Prevalence and Predictors of Chlamydia trachomatis and Neisseria gonorrhoeae Among HIV-Negative Pregnant Women in Kenya.

BACKGROUND: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections in pregnancy contribute to adverse perinatal outcomes. We identified predictors of CT and/or NG infection among pregnant Kenyan women. METHODS: Women without HIV were enrolled at 2 antenatal clinics in Western Kenya. Both CT and NG were assessed using endocervical samples for nucleic acid amplification tests. Poisson regression models were used to evaluate potential CT/NG risk factors. Classification and regression trees were generated to evaluate the joint effects of predictors. RESULTS: Overall, 1276 women had both CT and NG assessments. Women enrolled at a median of 26 weeks' gestation (interquartile range, 22-31 weeks), median age was 22 years (interquartile range, 19-27 years), and 78% were married. In total, 98 (7.7%) tested positive for CT/NG: 70 (5.5%) for CT and 32 (2.5%) for NG, 4 of whom (0.3%) had coinfections. Two-thirds (66%) of CT/NG cases were asymptomatic and would have been missed with only syndromic management. Risk factors of CT/NG included age <22 years, crowded living conditions, being unmarried, being in partnerships for <1 year, abnormal vaginal discharge, sexually transmitted infection history, and Trichomonas vaginalis diagnosis ( P < 0.1). Classification and regression tree analyses identified unmarried women <22 years in relationships for <1 year as 6.1 times more likely to have CT/NG compared with women without these characteristics (26% vs. 6%, adjusted prevalence ratio = 6.1, 95% confidence interval = 3.55-10.39, P < 0.001). CONCLUSIONS: Chlamydia trachomatis / Neisseria gonorrhoeae was frequently asymptomatic and common among young unmarried women in newer partnerships in this cohort. Integrating CT/NG testing into routine antenatal care may be beneficial, especially for young women in Kenya.

Perinatal depression and its impact on infant outcomes and maternal-nurse SMS communication in a cohort of Kenyan women.

BACKGROUND: Perinatal depression is broadly defined as depressive symptoms during pregnancy or within the 12 months following delivery, affecting approximately 20-25% of pregnant and postpartum women in low- and middle-income countries. The wide accessibility of mobile phones allows mobile health (mHealth) interventions to be considered a solution to identify perinatal depression and provide appropriate referrals for treatment. This study, nested in a larger SMS communication project, examined the prevalence and correlates of perinatal depression, determined the association between antenatal depression and infant morbidity and mortality, and compared SMS communication patterns between women with and without perinatal depression. METHODS: This was a prospective longitudinal cohort study of pregnant women seeking antenatal services at two public sector health clinics in Kenya. SMS messages were sent to participants with educational content related to their pregnancy and infant health and two-way SMS communication occurred with a nurse. Sociodemographic and obstetric characteristics, SMS messaging behaviors, infant health status, and depressive symptoms were assessed by a standardized questionnaire administered at enrollment (30-36 weeks gestation) and follow-up (14 weeks postpartum). Generalized estimating equation (GEE) with Poisson link was used to evaluate correlates of perinatal depressive symptoms, infant outcomes, and frequency of SMS messaging. RESULTS: Of the 572 women with complete follow-up information, 188 (32.9%) screened positive for elevated depressive symptoms (≥10 by EPDS scale) at some time point during pregnancy or postpartum. The strongest predictors of any depressive symptoms included interpersonal abuse during pregnancy, fewer years of schooling, and maternal unemployment. Antenatal depressive symptoms were associated with an increased risk of infant illness or hospitalization (RR = 1.12, 95% CI: 1.11, 1.13). Women with antenatal or persistent perinatal depressive symptoms sent fewer SMS messages during the study period than their counterparts without depression. CONCLUSIONS: Prevalence of elevated perinatal depressive symptoms was high in this cohort of Kenyan women. Our findings highlight the importance of screening perinatal women for experiences of symptoms of depression as well as abuse. Differences in messaging frequency between women with vs. without depressive symptoms presents an opportunity to provide more tailored support for those perinatal depression.

Chlamydia, Gonorrhea, and Incident HIV Infection During Pregnancy Predict Preterm Birth Despite Treatment.

