Prevalence and risk factors of unsuppressed viral load among pregnant and breastfeeding women in sub-Saharan Africa:analysis from population-based surveys

Objective: To examine the prevalence of viral suppression and risk factors for unsuppressed viral load among pregnant and breastfeeding women living with HIV (WLH).Design: Pooled analysis among pregnant and breastfeeding WLH from Population-Based HIV Impact Assessment (PHIA) cross-sectional surveys from 10 sub-Saharan African countries.Methods: Questionnaires included sociodemographic, relationship-related, and HIV-related items, while blood tests examined HIV serostatus and viral load (data collected 2015-2018). The weighted prevalence of viral suppression was calculated. Logistic regression was used to examine risk factors for unsuppressed viral load (≥1000 copies/mL). Results: Of 1685 pregnant or breastfeeding WLH with viral load results, 63.8% (95% CI:60.8-66.7%) were virally suppressed at the study visit. Among all included women, adolescence (aOR: 4.85, 95% CI:2.58-9.14, pConclusion: Viral suppression among pregnant and breastfeeding WLH in sub-Saharan Africa remains suboptimal. Relationship dynamics around non-disclosure of HIV-positive status to partners was an important risk factor for unsuppressed viral load. Improving HIV care via sensitive discussions around partner dynamics in pregnant and breastfeeding women could improve maternal HIV outcomes and prevention of mother-to-child transmission of HIV (PMTCT).<br/

Sexual violence and antiretroviral adherence among women of reproductive age in African population-based surveys: the moderating role of the perinatal phase

INTRODUCTION: Women face challenges in antiretroviral therapy (ART) adherence and achieving viral suppression despite progress in the expansion of HIV treatment. Evidence suggests that violence against women (VAW) is an important determinant of poor ART adherence in women living with HIV (WLH). In our study, we examine the association of sexual VAW and ART adherence among WLH and assess whether this association varies by whether women are pregnant/breastfeeding or not. METHODS: A pooled analysis was conducted among WLH from Population-Based HIV Impact Assessment cross-sectional surveys (2015-2018) from nine sub-Saharan African countries. Logistic regression was used to examine the association between lifetime sexual violence and suboptimal ART adherence (≥1 missed day in the past 30 days) among reproductive age WLH on ART, and to assess whether there was any evidence for interaction by pregnancy/breastfeeding status, after adjusting for key confounders. RESULTS: A total of 5038 WLH on ART were included. Among all included women, the prevalence of sexual violence was 15.2% (95% confidence interval [CI]: 13.3%-17.1%) and the prevalence of suboptimal ART adherence was 19.8% (95% CI: 18.1%-21.5%). Among only pregnant and breastfeeding women, the prevalence of sexual violence was 13.1% (95% CI: 9.5%-16.8%) and the prevalence of suboptimal ART adherence was 20.1% (95% CI: 15.7%-24.5%). Among all included women, there was evidence for an association between sexual violence and suboptimal ART adherence (adjusted odds ratio [aOR]: 1.69, 95% CI: 1.25-2.28). There was evidence that the association between sexual violence and ART adherence varied by pregnant/breastfeeding status (p = 0.004). Pregnant and breastfeeding women with a history of sexual violence had higher odds of suboptimal ART adherence (aOR: 4.11, 95% CI: 2.13-7.92) compared to pregnant and breastfeeding women without a history of sexual violence, while among non-pregnant and non-breastfeeding women, this association was attenuated (aOR: 1.39, 95% CI: 1.00-1.93). CONCLUSIONS: Sexual violence is associated with women's suboptimal ART adherence in sub-Saharan Africa, with a greater effect among pregnant and breastfeeding WLH. To improve women's HIV outcomes and to achieve the elimination of vertical transmission of HIV, violence prevention efforts within maternity services and HIV care and treatment should be a policy priority

Intimate partner violence against women during pregnancy: a systematic review and meta-analysis protocol for producing global and regional estimates

