60 research outputs found
an implementation study in Mbeya Region, Tanzania
Background The benefits of male partner involvement in antenatal care (ANC)
and prevention of mother-to-child transmission of HIV (PMTCT) for maternal and
infant health outcomes have been well recognised. However, in many sub-Saharan
African settings, male involvement in these services remains low. Previous
research has suggested written invitation letters as a way to promote male
partner involvement. Methods In this implementation study conducted at three
study sites in southwest Tanzania, acceptability of written invitation letters
for male partners was assessed. Pre-study CVCT rates of 2–19 % had been
recorded at the study sites. Pregnant women approaching ANC without a male
partner were given an official letter, inviting the partner to attend a joint
ANC and couple voluntary counselling and testing (CVCT) session. Partner
attendance was recorded at subsequent antenatal visits, and the invitation was
repeated if the partner did not attend. Analysis of socio-demographic indices
associated with male partner attendance at ANC was also performed. Results Out
of 318 women who received an invitation letter for their partner, 53.5 %
returned with their partners for a joint ANC session; of these, 81 % proceeded
to CVCT. Self-reported HIV-positive status at baseline was negatively
associated with partner return (p = 0.033). Male attendance varied
significantly between the rural and urban study sites (p < 0.001) with rates
as high as 76 % at the rural site compared to 31 % at the urban health centre.
The majority of women assessed the joint ANC session as a favourable
experience, however 7 (75 %) of women in HIV-positive discordant or concordant
relationships reported problems during mutual disclosure. Beneficial outcomes
reported one month after the session included improved client- provider
relationship, improved intra-couple communication and enhanced sexual and
reproductive health decision-making. Conclusion Official invitation letters
are a feasible intervention in a resource limited sub-Saharan African context,
they are highly accepted by couple members, and are an effective way to
encourage men to attend ANC and CVCT. Pre-intervention CVCT rates were
improved in all sites. However, urban settings might require extra emphasis to
reach high rates of partner attendance compared to smaller rural health
centres
Comparable Outcomes Using Written versus Verbal Invitations in an Urban Facility-Based Controlled Intervention Trial in Mbeya, Tanzania
In many Sub-Saharan African settings male partner involvement in antenatal
care (ANC) remains low, although great benefits for maternal and infant health
outcomes have been long recognised, in particular regarding the prevention of
HIV transmission. Yet there is paucity on evidence regarding the effectiveness
of strategies to increase male partner involvement. This controlled
intervention trial in Ruanda Health Centre in Mbeya, Tanzania, assessed the
effectiveness of invitation letters for male involvement in ANC. Pregnant
women approaching ANC without partners received official letters inviting the
partner to attend ANC. A control group was instructed to verbally invite
partners. Partner attendance was recorded at two subsequent ANC visits. Rates
for male partner return, couple voluntary counselling and testing (CVCT), and
influencing factors were analysed. From 199 ANC clients in total, 97 were
assigned to the invitation letter group; 30 of these (30.9%) returned with
their male partners for ANC. In the control group of 102 women, 28 (27.5%)
returned with their partner. In both groups CVCT rates among jointly returning
couples were 100%. Partner return/CVCT rate was not statistically different in
intervention and control group (OR 1.2, p = 0.59). Former partner attendance
at ANC during a previous pregnancy was the only factor found to be
significantly linked with partner return (p = 0.03). Our study demonstrates
that rather simple measures to increase male partner attendance in ANC and
CVCT can be effective, with written and verbal invitations having comparable
outcomes. In terms of practicability in Sub-Saharan African settings, we
recommend systematic coaching of ANC clients on how to verbally invite male
partners in the first instance, followed by written invitation letters for
