Pregnant Women In Zambia Research Articles

Cost-effectiveness of intervention combinations towards the elimination of vertical transmission of HIV in limited-resource settings: a mathematical modelling study

Since 2000, there has been a substantial global reduction in the vertical transmission of HIV. Despite effective interventions, gaps still remain in progress towards elimination in many low-income and middle-income countries. We developed a mathematical model to determine the most cost-effective combinations of interventions to prevent vertical transmission. We developed a 12-month Markov model to follow a cohort of women of childbearing age (aged 15-49 years) in Zambia (n=1 107 255) who were either pregnant, in delivery, or breastfeeding; the population included in the model reflects the estimated number of pregnant women in Zambia from the 2018 Zambia Demographic and Health Survey. The model incorporated nine interventions: infant prophylaxis; three different HIV retesting schedule options; oral pre-exposure prophylaxis; maternal peer-support groups; regimen shift; tracing of loss to follow-up; and point-of-care viral load testing. We analysed incident HIV infections among mothers and infants, intervention costs, and evaluated 190 scenarios of different combinations of inventions to calculate the incremental cost-effectiveness ratios (ICERs) over 1 year. Three interventions with the greatest reduction in vertical transmission, individually, were support groups for 80% of those in need (35% reduction in infant infections), HIV retesting schedules (6·5% reduction), and infant prophylaxis (4·5% reduction). Of all 190 scenarios evaluated, eight were on the cost-effectiveness frontier (ie, were considered to be cost-effective); all eight included increasing infant prophylaxis, regimen shift, and use of support groups. Excluding the highest-cost scenarios, for a 1-22% increase in total budget, 23-43% of infant infections could be prevented, producing ICERs between US$244 and $16 242. Using the interventions modelled, it is possible to reduce vertical transmission and to cost-effectively prevent up to 1734 infant HIV infections (43% reduction) in Zambia over a period of 1 year. To optimise their effect, these interventions must be scaled with fidelity. Future work is needed to incorporate evidence on additional innovative interventions and HIV risk factors, and to apply the model to other country contexts to support targeted implementation and resource use. The ELMA Foundation.

The prioritisation of curable sexually transmitted infections among pregnant women in Zambia and Papua New Guinea: Qualitative insights.

Curable sexually transmitted infections (STIs) are neglected in public health policy, services and society at large. Effective interventions are available for some STI but seem not to be prioritised at global, regional or local levels. Zambia and Papua New Guinea (PNG) have a high burden of STIs among pregnant women but little is known about the prioritisation of STI treatment and care among this group. We undertook a qualitative study to explore how STIs are prioritised among pregnant women in local health systems in Zambia and PNG. Semi-structured interviews were conducted with 19 key informants-health care workers providing antenatal care, and policy and programme advisers across the two countries. Audio recordings were transcribed and translated into English and stored, managed, and coded in NVivo v12. Analysis used deductive and inductive thematic analysis. Findings were coded against the World Health Organization health system building blocks. Participants spoke about the stigma of STIs at the community level. They described a broad understanding of morbidity associated with undiagnosed and untreated STIs in pregnant women. The importance of testing and treating STIs in pregnancy was well recognised but many spoke of constraints in providing these services due to stock outs of test kits for HIV and syphilis and antibiotics. In both settings, syndromic management remains the mainstay for treating curable STIs. Clinical practice and treatment were not in alignment with current STI guidelines in either country, with participants recognising the need for mentorship and in-service training, as well as the availability of commodities to support their clinical practice. Local disruptions to screening and management of syphilis, HIV and other curable STIs were widely reported in both countries. There is a need to galvanise priority at national and regional levels to ensure ongoing access to supplies needed to undertake STI testing and treatment.

1175. Low Treatment Rates and Associated Factors Among Pregnant Women with Syphilis in Zambia

Abstract Background Syphilis in pregnancy is common in Africa with prevalence as high as 10%. In high prevalence areas ( > 5%), WHO recommends universal syphilis screening and benzathine penicillin G treatment at the first antenatal clinic (ANC) visit. Implementation barriers include global stock outs and supply chain issues. Our goal was to document treatment rates and factors associated with lack of treatment among pregnant women with syphilis in Zambia. Methods The retrospective cohort study analyzed medical record data from pregnant women who sought care in 10 public ANC clinics in Lusaka, Zambia during 2018-2019 and tested positive for syphilis. Syphilis was diagnosed based on positive RPR testing and treatment was defined as documented penicillin therapy at the same facility. Patient characteristics were compared across treatment status using Wilcoxon Rank Sum Test for continuous variables, and Pearson Chi-Square Test for categorical variables. Simple logistic models with treatment status as the binary outcome were conducted to evaluate potential factors associated with lack of syphilis treatment in pregnancy. A multivariable logistic model was performed and a 2-sided P < 0.05 was accepted as statistically significant. Results Among 28,480 pregnant women screened for syphilis, 5.6% (n=1363) tested positive. Among those with syphilis, median age was 27 years, 21% of women were nulliparous and 43% were living with HIV. Most women (72%) had their initial ANC visit during the 2nd trimester and 96% were screened for syphilis at the first visit. The documented treatment rate was 42% and the only factor associated with lack of treatment was ANC entry in 2019 compared to 2018 (aOR 2.2; 95% CI 1.7-2.8; p < 0.001). (refer to Tables 1-2). Conclusion Syphilis prevalence among pregnant women tested in ANC clinic in Zambia during 2018-2019 was 5.6%. Recommended penicillin treatment was only documented in 42% of cases. No maternal or clinic characteristic was associated with lack of therapy. Calendar year may have been associated with treatment for unclear reasons. Novel approaches to ensure access to universal diagnosis and early treatment of syphilis among pregnant women in Zambia are needed to improve maternal and neonatal outcomes. Disclosures All Authors: No reported disclosures.

