Vaginal microbicides for preventing mother-to-child transmission of HIV infection - no evidence of an effect or evidence of no effect?

Background. Vaginal disinfection is a simple, potentially effective strategy for reducing mother-to-child transmission (MTCT) of HIV that can be implemented in combination with antiretroviraltherapy or even in the absence of prenatal HfV testing. We systematically reviewed currently available randomised controlled trials to estimate the benefits and risks of this intervention.Methods. We conducted an exhaustive search for published and. unpublished trials assessing the effect of vaginal microbicides on MTCT of HIV, extracted data in triplicate, assesed statistical heterogeneity between trial results, and conducted meta-analysis using Mantel-Haenszel's method.Findings. Five potentially eligible studies were iclentified, two of which met eligibility criteria. Pooling the data shows that the effect of vaginal disinfection on the risk of MTCT of HIV relative risk (RR) 0.94, 95% confidence interval (CI) 0.71 1.25) and neonatal death (RR 1.36, 95% CI 0.32- 5.79) is uncertain. The combined data (two trials with 708 participants) had less than 80% power to detect a 30% reduction in the risk of MTCT of HIV from a baseline risk of 30%, and are compatible with a widerange of effects; from a 29% reduction to a 25% increase in risk. One trial with 108 participants, showed no evidence that adverse effects increased inmothers (RR L02, 95% CI 0.87- 1.20) and found that adverse effects decreased in neonates (RR 0.45, 95% CI 0.32 - 0.64).Interpretation. At present there is insufficient and inconclusive evidence on the effect of vaginal microbicides on the risk of MTCT of HIV. This review identifies the need and provides the impetus for an adequately powered randomised controlled trial to assess the effect(s) of this inexpensive intervention

The difficulties of conducting maternal death reviews in Malawi

<p>Abstract</p> <p>Background</p> <p>Maternal death reviews is a tool widely recommended to improve the quality of obstetric care and reduce maternal mortality. Our aim was to explore the challenges encountered in the process of facility-based maternal death review in Malawi, and to suggest sustainable and logically sound solutions to these challenges.</p> <p>Methods</p> <p>SWOT (strengths, weaknesses, opportunities and threats) analysis of the process of maternal death review during a workshop in Malawi.</p> <p>Results</p> <p><it>Strengths</it>: Availability of data from case notes, support from hospital management, and having maternal death review forms. <it>Weaknesses</it>: fear of blame, lack of knowledge and skills to properly conduct death reviews, inadequate resources and missing documentation. <it>Opportunities</it>: technical assistance from expatriates, support from the Ministry of Health, national protocols and high maternal mortality which serves as motivation factor. <it>Threats</it>: Cultural practices, potential lawsuit, demotivation due to the high maternal mortality and poor planning at the district level. <it>Solutions</it>: proper documentation, conducting maternal death review in a blame-free manner, good leadership, motivation of staff, using guidelines, proper stock inventory and community involvement.</p> <p>Conclusion</p> <p>Challenges encountered during facility-based maternal death review are provider-related, administrative, client related and community related. Countries with similar socioeconomic profiles to Malawi will have similar 'pull-and-push' factors on the process of facility-based maternal death reviews, and therefore we will expect these countries to have similar potential solutions.</p

Co-formulated abacavir-lamivudine-zidovudine for initial treatment of HIV infection and AIDS.

The primary objective of this review was to evaluate the antiviral efficacy of co-formulated abacavir-lamivudine-zidovudine for initial treatment of HIV infection. The secondary objectives were to evaluate the safety and tolerability of the triple drug combination. We identified 15 potentially eligible studies, four of which met our inclusion criteria. Our findings indicate that co-formulated abacavirlamivudine-zidovudine remains a viable option for initiating antiretroviral therapy, especially in HIV-infected patients with pre-existing hyperlipidaemia and those who do not tolerate ritonavir

Effectiveness of the female condom in preventing HIV and sexually transmitted infections: a systematic review and meta-analysis

