Exploring health inequalities: determinants associated with home-based versus hospital-based deliveries in the Peruvian Amazon

In low-and-middle-income countries childbirth can still occur at home where unpredictable complications, infections, and other adverse events contribute to both maternal and infant morbidity and mortality. The objective of this study was to identify important determinants associated with home-based deliveries to inform health policy in the Peruvian Amazon. A one-to-one matched case-control study was conducted (case = home delivery and control = hospital delivery). Data were collected from pre-tested interviewer-administered questionnaires given to 112 women who had delivered within two months prior to the interview. Appropriate univariate and multivariate conditional logistic regression models were performed. The results suggest that women with lower number of antenatal care visits, lower education, higher parity, and partner being an agricultor were more likely to deliver at home. These findings provide much-needed local evidence to inform the development of appropriate interventions as well as local Ministry of Health discussions on policies and practices regarding home births.Dans de nombreux pays en voie de développement, les accouchements à domicile sont fréquents et entrainent souvent des complications imprévisibles, blessures ou autres évènements indésirables qui contribuent à la morbidité et mortalité à la fois maternelle et infantile. L'objectif de cette étude était d'identifier d'importants déterminants associés avec les accouchements à domicile afin d'éclairer les politiques de santé dans l'Amazonie péruvienne.Une étude de cas-témoins appariés a été réalisée (cas = accouchement à domicile et contrôle = accouchement à l'hopital). Les données ont été collectées par des questionnaires pré-testés administrés par un intervieweur auprès de 112 femmes qui ont accouché dans les deux mois précédant l'entrevue. Des modèles de régression logistiques simples et multiples ont été effectués.Les résultats suggèrent que les femmes ayant un nombre réduit de visites prénatales, une scolarité peu élevée, une parité plus élevée, et un partenaire agriculteur étaient plus susceptibles d'accoucher à domicile.Ces résultats fournissent les données nécessaires à l'élaboration d'interventions locales appropriées ainsi qu'aux discussions politiques et pratiques du Ministère de la Santé concernant les accouchements à domicile

Explaining the Presence of “Heterosexual” Female Clients of a Rapid HIV Testing Site Located in the Gay Village of Montreal, Quebec

Background: Increasing access and uptake of HIV testing among at-risk women is needed. Examining women’s motives for visiting a community-based rapid HIV testing site (Actuel sur Rue–AsR) oriented to men who have sex with men (MSM) could offer suggestions. Objective: To compare the “heterosexual” female and male clients of AsR, located in Montreal’s (Canada) gay village, to better understand the women’s particular HIV prevention and sexual health service needs. Methods: This cross-sectional pilot study analyzed questionnaire data provided by AsR clients and staff (nurse and community agent teams) between July 2012 and November 2013. Women and men reporting only opposite-sex partners were compared with chi-square, Fisher’s exact, and Kruskal-Wallis tests, as appropriate, on sociodemographics, HIV-related behaviors, motives for visiting AsR, and health service provision. Results: AsR received 1901 clients. Among these, 55 women and 147 men reported only opposite-sex partners. Women were significantly younger. Significantly greater proportions of women visited AsR because no appointment was necessary (67% vs 48%), sought testing for condom failure (18% vs 5%), and had no regular doctor (44% vs 27%). Both groups mainly chose AsR for the rapid test results (80% and 77%), visited it to receive the rapid HIV test (71% and 76%), and sought testing due to unprotected vaginal sex (44% and 43%). Similar proportions saw the nurse (91% and 89%), received the rapid HIV test (44% and 35%), and were linked to a medical clinic (49% and 52%), especially, to receive complete sexually transmitted infection testing (50% and 44%). Conclusions: The results of this innovative study highlight the draw of rapid HIV testing for “heterosexual” users of a site mainly targeting MSM. They also suggest that further research is warranted into the importance for this group of women clients of drop-in and linkage services, particularly given their possible lesser access to regular care

Incidence and Predictors of Advanced Liver Fibrosis by a Validated Serum Biomarker in Liver Transplant Recipients

Background and Aims. Serum fibrosis biomarkers have shown good accuracy in the liver transplant (LT) population. We employed a simple serum biomarker to elucidate incidence and predictors of advanced fibrosis after LT over a long follow-up period. Methods. We included 440 consecutive patients who underwent LT between 1991 and 2013. Advanced liver fibrosis was defined as FIB-4 > 3.25 beyond 12 months after LT. Results. Over 2030.5 person-years (PY) of follow-up, 189 (43%) developed FIB-4 > 3.25, accounting for an incidence of 9.3/100 PY (95% confidence interval [CI], 8.1–10.7). Advanced fibrosis was predicted by chronic HCV infection (adjusted hazard ratio (aHR) = 3.96, 95% CI 2.92–5.36, p < 0.001), hypoalbuminemia (aHR = 2.31, 95% CI 1.72–3.09; p < 0.001), and hyponatremia (aHR = 1.48, 95% CI 1.09–2.01; p = 0.01). LT recipients with more than 1 predictor had a higher incidence of advanced fibrosis, the highest being when all 3 predictors coexisted (log-rank: p < 0.001). Conclusions. Chronic HCV infection, hypoalbuminemia, and hyponatremia predict progression to advanced liver fibrosis following LT. Patients with these risk factors should be serially monitored using noninvasive fibrosis biomarkers and prioritized for interventions

