Mode of delivery among HIV-Infected pregnant women in Philadelphia, 2005-2013

Objective Current guidelines call for HIV-infected women to deliver via scheduled Caesarean when the maternal HIV viral load (VL) is >1,000 copies/ml. We describe the mode of delivery among HIV-infected women and evaluate adherence to relevant recommendations. Study Design We performed a population-based surveillance analysis of HIV-infected pregnant women in Philadelphia from 2005 to 2013, comparing mode of delivery (vaginal, scheduled Caesarean, or emergent Caesarean) by VL during pregnancy, closest to the time of delivery (≤1,000 copies/ml versus an unknown VL or VL >1,000 copies/ml) and associated factors in multivariable analysis. Results Our cohort included 824 deliveries from 648 HIV-infected women, of whom 69.4% had a VL ≤1,000 copies/ml and 30.6% lacked a VL or had a VL >1,000 copies/ml during pregnancy, closest to the time of delivery. Mode of delivery varied by VL: 56.6% of births were vaginal, 30.1% scheduled Caesarean, and 13.3% emergent Caesarean when the VL was ≤1,000 copies/ml; when the VL was unknown or >1,000 copies/ml, 32.9% of births were vaginal, 49.9% scheduled Caesarean and 17.5% emergent Caesarean. In multivariable analyses, Hispanic women (adjusted odds ratio (AOR) 0.17, 95% Confidence Interval (CI) 0.04–0.76) and non-Hispanic black women (AOR 0.27, 95% CI 0.10–0.77) were less to likely to deliver via scheduled Caesarean compared to non-Hispanic white women. Women who delivered prior to 38 weeks’ gestation (AOR 0.37, 95% CI 0.18–0.76) were also less likely to deliver via scheduled Caesarean compared to women who delivered after 38 weeks’ gestation. An interaction term for race and gestational age at delivery was significant in multivariable analysis. Non-Hispanic black (AOR 0.06, 95% CI 0.01–0.36) and Hispanic women (AOR 0.03, 95% CI 0.00–0.59) were more likely to deliver prematurely and less likely to deliver via scheduled C-section compared to non-Hispanic white women. Having a previous Caesarean (AOR 27.77, 95% CI 8.94–86.18) increased the odds of scheduled Caesarean delivery. Conclusions Only half of deliveries for women with an unknown VL or VL >1,000 copies/ml occurred via scheduled Caesarean. Delivery prior to 38 weeks, particularly among minority women, resulted in a missed opportunity to receive a scheduled Caesarean. However, even when delivering at or after 38 weeks’ gestation, a significant proportion of women did not get a scheduled Caesarean when indicated, suggesting a need for focused public health interventions to increase the proportion of women achieving viral suppression during pregnancy and delivering via scheduled Caesarean when indicated

Preparing for a trial to test a postpartum weight retention intervention among low income women: feasibility of a protocol in a community-based organization

Abstract Background Postpartum weight retention (PPWR) causes intergenerational harm, negatively affecting a mother’s cardiovascular health and ability to have future healthy pregnancies. Low-income minority women are at highest risk for PPWR with little guidance concerning timeline or strategy to lose weight after delivery. An academic-community partnership conducted observational and focus group work to develop an intervention for PPWR among low-income mothers. This study’s objective is to determine the feasibility of implementing a PPWR intervention trial in partnership with a community-based organization (CBO) serving low-income families with social service support. Methods We analyzed five implementation outcomes in this feasibility study: acceptability, adoption, appropriateness, penetration, and sustainability. Other secondary outcomes were the change in psychosocial and clinical outcomes from baseline to one year following the intervention delivery. Results An academic-community partnership developed and piloted a postpartum weight retention intervention among 17 participants that included 1) six weeks of interactive daily health texting, 2) exercise assistance with baby carrier, home exercise program, and pedometer provision, 3) two live healthy eating and baby feeding workshops, and 4) two 45-min home visits over one year to provide social support and acquire followup data. Implementation outcomes demonstrate an intervention supported by the organization and accepted by end-users, with increased capacity of the CBO to test and deliver an effective intervention. Weight loss was achieved by the majority of participants at one year (Md − 5 pounds (IQR = − 14.5 - 0.3). Conclusion We made protocol enhancements to the developed intervention based on the analysis of this study, and now prepare for a funded randomized controlled trial (RCT) in a community-based setting. Our central hypothesis is that low-income women who participate in a multi-component, low cost-intervention delivered by a CBO will have less postpartum weight retention than those women who do not participate in the program. Trial registration The trial was retrospectively registered, ID NCT02867631, 8/11/16

