Pregnant Women In South Africa Research Articles

Diet quality and associations with choline intake in pregnant women in Bloemfontein, South Africa

Rationale: Choline is essential during pregnancy and is an important component of a high-quality diet that can promote better short-and long-term health of both the mother and infant. The aim of this study was to determine diet quality of a sample of pregnant women in South Africa, and to determine associations with choline intake.

Prevalence, incidence and seroconversion of HIV and Syphilis infections among pregnant women of South Africa.

BackgroundPregnant women in South Africa suffer from HIV and syphilis infections resulting in negative pregnancy outcomes. Little is known about the prevalence, incidence, seroconversion, and associated risk factors for those attending a midwife run obstetric unit.MethodsA retrospective cohort study was undertaken among pregnant women attending antenatal clinic from January to December 2018. Logistic regression was conducted to determine the risk factors for HIV and syphilis.ResultsThe prevalence of HIV and syphilis were 44.3% (95% confidence interval [CI]; 41.6:46.7) and 3.8% (95% CI; 3.1:4.1), respectively. The seroconversion and incidence for HIV were 4.0% (95% CI; 3.6:4.6) and 17.1 per 100 person-years, and for syphilis 2.6% (95% CI; 2.3:2.8) and 10.9 per 100 person-years, respectively. Significant predictors for HIV prevalence were ages: ages < 20 years, Odds ratio (OR) = 0.11 (p < 0.05), ages 20–24 years, OR = 0.19 (p < 0.05) and ages 25–29 years, OR = 0.38 (p < 0.05); gestational age: second trimester, OR = 0.68 (p < 0.05) and non-reactive syphilis, OR = 0.45 (p < 0.05). Age was the predictor for HIV incidence or seroconversion (age < 20 year, OR = 0.12, p = 0.01). Predictors for syphilis were ages < 20 years, OR = 0.11 (p < 0.05), ages 20–24 years and HIV status. Gestational age > 27 weeks were nine times (OR = 9.2, p = 0.03) more likely to seroconvert to syphilis.ConclusionsThe present study found high rates of seroprevalence, seroconversion and incidence of HIV and syphilis among pregnant women.

Perspectives on COVID-19 vaccination for pregnant women in South Africa.

Coronavirus disease 2019 (COVID-19) is a pandemic that has created a global health crisis and upended conventional methodologies, both in the governance and clinical structures of Health Care Systems. The spread of COVID-19 has necessitated a coordinated public health response in an effective, extensive and expedited vaccination rollout strategy with the ultimate aim of limiting all nidi of infection for the pathogen. For this goal to be realised, pregnant women, as a cohort, cannot reasonably be excluded from this initiative, despite the initial reluctance to include them in clinical trials for various ethical and legal reasons. Weighing the detrimental complications of COVID-19 on maternal and perinatal outcomes against the hypothetical risk of vaccination in the context of promising, albeit indirect, safety and efficacy data, this report argues that all pregnant women should be offered the choice of whether or not to receive the COVID-19 vaccine based on the available evidence and their individualised risk-benefit ratio.

Maternal PrEP Use in HIV-Uninfected Pregnant Women in South Africa: Role of Stigma in PrEP Initiation, Retention and Adherence.

Pregnant women in sub-Saharan Africa are at high risk of HIV acquisition and require effective methods to prevent HIV. In a cohort of pregnant women offered Pre-exposure prophylaxis (PrEP), we evaluate the relationship between internalized and anticipated stigma and PrEP initiation at first antenatal visit, 3-month continuation and adherence using multivariable logistic regression. High internalized and anticipated PrEP stigma are associated with lower PrEP care initiation at first antenatal visit (aOR internalized stigma = 0.06; 95% CI = 0.03–0.11 and aOR anticipated stigma = 0.55; 95% CI = 0.31–1.00) compared to women with low reported stigma, after controlling for covariates. Women whose partners have not been tested for HIV or whose serostatus remains unknown have 1.6-times odds of PrEP retention at 3-months compared to women whose partners have been tested (aOR = 1.60; 95% CI = 1.02–2.52) after adjusting for covariates. PrEP counseling and maternal PrEP interventions must consider individual- and relational-level interventions to overcome anticipated PrEP stigma and other barriers to PrEP initiation and adherence.Supplementary InformationThe online version contains supplementary material available at 10.1007/s10461-021-03374-x.