Influence of Hepatitis C Virus Sustained Virological Response on Immunosuppressive Tryptophan Catabolism in ART-Treated HIV/HCV Coinfected Patients

Background: We previously reported an association between tryptophan (Trp) catabolism and immune dysfunction in HIV monoinfection. Coinfection with HIV is associated with more rapid evolution of hepatitis C virus (HCV)-associated liver disease despite antiretroviral therapy (ART), possibly due to immune dysregulation. We hypothesized that liver fibrosis in HIV/HCV coinfection would be associated with immune dysfunction and alterations in Trp metabolism. Methods: Trp catabolism and inflammatory soluble markers were assessed in plasma samples from ART-treated HIV/HCV-coinfected patients (n = 90) compared with ART-treated HIV-monoinfected patients and noninfected subjects. Furthermore, 17 additional coinfected patients with sustained virological response (SVR) were assessed longitudinally 6 months after completion of interferon-alpha/ribavirin treatment. Results: HIV/HCV patients had higher Trp catabolism compared with HIV-monoinfected and healthy individuals. Elevated kynurenine levels in HIV/HCV patients with liver fibrosis correlated with the prognostic aspartate aminotransaminase to platelet ratio (APRI scores) and insulin levels. Furthermore, HIV/HCV patients had elevated levels of disease progression markers interleukin-6 and induced protein 10 and shared similar levels of markers of microbial translocation (intestinal fatty acid-binding protein, soluble CD14 and lipopolysaccharide-binding protein) compared with HIV-monoinfected and healthy individuals. Successful HCV treatment improved APRI score and markers of disease progression and microbial translocation although elevated Trp catabolism remained unchanged 6 months after SVR. Conclusion: ART-treated HIV/HCV-coinfected patients had elevated immunosuppressive Trp catabolism when compared with monoinfected HIV-treated patients, which did not normalize after SVR. These findings suggest that a necroinflammatory liver syndrome persists through inflammation by Trp catabolism after 6 month of SVR

Hepatic Fibrosis Progression in HIV-Hepatitis C Virus Co-Infection – The Effect of Sex on Risk of Significant Fibrosis Measured by Aspartate-to-Platelet Ratio Index

In Hepatitis C virus (HCV) mono-infection, male sex is associated with faster liver fibrosis progression but the effects of sex have not been well studied in HIV-HCV co-infected patients. We examined the influence of sex on progression to significant liver fibrosis in HIV-HCV co-infected adults receiving antiretroviral therapy (ART) using the aspartate aminotransferase-to-platelet ratio index (APRI) as a surrogate biomarker of liver fibrosis

Kaplan Meier time to significant fibrosis stratified by sex.

<p>Kaplan Meier time to significant fibrosis stratified by sex.</p

Discrete time proportional hazards models of factors associated with development of significant fibrosis (APRI ≥ 1.5) in follow-up.

<p>Abbreviations: IDU, injection drug use; HCV, hepatitis C virus; cART, combination antiretroviral; PI, protease inhibitor;</p><p>NNRTI, non-nucleoside reverse transcriptase inhibitor; APRI, aspartate aminotransferase to platelet ratio;</p><p>BMI, body mass index; HR, hazard ratio; CI, confidence interval.</p><p>Discrete time proportional hazards models of factors associated with development of significant fibrosis (APRI ≥ 1.5) in follow-up.</p

Sociodemographic and clinical characteristics of HIV-HCV co-infected patients at baseline by sex (2003–2012).

<p>Abbreviations: HCV, hepatitis C virus; HIV, human immunodeficiency virus; IDU, injection drug use;</p><p>APRI, aspartate aminotransferase to platelet ratio; AST, aspartate aminotransferase; BMI, body mass index;</p><p>cART, combination antiretroviral; PI, protease inhibitor; NNRTI, non-nucleoside reverse transcriptase inhibitor.</p><p>^aSum of regimens >100% as some participants are on both PI, NNRTI and/or other cART.</p><p>^bFor HCVRNA VL only 166 (34/87 (39%) female and 132/221 (60%) male) had available quantitative HCV RNA values.</p><p>Sociodemographic and clinical characteristics of HIV-HCV co-infected patients at baseline by sex (2003–2012).</p

Participant Selection Flow Chart.

<p>Participant Selection Flow Chart.</p