Providers Have a Responsibility to Discuss Options for Infant Feeding With Pregnant People With Human Immunodeficiency Virus in High-Income Countries.

Guidelines in high-income countries generally recommend against breastfeeding for a pregnant person with HIV due to the historical risk of transmission to the infant and generally acceptable, safe, and sustainable access to formula. Maternal antiretroviral therapy and infant prophylaxis have been shown to significantly decrease the risk of transmission during breastfeeding. In addition, formula may not be acceptable to patients for a variety of cultural, social, or personal reasons, and its sustainability is called into question in the setting of the current nationwide formula shortage. Providers caring for pregnant people with HIV have a responsibility to discuss infant feeding with their patients, and help them weigh the risks and benefits within the limits of the current body of evidence. We outline a process, including a written agreement, that can be used to discuss infant feeding with all patients and help them make the best decision for their family.

Breastfeeding Among People With Human Immunodeficiency Virus in North America: A Multisite Study.

BACKGROUND: In North American countries, national guidelines have strongly recommended formula over breastmilk for people with human immunodeficiency virus (HIV) because of concern for HIV transmission. However, data from resource-limited settings suggest the risk is <1% among virally suppressed people. Information regarding breastfeeding experience in high-resource settings is lacking. METHODS: A retrospective multisite study was performed for individuals with HIV who breastfed during 2014-2022 in the United States (8 sites) and Canada (3 sites). Descriptive statistics were used for data analysis. RESULTS: Among the 72 cases reported, most had been diagnosed with HIV and were on antiretroviral therapy prior to the index pregnancy and had undetectable viral loads at delivery. Most commonly reported reasons for choosing to breastfeed were health benefits, community expectations, and parent-child bonding. Median duration of breastfeeding was 24 weeks (range, 1 day to 72 weeks). Regimens for infant prophylaxis and protocols for testing of infants and birthing parents varied widely among institutions. No neonatal transmissions occurred among the 94% of infants for whom results were available ≥6 weeks after weaning. CONCLUSIONS: This study describes the largest cohort to date of people with HIV who breastfed in North America. Findings demonstrate high variability among institutions in policies, infant prophylaxis, and infant and parental testing practices. The study describes challenges in weighing the potential risks of transmission with personal and community factors. Finally, this study highlights the relatively small numbers of patients with HIV who chose to breastfeed at any 1 location, and the need for further multisite studies to identify best care practices.

Screening for Substance Use Disorders during Pregnancy: A Decision at the Intersection of Racial and Reproductive Justice.

OBJECTIVE: Improve racial equity with routine universal drug screening / Study Design: Commentary on the medicolegal and social history of the United States and the field of obstetrics and gynecology regarding drug screening policy / Results: Critical aspects to inform an equitable drug screening policy include (1) racial bias and stigma related to substance use, (2) the legislative history surrounding substance use during pregnancy, (3) the relationship between substance use and mass incarceration which disproportionately affects persons of color, (4) propensity toward punitive measures for Black mothers with substance use, including termination of parental rights, (5) the role of the medical field in fostering mistrust among our patients / Conclusion: new practices in screening for substance use during pregnancy are needed. KEY POINTS: · Increasing demand for racial justice warrants reframing the issue of urine drug screening.. · The current legal constructs continue to disproportionately impact women of color.. · Routine verbal screening can replace urine drug screening and diminish implicit biases..

Incidence of abnormal cervical and vaginal cytology among women over age 65 years living with human immunodeficiency virus.