Factors associated with non-use of insecticide-treated bed nets among pregnant women in Zambia

BackgroundDespite the Zambian government’s efforts to ensure 80% use of insecticide-treated nets (ITNs) among pregnant women, ITN use remains critically low. Only 49% of pregnant women reported sleeping under an ITN in 2018 in the country. This study aims to determine the prevalence of, and the factors associated with the non-use of ITNs among pregnant women in Zambia.MethodsThis study was a secondary analysis of the data collected during the 2018 Zambian Demographic and Health Survey. One thousand one hundred and thirty-eight (1 138) pregnant women were included in the study. The prevalence of the non-use of ITNs was computed and univariable and multivariable logistic regression models were fitted to determine the factors associated with the non-use of ITNs in the study population.ResultsThe study found that 578 (50.8%) pregnant women reported not using an ITN the night before the survey. The results of the multivariable logistic regression indicated that, primary level education (OR = 2.13, 95% CI 1.23–3.68), ITN per household member (OR = 0.01, 95% CI 0.00–0.02), parity (OR = 0.83, 95% CI 0.70–0.99), moderate malaria prevalence provinces (OR = 0.34, 95% CI 0.23–0.50), high malaria prevalence provinces (OR = 0.26, 95% CI 0.18–0.39) and currently in a union (OR = 0.52, 95% CI 0.30–0.88) were significantly associated with the non-use of ITNs.ConclusionThis study showed a high prevalence of the non-use of ITNs among pregnant women in Zambia. Factors found to be associated with the non-use of ITNs in the study population are: ITN per household member, parity, education, marital status and malaria prevalence provinces. Addressing the identified factors will require intensification of ITN programming and other malaria preventive measures.

Identifying barriers to ART initiation and adherence: An exploratory qualitative study on PMTCT in Zambia.

BackgroundThough antiretroviral therapy (ART) is widely available, HIV positive pregnant women in Zambia are less likely to start and remain on therapy throughout pregnancy and after delivery. This study sought to understand readiness to start ART among HIV pregnant women from the perspectives of both women and men in order to suggest more holistic programs to support women to continue life-long ART after delivery.MethodsWe conducted a qualitative study with HIV positive pregnant women before and after ART initiation, and men with female partners, to understand readiness to start lifelong ART. We conducted 28 in-depth interviews among women and 2 focus group discussions among male partners. Data were transcribed verbatim and analyzed in NVivo 12 using thematic analysis. Emerging themes from the data were organized using the social ecological framework.ResultsMen thought of their female partners as young and needing their supervision to initiate and stay on ART. Women agreed that disclosure and partner support were necessary preconditions to ART initiation and adherence and, expressed fear of divorce as a prominent barrier to disclosure. Maternal love and desire to look after one’s children instilled a sense of responsibility among women which motivated them to overcome individual, interpersonal and health system level barriers to initiation and adherence. Women preferred adherence strategies that were discrete, the effectiveness of which, depended on women’s intrinsic motivation.ConclusionThe results support current policies in Zambia to encourage male engagement in ART care. To appeal to male partners, messaging on ART should be centered on emphasizing the importance of male involvement to ensure women remain engaged in ART care. Programs aimed at supporting postpartum ART adherence should design messages that appeal to both men’s role in couples’ joint decision-making and women’s maternal love as motivators for adherence.

Addition of HIV self-test kits to partner notification services to increase HIV testing of male partners of pregnant women in Zambia: two parallel randomised trials

