Gestational weight gain and adverse birth outcomes in South African women with HIV on antiretroviral therapy and without HIV: a prospective cohort study.

INTRODUCTION: Outside of pregnancy, evidence shows that persons with HIV initiating or switching to dolutegravir (DTG)-based antiretroviral therapy (ART) experience greater weight gain compared to those on other ART classes. However, there are few data on the impact of DTG-based ART on gestational weight gain (GWG) in sub-Saharan Africa where HIV is most common. According to the National Academy of Medicine (NAM), GWG below and above NAM guidelines is associated with adverse birth outcomes. Therefore, the objective of this study was to describe GWG by HIV status and ART regimen, and examine the associations with adverse birth outcomes. METHODS: We enrolled pregnant women with HIV (WHIV) and without HIV (≥18 years) in a peri-urban primary healthcare facility in Cape Town, South Africa between 2019 and 2022. GWG was study-measured at 24-28 (baseline) and 33-38 weeks gestation and converted to GWG rate (kg/week) in accordance with NAM guidelines. GWG z-scores were generated using the INTEGROWTH-21 and US standards to account for differing lengths of gestation. Birth outcome data were obtained from medical records. Associations of GWG z-score with adverse birth outcomes were assessed using multivariable linear or log-binomial regression. RESULTS: Among 292 participants (48% WHIV), median age was 29 years (IQR, 25-33), median pre-pregnancy body mass index (BMI) was 31 kg/m2 (IQR, 26-36) and 20% were primiparous at baseline. The median weekly rate of GWG was 0.30 kg/week (IQR, 0.12-0.50), 35% had GWG below NAM standards (59% WHIV) and 48% had GWG above NAM standards (36% WHIV). WHIV gained weight more slowly (0.25 vs. 0.37 kg/week, p<0.01) than women without HIV. Weekly rate of GWG did not differ by ART regimen (DTG-based ART 0.25 vs. efavirenz-based ART 0.27 kg/week, p = 0.80). In multivariable analyses, GWG z-score was positively associated with continuous birth weight (mean difference = 68.53 95% CI 8.96, 128.10) and categorical high birth weight of >4000 g (RR = 2.18 95% CI 1.18, 4.01). CONCLUSIONS: Despite slower GWG among WHIV, nearly half of all women gained weight faster than recommended by the NAM. GWG was positively associated with infant birth weight. Interventions to support healthy GWG in sub-Saharan Africa are urgently needed.

Intrauterine contraceptive discontinuation reasons among female trial participants living with HIV in Cape Town, South Africa: A qualitative analysis.

Introduction: While young women in South Africa may navigate both HIV infection and pregnancy risks, intrauterine contraceptive (IUC) use is low. Though IUCs have low failure rates, concerns exist about whether the IUC is an appropriate method choice for women living with HIV (WLHIV). In this qualitative study, we explore WLHIVs' experiences of using IUC and reasons for discontinuation. Methods: This qualitative study included in-depth interviews (IDIs) with 17 WLHIV who electively discontinued their allocated IUC while participating in a randomized controlled trial comparing the safety of the levonorgestrel intrauterine system (LNG-IUS) and the copper intrauterine device (C-IUD) in Cape Town, South Africa. The transcripts were coded and emergent themes were grouped to examine women's experiences with IUC use and reasons for discontinuation, highlighting experiential differences between the two methods. Results: Women's experience with the allocated IUC related most commonly to bleeding and/or abdominal pain just after insertion. Most C-IUD discontinuers, but only one LNG-IUS discontinuer, complained of pain and/or increased bleeding as the main reason for removal. Three women (two LNG-IUS, one C-IUD) requested removal because they desired pregnancy, while two others discontinued due to fears the IUC was exacerbating non-gynecologic conditions (hypertension, diabetes). Generally, women acknowledged advantages of IUC use and many expressed their desire to continue use if not for the side effects. Conclusions: In the South African context, IUC use for WLHIV should be promoted with specific counseling considerations. Both providers and potential users should receive specific information about potential menstrual-related side effects and countering common misperceptions to enable informed contraceptive decision-making.

A telemedicine model for abortion in South Africa: a randomised, controlled, non-inferiority trial.

