Clinical Trials That Have Changed Clinical Practice and Care of Pregnant People With HIV.

Over the last 4 decades, significant advances in the care of HIV during pregnancy have successfully reduced, and nearly eliminated, the risk of perinatal HIV transmission. The baseline risk of transmission without intervention (25% to 30%) is now <1% to 2% in the United States with contemporary antepartum, intrapartum, and postnatal interventions. In this review, we discuss 3 landmark clinical trials that substantially altered obstetric practice for pregnant individuals with HIV and contributed to this extraordinary achievement: 1) the Pediatric AIDS Clinical Trials Group 076 Trial determined that antepartum and intrapartum administration of antiretroviral drug zidovudine to the pregnant individual, and postnatally to the newborn, could reduce the risk of perinatal transmission by approximately two-thirds; 2) the European Mode of Delivery Collaboration Trial demonstrated performance of a prelabor cesarean birth before rupture of membranes among pregnant people with viremia reduced the risk of perinatal transmission compared with vaginal birth; and 3) the International Maternal Pediatric Adolescent AIDS Clinical Trials Network 2010 Trial identified that dolutegravir-containing, compared with efavirenz-containing, antiretroviral regimens during pregnancy achieved a significantly higher rate of viral suppression at delivery with shorter time to viral suppression, with fewer adverse pregnancy outcomes. Collectively, these trials not only advanced obstetric practice but also advanced scientific understanding of the timing, mechanisms, and determinants of perinatal HIV transmission. For each trial, we will describe key aspects of the study protocol and outcomes, insights gleaned about the dynamics of perinatal transmission, how each study changed clinical practice, and relevant updates to current practice since the trial's publication.

Statewide Implementation of Universal Third-Trimester Repeat HIV Testing in Illinois.

OBJECTIVE: This article aims to assess statewide uptake of HIV repeat testing in the first 2 years after the implementation of an amendment to the Illinois Perinatal HIV Prevention Act (IPHPA) mandating universal repeat HIV testing in the third trimester. STUDY DESIGN: This is a retrospective, population-based study of all birthing individuals in Illinois (2018-2019). Data were collected using the state-mandated closed system of perinatal HIV test reporting. We evaluated the incidence of mother-infant pairs with negative early tests and repeat third-trimester tests (RTTTs) performed in adherence with the law, as well as the timing of the performance of the RTTTs (outpatient vs. inpatient). Chi-square tests of trend by quarter were performed to ascertain sustainability. RESULTS: Of 138,805 individuals delivered in 2018, 80.6% presented with early test and RTTTs. In 2018, outpatient RTTTs improved from 71.8% (quarter 1) to 85.1% (quarter 4; p < 0.001). In 2018, the proportion of mother-infant dyads who received testing that was adherent to the IPHPA Amendment was 92.1, 95.5, 96.7, and 96.4% in quarters 1 through 4, respectively (p < 0.001). In 2019, outpatient RTTTs performance remained high (87.4%) and stable (p = 0.06). In 2019, 99.9% of mother-infant dyads had testing adherent to the mandate in quarters 1 through 4 (p = 0.39). Of individuals who presented without RTTTs, 93.5% (2018) and 98.8% (2019) underwent inpatient testing before delivery. CONCLUSION: Implementation of RTTTs in Illinois was rapid, successful, and sustained in its first 2 years. Public health methodologies from Illinois may benefit other states implementing RTTT programs. KEY POINTS: · In 2018, Illinois enacted statewide RTTT for HIV among all parturients.. · In 2019, over 99% of mother-infant dyads had documentation of both early and repeat HIV testing before hospital discharge.. · Implementation of repeat third-trimester HIV testing in Illinois was rapid, successful, and sustained in its first 2 years.. · Public health methodologies from Illinois may benefit other states implementing similar programs..

Evaluation of State-Mandated Third Trimester Repeat HIV Testing in a Large Tertiary Care Center.