Understanding Drivers of Coronavirus Disease 2019 Vaccine Hesitancy Among Blacks

BACKGROUND: Coronavirus disease 2019 (COVID-19) has disproportionately affected communities of color, with black persons experiencing the highest rates of disease severity and mortality. A vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has the potential to reduce the race mortality gap from COVID-19; however, hesitancy toward the vaccine in the black community threatens vaccine uptake. METHODS: We conducted focus groups with black barbershop and salon owners living in zip codes of elevated COVID-19 prevalence to assess their attitudes, beliefs, and norms around a COVID-19 vaccine. We used a modified grounded theory approach to analyze the transcripts.RESULTS: We completed 4 focus groups (N = 24 participants) in July and August 2020. Participants were an average age of 46 years, and 89% were black non-Hispanic. Hesitancy against the COVID-19 vaccine was high due to mistrust in the medical establishment, concerns with the accelerated timeline for vaccine development, limited data on short- and long-term side effects, and the political environment promoting racial injustice. Some participants were willing to consider the vaccine once the safety profile is robust and reassuring. Receiving a recommendation to take the vaccine from a trusted healthcare provider served as a facilitator. Health beliefs identified were similar to concerns around other vaccines and included the fear of getting the infection with vaccination and preferring to improve one’s baseline physical health through alternative therapies.CONCLUSIONS: We found that hesitancy of receiving the COVID-19 vaccine was high; however, provider recommendation and transparency around the safety profile might help reduce this hesitancy.SUMMARY: In focus group discussions, hesitancy of a COVID-19 vaccine was high among black participants due to health beliefs against vaccines in general, compounded by skepticism of vaccine development during the pandemic and the political environment fostering racial injustice

Perinatal Depressive Symptoms, Human Immunodeficiency Virus (HIV) Suppression, and the Underlying Role of Antiretroviral Therapy Adherence: A Longitudinal Mediation Analysis in the IMPAACT P1025 Cohort

Women with HIV have higher risk of depressive symptoms in the perinatal period. Evidence on how perinatal depressive symptoms affect viral suppression (VS) and adherence to antiretroviral therapy (ART) remains limited. Perinatal depressive symptoms were assessed using 6 items from the AIDS Clinical Trials Group (ACTG) Quality of Life questionnaire. VS (viral load <400 copies/mL) was the outcome. Adherence was defined as no missed dose in the past 1-4 weeks using the ACTG Adherence Questionnaire. Generalized mixed-effects structural equation models estimated the association of depressive symptoms on VS and the mediating role of ART adherence among women enrolled in the IMPAACT P1025 Perinatal Core Protocol (2002-2013). Among 1869 participants, 47.6% were 21-29 years, 57.6% non-Hispanic Black. In the third trimester, the mean depressive symptoms score was 14.0 (±5.2), 68.0% had consistent adherence, and 77.3% achieved VS. At 6 months postpartum, depressive symptoms declined while adherence and VS fell to 59.8% and 53.0%, respectively. In the fully adjusted model, a 1-SD increase in depressive symptoms was associated with a 3.8-percentage-point (95% CI: -5.7, -1.9) decline in VS. This effect is the sum of the indirect effect of depressive symptoms on VS via ART adherence (-0.4; 95% CI: -.7, -.2) and the direct effect through other pathways (-3.4; -5.2, -1.5). The decline in adherence driven by depressive symptoms accounted for ≥11% of the total negative effect of depressive symptoms on VS. Perinatal depressive symptoms were associated with decreased adherence and VS, highlighting the need to screen for, diagnose, and treat perinatal depression to optimize maternal outcomes. NCT00028145

Influence of toilet access on antiretroviral adherence intention among pregnant and breastfeeding women who are HIV-positive and enrolled in Option B.

