation(s)
- Kim Anderson
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Emma Kalk
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Alexa Heekes
- Health Intelligence, Western Cape Department of HealthCape TownSouth Africa
| | | | - Nisha Jacob
- Division of Public Health MedicineSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
- Health Intelligence, Western Cape Department of HealthCape TownSouth Africa
- Division of Public Health MedicineSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Ushma Mehta
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Reshma Kassanjee
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | | | | | - Vani Vannappagari
- ViiV HealthcareDurhamNorth CarolinaUSA
- Department of EpidemiologyGilling School of Public HealthUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Mary‐Ann Davies
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
- Health Intelligence, Western Cape Department of HealthCape TownSouth Africa
- Division of Public Health MedicineSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
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Ogunyemi AO, Odeyemi KA, Okusanya BO, Olorunfemi G, Simon M, Balogun MR, Akanmu AS. Impact of training and case manager support for traditional birth attendants in the linkage of care among HIV-positive pregnant women in Southwest Nigeria: a 3-arm cluster randomized control trial. BMC Pregnancy Childbirth 2024; 24:153. [PMID: 38383378 PMCID: PMC10880323 DOI: 10.1186/s12884-024-06332-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 02/07/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Mother-to-child transmission (MTCT) accounts for 90% of all new paediatric HIV infections in Nigeria and for approximately 30% of the global burden. This study aimed to determine the effectiveness of a training model that incorporated case managers working closely with traditional birth attendants (TBAs) to ensure linkage to care for HIV-positive pregnant women. METHODS This study was a 3-arm parallel design cluster randomized controlled trial in Ifo and Ado-Odo Ota, Ogun State, Nigeria. The study employed a random sampling technique to allocate three distinct TBA associations as clusters. Cluster 1 received training exclusively; Cluster 2 underwent training in addition to the utilization of case managers, and Cluster 3 served as a control group. In total, 240 TBAs were enrolled in the study, with 80 participants in each of the intervention and control groups. and were followed up for a duration of 6 months. We employed a one-way analysis of variance (ANOVA) statistical test to evaluate the differences between baseline and endline HIV knowledge scores and PMTCT practices. Additionally, bivariate analysis using the chi-square test was used to investigate linkage to care. Furthermore, logistic regression analysis was utilized to identify TBA characteristics associated with various PMTCT interventions, including the receipt of HIV test results and repeat testing at term for HIV-negative pregnant women. The data analysis was performed using Stata version 16.1.877, and we considered results statistically significant when p values were less than 0.05. RESULTS At the end of this study, there were improvements in the TBAs' HIV and PMTCT-related knowledge within the intervention groups, however, it did not reach statistical significance (p > 0.05). The referral of pregnant clients for HIV testing was highest (93.5%) within cluster 2 TBAs, who received both PMTCT training and case manager support (p ≤ 0.001). The likelihood of HIV-negative pregnant women at term repeating an HIV test was approximately 4.1 times higher when referred by TBAs in cluster 1 (AOR = 4.14; 95% CI [2.82-5.99]) compared to those in the control group and 1.9 times in cluster 2 (AOR = 1.93; 95% CI [1.3-2.89]) compared to the control group. Additionally, older TBAs (OR = 1.62; 95% CI [1.26-2.1]) and TBAs with more years of experience in their practice (OR = 1.45; 95% CI [1.09-1.93]) were more likely to encourage retesting among HIV-negative women at term. CONCLUSIONS The combination of case managers and PMTCT training was more effective than training alone for TBAs in facilitating the linkage to care of HIV-positive pregnant women, although this effect did not reach statistical significance. Larger-scale studies to further investigate the benefits of case manager support in facilitating the linkage to care for PMTCT of HIV are recommended. TRIAL REGISTRATION The study was retrospectively registered in the Pan African Clinical Trial Registry, and it was assigned the unique identification number PACTR202206622552114.
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Affiliation(s)
- Adedoyin O Ogunyemi
- Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria.
| | - Kofoworola A Odeyemi
- Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Babasola O Okusanya
- Department of Obstetrics and Gyneacology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Gbenga Olorunfemi
- Division of Epidemiology and Biostatistics, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Melissa Simon
- Department of Obstetrics and Gynaecology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Mobolanle R Balogun
- Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Alani S Akanmu
- Department of Haematology and Blood Transfusion, College of Medicine, University of Lagos, Lagos State, Lagos, Nigeria
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Joseph Davey DL, Nyemba DC, Mvududu R, Mashele N, Johnson L, Bekker LG, Dean SS, Bheemraj K, Coates TJ, Myer L. Pregnancy outcomes following self-reported and objective-measured exposure to oral preexposure prophylaxis in South Africa. AIDS 2024; 38:75-83. [PMID: 37720980 PMCID: PMC10715696 DOI: 10.1097/qad.0000000000003729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/19/2023]
Abstract
OBJECTIVE To compare pregnancy outcomes using self-reported and objective levels of intracellular tenofovir diphosphate (TFV-DP) in pregnant women using preexposure prophylaxis (PrEP). DESIGN We enrolled pregnant women >15 years without HIV at first antenatal care visit in an observational cohort study to compare pregnancy outcomes by PrEP use. METHODS Exposure defined as: any PrEP use [tenofovir disoproxil and emtricitabine (TDF/FTC]) prescription + reported taking PrEP], or objectively-measured TFV-DP in dried blood spots in PrEP-using pregnant women. The primary outcome was a composite of pregnancy loss, preterm birth (<37weeks), low birthweight (<2500 g), small for gestational age ([SGA] ≤ tenth percentile), or neonatal death. Multivariable logistic regression models evaluated individual and composite adverse outcomes by self-reported or objectively measured PrEP use adjusting for age, gestational age, gravidity and socio-economic status. RESULTS Between August 19 and February 23, we followed 1195 pregnant women and ascertained 1145 pregnancy outcomes (96%); 72% ( n = 826) reported taking PrEP while pregnant, 16% did not take PrEP ( n = 178), 12% were unconfirmed ( n = 141). Overall, 94.5% ( n = 1082) had singleton live births with a median birthweight of 3.2 kg [interquartile range (IQR) = 2.9-3.5], with no difference in pregnancy loss between self-reported PrEP exposed vs. unexposed [4.0 vs. 5.6%; adjusted odds ratio (aOR) = 0.65, 95% confidence interval (CI) = 0.32-1.47]. Composite adverse outcomes did not differ by reported PrEP use (20% for both groups; aOR = 1.07, 95% CI = 0.71-1.63). Comparing objective PrEP use (any TFV-DP vs. no TFV-DP or not on PrEP), adverse outcomes did not differ (aOR = 0.64, 95% CI = 0.39-1.04), nor did other outcomes including preterm birth nor SGA. CONCLUSIONS Pregnancy outcomes did not differ by PrEP exposure (self-reported or objective), suggesting real-world efficacy that TDF/FTC as PrEP is safe in pregnancy.
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Affiliation(s)
- Dvora Leah Joseph Davey
- Department of Epidemiology, Fielding School of Public Health
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
| | - Dorothy C. Nyemba
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
- Wits RHI, University of the Witwatersrand, Johannesburg
| | - Rufaro Mvududu
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
| | - Nyiko Mashele
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
| | - Leigh Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | | | - Sarah Schoetz Dean
- Department of Epidemiology, Fielding School of Public Health
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Kalisha Bheemraj
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
| | - Thomas J. Coates
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town
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Mmotsa TM, Magasana V, Nsibande DF, Buthelezi M, Dassaye R, Rodriguez VJ, Jones DL, Goga AE, Ngandu NK. Mixed-methods cross-sectional study of the prevention of vertical HIV transmission program users unaware of male partner's HIV status, in six South African districts with a high antenatal HIV burden. BMC Public Health 2023; 23:1988. [PMID: 37828512 PMCID: PMC10571358 DOI: 10.1186/s12889-023-16921-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 10/06/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Elimination of vertical HIV Transmission (VHT) and maternal deaths are global health priorities. Male involvement is one of the most important factors that influences women's decisions, including the uptake of Prevention of vertical HIV transmission (P-VHT). We sought to understand not knowing a male partner's HIV status (MPHIVs) amongst women using services to prevent vertical HIV transmission in six South African districts with high antenatal HIV burden. METHODS A mixed-methods cross-sectional study was conducted in six South African districts, and data collected through face-to-face interviews with women and focus group discussions (FGDs) with women or male partners. The quantitative data were analyzed using STATA SE-17.0 and an inductive approach was used for qualitative data analysis. RESULTS Overall, 28.7% of women were unaware of their MPHIVs, while 25.3% and 46.0% knew the MPHIVs was positive or negative, respectively. In multivariable logistic regression, single marital status and unplanned pregnancy increased the odds of not knowing a MPHIVs while a woman's disclosure of her HIV status to the male partner reduced the odds. FDGs highlighted complexities around MPHIVs disclosure, e.g., reluctance to test for HIV and potential interventions including healthcare worker (HCW) assisted HIV disclosure. CONCLUSION User-informed interventions to address MPHIVs non-disclosure amongst women of child-bearing age, particularly those at risk of unstable sexual partners and unplanned pregnancies, should be strengthened.
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Affiliation(s)
- Tshiamo M Mmotsa
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Vuyolwethu Magasana
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Duduzile F Nsibande
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Mbongeleni Buthelezi
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Reshmi Dassaye
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Violeta J Rodriguez
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Psychology (Clinical/Community Division), University of Illinois at Urbana-Champaign, Champaign, IL, United States of America
| | - Deborah L Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ameena E Goga
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa
| | - Nobubelo K Ngandu
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa.
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Wagner AD, Beima-Sofie K, Awuor M, Owade W, Neary J, Dettinger JC, Pintye J, Abuna F, Lagat H, Weiner BJ, Kohler P, Kinuthia J, John-Stewart G, O’Malley G. Implementation determinants and strategies in integration of PrEP into maternal and child health and family planning services: experiences of frontline healthcare workers in Kenya. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1205925. [PMID: 37799494 PMCID: PMC10548203 DOI: 10.3389/frph.2023.1205925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/04/2023] [Indexed: 10/07/2023] Open
Abstract
Background Delivery of PrEP to adolescent girls and young women (AGYW) and to pregnant women through maternal and child health (MCH) and family planning (FP) clinics is scaling up in Kenya. Evaluation of implementation challenges and strategies is critical to optimize delivery. Methods We conducted focus group discussions (FGDs) with healthcare workers (HCWs) in MCH and FP clinics offering PrEP in a large implementation project in Kisumu, Kenya. Discussion guides were based on the Consolidated Framework for Implementation Research (CFIR). FGDs were audio recorded and transcribed. Directed content analysis was used to identify implementation challenges and strategies to overcome them. Results Fifty HCWs from 26 facilities participated in 8 FGDs. HCWs believed PrEP integration was appropriate because it met the needs of AGYW and pregnant women by providing a female-controlled prevention strategy and aligned with policy priorities of elimination of vertical HIV transmission. They were universally accepting of PrEP provision, especially through MCH clinics, noting the relative advantage of this approach because it: (1) enabled high coverage, (2) harmonized PrEP and MCH visits, and (3) minimized stigma compared to PrEP offered through HIV care clinics. However, HCWs noted implementation challenges affecting feasibility and adoption including: (1) increased workload and documentation burden amid workforce shortages, (2) insufficient health care worker knowledge (3) multiple implementing partners with competing priorities (4) drug and documentation form stockouts. HCWs employed various implementation strategies to overcome challenges, including task shifting from nurses to HIV testing providers, patient flow modifications (e.g., fast-tracking PrEP clients to reduce wait times), PrEP demand generation and myth clarification during health talks, provider education, dedicated PrEP delivery rooms, and coordination with adolescent-friendly services. Additional suggested strategies to improve PrEP integration included community education to increase broader PrEP awareness and enable shorter counseling sessions, and task-shifting data entry and client risk assessments. Conclusions HCWs were enthusiastic about the appropriateness and acceptability of integrating PrEP services into MCH and FP clinics but noted challenges to adoption and feasibility. Strategies to address challenges focused on improving provider time and space constraints, and increasing provider and client knowledge.
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Affiliation(s)
- Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Kristin Beima-Sofie
- Department of Global Health, University of Washington, Seattle, WA, United States
| | | | | | - Jillian Neary
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Julia C. Dettinger
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Jillian Pintye
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, United States
| | - Felix Abuna
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Harison Lagat
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Bryan J. Weiner
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, United States
| | - Pamela Kohler
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, WA, United States
| | - John Kinuthia
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Departments of Pediatrics and Medicine, University of Washington, Seattle, WA, United States
| | - Gabrielle O’Malley
- Department of Global Health, University of Washington, Seattle, WA, United States
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Chappell E, Chimwaza A, Manika N, Wedderburn CJ, Mupambireyi Nenguke Z, Gannon H, Cowan F, Gibb T, Heys M, Fitzgerald F, Phillips A, Chimhuya S, Gibb DM, Ford D, Mushavi A, Bwakura-Dangarembizi M. Impact of the COVID-19 pandemic on the provision and uptake of services for the prevention of mother-to-child transmission of HIV in Zimbabwe. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002296. [PMID: 37578953 PMCID: PMC10424857 DOI: 10.1371/journal.pgph.0002296] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 07/21/2023] [Indexed: 08/16/2023]
Abstract
Zimbabwe is targeting elimination of mother-to-child transmission of HIV by December 2025, however the COVID-19 pandemic challenged health service delivery globally. Monthly aggregated data were extracted from DHIS-2 for all facilities delivering antenatal care (ANC). ZIMSTAT and Spectrum demographic estimates were used for population-level denominators. Programme indicators are among those in HIV care and population indicators reflect the total population. The mean estimated proportion of pregnant women booking for ANC per month did not change (91% pre-pandemic vs 91% during pandemic, p = 0.95), despite dropping to 47% in April 2020. At a programme-level, the estimated proportion of women who received at least one HIV test fell in April 2020 (3.6% relative reduction vs March (95% CI 2.2-5.1), p<0.001) with gradual recovery towards pre-pandemic levels. The estimated proportion of women who were retested among those initially negative in pregnancy fell markedly in April 2020 (39% reduction (32-45%), p<0.001) and the subsequent increase was much slower, only reaching 39% by September 2021 compared to average 53% pre-pandemic. The mean estimated proportion of pregnant women with HIV on ART was unchanged at programme-level (98% vs 98%, p = 0.26), but decreased at population-level (86% vs 80%, p = 0.049). Antiretroviral prophylaxis coverage decreased among HIV-exposed infants, at programme- (94% vs 87%, p = 0.001) and population-levels (76% vs 68%, p<0.001). There was no significant change in HIV-exposed infants receiving EID (programme: 107% vs 103%, p = 0.52; population: 87% vs 79%, p = 0.081). The estimated proportion of infants with HIV diagnosed fell from 27% to 18%, (p<0.001), while the estimated proportion on ART was stable at a programme (88% vs 90%, p = 0.82) but not population (22% vs 16%, p = 0.004) level. Despite a drop at the start of the pandemic most programme indicators rapidly recovered. At a population-level indicators were slower to return, suggesting less women with HIV identified in care.
