Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: 18-month follow-up of the HIVNET 012 randomised trial

Associations: Most common: S. aureus Foreign body: Coagulase-negative Staphylococcus or P. acnes Nosocomial: Enterobacteraceae, P. aeruginosa, Candida Bites, diabetic foot lesions, and decubitus ulcers: Streptococci and anaerobes Sickle cell disease: Salmonella or S. pneumonia HIV: Bartonella Bites, human or animal: P. multocida, E. corrodens Immunosuppressed: Aspergillis, C. albicans, Mycobacteria Populations where these organisms are prevalent: Brucella, TB, Coxiella burnetti, endemic fungi Microbiology and histology. The preferred culture sources are blood cultures (which are usually positive only with hematogenous osteomyelitis) or bone biopsy. Cultures from sinus tracts are often misleading. Tissue specimens showing more than 5 neutrophils/HPF show a sensitivity of 43% to 84% in specificity of 93% to 97% (AbdulKarim FW. Mod Pathol. 1998;11:427).

Recommendations for use of antiretroviral drugs in pregnant hiv-1-infected women for maternal health and interventions to reduce perinatal hiv-1 transmission in the United States

Setting: Thyolo District Hospital rural Malawi. Objectives: In a prevention of mother-to-child HIV transmission (PMTCT) programme to determine: the acceptability of offering opt-out voluntary counselling and HIV-testing (VCT); the progressive loss to follow up of HIV-positive mothers during the antenatal period at delivery and to the 6-month postnatal visit; and the proportion of missed deliveries in the district. Design: Cohort study. Methods: Review of routine antenatal VCT and PMTCT registers. Of 3136 new antenatal mothers 2996 [96% 95% confidence interval (CI): 95-97] were pretest counselled 2965 (95% CI: 94-96) underwent HIV-testing all of whom were post-test counselled. Thirty-one (1%) mothers refused HIV-testing. A total of 646 (22%) individuals were HIV-positive and were included in the PMTCT programme. Two hundred and eighty-eight (45%) mothers and 222 (34%) babies received nevirapine. The cumulative loss to follow up (n = 646) was 358 (55% CI: 51-59) by the 36-week antenatal visit 440 (68% CI: 64-71) by delivery 450 (70% CI: 66-73) by the first postnatal visit and 524 (81% CI: 78-84) by the 6-month postnatal visit. This left just 122 (19% CI: 16-22) of the initial cohort still in the programme. The great majority (87%) of deliveries occurred at peripheral sites where PMTCT was not available. In a rural district hospital setting at least 9 out of every 10 mothers attending antenatal services accepted VCT of whom approximately one-quarter were HIV-positive and included in the PMTCT programme. The progressive loss to follow up of more than three-quarters of this cohort by the 6-month postnatal visit demands a different way of acting if PMTCT is to be scaled up in our setting. (authors)

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-3156.2005.01526.x

High acceptability of voluntary counselling and HIV-testing but unacceptable loss to follow up in a prevention of mother-to-child HIV transmission programme in rural Malawi: scaling-up requires a different way of acting.

Background 
It is commonly assumed that sexual risk factors for heterosexual HIV transmission in sub-Saharan Africa, such as multi-partner sex, paid sex and co-infections, become less important as HIV epidemics mature and prevalence increases.


Methods and Findings 
We conducted a systematic review of 68 African epidemiological studies from 1986 to 2006 involving 17,000 HIV positive adults and 73,000 controls. We used random-effects methods and stratified results by gender, time, background HIV prevalence rates and other variables. The number of sex partners, history of paid sex, and infection with herpes simplex virus (HSV-2) or other sexually-transmitted infections (STIs) each showed significant associations with HIV infection. Among the general population, the odds ratio (OR) of HIV infection for women reporting 3+ sex partners versus 0–2 was 3.64 (95%CI [2.87–4.62]), with similar risks for men. About 9% of infected women reported ever having been paid for sex, versus 4% of control women (OR = 2.29, [1.45–3.62]). About 31% of infected men reported ever paying for sex versus 18% of uninfected men (OR = 1.75, [1.30–2.36]). HSV-2 infection carried the largest risk of HIV infection: OR = 4.62, [2.85–7.47] in women, and OR = 6.97, [4.68–10.38] in men. These risks changed little over time and stratification by lower and higher HIV background prevalence showed that risk ratios for most variables were larger in high prevalence settings. Among uninfected controls, the male-female differences in the number of sex partners and in paid sex were more extreme in the higher HIV prevalence settings than in the lower prevalence settings.


