Postpartum Loss to HIV Care and HIV Viral Suppression among Previously Diagnosed HIV-Infected Women with a Live Birth in New York State.

Mother-to-child-transmission of HIV in the United States has been greatly reduced, with clear benefits for the child. However, little is known about factors that predict maternal loss to HIV care in the postpartum year. This retrospective cohort study included 980 HIV-positive women, diagnosed with HIV at least one year before pregnancy, who had a live birth during 2008-2010 in New York State. Women who did not meet the following criterion in the 12 months after the delivery-related hospital discharge were considered to be lost to HIV care: two or more laboratory tests (CD4 or HIV viral load), separated by at least 90 days. Adjusted relative risks (aRR) and 95% confidence intervals (CI) for predictors of postpartum loss to HIV care were identified with Poisson regression, solved using generalized estimating equations. Having an unsuppressed (>200 copies/mL) HIV viral load in the postpartum year was also evaluated. Overall, 24% of women were loss to HIV care during the postpartum year. Women with low participation in HIV care during preconception were more likely to be lost to HIV care during the postpartum year (aRR: 2.70; 95% CI: 2.09-3.49). In contrast, having a low birth weight infant was significantly associated with a decreased likelihood of loss to HIV care (aRR: 0.72; 95% CI: 0.53-0.98). While 75% of women were virally suppressed at the last viral load before delivery only 44% were continuously suppressed in the postpartum year; 12% had no viral load test reported in the postpartum year and 44% had at least one unsuppressed viral load test. Lack of engagement in preconception HIV-related health care predicts postpartum loss to HIV care for HIV-positive parturient women. Many women had poor viral control during the postpartum period, increasing the risk of disease progression and infectivity.

Return on Investment From Expenditures Incurred to Eliminate Mother-To-Child Transmission Among HIV-Infected Women in New York State: 1998-2013.

BACKGROUND: Eliminating mother-to-child transmission (MTCT) of HIV has been one of New York State's public health priorities, and the goal has been virtually accomplished by meeting criteria established by the Centers for Disease Control and Prevention. METHODS: We use a return on investment (ROI) approach, from the perspective of the state, to compare expenditures incurred to prevent MTCT of HIV in NYS during the period 1998-2013 to benefits realized, as expressed as HIV treatment costs saved from averting an estimated number of HIV infections among newborns. Extrapolating from the 11.5% incidence rate of HIV-infected newborns in 1997, we projected the number of cases of MTCT of HIV that were averted over the 16-year period. A published estimate of lifetime HIV treatment costs was used to estimate HIV treatment costs saved from the averted infections; expenditures for clinical protocols and other services directly associated with preventing MTCT of HIV were also estimated. The ROI was then calculated by dividing program benefits by the expenditures incurred to achieve these benefits. RESULTS: We estimate that 898 cases of MTCT of HIV were averted between 1998 and 2013, resulting in a savings of $321.03 million in HIV treatment costs. Expenditures to achieve these benefits totaled $81.07 million, yielding an ROI of $3.96. CONCLUSIONS: Aside from the human suffering from MTCT of HIV that is averted, expenditures for treatment protocols and interventions to prevent MTCT of HIV are relatively inexpensive and can result in almost 4 times their value in HIV treatment cost savings realized.

An adequate interset rest period for strength recovery during a common isokinetic test.

