Trends in maternal mortality for the Greater Harare Maternity Unit: 1976 to 1997.

A CAJM article on trends in maternal death in a Harare, Zimbabwe hospital.Objective: To determine the magnitude, trends and the main causes of maternal death for Harare Maternity Hospital (HMH) and thereby identify potential areas for interventions. Design: A descriptive retrospective analysis of maternal mortality data from the institution included in publications and recent annual reports. Setting: Department of Obstetrics and Gynaecology Greater Harare Maternity Unit, Zimbabwe. Main Outcome Measures: The trends in maternal mortality ratios (MMR) and the relative importance, of different causes of death between 1976 and 1997. Results: There was a decline in MMR between 1976 and the early 1980s but there has been a steady increase in MMR for Harare residents from 50/100 000 in 1988 to 224/100 000 in 1997. Sepsis has remained the leading cause of maternal death. There has been a significant increase in indirect deaths due to meningitis, tuberculosis and pneumonia where HIV infection is an underlying factor. Avoidable factors were identified at patient/ community, local health facility and at the tertiary hospital. There has been a decline in the quality of care in recent years. Conclusion: Maternal mortality for HMH is unacceptably high and could still be rising. HIV infection has contributed to the worsening picture. Interventions to improve access and quality of care at all levels could lead to significant 'reduction in maternal deaths

Norplant in Zimbabwe: preliminary report

A research study on the introduction and effective use of Norplant as a family planning and birth control method used by women of child-bearing age, in Zimbabwe.During an ongoing study of a pre-introduction trial of Norplant in Zimbabwe, 197 women had the subdermal implant of six capsules containing levonorgestrel inserted between June and December 1991, atParirenyatwa, Harare Hospital and Spilhaus. Acceptability and efficacy were high and no significant side effects had been observed. Three implants were removed due to local infection, Our initial experience indicates that the Norplant continuation rate is much higher than for any other reversible method of contraception and it is highly acceptable as a long term contraceptive

Does rapid HIV disease progression prior to combination antiretroviral therapy hinder optimal CD4 + T-cell recovery once HIV-1 suppression is achieved?

Objective: This article compares trends in CD4+ T-cell recovery and proportions achieving optimal restoration (>=500 cells/µl) after viral suppression following combination antiretroviral therapy (cART) initiation between rapid and nonrapid progressors. Methods: We included HIV-1 seroconverters achieving viral suppression within 6 months of cART. Rapid progressors were individuals experiencing at least one CD4+ less than 200 cells/µl within 12 months of seroconverters before cART. We used piecewise linear mixed models and logistic regression for optimal restoration. Results: Of 4024 individuals, 294 (7.3%) were classified as rapid progressors. At the same CD4+ T-cell count at cART start (baseline), rapid progressors experienced faster CD4+ T-cell increases than nonrapid progressors in first month [difference (95% confidence interval) in mean increase/month (square root scale): 1.82 (1.61; 2.04)], which reversed to slightly slower increases in months 1–18 [-0.05 (-0.06; -0.03)] and no significant differences in 18–60 months [-0.003 (-0.01; 0.01)]. Percentage achieving optimal restoration was significantly lower for rapid progressors than nonrapid progressors at months 12 (29.2 vs. 62.5%) and 36 (47.1 vs. 72.4%) but not at month 60 (70.4 vs. 71.8%). These differences disappeared after adjusting for baseline CD4+ T-cell count: odds ratio (95% confidence interval) 0.86 (0.61; 1.20), 0.90 (0.38; 2.17) and 1.56 (0.55; 4.46) at months 12, 36 and 60, respectively. Conclusion: Among people on suppressive antiretroviral therapy, rapid progressors experience faster initial increases of CD4+ T-cell counts than nonrapid progressors, but are less likely to achieve optimal restoration during the first 36 months after cART, mainly because of lower CD4+ T-cell counts at cART initiation