BACKGROUND: Intimate partner violence is a devastating human rights violation and public health problem with high prevalence rates globally. Intimate partner violence during pregnancy is associated with devastating maternal, perinatal, and neonatal health effects. We present the protocol for a systematic review and meta-analysis to estimate the global lifetime prevalence of intimate partner violence during pregnancy. METHODS: This review aims to systematically synthesize the evidence on the global prevalence of violence against women by intimate partners during pregnancy using available population-based data. A comprehensive search of MEDLINE, EMBASE, Global Health, PsychInfo, and Web of Science databases will be conducted to identify all relevant articles. Manual searches will be conducted in Demographic and Health Survey (DHS) data reports and websites of national statistics and/or other offices. DHS data analysis will also be conducted. Based on inclusion and exclusion criteria, titles and abstracts will be screened for eligibility. Then, full-text articles will be assessed for eligibility. The following data will be extracted from included articles: study characteristics, population characteristics (e.g., ever-partnered, currently partnered, or any women, and age range), violence characteristics (e.g., type of violence, and perpetrator), estimate type (e.g., intimate partner violence during any pregnancy or during last pregnancy), subpopulation type (e.g., by age, marital status, urban/rural), prevalence estimate, and key quality indicators. A hierarchical Bayesian meta-regression framework will be used. This multilevel modelling approach will use survey-specific, country-specific, and region-specific random effects to pool observations. This modelling technique will be used to estimate global and regional prevalence. DISCUSSION: This systematic review and meta-analysis will provide estimates on the global and regional prevalence of intimate partner violence during pregnancy and contribute to monitoring progress towards Sustainable Development Goal (SDG) Target 5.2 on eliminating violence against women and to SDG Targets 3.1 and 3.2 on reducing maternal mortality and neonatal mortality. Given the significant health impacts of intimate partner violence during pregnancy, potential for intervention, and urgency to address violence and improve health, this review will provide critical evidence to governments, non-governmental organizations, and policymakers on the magnitude of violence during pregnancy. It will also inform effective policies and programs to prevent and respond to intimate partner violence during pregnancy. SYSTEMATIC REVIEW REGISTRATION: PROSPERO ID CRD42022332592

The landscape for HIV pre-exposure prophylaxis during pregnancy and breastfeeding in Malawi and Zambia: A qualitative study.

High HIV incidence rates have been observed among pregnant and breastfeeding women in sub-Saharan Africa. Oral pre-exposure prophylaxis (PrEP) can effectively reduce HIV acquisition in women during these periods; however, understanding of its acceptability and feasibility in antenatal and postpartum populations remains limited. To address this gap, we conducted in-depth interviews with 90 study participants in Malawi and Zambia: 39 HIV-negative pregnant/breastfeeding women, 14 male partners, 19 healthcare workers, and 18 policymakers. Inductive and deductive approaches were used to identify themes related to PrEP. As a public health intervention, PrEP was not well-known among patients and healthcare workers; however, when it was described to participants, most expressed positive views. Concerns about safety and adherence were raised, highlighting two critical areas for community outreach. The feasibility of introducing PrEP into antenatal services was also a concern, especially if introduced within already strained health systems. Support for PrEP varied among policymakers in Malawi and Zambia, reflecting the ongoing policy discussions in their respective countries. Implementing PrEP during the pregnancy and breastfeeding periods will require addressing barriers at the individual, facility, and policy levels. Multi- level approaches should be considered in the design of new PrEP programs for antenatal and postpartum populations

Pain coping skills training for African Americans with osteoarthritis (STAART): study protocol of a randomized controlled trial