BACKGROUND: Telemedicine for medical abortion increases access to safe abortion but its use has not been described in a controlled trial. We aimed to investigate the effectiveness, adherence, safety, and acceptability of a modified telemedicine protocol for abortion compared with standard care in a low-resource setting. METHODS: In this randomised, controlled, non-inferiority trial we recruited women seeking medical abortion at or before 9 gestational weeks at four public health clinics in South Africa. Participants were randomly allocated (1:1) by computer-generated blocks of varying sizes to telemedicine or standard care. The telemedicine group received asynchronous online abortion consultation and instruction, self-assessed gestational duration, and had a uterine palpation as a safety measure. Participants in this group took 200 mg mifepristone and 800 µg misoprostol at home. The standard care group received in-person consultation and instruction together with an ultrasound, took 200 mg mifepristone in clinic and 800 µg misoprostol at home. Our primary outcome was complete abortion after initial treatment, assessed at a 6-week interview. Our non-inferiority margin was 4%. Group differences were assessed by modified intention-to-treat (mITT) analysis and per protocol. The trial is registered at ClinicalTrials.gov, NCT04336358, and the Pan African Clinical Trials Registry, PACTR202004661941593. FINDINGS: Between Feb 28, 2020, and Oct 5, 2021, we enrolled 900 women, 153 (17·0%) of whom were discontinued before the abortion and were not included in the analysis. By mITT analysis, 355 (95·4%) of 372 women in the telemedicine group had a complete abortion compared with 338 (96·6%) of 350 in the standard care group (odds ratio 0·74 [95% CI 0·35 to 1·57]). The risk difference was -1·1% (-4·0 to 1·7). Among women who completed treatment as allocated (per protocol), 327 (95·6%) of 342 women in telemedicine group had complete abortion, compared with 338 (96·6%) of 350 in the standard care group (0·77 [0·36 to 1·68]), with a risk difference of -1·0% (-3·8 to 1·9). One participant (in the telemedicine group) had a ruptured ectopic pregnancy, and a further four participants were admitted to hospital (two in each group), of whom two had blood transfusions (one in each group). INTERPRETATION: Asynchronous online consultation and instruction for medical abortion and home self-medication, with uterine palpation as the only in-person component, was non-inferior to standard care with respect to rates of complete abortion, and did not affect safety, adherence, or satisfaction. FUNDING: Grand Challenges Canada and the Swedish Research Council.

Relationship between pre-pregnancy maternal body mass index and infant weight trajectories in HIV-exposed and HIV-unexposed infants.

BACKGROUND: Maternal HIV and antiretroviral therapy (ART) exposure in utero may influence infant weight, but the contribution of maternal y body mass index (BMI) to early life overweight and obesity is not clear. OBJECTIVE: To estimate associations between maternal BMI at entry to antenatal care (ANC) and infant weight through approximately 1 year of age and to evaluate whether associations were modified by maternal HIV status, maternal HIV and viral load, breastfeeding intensity through 6 months or timing of entry into ANC. METHODS: We followed HIV-uninfected and -infected pregnant women initiating efavirenz-based ART from first antenatal visit through 12 months postpartum. Infant weight was assessed via World Health Organization BMI and weight-for-length z-scores (WLZ) at 6 weeks, 3, 6, 9 and 12 months. We used multivariable linear mixed-effects models to estimate associations between maternal BMI and infant z-scores over time. RESULTS: In 861 HIV-uninfected infants (454 HIV-exposed; 407 HIV-unexposed), nearly 20% of infants were overweight or obese by 12 months of age, regardless of HIV exposure status. In multivariable analyses, increasing maternal BMI category was positively associated with higher infant BMIZ and WLZ scores between 6 weeks and 12 months of age and did not differ by HIV exposure status. However, HIV-exposed infants had slightly lower BMIZ and WLZ trajectories through 12 months of age, compared with HIV-unexposed infants across all maternal BMI categories. Differences in BMIZ and WLZ scores by HIV exposure were not explained by timing of entry into ANC or maternal viral load pre-ART initiation, but z-scores were slightly higher for HIV-exposed infants who were predominantly or exclusively versus partially breastfed. CONCLUSIONS: These findings suggest maternal BMI influences early infant weight gain, regardless of infant HIV exposure status. Intervention to reduce maternal BMI may help to address growing concerns about obesity among HIV-uninfected children.

