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/

HIV acquisition in pregnancy: implications for mother-to-child transmission at the population level in sub-Saharan Africa.

INTRODUCTION: A recent sero-discordant couple study showed an elevated risk of HIV-acquisition during the pregnancy/postpartum period per-condomless-coital-act. This, along with previous studies, has led to concern over possible increased risk of mother-to-child (vertical) transmission, due to the initial high viral load in the first months after seroconversion, in a time when the woman and health services may be unaware of her status. This study looks at whether behavioural differences during the pregnant/postpartum period could reduce the impact of elevated risk of HIV acquisition per-condomless-coital-act at the population level. METHODS: We used data from 60 demographic and health surveys from 32 sub-Saharan African countries. Using the HIV status of couples, we estimated differences in serodiscordancy between HIV-negative women who were pregnant/postpartum compared to those who were not pregnant/postpartum. We compare the risk of sexual activity over the pregnant/postpartum period to those not pregnant/postpartum. Using these risks of serodiscordancy and sexual activity along with estimates of increased HIV risk in the pregnancy/postpartum period per-condomless-coital-act, we estimated a population-level risk of HIV acquisition and acute infection, during pregnancy/postpartum compared to those not pregnant/postpartum. RESULTS: Sexual activity during pregnancy/postpartum varies considerably. In general, sexual activity is high in the first trimester of pregnancy, then declines to levels lower than among women not pregnant/postpartum, and is at its lowest in the first months postpartum. Adjusted for age and survey, pooled results show HIV-negative pregnant women are less likely to have an HIV-positive partner compared to those not pregnant/postpartum (risk ratio (RR) = 0.78, 95% CI = 0.68-0.89) and comparing the postpartum period (RR = 0.85, 95% CI = 0.73-0.99). Estimated population-level risk for HIV acquisition and acute infection in pregnancy/postpartum was lower than would be inferred directly from per-condomless-coital-act estimates in most countries, over the time of most risk of mother-to-child transmission, though there was variation by country and month of pregnancy/postpartum. CONCLUSIONS: Estimates of population-level HIV acquisition risk in sub-Saharan Africa should not be taken directly from per-condomless-coital-act studies to estimate vertical transmission. Changes in sexual behaviour and differences in HIV-serodiscordancy during pregnancy/postpartum reduce the impact of increased risk of HIV acquisition per-condomless-coital-act, this will vary by region

The effect of antiretroviral therapy provision on all-cause, AIDS and non-AIDS mortality at the population level--a comparative analysis of data from four settings in Southern and East Africa.

OBJECTIVE: To provide a broad and up-to-date picture of the effect of antiretroviral therapy (ART) provision on population-level mortality in Southern and East Africa. METHODS: Data on all-cause, AIDS and non-AIDS mortality among 15-59 year olds were analysed from demographic surveillance sites (DSS) in Karonga (Malawi), Kisesa (Tanzania), Masaka (Uganda) and the Africa Centre (South Africa), using Poisson regression. Trends over time from up to 5 years prior to ART roll-out, to 4-6 years afterwards, are presented, overall and by age and sex. For Masaka and Kisesa, trends are analysed separately for HIV-negative and HIV-positive individuals. For Karonga and the Africa Centre, trends in AIDS and non-AIDS mortality are analysed using verbal autopsy data. RESULTS: For all-cause mortality, overall rate ratios (RRs) comparing the period 2-6 years following ART roll-out with the pre-ART period were 0.58 (5.9 vs. 10.2 deaths per 1000 person-years) in Karonga, 0.79 (7.2 vs. 9.1 deaths per 1000 person-years) in Kisesa, 0.61 (6.7 compared with 11.0 deaths per 1000 person-years) in Masaka and 0.79 (14.8 compared with 18.6 deaths per 1000 person-years) in the Africa Centre DSS. The mortality decline was seen only in HIV-positive individuals/AIDS mortality, with no decline in HIV-negative individuals/non-AIDS mortality. Less difference was seen in Kisesa where ART uptake was lower. CONCLUSIONS: Falls in all-cause mortality are consistent with ART uptake. The largest falls occurred where ART provision has been decentralised or available locally, suggesting that this is important

Measuring the impact of antiretroviral therapy roll-out on population level fertility in three African countries