BACKGROUND: Identifying predictors of preterm birth (PTB) in high-burden regions is important as PTB is the leading cause of global child mortality. METHODS: This analysis was nested in a longitudinal study of human immunodeficiency virus (HIV) incidence in Kenya. HIV-seronegative women enrolled in pregnancy had nucleic acid amplification tests (chlamydia and gonorrhea), rapid plasma reagin (syphilis), wet mount microscopy (Trichomonas and yeast), and Gram stain (bacterial vaginosis); sexually transmitted infection (STI) treatment was provided. PTB predictors were determined using log-binomial regression. RESULTS: Among 1244 mothers of liveborn infants, median gestational age at enrollment was 26 weeks (IQR, 22-31), and at delivery was 39.1 weeks (IQR, 37.1-40.9). PTB occurred in 302 women (24.3%). Chlamydia was associated with a 1.59-fold (P = .006), gonorrhea a 1.62-fold (P = .04), and incident HIV a 2.08-fold (P = .02) increased PTB prevalence. Vaginal discharge and cervical inflammation were associated with PTB, as were age ≤21 (prevalence ratio [PR] = 1.39, P = .001) and any STI (PR = 1.47, P = .001). Associations with chlamydia and incident HIV remained in multivariable models. CONCLUSIONS: STIs and incident HIV in pregnancy predicted PTB despite treatment, suggesting the need for earlier treatment and interventions to decrease genital inflammation.

SMS messaging to improve retention and viral suppression in prevention of mother-to-child HIV transmission (PMTCT) programs in Kenya: A 3-arm randomized clinical trial.

BACKGROUND: Pregnant and postpartum women living with HIV (WLWH) need support for HIV and maternal child health (MCH) care, which could be provided using short message service (SMS). METHODS AND FINDINGS: We compared 2-way (interactive) and 1-way SMS messaging to no SMS in a 3-arm randomized trial in 6 MCH clinics in Kenya. Messages were developed using the Health Belief Model and Social Cognitive Theory; HIV messages were integrated into an existing MCH SMS platform. Intervention participants received visit reminders and prespecified weekly SMS on antiretroviral therapy (ART) adherence and MCH, tailored to their characteristics and timing. Two-way participants could message nurses as needed. Clinic attendance, viral load (VL), and infant HIV results were abstracted from program records. Primary outcomes were viral nonsuppression (VL ≥1,000 c/ml), on-time clinic attendance, loss to follow-up from clinical care, and infant HIV-free survival. Among 824 pregnant women randomized between November 2015 and May 2017, median age was 27 years, gestational age was 24.3 weeks, and time since initiation of ART was 1.0 year. During follow-up to 2 years postpartum, 9.8% of 3,150 VL assessments and 19.6% of women were ever nonsuppressed, with no significant difference in 1-way versus control (11.2% versus 9.6%, adjusted risk ratio (aRR) 1.02 [95% confidence interval (CI) 0.67 to 1.54], p = 0.94) or 2-way versus control (8.5% versus 9.6%, aRR 0.80 [95% CI 0.52 to 1.23], p = 0.31). Median ART adherence and incident ART resistance did not significantly differ by arm. Overall, 88.9% (95% CI 76.5 to 95.7) of visits were on time, with no significant differences between arms (88.2% in control versus 88.6% in 1-way and 88.8% in 2-way). Incidence of infant HIV or death was 3.01/100 person-years (py), with no significant difference between arms; risk of infant HIV infection was 0.94%. Time to postpartum contraception was significantly shorter in the 2-way arm than control. Study limitations include limited ability to detect improvement due to high viral suppression and visit attendance and imperfect synchronization of SMS reminders to clinic visits. CONCLUSIONS: Integrated HIV/MCH messaging did not improve HIV outcomes but was associated with improved initiation of postpartum contraception. In programs where most women are virally suppressed, targeted SMS informed by VL data may improve effectiveness. Rigorous evaluation remains important to optimize mobile health (mHealth) interventions. TRIAL REGISTRATION: ClinicalTrials.gov number NCT02400671.

Utility of Short Message Service (SMS) for Remote Data Collection for HIV in Low- and Middle-Income Countries.