Immediate versus delayed insertion of the copper intrauterine device after medical abortion at 17-20 gestational weeks: a randomised controlled trial.

INTRODUCTION: This trial reports on use of the copper intrauterine device (IUD) after immediate compared with delayed insertion following medical abortion at 17-20 gestational weeks (GW). METHODS: This randomised controlled trial was conducted at one tertiary hospital and five community healthcare centres in Cape Town, South Africa. Eligible consenting women were randomised to immediate (within 24 hours) or delayed (3 weeks post-abortion) insertion of the copper IUD. Follow-up was at 6 weeks, 3 months and 6 months. Main outcomes were use of the original IUD and use of any IUD, including replacement IUDs at 6 weeks post-abortion. Secondary outcomes included rates of expulsion and malposition at 6 weeks, use of any IUD at 3 and 6 months, and acceptability of the IUD. RESULTS: We recruited and randomised 114 women admitted for elective medical abortion between August 2018 and June 2019. In the immediate and delayed study arms, respectively, 45/55 (82%) and 12/57 (21%) women received the IUD as planned. By intention-to-treat, 56% in the immediate and 19% in the delayed arms were using the original IUD at 6 weeks (p<0.001), and 76% in the immediate and 40% in the delayed arms were using any IUD (p<0.001). Complete expulsion or removal occurred in 32% in the immediate and 7% in the delayed arms (p=0.044). CONCLUSIONS: Insertion of an IUD immediately after medical abortion at 17-20 GW results in increased use after 6 weeks compared with delayed insertion, however expulsion rates are higher than with interval insertion. CLINICAL TRIALS REGISTRATION: NCT03505047), Pan African Trials Registry (www.pactr.org), 201804003324963.

Maternal characteristics and pregnancy outcomes of hospitalized pregnant women with SARS-CoV-2 infection in South Africa: An International Network of Obstetric Survey Systems-based cohort study.

OBJECTIVE: To describe risk factors and outcomes of pregnant women infected with SARS-CoV-2 admitted to South African healthcare facilities. METHODS: A population-based cohort study was conducted utilizing an amended International Obstetric Surveillance System protocol. Data on pregnant women with SARS-CoV-2 infection, hospitalized between April 14, 2020, and November 24, 2020, were analyzed. RESULTS: A total of 36 hospitals submitted data on 673 infected hospitalized pregnant women; 217 (32.2%) were admitted for COVID-19 illness and 456 for other indications. There were 39 deaths with a case fatality rate of 6.3%: 32 (14.7%) deaths occurred in women admitted for COVID-19 illness compared to 7 (1.8%) in women admitted for other indications. Of the women, 106 (15.9%) required critical care. Maternal tuberculosis, but not HIV co-infection or other co-morbidities, was associated with admission for COVID-19 illness. Rates of cesarean delivery did not differ significantly between women admitted for COVID-19 and those admitted for other indications. There were 179 (35.4%) preterm births, 25 (4.7%) stillbirths, 12 (2.3%) neonatal deaths, and 162 (30.8%) neonatal admissions. Neonatal outcomes did not differ significantly from those of infected women admitted for other indications. CONCLUSION: The maternal mortality rate was high among women admitted with SARS-CoV-2 infection and higher in women admitted primarily for COVID-19 illness with tuberculosis being the only co-morbidity associated with admission.

Association between food intake and obesity in pregnant women living with and without HIV in Cape Town, South Africa: a prospective cohort study.