Physical Activity in Pregnancy: Beliefs, Benefits, and Information-Seeking Practices of Pregnant Women in South Africa.

BackgroundNotwithstanding the benefits of physical activity (PA) during pregnancy, anecdotal evidence suggests ignorance, unscientific beliefs, and lack of awareness about PA among pregnant South African women.AimThis study examined the beliefs, perceived benefits, and sources of information on PA during pregnancy.MethodsA cross-sectional descriptive study was employed between June and September 2019 using an interviewer-administered questionnaire with 1,082 pregnant women. These women were attending antenatal primary health–care clinics in Buffalo City, Eastern Cape, South Africa. A self-designed questionnaire solicited information on beliefs, benefits, and sources of information regarding PA during pregnancy.ResultsA majority of the participants held positive beliefs concerning PA during pregnancy. They maintained that PA was safe for mother and fetus, improved labor and delivery (93.1%), promoted energy (89.0%), and should be discontinued when tired (76.6%). Most held negative convictions that PA during pregnancy increased body temperature (64.5%) and that pregnancy was a time to rest and refrain from PA (56.5%). Predominantl sources of information received about PA during pregnancy were television, the radio, and other media (70.2%). Most participants were aware of the benefits of PA during pregnancy —— reduction in infant weight (61.4%), lessening of moodiness (90.4), and decreased risk of gestational diabetes mellitus (92.9%), pregnancy-induced hypertension (92.5%), and complications at birth (97.8%), while common negative perceptions included musculoskeletal discomfort (82.7%), and back pain (85.7%). An overwhelming majority affirmed that PA improved self-image (95.7%), sleep patterns (94.2%), and respiratory function (95.8%).ConclusionOur findings suggested that women hold positive beliefs and perceive PA as beneficial to their health and the baby; however, they received most of their information from the Internet. Most women regarded pregnancy as a period to relax and rest. Interventions to promote PA during pregnancy are needed.

Mother-to-child transmission of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis in HIV-infected pregnant women in South Africa.

Sexually transmitted infections (STIs) can be transmitted from mother to neonate. We determined the frequency of mother-to-child transmission (MTCT) of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis to the newborn nasopharynx. This study was nested in a cohort study of etiologic testing versus syndromic management for STIs among pregnant women living with human immunodeficiency virus in South Africa. Mothers were tested for STIs using the GeneXpert platform within 60 days after delivery. Nasopharyngeal swabs were obtained from newborns of mothers with a positive STI test; these were then tested by Xpert® on the same day based on the maternal STI diagnosis. We tested nasopharyngeal swabs from 85 STI-exposed newborns; 74 (87%) were tested within 2 weeks after birth (median five; range 2-12days). MTCT frequency of any STI was 30/74 (41%); 43% (23/53) for C. trachomatis, 29% (2/7) for N. gonorrhoeae, and 24% (6/25) for T. vaginalis. Also, 4/11 (36%) swabs obtained between 14 and 60days after delivery tested positive for STI. There was a high frequency of MTCT of STIs to the nasopharynx of newborns in our setting. The impact of nasopharyngeal colonization and the benefits of STI testing on newborn health remain to be determined.

Achieving maternal viral load suppression for elimination of mother-to-child transmission of HIV in South Africa.