BACKGROUND: Women with human immunodeficiency virus have higher rates of abnormal cervical and vaginal cytology and, subsequently, of cervical and vaginal cancers. Although professional bodies currently advocate for indefinite cytology screening for women living with human immunodeficiency virus, these recommendations are based on expert opinion, not evidence-based. In the general population, women who have never had an abnormal cytology result can cease screening at age 65 years. This is due to the relatively low incidence of dysplasia in this group and the risk of false-positive results as women age, invasive follow-up testing, and destructive treatments of lesions that are unlikely to progress to cancer. What is unclear, however, is how human immunodeficiency virus-infected women over age 65 years who have no history of abnormal cytology should be screened to maximize benefit while reducing harms of overscreening. This is a crucial question, as women over age 65 years who are living with human immunodeficiency virus comprise a rapidly growing population. OBJECTIVE: To describe the incidence of abnormal cervical and vaginal cytology results in women over the age of 65 years living with human immunodeficiency virus, with the goal of providing evidence for screening recommendations. MATERIALS AND METHODS: A retrospective chart review was performed, identifying 69 women who received gynecologic follow-up in a county hospital system in Houston, Texas, between 2000 and 2018 and who met study criteria. Incidence of abnormal cytology after age 65 was determined by analyzing all available cytology results after age 65. Demographic and clinical risk factors, including human immunodeficiency virus-specific clinical risk factors, were analyzed. Matched cervical and vaginal pathology results, if conducted, were also evaluated. Statistical analyses were conducted using Stata 15, including χ2 tests and Wilcoxon rank-sum tests for categorical and continuous variables, respectively. Estimates of the cumulative probability of developing an abnormal cytology result was calculated using the Kaplan-Meier method. RESULTS: Among 69 women with no history of abnormal cervical cytology, 12 (17%) went on to develop abnormal cytology results, including 3 (4%) showing high-grade squamous intraepithelial lesions. The incidence rate was 3.5 cases per 100 woman-years (95% confidence interval, 1.58, 7.81). No demographic or gynecologic characteristics were associated with abnormal cytology. A CD4 count of <200 at the time of human immunodeficiency virus diagnosis or at the time of cytology was associated with an abnormal Papanicolaou test result (P < .0001, P = .031). Of women with pathology results in the county hospital system (n = 8), 4 (50%) had cervical intraepithelial neoplasia 2+ or vaginal intraepithelial neoplasia 2+. No women developed invasive cancer. However, 50% of women who had an abnormal Papanicolaou test result in the study period were lost to follow-up; outcomes for these patients are unknown. CONCLUSION: Given the relatively high proportion (4%) of women with high-grade squamous intraepithelial lesions/cervical intraepithelial neoplasia 2+/vaginal intraepithelial neoplasia 2+ during the study period, we agree with current screening recommendations for continued routine Papanicolaou testing after the age of 65 years in women with human immunodeficiency virus. More evidence from larger studies is needed to solidify evidence-based screening recommendations in this unique and growing population.

Should Providers Discuss Breastfeeding With Women Living With HIV in High-Income Countries? An Ethical Analysis.

As men and women with human immunodeficiency virus (HIV) are living longer, healthier lives and having children, many questions regarding reproduction in the context of HIV arise. One question is whether breastfeeding is an option for mothers living with HIV. The established recommendation is that women living with HIV in high-income countries avoid breastfeeding. However, some women may still choose to breastfeed for a variety of personal, social, or cultural reasons. Nonmaleficence ("do no harm") must be weighed against maternal autonomy. We propose that providers caring for women in this situation are ethically justified in discussing breastfeeding as a reasonable, though inferior, option. Providers should pursue a shared decision-making approach, engaging in open conversations to learn about the mother's preferences and values, providing education about risks and benefits of various feeding options, and together with the mother formulating a plan to ensure the best possible outcome for the mother and baby.

Integrase inhibitors in late pregnancy and rapid HIV viral load reduction.