Background: African Americans bear a disproportionate burden of osteoarthritis (OA), with higher prevalence rates, more severe pain, and more functional limitations. One key barrier to addressing these disparities has been limited engagement of African Americans in the development and evaluation of behavioral interventions for management of OA. Pain Coping Skills Training (CST) is a cognitive-behavioral intervention with shown efficacy to improve OA-related pain and other outcomes. Emerging data indicate pain CST may be a promising intervention for reducing racial disparities in OA symptom severity. However, there are important gaps in this research, including incorporation of stakeholder perspectives (e.g. cultural appropriateness, strategies for implementation into clinical practice) and testing pain CST specifically among African Americans with OA. This study will evaluate the effectiveness of a culturally enhanced pain CST program among African Americans with OA. Methods/Design: This is a randomized controlled trial among 248 participants with symptomatic hip or knee OA, with equal allocation to a pain CST group and a wait list (WL) control group. The pain CST program incorporated feedback from patients and other stakeholders and involves 11 weekly telephone-based sessions. Outcomes are assessed at baseline, 12 weeks (primary time point), and 36 weeks (to assess maintenance of treatment effects). The primary outcome is the Western Ontario and McMaster Universities Osteoarthritis Index, and secondary outcomes include self-efficacy, pain coping, pain interference, quality of life, depressive symptoms, and global assessment of change. Linear mixed models will be used to compare the pain CST group to the WL control group and explore whether participant characteristics are associated with differential improvement in the pain CST program. This research is in compliance with the Helsinki Declaration and was approved by the Institutional Review Boards of the University of North Carolina at Chapel Hill, Durham Veterans Affairs Medical Center, East Carolina University, and Duke University Health System. Discussion: This culturally enhanced pain CST program could have a substantial impact on outcomes for African Americans with OA and may be a key strategy in the reduction of racial health disparities.Funded by Patient-Centered Outcomes Research Institute (PCORI) Award (AD-1408-19519)

Effectiveness of reactive focal mass drug administration and reactive focal vector control to reduce malaria transmission in the low malaria-endemic setting of Namibia: a cluster-randomised controlled, open-label, two-by-two factorial design trial.

BACKGROUND: In low malaria-endemic settings, screening and treatment of individuals in close proximity to index cases, also known as reactive case detection (RACD), is practised for surveillance and response. However, other approaches could be more effective for reducing transmission. We aimed to evaluate the effectiveness of reactive focal mass drug administration (rfMDA) and reactive focal vector control (RAVC) in the low malaria-endemic setting of Zambezi (Namibia). METHODS: We did a cluster-randomised controlled, open-label trial using a two-by-two factorial design of 56 enumeration area clusters in the low malaria-endemic setting of Zambezi (Namibia). We randomly assigned these clusters using restricted randomisation to four groups: RACD only, rfMDA only, RAVC plus RACD, or rfMDA plus RAVC. RACD involved rapid diagnostic testing and treatment with artemether-lumefantrine and single-dose primaquine, rfMDA involved presumptive treatment with artemether-lumefantrine, and RAVC involved indoor residual spraying with pirimiphos-methyl. Interventions were administered within 500 m of index cases. To evaluate the effectiveness of interventions targeting the parasite reservoir in humans (rfMDA vs RACD), in mosquitoes (RAVC vs no RAVC), and in both humans and mosquitoes (rfMDA plus RAVC vs RACD only), an intention-to-treat analysis was done. For each of the three comparisons, the primary outcome was the cumulative incidence of locally acquired malaria cases. This trial is registered with ClinicalTrials.gov, number NCT02610400. FINDINGS: Between Jan 1, 2017, and Dec 31, 2017, 55 enumeration area clusters had 1118 eligible index cases that led to 342 interventions covering 8948 individuals. The cumulative incidence of locally acquired malaria was 30·8 per 1000 person-years (95% CI 12·8-48·7) in the clusters that received rfMDA versus 38·3 per 1000 person-years (23·0-53·6) in the clusters that received RACD; 30·2 per 1000 person-years (15·0-45·5) in the clusters that received RAVC versus 38·9 per 1000 person-years (20·7-57·1) in the clusters that did not receive RAVC; and 25·0 per 1000 person-years (5·2-44·7) in the clusters that received rfMDA plus RAVC versus 41·4 per 1000 person-years (21·5-61·2) in the clusters that received RACD only. After adjusting for imbalances in baseline and implementation factors, the incidence of malaria was lower in clusters receiving rfMDA than in those receiving RACD (adjusted incidence rate ratio 0·52 [95% CI 0·16-0·88], p=0·009), lower in clusters receiving RAVC than in those that did not (0·48 [0·16-0·80], p=0·002), and lower in clusters that received rfMDA plus RAVC than in those receiving RACD only (0·26 [0·10-0·68], p=0·006). No serious adverse events were reported. INTERPRETATION: In a low malaria-endemic setting, rfMDA and RAVC, implemented alone and in combination, reduced malaria transmission and should be considered as alternatives to RACD for elimination of malaria. FUNDING: Novartis Foundation, Bill & Melinda Gates Foundation, and Horchow Family Fund

Prevalence and risk factors of unsuppressed viral load among pregnant and breastfeeding women in sub-Saharan Africa: analysis from population-based surveys.