BACKGROUND: Although global nutrition/dietary transition resulting from industrialisation and urbanisation has been identified as a major contributor to widespread trends of obesity, there is limited data in pregnant women, including those living with HIV in South Africa. We examined food-based dietary intake in pregnant women with and without HIV at first antenatal care (ANC) visit, and associations with maternal overweight/obesity and gestational weight gain (GWG). METHODS: In an urban South African community, consecutive women living with (n = 479) and without (n = 510) HIV were enrolled and prospectively followed to delivery. Interviewer-administered non-quantitative food frequency questionnaire was used to assess dietary intake (starch, protein, dairy, fruits, vegetables, legumes, oils/fats) at enrolment. Associations with maternal body mass index (BMI) and GWG were examined using logistic regression models. RESULTS: Among women (median age 29 years, IQR 25-34), the prevalence of obesity (BMI ≥ 30 kg/m2) at first ANC was 43% and that of excessive GWG (per IOM guidelines) was 37% overall; HIV prevalence was 48%. In women without HIV, consumption of potato (any preparation) (aOR 1.98, 95% CI 1.02-3.84) and pumpkin/butternut (aOR 2.13, 95% CI 1.29-3.49) for 1-3 days a week increased the odds of overweight/obesity compared to not consuming any; milk in tea/coffee (aOR 6.04, 95% CI 1.37-26.50) increased the odds of excessive GWG. Consumption of eggs (any) (aOR 0.52, 95% CI 0.32-0.86) for 1-3 days a week reduced the odds of overweight/obesity while peanut and nuts consumption for 4-7 days a week reduced the odds (aOR 0.34, 95% CI 0.14-0.80) of excessive GWG. In women with HIV, consumption of milk/yoghurt/maas to drink/on cereals (aOR 0.35, 95% CI 0.18-0.68), tomato (raw/cooked) (aOR 0.50, 95% CI 0.30-0.84), green beans (aOR 0.41, 95% CI 0.20-0.86), mixed vegetables (aOR 0.49, 95% CI 0.29-0.84) and legumes e.g. baked beans, lentils (aOR 0.50, 95% CI 0.28-0.86) for 4-7 days a week reduced the odds of overweight/obesity; tomato (raw/cooked) (aOR 0.48, 95% CI 0.24-0.96) and mixed vegetables (aOR 0.38, 95% CI 0.18-0.78) also reduced the odds of excessive GWG. CONCLUSIONS: Diet modification may promote healthy weight in pregnant women living with and without HIV.

High blood pressure at entry into antenatal care and birth outcomes among a cohort of HIV-uninfected women and women living with HIV initiating antiretroviral therapy in South Africa.

OBJECTIVE: To examine associations between high blood pressure (BP) when entering antenatal care (ANC) and birth outcomes in a cohort of pregnant HIV- and women living with HIV (WLHIV) initiating antiretroviral treatment (ART). STUDY DESIGN: Prospective cohort study. MAIN OUTCOME MEASURES: Cesarean delivery, preterm birth (<37 weeks' gestation), low birthweight (LBW, <2500 g), small-for-gestational age (SGA, <10th percentile), and large-for-gestational age (LGA, >10th percentile for GA). RESULTS: Of 1116 women (median GA 20 weeks; WLHIV 53%), 48% (53% WLHIV; 43% HIV-) entered ANC with high BP, defined as elevated (120-129 or < 80 mmHg), stage 1 (>130-139 or 80-89) or stage 2 hypertension (≥140 / or ≥ 90). WLHIV were more likely to have high BP (RR 1.32; 95%CI 1.12-1.57), controlling for pre-pregnancy body mass index and additional confounders. In multivariable analysis, there was no evidence that high BP increased the risk of cesarean delivery (RR 1.10, 95% CI 0.92-1.30), preterm birth (RR 1.15, 95% CI 0.81-1.62), LBW (RR 1.16, 95% CI 0.84-1.60) or SGA (RR 1.02, 0.72-1.44), overall or when stratified by HIV-status. High BP was associated with an increased risk of LGA (RR 1.43; 95% CI 1.00-2.03). CONCLUSION: In this setting, half of women had high BP at entry into ANC, with WLHIV at increased risk of high BP. There was no strong evidence that high BP increased the risk of adverse birth outcomes overall, or by HIV-status, with the exception of LGA. WLHIV may be at high risk of high BP during pregnancy and should be monitored closely.

Does HIV infection modify the relationship between pre-pregnancy body mass index and adverse birth outcomes?