PURPOSE OF REVIEW: Short message system (SMS) communication is widespread in low- and middle-income countries (LMICs), and may be a viable approach to address challenges with in-person data collection for HIV-related research and monitoring and evaluation. We reviewed the literature to characterize potential benefits and challenges with using SMS for remote data capture, including examples from HIV and sexual and reproductive health. RECENT FINDINGS: In our review, we found that studies that have used SMS to capture sensitive, self-reported data found this was an acceptable and feasible strategy, and may reduce social desirability bias of self-reported data; but studies are limited. Shared phones and privacy concerns have been described as challenges, but can be addressed with enhanced security features. Response rates to SMS surveys varied significantly by topic, population, and setting. SMS may improve generalizability and precision of health and behavior data for HIV in research and programs, but use in LMICs is limited. SMS systems should be carefully designed to overcome potential implementation hurdles.

Influence of Sexually Transmitted Infections in Pregnant Adolescents on Preterm Birth and Chorioamnionitis.

Background: Adolescents have an increased risk of preterm birth (PTB) and sexually transmitted infections (STIs). We examined the prevalence and impact of STIs (gonorrhea, chlamydia, and trichomonas) on PTB and chorioamnionitis in pregnant adolescents. Methods: This retrospective cohort study utilized the first pregnancy delivered at an urban hospital among patients ≤ 19 years old over a 5-year period. Poisson regression with robust standard errors was used to estimate prevalence ratios (PR) and 95% confidence intervals (CI) of the association between STIs and PTB (<37 weeks) and chorioamnionitis identified by clinical or placental pathology criteria. Results: 739 deliveries were included. 18.8% (n = 139) of births were preterm. The overall prevalence of STIs during pregnancy was 16.5% (Chlamydia trachomatis: 13.1%, n = 97; Trichomonas vaginalis: 3.7%, n = 27; and Neisseria gonorrheae: 3.1%, n = 23). Detection of C. trachomatis, T. vaginalis, or N. gonorrheae was not associated with increased PTB. While infection with N. gonorrheae and C. trachomatis did not increase the likelihood of any chorioamnionitis, infection with T. vaginalis significantly increased the likelihood of any chorioamnionitis diagnosis (aPR 2.19, 95% CI 1.26-3.83). Conclusion: In this adolescent population with a high rate of PTB, in whom most received appropriate STI treatment, we did not find an association between STI during pregnancy and an increased rate of PTB. However, an infection with T. vaginalis was associated with an increased likelihood of chorioamnionitis. Early detection of STIs may prevent adverse pregnancy outcomes. Continued vigilance in STI screening during pregnancy, including consideration of universal Trichomonas vaginalis screening, is merited in this high-risk population.

Sexually transmitted infections during pregnancy and subsequent risk of stillbirth and infant mortality in Kenya: a prospective study.

OBJECTIVES: We evaluated the relationship of sexually transmitted infections (STIs) and genital infections during pregnancy and subsequent risk for infant mortality and stillbirth. METHODS: This was a nested longitudinal analysis using data from a study of peripartum HIV acquisition in Kenya. In the parent study, HIV-uninfected women were enrolled during pregnancy and followed until 9 months postpartum. For this analysis, women who tested positive for HIV at any point, had a non-singleton pregnancy or a spontaneous abortion <20 weeks were excluded. At enrolment, laboratory methods were used to screen for bacterial vaginosis (BV), vaginal yeast, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV). Syphilis was diagnosed using rapid plasma reagin testing and genital ulcer disease (GUD) identified by clinical examination. Treatment of laboratory-confirmed STIs and syndromic management was provided per Kenyan national guidelines. Predictors of stillbirth and infant mortality were determined using logistic regression and Cox proportional hazards models. RESULTS: Overall, among 1221 women, 55% had STIs or genital infections detected: vaginal yeast (25%), BV (22%), TV (6%), CT (5%), NG (2%) and syphilis (1%). Among women with STIs/genital infections (n=592), 34% had symptoms. Overall, 19/1221 (2%) women experienced stillbirths. Among 1202 live births, 34 infant deaths occurred (incidence 4.0 deaths per 100 person-years, 95% CI 2.8 to 5.5). After adjustment for maternal age, education and study site, stillbirth was associated with maternal GUD (adjusted OR=9.19, 95% CI1.91 to 44.35, p=0.006). Maternal NG was associated with infant mortality (adjusted HR=3.83, 95% CI1.16 to 12.68, p=0.028); there was some evidence that maternal CT was associated with infant mortality. Stillbirth or infant mortality were not associated with other genital infections. CONCLUSIONS: STIs and genital infections were common, frequently asymptomatic and some associated with stillbirth or infant mortality. Expediting diagnosis and treatment of STIs in pregnancy may improve infant outcomes.

