Ecological Study of HIV Infection and Hypertension in Sub-Saharan Africa: Is There a Double Burden of Disease?

An ecological correlation study of the prevalence of hypertension with human immunodeficiency virus (HIV) prevalence in sub-Saharan Africa was conducted to determine the extent to which these conditions coincide at country level. Data on prevalence of hypertension were derived from a systematic search of literature published between 1975 and 2014 with corresponding national estimates on HIV prevalence and antiretroviral therapy (ART) coverage from the Demographic and Health Surveys and the joint United Nations Programme on HIV/AIDS databases. National estimates on gross national income (GNI) and under-five mortality were obtained from the World Bank database. Linear regression analyses using robust standard errors (allowing for clustering at country level) were carried out for associations of age-standardised hypertension prevalence ratios (standardized to rural Uganda’s hypertension prevalence data) with HIV prevalence, adjusted for national indicators, year of study and sex of the study population. In total, 140 estimates of prevalence of hypertension representing 25 nations were sex-and area-matched with corresponding HIV prevalence. A two-fold increase in HIV prevalence was associated with a 9.29% increase in age, sex and study year-adjusted prevalence ratio for hypertension (95% CI 2.0 to 16.5, p = 0.01), which increased to 16.3% (95% CI 9.3 to 21.1) after adjusting for under-five mortality, GNI per capita and ART coverage. Countries with a pronounced burden of HIV may also have an increased burden of non-communicable diseases such as hypertension with potential economic and health systems implications

Choosing where to give birth: Factors influencing migrant women’s decision making in two regions of Thailand

Background: Choosing where to give birth can be a matter of life and death for both mother and child. Migrants, registered or unregistered, may face different choices and challenges than non-migrants. Despite this, previous research on the factors migrant women consider when deciding where to give birth is very limited. This paper addresses this gap by examining women’s decision making in a respective border and urban locale in Thailand. Methods: We held focus group discussions [13] with 72 non-Thai pregnant migrant women at non-government clinics in a rural border area and at two hospitals in Chiang Mai, a large city in Northern Thailand in 2018. We asked women where they will go to give birth and to explain the factors that influenced their decision. Results: Women identified getting the relevant documentation necessary to register their child’s birth, safe birth and medical advice/quality care, as the top three factors that influenced their care seeking decision making. Language of service, free or low cost care, language of services, proximity to home, and limited alternate options for care were also identified as important considerations. Conclusion: Understanding factors that migrant women value when choosing where to deliver can help health care providers to create services that are responsive to migrants’ preferences and encourage provision of relevant information which may influence patient decision making. The desire to obtain birth documentation for their child appears to be important for migrants who understand the importance of personal documentation for the lives of their children. Healthcare institutions may wish to introduce processes to facilitate obtaining documentation for pregnant migrant women and their newborns.</p

Chiang Mai University Health Worker Study aiming toward a better understanding of noncommunicable disease development in Thailand: methods and description of study population