BACKGROUND: South Africa faces dual epidemics of HIV and obesity; however, little research has explored whether HIV status influences associations between pre-pregnancy body mass index (BMI) and adverse birth outcomes. OBJECTIVES: To examine associations between pre-pregnancy body mass index (BMI) and adverse birth outcomes, and if they differ by HIV status. METHODS: We followed HIV-uninfected and -infected pregnant women initiating antiretroviral therapy (ART) from first antenatal visit through delivery. HIV-infected women initiated ART (tenofovir-emtricitabine/lamivudine-efavirenz) in pregnancy. Estimated pre-pregnancy BMI (kg/m2 ) was categorised as underweight (<18.5), normal (18.5-24.9), overweight (25.0-29.9), and obese (≥30.0). We used modified Poisson regression to estimate risk ratios (RR) for associations between pre-pregnancy BMI and adverse birth outcomes and explored modification by HIV status. RESULTS: Among 1116 women (53% HIV-infected), 44% of HIV-uninfected women and 36% of HIV-infected women were classified as obese; 4% of women were underweight. Overall, 12% of infants were delivered preterm (<37 weeks), 10% small for gestational age (SGA, <10th percentile), and 9% large for gestational age (LGA, >90th percentile). Compared to HIV-uninfected women, HIV-infected women on ART had less LGA (5% vs 13%) but more SGA (12% vs 8%), and a similar proportion of preterm (13% vs 11%) infants. Pre-pregnancy BMI was not associated with preterm birth. Among HIV-uninfected women, obesity modestly increased the risk of LGA (RR 1.34, 95% confidence interval [CI] 0.82, 2.19), and underweight modestly elevated the risk of SGA (RR 1.66, 95% CI 0.79, 3.46). These associations were attenuated among HIV-infected women (RR 1.07, 95% CI 0.44, 2.64 for LGA, and RR 1.34, 95% CI 0.49, 3.64 for SGA). CONCLUSIONS: In this urban African setting of high HIV prevalence, pre-pregnancy obesity was common and did not vary by HIV status. In HIV-uninfected women, obesity increased the risk of LGA and being underweight the risk of SGA, compared with among HIV-uninfected women.

Safety and continued use of the levonorgestrel intrauterine system as compared with the copper intrauterine device among women living with HIV in South Africa: A randomized controlled trial.