To describe changes in maternal viral control over time in South African women living with HIV (WLHIV) using surveillance data from the National Health Laboratory Service's Corporate Data Warehouse (NHLS CDW). A retrospective cohort analysis of maternal viral load during pregnancy and up to 15 months postpartum was performed amongst WLHIV (15-49 years) within the public-health sector between 2016 and 2017. HIV and pregnancy-related test data were used to create a synthetic cohort of pregnant WLHIV from the NHLS CDW. Syphilis-screening, in association with ward type and/or postpregnancy cervical screening and/or birth HIV test and/or positive β-hCG, was used as a proxy for pregnancy. The syphilis-screening date marked the first antenatal care visit (fANC). Fractional polynomial models described viral load evolution from fANC up to 15 months postdelivery. Piecewise linear regression models determined factors associated with viral load decline. Among 178 319 pregnant WLHIV, 345 174 viral load tests were performed [median = 2 (IQR: 2-3) per woman]. At fANC, 85 545 (48%) women were antiretroviral therapy (ART) experienced; 88 877 (49.8%) were not and 3897 (2.2%) unknown. Proportions of viraemia (viral load ≥50 copies/ml) were 39 756 (53.6%) at first viral load performed during pregnancy, 14 780 (36.9%) at delivery and 24 328 (33.5%) postpartum. Maternal age at least 25 years, CD4+ cell count at least 500 cells/μl and viral load less than 50 copies/ml at baseline predicted sustained viral load suppression during follow-up. Despite high-ART coverage among pregnant women in South Africa, only 63% of WLHIV achieved viral load less than 50 copies/ml at delivery. Maternal viral load monitoring requires prioritization for maternal health and eMTCT.

Clinical Features and Outcomes of COVID-19 Infection among Pregnant Women in South Africa.

Background and Objective:Studies among COVID positive pregnant women are limited. Previous studies reported high rate of symptoms, comorbidities, and poor fetal/neonatal outcome among women of different ethnicity. To date, no study was reported among pregnant African women. This study was conducted to determine the clinical features and outcomes of COVID-19 positive pregnant women in Ekurhuleni District in South Africa.Methods:Retrospective record review of 103 COVID-19 infected pregnant women during the period of April to September 2020 was performed. Clinical features, symptoms, comorbidities, laboratory results, maternal, and neonatal outcomes were analyzed. Descriptive statistics (mean + standard deviation, number, and percentages) and inferential statistics (Chi-square test) were calculated. Ethical clearance was obtained from the Human Research Ethics Committee of the University of Witwatersrand, South Africa.Results:Majority of patients (90%) were of African ethnicity and symptomatic (53%). The most common symptom, comorbidity, and laboratory abnormality was cough (62%), hypertension (23%), and high LDH (20%), respectively. Thrombocytopenia and lymphocytopenia occurred among 9% and 15% of the women, respectively. Although association was not significant, symptoms were more common among women who were HIV positive, had comorbidity, and had abnormal results. The most common complications were preterm labor (8%) and macerated stillbirths (6%). Six (6%) mothers died.Conclusion and Global Health Implications:COVID-positive pregnant South African women were commonly symptomatic, but incidence of adverse fetal outcomes was low. High rate of preterm labor, macerated stillbirths, and maternal deaths was a concern. This study has several strengths. It included all COVID-positive women over a 6-month period at all healthcare facility levels, such as clinics, community health centers/midwifery units, district, and regional/tertiary hospitals conducted in an African country. Previous studies primarily included hospitals, which increased a high probability of mainly including severely-ill women. The study might benefit the health care workers in other African countries.

Aetiological testing compared with syndromic management for sexually transmitted infections in HIV‐infected pregnant women in South Africa: a non‐randomised prospective cohort study

ObjectiveTo measure the frequencies of sexually transmitted infections (STIs) and adverse pregnancy outcomes among women receiving either aetiological testing or syndromic management for STIs.DesignNon‐randomised prospective cohort study.SettingPrimary healthcare facilities in Tshwane, South Africa.PopulationHIV‐infected pregnant women attending antenatal care services.MethodsParticipants were enrolled to receive aetiological testing using Xpert® CT/NG and Xpert® TV assays or standard syndromic management. Outcome data were collected at the postnatal care visit (≤30 days from delivery) and from maternity records. Enrolment gestational age‐adjusted relative risk (aRR) was calculated.Main outcome measuresSTI prevalence at postnatal visit, and frequency of adverse pregnancy outcomes (preterm birth, low birthweight).ResultsWe enrolled 841 women. The prevalence of any STI at baseline was 40%; Chlamydia trachomatis 30%, Neisseria gonorrhoeae 5.6%, Trichomonas vaginalis 20%. The prevalence of STIs at postnatal care was lower among those receiving aetiological testing compared with those receiving syndromic management (14% versus 23%; aRR 0.61; 95% CI 0.35–1.05). No difference was observed between study groups for frequency of preterm birth (23% versus 23%; aRR 1.2, 95% CI 0.81–1.8) and low birth weight (15% versus 13%; aRR 1.1, 95% CI 0.66–1.7).ConclusionsAetiological testing provides an effective intervention to reduce the high burden of STIs in pregnant women in South Africa; however, the optimal implementation strategy remains to be determined.Tweetable abstractAetiological testing effectively reduces the burden of sexually transmitted infections in pregnancy.