We investigated the influence of toilet access on intention to adhere to antiretroviral therapy (ART) among women who are HIV-positive and enrolled in Option B+. A convenience sample of 150 women residing in Lusaka (urban) and Sinazongwe (rural) Districts of Zambia were recruited. if they were seeking pre- or post-natal care and were enrolled in Option B+. Intention to adhere to ART was assessed using four questions based on the Theory of Planned Behavior; the median score was used to distinguish high intention from low intention. Descriptive statistics were used to characterize access to toilet facilities and ART adherence intention in the entire sample and by rural and urban districts in Zambia. There was no significant difference (p = .19) between rural and urban women's access to a flush toilet. After adjusting for toilet access, however, rural women were significantly less likely to be in the high adherence intention group (PR = 0.80, 95% CI 0.71-0.90, p &lt; .001) but access to a flush toilet was associated with adherence intention (PR = 1.14, 95% CI (1.00 - 1.30). Community-led total sanitation in Zambia could increase ART adherence intention

Influence of toilet access on antiretroviral adherence intention among pregnant and breastfeeding women who are HIV-positive and enrolled in Option B.

We investigated the influence of toilet access on intention to adhere to antiretroviral therapy (ART) among women who are HIV-positive and enrolled in Option B+. A convenience sample of 150 women residing in Lusaka (urban) and Sinazongwe (rural) Districts of Zambia were recruited. if they were seeking pre- or post-natal care and were enrolled in Option B+. Intention to adhere to ART was assessed using four questions based on the Theory of Planned Behavior; the median score was used to distinguish high intention from low intention. Descriptive statistics were used to characterize access to toilet facilities and ART adherence intention in the entire sample and by rural and urban districts in Zambia. There was no significant difference (p = .19) between rural and urban women's access to a flush toilet. After adjusting for toilet access, however, rural women were significantly less likely to be in the high adherence intention group (PR = 0.80, 95% CI 0.71-0.90, p &lt; .001) but access to a flush toilet was associated with adherence intention (PR = 1.14, 95% CI (1.00 - 1.30). Community-led total sanitation in Zambia could increase ART adherence intention

Impact of attitudes and beliefs on antiretroviral treatment adherence intention among HIV-positive pregnant and breastfeeding women in Zambia.

ObjectiveThe aim of this study was to investigate if attitudes or behavioral beliefs about antiretroviral therapy (ART) influence ART adherence intention among pregnant and breastfeeding women in Zambia.MethodsWe recruited 150 HIV-positive women receiving ART in urban (Lusaka) and rural (Sinazongwe) districts of Zambia. Generalized modified Poisson regression models were used to assess the extent to which adherence intention was influenced by attitude toward ART or behavioral beliefs about ART.ResultsIntention to adhere to ART differed significantly by income, knowledge about HIV transmission, attitudes, and behavioral beliefs (all Ps &lt; .05). In addition, strong intention to adhere to ART differed by urban (69%) and rural (31%) place of residence (P ≤ .01). In adjusted models, women in the weak adherence intention group were more likely to be older, have less knowledge about HIV transmission, and have a more negative attitude toward ART (PR 0.74; 95% CI 0.67-0.82). Behavioral belief about ART, however, was significant in unadjusted model (PR 0.85; 95% CI 0.76-0.94) but not significant after adjusting for covariates such as age, knowledge of transmission, and district locality.ConclusionCompared to behavioral beliefs, attitudes about ART were more influential for intention to adhere. This knowledge will help inform effective and appropriate ART counseling for pregnant and breastfeeding women at different points along their ART time course

Time of HIV Diagnosis and Engagement in Prenatal Care Impact Virologic Outcomes of Pregnant Women with HIV