partners in case of their non-attendance. Further studies covering both urban
and rural settings will be more informative for effective translation into
policy
Sexual Risk Behavior in HIV-Uninfected Pregnant Women in Western Uganda
Our aim was to identify sexual risk behavior among HIV-negative pregnant women in Kabarole District, Uganda, by conducting a cross-sectional study among 1610 women within three healthcare settings. One in six women engaged in HIV-specific risk behaviors including multiple sexual partners or alcohol abuse; 80% of the pregnant women reported to generally abstain from using condoms. In multivariate analysis, predictors of sexual risk behavior included being a client of the public health facilities as compared to the private facility (AOR 3.6 and 4.8, p < 0.001), being single, widowed or divorced or not cohabiting with the partner (AOR 4.7 and 2.3, p < 0.001), as well as higher household wealth (AOR 1.8, p < 0.001) and lack of partner status knowledge (AOR 1.6, p = 0.008). Self-estimated risk perception was linked with engagement in HIV-related risk behaviors except for alcohol abuse. Our findings indicate that reducing risky behaviors in pregnancy in order to prevent HIV should be a high-priority public health concern
Postpartum adherence to Option B+ until 18 months in Western Uganda
Since 2012, the WHO recommends Option B+ for the prevention of mother-to-child
transmission of HIV. This approach entails the initiation of lifelong
antiretroviral therapy in all HIV-positive pregnant women, also implying
protection during breastfeeding for 12 months or longer. Research on long-term
adherence to Option B+ throughout breastfeeding is scarce to date. Therefore,
we conducted a prospective observational cohort study in Fort Portal, Western
Uganda, to assess adherence to Option B+ until 18 months postpartum. In 2013,
we recruited 67 HIV-positive, Option B+ enrolled women six weeks after giving
birth and scheduled them for follow-up study visits after six, twelve and 18
months. Two adherence measures, self-reported drug intake and amount of drug
refill visits, were combined to define adherence, and were assessed together
with feeding information at all study visits. At six months postpartum, 51% of
the enrolled women were considered to be adherent. Until twelve and 18 months
postpartum, adherence for the respective follow-up interval decreased to 19%
and 20.5% respectively. No woman was completely adherent until 18 months. At
the same time, 76.5% of the women breastfed for ≥12 months. Drug adherence was
associated with younger age (p<0.01), lower travel costs (p = 0.02), and lower
number of previous deliveries (p = 0.04). Long-term adherence to Option B+
seems to be challenging. Considering that in our cohort, prolonged
breastfeeding until ≥12 months was widely applied while postpartum adherence
until the end of breastfeeding was poor, a potential risk of postpartum
vertical transmission needs to be taken seriously into account for Option B+
implementation
Lack of effect of intermittent preventive treatment for malaria in pregnancy and intense drug resistance in western Uganda
Background Intermittent preventive treatment in pregnancy (IPTp) with
sulfadoxine–pyrimethamine (SP) is widely implemented in sub-Saharan Africa for
the prevention of malaria in pregnancy and adverse birth outcomes. However, in
areas of intense SP resistance, the efficacy of IPTp may be compromised.
Methods A cross-sectional study among 915 delivering women (728 analysable
live singleton deliveries) was conducted in Fort Portal, western Uganda, to
assess associations of reported IPTp use, Plasmodium falciparum infection,
maternal anaemia, low birth weight, and preterm delivery, and to estimate the
degree of SP resistance as reflected by pfdhfr/pfdhps mutations. Results
Plasmodium falciparum infection was detected by PCR in 8.9 % and by microscopy
of placental blood samples in 4.0 %. Infection was significantly associated
with stillbirth, early neonatal death, anaemia, low birth weight, and pre-term
delivery. Eighty percent of the women had taken at least one dose of IPTp, and
more than half had taken two doses. As compared to women without
chemoprophylaxis against malaria, IPTp had no significant influence on the
presence of P. falciparum infection (13.8 vs. 9.6 %, P = 0.31). Nor was it
associated with reductions in anaemia, low birth weight or preterm delivery.