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Affiliation(s)
| | | | - Ngoni Manika
- Ministry of Health and Child Care, Harare, Zimbabwe
| | - Catherine J. Wedderburn
- MRC Clinical Trials Unit at UCL, London, United Kingdom
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | | | - Hannah Gannon
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Frances Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Tom Gibb
- Picturing Health, United Kingdom
| | - Michelle Heys
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Felicity Fitzgerald
- Department of Infectious Disease, Imperial College London, London, United Kingdom
| | | | - Simbarashe Chimhuya
- Child and Adolescent Health Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Diana M. Gibb
- MRC Clinical Trials Unit at UCL, London, United Kingdom
| | - Deborah Ford
- MRC Clinical Trials Unit at UCL, London, United Kingdom
| | | | - Mutsa Bwakura-Dangarembizi
- Child and Adolescent Health Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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9
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Masenyetse LJ, Greenberg L, Samonyane F, Sekepe B, Mokone M, Mokone MJ, Tukei VJ, Beres LK. Oral HIV pre-exposure prophylaxis use among pregnant and postpartum women: results from real-world implementation in Lesotho. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1221752. [PMID: 37583546 PMCID: PMC10425268 DOI: 10.3389/frph.2023.1221752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/07/2023] [Indexed: 08/17/2023] Open
Abstract
Introduction Lesotho has reached epidemic control, PrEP is an important component in maintaining that and in reaching the goal of eliminating mother-to-child transmission. Methods We conducted a retrospective review of existing, routine PrEP health records in 26 health facilities in Lesotho. PrEP visit data were collected for pregnant and postpartum women screened for PrEP and/or enrolled in PrEP programs from 1 January 2019 through 30 June 2021 with follow-up data collected up to the date of data abstraction per site between October 2021 and May 2022. Poisson regression with robust variance was used to evaluate the association between patient characteristics and continuation of PrEP. Results Indications for starting PrEP were significantly associated with continuation in PrEP use. Women starting PrEP due to having a partner known to be living with HIV were the most likely to return for follow-up. In all age groups, the most common reason for starting PrEP was being in a serodiscordant relationship, though the proportion varies by age. Conclusion As Lesotho is now in the process of optimizing PrEP use among pregnant and postpartum women, it is critical to revise data sources to capture information that will link PrEP records and ANC/PNC records and document pregnancy/postpartum status in order to better understand PrEP use and gaps in this population.
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Affiliation(s)
| | - Lauren Greenberg
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States
| | | | - Bokang Sekepe
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | | | | | - Vincent J. Tukei
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
- Elizabeth Glaser Pediatric AIDS Foundation, Mbabane, Eswatini
| | - Laura K. Beres
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
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Kinuthia J, Dettinger JC, Stern J, Ngumbau N, Ochieng B, Gómez L, Abuna F, Watoyi S, Marwa M, Odinga D, Wagner AD, Richardson BA, Pintye J, Baeten JM, John‐Stewart G. Risk-based versus universal PrEP delivery during pregnancy: a cluster randomized trial in Western Kenya from 2018 to 2019. J Int AIDS Soc 2023; 26:e26061. [PMID: 36807505 PMCID: PMC9939942 DOI: 10.1002/jia2.26061] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/19/2023] [Indexed: 02/22/2023] Open
Abstract
INTRODUCTION Integrating pre-exposure prophylaxis (PrEP) delivery for pregnant and postpartum women within maternal and child health (MCH) clinics is feasible and acceptable. It is unknown whether a risk-guided model would facilitate appropriate PrEP use among MCH attendees better than universally offering PrEP. METHODS The PrEP Implementation for Mothers in Antenatal Care (PrIMA) study was a cluster randomized trial to assess two models for PrEP delivery among pregnant women seeking routine MCH care at 20 public clinics in Kenya between January 2018 and July 2019 (NCT03070600). In the Universal arm, all participants received PrEP counselling and self-selected whether to initiate PrEP. In the Targeted arm, participants underwent an HIV risk assessment, including an objective risk-scoring tool and an offer of HIV self-tests for at-home partner testing; those determined to be at high risk received a PrEP offer. Participants were followed through 9 months postpartum. Primary outcomes included incident HIV and appropriate PrEP use (defined as PrEP uptake among those at high risk and no PrEP uptake for those not at risk). Outcomes were compared using intention-to-treat analyses, adjusting for baseline HIV risk and marital status. RESULTS Among 4447 women enrolled, the median age was 24.0 years (interquartile range [IQR]: 20.9, 28.3), and most were married (84.8%). The median gestational age at enrolment was 24 weeks (IQR: 20, 30). Women in the Targeted arm were more likely to be at high risk for HIV acquisition at baseline (51.6% vs. 33.3%). During 4638 person-years (p-yr) of follow-up, there were 16 maternal HIV infections with no difference in maternal HIV incidence between arms: 0.31/100 p-yr (95% CI: 0.15, 0.65) Targeted and 0.38/100p-yr (95% CI: 0.20, 0.73) Universal (adjusted relative risk [aRR]: 0.85 [CI: 0.28, 2.55]). There was no significant difference in the frequency of appropriate PrEP use between the arms (68.2% vs. 59.1% in Targeted vs. Universal, respectively) (aRR: 1.03 [CI: 0.96, 1.10]). CONCLUSIONS Given comparable maternal HIV incidence and PrEP uptake in Universal and Targeted approaches, and the simplicity that universal PrEP offers, our findings suggest that universal PrEP counselling is optimal for integrating PrEP in MCH systems.
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Affiliation(s)
- John Kinuthia
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | | | - Joshua Stern
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Nancy Ngumbau
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Ben Ochieng
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Laurén Gómez
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Felix Abuna
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Salphine Watoyi
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Mary Marwa
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Daniel Odinga
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | - Anjuli D. Wagner
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Barbra A. Richardson
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA,Department of BiostatisticsUniversity of WashingtonSeattleWashingtonUSA,Division of Allergy and Infectious DiseasesUniversity of WashingtonSeattleWashingtonUSA,Vaccine and Infectious Disease DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA
| | - Jillian Pintye
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA,Department of Behavioral Nursing & Health InformaticsUniversity of WashingtonSeattleWashingtonUSA
| | - Jared M. Baeten
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA,Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA,Gilead SciencesFoster CityCaliforniaUSA
| | - Grace John‐Stewart
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA,Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA,Department of PediatricsUniversity of WashingtonSeattleWashingtonUSA
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11
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Mogaka JN, Otieno FA, Akim E, Beima-Sofie K, Dettinger J, Gomez L, Marwa M, Odhiambo B, Ngure K, Ronen K, Sharma M, John-Stewart G, Richardson B, Stern J, Unger J, Udren J, Watoyi S, Pintye J, Kinuthia J. A Text Messaging-Based Support Intervention to Enhance Pre-exposure Prophylaxis for HIV Prevention Adherence During Pregnancy and Breastfeeding: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e41170. [PMID: 36716092 PMCID: PMC9926344 DOI: 10.2196/41170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/22/2022] [Accepted: 12/06/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Cisgender women in Kenya are at elevated risk of HIV acquisition during pregnancy and post partum. Acute HIV infection during pregnancy and breastfeeding accounts for approximately one-third of all vertical HIV transmissions. The World Health Organization recommends offering oral tenofovir-based pre-exposure prophylaxis (PrEP) to pregnant and postpartum women who are HIV negative but at substantial and ongoing risk for HIV acquisition. PrEP delivery for pregnant and postpartum women is expanding within routine maternal child health clinics in Kenya. However, approximately half of pregnant women discontinue PrEP within 30 days of initiation. Therefore, it is crucial to develop PrEP adherence strategies that enhance support for adherence when peripartum events and health issues pose challenges to sustaining PrEP adherence. OBJECTIVE We are conducting a randomized controlled trial to determine the effect of a bidirectional communication platform named Mobile Solutions for Women's and Children's Health (mWACh), which utilizes two-way SMS text messaging between patients and remote nurses to support PrEP adherence and address maternal health concerns in real time during the peripartum period. METHODS The mWACh-PrEP study is a randomized trial designed to support PrEP adherence during the peripartum period by comparing mWACh-PrEP to the standard of care (ie, in-clinic adherence counseling) among women who are HIV negative and initiating PrEP. Purposive sampling was used to select 5 facilities offering PrEP in antenatal clinics in Kisumu and Siaya Counties, and block randomization will be used to divide participants into groups. Participants in the intervention arm will receive a customized messaging curriculum via SMS text messages targeted toward their particular perinatal stage. The primary outcome, PrEP adherence at 6 months post partum, will be evaluated using a log-binomial regression model, adjusting for imbalanced baseline characteristics. Based on a previous study of directly observed dosing conditions, we will use a hair tenofovir concentration cutoff of 0.038 ng/mg (corresponding to 7 doses/week) as the primary adherence outcome measured at 6 months post partum (binary outcome). Qualitative interviews and cost-effective analyses will be conducted to understand the feasibility, acceptability, and economic impact of the intervention. RESULTS Enrollment began in March 2022 and is projected to continue until July 2023, with follow-up through March 2024. The study results are expected to be reported in 2025. CONCLUSIONS This trial will provide insights into using mobile health to enhance PrEP adherence among pregnant and postpartum mothers. Additionally, the findings will have implications for the use of mobile health technology to improve adherence to other daily medications during the peripartum period. TRIAL REGISTRATION ClinicalTrials.gov NCT04472884; https://clinicaltrials.gov/ct2/show/NCT04472884. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/41170.
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Affiliation(s)
| | | | | | - Kristin Beima-Sofie
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Julia Dettinger
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Lauren Gomez
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Mary Marwa
- Kenyatta National Hospital, Nairobi, Kenya
| | | | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, WA, United States
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Keshet Ronen
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Barbra Richardson
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Joshua Stern
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Jennifer Unger
- Department of Global Health, University of Washington, Seattle, WA, United States
- Women and Infants Hospital, Providence, RI, United States
| | - Jenna Udren
- Department of Global Health, University of Washington, Seattle, WA, United States
| | | | - Jillian Pintye
- School of Nursing, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - John Kinuthia
- Kenyatta National Hospital, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, WA, United States
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12
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Mussa A, Mayondi GK, Diseko M, Mabuta J, Mmalane M, Makhema J, Lockman S, Morroni C, Shapiro R, Zash R. Incident HIV acquisition among pregnant women in Botswana: findings from the Tsepamo birth outcomes surveillance study. J Int AIDS Soc 2023; 26:e26008. [PMID: 36691796 PMCID: PMC9871722 DOI: 10.1002/jia2.26008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 08/24/2022] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION In Botswana, where almost all pregnant women known to have HIV receive antiretroviral therapy, a large proportion of vertical HIV transmission may occur among women with incident undiagnosed HIV infection during pregnancy. Botswana guidelines recommend repeat HIV testing every 3 months in pregnancy, with at least one test in the third trimester. We evaluated the rate of repeat HIV testing, calculated HIV incidence during pregnancy and estimated missed seroconversions. METHODS In the Botswana Tsepamo Study, we abstracted HIV test dates and results from obstetric records of all women who delivered at maternity wards in 18 communities between 7th May 2017 and 20th August 2021. We defined seroconversion as an initial negative/indeterminate HIV test in pregnancy followed by a positive test during pregnancy/at delivery. The incidence rate (IR) of seroconversion was calculated among women with > = 2 known test dates. Missed seroconversions were estimated among women without a test in the third trimester by applying the IR to the time after the last HIV test until delivery. RESULTS Among 103,529 women delivering in the study period testing negative at the first test and with known conception and HIV test dates, 29,085 (28%) were tested in one trimester of pregnancy, 73,156 (71%) were tested in ≥ 2 trimesters of pregnancy and 9628 (9%) had a test in all trimesters. A total of 78,162 (75%) women had a third-trimester test. There were 223 seroconversions (2.58/1000 pregnancies, 0.26%) among those with ≥ 2 known HIV test dates, yielding an IR of 0.69/100 person-years. Among 25,289 women who did not have a test in the third trimester, we estimate approximately 58 seroconversions may have been missed during pregnancy due to a lack of repeat testing. Factors associated with seroconversion during pregnancy included younger age, less education and not being married. CONCLUSIONS More than two-thirds of women had repeat HIV testing in pregnancy and HIV incidence was low. However, an estimated 21% of seroconversions in pregnancy were likely missed due to a lack of re-testing. To reach the goal of zero new paediatric HIV infections, Botswana will need to intensify repeat HIV testing in the third trimester of pregnancy.
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Affiliation(s)
- Aamirah Mussa
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Usher InstituteUniversity of EdinburghEdinburghUK
| | | | - Modiegi Diseko
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Judith Mabuta
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | | | - Joseph Makhema
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Shahin Lockman
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Brigham and Women's HospitalBostonMassachusettsUSA
- Harvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Chelsea Morroni
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- MRC Centre for Reproductive Health and Centre for Global HealthUniversity of EdinburghEdinburghUK
| | - Roger Shapiro
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Harvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Rebecca Zash
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Beth Israel Deaconess Medical CenterBostonMassachusettsUSA
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Dugdale CM, Ufio O, Alba C, Permar SR, Stranix‐Chibanda L, Cunningham CK, Fouda GG, Myer L, Weinstein MC, Leroy V, McFarland EJ, Freedberg KA, Ciaranello AL. Cost-effectiveness of broadly neutralizing antibody prophylaxis for HIV-exposed infants in sub-Saharan African settings. J Int AIDS Soc 2023; 26:e26052. [PMID: 36604316 PMCID: PMC9816086 DOI: 10.1002/jia2.26052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 11/28/2022] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Infant HIV prophylaxis with broadly neutralizing anti-HIV antibodies (bNAbs) could provide long-acting protection against vertical transmission. We sought to estimate the potential clinical impact and cost-effectiveness of hypothetical bNAb prophylaxis programmes for children known to be HIV exposed at birth in three sub-Saharan African settings. METHODS We conducted a cost-effectiveness analysis using the CEPAC-Pediatric model, simulating cohorts of infants from birth through death in Côte d'Ivoire, South Africa and Zimbabwe. These settings were selected to reflect a broad range of HIV care cascade characteristics, antenatal HIV prevalence and budgetary constraints. We modelled strategies targeting bNAbs to only WHO-designated "high-risk" HIV-exposed infants (HR-HIVE) or to all HIV-exposed infants (HIVE). We compared four prophylaxis approaches within each target population: standard of care oral antiretroviral prophylaxis (SOC), and SOC plus bNAbs at birth (1-dose), at birth and 3 months (2-doses), or every 3 months throughout breastfeeding (Extended). Base-case model inputs included bNAb efficacy (60%/dose), effect duration (3 months/dose) and costs ($60/dose), based on published literature. Outcomes included paediatric HIV incidence and incremental cost-effectiveness ratios (ICERs) calculated from discounted life expectancy and lifetime HIV-related costs. RESULTS The model projects that bNAbs would reduce absolute infant HIV incidence by 0.3-2.2% (9.6-34.9% relative reduction), varying by country, prophylaxis approach and target population. In all three settings, HR-HIVE-1-dose would be cost-saving compared to SOC. Using a 50% GDP per capita ICER threshold, HIVE-Extended would be cost-effective in all three settings with ICERs of $497/YLS in Côte d'Ivoire, $464/YLS in South Africa and $455/YLS in Zimbabwe. In all three settings, bNAb strategies would remain cost-effective at costs up to $200/dose if efficacy is ≥30%. If the bNAb effect duration were reduced to 1 month, the cost-effective strategy would become HR-HIVE-1-dose in Côte d'Ivoire and Zimbabwe and HR-HIVE-2-doses in South Africa. Findings regarding the cost-effectiveness of bNAb implementation strategies remained robust in sensitivity analyses regarding breastfeeding duration, maternal engagement in postpartum care, early infant diagnosis uptake and antiretroviral treatment costs. CONCLUSIONS At current efficacy and cost estimates, bNAb prophylaxis for HIV-exposed children in sub-Saharan African settings would be a cost-effective intervention to reduce vertical HIV transmission.
