Implementation of prevention of mother-to-child transmission (PMTCT) in South Africa: outcomes from a population-based birth cohort study in Paarl, Western Cape.

OBJECTIVES: The coverage of prevention of mother-to-child transmission (PMTCT) services in South Africa is variable. Identifying gaps in the implementation of these services is necessary to isolate steps needed to further reduce paediatric infections and eliminate transmission. SETTING: Two primary care clinics in Paarl, South Africa. PARTICIPANTS: 1225 pregnant women; inclusion criteria were 18 years or older, clinic attendance and remaining in area for at least 1 year. METHODS: Data were collected through the Drakenstein Child Health Study, a population-based birth cohort in a periurban area of the Western Cape, South Africa. A combination of clinic records, hospital records, national database searches and maternal self-report were collected during the study. RESULTS: Of the 1225 mothers enrolled in the cohort between 2012 and 2015, 260 (21%) were confirmed HIV infected antenatally and 1 mother tested positive in the postnatal period. Of those with documentation (n=250/260, 96%), the majority (99%) received antiretroviral prophylaxis or therapy (ART) before labour; however, there was a high rate of defaulting from ART noted during pregnancy (20%). All HIV-exposed infants with data received antiretroviral prophylaxis, 35% were exclusively breast fed until 6 weeks and 16% for 6 months. There were two cases of infant HIV infection (0.8%) who were initiated on ART but had complicated histories. CONCLUSION: Despite the low transmission rate in this cohort, reaching elimination will require further work, and this study illustrates several areas to improve implementation of PMTCT services and reduce paediatric infections including retesting at-risk HIV-negative mothers through the duration of breast feeding, infant HIV testing at any admission in addition to routine testing and improved counselling to prevent defaulting from treatment. Better data surveillance systems are essential for determining the implementation of PMTCT guidelines

Subcortical brain volumes in young infants exposed to antenatal maternal depression: Findings from a South African birth cohort.

BACKGROUND: Several studies have reported enlarged amygdala and smaller hippocampus volumes in children and adolescents exposed to maternal depression. It is unclear whether similar volumetric differences are detectable in the infants' first weeks of life, following exposure in utero. We investigated subcortical volumes in 2-to-6 week old infants exposed to antenatal maternal depression (AMD) from a South African birth cohort. METHODS: AMD was measured with the Beck Depression Inventory 2nd edition (BDI-II) at 28-32 weeks gestation. T2-weighted structural images were acquired during natural sleep on a 3T Siemens Allegra scanner. Subcortical regions were segmented based on the University of North Carolina neonatal brain atlas. Volumetric estimates were compared between AMD-exposed (BDI-II ⩾ 20) and unexposed (BDI-II < 14) infants, adjusted for age, sex and total intracranial volume using analysis of covariance. RESULTS: Larger volumes were observed in AMD-exposed (N = 49) compared to unexposed infants (N = 75) for the right amygdala (1.93% difference, p = 0.039) and bilateral caudate nucleus (left: 5.79% difference, p = 0.001; right: 6.09% difference, p < 0.001). A significant AMD-by-sex interaction was found for the hippocampus (left: F(1,118) = 4.80, p = 0.030; right: F(1,118) = 5.16, p = 0.025), reflecting greater volume in AMD-exposed females (left: 5.09% difference, p = 0.001, right: 3.54% difference, p = 0.010), but not males. CONCLUSIONS: Volumetric differences in subcortical regions can be detected in AMD-exposed infants soon after birth, suggesting structural changes may occur in utero. Female infants might exhibit volumetric changes that are not observed in male infants. The potential mechanisms underlying these early volumetric differences, and their significance for long-term child mental health, require further investigation

The Daily Relationship Between Food Insecurity and Medication Adherence Among People Living with HIV

Limited access to resources based on social position can significantly impact health behaviors. Previous research on food insecurity and HIV has focused on establishing the relationship between food insecurity and antiretroviral (ARV) medication non-adherence in a variety of social contexts (i.e. resource poor and resource rich environments). However, one main caveat of these studies is the level of analysis. Previous studies have used cross-sectional and longitudinal studies that concentrate on the individual level of analysis. However, these study designs do not allow for a true test of whether ARV medication non-adherence occurs on days with limited access to food. The current study utilized a prospective, observational design to test the daily relationship between food insecurity and medication non-adherence. Fifty-nine adults living with HIV were enrolled. They were followed for 45 days and completed daily assessments of food insecurity and alcohol use via two way text message surveys. Participants also used Wisepill devices to assess daily medication adherence. Results showed that severe food insecurity (i.e. hunger) significantly predicted missed doses of medication on a daily level. This relationship was moderated by alcohol use but not geospatial factors. Additionally, psychosocial factors did not mediate this relationship. There are several potential explanations for this daily relationship including competing resource demands and food requirements of prescriptions. Future research should tease apart these potential explanations in order to better understand the daily relationship between food insecurity and medication non-adherence and the ways that we can intervene

Just-in-Time Mobile Behavioral Self-Regulation Medication Adherence Counseling Intervention for People Living with HIV/AIDS: A Test of Concept

Sub-optimal antiretroviral adherence is a serious problem among people living with HIV (PLWH) that can lead to virologic rebound, resistance to medication regimens, and poor health outcomes. Emerging technologies allow for the detection of potential missed doses in real time as a possible point of intervention. Using these sensory technologies, this test of concept intervention trial was designed to target possible missed doses and initiate just-in-time self-regulation adherence counseling. The purpose of this study was to assess the acceptability, feasibility and potential efficacy of a just-in-time adherence counseling intervention using a Wisepill electronic pillbox device. Overall, there was trending evidence for greater medication adherence for those in the intervention condition (d=0.21). Additionally, the majority of participants found both the device and the intervention acceptable. However, the intervention had low feasibility. Only a small number (11.7%) of missed doses were able to be counseled. Thus, utilizing the Wisepill device for intervention initiation may not be the best way to use this device to increase medication adherence among PLWH. However, the opportunities that the Wisepill device and others like it afford have not yet been fully elucidated

A Pandemic of the Poor

The U.S. HIV/AIDS epidemic has evolved over the past 30 years and is now concentrated in socially marginalized and disenfranchised communities. The health disparities in this epidemic are striking, with most HIV infections occurring in sexual minorities and communities of color. While widely recognized, the health disparities in HIV and AIDS are not often discussed. In this article, we examine the factors underlying health disparities in the U.S. HIV epidemic. We first discuss the interlocking relationships between biological, social, and behavioral factors that drive HIV/AIDS epidemics. Guided by a well-established conceptual model of health disparities, we then describe the social positions of those most affected by HIV and AIDS, particularly racial and gender groups. Structural and economic conditions-including environmental resources, constraints, access to care, and psychosocial influences-are examined in relation to HIV disease trajectories. Greater attention to contextual factors and comorbidities is needed to reduce the health disparities in HIV/AIDS