Significance 
Multi-partner sex, paid sex, STIs and HSV-2 infection are as important to HIV transmission in advanced as in early HIV epidemics. Even in high prevalence settings, prevention among people with high rates of partner change, such as female sex workers and their male clients, is likely to reduce transmission overall.

/pdf/sexual-risk-factors-for-hiv-infection-in-early-and-advanced-1tcoj3pu2o.pdf

Sexual Risk Factors for HIV Infection in Early and Advanced HIV Epidemics in Sub-Saharan Africa: Systematic Overview of 68 Epidemiological Studies

Context Few studies have objectively evaluated the coverage of services to prevent transmission of human immunodeficiency virus (HIV) from mother to child. Objective To measure the coverage of services to prevent mother-to-child HIV transmission in 4 African countries. Design, Setting, and Patients Cross-sectional surveillance study of mother-infant pairs using umbilical cord blood samples collected between June 10, 2007, and October 30, 2008, from 43 randomly selected facilities (grouped as 25 service clusters) providing delivery services in Cameroon, Cote d’Ivoire, South Africa, and Zambia. All sites used at least single-dose nevirapine to prevent mother-to-child HIV transmission and some sites used additional prophylaxis drugs. Main Outcome Measure Population nevirapine coverage, defined as the proportion of HIV-exposed infants in the sample with both maternal nevirapine ingestion (confirmed by cord blood chromatography) and infant nevirapine ingestion (confirmed by direct observation). Results A total of 27 893 cord blood specimens were tested, of which 3324 were HIV seropositive (12%). Complete data for cord blood nevirapine results were available on 3196 HIV-seropositive mother-infant pairs. Nevirapine coverage varied significantly by site (range: 0%-82%). Adjusted for country, the overall coverage estimate was 51% (95% confidence interval [CI], 49%-53%). In multivariable analysis, failed coverage of nevirapine-based services was significantly associated with maternal age younger than 20 years (adjusted odds ratio [AOR], 1.44; 95% CI, 1.18-1.76) and maternal age between 20 and 25 years (AOR, 1.28; 95% CI, 1.07-1.54) vs maternal age of older than 30 years; 1 or fewer antenatal care visits (AOR, 2.91; 95% CI, 2.40-3.54), 2 or 3 antenatal care visits (AOR, 1.93; 95% CI, 1.60-2.33), and 4 or 5 antenatal care visits (AOR, 1.56; 95% CI, 1.34-1.80) vs 6 or more antenatal care visits; vaginal delivery (AOR, 1.22; 95% CI, 1.03-1.44) vs cesarean delivery; and infant birth weight of less than 2500 g (AOR, 1.34; 95% CI, 1.11-1.62) vs birth weight of 3500 g or greater. Conclusion In this random sampling of sites with services to prevent mother-to-child HIV transmission, only 51% of HIV-exposed infants received the minimal regimen of single-dose nevirapine.

https://jamanetwork.com/journals/jama/articlepdf/186254/joc05087_293_302.pdf

Coverage of nevirapine-based services to prevent mother-to-child HIV transmission in 4 African countries.

One quarter of pregnant women in Zambia are infected with HIV. Understanding how knowledge of HIV relates to personal risk perception and avoidance of risky behaviors is critical to devising effective HIV prevention strategies. In conjunction with a large clinical trial in Lusaka, Zambia, we surveyed postpartum women who had been tested for HIV but did not know their status before undergoing the questionnaire. Of 858 women for whom complete data were available, 248 (29%) were HIV infected. Women 22 years of age or older (adjusted odds ratio [AOR], 1.7; 95% confidence interval [CI], 1.1–2.5), women reporting ≥2 sexual partners in their lifetime (AOR, 1.8; 95% CI, 1.3–2.5), and women reporting a history of a sexually transmitted infection (AOR, 2.7; 95% CI, 1.7–4.3) were more likely to be HIV infected. Having had ≥2 lifetime sexual partners was a marker for perception of high personnel risk for HIV infection (AOR, 1.5; 95% CI, 1.1–2.1). However, there was no relationship between perceived risk of HIV infection and actual HIV status. In fact, 127 (52%) of 245 women who stated that they were at no or low risk for HIV infection were HIV infected. Living in an area of high HIV seroprevalence like Zambia seems to be the greatest risk factor for infection in unselected pregnant women. Before significant inroads can be made in decreasing the incidence of HIV infection among pregnant women, population-based strategies that involve men must be implemented.