Isoniazid Preventive Therapy in HIV-Infected Pregnant and Postpartum Women

CITATION: Gupta, A. et al. 2019. Isoniazid Preventive Therapy in HIV-Infected Pregnant and Postpartum Women. The New England Journal of Medicine, 381(14):1333-1346. doi:10.1056/NEJMoa1813060The original publication is available at https://www.nejm.org/BACKGROUND: The safety, efficacy, and appropriate timing of isoniazid therapy to prevent tuberculosis in pregnant women with human immunodeficiency virus (HIV) infection who are receiving antiretroviral therapy are unknown. METHODS: In this multicenter, double-blind, placebo-controlled, noninferiority trial, we randomly assigned pregnant women with HIV infection to receive isoniazid preventive therapy for 28 weeks, initiated either during pregnancy (immediate group) or at week 12 after delivery (deferred group). Mothers and infants were followed through week 48 after delivery. The primary outcome was a composite of treatment-related maternal adverse events of grade 3 or higher or permanent discontinuation of the trial regimen because of toxic effects. The noninferiority margin was an upper boundary of the 95% confidence interval for the between-group difference in the rate of the primary outcome of less than 5 events per 100 person-years. RESULTS: A total of 956 women were enrolled. A primary outcome event occurred in 72 of 477 women (15.1%) in the immediate group and in 73 of 479 (15.2%) in the deferred group (incidence rate, 15.03 and 14.93 events per 100 person-years, respectively; rate difference, 0.10; 95% confidence interval [CI], −4.77 to 4.98, which met the criterion for noninferiority). Two women in the immediate group and 4 women in the deferred group died (incidence rate, 0.40 and 0.78 per 100 person-years, respectively; rate difference, −0.39; 95% CI, −1.33 to 0.56); all deaths occurred during the postpartum period, and 4 were from liver failure (2 of the women who died from liver failure had received isoniazid [1 in each group]). Tuberculosis developed in 6 women (3 in each group); the incidence rate was 0.60 per 100 person-years in the immediate group and 0.59 per 100 person-years in the deferred group (rate difference, 0.01; 95% CI, −0.94 to 0.96). There was a higher incidence in the immediate group than in the deferred group of an event included in the composite adverse pregnancy outcome (stillbirth or spontaneous abortion, low birth weight in an infant, preterm delivery, or congenital anomalies in an infant) (23.6% vs. 17.0%; difference, 6.7 percentage points; 95% CI, 0.8 to 11.9). CONCLUSIONS: The risks associated with initiation of isoniazid preventive therapy during pregnancy appeared to be greater than those associated with initiation of therapy during the postpartum period. (Funded by the National Institutes of Health; IMPAACT P1078 TB APPRISE ClinicalTrials.gov number, NCT01494038. opens in new tab.)https://www.nejm.org/doi/full/10.1056/NEJMoa1813060Publisher’s versio

The concordance of the limiting antigen and the Bio-Rad avidity assays in persons from Estonia infected mainly with HIV-1 CRF06_cpx

BACKGROUND: Serological assays to determine HIV incidence have contributed to estimates of HIV incidence, monitoring of HIV spread, and evaluation of prevention strategies. Two frequently used incidence assays are the Sedia HIV-1 LAg-Avidity EIA (LAg) and the Bio-Rad avidity incidence (BRAI) assays with a mean duration of recent infection (MDRI) of 130 and 240 days for subtype B infections, respectively. Little is known about how these assays perform with recombinant HIV-1 strains. We evaluated the concordance of these assays in a population infected mainly with HIV-1 CRF06_cpx. MATERIAL/METHODS: Remnant serum samples (n = 288) collected from confirmed, newly-diagnosed HIV-positive persons from Estonia in 2013 were tested. Demographic and clinical data were extracted from clinical databases. LAg was performed according to the manufacturer’s protocol and BRAI testing was done using a validated protocol. Samples with LAg-pending or BRAI-invalid results were reclassified as recent if they were from persons with viral loads <1000 copies/mL or were reclassified as long-term if presenting with AIDS. RESULTS: In total 325 new HIV infections were diagnosed in 2013 in Estonia. Of those 276 persons were tested with both LAg and BRAI. Using assay results only, the recency rate was 44% and 70% by LAg and BRAI, respectively. The majority of samples (92%) recent by LAg were recent by BRAI. Similarly, 89% of samples long-term by BRAI were long-term by LAg. After clinical information was included in the analysis, the recency rate was 44% and 62% for LAg and BRAI, respectively. The majority of samples (86%) recent by LAg were recent by BRAI and 91% of long-term infections by BRAI were long-term by LAg. CONCLUSIONS: Comparison of LAg and BRAI results in this mostly CRF06_cpx-infected population showed good concordance for incidence classification. Our finding of a higher recency rate with BRAI in this population is likely related to the longer MDRI for this assay

Introducing misoprostol for the management of postpartum hemorrhage in Zimbabwe: final report on operational research

Postpartum Haemorrhage (PPH) is the most common cause of maternal mortality globally, leading to a woman's death every seven minutes. In Zimbabwe, there has been a 300% increase in the Maternal Mortality Ratio (MMR) between 1994 and 2010 and the MMR was estimated at 960 maternal deaths per 100,000 live births in 2012.2-3 Overall, 14% of all maternal deaths in Zimbabwe are due to PPH. Ensuring prompt access to high-quality prevention and treatment of PPH for all women who deliver is an essential strategy to combat PPH-related morbidity and mortality and to make progress toward reaching Millennium Development Goal 5, the reduction of maternal mortality by three-quarters by 2015

Visual infection of the cerviz as a primary means of cervial cancer screening: results of a pilot study

No Abstract. Central African Journal of Medicine Vol. 45 (2) 1999: pp. 30-3