OBJECTIVE: The Illinois Perinatal HIV Prevention Act was passed to ensure universal HIV testing once during pregnancy and was extended in 2018 to add third trimester repeat HIV screening. The objectives of this analysis were to describe uptake of, and patient factors associated with, third trimester repeat HIV testing at a high-volume birthing center. STUDY DESIGN: This is a retrospective cohort study of people who delivered at a single tertiary care hospital in Illinois during 2018. Women who delivered before 27 weeks, had an intrauterine fetal demise, a known diagnosis of HIV, or no HIV test during pregnancy were excluded. Repeat testing was defined as an HIV test at or after 27 weeks' gestation after an earlier negative HIV test during the same pregnancy. The primary outcome was the proportion of people who received repeat testing prior to delivery. Bivariable analyses were performed to identify patient characteristics associated with documentation of repeat HIV testing. RESULTS: Of 12,053 people eligible for inclusion, 3.4% (n = 414) presented without a documented third trimester repeat HIV test. The proportion of people with repeat testing improved from 80 to >99% in the first year. Patient factors were largely not associated with testing performance although multiparous people were more likely to have documented repeat testing. CONCLUSION: Rapid implementation of third trimester repeat HIV testing was achieved without disparity. Patient factors were largely not associated with testing performance which reinforces the goal of a universal screen to test all people equitably and effectively without bias. KEY POINTS: · Little is known about adherence to repeat third trimester HIV testing in pregnancy.. · Universal third trimester HIV screening was implemented with high uptake and without disparity.. · Protocolization of repeat HIV testing in pregnancy may reduce bias compared to risk based-screening..

Third-trimester repeat HIV testing: it is time we make it universal.

Since the 1990s, perinatal transmission of HIV has decreased substantially, largely as a result of improved detection secondary to routine HIV screening in pregnancy and the use of antiretroviral therapy. However, despite reductions in HIV transmission, elimination of perinatal transmission, defined as an incidence of perinatal HIV infection of <1 per 100,000 live births and a transmission rate of <1%, remains elusive. An estimated 80% of perinatal transmissions occur after 36 weeks' gestation, which highlights the importance of diagnosis and treatment of maternal HIV infection before the highest-risk period for perinatal transmission. With timely identification of seroconversion, intrapartum and neonatal interventions can lower the risk of perinatal transmission from 25% to 10%, substantially reducing perinatal transmission events. The American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention recommend that routine HIV testing be performed in all pregnancies, as early in the prenatal course as possible. Third-trimester repeat testing is only recommended for individuals known to be at high risk of acquiring HIV (ie, those who are incarcerated; who reside in jurisdictions with elevated HIV incidence; who are receiving care in facilities that have an HIV incidence in pregnant women > 1 per 1000 per year; or have signs or symptoms of acute HIV). However, among reproductive-age women, heterosexual intercourse is the most common mode of HIV transmission, and the risk of HIV seroconversion is greater during pregnancy than outside of pregnancy. Furthermore, state statutes for HIV testing in pregnancy are largely lacking. In this clinical opinion, we reviewed the evidence in support of universal third-trimester repeat HIV testing in pregnancy using a successful state-mandated testing program in Illinois. In addition, we provided clinical recommendations to further reduce missed perinatal transmission cases by implementing universal third-trimester repeat testing, obtaining hospital buy-in, monitoring testing adherence, bridging communications across multidisciplinary teams, and engaging clinicians in advocacy work.

Home Birth in the Era of COVID-19: Counseling and Preparation for Pregnant Persons Living with HIV.

With the coronavirus disease 2019 (COVID-19) pandemic in the United States, a majority of states have instituted "shelter-in-place" policies effectively quarantining individuals-including pregnant persons-in their homes. Given the concern for COVID-19 acquisition in health care settings, pregnant persons with high-risk pregnancies-such as persons living with HIV (PLHIV)-are increasingly investigating the option of a home birth. Although we strongly recommend hospital birth for PLHIV, we discuss our experience and recommendations for counseling and preparation of pregnant PLHIV who may be considering home birth or at risk for unintentional home birth due to the pandemic. We also discuss issues associated with implementing a risk mitigation strategy involving high-risk births occurring at home during a pandemic. KEY POINTS: · Coronavirus disease 2019 pandemic has increased interest in home birth.. · Women living with HIV are pursuing home birth.. · Safe planning is paramount for women living with HIV desiring home birth, despite recommending against the practice..