An mHealth SMS intervention on Postpartum Contraceptive Use Among Women and Couples in Kenya: A Randomized Controlled Trial.

Objectives. To assess the effect of 2-way short message service (SMS) with a nurse on postpartum contraceptive use among individual women and couples. Methods. From 2016 to 2017, we conducted a randomized controlled trial at 2 public hospitals in western Kenya. We assigned eligible pregnant women to receive 2-way SMS with a nurse or no SMS, with the option to include male partners. We delivered automated family planning-focused SMS messages weekly until 6 months postpartum. Women and men receiving SMS could interact with nurses via SMS. In intention-to-treat analysis, we compared highly effective contraceptive (HEC) use at 6 months postpartum between groups using the χ2 test. We used Poisson regression in adjusted analysis. Results. We randomized 260 women to 2-way SMS or control, and we enrolled 103 male partners. At 6 months postpartum, 69.9% women receiving SMS reported HEC use, compared with 57.4% in control (relative risk = 1.22; 95% confidence interval [CI] = 1.01, 1.47; P = .04). In analysis adjusted for baseline demographic differences, the adjusted relative risk for HEC use in the SMS group was 1.26 (95% CI = 1.04, 1.52; P = .02). Conclusions. Two-way SMS with a nurse, including optional male participation, increased postpartum contraceptive use. Trial Registration. ClinicalTrials.gov; identifier: NCT02781714.

Utilizing perspectives from HIV-infected women, male partners and healthcare providers to design family planning SMS in Kenya: a qualitative study.

BACKGROUND: Short message service (SMS) presents an opportunity to expand the reach of care and improve reproductive health outcomes. SMS could increase family planning (FP) use through education, support and demand generation. The purpose of this analysis is to determine the perspectives of potential FP users to inform design of SMS. METHODS: We conducted focus group discussions (FGD) with HIV-infected women and in-depth interviews (IDI) with male partners and health care workers (HCW) at urban and rural clinics in Kenya to design SMS content for a randomized controlled trial. RESULTS: Women and men indicated SMS could be used as a tool to discuss FP with their partners, and help decrease misconceptions about FP. Women stated SMS could make them more comfortable discussing sensitive topics with HCWs compared to in-person discussions. However, some women expressed concerns about FP SMS particularly if they used FP covertly or feared partner disapproval of FP use. These findings were common among women who had not disclosed their status. Providers viewed SMS as an important tool for tracking patients and clinical triage in conjunction with routine clinical visits. CONCLUSION: Our findings suggest that SMS has the potential to facilitate FP education, counselling, and interaction with HCWs around FP.

A systematic review and meta-analysis of postpartum contraceptive use among women in low- and middle-income countries.

BACKGROUND: Short birth intervals increase risk for adverse maternal and infant outcomes including preterm birth, low birth weight (LBW), and infant mortality. Although postpartum family planning (PPFP) is an increasingly high priority for many countries, uptake and need for PPFP varies in low- and middle-income countries (LMIC). We performed a systematic review and meta-analysis to characterize postpartum contraceptive use, and predictors and barriers to use, among postpartum women in LMIC. METHODS: PubMed, EMBASE, CINAHL, PsycINFO, Scopus, Web of Science, and Global Health databases were searched for articles and abstracts published between January 1997 and May 2018. Studies with data on contraceptive uptake through 12 months postpartum in low- and middle-income countries were included. We used random-effects models to compute pooled estimates and confidence intervals of modern contraceptive prevalence rates (mCPR), fertility intentions (birth spacing and birth limiting), and unmet need for contraception in the postpartum period. RESULTS: Among 669 studies identified, 90 were selected for full-text review, and 35 met inclusion criteria. The majority of studies were from East Africa, West Africa, and South Asia/South East Asia. The overall pooled mCPR during the postpartum period across all regions was 41.2% (95% CI: 15.7-69.1%), with lower pooled mCPR in West Africa (36.3%; 95% CI: 27.0-45.5%). The pooled prevalence of unmet need was 48.5% (95% CI: 19.1-78.0%) across all regions, and highest in South Asia/South East Asia (59.4, 95% CI: 53.4-65.4%). Perceptions of low pregnancy risk due to breastfeeding and postpartum amenorrhea were commonly associated with lack of contraceptive use and use of male condoms, withdrawal, and abstinence. Women who were not using contraception were also less likely to utilize maternal and child health (MCH) services and reside in urban settings, and be more likely to have a fear of method side effects and receive inadequate FP counseling. In contrast, women who received FP counseling in antenatal and/or postnatal care were more likely to use PPFP. CONCLUSIONS: PPFP use is low and unmet need for contraception following pregnancy in LMIC is high. Tailored counseling approaches may help overcome misconceptions and meet heterogeneous needs for PPFP.

