Stability in care and risk of loss to follow-up among clients receiving community health worker-led differentiated HIV care: Results from a prospective cohort study in northern Tanzania.

BACKGROUND: HIV services in Tanzania are facility-based but facilities are often overcrowded. Differentiated care models (DCM) have been introduced into the National Guidelines. We piloted a Community Health Worker (CHW)-led HIV treatment club model (CHW-DCM) in an urban region, and assessed its effectiveness in comparison to the standard of care (SoC, facility-based model), in terms of stability in care, loss to follow-up (LTFU) and treatment adherence. METHODS: In two clinics in the Shinyanga region, clients established on ART (defined as stable clients by national guidelines as on first-line ART >6 months, undetectable viral load, no opportunistic infections or pregnancy, and good adherence) were offered CHW-DCM. This prospective cohort study included all stable clients who enrolled in CHW-DCM between July 2018 and March 2020 (CHW-DCM) and compared them to stable clients who remained in SoC during that period. Multivariable Cox regression models were used to analyse factors associated with continued stability in care and the risk of LTFU during 18 months of follow-up; treatment adherence was assessed by pill count and compared using Chi-square tests. RESULTS: Of 2472 stable clients, 24.5% received CHW-DCM and 75.5% SoC. CHW-DCM clients were slightly older (mean 42.8 vs. 37.9 years) and more likely to be female (36.2% vs. 32.2%). Treatment adherence was better among CHW-DCM than SoC: 96.6% versus 91.9% and 98.5% versus 92.2%, respectively (both p = 0.001). SoC clients were more likely to not remain stable over time than CHW-DCM (adjusted Hazard ratio [AHR] = 2.68; 95% CI: 1.86-3.90). There was no difference in LTFU (adjusted hazard ratio [AHR] = 1.54; 95%CI: 0.82-2.93). CONCLUSION: Clients attending CHW-DCM demonstrated better stability in care and treatment adherence than SoC, and the risk of LTFU was not increased. These findings demonstrate the potential of CHW in delivering community-based HIV services in the local Tanzanian context. These results could be used to extend this CHW-DCM model to similar settings.

Effectiveness of provider-initiated versus client-initiated HIV testing by different health facility departments in Northern Tanzania.

BACKGROUND: HIV prevalence in Tanzania is still high at 4.7% among adults. Regular HIV testing is consistently advocated in the country to increase the level of awareness of HIV status, thus contributing to national HIV prevention. We report findings from three years of implementation of an HIV Test and Treat project utilizing provider-initiated and client-initiated testing and counselling (PITC and CITC). This study compared the effectiveness of PITC versus CITC in HIV case detection by the different departments of health facilities. METHOD: This retrospective cross-sectional study used health facility-based HIV testing data collected from adults aged 18 years and above between June 2017 - July 2019 in the Shinyanga region, Tanzania. Chi-square and logistic regression analysis were used to assess determinants of yield (HIV positivity). RESULTS: A total of 24,802 HIV tests were performed of which 15,814 (63.8%) were by PITC and 8,987 (36.2%) by CITC. Overall HIV positivity was 5.7%, higher among CITC at 6.6% than PITC at 5.2%. TB and IPD departments had the highest HIV positivity 11.8% and 7.8% respectively. Factors associated with a positive test were testing at a department in the facility compared to CITC, first-time test, and being or having been married compared to being single. CONCLUSION: Success in identifying HIV + patients was highest among people visiting the clinic for HIV testing (CITC) and first-time testers. With PITC, HIV + patient detection differed between departments, suggesting divergent risk profiles of respective clients and/or divergent HIV alertness of staff. This underscores the importance of increased targeting for PITC to identify HIV + patients.

Beyond viral suppression: Quality of life among stable ART clients in a differentiated service delivery intervention in Tanzania.