Isokinetic testing is used in rehabilitation settings on a regular basis; yet, there is a lack of consistency in rest period usage among protocols. Furthermore, the allotment of rest periods has been arbitrary (e.g., 30, 60, 90 seconds or more). This investigation examines the work:rest ratio as an effective method of standardizing rest periods in isokinetic testing. The purpose of this study was to establish an adequate rest period that would allow reproducibility of strength during a common isokinetic strength test. Twenty-seven healthy college-aged men (age, 23 ± 3.8 years; body weight, 79.54 ± 11.09 kg) were tested on 5 separate occasions: 2 familiarization sessions and 3 experimental sessions. Each subject performed a knee extension/flexion isokinetic strength protocol (Cybex NORM; Lumex, Inc., Ronkonkoma, NY, USA) to determine peak torque by performing 5 maximal reciprocal repetitions at each ascending velocity of 60, 180, and 300°·s. Work:rest ratios of 1:3, 1:8, and 1:12 were counterbalanced between sets. A 3 × 3 repeated measures analysis of variance was used to analyze the data. A significance level of α ≤ 0.05 was used for all tests. There was no significant difference in either knee extension or knee flexion peak torque when comparing work:rest ratios. These findings suggest that a 1:3 work:rest ratio is sufficient during a common isokinetic strength test.

Relationship of soccer heading to computerized neurocognitive performance and symptoms among female and male youth soccer players.

PRIMARY OBJECTIVE: The purpose of this study was to investigate the relationship between soccer heading and computerized neurocognitive performance and symptoms in female and male youth soccer players. RESEARCH DESIGN: Cross-sectional and prospective design. METHODS AND PROCEDURES: A total of 63 (27 females, 36 males) youth soccer players aged 13-18 years (M = 15.89, SD = 1.17) participated in the study. Participants completed the Immediate Post-concussion Assessment and Cognitive Test (ImPACT) and symptom report. MAIN OUTCOMES: Computerized neurocognitive performance (e.g., verbal and visual memory, motor processing, and reaction time) and symptoms. RESULTS: There were no differences in neurocognitive performance or symptoms among low-, moderate-, and high-exposure header groups. The current sample outperformed the 10th percentile norms for neurocognitive and symptom scores. Males headed the ball more frequently and reported lower verbal and visual memory and motor processing speed scores than females. CONCLUSION: The current findings did not support a relationship between soccer heading and computerized neurocognitive performance and symptoms. The researchers suggest that any purported effects of soccer heading in youth are subtle and may affect only a small number of athletes. The reported sex differences in heading exposure warrant further attention.

Program and policy interventions for preventing mother-to-child transmission of HIV in New York State.

Mother-to-child transmission (MTCT) of human immunodeficiency virus has been virtually eliminated in New York State (NYS) in a relatively short time. The dramatic reduction in MTCT was achieved through a comprehensive public health program that maximized the benefits of advances in both diagnosis and treatment of HIV infection. The multifaceted program encompassed interventions at multiple levels. It mobilized and engaged medical providers, and it changed clinical practice and the health care delivery system in NYS. Specific approaches were developed and modified over time by using data from multiple sources and in response to medical and scientific advances. This article describes factors associated with MTCT in NYS, the framework for program development, the evolution of NYS's public health program to prevent MTCT, remaining issues, and recommendations.

Progress in prevention of mother-to-child transmission of HIV in New York State: 1988-2008.

OBJECTIVES: To assess the outcomes of efforts to prevent mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) made over the last 2 decades in New York State (NYS), through review of data from multiple sources. METHODS: Using available surveillance, laboratory, and program monitoring data, the following were examined for NYS: (1) the rate of prenatal HIV testing, (2) HIV prevalence among childbearing women, (3) maternal prenatal and delivery care, (4) care of HIV-exposed infants, and (5) the rate of MTCT. Trends over time and comparisons among groups were assessed. RESULTS: In NYS, HIV prevalence in childbearing women has declined 70% since its peak in 1989. Rates of prenatal HIV testing have been more than 95% in recent years. Rates of MTCT have decreased significantly; since 2003, transmission in HIV-exposed births has ranged from 1.2% to 2.6% annually. On bivariate analysis, MTCT is more likely to occur with breastfeeding or absence of antiretroviral administration in the prenatal, labor/delivery, and newborn periods. CONCLUSIONS: Mother-to-child HIV transmission has declined dramatically in all groups in NYS. Universal newborn screening data have provided the foundation for identifying HIV-exposed births and for initiating follow-up to track all aspects of MTCT in NYS. Remaining challenges include universal prenatal care, prevention of acquisition of HIV infection during pregnancy, and adherence to antiretroviral therapy.

