Estimates of the impact of HIV infection on fertility in a rural Ugandan population cohort

Fertility rates in a population-based cohort of over 3500 women aged 15-49 years living in rural southwest Uganda are described and examined in relation to infection with HIV. Over a six-year follow-up period (1989/90 to 1995/6) the average general fertility rate was estimated as 199 births per thousand woman-years of observation (95 % confidence interval 191 to 207) with a total fertility rate of 6.2 births per woman. The overall prevalence of infection with HIV was 12 per cent and remained relatively stable during follow-up. With the exception of women aged 15-19 years, women who were not infected with HIV had higher fertility than HIV-infected women. The overall age-adjusted fertility rate in HIV-infected women was 0.74 of that of uninfected women (95% confidence interval 0.63 to 0.87, P<0.001) and this result was unaffected by additional adjustment for marital status. When combined with an overall HIV prevalence rate of 12 per cent, this corresponds to a three per cent reduction in fertility rates in the whole population. The lower fertility in HIV-positive women is unlikely to be explained by increased use of contraception, as use of modern contraceptive methods in rural Uganda is low and fewer than ten per cent of women are aware of their HIV-serostatus. More likely explanations are reduced sexual activity due to clinical symptoms associated with HIV infection or lower fertility associated with coexisting infections with other sexually transmitted diseases, such as syphilis. A reduction in fertility caused by HIV infection itself cannot be excluded. The implications of these findings for the use of antenatal clinic data to provide population estimates of HIV prevalence are discussed

HIV genotypic resistance among pregnant women initiating ART in Uganda: a baseline evaluation of participants in the Option B+ clinical trial

Background: Pre-treatment HIV drug resistance is a threat to elimination of mother to child HIV transmission and could lead to virological failure among HIV-positive pregnant women. We analysed genotypic HIV drug resistance (HIVDR) of baseline samples of participants enrolled in the Option B+ clinical trial in Uganda.Methods: HIV-infected pregnant women attending antenatal care were enrolled from Uganda’s National Referral Hospital (Mulago) and Mityana District general hospital and surrounding health centers (HCs). Genotypic HIV testing was performed on blood samples from the first 135 enrolled women out of a subset of 136 participants (25%) who had a baseline VL&gt;1000 copies/mL as one sample failed to amplify.Results: 159/540 (29.4%) had a VL &lt; 1000 copies/ml and 381/540 (70.6%) had a VL &gt;1,000 copies/ml. Of the women with VL&gt;1000 copies/ml, 32 (23.7%) had resistance mutations including 29/135 (21.5%) NNRTI mutations, 6/135 (4.4%) NRTI mutations and 3/135 (2.2%) had both NNRTI and NRTI mutations. The most common NNRTI resistance mutations were: K103KN (5), K103N (5), V179T (4) and E138A (4).Conclusions: One quarter of the HIV-infected pregnant women in this trial at baseline had NNRTI genotypic resistance mutations. Our findings support new WHO guidelines for first-line ART that were changed to dolutegravir-based regimens

Reproductive Intentions and Outcomes among Women on Antiretroviral Therapy in Rural Uganda: A Prospective Cohort Study

Background: Antiretroviral therapy (ART) may influence the biological, social and behavioral determinants of pregnancy in HIV-infected women. However, there are limited longitudinal data on the reproductive intentions and outcomes among women on ART in Africa. Methodology /Principal Findings: Using a prospective cohort design, we analyzed trends in desire for children and predictors of pregnancy among a cohort of 733 HIV-infected women in rural Uganda who initiated ART between May 2003 and May 2004 and were followed up in their homes until June 2006. Women answered in-depth social and behavioral questionnaires administered every quarter in year 1 after initiating ART, and every 6 to 12 months thereafter. Use of family planning methods was assessed at 18 and 24 months after starting ART. We tested for non-constant pregnancy incidence by using a shape parameter test from the Weibull distribution. We modeled repeated measurements of all variables related to the women’s desire for children over time using a generalized estimating equation (GEE) extension to the logistic regression model. Risk factors for pregnancy were examined using Cox proportional hazards model. 711 women eligible for the study were followed-up for a median time of 2.4 years after starting ART. During this time, less than 7 % of women reported wanting more children at any time point yet 120 (16.9%) women experienced 140 pregnancies and pregnancy incidence increased from 3.46 per 100 women-years (WY) in the first quarter to 9.5 per 100 WY at 24 months (p,0.0001). This wa