Ingestion of herbal medication during pregnancy and adverse perinatal outcomes

Background. Pregnant women in South Africa (SA) traditionally use herbal medicines even though the potential risk or benefit is not fully elucidated. Objectives. To determine the prevalence of the use of herbal medicines in pregnant women in our setting, as well as explore the reasons for use. Methods. This cross-sectional study was conducted at King Edward VIII Hospital, from 1 September 2014 to 31 December 2014. Women were interviewed using a structured questionnaire during the post-delivery period, irrespective of outcome. The questionnaires enquired about women’s demographic data, social and previous obstetric history and herbal medication use during current pregnancy. Results. Two hundred and ninety-nine women were interviewed. The prevalence of herbal medication use was 33.7% ( n =101), mainly via the oral route. Fifty-eight (57.4%) of these women used herbal medication throughout their pregnancy. Reasons given for herbal ingestion included general well-being, or to make labour easier or come sooner. There was a high rate of caesarean delivery among pregnant women who used herbal medication compared with those who did not (79.2% v. 52.8%; p =0.001). One hundred and eighteen women had meconium-stained liquor; 59% of the herbal medication users compared with 29.6% of the non-users ( p &lt;0.001) comprised this group.The perinatal mortality rate was also higher among users ( p &lt;0.04). There were no maternal deaths. Conclusion. Herbal medicine was used by a third of black South African pregnant women in this study and was associated with significant adverse obstetric and perinatal outcomes.

The South African National HIV Pregnancy Cohort: evaluating continuity of care among women living with HIV

BackgroundSouth Africa is home to more people living with HIV than any other country, including nearly one in three pregnant women attending antenatal care. Access to antiretroviral therapy (ART) has increased substantially since the start of the national ART program in 2004, with > 95% ART coverage during pregnancy and delivery, and vertical transmission of HIV greatly reduced. However, women who initiate ART during pregnancy are at heightened risk of dropping out of care, particularly after delivery, leading to the potential for viral transmission, morbidity and mortality. It is difficult to evaluate the success of policies of expanded access to ART care, and assess continuity of care, due to the lack of a national longitudinal HIV care database. Also, patient movement between unlinked facilities. For the first time on a national level, we propose to utilize routinely-collected laboratory data to develop and validate a cohort of pregnant women living with HIV in South Africa in a way that is uniquely robust to facility transfer.MethodsUsing laboratory test data matched to facility type, we will identify entry to antenatal care to build the cohort, then describe key treatment milestones, including 1) engagement in antenatal care, 2) initiation of ART, 3) HIV viremia, and 4) continuity of HIV care in the postpartum period. Second, we will measure the effect of system-wide factors impacting continuity of care among pregnant women. We will assess policies of expanded treatment access on continuity of care using regression-discontinuity analyses. We then will assess mobility and its effect on continuity of care during and after pregnancy. Third, we will identify individual-level risk factors for loss from HIV care in order to develop targeted interventions to improve engagement in HIV care.DiscussionThis work will create the world’s largest national cohort of pregnant women living with HIV. This novel cohort will be a powerful tool available to policymakers, clinicians and researchers for improving our understanding of engagement in care among pregnant women in South Africa and assessing the performance of the South African national ART program in caring for pregnant women living with HIV.Trial registrationN/A (not a clinical trial).

Physical Activity Level during Pregnancy in South Africa: A Facility-Based Cross-Sectional Study.