Abstract Background The effectiveness of female condoms for preventing HIV and sexually transmitted infections (STIs) remains inconclusive. We examined the effects of female condoms on the acquisition of HIV and STIs. Methods We searched four databases, two trial registries, and reference lists of relevant publications in October 2018 and updated our search in February 2020. We screened search output, evaluated study eligibility, and extracted data in duplicate; resolving differences through discussion. We calculated the effective sample size of cluster randomised trials using an intra-cluster correlation coefficient of 0·03. Data from similar studies were combined in a meta-analysis. We performed a non-inferiority analysis of new condoms relative to marketed ones using a non-inferiority margin of 3%. We assessed the certainty of evidence using GRADE. Results We included fifteen studies of 6921 women. We found that polyurethane female condoms (FC1) plus male condoms may be as effective as male condoms only in reducing HIV acquisition (1 trial, n = 149 women, RR 0.07, 95%CI 0.00–1.38; low-certainty evidence). However, the use of FC1 plus male condoms is superior to male condoms alone in reducing the acquisition of gonorrhoea (2 trials, n = 790, RR 0.59, 95%CI 0.41–0.86; high-certainty evidence) and chlamydia (2 trials, n = 790, RR 0.67, 95%CI 0.47–0.94; high-certainty evidence). Adverse events and failure rates of FC1 were very low and decreased during follow up. Although the functionality of newer female condoms (Woman’s, Cupid, Pheonurse, Velvet, and Reddy) may be non-inferior to FC2, there were no available studies assessing their efficacy in preventing HIV and STIs. Conclusion The use of female plus male condoms is more effective than use of male condoms only in preventing STIs and may be as effective as the male condom only in preventing HIV. There is a need for well conducted studies assessing the effects of newer female condoms on HIV and STIs. PROSPERO registration number CRD4201809071

Hormonal contraception, sexual behaviour and HIV prevalence among women in Cameroon

<p>Abstract</p> <p>Background</p> <p>Data on the effect of contraceptive methods, other than the condom, on HIV acquisition is not clear. The aim of this study was to describe hormonal contraceptive use, sexual behaviour and HIV prevalence among women in Cameroon in order to provide baseline information for future analytical studies.</p> <p>Methods</p> <p>This is a cross-sectional descriptive study based a nationally representative sample of 4486 sexually active women aged 15–49 years who participated in the 2004 Cameroon Demographic and Health Survey.</p> <p>Results</p> <p>The overall HIV prevalence was 7.4% (332/4486). The HIV prevalence was higher in the 25–35 year age group (10.03%), urban residents (9.39%), and formerly married (18.48%), compared to their compatriots. The prevalence was lower in women with five or more living child (3.67%), women in the low wealth index category (3.79%) and women who had no formal education (3.37%). The HIV prevalence was higher among women who had two or more partners in the last 12 months (10.26%) and women who reported to have had four or more partners in their lifetime (12.40%). The prevalence of HIV was higher among current hormonal contraceptive users (6.63%) compared to the current non-users (3.06%), among ever users of hormonal contraception (13.27%) compared to the never users (7.11%).</p> <p>Conclusion</p> <p>We conclude that the prevalence of HIV among sexually active women in Cameroon varies according to sociodemographic characteristics, sexual behaviour and hormonal contraceptive use. Our findings underscore the need to counsel women using hormonal contraception to be aware that hormonal methods do not protect against HIV infection. Given the biologic plausibility of the link between hormonal contraception and HIV infection, future research should focus on carefully designed prospective studies to establish the temporal relationship and estimate the incidence of HIV infection among women using and not using hormonal contraceptive methods.</p

Acceptability of intrapartum HIV counselling and testing in Cameroon

<p>Abstract</p> <p>Background</p> <p>To assess the acceptability of intrapartum HIV testing and determine the prevalence of HIV among labouring women with unknown HIV status in Cameroon.</p> <p>Method</p> <p>The study was conducted in four hospitals (two referral and two districts hospitals) in Cameroon. Labouring women with unknown HIV status were counselled and those who accepted were tested for HIV.</p> <p>Results</p> <p>A total of 2413 women were counselled and 2130 (88.3%) accepted to be tested for HIV. Of the 2130 women tested, 214 (10.1%) were HIV positive. Acceptability of HIV testing during labour was negatively associated with maternal age, parity and number of antenatal visits, but positively associated with level of education. HIV sero-status was positively associated with maternal age, parity, number of antenatal visits and level education.</p> <p>Conclusion</p> <p>Acceptability of intrapartum HIV testing is high and the prevalence of HIV is also high among women with unknown HIV sero-status in Cameroon. We recommend an opt-out approach (where women are informed that HIV testing will be routine during labour if HIV status is unknown but each person may decline to be tested) for Cameroon and countries with similar social profiles.</p