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Affiliation(s)
- Caitlin M. Dugdale
- Medical Practice Evaluation CenterDepartment of MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Division of Infectious DiseasesDepartment of MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Ogochukwu Ufio
- Medical Practice Evaluation CenterDepartment of MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Christopher Alba
- Medical Practice Evaluation CenterDepartment of MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Sallie R. Permar
- Department of PediatricsWeill Cornell MedicineNew YorkNew YorkUSA
- Department of PediatricsNew York‐Presbyterian/Weill Cornell Medical CenterNew YorkNew YorkUSA
| | - Lynda Stranix‐Chibanda
- Child and Adolescent Health UnitFaculty of Medicine and Health SciencesUniversity of ZimbabweHarareZimbabwe
| | - Coleen K. Cunningham
- Department of PediatricsUniversity of California IrvineIrvineCaliforniaUSA
- Department of PediatricsChildren's Hospital of Orange CountyOrangeCaliforniaUSA
| | - Genevieve G. Fouda
- Department of PediatricsDuke University Medical CenterDurhamNorth CarolinaUSA
- Duke Human Vaccine InstituteDurhamNorth CarolinaUSA
| | - Landon Myer
- Division of Epidemiology and BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Milton C. Weinstein
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Valériane Leroy
- CERPOP, InsermToulouse UniversityUniversité Paul SabatierToulouseFrance
| | - Elizabeth J. McFarland
- Department of PediatricsUniversity of Colorado Anschutz Medical Campus and Children's Hospital ColoradoAuroraColoradoUSA
| | - Kenneth A. Freedberg
- Medical Practice Evaluation CenterDepartment of MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Division of Infectious DiseasesDepartment of MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of General Internal MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Andrea L. Ciaranello
- Medical Practice Evaluation CenterDepartment of MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Division of Infectious DiseasesDepartment of MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
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Wyatt MA, Pisarski EE, Kriel Y, Smith PM, Mathenjwa M, Jaggernath M, Smit JA, Matthews LT, Ware NC. Influences on PrEP Uptake and Adherence Among South African Women During Periconception and Pregnancy: A Qualitative Analysis. AIDS Behav 2023; 27:208-217. [PMID: 35771311 PMCID: PMC9245881 DOI: 10.1007/s10461-022-03757-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2022] [Indexed: 01/24/2023]
Abstract
Pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, yet PrEP delivery to women in periconception and pregnancy has lagged. We report qualitative research from a study evaluating PrEP use as part of safer conception care for 330 South African women. Fifty-two semi-structured interviews were conducted with 25 study participants to identify influences on PrEP adherence. Influences were: (1) changing proximity to male partners; (2) COVID-19 lockdown; (3) mobile lifestyle; (4) PrEP-related stigma; (5) disclosure of PrEP use; and (6) pregnancy and motherhood. Data also revealed important contextual information shaping adherence influences for women, including: (a) not living with partners, (b) partners as drivers of pregnancy intention, and (c) feeling at high risk for HIV. Disclosure of PrEP use, addressing stigma, strategies for traveling with pills, and counseling on prevention effective adherence are promising components of PrEP-inclusive HIV prevention interventions for South African women who are pregnant or planning pregnancy.
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Affiliation(s)
- Monique A. Wyatt
- Department of Global Health & Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, USA ,Harvard Global, Cambridge, MA USA
| | - Emily E. Pisarski
- Department of Global Health & Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, USA
| | - Yolandie Kriel
- Maternal Adolescent and Child Health Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, KZN South Africa
| | - Patricia M. Smith
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL USA
| | - Mxolisi Mathenjwa
- Maternal Adolescent and Child Health Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, KZN South Africa
| | - Manjeetha Jaggernath
- Maternal Adolescent and Child Health Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, KZN South Africa
| | - Jennifer A. Smit
- Maternal Adolescent and Child Health Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, KZN South Africa
| | - Lynn T. Matthews
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL USA
| | - Norma C. Ware
- Department of Global Health & Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, USA ,Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
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Mugambi ML, Pintye J, Heffron R, Barnabas RV, John-Stewart G. HIV Prevention Tools Across the Pregnancy Continuum: What Works, What Does Not, and What Can We Do Differently? Curr HIV/AIDS Rep 2022; 19:293-300. [PMID: 35984551 PMCID: PMC9717592 DOI: 10.1007/s11904-022-00621-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Multiple tools exist to support the primary prevention of HIV in pregnant and postpartum women; however, there are opportunities to enhance their use and impact. This review summarizes the current status of HIV prevention tools and existing gaps and opportunities to improve their use along the pregnancy care continuum. RECENT FINDINGS HIV screening efforts have steadily improved with close to universal screening of pregnant women in several East and Southern African countries. Strategies to implement partner testing through the distribution of HIV self-test kits are promising though linkage to care remains challenging. Syphilis screening rates are increasing though detection of other sexually transmitted infections could benefit from improved diagnostic capacity. Male and female condoms are rarely used and are often not the optimal tool of choice during pregnancy. Oral pre-exposure prophylaxis (PrEP) is a promising tool, although barriers such as the need for daily adherence, side effects, and stigma may limit its use. There is a growing pipeline of PrEP agents with alternative delivery platforms that might suit women's preferences better and supports the notion that choice is vital to improving HIV prevention coverage during the pregnancy-postpartum continuum. Clear guidance on which tools to use and how to use them, safety data supporting their use, and surveillance data documenting the scale and effectiveness of the tools will be imperative in establishing a path to more impactful prevention efforts among pregnant and postpartum women.
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Affiliation(s)
- Melissa Latigo Mugambi
- Department of Global Health, Hans Rosling Center, University of Washington, 3980 15th Ave NE, Box 351620, Seattle, WA, 98195, USA.
| | - Jillian Pintye
- Department of Global Health, Hans Rosling Center, University of Washington, 3980 15th Ave NE, Box 351620, Seattle, WA, 98195, USA
- School of Nursing, University of Washington, Seattle, WA, USA
| | - Renee Heffron
- Department of Global Health, Hans Rosling Center, University of Washington, 3980 15th Ave NE, Box 351620, Seattle, WA, 98195, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- University of Alabama Birmingham, Birmingham, AB, USA
| | - Ruanne Vanessa Barnabas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Grace John-Stewart
- Department of Global Health, Hans Rosling Center, University of Washington, 3980 15th Ave NE, Box 351620, Seattle, WA, 98195, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
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16
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Hill LM, Golin CE, Saidi F, Phanga T, Tseka J, Young A, Pearce LD, Maman S, Chi BH, Mutale W. Understanding PrEP decision making among pregnant women in Lilongwe, Malawi: A mixed-methods study. J Int AIDS Soc 2022; 25:e26007. [PMID: 36074034 PMCID: PMC9454413 DOI: 10.1002/jia2.26007] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 08/23/2022] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Pre-exposure prophylaxis (PrEP) is a promising tool for HIV prevention during pregnancy. With increasing rollout in antenatal settings, counselling strategies to help pregnant women make appropriate decisions about PrEP use are needed. Understanding women's motivations and concerns for PrEP use-and how these inform their decision making and feelings about the decision to start PrEP-are critical to inform these strategies. METHODS We conducted a convergent mixed-methods study from June 2020 to June 2021 in the context of a PrEP adherence support trial among HIV-negative pregnant women in Lilongwe, Malawi. Two hundred women completed a survey reporting their motivations and concerns about PrEP use, and their feelings about the decision to start PrEP (Decisional Regret Scale). Thirty women completed in-depth interviews to better understand the decision-making process, including motivations and concerns weighed in women's decision to use PrEP. Analyses comprised descriptive and bivariate statistics, thematic qualitative analysis, and integration of quantitative and qualitative results. RESULTS Women initiating PrEP during pregnancy were highly motivated to obtain HIV protection for themselves and their unborn child, often due to perceived HIV risk connoted by a recent sexually transmitted infection and/or concerns about partner non-monogamy. These motivations prevailed despite some concerns about safety and side effects, anticipated stigmatization, and concerns about adherence burden and pill attributes. Many women had informed their partner of their decision to use PrEP yet few felt their decision was contingent upon partner approval. Most women felt positively about the decision to start PrEP (mean decisional regret = 1.2 out of 5), but those with a greater number of concerns reported greater decisional regret (B = 0.036; p = 0.005). Furthermore, women who were specifically concerned about partner disclosure, who disliked pills or who had no perceived HIV risk reported greater decisional regret. CONCLUSIONS Pregnant women were strongly motivated by the promise of HIV protection offered by PrEP and accepted it despite diverse concerns. A shared decision-making approach that centres pregnant women and offers partner involvement may help identify and address initial concerns about PrEP use and support prevention-effective use of PrEP during this important period.
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Affiliation(s)
- Lauren M. Hill
- Department of Health BehaviorUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Carol E. Golin
- Department of Health BehaviorUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Friday Saidi
- UNC Project‐MalawiLilongweMalawi
- Department of Obstetrics and GynecologySchool of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | | | | | - Alinda Young
- Department of Maternal and Child HealthUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Lisa D. Pearce
- Department of SociologyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Suzanne Maman
- Department of Health BehaviorUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Benjamin H. Chi
- Department of Obstetrics and GynecologySchool of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Wilbroad Mutale
- Department of Health PolicyUniversity of Zambia School of Public HealthLusakaZambia
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Kim E, Jonnalagadda S, Cuervo-Rojas J, Jahn A, Payne D, West C, Ogollah F, Maida A, Kayira D, Nyirenda R, Dobbs T, Patel H, Radin E, Voetsch A, Auld A. Toward elimination of mother-to-child transmission of HIV in Malawi: Findings from the Malawi Population-based HIV Impact Assessment (2015–2016). PLoS One 2022; 17:e0273639. [PMID: 36048781 PMCID: PMC9436140 DOI: 10.1371/journal.pone.0273639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/11/2022] [Indexed: 11/23/2022] Open
Abstract
Background Malawi spearheaded the development and implementation of Option B+ for prevention of mother-to-child transmission of HIV (PMTCT), providing life-long ART for all HIV-positive pregnant and breastfeeding women. We used data from the 2015–2016 Malawi Population-based HIV Impact Assessment (MPHIA) to estimate progress toward 90-90-90 targets (90% of those with HIV know their HIV-positive status; of these, 90% are receiving ART; and of these, 90% have viral load suppression [VLS]) for HIV-positive women reporting a live birth in the previous 3 years. Methods MPHIA was a nationally representative household survey; consenting eligible women aged 15–64 years were interviewed on pregnancies and outcomes, including HIV status during their most recent pregnancy, PMTCT uptake, and early infant diagnosis (EID) testing. Descriptive analyses were weighted to account for the complex survey design. Viral load (VL) results were categorized by VLS (<1,000 copies/mL) and undetectable VL (target not detected/below the limit of detection). Results Of the 3,153 women included in our analysis, 371 (10.1%, 95% confidence interval [CI]: 8.8%–11.3%) tested HIV positive in the survey. Most HIV-positive women (84.2%, 95% CI: 79.9%–88.6%) reported knowing their HIV-positive status; of these, 94.9% (95% CI: 91.7%–98.2%) were receiving ART; and of these, 91.2% (95% CI: 87.4%–95.0%) had VLS. Among the 371 HIV-positive women, 76.0% (95% CI: 70.4%–81.7%) had VLS and 66.5% (95% CI: 59.8%–73.2%) had undetectable VL. Among 262 HIV-exposed children, 50.8% (95% CI: 42.8%–58.8%) received EID testing within 2 months of birth, whereas 17.9% (95% CI: 11.9%–23.8%) did not receive EID testing. Of 190 HIV-exposed children with a reported HIV test result, 2.1% (95% CI: 0.0%–4.6%) had positive results. Conclusions MPHIA data demonstrate high PMTCT uptake at a population level. However, our results identify some gaps in VLS in postpartum women and EID testing.
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Affiliation(s)
- Evelyn Kim
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
- * E-mail:
| | - Sasi Jonnalagadda
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Juliana Cuervo-Rojas
- ICAP at Columbia University, New York, NY, United States of America
- Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Andreas Jahn
- Division of HIV and AIDS, Ministry of Health, Government of Malawi, Lilongwe, Malawi
| | - Danielle Payne
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Christine West
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Francis Ogollah
- ICAP at Columbia University, New York, NY, United States of America
| | - Alice Maida
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Dumbani Kayira
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Rose Nyirenda
- Division of HIV and AIDS, Ministry of Health, Government of Malawi, Lilongwe, Malawi
| | - Trudy Dobbs
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Hetal Patel
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Elizabeth Radin
- ICAP at Columbia University, New York, NY, United States of America
| | - Andrew Voetsch
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Andrew Auld
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
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18
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Joseph Davey DL, Dovel K, Cleary S, Khadka N, Mashele N, Silliman M, Mvududu R, Nyemba DC, Coates TJ, Myer L. Stepped care to optimize pre-exposure prophylaxis (PrEP) effectiveness in pregnant and postpartum women (SCOPE-PP) in South Africa: a randomized control trial. BMC Public Health 2022; 22:1306. [PMID: 35799121 PMCID: PMC9264672 DOI: 10.1186/s12889-022-13652-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 06/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV incidence among pregnant and postpartum women remains high in South Africa. Pre-exposure prophylaxis (PrEP) use remains suboptimal in this population, particularly during the postpartum period when women's engagement with routine clinic visits outside PrEP decreases. Key barriers to sustained PrEP use include the need for ongoing contact with the health facility and suboptimal counseling around effective PrEP use. METHODS Stepped Care to Optimize PrEP Effectiveness in Pregnant and Postpartum women (SCOPE-PP), is a two-stepped unblinded, individually randomized controlled trial (RCT) that aims to optimize peripartum and postpartum PrEP use by providing a stepped package of evidence-based interventions. We will enroll 650 pregnant women (> 25 weeks pregnant) who access PrEP at a busy antenatal clinic in Cape Town at the time of recruitment and follow them for 15 months. We will enroll and individually randomize pregnant women > 16 years who are not living with HIV who are either on PrEP or interested in starting PrEP during pregnancy. In step 1, we will evaluate the impact of enhanced adherence counselling and biofeedback (using urine tenofovir tests for biofeedback) and rapid PrEP collection (to reduce time required) on PrEP use in early peripartum compared to standard of care (SOC) (n = 325 per arm). The primary outcome is PrEP persistence per urine tenofovir levels and dried blood spots of tenofovir diphosphate (TFV-DP) after 6-months. The second step will enroll and individually randomize participants from Step 1 who discontinue taking PrEP or have poor persistence in Step 1 but want to continue PrEP. Step 2 will test the impact of enhanced counseling and biofeedback plus rapid PrEP collection compared to community PrEP delivery with HIV self-testing on PrEP use (n = up to 325 postpartum women). The primary outcome is PrEP continuation and persistence 6-months following second randomization (~ 9-months postpartum). Finally, we will estimate the cost effectiveness of SCOPE-PP vs. SOC per primary outcomes and disability-adjusted life-years (DALYs) averted in both Step 1 and 2 using micro-costing with trial- and model-based economic evaluation. DISCUSSION This study will provide novel insights into optimal strategies for delivering PrEP to peripartum and postpartum women in this high-incidence setting. TRIAL REGISTRATION NCT05322629 : Date of registration: April 12, 2022.
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Affiliation(s)
- Dvora Leah Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA. .,Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa. .,Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, 0833 Le Conte Ave, Los Angeles, CA, 90095, USA.
| | - Kathryn Dovel
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, 0833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - Susan Cleary
- Division of Health Economics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Nehaa Khadka
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Nyiko Mashele
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Miriam Silliman
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Rufaro Mvududu
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Dorothy C Nyemba
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Thomas J Coates
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, 0833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
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19
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Ramraj T, Abdelatif N, Chirinda W, Abdullah F, Kindra G, Goga A. A risk measurement tool for targeted HIV prevention measures amongst young pregnant and lactating women in South Africa. BMC Public Health 2022; 22:1277. [PMID: 35773638 PMCID: PMC9248185 DOI: 10.1186/s12889-022-13625-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/09/2022] [Indexed: 11/11/2022] Open
Abstract
Background We aimed to develop and validate a tool to identify which pregnant/lactating young South African women (≤ 24 years) are at risk of HIV infection. Methods Data from three national South African Prevention of Mother-to-Child Transmission (PMTCT) evaluations were used to internally validate three HIV acquisition risk models for young postpartum women. We used univariate and multivariable logistic regression analysis to determine which risk factors were significant. Model coefficients were rounded and stratified into risk groups and the area under the receiver operating curve (AUROC) was computed. Models were developed to determine which risk factors provided the most predictive accuracy whilst remining clinically meaningful. Results Data from 9 456 adult and 4 658 young pregnant and lactating women were included in the development and validation data sets, respectively. The optimal model included the following risk factors: age (20–24 years old), informal house structure, two or more pregnancies, mothers who had knowledge of when they received their last HIV test result, no knowledge of the infant’s father’s HIV status, no knowledge of breastfeeding as a mode of MTCT and knowledge of PMTCT programme. The mean AUROC was 0.71 and 0.72 in the development and validation datasets respectively. The optimum cut off score was ≥ 27, having 84% sensitivity, 44% specificity, and identifying 44% of high-risk women eligible for PrEP. Conclusion The optimal model to be used as a possible risk scoring tool to allow for early identification of those pregnant/lactating women most at-risk of HIV acquisition included both statistically as well as clinically meaningful risk factors. A field-based study is needed to test and validate the effectiveness of this targeted approach.
