Effects of short-course zidovudine on the selection of nevirapine-resistant HIV-1 in women taking single-dose nevirapine.

Single-dose nevirapine (sdNVP) given to prevent mother-to-child-transmission of HIV-1 selects NVP-resistance. Short-course zidovudine (ZDV) was hypothesized to lower rates of NVP-resistance. HIV-1 infected pregnant women administered sdNVP with or without short-course ZDV were assessed for HIV-1 mutations (K103N, Y181C, G190A, and V106M) prior to delivery and postpartum. Postpartum NVP-resistance was lower among 31 taking ZDV+sdNVP compared to 33 taking only sdNVP (35.5% vs. 72.7%; χ2 P = .003). NVP mutants decayed to <2% in 24/35 (68.6%) at a median 6 months postpartum, with no differences based on ZDV use (logrank P = .99). Short-course ZDV was associated with reduced NVP-resistance mutations among women taking sdNVP.

Nevirapine resistance by timing of HIV type 1 infection in infants treated with single-dose nevirapine.

BACKGROUND: In women, single-dose nevirapine for prophylaxis against mother-to-child transmission of human immunodeficiency virus type 1 (HIV-1) selects for nevirapine-resistant HIV-1, which subsequently decays rapidly. We hypothesized that the selection, acquisition, and decay of nevirapine-resistant HIV-1 differs in infants, varying by the timing of HIV-1 infection. METHODS: We conducted a prospective, observational study of 740 Mozambican infants receiving single-dose nevirapine prophylaxis and determined the timing of infection and concentrations of nevirapine-resistant HIV-1 over time. RESULTS: Infants with established in utero infection had a high rate (87.0%) of selection of nevirapine-resistant HIV-1 mutants, which rapidly decayed to undetectable levels. The few without nevirapine resistance received zidovudine with single-dose nevirapine and/or their mothers took alternative antiretroviral drugs. Infants with acute in utero infection had a lower rate of nevirapine-resistant HIV-1 (33.3%; P = .006, compared with established in utero infection), but mutants persisted over time. Infants with peripartum infection also had a lower rate of nevirapine-resistant HIV-1 (38.1%; P = .001, compared with established in utero infection) but often acquired 100% mutant virus that persisted over time (P = .017, compared with established in utero infection). CONCLUSIONS: The detection and persistence of nevirapine-resistant HIV-1 in infants after single-dose nevirapine therapy vary by the timing of infection and the antiretroviral regimen. In infants with persistent high-level nevirapine-resistant HIV-1, nevirapine-based antiretroviral therapy is unlikely to ever be efficacious because of concentrations in long-lived viral reservoirs. However, the absence or decay of nevirapine-resistant HIV-1 in many infants suggests that nevirapine antiretroviral therapy may be effective if testing can identify these individuals.

Antiretroviral-associated toxicity among HIV-1-seropositive pregnant women in Mozambique receiving nevirapine-based regimens.

OBJECTIVE: To assess toxicities associated with highly active antiretroviral therapy (HAART) among HIV-1-infected pregnant women treated with nevirapine-based regimens according to Mozambican national guidelines. STUDY DESIGN: Prospective cohort study. METHODS: HIV-1-infected antiretroviral-naive pregnant women with CD4 counts < or =350 cells/microL were initiated on nevirapine, lamivudine, and stavudine or zidovudine and followed monthly. Severe hepatotoxicity was defined as aspartate aminotransferase (AST) or alanine aminotransferase (ALT) levels > or =5-fold the upper limit of normal. Analyses were stratified by baseline CD4 count (<250 vs. 250-350 cells/microL). RESULTS: Among 146 pregnant women, 75 (52%) began nevirapine, lamivudine, and zidovudine and 71 (48%) began nevirapine, lamivudine, and stavudine. Overall, 79 (54%) women had CD4 counts <250 cells/microL, 7 (5%) had grade II hepatotoxicity, and 4 (3%) had severe (grade III or IV) hepatotoxicity. All 4 women with severe hepatotoxicity had baseline CD4 counts > or =250 cells/microL (P = 0.02). Rates of skin toxicity, anemia, and peripheral neuropathy did not differ by CD4 cell count group. Overall, 12 (8%) women changed or discontinued HAART as a result of drug toxicity. CONCLUSIONS: Severe hepatotoxicity from nevirapine-containing HAART in this cohort of pregnant women was more common at higher CD4 counts (6% vs. 0% among women with CD4 counts > or =250 cells/microL and CD4 counts <250 cells/microL, respectively), suggesting that laboratory monitoring is necessary when administering nevirapine-containing regimens to pregnant women with CD4 counts > or =250 cells/microL.