Sustainability of Statewide Rapid HIV Testing in Labor and Delivery.

The objective was to assess sustainability of a statewide program of HIV rapid testing (RT) for pregnant women presenting for delivery with unknown HIV status. This is a population-based retrospective cohort study of women delivered in Illinois hospitals (2012-15). Deidentified data on RT metrics from state-mandated surveillance reports were compared using descriptive statistics and non-parametric tests of trend. Over 95% of the 608,408 women delivered had documented HIV status at presentation. The rate of undocumented HIV status rose from 4.19 to 4.75% (p < 0.001). However, overall 99.60% of women with undocumented status appropriately received RT and the proportion who did not receive RT declined (p = 0.003). The number of neonates discharged with unknown HIV status declined (p = 0.011). RT identified 23 new HIV diagnoses, representing 4.62% of maternal HIV diagnoses. In conclusion, statewide perinatal HIV RT resulted in nearly 100% of Illinois mother-infant dyads with known HIV status. Sustained RT completion represents an important prevention safety net.

Is maternal disclosure of HIV serostatus associated with a reduced risk of postpartum depression?

BACKGROUND: Patients with chronic diseases that include HIV infection are at increased risk of experiencing postpartum depression. In addition, social isolation has been associated with depression among women with HIV. Yet, it is unclear whether disclosure of HIV serostatus before the birth is associated with the risk of postpartum depression. OBJECTIVE: The purpose of this study was to determine whether maternal disclosure of her positive HIV serostatus before the delivery is associated with the risk of early postpartum depression. STUDY DESIGN: In this retrospective cohort study, women who received obstetric care in a specialty perinatal HIV clinic (2007-2014) were stratified by whether, before the delivery, they had disclosed their HIV serostatus to (1) their sexual partner(s) or (2) at least 1 family member aside from sexual partner(s). Postpartum depression was identified initially by a positive result on a validated depression screening tool (Patient Health Questionnaire-9 or Edinburgh Postnatal Depression Scale) at the 6-week postpartum visit and then confirmed by evaluation with a mental health professional. Postpartum depression rates were compared by disclosure status. Multivariable logistic regression was performed to identify whether disclosure to either sexual partner(s) or family members remained associated independently with postpartum depression after we controlled for potential confounders that included antenatal mental health disorders. RESULTS: Of the 215 women who received perinatal HIV care in this center and who had a documented disclosure status, 149 women (71.3%) had disclosed to their sexual partner(s), and 78 women (42.9%) had disclosed to at least 1 family member who was not a sexual partner. Although disclosure to sexual partner(s) was associated with a reduction in the proportion of women with postpartum depression (15.6% vs 25.5%), this difference did not reach statistical significance (P = .126) and remained statistically insignificant after we controlled for potential confounders (adjusted odds ratio, 0.47; 95% confidence interval, 0.15-1.41). In contrast, disclosure to family member(s) was associated with a decreased prevalence of postpartum depression (11.4% vs 24.7%; P = .03), and this difference persisted in multivariable regression (adjusted odds ratio, 0.35; 95% confidence interval, 0.13-0.95). CONCLUSION: In this cohort, maternal disclosure of HIV serostatus to family members (other than sexual partner[s]) was associated independently with a reduction in postpartum depression by more than one-half. Disclosure of HIV serostatus to a family member may be a marker for psychosocial well-being and enhanced support that affords protection against postpartum depression.

RETINAL VASCULAR PERFUSION DENSITY MAPPING USING OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN NORMALS AND DIABETIC RETINOPATHY PATIENTS.

