Repeat pregnancy in women with HIV infection in Latin America and the Caribbean.

Intended and unintended pregnancies occur frequently among human immunodeficiency virus (HIV)-infected women. We evaluated the occurrence of repeat pregnancy and characteristics associated with this outcome among HIV-infected women in Latin America and the Caribbean who were participating in the National Institute of Child Health and Human Development (NICHD) International Site Development Initiative (NISDI). Of the 1342 HIV-infected pregnant women enrolled in NISDI, 124 (9.2%) had one or more repeat pregnancies on study. Median time between the index delivery and date of conception of the subsequent pregnancy was 1.4 years (range 0.1-5.7). Younger age (odds ratio [OR] = 1.07, 95% confidence interval [CI]: 1.04-1.11 per one year decrease in age), hospitalization during the index pregnancy or up to six months post-partum [OR = 2.0, 95% CI: 1.2-3.4], and poor index pregnancy outcome (stillbirth or spontaneous/therapeutic abortion; OR = 3.4, 95% CI: 1.4-8.4) were associated with increased occurrence of repeat pregnancy in multivariable analysis. Among women with repeat pregnancies, the proportion receiving antiretroviral treatment (vs. prophylaxis) increased from 39.4% at the time of the index pregnancy to 81.8% at the time of the repeat pregnancy (p < 0.001). These results can help identify women most likely to benefit from reproductive counseling in order to assist with healthy pregnancy planning and prevention of unintended pregnancies.

Pregnant women with HIV in rural Nigeria have higher rates of antiretroviral treatment initiation, but similar loss to follow-up as non-pregnant women and men.

BACKGROUND: We examined antiretroviral therapy (ART) initiation and retention by sex and pregnancy status in rural Nigeria. METHODS: We studied HIV-infected ART-naïve patients aged ≥15 years entering care from June 2009 to September 2013. We calculated the probability of early ART initiation and cumulative incidence of loss to follow-up (LTFU) during the first year of ART, and examined the association between LTFU and sex/pregnancy using Cox regression. RESULTS: The cohort included 3813 ART-naïve HIV-infected adults (2594 women [68.0%], 273 [11.8%] of them pregnant). The proportion of pregnant clients initiating ART within 90 days of enrollment (78.0%, 213/273) was higher than among non-pregnant women (54.3%,1261/2321) or men (53.0%, 650/1219), both p<0.001. Pregnant women initiated ART sooner than non-pregnant women and men (median [IQR] days from enrollment to ART initiation for pregnant women=7 days [0-21] vs 14 days [7-49] for non-pregnant women and 14 days [7-42] for men; p<0.001). Cumulative incidence of LTFU during the first year post-ART initiation was high and did not differ by sex and pregnancy status. Persons who were unemployed, bedridden, had higher CD4+ counts, and/or in earlier WHO clinical stages were more likely to be LTFU. CONCLUSIONS: Pregnant women with HIV in rural Nigeria were more likely to initiate ART but were no more likely to be retained in care. Our findings underscore the importance of effective retention strategies across all patient groups, regardless of sex and pregnancy status.

Enrolment trends in a comprehensive HIV programme in rural north-central Nigeria: improved care indices, but declining quality of clinical data over time.

BACKGROUND: Vanderbilt University affiliate Friends in Global Health was funded in 2008 to support comprehensive HIV/AIDS services in north-central Nigeria. We summarise programme characteristics and trends in enrolment and quality of data collection in this rural, resource-limited environment. METHODS: We used routinely collected programme data in supported sites from June 1 2009 to September 30, 2013.Baseline characteristics were defined as those collected closest to a 90-day window period before and after enrolment. Summary characteristics were compared by site and enrolment year. RESULTS: We enrolled 3,960 HIV-infected patients into care (68% women), median age of 32 years [interquartile range (IQR): 27-40]. Most clients were married (79%) and unemployed (60%). At enrolment, median CD4+ cell count was 230 cells/µL (IQR: 114-390) and haemoglobin was 10.7 g/dL (IQR: 9.3-11.9). Advanced clinical disease [World Health Organization (WHO) clinical stage III/IV] at enrolment was documented in 29% of clients. Cumulative enrolment increased from 377 patients in 2009 to 3,960 patients by 2013.With each successive year, more clients were enrolled at earlier stages of disease; in 2009, 37% of patients were identified as WHO clinical stage I, while in 2013, 55% of patients were so classified. While documentation of clinical staging remained stable, the completeness of CD4+ cell count and haemoglobin data declined with time. CONCLUSION: Expanded testing in a comprehensive HIV programme in rural Nigeria brought persons to care at earlier stages of illness. Yet, as clinical services expanded, data collection quality declined. The paradox of successful scaling up HIV services but deteriorating quality of data underscores the importance of data management training and quality improvement efforts.