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Affiliation(s)
- Trisha Ramraj
- Health Systems Research Unit, South African Medical Research Council, 491 Peter Mokaba Ridge, Durban, 4001, South Africa. .,HIV and other Infectious Diseases Research Unit, South African Medical Research Council, 491 Peter Mokaba Ridge, Durban, 4001, South Africa.
| | - Nada Abdelatif
- Biostatistics Research Unit, South African Medical Research Council, 491 Peter Mokaba Ridge, Durban, 4001, South Africa
| | - Witness Chirinda
- Health Systems Research Unit, South African Medical Research Council, 491 Peter Mokaba Ridge, Durban, 4001, South Africa
| | - Fareed Abdullah
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, 491 Peter Mokaba Ridge, Durban, 4001, South Africa.,Office of AIDS and TB Research, South African Medical Research Council, 1 Soutpansberg Road, Pretoria, 0001, South Africa.,Division of Infectious Diseases, University of Pretoria, Pretoria, SA, South Africa
| | - Gurpreet Kindra
- US Centers for Disease Control and Prevention, Division of Global HIV and Tuberculosis, Center for Global Health, Pretoria, SA, South Africa
| | - Ameena Goga
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, 491 Peter Mokaba Ridge, Durban, 4001, South Africa.,Department of Paediatrics and Child Health, University of Pretoria, Pretoria, SA, South Africa
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20
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Mmotsa TM, Ngandu NK, Adetokunboh OO, Nyasulu P. Male partner unknown HIV status as a risk factor for HIV incidence and clinical outcomes in prevention of mother-to-child transmission of HIV programmes in 21 WHO priority countries: a systematic review protocol. BMJ Open 2022; 12:e057190. [PMID: 35393320 PMCID: PMC8990715 DOI: 10.1136/bmjopen-2021-057190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Research has shown an association between increased disclosure of HIV status by pregnant and breastfeeding women and improved clinical health and that of their infant. Increasing awareness about their male partner's HIV status will no doubt lead to even better outcomes at the population level. Male partner involvement is important for improving outcomes of prevention of mother-to-child transmission of HIV (MTCT) as it improves social support and commitment from both parents of the baby to ensure sustained good health. Although lack of knowledge of the HIV status of a male partner is of great concern, limited research has been done to determine whether it remains one of the barriers to reaching the proposed goals of eliminating MTCT in pregnant or postpartum women. Our aim is to determine if lack of knowledge of a male partner's HIV status is a significant risk factor for HIV incidence and poor HIV clinical outcomes among pregnant women and postpartum women and their infants. METHODS AND ANALYSIS A systematic review and meta-analysis of experimental and observational studies will be conducted. The review will focus on knowledge of male partner's HIV status in the 21 priority countries most affected by HIV in Africa. We will search electronic databases such as PubMed/Medline, Scopus, Web of Science and Cochrane library, Science Direct, CINAHL, LILACS and SciELO databases from January 2011 to December 2021. We will also search the Pan African and WHO clinical trial registries and conference archives. We will conduct a quality assessment of eligible studies and evaluate the heterogeneity of the pooled studies using the I 2 statistic. The statistical analysis will be performed using STATA statistical software V.16. ETHICS AND DISSEMINATION The study will use publicly available data and ethics exemption has been obtained from Human Research Ethics Committees, Faculty of Medicine & Health Sciences, Stellenbosch University. The protocol was registered on Prospective Register of Systematic Reviews, registration number CRD42021247686, in May 2021. Findings of this systematic review will be disseminated in peer-review journals including various media platforms, that is, webinars, symposia, conferences or congresses. PROSPERO REGISTRATION NUMBER Registration number CRD42021247686.
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Affiliation(s)
| | - Nobubelo Kwanele Ngandu
- HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Olatunji O Adetokunboh
- DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, Western Cape, South Africa
- Division of Epidemiology and Biostatistics, Stellenbosch University, Stellenbosch, South Africa
- The University of the People, Pasadena, California, USA
| | - Peter Nyasulu
- Division of Epidemiology and Biostatistics, Stellenbosch University, Stellenbosch, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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21
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Astawesegn FH, Stulz V, Conroy E, Mannan H. Trends and effects of antiretroviral therapy coverage during pregnancy on mother-to-child transmission of HIV in Sub-Saharan Africa. Evidence from panel data analysis. BMC Infect Dis 2022; 22:134. [PMID: 35135474 PMCID: PMC8822759 DOI: 10.1186/s12879-022-07119-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 02/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background Antiretroviral therapy for pregnant women infected with HIV has evolved significantly over time, from single dosage antiretroviral and zidovudine alone to lifelong combination of antiretroviral therapy, but the effect of the intervention on population-level child HIV infection has not been well studied in sub-Saharan Africa. Therefore, this study aimed to establish the trend and effect of ART coverage during pregnancy on mother-to-child HIV transmission in sub-Saharan Africa from 2010 to 2019. Methods Country-level longitudinal ecological study design was used. Forty-one sub-Saharan Africa countries were included using publicly available data from the United Nations Programme on HIV/AIDS, World Health Organization, and World Bank. We created a panel dataset of 410 observations for this study from the years 2010–2019. Linear fixed effects dummy variable regression models were conducted to measure the effect of ART coverage during pregnancy on MTCT rate. Regression coefficients with their 95% confidence intervals (CIs) were estimated for each variable from the fixed effects model. Results ART coverage during pregnancy increased from 32.98 to 69.46% between 2010 and 2019. Over the same period, the rate of HIV transmission from mother to child reduced from 27.18 to 16.90% in sub-Saharan Africa. A subgroup analysis found that in southern Africa and upper-middle-income groups, higher ART coverage, and lower MTCT rates were recorded. The fixed-effects model result showed that ART coverage during pregnancy (β = − 0.18, 95% CI − 0.19–− 0.16) (p < 0.001) and log-transformed HIV incidence-to-prevalence ratio (β = 5.41, 95% CI 2.18–8.65) (p < 0.001) were significantly associated with mother-to-child HIV transmission rate. Conclusions ART coverage for HIV positive pregnant women and HIV incidence-to-prevalence ratio were significantly associated with MTCT rate in sub-Saharan Africa. Based on these findings we suggest countries scale up ART coverage by implementing varieties of proven strategies and control the HIV epidemic to achieve the global target of eliminating MTCT of HIV in the region.
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Affiliation(s)
- Feleke Hailemichael Astawesegn
- Translational Health Research Institute (THRI), Western Sydney University, Campbelltown campus, Penrith, NSW, 2751, Australia. .,School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia.
| | - Virginia Stulz
- School of Nursing and Midwifery Centre for Nursing and Midwifery Research, Western Sydney University, Nepean Hospital 1st Level Court Building, Derby Street, Kingswood, NSW, 2340, Australia
| | - Elizabeth Conroy
- Translational Health Research Institute (THRI), Western Sydney University, Campbelltown campus, Penrith, NSW, 2751, Australia
| | - Haider Mannan
- Translational Health Research Institute (THRI), Western Sydney University, Campbelltown campus, Penrith, NSW, 2751, Australia
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22
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Moran A, Mashele N, Mvududu R, Gorbach P, Bekker LG, Coates TJ, Myer L, Joseph Davey D. Maternal PrEP Use in HIV-Uninfected Pregnant Women in South Africa: Role of Stigma in PrEP Initiation, Retention and Adherence. AIDS Behav 2022; 26:205-217. [PMID: 34287756 PMCID: PMC8294266 DOI: 10.1007/s10461-021-03374-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2021] [Indexed: 11/29/2022]
Abstract
Pregnant women in sub-Saharan Africa are at high risk of HIV acquisition and require effective methods to prevent HIV. In a cohort of pregnant women offered Pre-exposure prophylaxis (PrEP), we evaluate the relationship between internalized and anticipated stigma and PrEP initiation at first antenatal visit, 3-month continuation and adherence using multivariable logistic regression. High internalized and anticipated PrEP stigma are associated with lower PrEP care initiation at first antenatal visit (aOR internalized stigma = 0.06; 95% CI = 0.03–0.11 and aOR anticipated stigma = 0.55; 95% CI = 0.31–1.00) compared to women with low reported stigma, after controlling for covariates. Women whose partners have not been tested for HIV or whose serostatus remains unknown have 1.6-times odds of PrEP retention at 3-months compared to women whose partners have been tested (aOR = 1.60; 95% CI = 1.02–2.52) after adjusting for covariates. PrEP counseling and maternal PrEP interventions must consider individual- and relational-level interventions to overcome anticipated PrEP stigma and other barriers to PrEP initiation and adherence.
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Affiliation(s)
- Alexander Moran
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, 615 E Charles Young Drive S, Los Angeles, CA, 90095, USA.
| | - Nyiko Mashele
- Department of Biostatistics and Epidemiology, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Rufaro Mvududu
- Department of Biostatistics and Epidemiology, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Pamina Gorbach
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, 615 E Charles Young Drive S, Los Angeles, CA, 90095, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Thomas J Coates
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Landon Myer
- Department of Biostatistics and Epidemiology, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Dvora Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, 615 E Charles Young Drive S, Los Angeles, CA, 90095, USA
- Department of Biostatistics and Epidemiology, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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23
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Joseph Davey DL, Knight L, Markt-Maloney J, Tsawe N, Gomba Y, Mashele N, Dovel K, Gorbach P, Bekker LG, Coates TJ, Myer L. "I had Made the Decision, and No One was Going to Stop Me" -Facilitators of PrEP Adherence During Pregnancy and Postpartum in Cape Town, South Africa. AIDS Behav 2021; 25:3978-3986. [PMID: 34085132 PMCID: PMC8174535 DOI: 10.1007/s10461-021-03320-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2021] [Indexed: 11/27/2022]
Abstract
PrEP is safe and effective but requires adherence during potential HIV exposure, yet the facilitators of long-term maternal adherence are not well understood. We conducted semi-structured interviews with 25 postpartum women who reported high adherence (PrEP use ≥ 25 days in last 30-days and never missed a PrEP prescription in pregnancy/postpartum period) within a PrEP service for pregnant and postpartum women. A thematic approach guided an iterative process of coding and analysis. Themes identified as drivers of optimal PrEP use were HIV risk perception, mainly because of partner’s behaviors and unknown serostatus, and a strong desire to have a baby free of HIV. Reported disclosure of PrEP use facilitated PrEP adherence. Women discussed having partner and family support, which included reminders to take PrEP daily. Primary barriers were anticipated or experienced stigma, overcome through education of partners and family about PrEP. Pregnant women experienced transient side-effects, but found ways to continue, including taking PrEP at night. PrEP programs for pregnant and postpartum women should integrate strategies to assist women with realistic appraisals of risk and teach skills for disclosure and securing support from significant others.
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Rees H, Chersich MF, Munthali RJ, Brumskine W, Palanee-Phillips T, Nkala B, Ahmed K, Sebe M, Mabude Z, Nchabeleng M, Bekker LG, Kotze P, Mogodiri T, Naidoo I, Panchia R, Myer L, Lombard C, Doncel GF, Gray G, Delany-Moretlwe S. HIV Incidence Among Pregnant and Nonpregnant Women in the FACTS-001 Trial: Implications for HIV Prevention, Especially PrEP Use. J Acquir Immune Defic Syndr 2021; 88:376-383. [PMID: 34710071 DOI: 10.1097/qai.0000000000002785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND During pregnancy and postpartum period, the sexual behaviors of women and their partners change in ways that may either increase or reduce HIV risks. Pregnant women are a priority population for reducing both horizontal and vertical HIV transmission. SETTING Nine sites in 4 South African provinces. METHODS Women aged 18-30 years were randomized to receive pericoital tenofovir 1% gel or placebo gel and required to use reliable modern contraception. We compared HIV incidence in women before, during, and after pregnancy and used multivariate Cox Proportional hazards models to compare HIV incidence by pregnancy status. RESULTS Rates of pregnancy were 7.1 per 100 woman-years (95% confidence interval [CI]: 6.3 to 8.1) and highest in those who reported oral contraceptive use (25.1 per 100 woman-years; adjusted hazard ratio 22.97 higher than other women; 95% CI: 5.0 to 105.4) or had 2 children. Birth outcomes were similar between trial arms, with 59.8% having full-term live births. No difference was detected in incident HIV during pregnancy compared with nonpregnant women (2.1 versus 4.3%; hazard ratio = 0.56, 95% CI: 0.14 to 2.26). Sexual activity was low in pregnancy and the early postpartum period, as was consistent condom use. CONCLUSIONS Pregnancy incidence was high despite trial participation being contingent on contraceptive use. We found no evidence that rates of HIV acquisition were elevated in pregnancy when compared with those in nonpregnant women. Risks from reductions in condom use may be offset by reduced sexual activity. Nevertheless, high HIV incidence in both pregnant and nonpregnant women supports consideration of introducing antiretroviral-containing pre-exposure prophylaxis for pregnant and nonpregnant women in high HIV prevalence settings.
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Affiliation(s)
- Helen Rees
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew Francis Chersich
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Richard J Munthali
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Busi Nkala
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Zonke Mabude
- MATCH, University of the Witwatersrand, Johannesburg, South Africa
| | - Maphoshane Nchabeleng
- Mecru Clinical Research Unit, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Philip Kotze
- Qhakaza Mbokodo Research Centre, Ladysmith, South Africa
| | - Thembisile Mogodiri
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ishana Naidoo
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ravindre Panchia
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa ; and
- Division of Epidemiology and Biostatistics, Department of Global Health, University of Stellenbosch, Stellenbosch, South Africa
| | | | - Glenda Gray
- Setshaba Research Centre, Soshanguve, South Africa
- South African Medical Research Council, Cape Town, South Africa
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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25
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Sekhon M, van der Straten A. Pregnant and breastfeeding women's prospective acceptability of two biomedical HIV prevention approaches in Sub Saharan Africa: A multisite qualitative analysis using the Theoretical Framework of Acceptability. PLoS One 2021; 16:e0259779. [PMID: 34784355 PMCID: PMC8594804 DOI: 10.1371/journal.pone.0259779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 10/26/2021] [Indexed: 11/19/2022] Open
Abstract
HIV infection during pregnancy and breastfeeding has implications for maternal health. Between May- November 2018, we explored prospective acceptability of two novel HIV Pre-exposure Prophylaxis (PrEP) products, oral pills and vaginal rings, through focus group discussions with 65 pregnant and breastfeeding women in Malawi, South Africa, Uganda, Zimbabwe. Qualitative analysis was completed, guided by the Theoretical Framework of Acceptability (TFA). First, a deductive thematic analysis was applied to relevant coded data, into the seven TFA constructs (Affective Attitude; Burden; Ethicality, Intervention Coherence; Opportunity Costs; Perceived Effectiveness; Self-efficacy). Next, an iterative analysis was completed to generate themes within each of the TFA constructs. Women’s positive attitudes towards daily oral PrEP highlighted the familiarity of taking pills, understanding the purpose of taking pills, and the perception that it is an effective method to protect mothers and babies from HIV during pregnancy and breastfeeding. Women emphasized the ease of using the ring given its monthly duration that lowers burden on the user, its discreetness and invisibility once in place. The TFA analysis highlighted how acceptability of both methods could be enhanced by focusing on perceptions of the end users (i.e. the women) and not just the products themselves. This approach provided insights into how to refine the intervention materials and plans for implementation.