SummaryBackgroundTesting men for HIV during their partner’s pregnancy can guide couples-based HIV prevention and treatment, but testing rates remain low. We investigated a combination approach, using evidence-based strategies, to increase HIV testing in male partners of HIV-positive and HIV-negative pregnant women.MethodsWe did two parallel, unmasked randomised trials, enrolling pregnant women who had an HIV-positive test result documented in their antenatal record (trial 1) and women who had an HIV-negative test result documented in their antenatal record (trial 2) from an antenatal setting in Lusaka, Zambia. Women in both trials were randomly assigned (1:1) to the intervention or control groups using permuted block randomisation. The control groups received partner notification services only, including an adapted version for women who were HIV-negative; the intervention groups additionally received targeted education on the use of oral HIV self-test kits for their partners, along with up to five oral HIV self-test kits. At the 30 day follow-up we collected information from pregnant women about their primary male partner’s HIV testing in the previous 30 days at health-care facilities, at home, or at any other facility. Our primary outcome was reported male partner testing at a health facility within 30 days following randomisation using a complete-case approach. Women also reported male partner HIV testing of any kind (including self-testing at home) that occurred within 30 days. Randomisation groups were compared via probability difference with a corresponding Wald-based 95% CI. The trial is registered at ClinicalTrials.gov (NCT04124536) and all enrolment and follow-up has been completed.FindingsFrom Oct 28, 2019, to May 26, 2020, 116 women who were HIV-positive (trial 1) and 210 women who were HIV-negative (trial 2) were enrolled and randomly assigned to study groups. Retention at 30 days was 100 (86%) in trial 1 and 200 (95%) in trial 2. Women in the intervention group were less likely to report facility-based male partner HIV testing in trial 1 (3 [6%] of 47 vs 15 [28%] of 53, estimated probability difference −21·9% [95% CI −35·9 to −7·9%]) and trial 2 (3 [3%] of 102 vs 33 [34%] of 98, estimated probability difference −30·7% [95% CI −40·6 to −20·8]). However, reported male partner HIV testing of any kind was higher in the intervention group than in the control group in trial 1 (36 [77%] of 47 vs 19 [36%] of 53, estimated probability difference 40·7% [95% CI 23·0 to 58·4%]) and trial 2 (80 [78%] of 102 vs 54 [55%] of 98, estimated probability difference 23·3% [95% CI 10·7 to 36·0%]) due to increased use of HIV self-testing. Overall, 14 male partners tested HIV-positive. Across the two trials, three cases of intimate partner violence were reported (two in the control groups and one in the intervention groups).InterpretationOur combination approach increased overall HIV testing in male partners of pregnant women but reduced the proportion of men who sought follow-up facility-based testing. This combination approach might reduce linkages to health care, including for HIV prevention, and should be considered in the design of comprehensive HIV programmes.FundingNational Institutes of Health.

Circulating angiogenic factors and HIV among pregnant women in Zambia: a nested case\u2013control study

BackgroundMaternal HIV increases the risk of adverse birth outcomes including preterm birth, fetal growth restriction, and stillbirth, but the biological mechanism(s) underlying this increased risk are not well understood. We hypothesized that maternal HIV may lead to adverse birth outcomes through an imbalance in angiogenic factors involved in the vascular endothelial growth factor (VEGF) signaling pathway.MethodsIn a case–control study nested within an ongoing cohort in Zambia, our primary outcomes were serum concentrations of VEGF-A, soluble endoglin (sEng), placental growth factor (PlGF), and soluble fms-like tyrosine kinase-1 (sFLT-1). These were measured in 57 women with HIV (cases) and 57 women without HIV (controls) before 16 gestational weeks. We used the Wilcoxon rank-sum and linear regression controlling for maternal body mass index (BMI) and parity to assess the difference in biomarker concentrations between cases and controls. We also used logistic regression to test for associations between biomarker concentration and adverse pregnancy outcomes (preeclampsia, preterm birth, small for gestational age, stillbirth, and a composite of preterm birth or stillbirth).ResultsCompared to controls, women with HIV had significantly lower median concentrations of PlGF (7.6 vs 10.2 pg/mL, p = 0.02) and sFLT-1 (1647.9 vs 2055.6 pg/mL, p = 0.04), but these findings were not confirmed in adjusted analysis. PlGF concentration was lower among women who delivered preterm compared to those who delivered at term (6.7 vs 9.6 pg/mL, p = 0.03) and among those who experienced the composite adverse birth outcome (6.2 vs 9.8 pg/mL, p = 0.02). Median sFLT-1 concentration was lower among participants with the composite outcome (1621.0 vs 1945.9 pg/mL, p = 0.04), but the association was not significant in adjusted analysis. sEng was not associated with either adverse birth outcomes or HIV. VEGF-A was undetectable by Luminex in all specimens.ConclusionsWe present preliminary findings that HIV is associated with a shift in the VEGF signaling pathway in early pregnancy, although adjusted analyses were inconclusive. We confirm an association between angiogenic biomarkers and adverse birth outcomes in our population. Larger studies are needed to further elucidate the role of HIV on placental angiogenesis and adverse birth outcomes.

Self-delay for Timely Antenatal Care, Rituals and Heavy-Handed in-laws: Cultural Practices Killing Pregnant Women in Zambia- Lundazi district

This study examined socio-cultural practices surrounding maternal deaths in Lundazi district –Zambia. The practices stealthily affect antenatal care received by antenatal women with subsequent maternal complications and deaths. Four Focus Group Discussions involving 40 members of Small Motherhood Action Groups (SMAGs) were conducted in March 2018.This study found that pregnant women in Lundazi district- Zambia delay to initiate antenatal care until 6th or 7th month of their pregnancy. The reasons given include fear of witchcraft stealing the human embryo for magic. Pregnant women are delayed further as they seek traditional medicines from Traditional Healers for pregnancy protection. Other pregnant women cannot attend antenatal care consistently because their mothers-in-law want them to do what is considered beneficial for a woman traditionally- do house chores or join the team going to the maize field. Late antenatal initiation is a crisis. It is an emergency in waiting for which some pregnant women never recover.