Engaging men in an mHealth approach to support postpartum family planning among couples in Kenya: a qualitative study.

BACKGROUND: Involving male partners in family planning (FP) education and counseling may improve FP utilization and help meet couples' reproductive health needs in the postpartum period. We aimed to explore Kenyan men's and women's perspectives on an interactive short message service (SMS) approach to support postpartum FP decision-making, and inform intervention content for a randomized controlled trial (RCT). METHODS: We conducted four focus group discussions (FGD) among men (n = 35) and two among pregnant/postpartum women (n = 15) in western Kenya. Female participants were recruited at antenatal clinics; male participants were referred by antenatal attendees. FGDs included participant critique of pilot theory-based SMS messages. FGD transcripts were coded by two investigators and analyzed using an iterative, modified grounded theory approach. These data informed the intervention and RCT design, in which women had the option to refer male partners for trial enrollment. RESULTS: Men strongly desired inclusion in FP programs, and frequently discussed negative relationship consequences of women's covert contraceptive use. Female and male participants voiced a variety of concerns about contraceptive side effects and potential harms, which were central to narratives of community influence on personal contraceptive choices. Most participants felt that receiving FP-focused SMS and including men would be beneficial. They perceived that SMS dialogue with a nurse about FP could reduce misperceptions and may stimulate communication within couples, thereby improving contraceptive access and continuation. Shared decision-making around FP within couple relationships, in consultation with clinicians, was highly valued. CONCLUSIONS: Health concerns about FP and limited couple communication are perceived contributors to postpartum unmet contraceptive need. With women's consent, the inclusion of male partners in FP services, and specifically in an mHealth SMS intervention, is acceptable and desired. Receiving SMS may trigger communication about postpartum FP within couples. SMS content should address contraceptive knowledge gaps, anticipated side effects and FP misperceptions, and allow for real-time method choice assistance.

Acceptability, feasibility and utility of a Mobile health family planning decision aid for postpartum women in Kenya.

BACKGROUND: Unmet need for contraception is high during the postpartum period, increasing the risk of unintended subsequent pregnancy. We developed a client facing mobile phone-based family planning (FP) decision aid and assessed acceptability, feasibility, and utility of the tool among health care providers and postpartum women. METHODS: Semi-structured in-depth interviews (IDIs) were conducted among postpartum women (n = 25) and FP providers (n = 17) at 4 Kenyan maternal and child health clinics, 2 in the Nyanza region (Kisumu and Siaya Counties) and 2 in Nairobi. Stratified purposive sampling was used to enroll postpartum women and FP providers. Data were analyzed using an inductive content analysis approach by 3 independent coders, with consensual validation. RESULTS: FP providers stated that the Interactive Mobile Application for Contraceptive Choice (iMACC) tool contained the necessary information about contraceptive methods for postpartum women and believed that it would be a useful tool to help women make informed, voluntary decisions. Most women valued the decision aid content, and described it as being useful in helping to dispel myths and misconceptions, setting realistic expectations about potential side effects and maintaining confidentiality. Both women and providers expressed concerns about literacy and lack of familiarity with smart phones or tablets and suggested inclusion of interactive multimedia such as audio or videos to optimize the effectiveness of the tool. CONCLUSIONS: The iMACC decision aid was perceived to be an acceptable tool to deliver client-centered FP counseling by both women and providers. Counseling tools that can support FP providers to help postpartum women make informed and individualized FP decisions in resource-limited settings may help improve FP counseling and contraceptive use in the postpartum period.