Chaisiri Angkurawaranon,1,2&nbsp;Anawat Wisetborisut,2&nbsp;Wichuda Jiraporncharoen,2&nbsp;Surinporn Likhitsathian,3&nbsp;Ronnaphob Uaphanthasath,2&nbsp;Patama Gomutbutra,2&nbsp;Surin Jiraniramai,2&nbsp;Chawin Lerssrimonkol,2 Apinun Aramrattanna,2 Pat Doyle,1&nbsp;Dorothea Nitsch1 1Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK; 2Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; 3Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Background: Urbanization is considered to be one of the key drivers of noncommunicable diseases (NCDs) in Thailand and other developing countries. These influences, in turn, may affect an individual&#39;s behavior and risk of developing NCDs. The Chiang Mai University (CMU) Health Worker Study aims to provide evidence for a better understanding of the development of NCDs and ultimately to apply the evidence toward better prevention, risk modification, and improvement of clinical care for patients with NCDs and NCD-related conditions. Methods: A cross-sectional survey of health care workers from CMU Hospital was conducted between January 2013 and June 2013. Questionnaires, interviews, and physical and laboratory examinations were used to assess urban exposure, occupational shift work, risk factors for NCDs, self-reported NCDs, and other NCD-related health conditions. Results: From 5,364 eligible workers, 3,204 participated (59.7%). About 11.1% of the participants had high blood pressure (systolic blood pressure &ge;140 mmHg or diastolic blood pressure &ge;90 mmHg) and almost 30% were considered to be obese (body mass index &ge;25 kg/m2). A total of 2.3% had a high fasting blood glucose level (&ge;126 mg/dL), and the most common abnormal lipid profile was high low-density lipoprotein (&ge;160 mg/dL), which was found in 19.2% of participants. Discussion: The study of health workers offers three potential advantages. The first is that the study of migrants was possible. Socioenvironmental influence on NCD risk factors can be explored, as changes in environmental exposures can be documented. Second, it allows the investigators to control for access to care. Access to care is potentially a key confounder toward understanding the development of NCDs. Lastly, a study of health personnel allows easy access to laboratory investigations and potential for long-term follow-up. This enables ascertainment of a number of clinical outcomes and provides potential for future studies focusing on therapeutic and prognostic issues related to NCDs. Keywords: urbanization, noncommunicable disease, risk factors, Thailan

Tenofovir for prevention of mother to child transmission of hepatitis B in migrant women in a resource-limited setting on the Thailand-Myanmar border: a commentary on challenges of implementation

BACKGROUND:The aim of this manuscript is to highlight challenges in the implementation of maternal tenofovir disoproxil fumarate (tenofovir) for prevention of mother to child transmission (PMTCT) of hepatitis B virus (HBV) in resource limited setting. Current preventive strategies in resource-limited settings fail mainly due to prohibitive costs of hepatitis B immunoglobulin (HBIG) and a high proportion of homebirths, meaning both HBIG and hepatitis B birth dose vaccine are not given. A new strategy for PMTCT without the necessity of HBIG, could be daily tenofovir commenced early in gestation. Implementation challenges to early tenofovir for PMTCT can provide insight to elimination strategies of HBV as the burden of disease is high in resource-limited settings. METHODS:Challenges encountered during implementation of a study of tenofovir for PMTCT before 20&#x2009;weeks gestation in rural and resource-limited areas on the Thailand-Myanmar border were identified informally from trial study logbooks and formally from comments from patients and staff at monthly visits. ClinicalTrials.gov Identifier: NCT02995005. MAIN BODY:During implementation 171 pregnant women were hepatitis B surface antigen (HBsAg) positive by point of-care test over 19&#x2009;months (May-2018 until Dec-2019). In this resource-limited setting where historically no clinic has provided tenofovir for PMTCT of HBV, information provided by staff resulted in a high uptake of study screening (95.5% (84/88) when offered to pregnant women. False positive point-of-care rapid tests hinder a test and treat policy for HBV and development of improved rapid tests that include HBeAg and/or HBV DNA would increase efficiency. Integrated care of HBV to antenatal care, transport assistance and local agreements to facilitate access, could increase healthcare at this critical stage of the life course. As safe storage of medication in households in resource-limited setting may not be ideal, interactive counseling about this must be a routine part of care. CONCLUSION:Despite challenges, results from the study to date suggest tenofovir can be offered to HBV-infected women in resource-limited settings before 20&#x2009;weeks gestation with a high uptake of screening, high drug accountability and follow-up, with provision of transportation support. This commentary has highlighted practical implementation issues with suggestions for strategies that support the objective of PMTCT and the World Health Organization goal of HBV elimination by 2030

Challenges of implementing tenofovir disoproxil fumarate in pregnancy for prevention of hepatitis B mother to child transmission in a rural population