BACKGROUND: Minimizing time to HIV viral suppression is critical in pregnancy. Integrase strand transfer inhibitors (INSTIs), like raltegravir, are known to rapidly suppress plasma HIV RNA in nonpregnant adults. There are limited data in pregnant women. OBJECTIVE: We describe time to clinically relevant reduction in HIV RNA in pregnant women using INSTI-containing and non-INSTI-containing antiretroviral therapy (ART) options. STUDY DESIGN: We conducted a retrospective cohort study of pregnant HIV-infected women in the United States from 2009 through 2015. We included women who initiated ART, intensified their regimen, or switched to a new regimen due to detectable viremia (HIV RNA >40 copies/mL) at ≥20 weeks gestation. Among women with a baseline HIV RNA permitting 1-log reduction, we estimated time to 1-log RNA reduction using the Kaplan-Meier estimator comparing women starting/adding an INSTI in their regimen vs other ART. To compare groups with similar follow-up time, we also conducted a subgroup analysis limited to women with ≤14 days between baseline and follow-up RNA data. RESULTS: This study describes 101 HIV-infected pregnant women from 11 US clinics. In all, 75% (76/101) of women were not taking ART at baseline; 24 were taking non-INSTI containing ART, and 1 received zidovudine monotherapy. In all, 39% (39/101) of women started an INSTI-containing regimen or added an INSTI to their ART regimen. Among 90 women with a baseline HIV RNA permitting 1-log reduction, the median time to 1-log RNA reduction was 8 days (interquartile range [IQR], 7-14) in the INSTI group vs 35 days (IQR, 20-53) in the non-INSTI ART group (P < .01). In a subgroup of 39 women with first and last RNA measurements ≤14 days apart, median time to 1-log reduction was 7 days (IQR, 6-10) in the INSTI group vs 11 days (IQR, 10-14) in the non-INSTI group (P < .01). CONCLUSION: ART that includes INSTIs appears to induce more rapid viral suppression than other ART regimens in pregnancy. Inclusion of an INSTI may play a role in optimal reduction of HIV RNA for HIV-infected pregnant women presenting late to care or failing initial therapy. Larger studies are urgently needed to assess the safety and effectiveness of this approach.

A qualitative assessment of the perceived risks of electronic cigarette and hookah use in pregnancy.

BACKGROUND: Studies reveal that electronic cigarette (e-cigarette) and hookah use are increasing among adolescents and young adults. However, the long-term health effects are unknown, especially with regards to pregnancy. Because of the increased use in women of reproductive age, and the unknown long-term health risks, our primary objectives were to determine the perceived risks of e-cigarette and hookah use in pregnancy, and learn common colloquial terms associated with e-cigarettes. Furthermore, we sought to determine if there is a stigma associated with e-cigarette use in pregnancy. METHODS: Eleven focus groups including 87 participants were conducted immediately following regularly scheduled CenteringPregnancy® prenatal care with women at three different clinics in the greater Houston area. A minimum of two facilitators led the groups, using ten lead-in prompts, with Spanish translation as necessary. Facilitators took notes which were compared immediately following each group discussion and each group was audio recorded and transcribed. Three facilitators utilized NVivo 9.0 software to organize the transcribed data into nodes to identify major themes. To increase rigor, transcripts were further analyzed by two obstetricians who were instructed to find the major themes. RESULTS: Analyses revealed contradicting themes concerning e-cigarette use. In general, e-cigarettes were perceived as safer alternatives to regular tobacco cigarettes, especially if used as smoking cessation devices. A major theme is that use in pregnancy is harmful to the fetus. However, it was perceived that use for smoking cessation in pregnancy may have fewer side effects. We found that a common term for e-cigarettes is "Blu." In our discussion of hookah use, participants perceived use as popular among teenagers and that use in pregnancy is dangerous for the fetus. CONCLUSIONS: Although a strong theme emerged against hookah use, we found contradicting themes in our discussions on e-cigarette use in pregnancy. It is possible that e-cigarette use will not carry the same stigma as regular cigarette smoking in pregnancy. In addition, the impression of e-cigarettes as a healthier alternative to smoking may influence use in pregnancy. Clinicians need to be prepared for questions of e-cigarette safety and efficacy as smoking cessation devices from their pregnant patients who smoke, and women who smoke and are planning to become pregnant.

Breastfeeding and HIV-infected women in the United States: harm reduction counseling strategies.

Social and cultural forces have led some human immunodeficiency virus (HIV)-infected women to question the recommendation in the United States not to breastfeed. Without an open dialogue, women may choose to breastfeed exclusively or intermittently and not disclose this to their provider. We review the evidence from global studies of the risks of breastfeeding among HIV-infected mothers and propose a harm reduction model for women considering breastfeeding.