An assessment of abortion services in public health facilities in Mozambique: women's and providers' perspectives.

Complications of unsafe abortion contribute to high maternal mortality and morbidity in Mozambique. In 2002, the Ministry of Health conducted an assessment of abortion services in the public health sector to inform efforts to make abortion safer. This paper reports on interviews with 461 women receiving treatment for abortion-related complications in 37 public hospitals and four health centres in the ten provinces of Mozambique. One head of both uterine evacuation and contraceptive services at each facility was also interviewed, and 128 providers were interviewed on abortion training and attitudes. Women reported lengthy waiting times from arrival to treatment, far longer than heads of uterine evacuation services reported. Similarly, fewer women reported being offered pain medication than head staff members thought was usual. Less than half the women said they received follow-up care information, and only 27% of women wanting to avoid pregnancy said they had received a contraceptive method. Clinical procedures such as universal precautions to prevent infection were less than adequate, in-service training was less than comprehensive in most cases, and few facilities reviewed major complications or deaths. Use of dilatation and curettage was far more common than medical or aspiration abortion methods. Current efforts by the Ministry to improve abortion care services have focused on training of providers in all these matters and integration of contraceptive provision into post-abortion care.

Assessment of the capacity of the health services to provide emergency obstetric care in Sofala Province: final report of the needs assessment

"Maternal mortality is a serious health problem in Mozambique. While the last DHS survey did not calculate exactly the maternal mortality ratio in the country; careful estimates indicate the MMR to be between 500 and 1500 deaths per 100 000 live births. Even with these important differences in estimation; the problem is being recognised as an important one for the health planners and the donors in the country. Mozambique has made a commitment to reduce the maternal mortality in the country. In 1998 a first general Safe Motherhood needs assessment was done which was followed in the same year by a systematic review of the causes of maternal deaths. ollowing this dynamism within the ministry of health a national strategy to reduce the maternal morbidity and mortality and neonatal mortality was formulated in 1999 and adopted in 2000; the ""...Estrategias para a reducao da morbimortalidade materna e neonatal"". This document forms the basis for formulating interventios and it is based on strengthening the health services with the concept of the provision of obstetric care (basic and comprehensive) with an adequate referral system; community involvement and an improved data collection system."

Avaliacao das necessidades e da disponibilidade e utilizacao dos cuidados obstetricos de emergencia na Provincia de Sofala: relatorio final da avaliacao das necessidades ano 2000

A mortalidade materna e um serio problema de saude em Mocambique. Durante o ultimo censo nao se calculou a taxa exacta da mortalidade materna no pais; tendo sido cuidadosamente estimada estar entre 5000 e 1500 por 100.000 nados vivos. Mesmo com estas importantes diferencas nas estimativas; foi reconhecido como um problema importante para os planificadores e para os doadores no pais. Mocambique comprometeu-se na reducao da mortalidade meterna no pais. Em 1998 foi realizada a primeira avaliacao das necessidades seguida de uma revisao sistematica das causas das mortes maternas no mesmo ano. Acompanhando este dinamismo; o Ministerio da Saude foi formulada a estrategia nacional para a reducao da mortalidade materna e neonatal em 1999 e adoptada no ano 2000. Este documento forma as bases para a formulacao das intervencoes e esta baseada no reforcos servicos de saude com os conceitos de prestacao de cuidados obstetricos (basicos e completos) com um adequado sistema de referencia; envolvimento comunitario e um sistema de colheita de dados melhorado

Avaliacao da capacidade dos servicos da saude na prestacao dos cuidados obstetricos na Provincia de Gaza; Mocambique: relatorio final da avaliacao das necessidades