Physical activity participation during pregnancy confers many maternal and foetal health benefits to the woman and her infant and is recommended by various health bodies and institutions. However, in South Africa, scant information exists about the physical activity status and its determinants among pregnant women. The aim of this study was to assess the physical activity level and associated factors among pregnant women. This cross-sectional study enrolled 1082 pregnant women attending public health facilities in Buffalo City Municipality, Eastern Cape, South Africa. Information on socio-demographic and maternal characteristics were obtained, and the Pregnancy Physical Activity Questionnaire was used to assess physical activity during pregnancy. Multiple logistic regression analyses were used to assess associations between physical activity and the predictor variables during pregnancy. Adjusted odds ratios with 95% confidence interval were applied to estimate factors associated with physical activity levels. Statistical significance was set at p < 0.05. Only 278 of the women (25.7%) met recommendations for prenatal activity (≥150 min moderate intensity exercise per week). The average time spent in moderate–vigorous physical activity was 151.6 min (95% CI: 147.2–156.0). Most of the women participated in light exercises with a mean of 65.9% (95% CI: 64.8–67.0), and 47.6% (95% CI: 46.3–48.9) participated in household activities. The majority of the women did not receive physical activity advice during prenatal care sessions (64.7%). Factors negatively associated with prenatal physical activity were lower age (<19 years) (adjusted odd ratio (AOR) = 0.3; CI: 0.16–0.76), semi-urban residence (AOR = 0.8; CI: 0.55–1.03), lower educational level (AOR = 0.5; CI: 0.20–0.71), unemployment (AOR = 0.5; CI: 0.29–0.77) and nulliparity (AOR = 0.6; CI: 0.28–1.31). However, prenatal physical activity was positively associated with starting physical activity in the first trimester (AOR = 1.9; CI: 1.06–3.31) compared to other trimesters. The findings of this study demonstrated low levels of physical activity during pregnancy in South Africa. The majority of women did not meet the recommendation of 150 min of moderate intensity activity per week. Light intensity and household activities were the most preferred form of activity. The factors affecting physical activity of women in this present study include lower age, semi-urban setting, low educational level, unemployment and nulliparity. In order to increase activity levels, future work should seek to improve knowledge, access and support for physical activity in pregnant women in South Africa. This should include education and advocacy regarding physical activity for professionals involved in maternal health provision.

Schistosomiasis infections in South African pregnant women: A review

Background: Schistosomiasis, a chronic parasitic disease caused by Schistosoma species, has a negative impact on pregnancy outcomes and child development. The disease affects over 230 million people worldwide, and in South Africa an estimated 5.2 million people are thought to be infected. However, there is scant data on the impact of schistosomiasis in pregnancy in South Africa and globally. The aim of this review was to analyse the current knowledge of schistosomiasis in pregnancy, particularly in South Africa, focusing on maternal and neonatal complications linked directly to the disease or its treatment. Methods: An electronic search of online databases was used to identify and collect relevant research articles related to schistosomiasis in pregnancy, with a focus on South Africa. Results: Schistosomiasis can cause severe organ damage when left untreated and influences maternal and foetal morbidity and mortality. Although South Africa’s first helminth control programme was established in 1997, there is currently no ongoing treatment strategy programme, and little information is available on prevalence rates in pregnant women for the last 20 years. There is also an absence of data from well-controlled clinical trials that focus on the efficacy and safety of treatment during pregnancy, which has led to this vulnerable group being neglected. Conclusion: This review highlights the dearth of information on the impact of schistosomiasis in pregnant women in South Africa and the need for high-quality evidence-based studies.