The influence of ART on the treatment of Trichomonas vaginalis among HIV-infected women.

OBJECTIVE: Among women who are human immunodeficiency virus positive (HIV+), both prevalent and persistent infections with Trichomonas vaginalis (TV) are common. TV has been shown to increase vaginal shedding of HIV, which may influence HIV sexual and perinatal transmission, making prevention important. In 1 cohort of HIV+ women in Kenya, antiretroviral therapy (ART) use, mostly nevirapine based, was associated with lower cure rates of TV for single-dose therapy. Our goal was to repeat this study in a US-based cohort of HIV+/TV+ women and compare outcomes to those with multidose therapy. METHODS: A secondary data analysis was performed on a multicentered cohort of HIV+/TV+ women who were randomized to single-dose (2 grams) or 7-day (500 mg twice daily) multidose metronidazole (MTZ) treatment. Test of cure visit, via culture, occurred 6-12 days after treatment completion. Information was collected on sex partner treatment and sexual exposures. Persistent TV infection rates were compared for women on ART at baseline vs not on ART. RESULTS: Of the 226 women included, those on ART had more treatment failures than women not on ART (24/146 [16.4%] vs 5/80 [6.3%]; P = .03). When stratified by treatment arm, more treatment failures were seen in the single-dose arm (17/73 [23.3%] vs 3/39 [7.7%]; P = .05) than in the multidose arm (7/73 [9.6%] vs 2/41 [4.8%]; P = .39). CONCLUSIONS: ART usage was associated with a higher TV persistent infection rate among those receiving the single-dose treatment, but not the multidose, providing more evidence that multidose should be the preferred treatment for HIV+ women.

Co-occurrence of Trichomonas vaginalis and bacterial vaginosis and vaginal shedding of HIV-1 RNA.

BACKGROUND: Trichomonas vaginalis (TV) and bacterial vaginosis (BV) are independently associated with increased risk of vaginal shedding in HIV-positive women. Because these 2 conditions commonly co-occur, this study was undertaken to examine the association between TV/BV co-occurrence and vaginal shedding of HIV-1 RNA. METHODS: HIV-positive women attending outpatient HIV clinics in 3 urban US cities underwent a clinical examination; were screened for TV, BV, Neisseria gonorrhoeae, Chlamydia trachomatis, and vulvovaginal candidiasis; and completed a behavioral survey. Women shedding HIV-1 RNA vaginally (≥50 copies/mL) were compared with women who had an undetectable (<50 copies/mL) vaginal viral load to determine if women who were TV positive and BV positive or had co-occurrence of TV/BV had higher odds of shedding vaginally when compared with women who did not have these conditions. RESULTS: In this sample of 373 HIV-positive women, 43.1% (n = 161) had co-occurrence of TV/BV and 33.2% (n = 124) were shedding HIV-1 RNA vaginally. The odds of shedding HIV vaginally in the presence of TV alone or BV alone and when TV/BV co-occurred were 4.07 (95% confidence interval [CI], 1.78-9.37), 5.65 (95% CI, 2.64-12.01), and 18.63 (95% CI, 6.71-51.72), respectively, when compared with women with no diagnosis of TV or BV, and after adjusting for age, antiretroviral therapy status, and plasma viral load. CONCLUSIONS: T. vaginalis and BV were independently and synergistically related to vaginal shedding of HIV-1 RNA. Screening and prompt treatment of these 2 conditions among HIV-positive women are important not only clinically but for HIV prevention, as well.

Qualitative assessment of attitudes and knowledge on preterm birth in Malawi and within country framework of care.