PURPOSE: To describe a new method of retinal vascular perfusion density mapping using optical coherence tomography angiography and to compare current staging of diabetic retinopathy based on clinical features with a new grading scale based on perifoveal perfusion densities. METHODS: A retrospective review was performed on subjects with diabetic retinopathy and age-matched controls imaged with a spectral domain optical coherence tomography system (Optovue XR Avanti, Fremont, CA). Split-spectrum amplitude-decorrelation angiography (SSADA) generated optical coherence tomography angiograms of the superficial retinal capillaries, deep retinal capillaries, and choriocapillaris. Skeletonized optical coherence tomography angiograms were used to create color-coded perfusion maps and capillary perfusion density values for each image. Capillary perfusion density values were compared with clinical staging, and groups were compared using analysis of variance and Kruskal-Wallis analyses. RESULTS: Twenty-one control and 56 diabetic retinopathy eyes were imaged. Diabetic eyes were grouped according to clinical stage. Capillary perfusion density values from each microvascular layer were compared across all groups. Capillary perfusion density values were significantly lower in nearly all layers of all study groups compared with controls. Trend analysis showed a significant decrease in capillary perfusion density values as retinopathy progresses for most layers. CONCLUSION: Quantitative retinal vascular perfusion density mapping agreed closely with grading based on clinical features and may offer an objective method for monitoring disease progression in diabetic retinopathy.

Abnormal fixation in individuals with age-related macular degeneration when viewing an image of a face.

PURPOSE: It has been reported that patients with macular disease have difficulties with face perception. Some of this difficulty may be caused by the sensory and perceptual consequences of using peripheral retina. However, strong correlations have not always been found between performance on face tasks and clinical measure of function. Based on the evidence of abnormal eye movements by patients with age-related macular degeneration (AMD), we explored whether abnormal fixation patterns occur when these patients view an image of a face. METHODS: An OPKO OCT/SLO was used to collect structural and functional data. For each subject, the structural location of disease was determined, and the locus and stability of fixation were quantified. A SLO movie of fundus movements was recorded while the subject viewed an image of a face. RESULTS: The number of fixations on internal (eyes, nose, and mouth) and external features were measured. A two-way repeated-measures analysis of variance found significant differences between the control and patient groups and among locations. A significant interaction between group and location was also found. Post hoc comparisons found a significantly greater proportion of fixations on external features for the AMD group than that in the control group. CONCLUSIONS: The observed patterns of fixations of our subjects with AMD were similar to those observed in other groups of patients who have difficulties with face perception. For example, individuals with social phobias, Williams syndrome, autism, schizophrenia, or prosopagnosia have altered face perceptions and also have a significantly greater proportion of fixations on external features of faces. Abnormal eye movement patterns and fixations may contribute to deficits in face perception in AMD patients.

Quantitative and qualitative spectral domain optical coherence tomography analysis of subretinal deposits in patients with acute central serous retinopathy.

PURPOSE: To perform qualitative and quantitative analyses of subretinal protein deposits (PDs), seen in acute central serous retinopathy (CSR) patients, using high-resolution spectral domain optical coherence tomography (SD-OCT), in order to investigate whether the present PDs have any significant impact on best corrected visual acuity (BCVA). METHODS: Patients diagnosed with acute CSR were included. Using SD-OCT, the following distances/heights were measured: central total retinal thickness, central neurosensory retinal thickness, the vertical and horizontal length of subfoveal subretinal fluid and subfoveal thickness of the PD layer, if present and could be measured. RESULTS: Thirty-eight patients with acute CSR were included. A significant correlation was found between the subfoveal thickness of the PD layer and baseline/final visual acuities in the eyes (r = 0.60, p ≤ 0.001 and r = 0.45, p = 0.008, respectively). CONCLUSIONS: The thickness of subfoveal PDs at baseline appears to be an important parameter related to the BCVA and time of CSR resolution.

Utilizing Natural Language Processing of Narrative Feedback to Develop a Predictive Model of Pre-Clerkship Performance: Lessons Learned.

