PROBABLE PERINATAL DEPRESSION, ENGAGEMENT IN HIV CARE, AND VIRAL SUPPRESSION AMONG MALAWIAN WOMEN

With broadened antiretroviral treatment (ART) eligibility, long-term HIV care engagement has been sub-optimal. Care engagement may be hindered by antenatal depression, yet depression screening is not routine in most African countries. We estimated factors associated with antenatal depression, the prevalence and incidence of perinatal depression, and the relationship of antenatal depression with HIV care engagement among a cohort study of pregnant women living with HIV (n=725) recruited from a government antenatal clinic in Malawi in 2015-2016. Depression was assessed at enrollment and four times postpartum with the Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire-9 (PHQ-9). Participants’ median age was 29 years, and at enrollment had a median 22 weeks gestation. Most were married (90%) and their current pregnancy was unintended (68%). Many women reported a history of depression or anxiety: 46% had a personal history and 20% had a family history; 17% reported experiencing intimate partner violence (IPV). Women were more likely to have probable antenatal depression if they reported a history of depression (adjusted prevalence ratio 2.42; 95%CI 1.48-3.95), IPV (1.77; 1.11-2.81), had an unintended current pregnancy (1.78; 0.99-3.21), were unmarried (1.66; 0.97-2.84), or were employed (1.56; 1.00-2.44). Among women initiating ART (n=299), 10% had probable antenatal depression, yet only 2-5% postpartum. Sensitivity analyses to account for loss to follow up suggested that postpartum depression prevalence could have ranged from 2-11%. EPDS and PHQ-9 scores were concordant for 95% of assessments. Most women were engaged in care through 12 months post-ART initiation: 85% attended all scheduled visits, and 81% were in care and virally suppressed. For both care engagement outcomes, there were no differences by antenatal depression status (visit attendance risk difference: -0.02; 95%CI -0.16-0.12; adjusted: -0.04; 95%CI -0.18-0.10) (viral suppression prevalence difference: -0.02; 95%CI -0.17-0.13; adjusted: -0.01; 95%CI -0.17-0.15). Probable perinatal depression was more common antenatally than postpartum among women with HIV in Malawi. Factors associated with probable antenatal depression represented heightened psychosocial stress. Women with and without antenatal depression were equally likely to remain engaged in care postpartum. Programs should consider screening and support services for psychosocial factors to facilitate women’s sustained HIV care engagement.Doctor of Philosoph

Abortion experiences among Zanzibari women: a chain-referral sampling study

Abstract Background In Zanzibar, a semi-autonomous region of Tanzania, induced abortion is illegal but common, and fewer than 12 % of married reproductive-aged women use modern contraception. As part of a multi-method study about contraception and consequences of unwanted pregnancies, the objective of this study was to understand the experiences of Zanzibari women who terminated pregnancies. Methods The cross-sectional study was set in Zanzibar, Tanzania. Participants were a community-based sample of women who had terminated pregnancies. We carried out semi-structured interviews with 45 women recruited via chain-referral sampling. We report the characteristics of women who have had abortions, the reasons they had abortions, and the methods used to terminate their pregnancies. Results Women in Zanzibar terminate pregnancies that are unwanted for a range of reasons, at various points in their reproductive lives, and using multiple methods. While clinical methods were most effective, nearly half of our participants successfully terminated a pregnancy using non-clinical methods and very few had complications requiring post abortion care (PAC). Conclusions Even in settings where abortion is illegal, some women experience illegal abortions without adverse health consequences, what we might call ‘safer’ unsafe abortions; these kinds of abortion experiences can be missed in studies about abortion conducted among women seeking PAC in hospitals

Altered mental status is an indicator of mortality and associated with both infectious and non-communicable disease in Lilongwe, Malawi

Little is known about diseases associated with Altered Mental Status in resource-poor settings. We studied adult medicine patients presenting with AMS in Lilongwe, Malawi and found that AMS and HIV infection were each significantly associated with mortality. It is therefore critical that evaluation and management in this patient population is improved