Gynaecological morbidity among HIV positive pregnant women in Cameroon

<p>Abstract</p> <p>Objective</p> <p>To compare the prevalence of gynaecological conditions among HIV infected and non-infected pregnant women.</p> <p>Methods</p> <p>Two thousand and eight (2008) pregnant women were screened for HIV, lower genital tract infections and lower genital tract neoplasia at booking antenatal visit.</p> <p>Results</p> <p>About 10% (198/2008) were HIV positive. All lower genital tract infections except candidiasis were more prevalent among HIV positive compared to HIV negative women: vaginal candidiasis (36.9% vs 35.4%; <it>p </it>= 0.678), Trichomoniasis (21.2% vs 10.6%; <it>p </it>< 0.001), gonorrhoea (10.1% vs 2.5%; <it>p </it>< 0.001), bacterial vaginosis (21.2% vs 15.2%; <it>p </it>= 0.026), syphilis (35.9% vs 10.6%; <it>p </it>< 0.001), and <it>Chlamydia trachomatis </it>(38.4% vs 7.1%; <it>p </it>< 0.001). Similarly, HIV positive women more likely to have preinvasive cervical lesions: low-grade squamous intraepithelial lesion (SIL) (18.2% vs 4.4%; <it>p </it>< 0.001) and high-grade squamous intraepithelial lesion (12.1% vs 1.5%; <it>p </it>< 0.001).</p> <p>Conclusion</p> <p>We conclude that (i) sexually transmitted infections (STIs) are common in both HIV positive and HIV negative pregnant women in Cameroon, and (ii) STIs and preinvasive cervical lesions are more prevalent in HIV-infected pregnant women compared to their non-infected compatriots. We recommend routine screening and treatment of STIs during antenatal care in Cameroon and other countries with similar social profiles.</p

Alcohol use and extramarital sex among men in Cameroon

<p>Abstract</p> <p>Background</p> <p>The spread of HIV in sub-Saharan Africa is believed to be driven by unsafe sex, and identification of modifiable risk factors of the latter is needed for comprehensive HIV prevention programming in the region. Some previous studies suggest an association between alcohol abuse and unsafe sexual behaviour, such as multiple concurrent sexual partnerships and inconsistent condom use in sex with non-spousal non-cohabiting partners. However, most of these studies were conducted in developed countries and the few studies in Africa were conducted among well-defined social groups such as men attending beer halls or sexually transmitted infection clinics. We therefore examined the association between alcohol and extramarital sex (a sign of multiple concurrent sexual partnerships) among men in a population-based survey in Cameroon; a low-income country in sub-Saharan Africa with a high rate of alcohol abuse and a generalised HIV epidemic.</p> <p>Methods</p> <p>We analyzed data from 2678 formally married or cohabiting men aged 15 to 59 years, who participated in the 2004 Cameroon Demographic and Health Survey, using a multivariate regression model.</p> <p>Results</p> <p>A quarter of the men (25.8%) declared having taken alcohol before their last sexual intercourse and 21% indicated that the last sex was with a woman other than their wife or cohabiting partner. After controlling for possible confounding by other socio-demographic characteristics, alcohol use was significantly associated with having extramarital sex: adjusted odds ratio (OR) 1.70, 95% confidence intervals (CI) 1.40 to 2.05. Older age (30–44 years: OR 3.06, 95%CI 2.16–4.27 and 45–59 years: OR 4.10, 95%CI 2.16–4.27), higher education (OR 1.25, 95%CI 1.10–1.45), and wealth (OR 1.71, 95%CI 1.50–1.98) were also significantly associated with higher odds of having extramarital sex. The men were more likely to have used a condom in their last sex if it was extramarital (OR 10.50, 95%CI 8.10–13.66). Older age at first sex (16–19 years: OR 0.81, 95%CI 0.72–0.90 and > 19 years: OR 0.74, 95% CI 0.65–0.87) and being the head of a household (OR 0.17, 95%CI 0.14–0.22) significantly decreased the odds of having sex outside of marriage. Religion and place of residence (whether urban or rural) were not significantly associated with extramarital sex.</p> <p>Conclusion</p> <p>Alcohol use is associated with having multiple concurrent non-spousal sexual partnerships among married men in Cameroon. We cannot infer a causal relationship between alcohol abuse and unsafe sex from this cross-sectional study, as both alcohol use and unsafe sexual behaviour may have a common set of causal personal and social factors. However, given the consistency with results of studies in other settings and the biologic plausibility of the link between alcohol intake and unsafe sex, our findings underscore the need for integrating alcohol abuse and HIV prevention efforts in Cameroon and other African countries with similar social profiles.</p