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Affiliation(s)
- Mandeep Sekhon
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
- * E-mail:
| | - Ariane van der Straten
- Center for AIDS prevention studies, University of California San Francisco, CA, United States of America
- Women’s Global Health imperative, RTI International, Berkeley, CA, United States of America
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26
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Davey DLJ, Davies N, Raphael Y, Pillay Y, Bekker LG. Urgent appeal to implement pre-exposure prophylaxis for pregnant and breastfeeding women in South Africa. S Afr Med J 2021; 111:1038-1039. [PMID: 34949264 PMCID: PMC9190765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 10/06/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Dvora L Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, California, USA; Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
| | | | - Yvette Raphael
- Advocacy for Prevention of HIV and AIDS (APHA), Johannesburg, South Africa
| | - Yogan Pillay
- Center for Global Health Innovation, Georgetown University, Washington, DC, USA
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Hans L, von Allmen N, Edelmann A, Hofmann J, Nilsson AY, Simon CO, Seiverth B, Gohl P, Carmona S. Early Diagnosis of HIV-1 and HIV-2 Using Cobas HIV-1/HIV-2 Qualitative Test: A Novel Qualitative Nucleic Acid Amplification Test for Plasma, Serum, and Dried Blood Spot Specimens. J Acquir Immune Defic Syndr 2021; 87:1187-1195. [PMID: 33883470 PMCID: PMC8263138 DOI: 10.1097/qai.0000000000002713] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/25/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Nucleic acid amplification tests (NATs) minimize the time from HIV infection to diagnosis, reducing transmission during acute HIV. NATs are especially useful for diagnosing HIV in children younger than 18 months and discriminating between HIV-1 and HIV-2. METHODS We evaluated the performance of the cobas HIV-1/HIV-2 qualitative (cobas HIV-1/2 Qual) test for use on cobas 6800/8800 Systems. The results of adult plasma and serum samples and pediatric dried blood spots were compared with those of the recomLine HIV-1 & HIV-2 Immunoglobulin G serological test and COBAS AmpliPrep/COBAS TaqMan HIV-1 qualitative test, v2.0. Genotype inclusivity and limits of detection were determined, and sensitivity on seroconversion panels was compared with that in the Bio-Rad Geenius HIV 1/2 Confirmatory Assay, Abbott ARCHITECT HIV Ag/Ab Combo serological test, and cobas TaqScreen MPX, v2.0. RESULTS Concordance of cobas HIV-1/2 Qual test with the comparator serological test and COBAS AmpliPrep/COBAS TaqMan test was ≥99.6% with all sample types. Reactivity with all HIV genotypes was 100%. LOD in plasma samples was 14.8, 12.6, and 27.9 copies/mL for HIV-1 group M, HIV-1 group O, and HIV-2, respectively, with similar results for serum samples. LOD in dried blood spots was 255 copies/mL for HIV-1 and 984 copies/mL for HIV-2. HIV infection was detected 18.9 days and 8.5 days earlier than the confirmatory and serological assays, respectively, and at a similar time to the NAT. CONCLUSIONS The cobas HIV-1/2 Qual test enables early and accurate diagnoses of HIV-1 and HIV-2 in adults and children across sample types. The assay could help avert transmission during acute HIV, simplify HIV diagnostic algorithms, and promote the survival of HIV-infected children.
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Affiliation(s)
- Lucia Hans
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Services, Johannesburg, South Africa;
| | | | - Anke Edelmann
- Department of Virology, Labor Berlin—Charité Vivantes Services GmbH
| | - Jörg Hofmann
- Department of Virology, Labor Berlin—Charité Vivantes Services GmbH
| | - Alex Y. Nilsson
- Global Development, Roche Diagnostics International AG, Rotkreuz, Switzerland;
| | | | - Britta Seiverth
- Global Clinical Operations, Roche Diagnostics International AG, Rotkreuz, Switzerland; and
| | - Peter Gohl
- Bioscientia Institut für Medizinische Diagnostik, Ingelheim, Germany.
| | - Sergio Carmona
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Services, Johannesburg, South Africa;
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Stranix-Chibanda L, Yu C, Isaacs MB, Allen M, Andriesen J, Walsh SR. A retrospective analysis of incident pregnancy in phase 1 and 2a HIV-1 vaccine study participants does not support concern for adverse pregnancy or birth outcomes. BMC Infect Dis 2021; 21:802. [PMID: 34380464 PMCID: PMC8356543 DOI: 10.1186/s12879-021-06431-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/13/2021] [Indexed: 11/10/2022] Open
Abstract
Background Pregnancies occur during HIV-1 vaccine clinical trials, despite requirements for women of reproductive potential to use effective contraception. Deployment of an effective HIV-1 vaccine regimen will likely target adolescents and young adults and therefore safety for pregnant and breastfeeding women will need to be addressed. Methods We performed a retrospective, cross-protocol analysis to identify and compare pregnancy outcomes reported in 53 Phase 1 and Phase 2a HIV-1 vaccine clinical trials conducted by the HIV Vaccine Trials Network (HVTN). Results Two thousand six hundred seventy-three women of reproductive potential were identified and 193 pregnancies were reported. 39 of 53 (74%) studies had at least one pregnancy reported with an overall pregnancy rate of 3.15 per 100 woman-years (w-yr). While active contraception use was required during study participation, 13 of the 53 studies also contained a long-term follow up period during which pregnancy was no longer discouraged. The pregnancy rate during main study participation was 3.09 per 100 w-yr, while pregnancies occurred at a slightly greater rate in the long-term follow up period (3.22 per 100 w-yr). Adverse pregnancy outcomes were reported at similar rates between vaccinees and placebo recipients when vaccine vectors, adjuvant used, or geographic region were examined. Conclusion Although there is considerable heterogeneity amongst the different vaccine trials, there appears to be no obvious indication of increased risk of adverse pregnancy or birth outcomes in these early phase HIV-1 vaccine studies. More complete data on pregnancy outcomes should be collected in early phase HIV-1 vaccine clinical trials to better inform subsequent efficacy trials. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06431-x.
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Affiliation(s)
| | - Chenchen Yu
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Mary Allen
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Jessica Andriesen
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Stephen R Walsh
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA.
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29
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McFarland EJ, Cunningham CK, Muresan P, Capparelli EV, Perlowski C, Morgan P, Smith B, Hazra R, Purdue L, Harding PA, Theron G, Mujuru H, Agwu A, Purswani M, Rathore MH, Flach B, Taylor A, Lin BC, McDermott AB, Mascola JR, Graham BS. Safety, Tolerability, and Pharmacokinetics of a Long-Acting Broadly Neutralizing HIV-1 Monoclonal Antibody VRC01LS in HIV-1-Exposed Newborn Infants. J Infect Dis 2021; 224:1916-1924. [PMID: 34009371 DOI: 10.1093/infdis/jiab229] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/26/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Perinatal HIV-1 continues to occur due to barriers to effective antiretroviral prevention that might be mitigated by long-acting broadly neutralizing monoclonal antibodies (bNAbs). METHODS Extended half-life bNAb, VRC01LS, was administered subcutaneously (SC) at 80 mg/dose after birth to HIV-1-exposed, non-breastfed (Cohort 1, n=10) and breastfed (Cohort 2, n=11) infants. Cohort 2 received a second dose (100mg) at 12 weeks. All received antiretroviral prophylaxis. VRC01LS levels were compared to VRC01 levels determined in a prior cohort. RESULTS Local reactions (all Grade <2) occurred in 67% and 20% after Dose 1 and Dose 2, respectively. The weight-banded dose (mean 28.8 mg/kg) of VRC01LS administrated SC achieved a mean +SD plasma level of 222.3 + 71.6 mcg/mL by 24 hours and 44.0 + 11.6 mcg/mL at week 12, prior to Dose 2. The pre-established target of > 50 mcg/mL was attained in 95% and 32% at week 8 and 12, respectively. The terminal half-life was 37-41 days. VRC01LS level after one dose was significantly greater (p=<0.002) than after a VRC01 dose (20mg/kg). No infants acquired HIV-1. CONCLUSIONS VRC01LS was well tolerated with pharmacokinetics that support further studies of more potent long-acting bNAbs as adjunct treatment with ARVs to prevent infant HIV-1 transmission.
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Affiliation(s)
- Elizabeth J McFarland
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Coleen K Cunningham
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, 27710, USA.,Children's Hospital Of Orange County (CHOC), 333 City Blvd West, Suite 800, Orange, CA, 92868, USA
| | - Petronella Muresan
- Statistical and Data Management Center/ Frontier Science Foundation, Brookline, MA, 02446, USA
| | - Edmund V Capparelli
- Departments of Pediatrics and Pharmacy, UC San Diego Schools of Medicine and Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, 92093, USA
| | | | - Patricia Morgan
- FHI 360, Durham, NC, 27701, USA.,Vaccine Research Center, National Institute of Allergy and Infectious Diseases, NIH Bethesda, MD, 20892, USA
| | - Betsy Smith
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Rohan Hazra
- Maternal and Pediatric Infectious Disease Branch Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Bethesda, MD, 20892, USA
| | - Lynette Purdue
- National Institute of Allergy and Infectious Diseases, Division of AIDS (Contractor), Bethesda, MD, USA
| | - Paul A Harding
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Gerhard Theron
- Department of Pediatrics, Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Hilda Mujuru
- University of Zimbabwe College of Health Sciences - Clinical Trials Research Centre (UZCHS-CTRC), Harare, Zimbabwe
| | - Allison Agwu
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Murli Purswani
- Department of Pediatrics, BronxCare Health Systems, affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, 10457, USA
| | - Mobeen H Rathore
- University of Florida Center for HIV/AIDS Research, Education and Service (UF CARES), University of Florida College of Medicine, Jacksonville, FL, USA
| | - Britta Flach
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, NIH Bethesda, MD, 20892, USA
| | - Alison Taylor
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, NIH Bethesda, MD, 20892, USA
| | - Bob C Lin
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, NIH Bethesda, MD, 20892, USA
| | - Adrian B McDermott
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, NIH Bethesda, MD, 20892, USA
| | - John R Mascola
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, NIH Bethesda, MD, 20892, USA
| | - Barney S Graham
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, NIH Bethesda, MD, 20892, USA
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30
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Mofenson LM, Cohn J, Sacks E. Challenges in the Early Infant HIV Diagnosis and Treatment Cascade. J Acquir Immune Defic Syndr 2021; 84 Suppl 1:S1-S4. [PMID: 32520908 DOI: 10.1097/qai.0000000000002366] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The first step in improving morbidity and mortality among children living with HIV is the timely and early identification of HIV infection, which must be followed by rapid engagement in care and provision of antiretroviral therapy. However, in 2018, only 59% of HIV-exposed infants received an infant nucleic acid diagnostic test by age 2 months and only 54% of children living with HIV received treatment. Because infant diagnosis requires molecular techniques to detect viral nucleic acid, programs for early diagnosis of infection in infants are more complex than those in adults and often require coordination and management of multiple health facilities as well as logistic, financial, and human resource challenges. This article will discuss challenges at each step in the early infant diagnosis cascade and innovations that may help overcome these challenges.
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Affiliation(s)
- Lynne M Mofenson
- Department of Research, Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC
| | - Jennifer Cohn
- Department of Innovation and New Technology, Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland; and.,Division of Infectious Diseases, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Emma Sacks
- Department of Research, Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC
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31
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Moyo F, Mazanderani AH, Murray T, Sherman GG, Kufa T. Achieving maternal viral load suppression for elimination of mother-to-child transmission of HIV in South Africa. AIDS 2021; 35:307-316. [PMID: 33394673 DOI: 10.1097/qad.0000000000002733] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe changes in maternal viral control over time in South African women living with HIV (WLHIV) using surveillance data from the National Health Laboratory Service's Corporate Data Warehouse (NHLS CDW). DESIGN A retrospective cohort analysis of maternal viral load during pregnancy and up to 15 months postpartum was performed amongst WLHIV (15-49 years) within the public-health sector between 2016 and 2017. METHODS HIV and pregnancy-related test data were used to create a synthetic cohort of pregnant WLHIV from the NHLS CDW. Syphilis-screening, in association with ward type and/or postpregnancy cervical screening and/or birth HIV test and/or positive β-hCG, was used as a proxy for pregnancy. The syphilis-screening date marked the first antenatal care visit (fANC). Fractional polynomial models described viral load evolution from fANC up to 15 months postdelivery. Piecewise linear regression models determined factors associated with viral load decline. FINDINGS Among 178 319 pregnant WLHIV, 345 174 viral load tests were performed [median = 2 (IQR: 2-3) per woman]. At fANC, 85 545 (48%) women were antiretroviral therapy (ART) experienced; 88 877 (49.8%) were not and 3897 (2.2%) unknown. Proportions of viraemia (viral load ≥50 copies/ml) were 39 756 (53.6%) at first viral load performed during pregnancy, 14 780 (36.9%) at delivery and 24 328 (33.5%) postpartum. Maternal age at least 25 years, CD4+ cell count at least 500 cells/μl and viral load less than 50 copies/ml at baseline predicted sustained viral load suppression during follow-up. CONCLUSION Despite high-ART coverage among pregnant women in South Africa, only 63% of WLHIV achieved viral load less than 50 copies/ml at delivery. Maternal viral load monitoring requires prioritization for maternal health and eMTCT.
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Affiliation(s)
- Faith Moyo
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand
- Paediatric HIV Diagnostics Division, Wits Health Consortium, Johannesburg
| | - Ahmad Haeri Mazanderani
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service
- Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Pretoria
| | - Tanya Murray
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service
- Paediatric HIV Diagnostics Division, Wits Health Consortium, Johannesburg
| | - Gayle G Sherman
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service
- Paediatric HIV Diagnostics Division, Wits Health Consortium, Johannesburg
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tendesayi Kufa
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand
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32
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Zar HJ, Moore DP, Andronikou S, Argent AC, Avenant T, Cohen C, Green RJ, Itzikowitz G, Jeena P, Masekela R, Nicol MP, Pillay A, Reubenson G, Madhi SA. Diagnosis and management of community-acquired pneumonia in children: South African Thoracic Society guidelines. Afr J Thorac Crit Care Med 2020; 26:10.7196/AJTCCM.2020.v26i3.104. [PMID: 34471872 PMCID: PMC7433705 DOI: 10.7196/ajtccm.2020.v26i3.104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pneumonia remains a major cause of morbidity and mortality amongst South African children. More comprehensive immunisation regimens, strengthening of HIV programmes, improvement in socioeconomic conditions and new preventive strategies have impacted on the epidemiology of pneumonia. Furthermore, sensitive diagnostic tests and better sampling methods in young children improve aetiological diagnosis. OBJECTIVES To produce revised guidelines for pneumonia in South African children under 5 years of age. METHODS The Paediatric Assembly of the South African Thoracic Society and the National Institute for Communicable Diseases established seven expert subgroups to revise existing South African guidelines focusing on: (i) epidemiology; (ii) aetiology; (iii) diagnosis; (iv) antibiotic management and supportive therapy; (v) management in intensive care; (vi) prevention; and (vii) considerations in HIV-infected or HIVexposed, uninfected (HEU) children. Each subgroup reviewed the published evidence in their area; in the absence of evidence, expert opinion was accepted. Evidence was graded using the British Thoracic Society (BTS) grading system. Sections were synthesized into an overall guideline which underwent peer review and revision. RECOMMENDATIONS Recommendations include a diagnostic approach, investigations, management and preventive strategies. Specific recommendations for HIV infected and HEU children are provided. VALIDATION The guideline is based on available published evidence supplemented by the consensus opinion of SA paediatric experts. Recommendations are consistent with those in published international guidelines.