"A mortalidade materna e um serio problema de saude em Mocambique. Durante o ultimo censo; realizado em 1997 o Inquerito Demografico de Saude (IDS) nao calculou a taxa exacta da mortalidade materna; mas estimou com muito cuidado estar entre 500 e 1500 por 100.000 nados vivos sem contudo ter disponibilizado nenhuma referencia. A unica informacao credivel e do estudo realizado pela ""Sisterhood Survey"" em 1991 e publicada somente em 1995; Apesar destas diferencas nas estimativas; a mortalidade materna e perinatal foi reconhecida como um problema importante para os planificadores e para os doadores no pais. Mocambique comprometeu-se claramente para a reducao da mortalidade meterna no pais. Em 1998 foi realizada a primeira avaliacao das necessidades para uma Maternidade Segura nacional seguida no ano de sistematica revisao das causas de 90 mortes maternas. Acompanhando este dinamismo; o Ministerio da Saude formulou a Estrategia Nacional para a Reducao da Morbilidade e Mortalidade Materna e Neonatal em 1999 e adoptada no ano 2000 e que foi lancada como "" ... Estrategia para a Reducao da Morbimortalidade Materna e Neonatal""... Este documento forma as bases para a formulacao das intervencoes para a reducao da mortalidade materna em Mocambique e esta baseada no reforco dos servicos de saude com os conceitos de prestacao de cuidados obstetricos (basicos e completos) com um adequado sistema de referencia; envolvimento da comunidade e uma melhoria de colheita de dados."

Need assessment of the availability and use of the emergency obstetric care in Tete Province: final report of needs assessment

"Maternal mortality is a serious health problem in Mozambique. While the last census in 1997 and the DHS did not calculate exactly the maternal mortality ratio in the country; careful estimates indicate the MMR to be between 500 and 1500 deaths per 100.000 live births; but no reference is given. The only reliable information that is available comes from a sisterhood survey done in 1995. Even with these important differences in estimation of the exact figure of the maternal mortality; the problem is being recongised as an important one for the health planners aand the donors in the country. Mozambique has made a clear commitment to reduce the maternal mortality in the country. In 1998 a first nation-wide Safe Motherhood needs assessment was done; which was followed in the same yaer by a systematic review of the causes of 90 maternal deaths. Following thisdynamism within the Ministry of Health; a national strategy to reduce the maternal morbidity and maternal and neonatal mortality was formulated in 1999 and adopted in 2000; the document was launched as the: ""...Estrategias para a reducao da morbimortalidade materna e neonatal"". This document forms the basis for formulating interventions to reduce maternal mortality in Mozambique. It is based on strengthening the health services with the concept of the provision of obstetric care (basic and comprehensive) with an adequate referral sistem; community involviment and an improved data collection sistem."

Avaliacao da capacidade dos servicos de saude para a prestacao dos servicos dos cuidados obstetricos essenciais na Provincia de Tete; Mocambique: relatorio final da avaliacao das necessidades

"A mortalidade materna e um serio problema de saude em Mocambique. Durante o ultimo censo; realizado em 1997 o Inquerito Demografico de Saude (IDS) nao calculou com exactidao a taxa da mortalidade materna no pais; mas estimou com muito cuidado estar entre 500 e 1500 por 100.000 nados vivos; sem contudo ter nenhuma referencia. A unica informacao credivel e disponivel e do estudo realizado pela ""Sisterhood Survey"" e publicada em 1995. Mesmo com estas importantes diferencas nas estimativas sobre os numeros exactos da mortalidade materna foi reconhecida como um problemas importantes para os planificadores de saude e os doadores no pais. Mocambique comprometeu-se claramente para a reducao da mortalidade meterna no pais. Em 1998 foi realizada a primeira avaliacao das necessidades para uma Maternidade Segura nacional; seguida no mesmo ano de uma sistematica revisao das causas de 90 mortes maternas. Acompanhando este dinamismo; o Ministerio da Saude desenhou a Estrategia Nacional para a Reducao da Morbilidade e Mortalidade Materna e Perinatal em 1999 que foi adoptada em 2000 e foi lancada como ""...Estrategias para a reducao da morbimortalidade materna e neonatal"". Este doumento forma as bases para a formulacao das internvecoes para a reducao da mortalidade materna em Mocambique. Esta baseada no reforco dos servicos de saude com os conceitos da provisao de Cuidados Obstetricos (basicos e completos) com um sistema de referencia adequado; envolvemento da comunidade e uma melhoria no sistema de colheita de dados."