A Missing Link: HIV-/AIDS-Related mHealth Interventions for Health Workers in Low- and Middle-Income Countries.

PURPOSE OF REVIEW: Through a review of the peer-reviewed and gray literature on HIV mobile health (mHealth) tools for health workers and in-depth interviews with mHealth leaders in the field, we provide a synthesis of current work and propose mHealth research priorities for HIV prevention, care, and treatment. RECENT FINDINGS: Significant investment in implementation research and bringing together researchers capable of identifying drivers of successful implementation and industry leaders capable of bringing efficacious tools to scale are needed to move this area forward. Effective and appropriate technologies to support health systems in the prevention and treatment of HIV/AIDS in low- and middle-income countries are needed to improve the efficiency and quality of health service delivery and ultimately improve health outcomes. Although a growing number of HIV mHealth tools have been developed to support health workers, few of these tools have been rigorously evaluated and even fewer have been brought to scale.

SMS messaging to improve ART adherence: perspectives of pregnant HIV-infected women in Kenya on HIV-related message content.

There is growing evidence that mobile health (mHealth) approaches including short messaging service (SMS) can improve antiretroviral therapy (ART) adherence, but consensus is lacking regarding communication of HIV-related information. Most interventions to date have delivered SMS that do not overtly refer to HIV or ART in order to avoid risk of status disclosure. In formative work for an ongoing randomized controlled trial (RCT) evaluating one-way and two-way educational SMS for prevention of mother-to-child-transmission (PMTCT) adherence in Kenya, we conducted 10 focus group discussions (FGDs) with 87 HIV-infected peripartum women to determine desirability and preferred terminology of HIV-related content. SMS for the RCT were developed based on FGD findings. Roughly half of FGD participants supported receiving SMS containing overtly HIV-related terms, such as "HIV" and "medication", citing desire for detailed educational messages about ART and PMTCT. Those opposed to overt content expressed concerns about confidentiality. Many participants argued that acceptability of HIV-related content depended on the recipient's disclosure status and others' access to her phone. Based on these findings, both covert and overt SMS were developed for the RCT and participants who owned their phone or had disclosed their HIV status to anyone with access to their phone were able to choose one of three options: (1) covert SMS only, (2) overt SMS only in response to HIV-related questions from the participant, (3) overt SMS routinely, initiated by the study. Of the 825 participants in the RCT, 94% were eligible to receive overt SMS. Of these, 66% opted to receive routine overt SMS and 10% to receive participant-initiated overt SMS. These findings show there may be interest in overt HIV-related information by SMS when risk of status disclosure is low, and support use of messaging strategies that allows participant choice in HIV-related content while protecting against undesired disclosure.

A Risk Assessment Tool for Identifying Pregnant and Postpartum Women Who May Benefit From Preexposure Prophylaxis.

Background: A human immunodeficiency virus (HIV) risk assessment tool for pregnant women could identify women who would most benefit from preexposure prophylaxis (PrEP) while minimizing unnecessary PrEP exposure. Methods: Data from a prospective study of incident HIV among pregnant/postpartum women in Kenya were randomly divided into derivation (n = 654) and validation (n = 650) cohorts. A risk score was derived using multivariate Cox proportional hazards models and standard clinical prediction rules. Ability of the tool to predict maternal HIV acquisition was assessed using the area under the curve (AUC) and Brier score. Results: The final risk score included the following predictors: having a male partner with unknown HIV status, number of lifetime sexual partners, syphilis, bacterial vaginosis (BV), and vaginal candidiasis. In the derivation cohort, AUC was 0.84 (95% confidence interval [CI], .72-.95) and each point increment in score was associated with a 52% (hazard ratio [HR], 1.52 [95% CI, 1.32-1.76]; P < .001) increase in HIV risk; the Brier score was 0.11. In the validation cohort, the score had similar AUC, Brier score, and estimated HRs. A simplified score that excluded BV and candidiasis yielded an AUC of 0.76 (95% CI, .67-.85); HIV incidence was higher among women with risk scores >6 than with scores ≤6 (7.3 vs 1.1 per 100 person-years, respectively; P < .001). Women with simplified scores >6 accounted for 16% of the population but 56% of HIV acquisitions. Conclusions: A combination of indicators routinely assessed in antenatal clinics was predictive of HIV risk and could be used to prioritize pregnant women for PrEP.