BACKGROUND: The overarching goal of this study was to qualitatively assess baseline knowledge and perceptions regarding preterm birth (PTB) and oral health in an at-risk, low resource setting surrounding Lilongwe, Malawi. The aims were to determine what is understood regarding normal length of gestation and how gestational age is estimated, to identify common language for preterm birth, and to assess what is understood as options for PTB management. As prior qualitative research had largely focused on patient or client-based focused groups, we primarily focused on groups comprised of community health workers (CHWs) and providers. METHODS: A qualitative study using focus-group discussions, incidence narrative, and informant interviews amongst voluntary participants. Six focus groups were comprised of CHWs, patient couples, midwives, and clinical officers (n = 33) at two rural health centers referring to Kamuzu Central Hospital. Semi-structured questions facilitated discussion of PTB and oral health (inclusive of periodontal disease), including definitions, perception, causation, management, and accepted interventions. RESULTS: Every participant knew of women who had experienced "a baby born too soon", or preterm birth. All participants recognized both an etiology conceptualization and disease framework for preterm birth, distinguished PTB from miscarriage and macerated stillbirth, and articulated a willingness to engage in studies aimed at prevention or management. Identified gaps included: (1) discordance in the definition of PTB (i.e., 28-34 weeks or less than the 8th month, but with a corresponding fetal weight ranging 500 to 2300 grams); (2) utility and regional availability of antenatal steroids for prevention of preterm infant morbidity and mortality; (3) need for antenatal referral for at-risk women, or with symptoms of preterm birth. There was no evident preference for route of progesterone for the prevention of recurrent PTB. CONCLUSIONS: Qualitative research was useful in (1) identifying gaps in knowledge in urban and rural Malawi, and (2) informing the development of educational materials and implementation of programs or trials ultimately aimed at reducing PTB. As a result of this qualitative work, implementation planning was focused on the gaps in knowledge, dissemination of knowledge (to both patients and providers), and practical solutions to barriers in known efficacious therapies.

Tilting the Scale: Current Provider Perspectives and Practices on Breastfeeding with HIV in the United States.

The risk of vertical transmission from breastfeeding with HIV (BFHIV) has been found to be very low in optimal scenarios with sustained maternal viral suppression during pregnancy and postpartum. Medical providers must account for the risk of this serious adverse event alongside parental autonomy, breastfeeding benefits, and patient values. To assess provider practices, comfort, and challenges with BFHIV, an online mixed-method survey was sent to breastfeeding and HIV provider listservs from June to July 2021. The target population was US medical professionals from diverse practice settings with experience in clinical issues associated with BFHIV, including physicians, advanced practice providers, nurses, and lactation consultants. Data analysis utilized nonparametric hypothesis testing, ordinal regression, and reflexive thematic analysis. Most providers reported counseling pregnant people with HIV on infant feeding choices, but fewer specifically endorsed counseling about breastfeeding. Of 84 unique institutions identified by 100 included respondents, 10% had an institutional protocol supporting BFHIV. Institutional protocols were associated with higher degrees of provider comfort with BFHIV in optimal scenario clinical vignettes. Providers perceived that White patients faced fewer BFHIV barriers than patients with other racial identities. Discomfort balancing the goals to protect infants from infection risk and support the parent's role in infant feeding decisions was a key theme in free text responses; this manifested in a spectrum of management styles ranging from patient's informed choice to paternalism. This study highlights the tension providers navigate regarding BFHIV discussions, calling for patient care guidelines and protocols grounded in risk reduction and respect of patient autonomy.

Educating health professionals in obstetrics and gynecology regarding rapid human immunodeficiency virus (HIV) testing in labor and delivery: a local initiative.

Although, the Centers for Disease Control and the American College of Obstetricians and Gynecologists have advised rapid HIV testing for laboring women of unknown human immunodeficiency virus (HIV) status since 2004 to ensure that results are known prior to delivery, physicians and hospital staff have been slow to follow the recommendation. A multi-component intervention was implemented to educate physicians and hospital staff. There was low baseline knowledge (<50% correct) in the areas of HIV prevalence, use of rapid testing in the prevention of perinatal HIV transmission, and treatment. On 9 out of 14 items, participants demonstrated a >35% increase in correct responses from pre-test to 3 month post-test. Baseline knowledge among obstetric health care providers about how to diagnose and treat newly diagnosed pregnant women was low. Brief exposure to an educational program yielded a marked increase in knowledge that was sustained over 3 months. Educating health professionals in obstetrics and gynecology regarding rapid human immunodeficiency virus (HIV) testing in labor and delivery: a local initiative.