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Affiliation(s)
- H J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
- South African Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, South Africa
| | - D P Moore
- Department of Paediatrics and Child Health, Chris Hani Baragwanath Academic Hospital, and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - S Andronikou
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
- Department of Pediatric Radiology, Perelman School of Medicine, University of Philadephia, USA
| | - A C Argent
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
| | - T Avenant
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Pretoria, South Africa
| | - C Cohen
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - R J Green
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Pretoria, South Africa
| | - G Itzikowitz
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
| | - P Jeena
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - R Masekela
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - M P Nicol
- Division of Medical Microbiology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, South Africa; and Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - A Pillay
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - G Reubenson
- Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - S A Madhi
- South African Medical Research Council Vaccine and Infectious Diseases Analytics Unit, University of the Witwatersrand, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: South African Research Chair in Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Yapa HM, De Neve JW, Chetty T, Herbst C, Post FA, Jiamsakul A, Geldsetzer P, Harling G, Dhlomo-Mphatswe W, Moshabela M, Matthews P, Ogbuoji O, Tanser F, Gareta D, Herbst K, Pillay D, Wyke S, Bärnighausen T. The impact of continuous quality improvement on coverage of antenatal HIV care tests in rural South Africa: Results of a stepped-wedge cluster-randomised controlled implementation trial. PLoS Med 2020; 17:e1003150. [PMID: 33027246 PMCID: PMC7540892 DOI: 10.1371/journal.pmed.1003150] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 06/25/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Evidence for the effectiveness of continuous quality improvement (CQI) in resource-poor settings is very limited. We aimed to establish the effects of CQI on quality of antenatal HIV care in primary care clinics in rural South Africa. METHODS AND FINDINGS We conducted a stepped-wedge cluster-randomised controlled trial (RCT) comparing CQI to usual standard of antenatal care (ANC) in 7 nurse-led, public-sector primary care clinics-combined into 6 clusters-over 8 steps and 19 months. Clusters randomly switched from comparator to intervention on pre-specified dates until all had rolled over to the CQI intervention. Investigators and clusters were blinded to randomisation until 2 weeks prior to each step. The intervention was delivered by trained CQI mentors and included standard CQI tools (process maps, fishbone diagrams, run charts, Plan-Do-Study-Act [PDSA] cycles, and action learning sessions). CQI mentors worked with health workers, including nurses and HIV lay counsellors. The mentors used the standard CQI tools flexibly, tailored to local clinic needs. Health workers were the direct recipients of the intervention, whereas the ultimate beneficiaries were pregnant women attending ANC. Our 2 registered primary endpoints were viral load (VL) monitoring (which is critical for elimination of mother-to-child transmission of HIV [eMTCT] and the health of pregnant women living with HIV) and repeat HIV testing (which is necessary to identify and treat women who seroconvert during pregnancy). All pregnant women who attended their first antenatal visit at one of the 7 study clinics and were ≥18 years old at delivery were eligible for endpoint assessment. We performed intention-to-treat (ITT) analyses using modified Poisson generalised linear mixed effects models. We estimated effect sizes with time-step fixed effects and clinic random effects (Model 1). In separate models, we added a nested random clinic-time step interaction term (Model 2) or individual random effects (Model 3). Between 15 July 2015 and 30 January 2017, 2,160 participants with 13,212 ANC visits (intervention n = 6,877, control n = 6,335) were eligible for ITT analysis. No adverse events were reported. Median age at first booking was 25 years (interquartile range [IQR] 21 to 30), and median parity was 1 (IQR 0 to 2). HIV prevalence was 47% (95% CI 42% to 53%). In Model 1, CQI significantly increased VL monitoring (relative risk [RR] 1.38, 95% CI 1.21 to 1.57, p < 0.001) but did not improve repeat HIV testing (RR 1.00, 95% CI 0.88 to 1.13, p = 0.958). These results remained essentially the same in both Model 2 and Model 3. Limitations of our study include that we did not establish impact beyond the duration of the relatively short study period of 19 months, and that transition steps may have been too short to achieve the full potential impact of the CQI intervention. CONCLUSIONS We found that CQI can be effective at increasing quality of primary care in rural Africa. Policy makers should consider CQI as a routine intervention to boost quality of primary care in rural African communities. Implementation research should accompany future CQI use to elucidate mechanisms of action and to identify factors supporting long-term success. TRIAL REGISTRATION This trial is registered at ClinicalTrials.gov under registration number NCT02626351.
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Affiliation(s)
- H. Manisha Yapa
- The Kirby Institute, University of New South Wales Sydney, NSW, Australia
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
- * E-mail:
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Terusha Chetty
- Health systems Research Unit, South African Medical Research Council, Durban, South Africa
| | - Carina Herbst
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
| | - Frank A. Post
- King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Awachana Jiamsakul
- The Kirby Institute, University of New South Wales Sydney, NSW, Australia
| | - Pascal Geldsetzer
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Guy Harling
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
- Institute for Global Health, University College London, London, United Kingdom
| | - Wendy Dhlomo-Mphatswe
- School of Clinical Medicine, Discipline of Obstetrics and Gynaecology, University of KwaZulu-Natal, Durban, South Africa
| | - Mosa Moshabela
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Philippa Matthews
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
- Islington GP Federation, London, United Kingdom
| | - Osondu Ogbuoji
- Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Frank Tanser
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, United Kingdom
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Dickman Gareta
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
| | - Kobus Herbst
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
| | - Deenan Pillay
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Sally Wyke
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
- Institute for Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Till Bärnighausen
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
- Institute for Global Health, University College London, London, United Kingdom
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Yapa HM, Drayne R, Klein N, De Neve JW, Petoumenos K, Jiamsakul A, Herbst C, Pillay D, Post FA, Bärnighausen T. Infant feeding knowledge and practice vary by maternal HIV status: a nested cohort study in rural South Africa. Int Breastfeed J 2020; 15:77. [PMID: 32873311 PMCID: PMC7466779 DOI: 10.1186/s13006-020-00317-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 08/10/2020] [Indexed: 11/10/2022] Open
Abstract
Background We investigate whether correct infant feeding knowledge and practice differ by maternal HIV status in an era of evolving clinical guidelines in rural South Africa. Methods This cohort study was nested within the MONARCH stepped-wedge cluster-randomised controlled trial (www.clinicaltrials.gov: NCT02626351) which tested the impact of continuous quality improvement on antenatal care quality at seven primary care clinics in KwaZulu-Natal, from July 2015 to January 2017. Women aged ≥18 years at delivery were followed up to 6 weeks postpartum. Clinical data were sourced from routine medical records at delivery. Structured interviews at early postnatal visits and the 6-week postnatal immunisation visit provided data on infant feeding knowledge and feeding practices respectively. We measured the relationship between maternal HIV status and (i) correct infant feeding knowledge at the early postnatal visit; and (ii) infant feeding practice at 6 weeks, using Poisson and multinomial regression models, respectively. Results We analysed data from 1693 women with early postnatal and 471 with 6-week postnatal interviews. HIV prevalence was 47% (95% confidence interval [CI] 42, 52%). Women living with HIV were more knowledgeable than women not living with HIV on correct infant feeding recommendations (adjusted risk ratio, aRR, 1.08, p < 0.001). More women living with HIV (33%; 95% CI 26, 41%) were not breastfeeding than women not living with HIV (15%; 95% CI 11, 21%). However, among women who were currently breastfeeding their infants, fewer women living with HIV (5%; 95% CI 2, 9%) mixed fed their babies than women not living with HIV (21%; 95% CI 14, 32%). In adjusted analyses, women living with HIV were more likely to avoid breastfeeding (adjusted relative risk ratio, aRRR, 2.78, p < 0.001) and less likely to mixed feed (aRRR 0.22, p < 0.001) than women not living with HIV. Conclusions Many mothers in rural South Africa still do not practice exclusive breastfeeding. Women living with HIV were more knowledgeable but had lower overall uptake of breastfeeding, compared with women not living with HIV. Women living with HIV were also more likely to practice exclusive breastfeeding over mixed feeding if currently breastfeeding. Improved approaches are needed to increase awareness of correct infant feeding and exclusive breastfeeding uptake.
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Affiliation(s)
- H Manisha Yapa
- The Kirby Institute, University of New South Wales Sydney, Sydney, Australia. .,Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa.
| | - Róisín Drayne
- School of Population Health & Environmental Sciences, King's College London, London, UK
| | - Nigel Klein
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa.,UCL Great Ormond Street Institute of Child Health, London, UK
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Kathy Petoumenos
- The Kirby Institute, University of New South Wales Sydney, Sydney, Australia
| | - Awachana Jiamsakul
- The Kirby Institute, University of New South Wales Sydney, Sydney, Australia
| | - Carina Herbst
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
| | - Deenan Pillay
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa.,Division of Infection & Immunity, University College London, London, UK
| | - Frank A Post
- King's College Hospital NHS Foundation Trust, London, UK
| | - Till Bärnighausen
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa.,Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA.,Institute for Global Health, University College London, London, UK
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35
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Pintye J, Davey DLJ, Wagner AD, John-Stewart G, Baggaley R, Bekker LG, Celum C, Chi BH, Coates TJ, Groves AK, Haberer JE, Heffron R, Kinuthia J, Matthews LT, McIntyre JA, Moodley D, Mofenson LM, Mugo N, Mujugira A, Myer L, Shoptaw S, Stranix-Chibanda L, Baeten JM. Defining gaps in pre-exposure prophylaxis delivery for pregnant and post-partum women in high-burden settings using an implementation science framework. Lancet HIV 2020; 7:e582-e592. [PMID: 32763221 DOI: 10.1016/s2352-3018(20)30102-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/20/2020] [Accepted: 03/24/2020] [Indexed: 01/01/2023]
Abstract
Pregnancy is a high-risk period for HIV acquisition in African women, and pregnant women who become acutely infected with HIV account for up to a third of vertical HIV transmission cases in African settings. To protect women and eliminate vertical transmission, WHO recommends offering oral pre-exposure prophylaxis (PrEP) based on tenofovir to HIV-negative pregnant and post-partum women with a substantial risk of HIV acquisition. PrEP implementation for pregnant and post-partum women lags behind implementation for other high-risk populations. Unique considerations for PrEP implementation arise during pregnancy and post partum, including the integration of provider training with clinical delivery and monitoring of PrEP exposure and outcomes within existing maternal health systems, yet scarce implementation data are available to generate evidence in this context.
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Affiliation(s)
- Jillian Pintye
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Dvora L Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA; Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
| | | | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - Thomas J Coates
- Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Allison K Groves
- Department of Community Health and Prevention, Drexel University, Philadelphia, PA, USA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Lynn T Matthews
- Department of Medicine, University of Alabama, Birmingham, AL, USA
| | - James A McIntyre
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; Anova Health Institute, Johannesburg, South Africa
| | | | | | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA; Kenya Medical Research Institute (KEMRI), Center for Clinical Research, Nairobi, Kenya
| | - Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, WA, USA; Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Steven Shoptaw
- Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
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Joseph Davey D, Bekker LG, Coates TJ, Myer L. Contracting HIV or Contracting SAR-CoV-2 (COVID- 19) in Pregnancy? Balancing the Risks and Benefits. AIDS Behav 2020; 24:2229-2231. [PMID: 32285221 PMCID: PMC7153351 DOI: 10.1007/s10461-020-02861-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Dvora Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, USA.
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Thomas J Coates
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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37
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Chi BH, Mbori‐Ngacha D, Essajee S, Mofenson LM, Tsiouris F, Mahy M, Luo C. Accelerating progress towards the elimination of mother-to-child transmission of HIV: a narrative review. J Int AIDS Soc 2020; 23:e25571. [PMID: 32820609 PMCID: PMC7440973 DOI: 10.1002/jia2.25571] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/28/2020] [Accepted: 06/08/2020] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Findings from biomedical, behavioural and implementation studies provide a rich foundation to guide programmatic efforts for the prevention of mother-to-child HIV transmission (PMTCT). METHODS We summarized the current evidence base to support policy makers, programme managers, funding agencies and other stakeholders in designing and optimizing PMTCT programmes. We searched the scientific literature for PMTCT interventions in the era of universal antiretroviral therapy for pregnant and breastfeeding women (i.e. 2013 onward). Where evidence was sparse, relevant studies from the general HIV treatment literature or from prior eras of PMTCT programme implementation were also considered. Studies were organized into six categories: HIV prevention services for women, timely access to HIV testing, timely access to ART, programme retention and adherence support, timely engagement in antenatal care and services for infants at highest risk of HIV acquisition. These were mapped to specific missed opportunities identified by the UNAIDS Spectrum model and embedded in UNICEF operational guidance to optimize PMTCT services. RESULTS AND DISCUSSION From May to November 2019, we identified numerous promising, evidence-based strategies that, properly tailored and adopted, could contribute to population reductions in vertical HIV transmission. These spanned the HIV and maternal and child health literature, emphasizing the importance of continued alignment and integration of services. We observed overlap between several intervention domains, suggesting potential for synergies and increased downstream impact. Common themes included integration of facility-based healthcare; decentralization of health services from facilities to communities; and engagement of partners, peers and lay workers for social support. Approaches to ensure early HIV diagnosis and treatment prior to pregnancy would strengthen care across the maternal lifespan and should be promoted in the context of PMTCT. CONCLUSIONS A wide range of effective strategies exist to improve PMTCT access, uptake and retention. Programmes should carefully consider, prioritize and plan those that are most appropriate for the local setting and best address existing gaps in PMTCT health services.
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Affiliation(s)
- Benjamin H Chi
- University of North Carolina at Chapel HillChapel HillNCUSA
| | | | | | | | | | - Mary Mahy
- Joint United Nations Programme on HIV/AIDS (UNAIDS)GenevaSwitzerland
| | - Chewe Luo
- United Nations Children’s Fund (UNICEF)New YorkNYUSA
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Hatcher AM, Darbes L, Kwena Z, Musoke PL, Rogers AJ, Owino G, Helova A, Anderson JL, Oyaro P, Bukusi EA, Turan JM. Pathways for HIV Prevention Behaviors Following a Home-Based Couples Intervention for Pregnant Women and Male Partners in Kenya. AIDS Behav 2020; 24:2091-2100. [PMID: 31894444 DOI: 10.1007/s10461-019-02774-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pregnancy is a time of heightened HIV risk, but also a phase when a couple can prioritize family health. We conducted secondary analysis of a home-based intervention in rural Kenya to explore couple-level adherence to HIV prevention behaviors. The intervention included health education, relationship-building skills, and Couples HIV Testing and Counseling. Pregnant women were randomized to the intervention (n = 64) or standard care (n = 63) along with male partners. Of 96 couples, 82 (85.0%) were followed to 3 months postpartum, when 31.0% of couples reported perfect adherence to HIV prevention. In logistic regression, intervention condition couples had three-fold higher odds of perfect adherence (AOR = 3.07, 95% CI = 1.01-9.32). A structural equation model found the intervention had moderate effects on couple communication, large effects on couple efficacy to take action around HIV, which in turn improved HIV prevention behaviors (CFI = 0.969; TLI = 0.955; RMSEA = 0.049). Strengthening couple communication and efficacy may help prevent the spread of HIV to infants or partners around the time of pregnancy.
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Joseph Davey DL, Daniels J, Beard C, Mashele N, Bekker LG, Dovel K, Ncayiyana J, Coates TJ, Myer L. Healthcare provider knowledge and attitudes about pre-exposure prophylaxis (PrEP) in pregnancy in Cape Town, South Africa. AIDS Care 2020; 32:1290-1294. [PMID: 32576023 DOI: 10.1080/09540121.2020.1782328] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Pre-exposure prophylaxis (PrEP) in pregnancy can reduce HIV incidence and vertical transmission. Healthcare providers (HCPs) play a critical role in delivering PrEP in antenatal care but little is known about HCP knowledge and attitudes about PrEP in pregnancy. We conducted a qualitative study in two healthcare facilities to assess HCPs' PrEP knowledge and perspectives relating to HIV prevention in pregnant women. Between January-March'19, we administered in-depth interviews among antenatal HCPs. We utilized a constant comparison approach to identify major qualitative findings. We enrolled 35 female HCPs (median age=43yrs. Fewer than half of HCPs had heard of PrEP before. Of those who had heard of PrEP, most felt that it was safe to take during pregnancy. Most HCPs described inaccurate PrEP knowledge regarding effectiveness, and most who knew about PrEP lacked clinical detail. HCPs highlighted important potential barriers to maternal PrEP use including: fear that PrEP may be unsafe, or belief that women must talk to partners/parents before initiating PrEP. Facilitators include good knowledge about serodiscordancy and vulnerability to seroconversion in pregnancy and desire to help women gain control overHIV prevention. We recommend integrating PrEP training into HIV testing and PMTCT nurse training to improve counseling and maternal PrEP delivery.