The prevalence, risk factors and outcomes of anaemia in South African pregnant women: a protocol for a systematic review and meta-analysis

BackgroundA significant cause of morbidity and mortality during pregnancy is maternal anaemia. The causes of anaemia and the sequelae are varied, and the prevention and management are public health challenges, especially in resource-limited settings and certain geographic locations. South Africa is plagued by a quadruple burden of disease, with high maternal mortality rates affected by hypertensive disorders of pregnancy, HIV, tuberculosis and neglected tropical diseases. This is most prevalent in people of lower socio-economic status. Poor nutrition, chronic infections, lack of access to health care facilities and poor compliance with micronutrient supplementation all contribute to maternal anaemia. The aim of this study is to systematically map the literature to ascertain the pooled prevalence and associated causes of anaemia in the South African pregnant population, which will enable health care workers and other key stakeholders to more pertinently address Sustainable Development Goal 3 focussing on good health and reducing maternal mortality.MethodsPubMed, CINAHL, EMBASE, EBSCO, Ovid maternity and infant care databases, Cochrane Database of Systematic Reviews, Web of Science and SCOPUS will be searched using the keywords ‘anaemia’, ‘haemoglobin’, ‘pregnancy’, and ‘South Africa’ to conduct a systematic review and meta-analysis to explore, describe and map literature on the distribution and burden of anaemia in pregnant women in South Africa. The reference list of articles selected for review will be scanned for other articles of interest to our study question. Studies published in any language will be included in this review. As there may be differences in sampled populations in South Africa based on geography and sociodemographic factors, a weighted inverse-variance meta-analysis using a random-effects model will be carried out to generate a pooled prevalence estimate. A Funnel plot and Egger’s regression test will be conducted to assess publication bias. Heterogeneity among studies will be checked using I2 to determine dispersion and meta-regression analysis will be performed to investigate the source of heterogeneity. The articles obtained by these searches will be analysed for causative factors, severity and outcomes by a parallel and independent review team, using suitable eligibility criteria. Screening, data extraction and quality appraisal will be conducted independently by two authors. Disagreement will be resolved by independent assessment by a third reviewer. Sub group analysis by region, stage of pregnancy, socio-economic status, severity and cause of anaemia will be conducted if sufficient data is available. Data will be analysed using statistical software and presented in evidence tables and in meta-analytic forest plots.DiscussionThis protocol is developed to systematically review the literature on the prevalence and severity of anaemia, risk factors and outcomes in pregnant women in South Africa. Correlation of factors contributing to the development of anaemia and other disorders during pregnancy will facilitate exploration of appropriate medical and behavioural change interventions implemented within other countries or regions that mitigate risk. This study will assist local health systems to inform public health policies and practises for more favourable maternal and fetal outcomes.Trial registrationThis protocol is registered with PROSPERO (CRD42020157191)

Understanding and Responding to Prescribing Patterns of Sodium Valproate-Containing Medicines in Pregnant Women and Women of Childbearing Age in Western Cape, South Africa.

IntroductionGrowing evidence of the teratogenic potential of sodium valproate (VPA) has changed prescribing practices across the globe; however, the impact of this research and the consequent dissemination of a Dear Health Care Professional Letter (DHCPL) in December 2015, recommending avoidance of the teratogen VPA in women of childbearing age (WOCBA) and pregnant women in South Africa, is unknown. We explored trends and reasons for VPA use among pregnant women and WOCBA in the public sector in Western Cape Province from 1 January 2015 to 31 December 2017.MethodsUsing the provincial health information exchange that collates routine electronic health data via unique patient identifiers, we analysed clinical and pharmacy records from 2015 to 2017 to determine prescription patterns of VPA and other antiepileptic drug (AED) and mood-stabilising medicine (MSM) use in WOCBA and pregnant women. Senior clinicians and policy makers were consulted to understand the determinants of VPA use.ResultsAt least one VPA prescription was dispensed to between 8205 (0.79%) and 9425 (0.94%) WOBCA from a cohort of approximately 1 million WOCBA attending provincial health care facilities per year. Prescriptions were more likely in HIV-infected women compared with HIV-uninfected women (1.1–1.3% vs. 0.7–0.9%; p < 0.001). VPA use in WOCBA remained stable at 0.8–0.9% over the review period despite the 2016 DHCPL. VPA was the most prescribed AED/MSM, constituting 43.2–45.5% of all WOCBA taking at least one such agent, while lamotrigine, the other recommended first-line agent, was only prescribed in 7.8–8.9% of WOCBA. Over 3 years, approximately 663 pregnancies were exposed to VPA, with a steady rise in the number of exposures each year (n = 204, 214 and 245, respectively).ConclusionDespite warnings, VPA remained the most frequently prescribed AED or MSM in WOCBA. Contributing factors are described.Electronic supplementary materialThe online version of this article (10.1007/s40264-020-00987-4) contains supplementary material, which is available to authorized users.

