Cervical Cancer Screening and Treatment algorithms using Human Papillomavirus testing - lessons learnt from a South African pilot randomized controlled trial.

BACKGROUND: To report quantitative and qualitative results on cervical cancer (CC) HPV-based screening and treatment algorithms, with/out triage with visual inspection after acetic acid (VIA), followed by ablative treatment (AT). METHODS: Women 30-54 years-old from Durban, South Africa were recruited, regardless of HIV status, randomized into one of two study arms and screened for HPV. VIA-triage arm: HPV-positive women were triaged using VIA, biopsied and received AT if VIA-positive and eligible; no-triage arm: eligible HPV-positive women received AT. Women ineligible for AT were referred to colposcopy. Women were asked about side effects immediately and one week after AT. Retention to screening and treatment algorithms was compared between arms. RESULTS: 350 women (275 HIV-uninfected and 75 women living with HIV, (WLWH)) were allocated to receive HPV testing with VIA-triage (n=175) or no-triage (n=175). HPV prevalence was 28% (95%CI=23-33); WLWH: 52% (95%CI=40-64) vs HIV-uninfected: 21% (95%CI=17-27) (p<0.05). Among women who underwent VIA triage with histological diagnosis, 3/17 were VIA negative with CIN2+; 14/18 were VIA positive with

An increase in rates of obstetric haemorrhage in a setting of high HIV seroprevalence.

BACKGROUND: Obstetric haemorrhage (OH) is the leading cause of maternal mortality worldwide, although, indirectly, HIV is also a leading cause of maternal mortality in some settings with a high HIV seroprevalence. OBJECTIVE: To determine the possible association between increasing rates of OH and HIV or its treatment. METHODS: We conducted a retrospective chart review of women with OH at King Edward VIII Hospital, Durban, South Africa, over a 3-year period (2009 - 2011), during which the drug regimen for the prevention of mother-to-child transmission was evolving from single-dose nevirapine to antenatal zidovudine combined with intrapartum nevirapine (also referred to as dual therapy), and finally to a combination or highly active antiretroviral therapy (cART or HAART). Cases of OH (including abruptio placentae, placenta praevia, unspecified antepartum haemorrhage (APH), and postpartum haemorrhage (PPH)) were identified from maternity delivery records, and the relevant data extracted. RESULTS: We analysed the records of 448 women diagnosed with OH. Even though the incidence of OH was low, the study found an increasing number of cases during the 3-year period. PPH - not APH - was associated with HIV seropositivity (odds ratio 1.84, 95% confi-dence interval 1.14 - 2.95). cART was not associated with an increased risk of haemorrhage. CONCLUSION: HIV was associated with a high risk of PPH, and its possible association with HIV treatment needs further research.

Associations between HIV, highly active anti-retroviral therapy, and hypertensive disorders of pregnancy among maternal deaths in South Africa 2011-2013.

OBJECTIVE: To explore potential relationships between HIV and highly active anti-retroviral therapy (HAART), and hypertensive disorders of pregnancy (HDP). METHODS: A retrospective secondary analysis of maternal-deaths data from the 2011-2013 Saving Mothers Report from South Africa. The incidence of HIV infection amongst individuals who died owing to HDP was determined and comparisons were made based on HIV status and the use of HAART. RESULTS: Among 4452 maternal deaths recorded in the Saving Mothers report, a lower risk of a maternal deaths being due to HDP was observed among women who had HIV infections compared with women who did not have HIV (relative risk [RR] 0.57, 95% confidence interval [CI] 0.51-0.64). Further, reduced odds of death being due to HDP were recorded among women with AIDS not undergoing HAART compared with women with HIV who did not require treatment (RR 0.42, 95% CI 0.3-0.58). Notably, among all women with AIDS, a greater risk of death due to HDP was demonstrated among those who received HAART compared with those who did not (RR 1.15, 95% CI 1.02-1.29). CONCLUSION: HIV and AIDS were associated with a decreased risk of HDP being the primary cause of death; the use of HAART increased this risk.