The influence of bacterial vaginosis on the response to Trichomonas vaginalis treatment among HIV-infected women.

OBJECTIVE: Trichomonas vaginalis (TV) is common in HIV+ women, and host factors may play a role in TV treatment outcomes. The purpose of this study was to examine the influence of bacterial vaginosis (BV) on the response to TV treatment among HIV+ women. METHODS: A secondary analysis was conducted of a clinical trial which randomised HIV+/TV+ women to metronidazole (MTZ) treatment: 2 g (single-dose) versus 7 day 500 mg twice daily (multidose). BV was classified using Nugent scores from baseline Gram stains. Women were recultured for TV at test-of-cure (TOC) and again at 3 months if TV-negative at TOC. Repeat TV infection rates were compared for women with a baseline TV/BV coinfection versus baseline TV infection only, and stratified by treatment arm. RESULTS: Among 244 HIV+/TV+ women (mean age=40.3, ±9.5; 92.2% African-American), the rate of BV was 66.8%. Women with BV were more likely to report douching and ≥1 recent sex partners. HIV+ women with baseline TV/BV coinfection were more likely to be TV-positive at TOC than women with baseline TV infection only (RR 2.42 (95% CI 0.96 to 6.07; p=0.05)). When stratified by treatment arm, the association was only found in the single-dose arm (p=0.02) and not in the multidose arm (p=0.92). This interaction did not persist at 3 months. CONCLUSIONS: For HIV+/TV+ women, the rate of BV was high, and BV was associated with early failure of the MTZ single-dose treatment for TV. Biological explanations require further investigation.

Increasing use of rapid HIV testing in labor and delivery among women with no prenatal care: a local initiative.

Pregnant women who do not receive prenatal care and may not be aware of their HIV status are at greatest risk of transmitting HIV to their newborn. A multi-component intervention was designed and implemented to increase the use of rapid HIV testing among pregnant women with no prenatal care at labor and delivery in two county hospitals in Houston/Harris County, Texas. The intervention involved establishing a local task force including representatives from each hospital, assessing each hospital's readiness to implement rapid testing, providing educational presentations and materials, and offering individualized follow-up. Outcomes data were obtained and included the number of patients presenting with no prenatal care who received rapid HIV testing on admission. Before the intervention, both hospitals had rapid test kits available but were not using them consistently. Following the intervention, we observed a significant increase in the use of rapid HIV testing at both institutions (P < 0.001). In the 3 months immediately following the intervention, use of rapid testing at Hospital 1 increased from 7.4 to 35.3% and at Hospital 2 from 27.4 to 41.5%. At 1 year, almost 100% of women with no prenatal care at both hospitals received rapid testing. Educating staff and clinicians and implementing system-wide changes may facilitate behavior change regarding prenatal HIV testing.

Considerations and Recommendations for Pregnancy and Postpartum Care for People Living With Human Immunodeficiency Virus.

Considerable strides have been made in reducing the rate of perinatal human immunodeficiency virus (HIV) transmission within the United States and around the globe. Despite this progress, preventable perinatal HIV transmission continues to occur. Adherence to HIV screening and treatment recommendations preconception and during pregnancy can greatly reduce the risk of perinatal HIV transmission. Early and consistent usage of highly active antiretroviral therapy (ART) can greatly lower the HIV viral load, thus minimizing HIV transmission risk. Additional intrapartum interventions can further reduce the risk of HIV transmission. Although the current standard is to recommend abstinence from breastfeeding for individuals living with HIV in settings where there is safe access to breast milk alternatives (such as in the United States), there is guidance available on counseling and risk-reduction strategies for individuals on ART with an undetectable viral load who elect to breastfeed.

Missed Opportunities for HIV Prevention in Perinatal Care Settings in the United States.