Criteria for clinical audit of women friendly care and providers' perception in Malawi

Background There are two dimensions of quality of maternity care, namely quality of health outcomes and quality as perceived by clients. The feasibility of using clinical audit to assess and improve the quality of maternity care as perceived by women was studied in Malawi. Objective We sought to (a) establish standards for women friendly care and (b) explore attitudinal barriers which could impede the proper implementation of clinical audit. Methods We used evidence from Malawi national guidelines and World Health Organisation manuals to establish local standards for women friendly care in three districts. We equally conducted a survey of health care providers to explore their attitudes towards criterion based audit. Results The standards addressed different aspects of care given to women in maternity units, namely (i) reception, (ii) attitudes towards women, (iii) respect for culture, (iv) respect for women, (v) waiting time, (vi) enabling environment, (vii) provision of information, (viii) individualised care, (ix) provision of skilled attendance at birth and emergency obstetric care, (x) confidentiality, and (xi) proper management of patient information. The health providers in Malawi generally held a favourable attitude towards clinical audit: 100.0% (54/54) agreed that criterion based audit will improve the quality of care and 92.6% believed that clinical audit is a good educational tool. However, there are concerns that criterion based audit would create a feeling of blame among providers (35.2%), and that manager would use clinical audit to identify and punish providers who fail to meet standards (27.8%). Conclusion Developing standards of maternity care that are acceptable to, and valued by, women requires consideration of both the research evidence and cultural values. Clinical audit is acceptable to health professionals in Malawi although there are concerns about its negative implications to the providers

A survey of knowledge, attitudes and practice of emergency contraception among university students in Cameroon

<p>Abstract</p> <p>Background</p> <p>Unsafe abortion is a major public health problem in low-and-middle income countries. Young and unmarried women constitute a high risk group for unsafe abortions. It has been estimated that widespread use of emergency contraception may significantly reduce the number of abortion-related morbidity and mortality. The purpose of this study was to evaluate the knowledge, attitudes and experiences on emergency contraceptive pills by the university students in Cameroon in order to develop and refine a national health programme for reducing unwanted pregnancies and their associated morbidity and mortality.</p> <p>Methods</p> <p>A convenient sample of 700 students of the University of Buea (Cameroon) was selected for the study. Data was collected by a self-administered, anonymous and pre-tested questionnaire.</p> <p>Results</p> <p>The response rate was 94.9% (664/700). General level of awareness of emergency contraceptive pills was 63.0% (418/664). However, knowledge of the general features of emergency contraceptive pills was low and misinformation was high among these students. Knowledge differed according to the source of information: informal source was associated with misinformation, while medical and informational sources were associated with better knowledge. Although the students generally had positive attitudes regarding emergency contraceptive pills, up to 65.0% (465/664) believed that emergency contraceptive pills were unsafe. Those with adequate knowledge generally showed favourable attitudes with regards to emergency contraceptive pills (Mann-Whitney U = 2592.5, p = 0.000). Forty-nine students (7.4%) had used emergency contraceptive pills themselves or had a partner who had used them.</p> <p>Conclusion</p> <p>Awareness of emergency contraception pills by Cameroonian students is low and the method is still underused. Strategies to promote use of emergency contraception should be focused on spreading accurate information through medical and informational sources, which have been found to be reliable and associated with good knowledge on emergency contraceptive pills.</p