The impact of highly active antiretroviral therapy on obstetric conditions: A review.

HIV is the leading cause of maternal and neonatal morbidity and mortality in resource constrained countries. Highly active antiretroviral treatment (HAART) initiated in pregnancy has now almost eliminated mother to child transmission of the virus, and is beginning to show the desired effect of reducing HIV related maternal mortality. By modulating host immunological responses HAART has the potential to alter infections during pregnancy, in addition to modifying clinical conditions such as preeclampsia. There is increasing evidence of the benefits of HAART given to pregnant women, however there is paucity of data that distinguishes HIV or HAART as the cause or exacerbation of pre-existing medical conditions or conditions specific to pregnancy. Anaemia is the commonest haematological disorder seen in HIV infected women and is more pronounced during pregnancy. The use of HAART has the potential to reduce the incidence and severity of the disease. Tuberculosis (TB) is the commonest chest infection amongst HIV infected people, being more common amongst pregnant than non-pregnant women. It is the leading cause of death from infectious diseases amongst women of reproductive age, and accounts for at least a quarter of all cases of maternal deaths associated with non-pregnancy related infections (NPRI). TB can manifest at any stage of the HIV infection, including during treatment with HAART. The latter (ie TB manifestation during HAART treatment) is thought to be the commonest manifestation of what is now known as immune reconstitution inflammatory syndrome (IRIS). In a South African report on maternal deaths, 55% of women who died of TB were on HAART, and a further 35% of women in the NPRI category died from other pneumoniae, notably pneumocystis jorevicci, which is also related to HIV infection. With regards to puerperal sepsis, studies are yet to show the impact of HAART independent of antibiotics in reducing infectious morbidity in HIV infected women. Preeclampsia has been associated with HIV infection, where most studies point towards a reduced risk in HIV infected women. There is increasing evidence that this reduced risk is reversed in the presence of HAART, with women accessing HAART having almost the same risk as HIV uninfected women. HIV or its treatment may be associated with increased risk of obstetric haemorrhage, and an increasing trend of obstetric haemorrhage as a cause of maternal deaths has been recently reported, proportionally in line with the introduction and increasing availability of HAART for pregnant women The mechanism by which this may occur remains elusive since pregnancy is a pro-thrombotic state, however, HIV-related thrombocytopenia or vasculitis could account for the association, if found. HAART would then be expected to reverse this. HAART especially protease inhibitor containing combinations, have been associated with preterm deliveries and low birth weight, particularly when initiated prior to the index pregnancy. With these overall findings of the effect of HAART on obstetric conditions, this review is intended to encourage heightened surveillance of adverse events associated with HAART use in pregnant women.

Contraceptive Use and Prevalence of Sexually Transmitted Infections among Women Seeking Termination of Pregnancy at a District Hospital in Kwazulu-Natal

Termination of pregnancy (TOP) is one of the components of female reproductive health and rights that are freely available in South Africa within the public health system; and yet unwanted pregnancies still remain a challenge. The objectives of this study were to determine the level of knowledge and use of contraceptive methods among women seeking TOP services and to evaluate the prevalence of human immunodeficiency virus (HIV) and other sexually transmitted infections in this group of women. This population-based study was conducted at Northdale Hospital in KwaZulu-Natal. Four hundred and ninety-seven women seeking TOP were interviewed over a period of six months; using a structured questionnaire. The mean age of the women was 25 years. The majority of the participants were black Africans (n = 424; 85.3;) and single (n = 423; 85); respectively. Most participants (n = 354; 71) were unemployed; having obtained a secondary school education level. The majority (n = 420; 84.5) indicated that they had previously used some form of contraception. However; condom use was used by only 18 (n = 78). The HIV prevalence among women requesting TOP was 39. Nearly half of the participants (45.9) had abnormal vaginal discharge and 50 of those who had tested for syphilis received an abnormal result. This study reinforces the need to intensify sexual and reproductive health programmes among women seeking TOP