Effect of Enhanced Adherence Package on Early ART Uptake Among HIV-Positive Pregnant Women in Zambia: An Individual Randomized Controlled Trial.

We evaluated the effect of an option B-plus Enhanced Adherence Package (BEAP), on early ART uptake in a randomized controlled trial. HIV-positive, ART naïve pregnant women in Lusaka, Zambia, were randomized to receive BEAP (phone calls/home visits, additional counseling, male partner engagement and missed-visit follow-up) versus standard of care (SOC). The primary outcome was initiating and remaining on ART at 30days. Analysis was by intention to treat (ITT) using logistic regression. Additional per protocol analysis was done. We enrolled 454 women; 229 randomized to BEAP and 225 to SOC. Within 30days of eligibility, 445 (98.2%) initiated ART. In ITT analysis, 82.5% BEAP versus 80.4% SOC participants reached primary outcome (crude relative risk [RR] 1.03; 95% confidence interval [CI] 0.91-1.16; Wald test statistic = 0.44; p-value = 0.66). In per protocol analysis, (92 participants (40.2%) excluded), 91.9% BEAP versus 80.4% SOC participants reached primary outcome (crude RR 1.14; 95% CI 1.02-1.29; Wald test statistic = 2.23; p-value = 0.03). Early ART initiation in pregnancy was nearly universal but there was early drop out suggesting need for additional adherence support.This trial was registered at ClinicalTrials.gov (trials number NCT02459678) on May 14, 2015.

Vaginal progesterone to prevent preterm delivery among HIV-infected pregnant women in Zambia: A feasibility study.

Antenatal vaginal progesterone (VP) reduces the risk of preterm birth (PTB) in women with shortened cervical length, and we hypothesize that it may also prevent PTB in women with HIV as their primary risk factor. We conducted a pilot feasibility study in Lusaka, Zambia to investigate uptake, adherence, and retention in preparation for a future efficacy trial. This was a double-masked, placebo-controlled, randomized trial of 200mg daily self-administered VP suppository or placebo. Pregnant women with HIV who were initiating or continuing antiretroviral therapy were eligible for participation. Potential participants underwent ultrasound to assess eligibility; we excluded those ≥24 gestational weeks, with non-viable, multiple gestation, or extrauterine pregnancies, with short cervix (<2.0cm), or with prior spontaneous PTB. Participants initiated study product between 20–24 weeks of gestation and continued to 37 weeks (or delivery, if sooner). The primary outcome was adherence (proportion achieving ≥80% study product use), assessed by dye stain assay of returned single-use vaginal applicators. Secondary outcomes with pre-defined feasibility targets were: uptake (≥50% eligible participants enrolled) and retention (≥90% ascertainment of delivery outcomes). We also evaluated preliminary efficacy by comparing the risk of spontaneous PTB <37 weeks between groups. From July 2017 to June 2018, 208 HIV-infected pregnant women were eligible for screening and 140 (uptake = 67%) were randomly allocated to VP (n = 70) or placebo (n = 70). Mean adherence was 94% (SD±9.4); 91% (n = 125/137) achieved overall adherence ≥80%. Delivery outcomes were ascertained from 134 (96%) participants. Spontaneous PTB occurred in 10 participants (15%) receiving placebo and 8 (12%) receiving progesterone (RR 0.82; 95%CI:0.34–1.97). Spontaneous PTB < 34 weeks occurred in 6 (9%) receiving placebo and 4 (6%) receiving progesterone (RR 0.67; 95%CI:0.20–2.67). In contrast to findings from vaginal microbicide studies in HIV-uninfected, non-pregnant women, our trial participants were highly adherent to daily self-administered vaginal progesterone. The study’s a priori criteria for uptake, adherence, and retention were met, indicating that a phase III efficacy trial would be feasible.

Effect of Enhanced Adherence Package on Early Retention in Care Among HIV-Positive Pregnant Women in Zambia: An Individual Randomized Controlled Trial