Background: Natural language processing is a promising technique that can be used to create efficiencies in the review of narrative feedback to learners. The Feinberg School of Medicine has implemented formal review of pre-clerkship narrative feedback since 2014 through its portfolio assessment system but this process requires considerable time and effort. This article describes how natural language processing was used to build a predictive model of pre-clerkship student performance that can be utilized to assist competency committee reviews. Approach: The authors took an iterative and inductive approach to the analysis, which allowed them to identify characteristics of narrative feedback that are both predictive of performance and useful to faculty reviewers. Words and phrases were manually grouped into topics that represented concepts illustrating student performance. Topics were reviewed by experienced reviewers, tested for consistency across time, and checked to ensure they did not demonstrate bias. Outcomes: Sixteen topic groups of words and phrases were found to be predictive of performance. The best-fitting model used a combination of topic groups, word counts, and categorical ratings. The model had an AUC value of 0.92 on the training data and 0.88 on the test data. Reflection: A thoughtful, careful approach to using natural language processing was essential. Given the idiosyncrasies of narrative feedback in medical education, standard natural language processing packages were not adequate for predicting student outcomes. Rather, employing qualitative techniques including repeated member checking and iterative revision resulted in a useful and salient predictive model.

Telephone triage of influenza-like illness during pandemic 2009 H1N1 in an obstetric population.

We sought to determine the safety and efficiency of a telephone-based triage system for influenza-like illness, during the 2009 pandemic, at our institution. A triage system was implemented that involved initial telephone screening by a provider who determined whether outpatient telephone-based care or assessment in a centralized evaluation unit was needed. Those who received outpatient care were empirically treated. Those seen in the evaluation unit were assessed for inpatient admission. Of the 230 women who were evaluated, 41% were treated as outpatients and 59% were seen in the evaluation unit. Of those treated as outpatients, 9% were eventually seen in the evaluation unit and only 4% were ultimately admitted, with a maximum hospitalization of 4 days. Of the 135 patients initially seen in the evaluation unit, 32% were admitted and 44% had a positive polymerase chain reaction for respiratory pathogens. This triage system improved efficiency of resource utilization without incurring apparent influenza-like illness morbidity.

Perinatal HIV testing and diagnosis in Illinois after implementation of the Perinatal Rapid Testing Initiative.

OBJECTIVE: The objective of the study was to assess whether implementation of a statewide initiative was associated with changes in perinatal human immunodeficiency virus (HIV) testing practices. STUDY DESIGN: This was an observational cohort study of all 1,141,799 women who delivered in Illinois birthing hospitals over a 7 year period after the introduction of the Perinatal Rapid Testing Implementation in Illinois (PRTII) initiative. Changes in the frequencies of HIV status documentation, rapid test utilization, and newborns discharged with unknown HIV status were assessed. RESULTS: The comparison of annual data from 2005 to 2011 demonstrated a 63% decrease in women with undocumented HIV status (11.7% vs 4.3%, P < .001), a 98% decrease in women with unknown status who did not receive rapid testing (29.6% vs 0.5%, P < .001), and a greater than 99% decrease in newborns with undocumented status at discharge (2.74% vs 0.01%, P < .001). CONCLUSION: This statewide initiative resulted in a significant and sustained increase in the frequency of maternal-baby pairs who were discharged from the hospital with documented HIV status.

The physics and psychophysics of microperimetry.

PURPOSE: To assess the influences of stimulus parameters (physics) on measures of visual field sensitivity (psychophysics). METHODS: Subjects' thresholds were measured on three different clinically available perimeters: the Humphrey Field Analyzer (HFA), the Nidek MP1 (MP1), and the Opko OCT/SLO (OSLO). On all machines, visual field testing was done with a 10-2 spatial distribution of test points, using Goldmann Size III and Size I stimuli, with a presentation time of 200 ms, and using a 4-2 threshold algorithm. RESULTS: All the MP1 and OSLO data fell below the values for the corresponding points on the HFA. For the Goldmann Size III target, the HFA median threshold was 33 dB, whereas the MP1 median threshold was 19 dB and the OLSO, 18 dB. Using the increment intensity values at each dB level for each microperimeter, the data were converted to equivalent HFA dB. Using this conversion, the smallest increment displayed in the MP1 (1.27 cd/m) was equivalent to 34 HFA dB, and the brightest increment displayed by the MP1 was 14 HFA dB (127 cd/m). The smallest increment displayed in the OSLO (1.56 cd/m) was equivalent to 33.1 HFA dB, and the brightest increment displayed by the OSLO was 13.6 HFA dB (137 cd/m). There was good correspondence among these results when compared using equivalent increment threshold units. However, discrepancies in our findings made us acutely aware of the importance of evaluating the consequences of design choices made by the manufacturers. CONCLUSIONS: The findings underscore the need for users to check their assumptions about what the equipment is doing and to always evaluate the psychophysical consequences of the stimuli that are used by a particular instrument.