BACKGROUND: Women living with HIV (WLHIV) have lower rates of contraceptive use than noninfected peers, yet concerns regarding contraceptive efficacy and interaction with antiretroviral therapy (ART) complicate counseling. Hormonal contraceptives may increase genital tract HIV viral load (gVL) and sexual transmission risk to male partners. We compared gVL, plasma VL (pVL), and intrauterine contraceptive (IUC) continuation between the levonorgestrel intrauterine system (LNG-IUS) and copper intrauterine device (C-IUD) in Cape Town, South Africa. METHODS AND FINDINGS: In this double-masked, randomized controlled noninferiority trial, eligible WLHIV were ages 18-40, not pregnant or desiring pregnancy within 30 months, screened and treated (as indicated) for reproductive tract infections (RTIs) within 1 month of enrollment, and virologically suppressed using ART or above treatment threshold at enrollment (non-ART). Between October 2013, and December 2016, we randomized consenting women within ART groups, using 1:1 permuted block randomization stratified by ART use, age (18-23, 24-31, 32-40), and recent injectable progestin contraceptive (IPC) exposure, and provided the allocated IUC. At all visits, participants provided specimens for gVL (primary outcome), pVL, RTI, and pregnancy testing. We assessed gVL and pVL across 6 and 24 months controlling for enrollment measures, ART group, age, and RTI using generalized estimating equation and generalized linear models (non-ART group pVL and hemoglobin) in as-treated analyses. We measured IUC discontinuation rates with Kaplan-Meier estimates and Cox proportional hazards models. We enrolled 71 non-ART (36 LNG-IUS, 31 C-IUD; 2 declined and 2 were ineligible) and 134 ART-using (65 LNG-IUS, 67 C-IUD; 1 declined and 1 could not complete IUC insertion) women. Participant median age was 31 years, and 95% had 1 or more prior pregnancies. Proportions of women with detectable gVL were not significantly different comparing LNG-IUS to C-IUD across 6 (adjusted odds ratio [AOR]: 0.78, 95% confidence interval [CI] 0.44-1.38, p = 0.39) and 24 months (AOR: 1.03, 95% CI: 0.68-1.57, p = 0.88). Among ART users, proportions with detectable pVL were not significantly different at 6 (AOR = 0.83, 95% CI 0.37-1.86, p = 0.65) and 24 months (AOR = 0.94, 95% CI 0.49-1.81, p = 0.85), whereas among non-ART women, mean pVL was not significantly different at 6 months (-0.10 log10 copies/mL, 95% CI -0.29 to 0.10, p = 0.50) between LNG-IUS and C-IUD users. IUC continuation was 78% overall; C-IUD users experienced significantly higher expulsion (8% versus 1%, p = 0.02) and elective discontinuation (adjusted hazard ratio: 8.75, 95% CI 3.08-24.8, p < 0.001) rates. Sensitivity analysis adjusted for differential IUC discontinuation found similar gVL results. There were 39 serious adverse events (SAEs); SAEs believed to be directly related to IUC use (n = 7) comprised 3 pelvic inflammatory disease (PID) cases and 4 pregnancies with IUC in place with no discernible trend by IUC arm. Mean hemoglobin change was significantly higher among LNG-IUS users across 6 (0.57 g/dL, 95% CI 0.24-0.90; p < 0.001) and 24 months (0.71 g/dL, 95% CI 0.47-0.95; p < 0.001). Limitations included not achieving non-ART group sample size following change in ART treatment guidelines and truncated 24 months' outcome data, as 17 women were not yet eligible for their 24-month visit at study closure. Also, a change in VL assay during the study may have caused some discrepancy in VL values because of different limits of detection. CONCLUSIONS: In this study, we found that the LNG-IUS did not increase gVL or pVL and had low levels of contraceptive failure and associated PID compared with the C-IUD among WLHIV. LNG-IUS users were significantly more likely to continue IUC use and had higher hemoglobin levels over time. The LNG-IUS appears to be a safe contraceptive with regard to HIV disease and may be a highly acceptable option for WLHIV. TRIAL REGISTRATION: ClinicalTrials.gov NCT01721798.

Difficult etonogestrel implant removals in South Africa: A review of 74 referred cases.

OBJECTIVES: To assess etonogestrel contraceptive implant location and outcomes among women referred for "difficult" removal to a specialist clinic in South Africa. STUDY DESIGN: We performed a retrospective review of cases referred to our clinic for removal of nonpalpable, deep, migrated, or damaged implants, or failed removals from March to August 2017. RESULTS: Most (n = 68, 92%) of the 74 referrals were nonpalpable in our clinic. We used ultrasound for localization and successfully removed 72 implants (97%) in the outpatient clinic. CONCLUSION: With proper protocols and equipment, localization and removal of nonpalpable implants can be safely and effectively achieved in an outpatient African setting. IMPLICATIONS: Access to providers specially trained in ultrasound localization should be available in all settings where implants are offered. Providing timely access to safe and effective implant removals in routine and difficult cases is essential to ensuring that implant programs are in alignment with rights-based, client-centered family planning principles.

Closing the Gap: Ensuring Access to and Quality of Contraceptive Implant Removal Services is Essential to Rights-based Contraceptive Care.

The use of the subdermal contraceptive implant is increasing globally, and particularly so in lower- and middle-income countries in sub-Saharan Africa. For initiation or discontinuation of the implant, users need to have access to services for insertion and removal by healthcare providers. Providing access to safe and effective contraceptive implant removal services presents both clinical and programmatic challenges. The most challenging implant removal cases, termed -difficult removals‖, place additional demands upon removal services. In this commentary, we outline challenges for the provision of removal services. Based on our experience in this field, we make recommendations on how healthcare providers and health services can plan for these challenges. Through maximising the provision of comprehensive and accessible implant removal services, including those for difficult removals, implant users can be empowered to discontinue their use of this method of contraception if they choose, thus upholding the principles of rights-based contraceptive care.

Case Report: Traumatic Incomplete Fracture of an Implanon NXT® Contraceptive Implant.