Ten-year trends of syphilis in sero-surveillance of pregnant women in Rwanda and correlates of syphilis-HIV co-infection

Syphilis can be transmitted by pregnant women to their children and is a public health problem in Africa. A cross-sectional survey was conducted in 24 antenatal clinics from 2002 to 2003 and increased to 30 sites from 2005 to 2011. Participants were tested for syphilis and HIV. Multi-variate logistic regression was performed to identify risks associated with syphilis and its co-infection with HIV. Results showed that syphilis decreased from 3.8% in 2002 to 2.0% in 2011. Syphilis in the HIV-infected participants increased from 6.0% in 2002 to 10.8% in 2011, but decreased from 3.7% to 1.7% in the HIV-negative participants. In 2011, syphilis in urban participants was 2.7% and 1.4% in rural ones. HIV-infected participants screened positive for syphilis more frequently in both rural (aOR = 3.64 [95% CI: 1.56%-8.51%]) and urban areas (aOR = 7.26 [95% CI: 5.04%-10.46%]). Older participants (25-49 years) residing in urban areas (aOR = 0.43[95% CI: 0.32%-0.58%]) and women with secondary or high education (aOR = 0.35[95% CI: 0.20%-0.62%]) were less likely to screen positive for syphilis. HIV-syphilis co-infection was more likely in women residing in urban areas (aOR = 8.32[95% CI: 3.54%-19.56%]), but less likely in women with secondary/high education (aOR = 0.11[95% CI: 0.01%-0.77%]). In conclusion, syphilis increased in HIV-positive pregnant women, but decreased in HIV-negative women. Positive HIV status and young age were associated risks for syphilis. HIV-syphilis co-infection was associated with a lower level of education and urban residence

Hepatitis B virus and HIV co-infection among pregnant women in Rwanda

Background Hepatitis B virus (HBV) affects people worldwide but the local burden especially in pregnant women and their new born babies is unknown. In Rwanda HIV-infected individuals who are also infected with HBV are supposed to be initiated on ART immediately. HBV is easily transmitted from mother to child during delivery. We sought to estimate the prevalence of chronic HBV infection among pregnant women attending ante-natal clinic (ANC) in Rwanda and to determine factors associated with HBV and HIV co-infection. Methods This study used a cross-sectional survey, targeting pregnant women in sentinel sites. Pregnant women were tested for hepatitis B surface antigen (HBsAg) and HIV infection. A series of tests were done to ensure high sensitivity. Multivariable logistic regression was used to identify independent predictors of HBV-HIV co-infection among those collected during ANC sentinel surveillance, these included: age, marital status, education level, occupation, residence, pregnancy and syphilis infection. Results The prevalence of HBsAg among 13,121 pregnant women was 3.7% (95% CI: 3.4–4.0%) and was similar among different socio-demographic characteristics that were assessed. The proportion of HIV-infection among HBsAg-positive pregnant women was 4.1% [95% CI: 2.5–6.3%]. The prevalence of HBV-HIV co-infection was higher among women aged 15-24 years compared to those women aged 25–49 years [aOR = 6.9 (95% CI: 1.8–27.0)]. Women residing in urban areas seemed having HBV-HIV co-infection compared with women residing in rural areas [aOR = 4.3 (95% CI: 1.2–16.4)]. Women with more than two pregnancies were potentially having the co-infection compared to those with two or less (aOR = 6.9 (95% CI: 1.7–27.8). Women with RPR-positive test were seemed associated with HBV-HIV co-infection (aOR = 24.9 (95% CI: 5.0–122.9). Conclusion Chronic HBV infection is a public health problem among pregnant women in Rwanda. Understanding that HBV-HIV co-infection may be more prominent in younger women from urban residences will help inform and strengthen HBV prevention and treatment programmes among HIV-infected pregnant women, which is crucial to this population.Medicine, Faculty ofNon UBCPopulation and Public Health (SPPH), School ofReviewedFacult

Cango Lyec (Healing the Elephant): Chronic Hepatitis B Virus among post-conflict affected populations living in mid-Northern Uganda.