Correlates of suboptimal entry into early infant diagnosis in rural north central Nigeria.

BACKGROUND: Despite an estimated 59,000 incident pediatric HIV infections in 2012 in Nigeria, rates of early infant diagnosis (EID) of HIV service uptake remain low. We evaluated maternal factors independently associated with EID uptake in rural North Central Nigeria. METHODS: We performed a cohort study using HIV/AIDS program data of HIV-infected pregnant women enrolled into HIV care/treatment on or before December 31, 2012 (n = 712). We modeled the probability of initiation of EID using multivariable logistic regression. RESULTS: Three hundred fifty-seven HIV-infected pregnant women enrolled their infants in EID across the 4 study sites. Women who enrolled their infants in EID vs. those who did not were similar across age, occupation, referral source, and select laboratory variables. Clinic of enrollment and date of enrollment were strong predictors for EID entry (P < 0.001). Women enrolled more recently were less likely to have their infants undergo EID than those enrolled at the beginning of the project (January 2011 vs. January 2010, adjusted odds ratio = 0.35, 95% confidence interval: 0.22 to 0.56; January 2012 vs. January 2010, adjusted odds ratio = 0.30, 95% confidence interval: 0.14 to 0.61). Women who received care in the more urban setting of Umaru Yar Adua Hospital were more likely to have their infants enrolled in EID than those who received care in the other 3 clinics. CONCLUSIONS: HIV-infected women in our prevention of mother-to-child HIV transmission program were more likely to bring in their infants for EID if they were enrolled in a more urbanized clinic location, and if they presented during an earlier phase of the program. The need for more intensive family engagement and program quality improvement is apparent, especially in rural settings.

Hypertension, preeclampsia and eclampsia among HIV-infected pregnant women from Latin America and Caribbean countries.

OBJECTIVES: To evaluate the incidence of and risk factors for hypertensive disorders in a cohort of HIV-infected pregnant women. METHODS: Hypertensive disorders (HD) including preeclampsia/eclampsia (PE/E) and pregnancy induced hypertension, and risk factors were evaluated in a cohort of HIV-infected pregnant women from Latin America and the Caribbean enrolled between 2002 and 2009. Only pregnant women enrolled for the first time in the study and delivered at ≥20 weeks gestation were analyzed. RESULTS: HD were diagnosed in 73 (4.8%, 95% CI: 3.8%-6.0%) of 1513 patients; 35 (47.9%) had PE/E. HD was significantly increased among women with a gestational age-adjusted body mass index (gBMI) ≥25 kg/m(2) (OR = 3.1; 95% CI: 1.9-5.0), hemoglobin (Hg) ≥11 g/dL at delivery (OR = 2.1; 95% CI: 1.2-3.6) and age ≥35 years (OR = 1.8; 95% CI: 1.1-3.2). PE/E was increased among women with a gBMI ≥25 kg/m(2) (OR = 3.0; 95% CI: 1.5-6.0) and Hg ≥11 g/dL at delivery (OR = 2.8; 95% CI: 1.2-6.5). A previous history of PE/E increased the risk of PE/E 6.7 fold (95% CI: 1.8-25.5). HAART before conception was associated with PE/E (OR = 2.3; 95% CI: 1.1-4.9). CONCLUSIONS: HIV-infected women, with a previous history of PE/E, a gBMI ≥25 kg/m(2), Hg at delivery ≥11 g/dL and in use of HAART before conception are at an increased risk of developing PE/E during pregnancy.

Risk factors for delayed initiation of combination antiretroviral therapy in rural north central Nigeria.