Male partner circumcision associated with lower Trichomonas vaginalis incidence among pregnant and postpartum Kenyan women: a prospective cohort study.

OBJECTIVE: Trichomonas vaginalis is the world's most common curable STI and has implications for reproductive health in women. We determined incidence and correlates of T. vaginalis in an HIV-uninfected peripartum cohort. METHODS: Women participating in a prospective study of peripartum HIV acquisition in Western Kenya were enrolled during pregnancy and followed until 9 months post partum. T. vaginalis was assessed every 1-3 months using wet mount microscopy. Correlates of incident T. vaginalis were determined using Cox proportional hazards models. RESULTS: Among 1271 women enrolled, median age was 22 years (IQR 19-27) and gestational age was 22 weeks (IQR 18-26); most (78%) were married and had uncircumcised male partners (69%). Prevalent T. vaginalis was detected in 81 women (6%) at enrolment. Among women without T. vaginalis at enrolment, 112 had T. vaginalis detected during 1079 person-years of follow-up (10.4 per 100 person-years). After adjustment for socio-economic factors, male partner circumcision status, pregnancy status and other STIs, T. vaginalis incidence was higher during pregnancy than post partum (22.3 vs 7.7 per 100 person-years, adjusted HR (aHR) 3.68, 95% CI 1.90 to 7.15, p<0.001). Women with circumcised male partners had a 58% lower risk of incident T. vaginalis compared with women with uncircumcised partners (aHR 0.42, 95% CI 0.23 to 0.76, p=0.004). Employed women had lower risk of incident T. vaginalis than unemployed women (aHR 0.49, 95% CI 0.31 to 0.79, p=0.003); recent STI was associated with increased T. vaginalis risk (aHR 2.97, 95% CI 1.49 to 5.94, p=0.002). CONCLUSIONS: T. vaginalis was relatively common in this peripartum cohort. Male circumcision may confer benefits in preventing T. vaginalis.

Patient-Delivered Partner Treatment for Chlamydia, Gonorrhea, and Trichomonas Infection Among Pregnant and Postpartum Women in Kenya.

BACKGROUND: Patient-delivered partner treatment (PDPT) for sexually transmitted infections (STIs) increases rates of partner treatment and decreases reinfection, but has not been evaluated during pregnancy. METHODS: This prospective cohort was nested within a larger study of peripartum HIV acquisition. Participants with microbiologic diagnosis of Chlamydia trachomatis, Neisseria gonorrhoeae, and/or Trichomonas vaginalis were screened for participation. Questionnaires were administered to determine PDPT acceptability and barriers. Women were reassessed at least 30 days to determine partner treatment and reinfection. Women whose partners did or did not receive PDPT were compared. RESULTS: One hundred twelve (22.2%) women in the parent cohort had a treatable STI; 78 within the PDPT study period, of whom 66 were eligible and 59 (89.3%) accepted PDPT. Fifty-one women had PDPT outcome data, 37 (73%) of whom reported partners treated with PDPT. Fourteen women (27%) refused or did not deliver partner treatment. Median age was 22 years (interquartile range, 20-26 years) and 88% were married. Compared with women who delivered PDPT, those who did not were more likely to have a partner living far away (23% vs. 0%, P = 0.004) and to report current intimate partner violence (14% vs. 0%, P = 0.02). Reported PDPT barriers included fear of partner's anger/abuse (5%) and accusations of being STI source (5%). CONCLUSION: Patient-delivered partner treatment was acceptable and feasible for pregnant/postpartum Kenyan women and may reduce recurrent STIs in pregnancy.

A lifecycle approach to HIV prevention in African women and children.

Effective biomedical and structural HIV prevention approaches are being implemented throughout sub-Saharan Africa. A "lifecycle approach" to HIV prevention recognizes the interconnectedness of the health of women, children and adolescents, and prioritizes interventions that have benefits across these populations. We review new biomedical prevention strategies for women, adolescents and children, structural prevention approaches, and new modalities for eliminating infant HIV infection, and discuss the implications of a lifecycle approach for the success of these methods. Some examples of the lifecycle approach include evaluating education and HIV prevention strategies among adolescent girls not only for their role in reducing risk of HIV infection and early pregnancy, but also to promote healthy adolescents who will have healthier future children. Similarly, early childhood interventions such as exclusive breastfeeding not only prevent HIV, but also contribute to better child and adolescent health outcomes. The most ambitious biomedical infant HIV prevention effort, Option B+, also represents a lifecycle approach by leveraging the prevention benefits of optimal HIV treatment for mothers; maternal survival benefits from Option B+ may have ultimately more health impact on children than the prevention of infant HIV in isolation. The potential for synergistic and additive benefits of lifecycle interventions should be considered when scaling up HIV prevention efforts in sub-Saharan Africa.