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Affiliation(s)
- Dvora L Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Joseph Daniels
- Department of Psychiatry and Human Behaviors, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| | - Cindy Beard
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Nyiko Mashele
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Kathryn Dovel
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Jabulani Ncayiyana
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Thomas J Coates
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Active pediatric HIV case finding in Kenya and Uganda: A look at missed opportunities along the prevention of mother-to-child transmission of HIV (PMTCT) cascade. PLoS One 2020; 15:e0233590. [PMID: 32484815 PMCID: PMC7266341 DOI: 10.1371/journal.pone.0233590] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 05/04/2020] [Indexed: 01/24/2023] Open
Abstract
Background Children living with HIV remain undiagnosed due to missed opportunities along the prevention of mother-to-child HIV transmission cascade. This study addresses programmatic gaps in the cascade by describing pregnancy and HIV-related services received by mothers of children newly identified as HIV-positive through active case finding. Methods This was a prospective observational cohort (2017–2018) of HIV-positive children <15 years of age newly diagnosed at study facilities and/or surrounding communities in Kenya and Uganda. At enrollment, caregivers were interviewed about maternal and child health and HIV history. Child medical and laboratory information was abstracted at two months post-diagnosis. Descriptive summary statistics were calculated; associations between selected factors and child age at HIV diagnosis were evaluated using generalized estimating equations. Results 174 HIV-positive children (median age 2.4 years) were enrolled. Among maternal caregivers, 110/132 (83.3%) attended antenatal care and 60 (45.5%) reported testing HIV-negative in antenatal care. Of 41 and 56 women known to be HIV-positive during pregnancy and breastfeeding respectively, 17 (41.5%) and 15 (26.8%) did not receive antiretroviral drugs. Despite known maternal HIV-positive status during pregnancy, 39% of these children were not diagnosed until after two years of age; children were diagnosed at younger ages in Uganda (p = 0.0074) and if mother was the caregiver (p<0.0001). The most common HIV testing points identifying children were outpatient (44.3%) and maternal/child health departments (29.9%). Nearly all children initiated antiretroviral therapy within two weeks of diagnosis. Conclusions Multiple missed opportunities for HIV prevention and delays in HIV testing of HIV-exposed children were identified in newly diagnosed children. Findings support critical prevention messaging and retesting of HIV-negative women during pregnancy and breastfeeding, strengthening HIV treatment initiation and follow-up systems and interventions to ensure HIV-positive women receive lifelong antiretroviral therapy throughout the cascade, and broader implementation of community case finding so children not engaged in care receive testing services.
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Burrage AB, Mushavi A, Shiraishi RW, Barr BT, Shambira G, Nyakura J, Balachandra S, Kilmarx PH, Dinh TH. Mother-To-Child Transmission of HIV in Adolescents and Young Women: Findings From a National Prospective Cohort Survey, Zimbabwe, 2013-2014. J Adolesc Health 2020; 66:455-463. [PMID: 31964611 PMCID: PMC8740363 DOI: 10.1016/j.jadohealth.2019.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/21/2019] [Accepted: 10/18/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE We assessed 18-month cumulative mother-to-child HIV transmission (MTCT) risk and risk factors for no antiretroviral medication use during pregnancy among adolescent, young women, and adult mothers in Zimbabwe. METHODS We analyzed data from a prospective survey of 1,171 mother-infant pairs with HIV-exposed infants aged 4-12 weeks who were recruited from 151 immunization clinics from February to August 2013. HIV-exposed infants were followed until diagnosed with HIV, death, or age 18 months. Findings were weighted and adjusted for complex survey design and nonresponse. RESULTS The 18-month cumulative MTCT risk was highest among adolescent aged ≤19 years (12%) followed by young women aged 20-24 years (7.5%) and adult women aged ≥25 years (6.9%). Across these groups, more than 94% had ≥1 antenatal care visit by 21 weeks of gestation, more than 95% had ≥1 HIV test, and more than 98% knew their HIV status. Of known HIV-positive mothers, maternal antiretroviral medication coverage during pregnancy was 76.8% (95% confidence interval: 65.1-85.5), 83.8% (78.6-87.9), and 87.8% (84.6-90.4) among adolescent, young women, and adult mothers, respectively. Among HIV-positive mothers diagnosed prenatally, the adjusted odds ratio of no ARV use during pregnancy was increased among those who had no antenatal care attendance (adjusted odds ratio: 7.7 [3.7-16.0]), no HIV testing (7.3 [2.3-23.5]), no prepartum CD4 count testing (2.1 [1.3-3.4]), and maternal HIV identification during pregnancy (2.9 [1.8-4.8]). Age was not a risk factor. CONCLUSIONS With similar coverage of prevention of MTCT services, the 18-month cumulative MTCT risk was higher among adolescents and young women, compared with adults. Additional research should examine the causes to develop targeted interventions.
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Affiliation(s)
- Amanda B Burrage
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Center for Global Health, Atlanta, Georgia
| | - Angela Mushavi
- AIDS and TB Department, Ministry of Health and Child Care of Zimbabwe, Harare, Zimbabwe
| | - Ray W Shiraishi
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Center for Global Health, Atlanta, Georgia
| | - Beth Tippett Barr
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Center for Global Health, Harare, Zimbabwe
| | - Geral Shambira
- Department of Community Health, University of Zimbabwe, Harare, Zimbabwe
| | - Justice Nyakura
- Department of Community Health, University of Zimbabwe, Harare, Zimbabwe
| | - Shirish Balachandra
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Center for Global Health, Harare, Zimbabwe
| | - Peter H Kilmarx
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Center for Global Health, Atlanta, Georgia; Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Center for Global Health, Harare, Zimbabwe
| | - Thu-Ha Dinh
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Center for Global Health, Atlanta, Georgia.
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Pintye J, Rogers Z, Kinuthia J, Mugwanya KK, Abuna F, Lagat H, Sila J, Kemunto V, Baeten JM, John-Stewart G, Unger JA. Two-Way Short Message Service (SMS) Communication May Increase Pre-Exposure Prophylaxis Continuation and Adherence Among Pregnant and Postpartum Women in Kenya. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:55-67. [PMID: 32139420 PMCID: PMC7108943 DOI: 10.9745/ghsp-d-19-00347] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 02/05/2020] [Indexed: 11/15/2022]
Abstract
INTRODUCTION We evaluated a 2-way short message service (SMS) communication platform to improve continuation of pre-exposure prophylaxis (PrEP) for HIV prevention among Kenyan women who initiated PrEP within routine maternal child health (MCH) and family planning clinics. METHODS We adapted an existing SMS platform (Mobile WACh [mWACh]) to send PrEP-tailored, theory-based SMS and allow clients to communicate with a remote nurse. Women who did not have HIV and who were initiating PrEP at 2 MCH/family planning clinics in Kisumu County, Kenya, from February to October 2018, were offered enrollment into the mWACh-PrEP program; SMS communication was free. We evaluated acceptability, satisfaction, and implementation metrics. In a pre/postevaluation, we compared PrEP continuation at 1-month postinitiation among women who initiated PrEP in the period before (n=166) versus after mWACh-PrEP implementation, adjusting for baseline differences. RESULTS Of the 334 women who were screened for enrollment into the mWACh-PrEP program; 193 (58%) were eligible and of those, 190 (98%) accepted enrollment. Reasons for ineligibility (n=141) included no phone access (29%) and shared SIM cards (25%). Median age was 25 years (interquartile range=22-30), and 91% were MCH clients. Compared to women who initiated PrEP in the month before mWACh-PrEP implementation, women who enrolled in mWACh-PrEP were more likely to return for their first PrEP follow-up visit (40% vs. 53%; adjusted risk ratio [aRR]=1.26; 95% confidence interval [CI]= 1.06, 1.50; P=.008) and more likely to continue PrEP (22% vs. 43%; aRR=1.75; 95% CI=1.21, 2.55; P=.003). Among those who returned, 99% reported successful receipt of SMS through the mWACh-PrEP system and 94% reported that mWACh-PrEP helped them understand PrEP better. Concerns about PrEP use, how it works, and side effects accounted for the majority (80%) of issues raised by participants using SMS. CONCLUSIONS Two-way SMS expanded support for PrEP and opportunities for dialogue beyond the clinic and enabled women to ask and receive answers in real time regarding PrEP, which facilitated its continued use.
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Affiliation(s)
- Jillian Pintye
- Department of Global Health, University of Washington, Seattle, Washington, USA. .,Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, USA
| | - Zoe Rogers
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Department of Obstetrics/Gynecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Kenneth K Mugwanya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Felix Abuna
- Department of Obstetrics/Gynecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Harison Lagat
- Department of Obstetrics/Gynecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Joseph Sila
- Department of Obstetrics/Gynecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Valarie Kemunto
- Department of Obstetrics/Gynecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Department of Obstetrics/Gynecology, Kenyatta National Hospital, Nairobi, Kenya.,Department of Epidemiology, University of Washington, Seattle, Washington, USA.,Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Jennifer A Unger
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Department of Obstetrics/Gynecology, University of Washington, Seattle, Washington, USA
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Joseph Davey DL, Pintye J, Baeten JM, Aldrovandi G, Baggaley R, Bekker L, Celum C, Chi BH, Coates TJ, Haberer JE, Heffron R, Kinuthia J, Matthews LT, McIntyre J, Moodley D, Mofenson LM, Mugo N, Myer L, Mujugira A, Shoptaw S, Stranix‐Chibanda L, John‐Stewart G. Emerging evidence from a systematic review of safety of pre-exposure prophylaxis for pregnant and postpartum women: where are we now and where are we heading? J Int AIDS Soc 2020; 23:e25426. [PMID: 31912985 PMCID: PMC6948023 DOI: 10.1002/jia2.25426] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 11/20/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION HIV incidence is high during pregnancy and breastfeeding with HIV acquisition risk more than doubling during pregnancy and the postpartum period compared to when women are not pregnant. The World Health Organization recommends offering pre-exposure prophylaxis (PrEP) to pregnant and postpartum women at substantial risk of HIV infection. However, maternal PrEP national guidelines differ and most countries with high maternal HIV incidence are not offering PrEP. We conducted a systematic review of recent research on PrEP safety in pregnancy to inform national policy and rollout. METHODS We used a standard Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) approach to conduct a systematic review by searching for completed, ongoing, or planned PrEP in pregnancy projects or studies from clinicaltrials.gov, PubMed and NIH RePORTER from 2014 to March 2019. We performed a systematic review of studies that assess tenofovir disoproxil fumarate (TDF)-based oral PrEP safety in pregnant and breastfeeding HIV-uninfected women. RESULTS AND DISCUSSION We identified 14 completed (n = 5) and ongoing/planned (n = 9) studies that evaluate maternal and/or infant outcomes following PrEP exposure during pregnancy or breastfeeding. None of the completed studies found differences in pregnancy or perinatal outcomes associated with PrEP exposure. Nine ongoing studies, to be completed by 2022, will provide data on >6200 additional PrEP-exposed pregnancies and assess perinatal, infant growth and bone health outcomes, expanding by sixfold the data on PrEP safety in pregnancy. Research gaps include limited data on (1) accurately measured PrEP exposure within maternal and infant populations including drug levels needed for maternal protection; (2) uncommon perinatal outcomes (e.g. congenital anomalies); (3) infant outcomes such as bone growth beyond one year following PrEP exposure; (4) outcomes in HIV-uninfected women who use PrEP during pregnancy and/or lactation. CONCLUSIONS Expanding delivery of PrEP is an essential strategy to reduce HIV incidence in pregnancy and breastfeeding women. Early safety studies of PrEP among pregnant women without HIV infection are reassuring and ongoing/planned studies will contribute extensive new data to bolster the safety profile of PrEP use in pregnancy. However, addressing research gaps is essential to expanding PrEP delivery for women in the context of pregnancy.
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Affiliation(s)
- Dvora L Joseph Davey
- Department of EpidemiologyFielding School of Public HealthUniversity of CaliforniaLos AngelesCAUSA
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jillian Pintye
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Jared M Baeten
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
| | - Grace Aldrovandi
- Geffen School of MedicineUniversity of CaliforniaLos AngelesCAUSA
| | | | - Linda‐Gail Bekker
- Faculty of Health SciencesDesmond Tutu HIV CentreInstitute of Infectious Disease and Molecular MedicineUniversity of Cape TownCape TownNCSouth Africa
| | - Connie Celum
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Benjamin H Chi
- Department of Obstetrics and GynecologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Thomas J Coates
- Geffen School of MedicineUniversity of CaliforniaLos AngelesCAUSA
| | | | - Renee Heffron
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - John Kinuthia
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of Research and ProgramsKenyatta National HospitalNairobiKenya
| | | | - James McIntyre
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- ANOVAJohannesburgSouth Africa
| | - Dhayendre Moodley
- Department of Obstetrics and GynaecologyUniversity of KwaZulu‐NatalDurbanSouth Africa
- Centre for AIDS Research in South AfricaDurbanSouth Africa
| | | | - Nelly Mugo
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Center for Clinical ResearchKenya Medical Research Institute (KEMRI)NairobiKenya
| | - Landon Myer
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Andrew Mujugira
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
| | - Steven Shoptaw
- Geffen School of MedicineUniversity of CaliforniaLos AngelesCAUSA
- Department of Family MedicineUniversity of CaliforniaLos AngelesCAUSA
| | | | - Grace John‐Stewart
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
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de Beer S, Kalk E, Kroon M, Boulle A, Osler M, Euvrard J, Timmerman V, Davies M. A longitudinal analysis of the completeness of maternal HIV testing, including repeat testing in Cape Town, South Africa. J Int AIDS Soc 2020; 23:e25441. [PMID: 31997583 PMCID: PMC6989397 DOI: 10.1002/jia2.25441] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 12/04/2019] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The virtual elimination of mother-to-child transmission of HIV cannot be achieved without complete maternal HIV testing. The World Health Organization recommends that women in high HIV prevalent settings repeat HIV testing in the third trimester, and at delivery or directly thereafter. The Western Cape Province (South Africa) prevention of mother-to-child transmission (PMTCT) guidelines recommend a repeat maternal HIV test between 32 and 34 weeks gestation and at delivery in addition to testing at the first antenatal visit (ideally <20 weeks gestation). There are few published longitudinal studies on the uptake of initial and repeated maternal HIV testing programmes in sub-Saharan Africa. We aimed to investigate the implementation of initial and repeat maternal HIV testing guidelines in Cape Town, South Africa. METHODS Between 2013 and 2016 we established an electronic PMTCT register that consolidated routine data from a primary healthcare facility and its secondary and tertiary referral sites in Cape Town. This provided a longitudinal record for each participant, from first antenatal visit to delivery. Utilizing these data, we conducted a retrospective analysis investigating the completeness of maternal HIV testing according to the PMTCT HIV testing guidelines in Cape Town, and predictors of complete testing, from 2014 to 2016. RESULTS Among 8558 enrolled pregnant women, 7213 (84%) were not known to be HIV positive at their first visit and thus eligible for HIV testing; 91% of them received ≥1 HIV test during pregnancy/delivery. Testing at the first visit was 98% among the 85% of women who attended antenatal care. Among women eligible to receive all three recommended HIV tests, only 11% achieved all three tests. Delivery HIV testing completion among all women without an HIV-positive diagnosis was 23%. HIV prevalence at delivery was 21% and HIV incidence between first visit and delivery in those with ≥2 HIV tests was 0.2%. Women who enrolled after 2014 were more likely to receive the three recommended tests (aOR: 1.41; 95% CI: 1.10 to 1.81) and retest at delivery (aOR: 1.20; 95% CI: 1.05 to 1.39). CONCLUSIONS Implementation of maternal HIV testing in Cape Town improved between 2014 and 2016 but major gaps remain, particularly at delivery.