P. falciparum with intense SP resistance (pfdhfr/pfdhps quintuple or sextuple
mutations) were observed in 93 % (pfdhps 581G, 36 %), and the additional high
resistance allele pfhdr 164L in 36 %. Conclusions In Fort Portal, Uganda,
reported use of IPTp with SP does not provide an observable benefit. The
molecular markers of P. falciparum indicate high grade SP resistance reaching
the threshold set by WHO for the discontinuation of IPTp with SP. Alternative
approaches for the prevention of malaria in pregnancy are urgently needed
Comparison of 454 Ultra-Deep Sequencing and Allele-Specific Real-Time PCR with Regard to the Detection of Emerging Drug-Resistant Minor HIV-1 Variants after Antiretroviral Prophylaxis for Vertical Transmission
Background: Pregnant HIV-infected women were screened for the development of HIV-1 drug resistance after implementation of a triple-antiretroviral transmission prophylaxis as recommended by the WHO in 2006. The study offered the opportunity to compare amplicon-based 454 ultra-deep sequencing (UDS) and allele-specific real-time PCR (ASPCR) for the detection of drug-resistant minor variants in the HIV-1 reverse transcriptase (RT). Methods: Plasma samples from 34 Tanzanian women were previously analysed by ASPCR for key resistance mutations in the viral RT selected by AZT, 3TC, and NVP (K70R, K103N, Y181C, M184V, T215Y/F). In this study, the RT region of the same samples was investigated by amplicon-based UDS for resistance mutations using the 454 GS FLX System. Results: Drug-resistant HIV-variants were identified in 69% (20/29) of women by UDS and in 45% (13/29) by ASPCR. The absolute number of resistance mutations identified by UDS was twice that identified by ASPCR (45 vs 24). By UDS 14 of 24 ASPCR-detected resistance mutations were identified at the same position. The overall concordance between UDS and ASPCR was 61.0% (25/41). The proportions of variants quantified by UDS were approximately 2–3 times lower than by ASPCR. Amplicon generation from samples with viral loads below 20,000 copies/ml failed more frequently by UDS compared to ASPCR (limit of detection = 650 copies/ml), resulting in missing or insufficient sequence coverage. Conclusions: Both methods can provide useful information about drug-resistant minor HIV-1 variants. ASPCR has a higher sensitivity than UDS, but is restricted to single resistance mutations. In contrast, UDS is limited by its requirement for high viral loads to achieve sufficient sequence coverage, but the sequence information reveals the complete resistance patterns within the genomic region analysed. Improvements to the UDS limit of detection are in progress, and UDS could then facilitate monitoring of drug-resistant minor variants in the HIV-1 quasispecies
Hematological Changes in Women and Infants Exposed to an AZT-Containing Regimen for Prevention of Mother-to-child-transmission of HIV in Tanzania.
Tanzanian guidelines for prevention of mother-to-child-transmission of HIV (PMTCT) recommend an antiretroviral combination regimen involving zidovudine (AZT) during pregnancy, single-dosed nevirapine at labor onset, AZT plus Lamivudine (3TC) during delivery, and AZT/3TC for 1-4 weeks postpartum. As drug toxicities are a relevant concern, we assessed hematological alterations in AZT-exposed women and their infants. A cohort of HIV-positive women, either with AZT intake (n = 82, group 1) or without AZT intake (n = 62, group 2) for PMTCT during pregnancy, was established at Kyela District Hospital, Tanzania. The cohort also included the infants of group 1 with an in-utero AZT exposure ≥4 weeks, receiving AZT for 1 week postpartum (n = 41), and infants of group 2 without in-utero AZT exposure, receiving a prolonged 4-week AZT tail (n = 58). Complete blood counts were evaluated during pregnancy, birth, weeks 4-6 and 12. For women of group 1 with antenatal AZT intake, we found a statistically significant decrease in hemoglobin level, red blood cells, white blood cells, granulocytes, as well as an increase in red cell distribution width and platelet count. At delivery, the median red blood cell count was significantly lower and the median platelet count was significantly higher in women of group 1 compared to group 2. At birth, infants from group 1 showed a lower median hemoglobin level and granulocyte count and a higher frequency of anemia and granulocytopenia. At 4-6 weeks postpartum, the mean neutrophil granulocyte count was significantly lower and neutropenia was significantly more frequent in infants of group 2. AZT exposure during pregnancy as well as after birth resulted in significant hematological alterations for women and their newborns, although these changes were mostly mild and transient in nature. Research involving larger cohorts is needed to further analyze the impact of AZT-containing regimens on maternal and infant health