Mode of delivery and postpartum HIV-1 disease progression and mortality in a Kenyan cohort.

BACKGROUND: There are limited data on the impact of cesarean section delivery on HIV-1 infected women in Sub-Saharan Africa. The purpose of this study was to assess the effect of mode of delivery on HIV-1 disease progression and postpartum mortality in a Kenyan cohort. METHODS: A prospective cohort study was conducted in Nairobi, Kenya from 2000-2005. We determined changes in CD4+ counts, HIV-1 RNA levels and mortality during the first year postpartum between HIV-1 infected women who underwent vaginal delivery (VD), non-scheduled cesarean section (NSCS) and scheduled cesarean section (SCS) and received short-course zidovudine. Loess curves and multivariate linear mixed effects models were used to compare longitudinal changes in maternal HIV-1 RNA and CD4+ counts by mode of delivery. Kaplan Meier curves, the log rank test, and Cox proportional hazards regression were used to assess difference in mortality. RESULTS: Of 501 women, 405 delivered by VD, 74 delivered by NSCS and 22 by SCS. Baseline characteristics were similar between the VD and NSCS groups. Baseline antenatal CD4+ counts were lowest and HIV-1 RNA levels highest in the NSCS group but HIV-1 RNA levels were similar between groups at delivery. The rate of decline in CD4+ cells and rate of increase in HIV-1 RNA did not differ between groups. After adjusting for confounders, women who underwent NSCS had a 3.39-fold (95% CI 1.11, 10.35, P = 0.03) higher risk of mortality in the first year postpartum compared to women with VD. CONCLUSIONS: Non-scheduled cesarean section was an independent risk factor for postpartum mortality in HIV-1 positive Kenyan women. The cause of death was predominantly due to HIV-1 related infections, and not direct maternal deaths, however, this was not mirrored by differential changes in HIV-1 progression markers between the groups.

HIV Viral Load Patterns and Risk Factors Among Women in Prevention of Mother-To-Child Transmission Programs to Inform Differentiated Service Delivery.

BACKGROUND: Differentiated service delivery (DSD) approaches decrease frequency of clinic visits for individuals who are stable on antiretroviral therapy. It is unclear how to optimize DSD models for postpartum women living with HIV (PWLH). We evaluated longitudinal HIV viral load (VL) and cofactors, and modelled DSD eligibility with virologic failure (VF) among PWLH in prevention of mother-to-child transmission programs. METHODS: This analysis used programmatic data from participants in the Mobile WAChX trial (NCT02400671). Women were assessed for DSD eligibility using the World Health Organization criteria among general people living with HIV (receiving antiretroviral therapy for ≥6 months and having at least 1 suppressed VL [<1000 copies/mL] within the past 6 months). Longitudinal VL patterns were summarized using group-based trajectory modelling. VF was defined as having a subsequent VL ≥1000 copies/mL after being assessed as DSD-eligible. Predictors of VF were determined using log-binomial models among DSD-eligible PWLH. RESULTS: Among 761 women with 3359 VL results (median 5 VL per woman), a 3-trajectory model optimally summarized longitudinal VL, with most (80.8%) women having sustained low probability of unsuppressed VL. Among women who met DSD criteria at 6 months postpartum, most (83.8%) maintained viral suppression until 24 months. Residence in Western Kenya, depression, reported interpersonal abuse, unintended pregnancy, nevirapine-based antiretroviral therapy, low-level viremia (VL 200-1000 copies/mL), and drug resistance were associated with VF among DSD-eligible PWLH. CONCLUSIONS: Most postpartum women maintained viral suppression from early postpartum to 24 months and may be suitable for DSD referral. Women with depression, drug resistance, and detectable VL need enhanced services.