BACKGROUND: With antiretroviral therapy, more people living with HIV (PLHIV) in resource-limited settings are virally suppressed and living longer. WHO recommends differentiated service delivery (DSD) as an alternative, less resource-demanding way of expanding HIV services access. Monitoring client's health-related quality of life (HRQoL) is necessary to understand patients' perceptions of treatment and services but is understudied in sub-Saharan Africa. We assessed HRQoL among ART clients in Tanzania accessing two service models. METHODS: Cross-sectional survey from May-August 2019 among stable ART clients randomly sampled from clinics and clubs in the Shinyanga region providing DSD and clinic-based care. HRQoL data were collected using a validated HIV-specific instrument-Functional Assessment of HIV infection (FAHI), in addition to socio-demographic, HIV care, and service accessibility data. Descriptive analysis of HRQoL, logistic regression and a stepwise multiple linear regression were performed to examine HRQoL determinants. RESULTS: 629 participants were enrolled, of which 40% accessed DSD. Similar HRQoL scores [mean (SD), p-value]; FAHI total [152.2 (22.2) vs 153.8 (20.6), p 0.687] were observed among DSD and clinic-based care participants. Accessibility factors contributed more to emotional wellbeing among DSD participants compared to the clinic-based care participants (53.4% vs 18.5%, p = < 0.001). Satisfactory (> 80% of maximum score) HRQoL scoring was associated with (OR [95% CI], p-value) being male (2.59 [1.36-4.92], p 0.004) among clinic participants and with urban residence (4.72 [1.70-13.1], p 0.001) among DSD participants. CONCLUSIONS: Similar HRQoL was observed in DSD and clinic-based care. Our research highlights focus areas to identify supporting interventions, ultimately optimizing HRQoL among PLHIV.

It Takes Two: An antenatal to postnatal RDoC framework for investigating the origins of maternal attachment and mother-infant social communication.

Transformation of the maternal-fetal relationship into the mother-infant relationship remains an enigmatic process. This progression is considered using an RDoC-informed approach centered on domains of Arousal/Regulation, Positive/Negative Valence, and Social Processes. 158 maternal-fetal dyads began participation during pregnancy, maternal-infant dyads were followed at 6-months postpartum. Women exhibited stability in feelings of attachment to the fetus and infant, and in positive/negative appraisal of pregnancy and motherhood. Elicited maternal physiological arousal to emotionally evocative videos generated fetal heart rate variability and motor activity responses. Parasympathetic (i.e., heart rate variability) suppression in the fetus was associated with more positive and regulated infant social communication in the Face-to-face Still Face protocol; suppression of maternal respiratory sinus arrhythmia was related to infant affect but in the opposite direction. Maternal ratings of infant temperament aligned with maternal antenatal affective valence. Attachment trajectories characterized by stability from antenatal to postnatal periods were most associated with maternal affective appraisal of pregnancy; shifts were influenced by infant characteristics and maternal sympathetic responsivity. Results illustrate how variation in arousal and regulatory systems of the pregnant woman and fetus operate within the context of maternal positive and negative valence systems to separately and jointly shape affiliation and temperament in early infancy.

Predicting child temperament and behavior from the fetus.

There remains little debate that the period before birth sets the stage for subsequent development, yet scant evidence exists showing continuity from characteristics of the individual fetus to characteristics of the child. This report examines, in two studies, whether baseline and evoked fetal neurobehavioral functioning are predictive of features of child temperament and behavior as reported by mothers when offspring were between 7 and 14 years old (M = 10.1 years). Study 1 utilizes data generated from 333 maternal-fetal pairs collected during an undisturbed condition during the second half of gestation in relation to the child temperament dimensions of behavioral inhibition and exuberance. Associations at 32 weeks gestation were detected between all features of fetal neurobehavior and behavioral inhibition. In adjusted models, slower fetal heart rate and less fetal movement were associated with significant unique variance in predicting higher levels of childhood behavioral inhibition. No associations were detected for exuberance. Study 2 focuses on the association of evoked fetal reactivity and recovery to induced maternal arousal with subsequent child behavioral difficulties in a subset of the full sample (n = 130). Greater recovery in fetal heart rate following maternal stimulation was predictive of fewer behavioral difficulties and more prosocial behavior in childhood. Results from both studies provide support for gestational origins of core individual differences that portend childhood outcomes with foundational reactivity and regulatory components.

Maternal salivary testosterone in pregnancy and fetal neuromaturation.