Background: Hepatitis B is highly endemic in south-east Asia with the most common route of transmission being from mother to child. In rural settings, current preventive strategies with hepatitis B immunoglobulins and vaccinations fail due to costs, need for cold chain, homebirths, and transportation difficulties. A new strategy for prevention of mother to child transmission (PMTCT) could be early (<20 weeks gestation) daily tenofovir disoproxil fumarate (TDF), a potent antiviral agent that is safe in pregnancy. Assessment of barriers to early TDF for PMTCT-Hep B is important before possible implementation. Methods & Materials: Narrative and visual review of start-up challenges encountered during implementation of a study of TDF for PMTCT before 20 weeks gestation in rural areas on the Thailand-Myanmar border. ClinicalTrials.gov Identifier: NCT02995005. Results: Major challenges of implementation from June 2018 to September 2019 included: gestation of pregnancy at presentation, point-of-care (POC)-testing reliability, tablet storage and handling. Overall, 156 women tested positive for HBsAg by Rapid Diagnostic Test (RDT) POC-testing but late presentation (≥20 weeks) was common: 53% (83/156). In women <20 weeks gestation with positive-HBsAg, consent for study screening was 89.0% (65/73). Exclusion after RDT-testing was 21.5% (14/65): three had a negative HBsAg at confirmation, nine had an undetectable viral load, two had elevated phosphate levels. Daily ambient temperatures were high: only 3/365 days (0.8%) were within manufacturer recommended TDF storage temperatures (20–25 °C), and for 187 days of the year the temperature was 30 °C. Drug accountability was high but one in 10 of the women reported incidents of tablet misplacement: “pills dropped though the [bamboo] floor and fell in the mud”, “children played with the bottle”. Financial support of transportation resulted in follow-up rates of 84.3% (43/51) attending all of the expected appointments. The missed appointments were highest in rainy season when the rivers become impassable, 62.5% (5/8). Conclusion: Improved public awareness of the benefits or early antenatal care, better RDT-tests, and confirmation of TDF bioavailability at higher ambient temperatures, are important in the rural tropics for prevention of mother to child transmission for hepatitis B programs

'Because the baby asks for it': A mixed-methods study on local perceptions toward nutrition during pregnancy among marginalised migrant women along the Myanmar-Thailand border

Background Under- and over-nutrition during pregnancy are known risk factors for pregnancy complications and adverse pregnancy and infant outcomes. Understanding perceptions around nutrition in pregnancy can create culturally appropriate interventions for improved health outcomes. Objective A mixed-methods study was performed to explore local perceptions and practices of diet and physical activity in pregnancy in a marginalised population along the Myanmar– Thailand border. Methods From April to July 2017, a cross-sectional survey and focus group discussions were conducted with pregnant women reporting to antenatal care; in-depth interviews were conducted with senior midwives at participating organisations along the Myanmar– Thailand border. Results A total of 388 pregnant women were interviewed at two clinic sites along the Myanmar–Thailand border. A high proportion of women had limited knowledge of and poor dietary practices. Consuming a sweetened drink in the last 24 hours as well as being a non-teenage, multigravida woman was significantly associated with high body mass index (BMI) compared to normal BMI. Qualitative analysis combined focus group discussions (n = 66) and in-depth interviews (n = 4) summarising emergent themes: common foods eaten or avoided and rationale; benefits of nutrition; perceptions of overweight and weight gain during pregnancy; barriers to a healthy diet; and sources of diet information. Conclusions There is limited awareness about healthy diets and lifestyle in these marginalised, migrant communities along the Myanmar–Thailand border. This study suggests that simple, culturally appropriate messaging should be provided to women and communities with low health literacy to generate awareness about healthy lifestyles and their effects on pregnancy outcomes as an important element of a broader strategy to address maternal nutrition in this population. However, more studies to determine the effectiveness of a broad range of interventions in low- and middle-income countries (LMIC) are needed, especially in marginalised migrant populations.</p

Tenofovir for prevention of mother to child transmission of hepatitis B in migrant women in a resource-limited setting on the Thailand-Myanmar border: a commentary on challenges of implementation