OBJECTIVE: To examine the prevalence of viral suppression and risk factors for unsuppressed viral load among pregnant and breastfeeding women living with HIV (WLH). DESIGN: Pooled analysis among pregnant and breastfeeding WLH from Population-Based HIV Impact Assessment (PHIA) cross-sectional surveys from 10 sub-Saharan African countries. METHODS: Questionnaires included sociodemographic, relationship-related, and HIV-related items, while blood tests examined HIV serostatus and viral load (data collected 2015-2018). The weighted prevalence of viral suppression was calculated. Logistic regression was used to examine risk factors for unsuppressed viral load (≥1000 copies/ml). RESULTS: Of 1685 pregnant or breastfeeding WLH with viral load results, 63.8% (95% confidence interval (CI): 60.8-66.7%) were virally suppressed at the study visit. Among all included women, adolescence (adjusted odds ratio (aOR): 4.85, 95% CI: 2.58-9.14, P < 0.001) and nondisclosure of HIV status to partner (aOR: 1.48, 95% CI: 1.02-2.14, P = 0.04) were associated with unsuppressed viral load. Among only partnered women, adolescence (aOR: 7.95, 95% CI: 3.32-19.06, P < 0.001), and lack of paid employment (aOR: 0.67, 95% CI: 0.47-0.94, P = 0.02) were associated with unsuppressed viral load. Examining only women on ART, nondisclosure of HIV status to partner (aOR: 1.85, 95% CI: 1.19-2.88, P = 0.006) was associated with unsuppressed viral load. CONCLUSION: Viral suppression among pregnant and breastfeeding WLH in sub-Saharan Africa remains suboptimal. Relationship dynamics around nondisclosure of HIV-positive status to partners was an important risk factor for unsuppressed viral load. Improving HIV care via sensitive discussions around partner dynamics in pregnant and breastfeeding women could improve maternal HIV outcomes and prevention of mother-to-child transmission of HIV (PMTCT)

Cost and cost effectiveness of reactive case detection (RACD), reactive focal mass drug administration (rfMDA) and reactive focal vector control (RAVC) to reduce malaria in the low endemic setting of Namibia: an analysis alongside a 2×2 factorial design cluster randomised controlled trial.

OBJECTIVES: To estimate the cost and cost effectiveness of reactive case detection (RACD), reactive focal mass drug administration (rfMDA) and reactive focal vector control (RAVC) to reduce malaria in a low endemic setting. SETTING: The study was part of a 2×2 factorial design cluster randomised controlled trial within the catchment area of 11 primary health facilities in Zambezi, Namibia. PARTICIPANTS: Cost and outcome data were collected from the trial, which included 8948 community members that received interventions due to their residence within 500 m of malaria index cases. OUTCOME MEASURES: The primary outcome was incremental cost effectiveness ratio (ICER) per in incident case averted. ICER per prevalent case and per disability-adjusted life years (DALY) averted were secondary outcomes, as were per unit interventions costs and personnel time. Outcomes were compared as: (1) rfMDA versus RACD, (2) RAVC versus no RAVC and (3) rfMDA+RAVC versus RACD only. RESULTS: rfMDA cost 1.1× more than RACD, and RAVC cost 1.7× more than no RAVC. Relative to RACD only, the cost of rfMDA+RAVC was double ($3082 vs$1553 per event). The ICERs for rfMDA versus RACD, RAVC versus no RAVC and rfMDA+RAVC versus RACD only were $114,$1472 and $842, per incident case averted, respectively. Using prevalent infections and DALYs as outcomes, trends were similar. The median personnel time to implement rfMDA was 20% lower than for RACD (30 vs 38 min per person). The median personnel time for RAVC was 34 min per structure sprayed. CONCLUSION: Implemented alone or in combination, rfMDA and RAVC were cost effective in reducing malaria incidence and prevalence despite higher implementation costs in the intervention compared with control arms. Compared with RACD, rfMDA was time saving. Cost and time requirements for the combined intervention could be decreased by implementing rfMDA and RAVC simultaneously by a single team. TRIAL REGISTRATION NUMBER: NCT02610400; Post-results