Background: Suboptimal retention may undermine the individual and public health benefits of immediate lifelong antiretroviral therapy (ART) for HIV-positive pregnant women (i.e., Option B+). We evaluated the effect of an intervention called the B-plus Enhanced Adherence Package (BEAP) on early ART uptake and short-term retention among newly diagnosed HIV-positive pregnant women in Lusaka, Zambia. Methods: Pregnant women at 3 public sector facilities in Lusaka urban district who were 18+ years old, HIV-positive, and ART naA¯ve were enrolled between March 02, 2017 and December 18, 2017 and randomized 1:1 to BEAP versus standard of care (SOC) services. All participants were eligible for Option B+ per national guidelines. BEAP involved early (within 1-2 weeks of eligibility for option B+) phone calls and home visits from a male-female pair of community health workers (CHW) to provide additional counseling, engage male partners in HIV testing, and follow-up any missed ART appointments. CHW documented all BEAP activities. The primary outcome, initiation and retention on ART per pharmacy records at 30 days after Option B+ eligibility, was compared by study arm in an intention to treat (ITT) analysis using logistic regression. In a per protocol analysis we also assessed the impact of BEAP on initiation and retention among those women who were confirmed to have received BEAP services. In pre-planned subgroup analyses, we also evaluated the BEAP's impact according to participant age, parity, baseline HIV partner disclosure status and baseline CD4+ count. Findings: Among 454 women enrolled, 229 were randomized to BEAP and 225 to SOC. The two arms were balanced with respect to age (p=0.16) and gestational age (p=0.09). Within 30 days of Option B+ eligibility, 445 (98.2%) initiated ART; however, only 369 (82.9%) of those women who started ART were still in care at 30 days. In ITT analysis, the proportion initiating and remaining on ART at 30 days was similar between women randomized to BEAP versus SOC (82.5% versus 80.4%; crude relative risk [RR], 1.03; 95% confidence interval [CI], 0.91-1.16). After exclusion of 92 participants (40.2%) due to not receiving BEAP services based on CHW documentation and 1 participant due to ineligibility, BEAP was associated with being on ART at 30 days versus SOC (91.9.0% versus 80.4%; crude RR 1.14; 95% CI, 1.02-1.29). No significant variation was found in the effect of BEAP in subgroup analyses based on parity, age, baseline HIV disclosure status, and/or baseline CD4+ count. Interpretation: Uptake of Option B+ within 30 days of eligibility was nearly universal among HIV-positive pregnant women in urban Zambia. Women who received the BEAP intervention were statistically more likely to be on ART at 30 days compared to those receiving standard services. This difference, though modest, supports the potential of targeted early interventions to optimize the implementation of Option B+. Trial Registration: The trial was also registered at ClinicalTrials.gov (trials number NCT02459678). Funding Statement: This research has been supported by the President's Emergency Plan for AIDS Relief (PEPFAR) through the United States Centers for Disease Control and Prevention (CDC) under the terms of cooperative agreement number U01GH000530. Additional investigator support was provided by the National Institutes of Health (K24 AI120796). Declaration of Interests: MM declares that the Centre for Infectious Disease Research in Zambia (CIDRZ), received a grant from the Centers for Disease Control and Prevention (CDC) (grant number: GH000530) to carry out this study. The rest of the authors declare no conflict of interest. Ethics Approval Statement: Approval for the study was obtained from the University of Zambia Biomedical Research Ethics Committee (Lusaka, Zambia) and the University of North Carolina at Chapel Hill Instituitional Review Board (Chapel Hill, NC, USA). The study was reviewed in accordance with the Centers for Disease Control and Prevention (CDC) human research protection procedures and was determined to be research, but CDC investigators did not interact with human subjects or have access to identifiable data or specimens for research purposes. Women who were eligible and agreed to participate provided written informed consent.

Highly diverse anaerobe-predominant vaginal microbiota among HIV-infected pregnant women in Zambia.

Vaginal dysbiosis has been shown to increase the risk of some adverse birth outcomes. HIV infection may be associated with shifts in the vaginal microbiome. We characterized microbial communities in vaginal swabs collected between 16–20 gestational weeks in the Zambian Preterm Birth Prevention Study to investigate whether HIV and its treatment alter the microbiome in pregnancy. We quantified relative abundance and diversity of bacterial taxa by whole-genome shotgun sequencing and identified community state types (CST) by hierarchical clustering. Associations between exposures—HIV serostatus (HIV+ vs HIV-) and preconceptional ART (ART+ vs ART-)—and microbiome characteristics were tested with rank-sum, and by linear and logistic regression, accounting for sampling by inverse-probability weighting. Of 261 vaginal swabs, 256 (98%) had evaluable sequences; 98 (38%) were from HIV+ participants, 55 (56%) of whom had preconceptional ART exposure. Major CSTs were dominated by: L. crispatus (CST 1; 17%), L.] iners (CST 3; 32%), Gardnerella vaginalis (CST 4-I; 37%), G. vaginalis & Atopobium vaginae (CST 4-II; 5%), and other mixed anaerobes (CST 4-III; 9%). G. vaginalis was present in 95%; mean relative abundance was higher in HIV+ (0.46±0.29) compared to HIV- participants (0.35±0.33; rank-sum p = .01). Shannon diversity was higher in HIV+/ART+ (coeff 0.17; 95%CI (0.01,0.33), p = .04) and HIV+/ART- (coeff 0.37; 95%CI (0.19,0.55), p < .001) participants compared to HIV-. Anaerobe-dominant CSTs were more prevalent in HIV+/ART+ (63%, AOR 3.11; 95%CI: 1.48,6.55, p = .003) and HIV+/ART- (85%, AOR 7.59; 95%CI (2.80,20.6), p < .001) compared to HIV- (45%). Restricting the comparison to 111 women in either CST 3 (L. iners dominance) or CST 1 (L. crispatus dominance), CST 3 frequency was similar in HIV- (63%) and HIV+/ART- participants (67%, AOR 1.31; 95%CI: (0.25,6.90), p = .7), but higher in HIV+/ART+ (89%, AOR 6.44; 95%CI: (1.12,37.0), p = .04). Pregnant women in Zambia, particularly those with HIV, had diverse anaerobe-dominant vaginal microbiota.