The etonogestrel (ENG) subdermal contraceptive implant (Implanon NXT®) is a safe and highly effective method of contraception which is increasing in popularity globally. This case report describes a 26-year-old woman who requested removal of the Implanon NXT® contraceptive implant. She reported that her implant had bent following direct trauma. The implant was removed in accordance with her request and without complication, but was noted to be incompletely fractured. We compare this case with a summary of the existing literature on fractured or damaged contraceptive implants. Structural damage detected whilst the implant is in situ is one potential complication of contraceptive implant use. The incidence of this complication and the implications for contraceptive efficacy are unknown. Damaged implants may present healthcare providers with more technically challenging "difficult removals". With the scale-up of services for implant provision, consideration should be given to this issue in order to inform counselling and removal services.

A systematic review of contraceptive continuation among women living with HIV.

BACKGROUND: Women living with HIV (WLHIV) experience high rates of unmet contraceptive need and unintended pregnancy. Contraceptive method-specific continuation rates and associated factors are critical for guiding providers tasked with both reproductive health (RH) and HIV care. We conducted this systematic review to determine whether contraceptive continuation rates differ between WLHIV and uninfected women and, for WLHIV, whether differences are impacted by method type, antiretroviral therapy use or other factors. METHODS: We searched Ovid MEDLINE, POPLINE and PubMed.gov for studies published between January 1, 2000, and August 31, 2016. Inclusion criteria comprised prospective data of WLHIV, nonbarrier method continuation as an outcome measure, and recorded method switching and/or discontinuation. RESULTS: Of 939 citations screened, 22 articles from 18 studies were eligible. For studies with comparator groups, data quality was moderate overall based on Grading of Recommendations, Assessment, Development and Evaluations and Newcastle-Ottawa Quality Assessment scales. Of four studies comparing women by HIV serostatus, two showed higher rates of contraceptive continuation among WLHIV versus uninfected women, while two others detected lower continuation rates for the same comparison. Generally, baseline method continuation exceeded 60% for studies with >12months of follow-up. Studies providing contraception had higher continuation rates than studies not providing contraception, while women allocated to contraceptive methods in trials had similar continuation rates to those choosing contraceptive methods. Across all studies, continuation rates differed by method and context, with the copper intrauterine device showing greatest variability between sites (51%-91% continuation rates at ≥12months). Implant continuation rates were ≥86%, though use was low relative to other methods and limited to few studes. CONCLUSIONS: Contraceptive continuation among WLHIV differs by method and context. More longitudinal studies with contraceptive continuation as a measured outcome following ≥12months are needed to strengthen integration of RH and HIV care.

Mid-upper arm circumference: A surrogate for body mass index in pregnant women.

BACKGROUND: Nutrition in pregnancy has implications for both mother and fetus, hence the importance of an accurate assessment at the booking visit during antenatal care. The body mass index (BMI, kg/m2) is currently the gold standard for measuring body fatness. However, pregnancy-associated weight gain and oedema, as well as late booking in our population setting, cause concern about the reliability of using the BMI to assess body fat or nutritional status in pregnancy. The mid-upper arm circumference (MUAC) has been used for many decades to assess malnutrition in children aged <5 years. Several studies have also shown a strong correlation between MUAC and BMI in both pregnant and non-pregnant adult populations. OBJECTIVE: To assess the correlation between the MUAC and BMI in pregnant women booking for antenatal care in the Metro West area of Cape Town, South Africa. METHODS: We conducted a cross-sectional study of women booking at four midwife obstetric units. Anthropometric measurements (height, weight and MUAC) were carried out on pregnant women at their first antenatal booking visit. RESULTS: The results showed a strong correlation between MUAC and BMI in pregnant women up to 30 weeks' gestation. The correlation was calculated at 0.92 for the entire group. The MUAC cut-offs for obesity (BMI >30) and malnutrition (BMI <18.5) were calculated as 30.57 cm and 22.8 cm, respectively. CONCLUSION: MUAC correlates strongly with BMI in pregnancy up to a gestation of 30 weeks in women attending Metro West maternity services. In low-resource settings, the simpler MUAC measurement could reliably be substituted for BMI to assess nutritional status.

Clinical Outcomes and Women's Experiences before and after the Introduction of Mifepristone into Second-Trimester Medical Abortion Services in South Africa.