Testosterone exposure during pregnancy has been hypothesized as a mechanism for sex differences in brain and behavioral development observed in the postnatal period. The current study documents the natural history of maternal salivary testosterone from 18 weeks gestation of pregnancy to 6 months postpartum, and investigates associations with fetal heart rate, motor activity, and their integration. Findings indicate maternal salivary testosterone increases with advancing gestation though no differences by fetal sex were detected. High intra-individual stability in prenatal testosterone levels extend into the postnatal period, particularly for pregnancies with male fetuses. With respect to fetal development, by 36 weeks gestation higher maternal prenatal salivary testosterone was significantly associated with faster fetal heart rate and less optimal somatic-cardiac integration. Measurement of testosterone in saliva is a useful tool for repeated-measures studies of hormonal concomitants of pregnancy. Moreover, higher maternal testosterone levels are associated with modest interference to fetal neurobehavioral development.

STUDIES IN FETAL BEHAVIOR: REVISITED, RENEWED, AND REIMAGINED.

Among the earliest volumes of this monograph series was a report by Lester Sontag and colleagues, of the esteemed Fels Institute, on the heart rate of the human fetus as an expression of the developing nervous system. Here, some 75 years later, we commemorate this work and provide historical and contemporary context on knowledge regarding fetal development, as well as results from our own research. These are based on synchronized monitoring of maternal and fetal parameters assessed between 24 and 36 weeks gestation on 740 maternal-fetal pairs compiled from eight separate longitudinal studies, which commenced in the early 1990s. Data include maternal heart rate, respiratory sinus arrhythmia, and electrodrmal activity and fetal heartrate, motor activity, and their integration. Hierarchical linear modeling of developmental trajectories reveals that the fetus develops in predictable ways consistent with advancing parasympathetic regulation. Findings also include:within-fetus stability (i.e., preservation of rank ordering over time) for heart rate, motor, and coupling measures; a transitional period of decelerating development near 30 weeks gestation; sex differences in fetal heart rate measures but not in most fetal motor activity measures; modest correspondence in fetal neurodevelopment among siblings as compared to unrelated fetuses; and deviations from normative fetal development in fetuses affected by intrauterine growth restriction and other conditions. Maternal parameters also change during this period of gestation and there is evidence that fetal sex and individual variation in fetal neurobehavior influence maternal physio-logical processes and the local intrauterine context. Results are discussed within the framework of neuromaturation, the emergence of individual differences, and the bidirectional nature of the maternal-fetal relationship.We pose a number of open questions for future research. Although the human fetus remains just out of reach, new technologies portend an era of accelerated discovery of the earliest period of development

Information and Communication Technology Use Among Low-Income Pregnant and Postpartum Women by Race and Ethnicity: A Cross-Sectional Study.

BACKGROUND: Pregnancy and the postpartum period provide windows of opportunity to impact perinatal and lifelong preventive health behavior for women and their families, but these opportunities are often missed. Understanding racial/ethnic differences in information and communication technology (ICT) use could inform technology-based interventions in diverse populations. OBJECTIVE: The objective of the study was to evaluate differences in the use of ICT between racial and ethnic groups as well as by English language proficiency. METHODS: We conducted a cross-sectional study of 246 women who were aged 18 years or older and pregnant or within 1 year of delivery. They were recruited from 4 hospital-based outpatient clinics and completed a self-administered survey. We used multivariate regression analysis to evaluate the association between race/ethnicity and ICT (mobile phone/short message service [SMS] text message, Internet, and social network) usage by race/ethnicity and perceived English language proficiency after adjusting for age, income, marital status, and insurance status. RESULTS: In all, 28% (69/246) of participants were Latina, 40% (98/246) were African American, 23% (56/246) were white, and 9% (23/246) from other racial/ethnic groups. Of the Latinas, 84% (58/69) reported limited English language proficiency and 59% (41/69) were uninsured. More than 90% of all participants reported mobile phone use, but more than 25% (65/246) had changed phone numbers 2 or more times in the past year. Compared to white women, African American women were less likely to SMS text message (OR 0.07, 95% CI 0.01-0.63) and Latinas were less likely to use the Internet to find others with similar concerns (OR 0.23, 95% CI 0.08-0.73). Women with limited English language proficiency were less likely to use the Internet overall (OR 0.30, 95% CI 0.09-0.99) or use email (OR 0.22, 95% CI 0.08-0.63) compared to women with adequate English language proficiency. CONCLUSIONS: Mobile phones are widely available for the delivery of health interventions to low-income, racially diverse pregnant and postpartum women, but disparities in Internet use and SMS text messaging exist. Interventions or programs requiring Web-based apps may have lower uptake unless alternatives are available, such as those adapted for limited English proficiency populations.