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Affiliation(s)
- Shani de Beer
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Emma Kalk
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Max Kroon
- Department of PaediatricsMowbray Maternity HospitalUniversity of Cape TownCape TownSouth Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
| | - Meg Osler
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Venessa Timmerman
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Mary‐Ann Davies
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
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HIV-1 Reverse Transcriptase Promotes Tumor Growth and Metastasis Formation via ROS-Dependent Upregulation of Twist. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2019; 2019:6016278. [PMID: 31885806 PMCID: PMC6915010 DOI: 10.1155/2019/6016278] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 11/01/2019] [Accepted: 11/05/2019] [Indexed: 12/15/2022]
Abstract
HIV-induced immune suppression results in the high prevalence of HIV/AIDS-associated malignancies including Kaposi sarcoma, non-Hodgkin lymphoma, and cervical cancer. HIV-infected people are also at an increased risk of “non-AIDS-defining” malignancies not directly linked to immune suppression but associated with viral infections. Their incidence is increasing despite successful antiretroviral therapy. The mechanism behind this phenomenon remains unclear. Here, we obtained daughter clones of murine mammary gland adenocarcinoma 4T1luc2 cells expressing consensus reverse transcriptase of HIV-1 subtype A FSU_A strain (RT_A) with and without primary mutations of drug resistance. In in vitro tests, mutations of resistance to nucleoside inhibitors K65R/M184V reduced the polymerase, and to nonnucleoside inhibitors K103N/G190S, the RNase H activities of RT_A. Expression of these RT_A variants in 4T1luc2 cells led to increased production of the reactive oxygen species (ROS), lipid peroxidation, enhanced cell motility in the wound healing assay, and upregulation of expression of Vimentin and Twist. These properties, particularly, the expression of Twist, correlated with the levels of expression RT_A and/or the production of ROS. When implanted into syngeneic BALB/C mice, 4T1luc2 cells expressing nonmutated RT_A demonstrated enhanced rate of tumor growth and increased metastatic activity, dependent on the level of expression of RT_A and Twist. No enhancement was observed for the clones expressing mutated RT_A variants. Plausible mechanisms are discussed involving differential interactions of mutated and nonmutated RTs with its cellular partners involved in the regulation of ROS. This study establishes links between the expression of HIV-1 RT, production of ROS, induction of EMT, and enhanced propagation of RT-expressing tumor cells. Such scenario can be proposed as one of the mechanisms of HIV-induced/enhanced carcinogenesis not associated with immune suppression.
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Ukoha WC, Dube M. Primary health care nursing students' knowledge of and attitude towards the provision of preconception care in KwaZulu-Natal. Afr J Prim Health Care Fam Med 2019; 11:e1-e8. [PMID: 31714127 PMCID: PMC6890566 DOI: 10.4102/phcfm.v11i1.1916] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 03/15/2019] [Accepted: 05/02/2019] [Indexed: 11/17/2022] Open
Abstract
Background Sub-Saharan African countries have been the worst affected by the high incidence of maternal and child mortality rates and HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) pandemic. Preventive care is the area that requires serious attention as a lot of maternal and child morbidity and mortality can be averted through rendering comprehensive care to women of child-bearing age. Preconception care (PCC) is recognised as an important factor in improving pregnancy outcome; yet, most primary health care (PHC) nurses lack the necessary resources to render PCC. Aim To describe the PHC nursing student’s knowledge of and attitude towards the provision of PCC. Setting Higher Education Institution that offers PHC programme at six different sites to nurses working in the PHC clinics in the province. Methods A quantitative, non-experimental, descriptive study design was used. The total population from three sites selected, based on their geographical location were all invited to participate in the study. Questionnaire was used to collect data which was subsequently analysed using the Statistical Package for Social Sciences (SPSS) version 24. Results The response rate was approximately 85% (n = 138). The respondents have practised in the PHC clinic for more than 1 year. Study centre, age and area of employment were found to be predictors of knowledge, but no direct association was found between the demographic factor and attitude. Furthermore, a significant difference was found between knowledge and age, and between the area of employment and attitude. Conclusion PHC nursing students were knowledgeable and had a favourable attitude towards PCC, but the absence of PCC resources in many practices has hindered them to a greater extent. It is recommended that for proper implementation of PCC to occur, health care workers should be provided with the necessary resources.
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Affiliation(s)
- Winifred C Ukoha
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban.
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Wei L, Mansoor N, Khan RA, Czejka M, Ahmad T, Ahmed M, Ali M, Yang DH. WB-PBPK approach in predicting zidovudine pharmacokinetics in preterm neonates. Biopharm Drug Dispos 2019; 40:341-349. [PMID: 31693190 DOI: 10.1002/bdd.2208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 10/07/2019] [Accepted: 10/09/2019] [Indexed: 01/17/2023]
Abstract
Antiretroviral therapy has been the mainstay of treatment for neonates born to HIV infected mothers. Neonates born prematurely to HIV positive mothers are underdeveloped not only in anatomical terms but also in their physiological systems. Zidovudine, the first antiretroviral drug in clinical therapy for the treatment of HIV has been approved for use in preterm neonates both prophylactically and therapeutically. The present work describes the whole body physiologically based pharmacokinetic (WB-PBPK) model development for zidovudine in preterm neonates of varying gestational ages, to observe the pharmacokinetic behavior of the drug in this vulnerable group of the population. Along with the height, weight, post-natal, and gestational ages of the preterm neonates, metabolic enzymes CYP2A6, CYP2C8, etc. were incorporated for each neonate. The composition of the different organs in terms of water and lipid components, blood flow rates, etc. were specified during simulations according to the gestational ages of these neonates. The following PK parameters were estimated for preterm neonates using simulated plasma profiles: AUC 2686.41 ± 123.49 μmol min/L, Cmax 6.46 ± 0.74 μmol/L, half-life 8.98 ± 2.36 hr, mean residence time 12.23 ± 3.43 hr, and total plasma clearance 1.48 ± 0.19 ml/min/kg in comparison with the observed PK parameters of a clinical study by Mirochknic et al. in preterm neonates with AUC 2020.04 μmol/min/L, Cmax 6.10 μmol/L, and total plasma clearance 1.62 ml/min/kg. PBPK simulations provide an opportunity to visualize the possible impact of physiological maturity levels at varying gestational ages on the pharmacokinetic behavior of zidovudine in preterm neonates.
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Affiliation(s)
- Liuya Wei
- School of Pharmacy, Weifang Medical University, Weifang, 261053, China.,Department of Pharmaceutical Sciences, St John's University, New York, 11439, USA
| | - Najia Mansoor
- Department of Pharmacology, Faculty of Pharmacy & Pharmaceutical Sciences, University of Karachi, Karachi, 75270, Pakistan
| | - Rafeeq Alam Khan
- Department of Pharmacology, Faculty of Pharmacy & Pharmaceutical Sciences, University of Karachi, Karachi, 75270, Pakistan
| | - Martin Czejka
- Department of Clinical Pharmacy and Diagnostics, University of Vienna, Vienna, A-1090, Austria
| | - Tasneem Ahmad
- Pharma Professional Services, Karachi, 75270, Pakistan
| | - Mansoor Ahmed
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy & Pharmaceutical Sciences, University of Karachi, Karachi, 75270, Pakistan
| | - Mohsin Ali
- Department of Chemistry, University of Karachi, Karachi, 75270, Pakistan
| | - Dong-Hua Yang
- Department of Pharmaceutical Sciences, St John's University, New York, 11439, USA
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Brief Report: Integration of PrEP Services Into Routine Antenatal and Postnatal Care: Experiences From an Implementation Program in Western Kenya. J Acquir Immune Defic Syndr 2019; 79:590-595. [PMID: 30204720 DOI: 10.1097/qai.0000000000001850] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Programmatic approaches for delivering pre-exposure prophylaxis (PrEP) to pregnant and postpartum women in settings with high HIV burden are undefined. The PrEP Implementation for Young Women and Adolescents (PrIYA) Program developed approaches for delivering PrEP in maternal child health (MCH) clinics. METHODS Under the PrIYA Program, nurse-led teams worked with MCH staff at 16 public, faith-based, and private facilities in Kisumu, Kenya, to determine optimal clinic flow for PrEP integration into antenatal care (ANC) and postnatal care (PNC). A program-dedicated nurse facilitated integration. HIV-uninfected women were screened for behavioral risk factors; same-day PrEP was provided to interested and medically eligible women. PrEP and MCH services were evaluated using standardized flow mapping and time-and-motion surveys. RESULTS Clinics developed 2 approaches for integrating PrEP delivery within ANC/PNC: (1) co-delivery: ANC/PNC and PrEP services delivered by same MCH nurse or (2) sequential services: PrEP services after ANC/PNC by a PrEP-specialized nurse. Three clinics selected co-delivery and 13 sequential services, based on patient volume and space availability. Overall, 86 ANC/PNC visits were observed. Clients who initiated PrEP took a median of 18 minutes (interquartile range 15-26) for PrEP-related activities (risk assessment, PrEP counseling, creatinine testing, dispensation, and documentation) in addition to other routine ANC/PNC activities. For clients who declined PrEP, an additional 13 minutes (interquartile range 7-15) was spent on PrEP-related risk assessment and counseling. CONCLUSIONS PrEP delivery within MCH used co-delivery or sequential approaches. The moderate additional time burden for PrEP initiation in MCH would likely decline with community awareness and innovations such as group/peer counseling or expedited dispensing.
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Goga AE, Dinh TH, Essajee S, Chirinda W, Larsen A, Mogashoa M, Jackson D, Cheyip M, Ngandu N, Modi S, Bhardwaj S, Chirwa E, Pillay Y, Mahy M. What will it take for the Global Plan priority countries in Sub-Saharan Africa to eliminate mother-to-child transmission of HIV? BMC Infect Dis 2019; 19:783. [PMID: 31526371 PMCID: PMC6745780 DOI: 10.1186/s12879-019-4393-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The 2016 'Start Free, Stay Free, AIDS Free' global agenda, builds on the 2011-2015 'Global Plan'. It prioritises 22 countries where 90% of the world's HIV-positive pregnant women live and aims to eliminate vertical transmission of HIV (EMTCT) and to keep mothers alive. By 2019, no Global Plan priority country had achieved EMTCT; however, 11 non-priority countries had. This paper synthesises the characteristics of the first four countries validated for EMTCT, and of the 21 Global Plan priority countries located in Sub-Saharan Africa (SSA). We consider what drives vertical transmission of HIV (MTCT) in the 21 SSA Global Plan priority countries. METHODS A literature review, using PubMed, Science direct and the google search engine was conducted to obtain global and national-level information on current HIV-related context and health system characteristics of the first four EMTCT-validated countries and the 21 SSA Global Plan priority countries. Data representing only one clinic, hospital or region were excluded. Additionally, key global experts working on EMTCT were contacted to obtain clarification on published data. We applied three theories (the World Health Organisation's building blocks to strengthen health systems, van Olmen's Health System Dynamics framework and Baral's socio-ecological model for HIV risk) to understand and explain the differences between EMTCT-validated and non-validated countries. Additionally, structural equation modelling (SEM) and linear regression were used to explain associations between infant HIV exposure, access to antiretroviral therapy and two outcomes: (i) percent MTCT and (iii) number of new paediatric HIV infections per 100 000 live births (paediatric HIV case rate). RESULTS EMTCT-validated countries have lower HIV prevalence, less breastfeeding, fewer challenges around leadership, governance within the health sector or country, infrastructure and service delivery compared with Global Plan priority countries. Although by 2016 EMTCT-validated countries and Global Plan priority countries had adopted a public health approach to HIV prevention, recommending lifelong antiretroviral therapy (ART) for all HIV-positive pregnant and lactating women, EMCT-validated countries had also included contact tracing such as assisted partner notification, and had integrated maternal and child health (MCH) and sexual and reproductive health (SRH) services, with services for HIV infection, sexually transmitted infections, and viral hepatitis. Additionally, Global Plan priority countries have limited data on key SRH indicators such as unmet need for family planning, with variable coverage of antenatal care, HIV testing and triple antiretroviral therapy (ART) and very limited contact tracing. Structural equation modelling (SEM) and linear regression analysis demonstrated that ART access protects against percent MTCT (p<0.001); in simple linear regression it is 53% protective against percent MTCT. In contrast, SEM demonstrated that the case rate was driven by the number of HIV exposed infants (HEI) i.e. maternal HIV prevalence (p<0.001). In linear regression models, ART access alone explains only 17% of the case rate while HEI alone explains 81% of the case rate. In multiple regression, HEI and ART access accounts for 83% of the case rate, with HEI making the most contribution (coef. infant HIV exposure=82.8, 95% CI: 64.6, 101.1, p<0.001 vs coef. ART access=-3.0, 95% CI: -6.2, 0.3, p=0.074). CONCLUSION Reducing infant HIV exposure, is critical to reducing the paediatric HIV case rate; increasing ART access is critical to reduce percent MTCT. Additionally, our study of four validated countries underscores the importance of contact tracing, strengthening programme monitoring, leadership and governance, as these are potentially-modifiable factors.
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Affiliation(s)
- Ameena E. Goga
- Health Systems Research Unit, South African Medical Research Council, Pretoria, 0001 South Africa
- HIV Prevention Research Unit, South African Medical Researh Council, Pretoria, South Africa
- Department of Paediatrics, University of Pretoria, Pretoria, 0001 South Africa
| | - Thu-Ha Dinh
- Division of Global HIV and Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA 30329 USA
| | - Shaffiq Essajee
- Department of HIV/AIDS, World Health Organisation, 27, CH-1211 Geneva, Switzerland
| | - Witness Chirinda
- Health Systems Research Unit, South African Medical Research Council, Pretoria, 0001 South Africa
| | - Anna Larsen
- Centers for Disease Control and Prevention, Pretoria, 0001 South Africa
| | - Mary Mogashoa
- Centers for Disease Control and Prevention, Pretoria, 0001 South Africa
| | - Debra Jackson
- Health section, United Nations Children’s Fund (UNICEF), New York, 10017 USA
- School of Public Health, University of the Western Cape, Cape Town, 7535 South Africa
| | - Mireille Cheyip
- Centers for Disease Control and Prevention, Pretoria, 0001 South Africa
| | - Nobubelo Ngandu
- Health Systems Research Unit, South African Medical Research Council, Pretoria, 0001 South Africa
| | - Surbhi Modi
- Division of Global HIV and Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA 30329 USA
| | - Sanjana Bhardwaj
- Health section, UNICEF South Africa, Pretoria, 0001 South Africa
| | - Esnat Chirwa
- Gender and Health Research Unit, South African Medical Research Council, Pretoria, 0001 South Africa
- School of Public Health, University of Witwatersrand, Johannesburg, 2193 South Africa
| | - Yogan Pillay
- Chief Director HIV/AIDS, TB, MCWHN, National Department of Health, Pretoria, 0001 South Africa
| | - Mary Mahy
- Strategic Information and Evaluation Department, UNAIDS, 1211 Geneva, Switzerland
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Kuhn L, Goga AE. Moving towards elimination: findings from the South Africa prevention of mother to child transmission evaluation (SAPMTCTE). BMC Infect Dis 2019; 19:782. [PMID: 31526365 PMCID: PMC6745774 DOI: 10.1186/s12879-019-4334-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Louise Kuhn
- Gertrude H. Sergievsky Center, College of Physicians and Surgeons, Columbia University Medical Center, 630 W 168th Street, New York, NY, 10032, USA. .,Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, 630 W 168th Street, New York, NY, 10032, USA.
| | - Ameena E Goga
- Health Systems Research Unit, South African Medical Research Council, Pretoria, 0001, South Africa.,Department of Paediatrics, University of Pretoria, Pretoria, 0001, South Africa
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