<div><p>Background</p><p>HIV suppression at parturition is beneficial for maternal, fetal and public health. To eliminate mother-to-child transmission of HIV, an understanding of missed opportunities for antiretroviral therapy (ART) use during pregnancy and HIV suppression at delivery is required.</p><p>Methodology</p><p>We performed a retrospective analysis of 836 mother-to-child pairs involving 656 HIV-infected women in Philadelphia, 2005-2013. Multivariable regression examined associations between patient (age, race/ethnicity, insurance status, drug use) and clinical factors such as adequacy of prenatal care measured by the Kessner index which classifies prenatal care as inadequate, intermediate, or adequate prenatal care; timing of HIV diagnosis; and the outcomes: receipt of ART during pregnancy and viral suppression at delivery.</p><p>Results</p><p>Overall, 25% of the sample was diagnosed with HIV during pregnancy; 39%, 38%, and 23% were adequately, intermediately, and inadequately engaged in prenatal care. Eight-five percent of mother-to-child pairs received ART during pregnancy but only 52% achieved suppression at delivery. Adjusting for patient factors, pairs diagnosed with HIV during pregnancy were less likely to receive ART (AOR 0.39, 95% CI 0.25-0.61) and achieve viral suppression (AOR 0.70, 95% CI 0.49-1.00) than those diagnosed before pregnancy. Similarly, women with inadequate prenatal care were less likely to receive ART (AOR 0.06, 95% CI 0.03-0.11) and achieve viral suppression (AOR 0.31, 95% CI 0.20-0.47) than those with adequate prenatal care.</p><p>Conclusions</p><p>Targeted interventions to diagnose HIV prior to pregnancy and engage HIV-infected women in prenatal care have the potential to improve HIV related outcomes in the perinatal period.</p></div

Impact of attitudes and beliefs on antiretroviral treatment adherence intention among HIV-positive pregnant and breastfeeding women in Zambia.

ObjectiveThe aim of this study was to investigate if attitudes or behavioral beliefs about antiretroviral therapy (ART) influence ART adherence intention among pregnant and breastfeeding women in Zambia.MethodsWe recruited 150 HIV-positive women receiving ART in urban (Lusaka) and rural (Sinazongwe) districts of Zambia. Generalized modified Poisson regression models were used to assess the extent to which adherence intention was influenced by attitude toward ART or behavioral beliefs about ART.ResultsIntention to adhere to ART differed significantly by income, knowledge about HIV transmission, attitudes, and behavioral beliefs (all Ps &lt; .05). In addition, strong intention to adhere to ART differed by urban (69%) and rural (31%) place of residence (P ≤ .01). In adjusted models, women in the weak adherence intention group were more likely to be older, have less knowledge about HIV transmission, and have a more negative attitude toward ART (PR 0.74; 95% CI 0.67-0.82). Behavioral belief about ART, however, was significant in unadjusted model (PR 0.85; 95% CI 0.76-0.94) but not significant after adjusting for covariates such as age, knowledge of transmission, and district locality.ConclusionCompared to behavioral beliefs, attitudes about ART were more influential for intention to adhere. This knowledge will help inform effective and appropriate ART counseling for pregnant and breastfeeding women at different points along their ART time course

Water Access and Adherence Intention Among HIV-Positive Pregnant Women and New Mothers Receiving Antiretroviral Therapy in Zambia.

BackgroundMother-to-infant transmission of HIV is a major problem in Sub-Saharan Africa despite free or subsidized antiretroviral treatment (ART), but is significantly reduced when mothers adhere to ART. Because potable water access is limited in low-resource countries, we investigated water access and ART adherence intention among HIV-positive pregnant women and new mothers in Zambia.MethodsOur convenience sample consisted of 150 pregnant or postpartum women receiving ART. Descriptive statistics compared type of water access by low and high levels of ART adherence intention.ResultsMost (71%) had access to piped water, but 36% of the low-adherence intention group obtained water from a well, borehole, lake or stream, compared to only 22% of the high-adherence intention group. The low-adherence intention group was more rural (62%) than urban (38%) women but not statistically significant [unadjusted Prevalence Ratio (PR) 0.73, 95% CI: 0.52-1.02; adjusted PR 1.06, 95% CI: 0.78-1.45].ConclusionProviding potable water may improve ART adherence. Assessing available water sources in both rural and urban locations is critical when educating women initiating ART