Concurrent levels of maternal salivary cortisol are unrelated to self-reported psychological measures in low-risk pregnant women.

Associations between salivary cortisol and maternal psychological distress and well-being were examined prospectively on 112 women with normally progressing, singleton pregnancies between 24 and 38 weeks gestation. At each of 5 visits, conducted in 3-week intervals, women provided a saliva sample and completed questionnaires measuring trait anxiety, depressive symptoms, pregnancy-specific hassles and uplifts, and psychological well-being. Maternal salivary cortisol was unrelated to psychological measures with the exception of minor associations detected with measures of anxiety and depressive symptoms between 30 and 32 weeks only. Findings indicate that self-reported maternal psychological distress and well-being are not associated with significant variation in maternal salivary cortisol levels during the second half of gestation. This suggests that studies that measure psychological factors in pregnancy but do not measure maternal cortisol should exercise caution in assuming activation of the maternal hypothalamic-pituitary-adrenal axis is the mechanism through which maternal psychological factors are transduced to the fetus.

Prenatal antecedents of newborn neurological maturation.

Fetal neurobehavioral development was modeled longitudinally using data collected at weekly intervals from 24 to 38 weeks gestation in a sample of 112 healthy pregnancies. Predictive associations between 3 measures of fetal neurobehavioral functioning and their developmental trajectories to neurological maturation in the first weeks after birth were examined. Prenatal measures included fetal heart rate (FHR) variability, fetal movement, and coupling between fetal motor activity and heart rate patterning; neonatal outcomes include a standard neurologic examination (n = 97) and brainstem auditory evoked potential (BAEP; n = 47). Optimality in newborn motor activity and reflexes was predicted by fetal motor activity, FHR variability, and somatic-cardiac coupling predicted BAEP parameters. Maternal pregnancy-specific psychological stress was associated with accelerated neurologic maturation.

Fetal motor activity and maternal cortisol.

The contemporaneous association between maternal salivary cortisol and fetal motor activity was examined at 32 and 36 weeks gestation. Higher maternal cortisol was positively associated with the amplitude of fetal motor activity at 32 weeks, r(48) = .39, p < .01, and 36 weeks, r(77) = .27, p < .05, and the amount of time fetuses spent moving at 32 weeks during the 50 min observation period, r(48) = 33, p < .05. Observation of periods of unusually intense fetal motor activity were more common in fetuses of women with higher cortisol, Mann-Whitney U = 58.5. There were no sex differences in fetal motor activity, but the associations between maternal cortisol and fetal motor amplitude and overall movement were significantly stronger for male than female fetuses.

Diurnal rhythm of cortisol during late pregnancy: associations with maternal psychological well-being and fetal growth.

Maternal psychological functioning during pregnancy affects both maternal and fetal well-being. The hypothalamic-pituitary-adrenal (HPA) axis provides one mechanism through which maternal psychosocial factors may be transduced to the fetus. However, few studies have examined maternal psychological factors or birth outcomes in relation to the diurnal pattern of cortisol across the day. The current study examined maternal psychological well-being, parity status, and birth weight in relation to the maternal cortisol diurnal rhythm in a group of 98 low-risk pregnant women (51 primiparae). At 36 weeks gestation, participants completed both pregnancy-specific and general self-report measures of psychological functioning and provided saliva samples at 8:00, 12:00, and 16:00 h on 2 consecutive working days for the assay of cortisol. The expected diurnal decline in salivary cortisol was observed. Higher trait anxiety was associated with a flatter afternoon decline for all mothers. For primiparae, steeper morning cortisol declines were associated with lower infant birth weight. The findings suggest that regulation of the HPA axis may differ by parity status with downstream implications for fetal growth and development.

Fetal responses to induced maternal relaxation during pregnancy.