BackgroundUNAIDS official estimates of national HIV prevalence are based on trends observed in antenatal clinic surveillance, after adjustment for the reduced fertility of HIV positive women. Uptake of ART may impact on the fertility of HIV positive women, implying a need to re-estimate the adjustment factors used in these calculations. We analyse the effect of antiretroviral therapy (ART) provision on population-level fertility in Southern and East Africa, comparing trends in HIV infected women against the secular trends observed in uninfected women.MethodsWe used fertility data from four community-based demographic and HIV surveillance sites: Kisesa (Tanzania), Masaka and Rakai (Uganda) and uMkhanyakude (South Africa). All births to women aged 15–44 years old were included in the analysis, classified by mother’s age and HIV status at time of birth, and ART availability in the community. Calendar time period of data availability relative to ART Introduction varied across the sites, from 5 years prior to ART roll-out, to 9 years after. Calendar time was classified according to ART availability, grouped into pre ART, ART introduction (available in at least one health facility serving study site) and ART available (available in all designated health facilities serving study site). We used Poisson regression to calculate age adjusted fertility rate ratios over time by HIV status, and investigated the interaction between ART period and HIV status to ascertain whether trends over time were different for HIV positive and negative women.ResultsAge-adjusted fertility rates declined significantly over time for HIV negative women in all four studies. However HIV positives either had no change in fertility (Masaka, Rakai) or experienced a significant increase over the same period (Kisesa, uMkhanyakude). HIV positive fertility was significantly lower than negative in both the pre ART period (age adjusted fertility rate ratio (FRR) range 0.51 95%CI 0.42–0.61 to 0.73 95%CI 0.64–0.83) and when ART was widely available (FRR range 0.57 95%CI 0.52–0.62 to 0.83 95%CI 0.78–0.87), but the difference has narrowed. The interaction terms describing the difference in trends between HIV positives and negatives are generally significant.ConclusionsDifferences in fertility between HIV positive and HIV negative women are narrowing over time as ART becomes more widely available in these communities. Routine adjustment of ANC data for estimating national HIV prevalence will need to allow for the impact of treatment

The impact of antiretroviral therapy on adult mortality in rural Tanzania.

OBJECTIVE: To describe the impact of antiretroviral therapy (ART) on mortality rates among adults participating in an HIV community cohort study in north-west Tanzania. METHODS: Serological and demographic surveillance rounds have been undertaken in a population of approximately 30,000 people since 1994. Free HIV care including ART has been available since 2005. Event history analysis was used to compare mortality rates among HIV-negative and HIV-positive adults in the 5-year period before and after the introduction of ART. Crude and adjusted hazard ratios were calculated using exponential regression models. Interaction between time period and HIV status was assessed to investigate whether there was a non-linear relationship between these two variables. RESULTS: Male and female mortality patterns varied over the pre- and post-ART period. In women, the crude death rate fell for both HIV negatives and HIV positives hazard rate ratio (HRR = 0.71; 95%CI 0.51-0.99 and HRR = 0.68; 95%CI: 0.46-0.99, respectively). For men, the mortality among the HIV negatives increased (HRR = 1.47; 95%CI: 1.06-2.03) while the decline in mortality among the HIV positives (HRR = 0.77; 95%CI 0.52-1.13) was not statistically significant. The largest decrease in HIV-positive mortality over the two periods was among the 30- to 44-year-old age group for women and among the 45- to 59-year-old age group for men. CONCLUSION: There has been a modest effect on mortality in the study population following the introduction of free ART 5 years ago. Improving access to treatment and placing greater focus on retaining individuals on treatment are essential if the full potential of treatment for reducing HIV-related mortality is to be realised

Trends in sexual activity and demand for and use of modern contraceptive methods in 74 countries: a retrospective analysis of nationally representative surveys.

BACKGROUND: A quarter of a century ago, two global events-the International Conference on Population and Development in Cairo, and the Fourth World Conference on Women in Beijing-placed gender equality and reproductive health and rights at the centre of the development agenda. Progress towards these goals has been slower than hoped. We used survey data and national-level indicators of social determinants from 74 countries to examine change in satisfaction of contraceptive need from a contextual perspective. METHODS: We searched for individual-level data from repeated nationally representative surveys that included information on sexual and reproductive health, and created a single dataset by harmonising data from each survey to a standard data specification. We described the relative timings of sexual initiation, first union (cohabitation or marriage), and first birth and used logistic regression to show the change in prevalence of sexual activity, demand for contraception, and modern contraceptive use. We used linear regression to examine country-level associations between the gender development index and the expected length of time in education for women and the three outcomes: sexual activity, demand for contraception, and modern contraceptive use. We used principal component analysis to describe countries using a combination of social-structural and behavioural indicators and assessed how well the components explained country-level variation in the proportion of women using contraception with fractional logistic regression. FINDINGS: In 34 of the 74 countries examined, proportions of all women who were sexually active, not wanting to conceive, and not using a modern contraceptive method decreased over time. Proportions of women who had been sexually active in the past year changed over time in 43 countries, with increases in 30 countries; demand for contraception increased in 42 countries, and use of a modern method of contraception increased in 37 countries. Increases over time in met need for contraception were correlated with increases in gender equality and with women's time in education. Regression analysis on the principal components showed that country-level variation in met contraceptive need was largely explained by a single component that combined behavioural and social-contextual variables. INTERPRETATION: Progress towards satisfying demand for contraception should take account of the changing context in which it is practised. To remove the remaining barriers, policy responses-and therefore research priorities-could require a stronger focus on social-structural determinants and broader aspects of sexual health. FUNDING: UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction

Changes in fertility at the population level in the era of ART in rural Malawi

Introduction: HIV reduces fertility through biological and social pathways, and antiretroviral treatment (ART) can ameliorate these effects. In northern Malawi, ART has been available since 2007 and lifelong ART is offered to all pregnant or breastfeeding HIV-positive women. Methods: Using data from the Karonga Health and Demographic Surveillance Site in Malawi from 2005 to 2014, we used total and age-specific fertility rates and Cox regression to assess associations between HIV and ART use and fertility. We also assessed temporal trends in in utero and breastfeeding HIV and ART exposure among live births. Results: From 2005 to 2014, there were 13,583 live births during approximately 78,000 person years of follow-up of women aged 15–49 years. The total fertility rate in HIV-negative women decreased from 6.1 [95% confidence interval (CI): 5.5 to 6.8] in 2005–2006 to 5.1 (4.8–5.5) in 2011–2014. In HIV-positive women, the total fertility rate was more stable, although lower, at 4.4 (3.2–6.1) in 2011–2014. In 2011–2014, compared with HIV-negative women, the adjusted (age, marital status, and education) hazard ratio was 0.7 (95% CI: 0.6 to 0.9) and 0.8 (95% CI: 0.6 to 1.0) for women on ART for at least 9 months and not (yet) on ART, respectively. The crude fertility rate increased with duration on ART up to 3 years before declining. The proportion of HIV-exposed infants decreased, but the proportion of ART-exposed infants increased from 2.4% in 2007–2010 to 3.5% in 2011–2014. Conclusions: Fertility rates in HIV-positive women are stable in the context of generally decreasing fertility. Despite a decrease in HIV-exposed infants, there has been an increase in ART-exposed infants

The association of breastfeeding with cognitive development and educational achievement in sub-Saharan Africa: A systematic review.

Background: Systematic reviews and meta-analyses of studies mainly from high-income countries suggest that breastfeeding improves cognitive function and educational achievement. However, these associations may be a manifestation of who breastfeeds in these settings rather than an actual effect of breastfeeding. We investigated the association of breastfeeding with cognitive development and educational achievements in sub-Saharan Africa, where breastfeeding is the norm, and socioeconomic status is not strongly correlated with ever breastfeeding. Methods: We searched Medline, Embase, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), and Africa-Wide Information in January 2021 for studies that assessed the cognitive and educational benefits of breastfeeding in children and adolescents in sub-Saharan Africa. Two reviewers independently screened, extracted, and critically appraised the included studies. Results: After reviewing 5552 abstracts and 151 full-text articles, seventeen studies on cognitive development and two on educational achievements met our predefined inclusion criteria. The included studies were from ten sub-Saharan African countries and published between 2013 and 2021, with sample sizes ranging from 54 to 6573. Most of the studies (n = 14) were prospective cohort studies, but only nine collected data on breastfeeding prospectively. The studies differed in analytic approaches and cognitive and educational achievements measurements. Of the 17 studies on cognitive development, only four adjusted sufficiently for key confounders. None of these four studies found an overall association between breastfeeding and cognitive development in children or adolescents in sub-Saharan Africa. The two studies on education measured achievements based on the highest grade of school attained, 12 or more years of education, or grade repetition at age 7-11 years. Both studies adjusted for a range of sociodemographic factors and found no evidence that children exclusively breastfed or breastfed for a longer duration have a better educational outcome than sub-optimally breastfed children. Conclusions: The current evidence from sub-Saharan Africa is limited but does not corroborate previous findings that breastfeeding is associated with improved cognitive development and educational achievement. Registration: This study is registered with PROSPERO, CRD42021236009

Changes in Fertility at the Population Level in the Era of ART in Rural Malawi.

INTRODUCTION: HIV reduces fertility through biological and social pathways, and antiretroviral treatment (ART) can ameliorate these effects. In northern Malawi, ART has been available since 2007 and lifelong ART is offered to all pregnant or breastfeeding HIV-positive women. METHODS: Using data from the Karonga Health and Demographic Surveillance Site in Malawi from 2005 to 2014, we used total and age-specific fertility rates and Cox regression to assess associations between HIV and ART use and fertility. We also assessed temporal trends in in utero and breastfeeding HIV and ART exposure among live births. RESULTS: From 2005 to 2014, there were 13,583 live births during approximately 78,000 person years of follow-up of women aged 15-49 years. The total fertility rate in HIV-negative women decreased from 6.1 [95% confidence interval (CI): 5.5 to 6.8] in 2005-2006 to 5.1 (4.8-5.5) in 2011-2014. In HIV-positive women, the total fertility rate was more stable, although lower, at 4.4 (3.2-6.1) in 2011-2014. In 2011-2014, compared with HIV-negative women, the adjusted (age, marital status, and education) hazard ratio was 0.7 (95% CI: 0.6 to 0.9) and 0.8 (95% CI: 0.6 to 1.0) for women on ART for at least 9 months and not (yet) on ART, respectively. The crude fertility rate increased with duration on ART up to 3 years before declining. The proportion of HIV-exposed infants decreased, but the proportion of ART-exposed infants increased from 2.4% in 2007-2010 to 3.5% in 2011-2014. CONCLUSIONS: Fertility rates in HIV-positive women are stable in the context of generally decreasing fertility. Despite a decrease in HIV-exposed infants, there has been an increase in ART-exposed infants