Drusen characteristics revealed by spectral-domain optical coherence tomography and their corresponding fundus autofluorescence appearance in dry age-related macular degeneration.

PURPOSE: To analyze the relationship between drusen morphology revealed by spectral-domain optical coherence tomography (SD-OCT) and corresponding fundus autofluorescence (FAF) features of the same drusen using the Heidelberg Retina Angiograph 2 (HRA2), in patients with dry age-related macular degeneration (AMD). METHODS: Dry AMD patients were imaged with SD-OCT and HRA2 on the same day. SD-OCT B scans were then precisely overlaid onto the HRA2 images, and the SD-OCT morphological characteristics of the drusen were correlated with the corresponding FAF appearance. The analyzed morphological features of the drusen included: size, status of the inner segment/outer segment (IS-OS) junctional layer above the drusen, shape of the drusen, internal reflectivity, homogeneity and presence of overlaying hyperreflective foci. The FAF characteristics of each druse were rated as hyperautofluorescent, hypoautofluorescent or normally autofluorescent. Spearman's correlation coefficient was used to analyze the correlation between the 2 primary outcomes: SD-OCT morphology of the drusen and their autofluorescent appearance. RESULTS: 431 drusen in 32 eyes of 16 dry AMD patients were evaluated. Of the 7 morphological characteristics assessed by SD-OCT, only drusen size and the status of the IS-OS layer above the drusen were strongly correlated with the autofluorescent appearance (r = 0.78, p < 0.001, and r = 0.58, p < 0.001, respectively). The strength of correlation with other features appeared less robust: homogeneity (r = 0.38; p = 0.001), shape (r = 0.29; p = 0.004), reflectivity (r = 0.28; p = 0.004) and presence of overlaying foci (r = 0.25; p = 0.12). CONCLUSIONS: Autofluorescent changes most strongly correlate with drusen size and disruption of the IS-OS layer and may be useful as an additional functional-morphological feature by which drusen and their impact upon overlying photoreceptors may be judged.

Initial report of quantification of retinal blood flow velocity in normal human subjects using the Retinal Functional Imager (RFI).

The Retinal Functional Imager (RFI) is a novel method for assessing retinal blood flow (RBF) velocity. The purpose of this study was to evaluate RBF velocities in normal human retinas using the RFI. RBF velocity measurements were performed in normal subjects using the RFI (Optical Imaging Ltd., Rehovot, Israel) at the Retina Center of The New York Eye and Ear Infirmary, New York, USA. Using proprietary software processing, the characteristics of the RBF were visualized and measured. The study population comprised fifty-four eyes of 27 normal subjects (20 male and 34 female). The average arterial blood flow velocity was 4.6 ± 0.6 mm/s in males and 4.8 ± 0.7 mm/s in females (the difference was not statistically significant, p value = 0.27). The average venous blood flow velocity was 3.8 ± 0.5 mm/s in males and 3.6 ± 0.4 mm/s in females (the difference again was not statistically significant, p value = 0.11). The average arterial blood flow velocity was 4.8 ± 0.5 mm/s in the right eye and 4.6 ± 0.7 mm/s in the left eye. The average venous blood flow velocity was 3.7 ± 0.4 mm/s in the right eye and 3.6 ± 0.3 mm/s in the left eye. Venous and arterial blood flow velocities were found to be faster in the right eye than in the left eye in our sample, but the differences were not statistically significant (p value = 0.53 and 0.33, respectively). This is the first report of quantification of the RBF using the RFI. The RFI appears to be an effective tool in quantitative evaluations of RBF velocities. The values from the study constitute a normative database which can be used to evaluate and compare eyes with known or suspected pathology.