Fetal responses to induced maternal relaxation during the 32nd week of pregnancy were recorded in 100 maternal-fetal pairs using a digitized data collection system. The 18-min guided imagery relaxation manipulation generated significant changes in maternal heart rate, skin conductance, respiration period, and respiratory sinus arrhythmia. Significant alterations in fetal neurobehavior were observed, including decreased fetal heart rate (FHR), increased FHR variability, suppression of fetal motor activity (FM), and increased FM-FHR coupling. Attribution of the two fetal cardiac responses to the guided imagery procedure itself, as opposed to simple rest or recumbency, is tempered by the observed pattern of response. Evaluation of correspondence between changes within individual maternal-fetal pairs revealed significant associations between maternal autonomic measures and fetal cardiac patterns, lower umbilical and uterine artery resistance and increased FHR variability, and declining salivary cortisol and FM activity. Potential mechanisms that may mediate the observed results are discussed.

Prenatal origins of temperamental reactivity in early infancy.

BACKGROUND: Temperament theory has long considered individual differences in reactivity and regulation to be present at birth. Recent evidence suggests that such differences may be present prenatally and moderated by maternal emotionality. AIMS: To determine whether induced maternal emotional activation generates a fetal response and whether observed fetal responsivity is associated with early infant temperament. STUDY DESIGN: Women viewed an emotionally evocative labor and delivery documentary at 32 weeks gestation while physiological indices were evaluated and their infant's temperament was assessed at 6 weeks postnatal age. SUBJECTS: Participants were 137 pregnant women and their infants. OUTCOME MEASURES: Maternal physiological (heart rate and skin conductance) and fetal neurobehavioral (heart rate and motor activity) data were collected during gestation in response to the stimulus. Infant temperament (irritability and consolability) data were based on observational methods after birth. RESULTS: Fetuses reacted to maternal viewing of the video with decreased heart rate variability, fewer motor bouts, and decreased motor activity. There was correspondence between the nature of individual maternal physiological responses to the full video, as well as phasic responses to a graphic birth scene, and fetal responsivity. Fetuses that reacted more intensively to maternal stimulation were significantly more likely to become infants that demonstrated greater irritability during a developmental examination at 6 weeks of age. DISCUSSION: These results support the presumption that early postnatal temperamental characteristics emerge during the prenatal period.

Continuity in self-report measures of maternal anxiety, stress, and depressive symptoms from pregnancy through two years postpartum.

This study examined stability and change in maternal anxiety, stress and depression both during the second half of pregnancy and from pregnancy to six weeks and two years postpartum. Self-report measures included those designed to measure mood and state as well as more persistent attributes. Longitudinal data were collected from 137 women during pregnancy, 120 at six weeks, and 97 at two years. There was significant individual stability in scores on specific measures during pregnancy (range in Pearson rs=0.30-0.86) and from pregnancy through two years postpartum (rs=0.30-0.74). Comparable levels of convergence among measures of different constructs both within pregnancy and over time were also demonstrated, suggesting lack of precision in measurement instruments designed for specific constructs. Despite intra-individual stability, changes in mean levels were also observed over time with somewhat different patters for each variable. However, maternal parity was an important contributor to both level and trajectory. A summary composite score showed an elevated level of psychological distress during pregnancy in multiparous women, followed by a decline through two years postpartum; primiparous women displayed a gradual increase in distress [main effect F (1,87)=3.97, p < 0.05; time interaction F (2,174)= 7.15, p < 0.001] to multiparous levels by two years. Results are discussed in terms of a "motherhood" effect on psychological distress.

The pregnancy experience scale-brief version.

The role of maternal stress during pregnancy remains a focus of academic and clinical inquiry, yet there are few instruments available that measure pregnancy-specific contributors to maternal psychological state. This report examines the psychometric properties of an abbreviated version of the Pregnancy Experience Scale (PES) designed to evaluate maternal appraisal of positive and negative stressors during pregnancy. The PES-Brief consists of the top 10 items endorsed as pregnancy hassles and 10 pregnancy uplifts from the original scale. The PES-Brief was administered to 112 women with low risk, singleton pregnancies five times between 24 and 38 weeks gestation. Scoring includes frequency and intensity measures for hassles and uplifts, as well as composite measures for the relation between the two. Internal reliability, test-retest reliability and convergent validity were comparable with the original version. The PES-Brief provides an economical source of information on stress appraisal and emotional valence towards pregnancy.