Universal opt-out HIV screening in pregnancy is an essential intervention toward eliminating perinatal HIV transmission in the US. However, it fails to identify pregnant people who are HIV negative at the time of testing but are at ongoing risk for HIV acquisition. Those of us involved in caring for women living with HIV are acutely aware of the many diagnoses of HIV that might have been prevented if only a partner had been tested for HIV or preexposure prophylaxis (PrEP) had been offered to a patient. This perspective article will review current recommendations and evidence-based interventions to evaluate missed opportunities for HIV prevention in US perinatal care settings. We identified three barriers to implementation of HIV prevention strategies during pregnancy and breastfeeding: (1) HIV risk for women is underestimated and poorly defined in clinical practice; (2) Partner testing is challenging and implementation studies in the US are lacking; and (3) PrEP remains underutilized. In March 2020, the National Perinatal HIV Hotline convened a group of clinicians and researchers specializing in perinatal HIV care to a case-based discussion of missed opportunities in perinatal HIV prevention. From our review of the literature via PubMed search as well as expert opinions gathered in this discussion, we make recommendations for addressing these barriers.

HIV-Adapted Group Prenatal Care: Assessing Viral Suppression and Postpartum Retention in Care.

Viral suppression and postpartum retention in care have far-reaching health implications for pregnant women living with HIV and their children, yet remain public health challenges. Prenatal care presents a unique opportunity to engage pregnant women in care. The purpose of this study is to evaluate whether group prenatal care is effective in impacting these outcomes for pregnant women living with HIV. A retrospective cohort study was performed of all women living with HIV who obtained prenatal care from a community-based health center between 2013 and 2019. Women who spoke English or Spanish, remained within the system, and had not participated in group prenatal care previously were included. Women self-selected a prenatal care model: 85 selected group care and 109 elected individual care. Group prenatal care followed a standard Centering Pregnancy® curriculum with the addition of HIV-related topics. The primary outcomes of the study were viral suppression (viral load <20 copies/mL) and postpartum retention in care (attending at least one or two visits with HIV primary care within 12 months postpartum). After adjusting for potential confounding factors, women who participated in group prenatal care were significantly more likely to have at least one HIV primary care visit postpartum {adjusted odds ratio (aOR) = 2.71 [95% confidence interval (CI 1.14-6.46)]; p = 0.024}, and had a trend for achieving viral suppression by the time of delivery [aOR = 2.29 (95% CI 0.94-5.55); p = 0.068]. We have demonstrated that group prenatal care for pregnant women living with HIV is feasible and effective, with positive impacts on retention in care and viral suppression, factors that affect long-term outcomes from patients living with HIV.

Reinventing the Pregnancy Wheel to Improve Pregnancy Dating and Antenatal Care Visits: A Pilot Randomized Trial in Malawi.

BACKGROUND AND OBJECTIVES: The purpose of this study was to evaluate the feasibility of a customized, culturally sensitive pregnancy wheel given to pregnant women to improve gestational age dating accuracy at the time of delivery and to improve antenatal care attendance. METHODS: This was a pilot randomized trial involving pregnant women presenting to a regional hospital in Lilongwe, Malawi. The primary outcome was accuracy of gestational age at the time of presentation to the hospital in labor. The secondary outcome was the number of antenatal visits. RESULTS: At final analysis, 14 subjects were included in the pregnancy wheel (intervention) arm and 11 in the standard care arm. Fifty percent (n=7) of women in the intervention arm were accurately dated at the time of presentation for delivery, compared to only 9% (n=1) in the standard antenatal care arm (p=0.04). There was not a significant difference in the number of antenatal visits between the two study arms. No patients met the World Health Organization's recommended eight antenatal care visits for prenatal care. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: The customized pregnancy wheel given to patients could improve gestational age dating accuracy, and as a result, clinical decision making. However, the barriers to greater antenatal care access are more complex and likely require a more complex solution. Significant attrition in this pilot trial limited statistical power, suggesting the need for future larger interventions. Accurate gestational dating requires access to ultrasonography and early antenatal care initiation, both of which are inadequate in Malawi. Although the customized pregnancy wheel did not improve antenatal care attendance, it improved gestational age dating accuracy in a pilot study at a central hospital in Lilongwe, Malawi.