BackgroundThe legacy of war in Northern Uganda continues to impact people's health and wellbeing in the Acholi region. Despite increasing attention to Hepatitis B Virus (HBV) in Uganda and globally, concerns remain that unique drivers of infection, and barriers to screening, and treatment, persist among those affected by conflict.MethodsCango Lyec (Healing the Elephant) cohort survey involved conflict-affected adults aged 13-49 in three mid-Northern Uganda districts (Gulu, Amuru and Nwoya). Baseline (2011-2012) samples were tested for HBV surface antigen (HBsAg), HBV e-antigen (HBeAg), antibodies to HBV surface antigen (HBsAb), antibodies to HBV e-antigen (HBeAb), and antibodies to HBV core antigen (HBcAb). All HBsAg positive samples were tested for IgM antibodies to HBV B core antigen (HBc-IgM) and where available, >6-month follow-up samples were tested for HBeAg and HBV DNA. Data were analyzed using STATA 15 software. Logistic regression accounted for variance due to complex two-stage sampling that included stratification, unequal selection probabilities and community clustering. Odds ratios measured effect potential risk factors associated with chronic HBV infection.ResultsAmong 2,421 participants, 45.7% were still susceptible to HBV infection. HBsAg seropositivity was 11.9% (10.9-13.0), chronic HBV was 11.6% (10.4-12.8), acquired immunity resulting from vaccination was 10.9%, and prior natural infection was 31.5%. Older age (OR:0.570; 95%CI:0.368-0.883) and higher education (OR:0.598; 95%CI:0.412-0.868) were associated with reduced odds of chronic HBV infection. Being male (OR:1.639; 95%CI:1.007-2.669) and having been abducted (OR:1.461; 95%CI:1.055-2.023) were associated with increased odds of infection. Among women, having 1 or 2 pregnancies (compared to none or >2) was associated with increased odds of infection (OR:1.764; 95%CI:1.009-3.084).ConclusionChronic HBV is endemic in Gulu, Amuru and Nwoya districts. Recommended strategies to reduce post-conflict prevalence include establishment of Northern Uganda Liver Wellness Centres, integration of screening and treatment into antenatal care, and roll out of birth-dose vaccination

High HIV prevalence and associated risk factors among female sex workers in Rwanda

Human immunodeficiency virus (HIV) prevalence is often high among female sex workers (FSWs) in sub-Saharan Africa. Understanding the dynamics of HIV infection in this key population is critical to developing appropriate prevention strategies. We aimed to describe the prevalence and associated risk factors among a sample of FSWs in Rwanda from a survey conducted in 2010. A cross-sectional biological and behavioral survey was conducted among FSWs in Rwanda. Time-location sampling was used for participant recruitment from 4 to 18 February 2010. HIV testing was done using HIV rapid diagnostic tests (RDT) as per Rwandan national guidelines at the time of the survey. Elisa tests were simultaneously done on all samples tested HIV-positive on RDT. Proportions were used for sample description; multivariable logistic regression model was performed to analyze factors associated with HIV infection. Of 1338 women included in the study, 1112 consented to HIV testing, and the overall HIV prevalence was 51.0%. Sixty percent had been engaged in sex work for less than five years and 80% were street based. In multivariable logistic regression, HIV prevalence was higher in FSWs 25 years or older (adjusted odds ratio [aOR] = 1.83, 95% [confidence interval (CI): 1.42-2.37]), FSWs with consistent condom use in the last 30 days (aOR = 1.39, [95% CI: 1.05-1.82]), and FSWs experiencing at least one STI symptom in the last 12 months (aOR = 1.74 [95% CI: 1.34-2.26]). There was an inverse relationship between HIV prevalence and comprehensive HIV knowledge (aOR = 0.65, [95% CI: 0.48-0.88]). HIV prevalence was high among a sample of FSWs in Rwanda, and successful prevention strategies should focus on HIV education, treatment of sexually transmitted infections, and proper and consistent condom use using an outreach approach