Inflammatory and Nutritional Biomarkers in the Plasma of Women in Zambia Reflect Low DHA and HIV Status

Docosahexanenoic Acid (DHA) is a fatty acid that is abundant in the brain, retina, and cerebral cortex. It is critical in fetal brain development and is implicated in resolution of inflammation. In recent years, there has been a growing concern that low dietary levels of DHA in pregnancy may lead to poor birth outcomes and delayed or reduced cognitive function in children after birth. Uncontrolled HIV infection may lead to cognitive impairments as well as reduced immune function. Therefore, for pregnant women living with food insecurity and HIV infection, these problems may be compounded and health risks to their infants high. To evaluate these concerns, a pre‐clinical trial was conducted in pregnant women in Zambia, a country where malnutrition and HIV are endemic. The study participants included 91 women in the second trimester of pregnancy, 46 of which were HIV seropositive and 45 HIV seronegative. Among the HIV positive participants 11 had high viral load. The overarching study goal was to determine if plasma DHA levels were low relative to global averages and if they correlated with inflammation and HIV status. Hematological assessment included measurement of biomarkers for nutritional status, HIV status and viral load, as well as inflammation. Plasma lipids were assessed using the Folch extraction method, fatty acid methyl esters were prepared and analyzed by gas chromatography/mass spectrometry. Protein biomarkers data were measured using commercial ELISA kits. Overall, DHA levels were low at 2.16±0.75 mass percent of total fatty acids but did not vary significantly with HIV status. Averages of the nutritional biomarkers insulin and leptin were low and high, respectively, compared to global averages when comparing all participants. Insulin was not significantly different based on HIV status. Leptin was reduced in HIV seropositive participants compared to those who were seronegative and this correlated, as expected, with pre‐pregnancy BMI. For the inflammatory markers CRP and LCN2, only LCN2 was significantly different dependent on HIV status, and levels were on average lower in seropositive individuals. Within the HIV positive participants, the 11 with high vial load did not have levels of insulin, leptin, CRP or LCN2 that were significantly different from those with low viral load. These data demonstrate that select protein biomarkers for inflammation and nutrition are variably affected by HIV and nutritional status. Currently, these studies are being expanded to understand the role of dietary fatty acids in contributing to health outcomes in pregnancy and dependent upon HIV status.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Evaluation of n‐3 fatty acid status of pregnant women in Zambia with relation to HIV infection

Malnutrition and human immunodeficiency virus (HIV) are independent risk factors for impairment of fetal and early childhood development, altered brain structure, and reduced cognitive function. Docosahexaenoic acid (DHA (C22:6cisΔ 4,7,10,13,16,19 ω3)) is a fatty acid that is abundant in the brain, retina, and cerebral cortex. Additionally, DHA‐derived eicosanoids function in the resolution of inflammation. Thus, there it is hypothesized to be a link between DHA status, brain function and inflammation that may be critical in HIV positive pregnant women. Brain development and DHA incorporation into neuronal tissues occur largely during the last trimester of pregnancy to 24 months after birth. DHA may be acquired either through de novo synthesis from linolenic acid (LN (C18:3 cisΔ 9,12,15 ω3)) or from the diet. The present study was undertaken to evaluate DHA status in terms of dietary intake and plasma levels in pregnant women in Zambia, a country where food insecurity and HIV infection are highly prevalent. Initially, 113 women were enrolled in this study at the antenatal clinic of the Women and Children's Hospital in Lusaka, Zambia. The participants completed a health and dietary questionnaire and then a fasting blood sample was acquired. Ultimately, 45 HIV seronegative and 46 HIV seropositive women were included in the study cohort. Pre‐pregnancy BMI had a mean of 22 and ranged from 17.9 to 24.9, thus none of the women were clinically underweight. Gestational age ranged from 20–29 weeks with an average of 22. Blood lipids were measured to quantitate and compare triglyceride, lipoprotein and total cholesterol, and fatty acid levels. Total fatty acid profiles were assessed using gas chromatography/mass spectrometry (GC/MS). Essentially all participants reported eating fish on a regular basis averaging 2‐times per week and most (80%) consumed the small sardine‐like fresh water fish Kapenta, that is known to be relatively high in DHA. However, plasma fatty acid profiles indicated a high ω6 to ω3 ratio and low LN, EPA and DHA levels overall. There were no significant differences in these values between HIV seropositive and seronegative participants. Therefore, we propose DHA supplementation is warranted to raise blood DHA levels during pregnancy in Zambia to address both child development and the mother's health.Support or Funding InformationWorld Health Organization (WHO)Undergraduate Creative Activities and Research Experience (UCARE)This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Effect of prevention of mother-to-child transmission strategies on antiretroviral therapy coverage in pregnant women in Zambia: analysis using routinely collected data (2010–15)