OBJECTIVE: To document clinical outcomes and women's experiences following the introduction of mifepristone into South African public sector second-trimester medical abortion services, and compare with historic cohorts receiving misoprostol-only. METHODS: Repeated cross-sectional observational studies documented service delivery and experiences of women undergoing second-trimester medical abortion in public sector hospitals in the Western Cape, South Africa. Women recruited to the study in 2008 (n = 84) and 2010 (n = 58) received misoprostol only. Those recruited in 2014 (n = 208) received mifepristone and misoprostol. Consenting women were interviewed during hospitalization by study fieldworkers with respect to socio-demographic information, reproductive history, and their experiences with the abortion. Clinical details were extracted from medical charts following discharge. Telephone follow-up interviews to record delayed complications were conducted 2-4 weeks after discharge for the 2014 cohort. RESULTS: The 2014 cohort received 200 mg mifepristone, which was self-administered 24-48 hours prior to admission. For all cohorts, following hospital admission, initial misoprostol doses were generally administered vaginally: 800 mcg in the 2014 cohort and 600 mcg in the earlier cohorts. Women received subsequent doses of misoprostol 400 mcg orally every 3-4 hours until fetal expulsion. Thereafter, uterine evacuation of placental tissue was performed as needed. With one exception, all women in all cohorts expelled the fetus. Median time-to-fetal expulsion was reduced to 8.0 hours from 14.5 hours (p<0.001) in the mifepristone compared to the 2010 misoprostol-only cohort (time of fetal expulsion was not recorded in 2008). Uterine evacuation of placental tissue using curettage or vacuum aspiration was more often performed (76% vs. 58%, p<0.001) for those receiving mifepristone; major complication rates were unchanged. Hospitalization duration and extreme pain levels were reduced (p<0.001), but side effects of medication were similar or more common for the mifepristone cohort. Overall satisfaction remained unchanged (95% vs. 91%), while other acceptability measures were higher (p<0.001) for the mifepristone compared to the misoprostol-only cohorts. CONCLUSION: The introduction of a combined mifepristone-misoprostol regimen into public sector second-trimester medical abortion services in South Africa has been successful with shorter time-to-abortion events, less extreme pain and greater acceptability for women. High rates of uterine evacuation for placental tissue need to be addressed.

Plasma viraemia in HIV-positive pregnant women entering antenatal care in South Africa.

INTRODUCTION: Plasma HIV viral load (VL) is the principle determinant of mother-to-child HIV transmission (MTCT), yet there are few data on VL in populations of pregnant women in sub-Saharan Africa. We examined the distribution and determinants of VL in HIV-positive women seeking antenatal care (ANC) in Cape Town, South Africa. METHODS: Consecutive HIV-positive pregnant women making their first antenatal clinic visit were recruited into a cross-sectional study of viraemia in pregnancy, including a brief questionnaire and specimens for VL testing and CD4 cell enumeration. RESULTS & DISCUSSION: Overall 5551 pregnant women sought ANC during the study period, of whom 1839 (33%) were HIV positive and 1521 (85%) were included. Approximately two-thirds of HIV-positive women in the sample (n=947) were not on antiretrovirals at the time of the first ANC visit, and the remainder (38%, n=574) had initiated antiretroviral therapy (ART) prior to conception. For women not on ART, the median VL was 3.98 log10 copies/mL; in this group, the sensitivity of CD4 cell counts ≤350 cells/µL in detecting VL>10,000 copies/mL was 64% and this increased to 78% with a CD4 threshold of ≤500 cells/µL. Among women on ART, 78% had VL<50 copies/mL and 13% had VL >1000 copies/mL at the time of their ANC visit. CONCLUSIONS: VL >10,000 copies/mL was commonly observed in women not on ART with CD4 cell counts >350 cells/µL, suggesting that CD4 cell counts may not be adequately sensitive in identifying women at greatest risk of MTCT. A large proportion of women entering ANC initiated ART before conception, and in this group more than 10% had VL>1000 copies/mL despite ART use. VL monitoring during pregnancy may help to identify pregnancies that require additional clinical attention to minimize MTCT risk and improve maternal and child health outcomes.