Factors Influencing Graduate Program Choice Among Undergraduate Women

Context: Despite equal enrollment proportions in MD and PhD programs, there are fewer women than men in MD-PhD programs and academic medicine. Factors important in degree program selection, including the perception of gender disparities, among undergraduate students were characterized. Methods: In 2017, pre-health students at four public North Carolina universities were invited to participate in an online survey regarding career plans, decision factors, and perceptions of gender disparities in MD, PhD and MD-PhD pathways. The authors characterized factors important to program selection, and evaluated the association of intended graduate program with perceived gender disparities using Fisher’s exact tests. Results: Among the n=186 female survey participants, most were white (54%) and intended MD, PhD, and/or MD-PhD programs (52%). Sixty percent had heard of MD-PhD programs, over half had no research experience, and half were considering but uncertain about pursuing a research career. The most common factors influencing degree program choice were perceived competitiveness as an applicant, desired future work environment, and desire for patient interaction. Twenty-five percent of students considering MD, PhD, and MD-PhD programs stated that perceived gender disparities during training for those degrees will influence their choice of program, however intended degree was not statistically associated with perceived gender disparities. Discussion: Perceived gender disparities may influence choice of graduate training program but are not among the top factors. Perceived competitiveness as an applicant is an important career consideration among undergraduate women. Strategies to increase awareness of MD-PhD programs, to encourage women to consider all training paths for which they are qualified are needed. Keywords: Education, Graduate; Sexism; Career Choice; Biomedical Research/education; Female What is known: Though men and women are nearly equally represented in MD-only and PhD-only programs, women are underrepresented in MD-PhD programs, which train physician-scientists. Prior studies have shown gender is not associated with rates of attrition from MD-PhD programs or differences in academic preparation, research interest, or research experience, suggesting enrollment differences by gender may be due to fewer women applying to MD-PhD programs. Gender parity in the physician-scientist workforce is critical to equitably serving a diverse patient population. What this study adds: This study is the first to examine the role of gender disparities in the career choices of undergraduate women. Given the moderate familiarity with MD-PhD training and lack of research experience among respondents, increased awareness of MD-PhD programs and expanded research opportunities may help undergraduates make informed career choices. This may increase women MD-PhD applicants, creating a more balanced physician-scientist workforce to address the needs of patients from all backgrounds

Abortion experiences among Zanzibari women: a chain-referral sampling study

Abstract Background In Zanzibar, a semi-autonomous region of Tanzania, induced abortion is illegal but common, and fewer than 12 % of married reproductive-aged women use modern contraception. As part of a multi-method study about contraception and consequences of unwanted pregnancies, the objective of this study was to understand the experiences of Zanzibari women who terminated pregnancies. Methods The cross-sectional study was set in Zanzibar, Tanzania. Participants were a community-based sample of women who had terminated pregnancies. We carried out semi-structured interviews with 45 women recruited via chain-referral sampling. We report the characteristics of women who have had abortions, the reasons they had abortions, and the methods used to terminate their pregnancies. Results Women in Zanzibar terminate pregnancies that are unwanted for a range of reasons, at various points in their reproductive lives, and using multiple methods. While clinical methods were most effective, nearly half of our participants successfully terminated a pregnancy using non-clinical methods and very few had complications requiring post abortion care (PAC). Conclusions Even in settings where abortion is illegal, some women experience illegal abortions without adverse health consequences, what we might call ‘safer’ unsafe abortions; these kinds of abortion experiences can be missed in studies about abortion conducted among women seeking PAC in hospitals

Prevalence of antiretroviral therapy treatment failure among HIV-infected pregnant women at first antenatal care: PMTCT Option B+ in Malawi.

BACKGROUND:In Malawi's PMTCT Option B+ program, HIV-infected pregnant women who are already receiving ART are continued on their current therapy regimen without testing for treatment failure at the first antenatal care (ANC) visit. HIV RNA screening at ANC may identify women with treatment failure and ensure that viral suppression is maintained throughout the pregnancy. METHODS:We conducted a cross-sectional study of HIV-infected pregnant women who had been receiving ART for at least 6 months at the first ANC visit under the PMTCT Option B+ program at Bwaila Hospital in Lilongwe, Malawi from June 2015 to December 2017. Poisson regression models with robust variance were used to investigate the predictors of ART treatment failure defined as viral load ≥1000 copies/ml. RESULTS:The median age of 864 women tested for ART failure was 31.1 years (interquartile range: 26.9-34.5). The prevalence of treatment failure was 7.6% (95% confidence interval (CI): 6.0-9.6). CD4 cell count (adjusted prevalence ratio (aPR) = 0.57; 95% CI: 0.50-0.65) was strongly associated with treatment failure. CONCLUSION:The low prevalence of treatment failure among women presenting for their first ANC in urban Malawi demonstrates success of Option B+ in maintaining viral suppression and suggests progress towards the last 90% of the UNAIDS 90-90-90 targets. Women failing on ART should be identified early for adherence counseling and may require switching to an alternative ART regimen