Personal Risk Perception, HIV Knowledge and Risk Avoidance Behavior, and Their Relationships to Actual HIV Serostatus in an Urban African Obstetric Population

Context: Single-dose intrapartum and neonatal nevirapine (NVP) reduces perinatal HIV transmission and is in increasingly common use throughout the developing world. Objective: We studied risk factors for perinatal transmission in the setting of NVP. Design and setting: A prospective cohort study at two public obstetrical clinics in Lusaka Zambia. Patients and methods: In a volunteer sample of HIV-infected pregnant women and their newborns the women received a 200 mg oral dose of NVP at the onset of labor; their infants received 2 mg/kg of NVP syrup within 24 h of birth. The main outcome measure was the infant HIV infection status at 6 weeks of life determined by DNA polymerase chain reaction. Results: Only 31 of 278 (11.2%) infants were infected at 6 weeks. In logistic regression viral load exceeding the median [adjusted odds ratio (AOR) 3.1; 95% confidence interval (CI) 1.1–8.7] and 1 h or less elapsing between NVP ingestion and delivery (AOR 5.0; 95% CI 1.8–14) were associated with transmission. Women delivering within 1 h of NVP ingestion had a lower mean drug concentration (351 versus 942 ng/ml; P 100 ng/ml (12.9 versus 11.7%; P = 0.8). We did not identify a threshold concentration below which risk of transmission increased. Conclusions: We confirmed low perinatal transmission rates with single-dose NVP. At least 1 h of pre-delivery NVP prophylaxis was a critical threshold for efficacy. (authors)

/pdf/timing-of-the-maternal-drug-dose-and-risk-of-perinatal-hiv-24opk9viin.pdf

Timing of the maternal drug dose and risk of perinatal HIV transmission in the setting of intrapartum and neonatal single-dose nevirapine.

The objective was to assess the uptake of and adherence to nevirapine to prevent mother-to-child HIV transmission among women of unknown HIV serostatus presenting in labor. We also assessed preliminary efficacy of the approach. Women of unknown HIV serostatus presenting in labor were offered singledose nevirapine in a prospective cohort study. Two additional contemporaneous comparison populations were also studied. Methods: We measured uptake by counting the number of women that accepted enrollment when offered. We measured adherence with cord blood nevirapine assay. We measured preliminary efficacy with HIV DNA polymerase chain reaction of infant blood spots at 4–6 weeks of life. Of 1591 women approached in labor 634 (40%) took up the intervention and received nevirapine of whom 185 (29%) were HIV infected. Of 179 cord blood specimens from HIV-exposed infants that could be evaluated 178 (99.4%) had nevirapine detected. This was higher than the 73 of 98 (74%) adherence rate observed in a comparison cohort in which women self-administered nevirapine before presenting to the labor ward (P 0.001). Of 145 available infant specimens 17 (11.7%) showed evidence of infection at 4–6 weeks compared with 12 of 60 (20%) infants born immediately prior to study commencement whose HIV-infected mothers did not receive nevirapine (P 0.05). Nevirapine without HIV testing upon presentation in labor was accepted by two-fifths of women. Because therapy is directly observed adherence is nearly perfect. Labor ward dosing to enhance nevirapine coverage should be considered as an adjunct to antenatal nevirapine administration for prevention of mother-to-child transmission of HIV. (authors)

/pdf/universal-nevirapine-upon-presentation-in-labor-to-prevent-33rimpjn61.pdf

Rosemary Kumwenda

Papers

Personal Risk Perception, HIV Knowledge and Risk Avoidance Behavior, and Their Relationships to Actual HIV Serostatus in an Urban African Obstetric Population

Timing of the maternal drug dose and risk of perinatal HIV transmission in the setting of intrapartum and neonatal single-dose nevirapine.

Universal nevirapine upon presentation in labor to prevent mother-to-child HIV transmission in high prevalence settings.