Dolutegravir versus efavirenz in women starting HIV therapy in late pregnancy (DolPHIN-2): an open-label, randomised controlled trial

Late initiation of HIV antiretroviral therapy (ART) in pregnancy is associated with not achieving viral suppression before giving birth and increased mother-to-child transmission of HIV. We aimed to investigate virological suppression before giving birth with dolutegravir compared with efavirenz, when initiated during the third trimester. In this randomised, open-label trial, DolPHIN-2, we recruited pregnant women in South Africa and Uganda aged at least 18 years, with untreated but confirmed HIV infection and an estimated gestation of at least 28 weeks, initiating ART in third trimester. Participants were randomly assigned (1:1) to dolutegravir-based or efavirenz-based therapy. HIV viral load was measured 7 days and 28 days after antiretroviral initiation, at 36 weeks' gestation, and at the post-partum visit (0-14 days post partum). The primary efficacy outcome was a viral load of less than 50 copies per mL at the first post-partum visit, and the primary safety outcome was the occurrence of drug-related adverse events in mothers and infants until the post-partum visit. Longer-term follow-up of mothers and infants continues. This study is registered with ClinicalTrials.gov, NCT03249181. Between Jan 23, and Aug 15, 2018, we randomly assigned 268 mothers to dolutegravir (135) or efavirenz (133). All mothers and their infants were included in the safety analysis, and 250 mothers (125 in the dolutegravir group, 125 in the efavirenz group) and their infants in efficacy analyses, by intention-to-treat analyses. The median duration of maternal therapy at birth was 55 days (IQR 33-77). 89 (74%) of 120 in the dolutegravir group had viral loads less than 50 copies per mL, compared with 50 (43%) of 117 in the efavirenz group (risk ratio 1·64, 95% CI 1·31-2·06). 30 (22%) of 137 mothers in the dolutegravir group reported serious adverse events compared with 14 (11%) of 131 in the efavirenz group (p=0·013), particularly surrounding pregnancy and puerperium. We found no differences in births less than 37 weeks and less than 34 weeks gestation (16·4% vs 3·3%, across both groups). Three stillbirths in the dolutegravir group and one in the efavirenz group were considered unrelated to treatment. Three infant HIV infections were detected, all in the dolutegravir group, and were considered likely to be in-utero transmissions. Our data support the revision to WHO guidelines recommending the transition to dolutegravir in first-line ART for all adults, regardless of pregnancy or child-bearing potential. Unitaid.

Prevalence and risk factors for Trichomonas vaginalis infection in pregnant women in South Africa.

There are insufficient data on the prevalence of Trichomonas vaginalis infection in pregnant women in South Africa. The present study aims to determine the prevalence of T. vaginalis (TV) in pregnant women and identify the risk factors associated with this infection in pregnancy. This was a cross-sectional study which included 362 pregnant women attending the antenatal clinic at the King Edward VIII Hospital in Durban, South Africa. A self-collected vaginal swab was provided by the enrolled women for laboratory diagnosis by real-time polymerase chain reaction. The protozoan load was determined as the logarithm of gene copies per milliliter. The prevalence of TV infection was 12.9% and 59.6% of the women who tested positive were asymptomatic ( p = 0.011). Women who presented with abnormal vaginal discharge had a 4.6 times likelihood of testing positive for TV infection (odds ratio 4.62; 95% confidence interval 1.83 to 11.70; p = 0.001). TV infection was high amongst pregnant women. Therefore, routine testing for this sexually transmitted infection is encouraged for proper management.

Time Preferences and Medication Adherence: A Field Experiment With Pregnant Women in South Africa

The effectiveness of health recommendations and treatment plans depends on the extent to which individuals follow them. For the individual, medication adherence involves an inter-temporal trade-off between expected future health benefits and immediate effort costs. Therefore examining time preferences may help us to understand why some people fail to follow health recommendations and treatment plans. In this paper, we use a simple, real-effort task implemented via text message to elicit the time preferences of pregnant women in South Africa. We find evidence that high discounters are significantly less likely to report to adhere to the recommendation of taking daily iron supplements daily during pregnancy. There is some indication that time-inconsistency also negatively affects adherence. Together our results suggest that measuring time preferences could help predict medication adherence and thus be used to improve preventive health care measures.