Getting to Zero: A Demonstration Project of Partner HIV Testing in the Prenatal Setting in Chicago, Illinois.

Women who experience HIV seroconversion during pregnancy are missed during early routine pregnancy HIV screening and are at high risk of perinatal HIV transmission. Male partner HIV testing during routine prenatal care may be an effective primary prevention strategy by identifying women at risk of seroconversion and mitigating their risk. Our objective was to assess interest in and uptake of male partner HIV testing services offered during prenatal care. This demonstration project included all pregnant, English-speaking, HIV-negative women receiving publicly funded prenatal care in an urban hospital-based practice located in a high HIV prevalence area. Women were offered free HIV screening for their male sexual partners. From April 2017 to June 2018, enrolled women completed surveys on social demographics, medical access characteristics, and HIV testing history. Women were invited to bring their partners to a prenatal visit where HIV testing was offered to their male partners. Factors associated with women's interest in testing and completion of partner testing were assessed using bivariable and multivariable analyses. Of 392 women approached, 70% (N = 274) completed study surveys. Although the majority (76%, N = 200 of 264 respondents) of women desired their partner undergo HIV testing, testing was underutilized as only 18 (7%) male partners completed testing. While neither maternal characteristics nor male social or attitudinal factors were associated with interest in or completion of partner HIV testing, sensitivity analyses, performed with multiple imputation, demonstrated some association between interest and completion of partner testing and partner medical care access and utilization. In conclusion, although the majority of low-income women in an urban prenatal clinic expressed interest in having their partners undergo HIV testing, uptake of free partner HIV testing services was uncommon. A focused assessment of implementation and uptake barriers is needed to optimize partner testing and eliminate HIV transmission to mothers and their babies.

Inner segment-outer segment junctional layer integrity and corresponding retinal sensitivity in dry and wet forms of age-related macular degeneration.

PURPOSE: To investigate a relationship between the inner segment-outer segment (IS-OS) junctional layer integrity and the overlying retinal sensitivity assessed by Spectral OCT/SLO (spectral-domain optical coherence tomography) and microperimetry testing in patients with dry and wet forms of age-related macular degeneration (AMD). METHODS: Spectral-domain optical coherence tomography examination and microperimetry testing were performed in 55 eyes of 43 consecutive patients with AMD. Microperimetry maps were registered onto three-dimensional retinal topography maps, and point-to-point analysis of correlation between microperimetric retinal sensitivities and corresponding status of the underlying IS-OS junctional layer was performed. In addition, the analysis of correlation between the best-corrected visual acuity and the integrity of IS-OS layer in the center of the fovea also was performed. RESULTS: Retinal sensitivity was inversely and strongly correlated with the integrity of IS-OS layer in both dry and wet forms of AMD (correlation coefficient [r] = -0.75 [95% confidence interval, 0.49-0.88], P < 0.001, and -0.79 [95% confidence interval, 0.61-0.89], P < 0.001, respectively). The correlation between the best-corrected visual acuity and the integrity of IS-OS layer in the center of fovea was less significant (r = -0.58 [95% confidence interval, 0.19-0.79], P = 0.02, for dry AMD, and r = -0.6 [95% confidence interval, 0.32-0.78], P = 0.015, for wet AMD). CONCLUSION: Retinal sensitivity consistently correlated with the status of underlying IS-OS junctional layer in both dry and wet forms of AMD. Loss of IS-OS layer is significantly associated with poor retinal sensitivity, assessed by microperimetry. Compared with visual acuity, functional testing with microperimetry appears to more consistently correlate with changes in the outer retina, such as IS-OS junctional integrity, especially, in patients with wet AMD.

Unintended pregnancy and viral suppression in pregnant women living with HIV.