BackgroundThe WHO recommendation for lifelong antiretroviral therapy (ART) for all pregnant and lactating women (Option B+) has been adopted by nearly all countries with the highest HIV burdens. In January, 2013, Zambia announced that it would revise its guidelines on prevention of mother-to-child transmission (PMTCT) and adopt Option B+. Accurate estimates of coverage of PMTCT services in pregnant women with HIV are vital for monitoring progress towards HIV elimination targets. We aimed to show trends in the coverage of PMTCT services in Zambia from 2010 to 2015. We describe the proportion of women attending antenatal care who are HIV positive, the proportion of HIV-positive pregnant women who started ART, the proportion of HIV-infected women already on ART, and time to treatment initiation.MethodsThis was a retrospective cohort study using routinely collected data from SmartCare, an electronic health record system. We included data from all pregnant women who attended antenatal care in the 889 health facilities using the SmartCare database in Zambia.FindingsWe included data for 104 155 pregnant women who attended antenatal services in SmartCare facilities between Jan 1, 2010, and Dec 31, 2015. Of these women, 9% (9262) tested HIV-positive during antenatal visits and 43% (44 387) had missing HIV test results. Almost half (47%, [4375]) the pregnant women who tested HIV-positive in their antenatal visit were recorded in 2010. Among HIV-positive women, there was an increase in those already on ART at first antenatal visit from 9% (40) in 2011 to 74% (1 155) in 2015. In our study, 65% (983/1501) of the women who started ART after testing HIV-positive during antenatal care were documented after the adoption of Option B+ (2013–15). Mean time lag between starting antenatal care and ART initiation was 7 months over the 6 year study period, but there were notable variations between provinces and years.InterpretationThe implementation of WHO PMTCT guidelines introduced after 2010 in Zambia has resulted in an increase in the proportion of HIV-infected pregnant women attending antenatal care who are already on ART. The SmartCare database could enable Zambian health policy makers to act on urgent PMTCT interventions and improve health-care quality and outcomes for mothers and their infants. However, there is a need first to improve procedures for data collection and entry. The number of missing data observations indicate the need for further qualitative research on why so many records were missing from the database.FundingSEARCH (Sustainable Evaluation through Analysis of Routinely Collected HIV data) and the Bill & Melinda Gates Foundation (grant number OPP1084472).

Maternity Waiting Home Use by HIV-positive Pregnant Women in Zambia: Opportunity for Improved Prevention of Maternal to Child Transmission of HIV.

Background:Maternity waiting homes (MWHs), defined as residential lodging near health facilities, are an intervention to improve access to maternal care recommended by the World Health Organization. Little is known about utilization of MWHs by HIV-positive women. This paper describes: 1) maternal awareness and utilization of MWHs in rural Zambia among HIV-positive women, and 2) health outcomes for HIV-positive women and their infants with regards to utilization of MWHs.Methods:Data were collected from recently delivered women (delivered after 35 weeks in the previous 12 months) living >9.5 km from 40 health facilities in rural Zambia. For our analysis, primary outcomes were compared between self-identified HIV-positive and HIV-negative women in the sample. Primary outcomes include: 1) awareness of MWHs and 2) utilization of MWHs. We summarized simple descriptive statistics, stratified by maternal self-reported HIV status. We conducted bivariate analyses using chi-square tests, t-tests and Wilcoxon rank sum test.Results:Among 2,381 women, 50 (2.4%) self-identified as HIV-positive. HIV-positive women were older and had more pregnancies and children than HIV-negative women (p<0.001). There was no difference in awareness of MWHs, but HIV-positive women were more likely to use a MWH than HIV-negative women. There was no difference in receipt of infant antiretroviral prophylaxis between women who did or did not stay at a MWH.Conclusion and Global Health Implications:Though HIV prevalence in this sample was lower than expected, MWHs may represent a useful strategy to improve prevention of mother to child transmission of HIV in high prevalence, low-resource settings.

9. Perinatal care for zambian pregnant women complicated with preeclampsia: The medication rooted in the region to stabilize its local management in zimba

Background Preeclampsia (PE) is a hypertensive disorders of pregnancy (HDP) that is associated with proteinuria or some organ failure and it is still a major cause of perinatal death worldwide. Maternal mortality in developing countries is high due to PE. To reduce the maternal mortality in Zambia, it is important to survey the status of PE and prevent eclampsia. At first, we aimed at surveillance of obstetric status in Zambia. Objectives In this study, we surveyed detailed obstetric profile including PE morbidity in local area of Zambia and aimed at raising awareness of PE statistics at a low-income local area in Zambia. Methods All deliveries from January through December in 2017 at Zimba Mission Hospital, Zambia were enrolled in this study. The number of patients complicated with preeclampsia and eclampsia were analyzed, and the clinical condition, the treatment, and the outcome were also analyzed. Results Among the 1712 deliveries in Zimba, 42 women (2.6%) were complicated with HDP (gestational hypertension (GH): 17, PE: 25). There was two still births in PE. All eclampsia (n = 8; 19.0%) happened out of hospital and the patients were taken to our hospital. Magnesium sulfate was administered to PE patients by intramuscular injection to prevent the occurrence of eclampsia along the suitable protocol for low-income pregnant women proposed by University Teaching Hospital (UTH) in Zambia and no eclampsia happened later. Conclusions We surveyed and evaluated the obstetric profile and morbidity of PE. The protocol for preventing eclampsia by UTH was suitable for a local clinic and hospital for low-income pregnant women in Zambia. However, the morbidity of eclampsia is still high out of hospital. We have to educate pregnant women about the seriousness of PE and encourage to measure BP of pregnant women in local clinic and hospital in Zambia.