Viral suppression and factors associated with failure to achieve viral suppression among pregnant women in South Africa.

To describe viral load levels among pregnant women and factors associated with failure to achieve viral suppression (viral load ≤50 copies/ml) during pregnancy. Between 1 October and 15 November 2017, a cross-sectional survey was conducted among 15-49-year-old pregnant women attending antenatal care (ANC) at 1595 nationally representative public facilities. Blood specimens were taken from each pregnant woman and tested for HIV. Viral load testing was done on all HIV-positive specimens. Demographic and clinical data were extracted from medical records or self-reported. Survey logistic regression examined factors associated with failure to achieve viral suppression. Of 10 052 HIV-positive participants with viral load data, 56.2% were virally suppressed. Participants initiating antiretroviral therapy (ART) prior to pregnancy had higher viral suppression (71.0%) by their third trimester compared with participants initiating ART during pregnancy (59.3%). Booking for ANC during the third trimester vs. earlier: [adjusted odds ratio (AOR) 1.8, 95% confidence interval (CI):1.4-2.3], low frequency of ANC visits (AOR for 2 ANC visits vs. ≥4 ANC visits: 2.0, 95% CI:1.7-2.4), delayed initiation of ART (AOR for ART initiated at the second trimester vs. before pregnancy:2.2, 95% CI:1.8-2.7), and younger age (AOR for 15-24 vs. 35-49 years: 1.4, 95% CI:1.2-1.8) were associated with failure to achieve viral suppression during the third trimester. Failure to achieve viral suppression was primarily associated with late ANC booking and late initiation of ART. Efforts to improve early ANC booking and early ART initiation in the general population would help improve viral suppression rates among pregnant women. In addition, the study found, despite initiating ART prior to pregnancy, more than one quarter of participants did not achieve viral suppression in their third trimester. This highlights the need to closely monitor viral load and strengthen counselling and support services for ART adherence.

Inequality in uptake of isoniazid prevention therapy and Mantoux test among pregnant women with HIV in the Eastern Cape, South Africa

BackgroundHIV-associated tuberculosis (TB) is a major cause of death among pregnant women in South Africa. Isoniazid prevention therapy (IPT) strategy was implemented in South Africa concurrently with life-long antiretroviral therapy (ART) to reduce the TB-associated morbidity and mortality in individuals living with HIV. This study assessed the extent of the implementation of IPT and the performance of the Mantoux test by geographic settings of health facilities and residences of pregnant women living with HIV in the Eastern Cape, South Africa.MethodsWe conducted a data analysis of 1709 pregnant women enrolled in the new electronic database of the prevention of mother-to-child transmission programme of the East London Prospective Cohort Study. Relevant data on place of residence and antenatal care, performance of the Mantoux test and subsequent initiation of IPT were obtained. Descriptive and inferential statistics were employed to analyse the geographical variations and accessibility to Mantoux test and IPT.ResultsThe analysis shows that Mantoux test was performed on 803 pregnant women (47%) with significant geographical variation. After controlling for relevant covariates, pregnant women who resided in rural areas (AOR:0.63; CI: 0.47–0.84) compared to those who resided in urban areas were significantly less likely to receive Mantoux test. The rate of uptake of IPT was 79% with significant geographic variations. In the unadjusted model, rural place of residence (UOR:0.68; CI: 0.49–0.96) was independently associated with lower likelihood of uptake of INH prophylaxis; however, the effect was not significant after controlling for important covariates.ConclusionsThe high uptake rate of isoniazid prevention therapy in pregnant women living with HIV at the study sites is commendable; however, concerted efforts are needed to address the inequality gaps in the roll-out of IPT. Poor performance of Mantoux test is a serious concern and requires the attention of TB programme managers and other relevant authorities.