BACKGROUND: Approximately half of pregnancies in the United States are unintended; the likelihood of unintended pregnancy may be even higher for women living with HIV. Women with unintended pregnancies often have worse obstetrical outcomes than women who planned their pregnancies, although the relationship of unintended pregnancy to outcomes among women living with HIV in the United States is unknown. OBJECTIVE: This study aimed to determine whether pregnancy intendedness among women living with HIV attending a specialty obstetrical clinic was associated with achievement of maternal viral suppression by delivery, a key component of preventing perinatal transmission of HIV. STUDY DESIGN: This is a retrospective cohort study of pregnant women living with HIV who received prenatal care and had a live-born infant at a single tertiary center (2007-2014). Women were asked as part of routine clinical care whether they intended their current pregnancy. Women who expressed at their initial obstetrician visit that their pregnancy was mistimed or undesired were determined to have an unintended pregnancy. Women were considered virally suppressed when the HIV RNA viral load was <20 copies/mL. We examined whether pregnancy intendedness was associated with whether the viral load was undetectable at the time of delivery. We also determined whether women with unintended pregnancies were less likely to be on antiretroviral therapy at the time of entry to prenatal care. Wilcoxon rank-sum tests and chi-square tests were used for bivariable analyses, and logistic and linear regression were used for multivariable analyses. RESULTS: Of the 215 women who met inclusion criteria, 201 (93.5%) had complete data on pregnancy intendedness. Of these 201 women, 137 (68.2%) had an unintended pregnancy. Unintended pregnancy was associated with lower odds of viral suppression at delivery (95.3% of women with planned pregnancies were virally suppressed at delivery compared with 76.6% of women with unplanned pregnancies; adjusted odds ratio, 0.22; 95% CI, 0.05-0.89, after adjusting for potential confounders). In this study, 48.9% of women with unintended pregnancies presented later in pregnancy for prenatal care (after the first trimester) compared with 21.9% of women with intended pregnancies (P<.001). Women with unintended pregnancies were also less likely to be on antiretroviral therapy before entry to prenatal care (20.4% of women with unintended pregnancies vs 50.0% of women with intended pregnancies; adjusted odds ratio, 0.35; 95% CI, 0.15-0.81; P<.001). CONCLUSION: Among pregnant women living with HIV, women with an unintended pregnancy were less likely to be on antiretroviral therapy before initiating prenatal care and were less likely to be virally suppressed at the time of delivery.

Combined three-dimensional spectral OCT/SLO topography and Microperimetry: steps toward achieving functional spectral OCT/SLO.

AIMS: To investigate the combination of 3D optical coherence tomography (OCT) retinal thickness measurements and superimposed scanning laser ophthalmoscopy (SLO) microperimetry obtained using a Spectral OCT/SLO and to test the correlation between retinal thickness and retinal sensitivity in retinal diseases grouped according to anatomic locations. METHODS: Patients with various retinal diseases and subjects with normal fundi underwent microperimetry testing and imaging with the Spectral OCT/SLO. Based on the Spectral OCT/SLO findings, the participants were divided into 4 groups: patients with retinal thickening due to the outer retina pathology (group I); patients with retinal thickening due to the cystic changes observed in the inner retina (group II); patients with macular neurosensory retina thinning associated with geographic atrophy or underlying subretinal cicatricial changes (group III), and subjects with unremarkable fundus appearance and normal appearing retina on Spectral OCT/SLO (group IV). The primary outcome was the correlation coefficient (r) between Spectral OCT/SLO-measured macular thickness and microperimetry values. RESULTS: Correlations between retinal thickness and psychophysical thresholds were calculated for each patient, and these values were averaged within groups. The mean correlation values (Pearson product movement) were as follows: for group I (n = 21 eyes) r = 0.04; for group II (n = 24 eyes) r = -0.53; for group III (n = 16 eyes) r = 0.41, and for group IV (n = 15 eyes) r = 0.04. CONCLUSIONS: The combination of 3D OCT images and superimposed SLO microperimetry obtained by Spectral OCT/SLO demonstrated that thickening due to cystic changes of the inner retinal layers or thinning of the neurosensory retina on OCT correlated most significantly with decreases in psychophysical threshold sensitivities.