Anaemia in pregnancy among pregnant women in Lusaka District, Zambia

Objectives: This study investigated the problem of anaemia in pregnancy and its associated factors.Methods: The study involved 216 women booking for antenatal care between September 2015 and January 2016. A structured questionnaire was administered to all eligible women to determine their socio demographic and economic status, reproductive factors, health seeking behaviour and clinical state. Blood for a full blood count was collected. Women found with anaemia were immediately referred to their clinicians for further management. Data was analysed using SPSS software. Inferential analyses were conducted using Chi square and Ttest. For the historical independent variables with a known significant association with anaemia, a stepwise backward logistic regression was done.Results: Out of 216 women enrolled in the study, Seventy nine (36.2%) were found to be anaemic. The mean haemoglobin was 11.2g/dl. Thirty six women (45.6%) had mild anaemia, forty one (51.9%) had moderate anaemia while two (2.5%) had severe anaemia. In analysis lower family income and lower intake of vegetables were statistically significant with p values of 0.020 and 0.023 respectively. After adjusting for confounders, HIV infection remained significant with HIV positive women being 2.7 times more likely to have anaemia (OR 2.7, CI 1.06-6.70) univariateConclusion: Anaemia remains a public health problem among pregnant women in Zambia. Risk factors include HIV infection, Low intake of vegetables and low family income. Recommendations: Women need continued education on importance of vegetable intake during pregnancy and involvement in legal income generating activities to boost family income. Women of reproductive age under HIV care need continuous education on anaemia prevention in pregnancy.

Anaemia in Pregnancy among Pregnant Women in Lusaka District, Zambia

Objectives: This study investigated the problem of anaemia in pregnancy and its associated factors.&#x0D; Methods: The study involved 216 women booking for antenatal care between September 2015 and January 2016. A structured questionnaire was administered to all eligible women to determine their socio demographic and economic status, reproductive factors, health seeking behaviour and clinical state. Blood for a full blood count was collected. Women found with anaemia were immediately referred to their clinicians for further management.&#x0D; Data was analysed using SPSS software. Inferential analyses were conducted using Chi square and T-test. For the historical independent variables with a known significant association with anaemia, a stepwise backward logistic regression was done.&#x0D; Results: Out of 216 women enrolled in the study, Seventy nine (36.2%) were found to be anaemic. The mean haemoglobin was 11.2g/dl. Thirty six women (45.6%) had mild anaemia, forty one (51.9%) had moderate anaemia while two (2.5%) had severe anaemia.&#x0D; In bivariate analysis lower family income and lower intake of vegetables were statistically significant with p values of 0.020 and 0.023 respectively.&#x0D; After adjusting for confounders, HIV infection remained significant with HIV positive women being 2.7 times more likely to have anaemia (OR 2.7, CI 1.06-6.70)&#x0D; Conclusion: Anaemia remains a public health problem among pregnant women in Zambia. Risk factors include HIV infection, Low intake of vegetables and low family income.

Vaginal progesterone to reduce preterm birth among HIV-infected pregnant women in Zambia: a feasibility study protocol

BackgroundWomen infected with HIV have a risk of preterm birth (PTB) that is twice that among uninfected women, and treatment with antiretroviral therapy (ART) may further increase this risk. Progesterone supplementation reduces the risk of preterm delivery in women who have a shortened cervix in the midtrimester. We propose to study the feasibility of a trial of vaginal progesterone (VP) to prevent PTB among HIV-infected women receiving ART in pregnancy. Given low adherence among women self-administering vaginal study product in recent microbicide trials, we plan to investigate whether adequate adherence to VP can be achieved prior to launching a full-scale efficacy trial.Methods and designOne hundred forty HIV-infected pregnant women in Lusaka, Zambia, will be randomly allocated to daily self-administration of either VP or matched placebo, starting between 20 and 24 gestational weeks. The primary outcome will be adherence, defined as the proportion of participants who achieve at least 80% use of study product, assessed objectively with a validated dye stain assay that confirms vaginal insertion of returned single-use applicators. Secondary outcomes will be study uptake, retention, and preliminary efficacy. We will concurrently perform semi-structured interviews with participants enrolled in the study and with women who decline enrollment to assess the acceptability of VP to prevent PTB and of enrollment to a randomized controlled trial.DiscussionWe hypothesize that VP could prevent PTB among women receiving ART in pregnancy. In preparation for a trial to test this hypothesis, we plan to assess whether participants will be adherent to study product and protocol.Trial registrationClinicalTrial.gov, NCT02970552.