The relationship between hiccups and heart rate in the fetus.

OBJECTIVE: The purpose of this study was to determine the effect of fetal hiccups on fetal heart rate from 20 weeks of gestation onward. METHODS: One thousand four hundred and fifty-six collected fetal heart rate tracings from three cohorts that participated in longitudinal studies of fetal neurobehavioral development were reviewed retrospectively for fetal hiccups. Tracings were recorded at four-week intervals from 20 weeks. A hiccup-free period before or after the episode of hiccups was used as the control fetal heart rate; thus each fetus was used as its own control. The paired t-test was used for statistical analysis. RESULTS: From 28 weeks onward, the mean fetal heart rate increased with hiccups reaching statistical significance at 32 weeks. Fetal heart rate variability was unaffected by hiccups until 36 weeks, at which time it decreased during hiccup periods. CONCLUSION: This change in response to fetal hiccups may represent another neurodevelopment milestone for the fetus.

Fetal heart rate and motor development in overweight and obese pregnant women.

OBJECTIVE: To determine the relationship between maternal prepregnancy body mass index (BMI) and fetal cardiac and motor activity and integration during the second half of pregnancy. METHODS: Longitudinal data were collected from 610 nonsmoking women with normally progressing pregnancies at three gestational periods (24, 30-32, and 36 weeks) across eight cohorts studied between 1997 and 2013. Fifty minutes of fetal heart rate and motor activity data were collected at each period via actocardiography in a laboratory setting. Data were digitized and analyzed using customized software. Standard BMI categories were computed from maternal prepregnancy weight and height. Participants were stratified into normal weight (n=401, 65.7%), overweight (n=137, 22.5%), or obese (n=72, 11.8%). RESULTS: Fetuses of obese women showed lower heart rate variability and fewer accelerations relative to fetuses of normal weight women. Fetuses of both obese and overweight women exhibited more vigorous motor activity than fetuses of normal weight women. Cardiac-somatic integration was reduced in both obese and overweight groups. Findings differed by gestational age at assessment. CONCLUSIONS: Excess maternal prepregnancy weight in overweight and obese women alters the normal trajectory of fetal cardiac and motor development and their integration, with effects amplified as pregnancy progresses.

Psychosocial influences in dietary patterns during pregnancy.

There is increasing evidence that psychosocial factors may affect dietary intakes and health. The current analysis examined the association of six indices of psychosocial well-being with dietary intake during pregnancy. One hundred thirty-four women with low-risk, normal pregnancies participated in a cross-sectional, observational study that assessed dietary intake at 28 weeks' gestation. Psychosocial characteristics, including anxiety, depressed mood, anger, fatigue, social support, and stress were assessed between 24 and 32 weeks' gestation. Pearson product-moment correlations were calculated to determine the relationships between psychosocial factors and diet. Findings suggest that pregnant women who were more fatigued, stressed, and anxious consumed more foods, as evidenced by their increased macronutrient intakes, while appearing to have decreased intakes of some micronutrients. Psychosocial factors should be considered when counseling women regarding diet during pregnancy.

Maternal psychophysiological change during the second half of gestation.

This study investigated the trajectory of physiological and psychological functioning during the second half of pregnancy and compared responsiveness to a laboratory stressor between pregnant and non-pregnant women. Monitoring of 137 pregnant women at 20, 24, 28, 32, 36, and 38 weeks of pregnancy included measures of heart period (HP), heart period variability (HPV), skin conductance (SCL), respiratory period (RP), respiratory sinus arrhythmia (RSA), and self-report of mood disturbance. HP and RSA declined during this period; SCL and mood disturbance increased. Parity was a significant moderator. HP and SCL responsiveness to the Stroop color-word task was assessed twice in pregnant participants and compared to a sample of 27 non-pregnant women. Physiologic responsiveness was reduced in pregnant women. Pregnant women perceived the Stroop to be more difficult, but performance was unaffected. Despite buffered responsivity to stressful stimuli during pregnancy, advancing gestation is associated with escalating sympathetic tone and declining parasympathetic tone.