BACKGROUND: Timely initiation of combination antiretroviral therapy (ART) in eligible HIV-infected patients is associated with substantial reduction in mortality and morbidity. Nigeria has the second largest number of persons living with HIV/AIDS in the world. We examined patient characteristics, time to ART initiation, retention, and mortality at 5 rural facilities in Kwara and Niger states of Nigeria. METHODS: We analyzed program-level cohort data for HIV-infected ART-naive clients (≥15 years) enrolled from June 2009 to February 2011. We modeled the probability of ART initiation among clients meeting national ART eligibility criteria using logistic regression with splines. RESULTS: We enrolled 1948 ART-naive adults/adolescents into care, of whom, 1174 were ART eligible (62% female). Only 74% of the eligible patients (n = 869) initiated ART within 90 days after enrollment. The median CD4 count for eligible clients was 156 cells/µL (interquartile range: 81-257), with 67% in WHO stage III/IV disease. Adjusting for CD4 count, WHO stage, functional status, hemoglobin, body mass index, sex, age, education, marital status, employment, clinic of attendance, and month of enrollment, we found that immunosuppression [CD4 350 vs. 200, odds ratio (OR) = 2.10, 95% confidence interval (CI): 1.31 to 3.35], functional status [bedridden vs. working, OR = 4.17 (95% CI: 1.63 to 10.67)], clinic of attendance [Kuta Hospital vs. referent: OR = 5.70 (95% CI: 2.99 to 10.89)], and date of enrollment [December 2010 vs. June 2009: OR = 2.13 (95% CI: 1.19 to 3.81)] were associated with delayed ART initiation. CONCLUSIONS: Delayed initiation of ART was associated with higher CD4 counts, lower functional status, clinic of attendance, and later dates of enrollment among ART-eligible clients. Our findings provide targets for quality improvement efforts that may help reduce attrition and improve ART uptake in similar settings.

Haemoglobin recovery among HIV-1 infected patients on zidovudine-based antiretroviral therapy and other regimens in north-central Nigeria.

We conducted a study to assess trends in haemoglobin recovery among HIV-infected patients initiated on zidovudine-based combination antiretroviral therapy (cART) stratified by baseline haemoglobin level. Haemoglobin data from non-pregnant adult patients initiating cART in rural north-central Nigeria between June 2009 and May 2011 were analysed using a linear mixed effects model to assess the interaction between time, zidovudine-containing regimen and baseline haemoglobin level on the outcome of subsequent haemoglobin level. Best-fit curves were created for baseline haemoglobin in the 10th, 25th, 75th and 90th percentiles. We included 313 patients with 736 measures of haemoglobin in the analysis (239 on zidovudine and 74 on non-zidovudine-containing regimens). Median haemoglobin increased over time in both groups, with differences in haemoglobin response over time related to baseline haemoglobin levels and zidovudine use (p = 0.003). The groups of patients on zidovudine at the 10th and 90th percentiles had downward sloping curves while all other groups had upward trending haemoglobin levels. Although haemoglobin levels increased overall for patients on zidovudine-containing regimens, for those in the 10th and 90th percentiles haemoglobin levels trended downward over time. These results have implications for decisions regarding when to initiate, switch from or avoid the use of zidovudine.

Dyslipidemia in a cohort of HIV-infected Latin American children receiving highly active antiretroviral therapy.

In order to describe the prevalence of hypercholesterolemia and hypertriglyceridemia in a cohort of HIV-infected children and adolescents in Latin America and to determine associations with highly active antiretroviral therapy (HAART), we performed this cross-sectional analysis within the NICHD International Site Development Initiative pediatric cohort study. Eligible children had to be at least 2 years of age and be on HAART. Among the 477 eligible HIV-infected youth, 98 (20.5%) had hypercholesterolemia and 140 (29.4%) had hypertriglyceridemia. In multivariable analyses, children receiving protease inhibitor (PI)-containing HAART were at increased risk for hypercholesterolemia [adjusted odds ratio (AOR) = 2.7, 95% confidence interval (CI) 1.3-5.6] and hypertriglyceridemia (AOR = 3.5, 95% CI 1.9-6.4) compared with children receiving non-nucleoside reverse transcriptase inhibitor (NNRTI)-containing HAART. In conclusion, HIV-infected youth receiving PI-containing HAART in this Latin American cohort were at increased risk for hypercholesterolemia and hypertriglyceridemia compared with those receiving NNRTI-containing HAART.

A cluster-randomized trial of enhanced labor ward-based PMTCT services to increase nevirapine coverage in Lusaka, Zambia.

OBJECTIVE: Determine whether enhanced labor ward-based services for prevention of mother-to-child transmission of HIV (PMTCT) would improve nevirapine (NVP) coverage. DESIGN: Cluster-randomized trial at 12 public-sector delivery centers in Lusaka, Zambia. METHODS: Following a baseline surveillance period, 12 labor wards were randomized, six to offer opt-in HIV testing to women of unknown serostatus (with NVP administration as indicated) and to assess NVP adherence among known HIV-infected women. The six control labor wards provided the standard of care. The NVP coverage endpoint was defined as the proportion of HIV-infected/exposed women/infant pairs with confirmed NVP ingestion. We used generalized estimating equations (GEE) to determine the odds of coverage associated with the intervention and ultimately used the parameters for the estimated GEE model to estimate relative risk. RESULTS: Between October 2005 and January 2006, 7664 women gave birth at participating clinics. We collected anonymous-linked blood from 7592 (99%) umbilical cords; tested 7438 (97%) for HIV, 1618 (22%) were seropositive, and of these, 1279 (79%) were tested for NVP. At baseline (preintervention), the probability of HIV-infected/exposed women/infant pairs receiving NVP in treatment clinics (42%) was 0.89 times the probability of being covered in control clinics (53%) whereas during the intervention period the probability of treatment clinic coverage (52%) was 1.22 the probability control clinic coverage (43%), representing a multiplicative effect of 1.37 upon the RR at baseline (ratio of relative risks 1.37, bootstrapped 95% CI, 1.04-1.77). CONCLUSION: Labor ward-based PMTCT programs are feasible and can have a significant, positive impact on NVP coverage.