Acquiring human immunodeficiency virus during pregnancy and mother-to-child transmission in New York: 2002-2006.

OBJECTIVE: To assess perinatal human immunodeficiency virus (HIV) exposure and factors associated with mother-to-child HIV transmission. METHODS: A cohort analysis of HIV-exposed births in New York State from 2002 to 2006 was undertaken using routinely collected public health surveillance and regulatory data, including Newborn Screening HIV antibody results, pediatric HIV diagnostic test results, and maternal and pediatric medical record abstractions. RESULTS: Between January 2002 and December 2006, we identified 3,396 HIV-exposed neonoates. Subsequent analysis of 3,102 (91%) birth events showed that mother-to-child HIV transmission was presumed or confirmed to have occurred in 65 neonates (2.1%) born to 63 mothers. On multivariable analysis, the following significant associations with transmission were identified: maternal HIV diagnosis at or after delivery (odds ratio [OR] 3.24, 95% [CI] 1.15-8.15), maternal acquisition of HIV during pregnancy (OR 15.19, 95% CI 3.98-56.30), illicit substance use during pregnancy (OR 2.66, 95% CI 1.33-5.27), 0-2 prenatal care visits (OR 2.37, 95% CI 1.11-4.91), and neonatal birth weight less than 2,500 g (OR 2.46, 95% CI 1.26-4.74). CONCLUSION: Acquisition of HIV during pregnancy is a significant risk factor for mother-to-child HIV transmission and must be addressed along with other known risks to reduce mother-to-child transmission to the greatest extent possible. LEVEL OF EVIDENCE: II.

Decline in perinatal HIV transmission in New York State (1997-2000).

BACKGROUND: Perinatal HIV transmission has declined significantly in New York State (NYS) since implementation of a 3-part regimen of zidovudine prophylaxis in the antenatal, intrapartum, and newborn periods. This study describes the factors associated with perinatal transmission in NYS from 1997 to 2000, the first 4 years of NYS's comprehensive program in which all HIV-exposed newborns were identified through universal HIV testing of newborns. METHODS: This population-based observational study included all HIV-exposed newborns whose infection status was known and their mothers identified in NYS through the universal Newborn HIV Screening Program (NSP) from February 1997 to December 2000. Antepartum, intrapartum, newborn, and pediatric medical records of HIV-positive mothers/infants were reviewed for history of prenatal care, antiretroviral therapy (ART), and infant infection status. Risks associated with perinatal HIV transmission were examined. RESULTS: Perinatal HIV transmission declined significantly from 11.0% in 1997 to 3.7% in 2000 (P < 0.05). Prenatal ART was associated with a decline in perinatal HIV transmission both for monotherapy (5.8%, relative risk [RR] = 0.3, 95% confidence interval: 0.2%-0.5%) and combination therapy [2.4%, RR = 0.1, 95% confidence interval: 0.1%-0.2%) compared with no prenatal antiretroviral prophylaxis (P < 0.05). CONCLUSIONS: Public health policies to improve access to care for pregnant women and advances in clinical care, including receipt of appropriate preventive therapies, have contributed to declines in perinatal HIV transmission in NYS.

Intramuscular injection angle: evidence for practice?

This article presents the findings of a search for evidence to support the 45-60 degree angle of insertion for intramuscular injection of vaccine which is recommended in New Zealand. With the objective of discovering the evidence base for an intramuscular injection angle which differs from that recommended by the World Health Organisation and the accepted practice experienced by the author in the UK, Canada, Malawi and the USA, a comprehensive library and internet literature search was undertaken. As well, information was sought by personal correspondence and contact with a range of immunisation specialists. Both the literature specifically on needle angle and that which includes needle angle within a wider investigation of technique is included. Overwhelmingly the evidence supports a 90 degree angle of needle insertion for intramuscular injection as being that most effective in terms of patient comfort, safety and efficacy of vaccine.