BACKGROUND: The aim of this manuscript is to highlight challenges in the implementation of maternal tenofovir disoproxil fumarate (tenofovir) for prevention of mother to child transmission (PMTCT) of hepatitis B virus (HBV) in resource limited setting. Current preventive strategies in resource-limited settings fail mainly due to prohibitive costs of hepatitis B immunoglobulin (HBIG) and a high proportion of homebirths, meaning both HBIG and hepatitis B birth dose vaccine are not given. A new strategy for PMTCT without the necessity of HBIG, could be daily tenofovir commenced early in gestation. Implementation challenges to early tenofovir for PMTCT can provide insight to elimination strategies of HBV as the burden of disease is high in resource-limited settings. METHODS: Challenges encountered during implementation of a study of tenofovir for PMTCT before 20 weeks gestation in rural and resource-limited areas on the Thailand-Myanmar border were identified informally from trial study logbooks and formally from comments from patients and staff at monthly visits. ClinicalTrials.gov Identifier: NCT02995005. MAIN BODY: During implementation 171 pregnant women were hepatitis B surface antigen (HBsAg) positive by point of-care test over 19 months (May-2018 until Dec-2019). In this resource-limited setting where historically no clinic has provided tenofovir for PMTCT of HBV, information provided by staff resulted in a high uptake of study screening (95.5% (84/88) when offered to pregnant women. False positive point-of-care rapid tests hinder a test and treat policy for HBV and development of improved rapid tests that include HBeAg and/or HBV DNA would increase efficiency. Integrated care of HBV to antenatal care, transport assistance and local agreements to facilitate access, could increase healthcare at this critical stage of the life course. As safe storage of medication in households in resource-limited setting may not be ideal, interactive counseling about this must be a routine part of care. CONCLUSION: Despite challenges, results from the study to date suggest tenofovir can be offered to HBV-infected women in resource-limited settings before 20 weeks gestation with a high uptake of screening, high drug accountability and follow-up, with provision of transportation support. This commentary has highlighted practical implementation issues with suggestions for strategies that support the objective of PMTCT and the World Health Organization goal of HBV elimination by 2030

Prevention of mother-to-child transmission of hepatitis B virus: protocol for a one-arm, open-label intervention study to estimate the optimal timing of tenofovir in pregnancy

INTRODUCTION:Hepatitis B virus (HBV) remains a public health threat and the main route of transmission is from mother to child (MTCT). Tenofovir disoproxil fumarate (TDF) treatment can reduce MTCT of HBV although the optimal timing to attain undetectable HBV DNA concentrations at delivery is unknown. This protocol describes the procedures following early initiation of maternal TDF prior to 20 weeks gestation to determine efficacy, safety and feasibility of this approach in a limited-resource setting. METHODS AND ANALYSES:One hundred and seventy pregnant women from the Thailand-Myanmar border between 12 and &lt;20 weeks gestational age will be enrolled into a one-arm, open-label, TDF treatment study with cessation of TDF 1&#x2009;month after delivery. Sampling occurs monthly prenatal, at birth and at 1, 2, 4 and 6 months post partum. Measurement of tenofovir concentrations in maternal and cord plasma is anticipated in 10-15 women who have detectable HBV DNA at delivery and matched to 20-30 women with no detectable HBV DNA. Infant HBsAg status will be determined at 2&#x2009;months of age and HBV DNA confirmed in HBsAg positive cases. Adverse events including risk of flare and adherence, based on pill count and questionnaire, will be monitored. Infants will receive HBV vaccinations at birth, 2, 4 and 6 months and hepatitis B immunoglobulin at birth if the mother is hepatitis B e antigen positive. Infant growth and neurodevelopment at 6&#x2009;months will be compared with established local norms. ETHICS AND DISSEMINATION:This study has ethical approval by the Ethics Committee of the Faculty of Tropical Medicine, Mahidol University (FTM ECF-019-06), Johns Hopkins University (IRB no: 00007432), Chiang Mai University (FAM-2559-04227), Oxford Tropical Research Ethics Committee (OxTREC Reference: 49-16) and by the local Tak Community Advisory Board (TCAB-02/REV/2016). The article will be published as an open-access publication. TRIAL REGISTRATION NUMBER:NCT02995005, Pre-results