Macronutrient supplementation for malnourished HIV-infected adults: a review of the evidence in resource-adequate and resource-constrained settings.

Access to antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection has expanded rapidly throughout sub-Saharan Africa, but malnutrition and food insecurity have emerged as major barriers to the success of ART programs. Protein-calorie malnutrition (a common form of malnutrition in the region) hastens HIV disease progression, and food insecurity is a barrier to medication adherence. Analyses of patient outcomes have identified a low body mass index after the start of ART as an independent predictor of early mortality, but the causes of a low body mass index are multifactorial (eg, normal anthropometric variation, chronic inadequate food intake, and/or wasting associated with HIV infection and other infectious diseases). Although there is much information on population-level humanitarian food assistance, few data exist to measure the effectiveness of macronutrient supplementation or to identify individuals most likely to benefit. In this report, we review the current evidence supporting macronutrient supplementation for HIV-infected adults, we report on clinical trials in resource-adequate and resource-constrained settings, and we highlight priority areas for future research.

Predictors of rapid HIV testing acceptance and successful nevirapine administration in Zambian labor wards.

BACKGROUND: Provision of HIV testing in labor provides an opportunity to reach susceptible women and infants. METHODS: As part of a cluster randomized trial of labor ward-based prevention of mother-to-child transmission services in Lusaka, Zambia, we determined predictors of testing acceptance and nevirapine (NVP) administration in labor. HIV counseling and testing were offered to women unaware of their HIV status. NVP was administered to women who tested positive, and an inert (calcium) tablet was provided to women who tested negative, to avoid stigmatization. RESULTS: Among the 2435 women who presented in labor, 393 (16%) were unaware of their HIV status, of whom 278 (71%) met eligibility criteria. We offered counseling to 217 (78%) of eligible women: 146 (67%) agreed, 82 (56%) of those counseled were tested for HIV, and 23 (28%) were seropositive. Testing rates were higher among primigravida women [adjusted odds ratio (AOR) 1.5; 95% confidence interval (CI): 1.1 to 2.1] and among those not offered HIV testing during their pregnancy (AOR 3.7; 95% CI: 2.8 to 5.1). Cervical dilation 1 hour (AOR 11.5; 95% CI: 4.5 to 29.2) and >2 hours (AOR 11.4; 95% CI: 4.7 to 27.5) before delivery. CONCLUSION: Labor ward HIV testing is feasible in this resource-limited setting.

Declining HIV prevalence among young pregnant women in Lusaka, Zambia.

OBJECTIVE: HIV prevention has been ongoing in Lusaka for many years. Recent reports suggest a possible decline in HIV sero-incidence in Zambia and some neighbouring countries. This study aimed to examine trends in HIV seroprevalence among pregnant and parturient women between 2002 and 2006. METHODS: We analysed HIV seroprevalence trends from two Lusaka sources: (i) antenatal data from a city-wide programme to prevent mother-to-child HIV transmission, and (ii) delivery data from two anonymous unlinked cord-blood surveillances performed in 2003 and again in 2005-2006, where specimens from > 97% of public-sector births in each period were obtained and analysed. FINDINGS: Between July 2002 and December 2006, the Lusaka district tested 243 302 antenatal women for HIV; 54 853 (22.5%) were HIV infected. Over this period, the HIV seroprevalence among antenatal attendees who were tested declined steadily from 24.5% in the third quarter of 2002 to 21.4% in the last quarter of 2006 (P < 0.001). The cord-blood surveillances were conducted between June and August 2003 and again between October 2005 and January 2006. Overall HIV seroprevalence declined from 25.7% in 2003 to 21.8% in 2005-2006 (P = 0.001). Among women < or =17 years of age, seroprevalence declined from 12.1% to 7.7% (P = 0.015). CONCLUSION: HIV seroprevalence appears to be declining among antenatal and parturient women in Lusaka. The decline is most dramatic among women < or = 17 years of age, suggesting a reduction in sero-incidence in this important age group.