Adherence to Combination Prophylaxis for Prevention of Mother-to-Child-Transmission of HIV in Tanzania
BACKGROUND: Since 2008, Tanzanian guidelines for prevention of mother-to-child-transmission of HIV (PMTCT) recommend combination regimen for mother and infant starting in gestational week 28. Combination prophylaxis is assumed to be more effective and less prone to resistance formation compared to single-drug interventions, but the required continuous collection and intake of drugs might pose a challenge on adherence especially in peripheral resource-limited settings. This study aimed at analyzing adherence to combination prophylaxis under field conditions in a rural health facility in Kyela, Tanzania. METHODS AND FINDINGS: A cohort of 122 pregnant women willing to start combination prophylaxis in Kyela District Hospital was enrolled in an observational study. Risk factors for decline of prophylaxis were determined, and adherence levels before, during and after delivery were calculated. In multivariate analysis, identified risk factors for declining pre-delivery prophylaxis included maternal age below 24 years, no income-generating activity, and enrolment before 24.5 gestational weeks, with odds ratios of 5.8 (P = 0.002), 4.4 (P = 0.015) and 7.8 (P = 0.001), respectively. Women who stated to have disclosed their HIV status were significantly more adherent in the pre-delivery period than women who did not (P = 0.004). In the intra- and postpartum period, rather low drug adherence rates during hospitalization indicated unsatisfactory staff performance. Only ten mother-child pairs were at least 80% adherent during all intervention phases; one single mother-child pair met a 95% adherence threshold. CONCLUSIONS: Achieving adherence to combination prophylaxis has shown to be challenging in this rural study setting. Our findings underline the need for additional supervision for PMTCT staff as well as for clients, especially by encouraging them to seek social support through status disclosure. Prophylaxis uptake might be improved by preponing drug intake to an earlier gestational age. Limited structural conditions of a healthcare setting should be taken into serious account when implementing PMTCT combination prophylaxis
Emergence of Minor Drug-Resistant HIV-1 Variants after Triple Antiretroviral Prophylaxis for Prevention of Vertical HIV-1 Transmission
Background: WHO-guidelines for prevention of mother-to-child transmission of HIV-1 in resource-limited settings recommend complex maternal antiretroviral prophylaxis comprising antenatal zidovudine (AZT), nevirapine single-dose (NVP-SD) at labor onset and AZT/lamivudine (3TC) during labor and one week postpartum. Data on resistance development selected by this regimen is not available. We therefore analyzed the emergence of minor drug-resistant HIV-1 variants in Tanzanian women following complex prophylaxis. Method: 1395 pregnant women were tested for HIV-1 at Kyela District Hospital, Tanzania. 87/202 HIV-positive women started complex prophylaxis. Blood samples were collected before start of prophylaxis, at birth and 1–2, 4–6 and 12–16 weeks postpartum. Allele-specific real-time PCR assays specific for HIV-1 subtypes A, C and D were developed and applied on samples of mothers and their vertically infected infants to quantify key resistance mutations of AZT (K70R/T215Y/T215F), NVP (K103N/Y181C) and 3TC (M184V) at detection limits of,1%. Results: 50/87 HIV-infected women having started complex prophylaxis were eligible for the study. All women took AZT with a median duration of 53 days (IQR 39–64); all women ingested NVP-SD, 86 % took 3TC. HIV-1 resistance mutations were detected in 20/50 (40%) women, of which 70 % displayed minority species. Variants with AZT-resistance mutations were found in 11/50 (22%), NVP-resistant variants in 9/50 (18%) and 3TC-resistant variants in 4/50 women (8%). Three wome
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