A Scoring Tool to Identify East African HIV-1 Serodiscordant Partnerships with a High Likelihood of Pregnancy

Introduction

HIV-1 prevention programs targeting HIV-1 serodiscordant couples need to identify couples that are likely to become pregnant to facilitate discussions about methods to minimize HIV-1 risk during pregnancy attempts (i.e. safer conception) or effective contraception when pregnancy is unintended. A clinical prediction tool could be used to identify HIV-1 serodiscordant couples with a high likelihood of pregnancy within one year.

Methods

Using standardized clinical prediction methods, we developed and validated a tool to identify heterosexual East African HIV-1 serodiscordant couples with an increased likelihood of becoming pregnant in the next year. Datasets were from three prospectively followed cohorts, including nearly 7,000 couples from Kenya and Uganda participating in HIV-1 prevention trials and delivery projects.

Results

The final score encompassed the age of the woman, woman’s number of children living, partnership duration, having had condomless sex in the past month, and non-use of an effective contraceptive. The area under the curve (AUC) for the probability of the score to correctly predict pregnancy was 0.74 (95% CI 0.72–0.76). Scores ≥7 predicted a pregnancy incidence of >17% per year and captured 78% of the pregnancies. Internal and external validation confirmed the predictive ability of the score.

Discussion

A pregnancy likelihood score encompassing basic demographic, clinical and behavioral factors defined African HIV-1 serodiscordant couples with high one-year pregnancy incidence rates. This tool could be used to engage African HIV-1 serodiscordant couples in counseling discussions about fertility intentions in order to offer services for safer conception or contraception that align with their reproductive goals.

Below:  Pregnancy incidence rates by score among women in the A) Partners PrEP Study B) Partners in Prevention HSV/HIV Transmission Study at Kenyan and Ugandan sites and C) Partners Demonstration Project.

Full article at:   http://goo.gl/uBRQFe

By:   

Renee Heffron, Kenneth Ngure, Elizabeth Bukusi, Nelly Mugo, Connie Celum, Jared M. Baeten

Department of Global Health, University of Washington, Seattle, United States of America

Renee Heffron, Connie Celum, Jared M. Baeten

Department of Epidemiology, University of Washington, Seattle, United States of America

Connie Celum, Jared M. Baeten

Department of Medicine, University of Washington, Seattle, United States of America

Craig R. Cohen

Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, United States of America

Kenneth Ngure

Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya

Elizabeth Bukusi

Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya

Nelly Mugo

Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya

Nelly Mugo

Department of Obstetrics & Gynecology, Kenya Medical Research Institute, Nairobi, Kenya

Edwin Were

Department of Reproductive Health, Moi University, Eldoret, Kenya

James Kiarie

Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya

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Impact and Cost-Effectiveness of Hypothetical Strategies to Enhance Retention in Care within HIV Treatment Programs in East Africa

OBJECTIVES:

Attrition from care among HIV infected patients can lead to poor clinical outcomes. Our objective was to evaluate hypothetical interventions seeking to improve retention-in-care (RIC) for HIV-infected patients in East Africa, asking whether they could offer favorable value compared to earlier ART initiation.

METHODS:

We used a micro-simulation model to analyze two RIC focused strategies within an East African HIV treatment program--"risk reduction," defined as intervention(s) that decrease the risk of attrition from care; and "outreach," defined as interventions that find patients and relink them with care. We compared this to earlier ART treatment as a measure of the potential health benefits forgone (e.g., opportunity cost).

RESULTS:

Reducing attrition by 40% at an average cost of $10 per person remains a less efficient use of resources compared to ensuring full access to ART (cost- effectiveness ratio $1300 vs $3700) for ART eligible patients. An outreach intervention had limited clinical benefit in our simulation. If intervention costs are <$10 per person, however, an intervention able to achieve a 40% (or greater) reduction in attrition may be a cost-effective next implementation option following implementation of earlier ART treatment.

CONCLUSIONS:

Our results suggest that programs should consider retention focused programs once they have already achieved high degrees of ART coverage among eligible patients. It is important that decision makers understand the epidemiology and associated outcomes of those patients who are classified as lost to follow up in their systems prior to implementation in order to achieve the highest value.

Purchase full article at:   http://goo.gl/WU2hmw

By:   Kessler J1, Nucifora K2, Li L2, Uhler L2, Braithwaite S2.

• 1Department of Population Health, New York University School of Medicine, New York, NY, USA. Electronic address: Jason.Kessler@nyumc.org.
• 2Department of Population Health, New York University School of Medicine, New York, NY, USA. 

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Are Women with Complications of an Incomplete Abortion More Likely to be HIV Infected Than Women without Complications?

There is limited published evidence about the status of HIV among women who have had abortions or suffered from abortion complications. Understanding this connection is critical for building the evidence base and for guiding strategies to manage the sexual and reproductive health needs of women living with HIV.

The purpose of this study is to determine whether women who suffered incomplete abortion complications are more likely to be HIV infected than those without complications. We hypothesized that women with incomplete abortion complications have higher rates of HIV infection than women who attended clinic for other obstetric reasons.

The analysis used a secondary dataset from a published case–control study that enrolled 1) 70 women at discharge after receiving in-patient care for complications resulting from induced abortion, and 2) 69 women (the comparison group) who visited the same hospital during the same time period for other obstetric needs. The primary outcome was seeking care for complications of incomplete abortion versus seeking care for other obstetric needs (dichotomous). The primary exposure variable was self-reported HIV status which was categorized into three groups: HIV positive, HIV negative, and HIV unknown. Unadjusted and adjusted associations between being in the abortion complications group, HIV status and other selected population characteristics were estimated using univariate and multivariate logistic regression.

Of 139 women enrolled in this study. Seventy (50.4 %) women had abortion complications and 69 (49.6 %) did not. Of the total study population, 18 (12.9 %) were HIV positive, 50 (36.0 %) were HIV negative, and the HIV status of 71 women (51.1 %) was unknown.

Compared to women who were HIV negative, women who were HIV positive had similar odds of being in the abortion complications group in both univariate and multivariate analyses (ρ =0.62 and ρ = 0.76). However, compared to HIV-negative women, those women who did not know their HIV status had greater odds of being in the abortion complications group (OR = 3.8, 95 % CI, 1.88, 8.20) in univariate analysis. After adjusting for potential confounding variables, the odds of being in the abortion complications group remained greater among women who did not know their HIV status compared to HIV-negative women (adjusted OR = 2.8, 95 % CI, 1.20, 6.54).

This study points to the need for targeted interventions aimed at strengthening the delivery and coverage of HIV-testing programs for pregnant women and post-abortion care. In addition, more research is needed to better understand the relationships between unsafe abortion, abortion complications and unknown HIV status.

Below:  Percentage of maternal death resulting from unsafe abortion (2008) [5], [6]. The figure shows that the proportion of maternal deaths due to unsafe abortion in Uganda (26%) far exceeds estimates for East Africa (18 %) and the World (13 %)

Full article at: http://goo.gl/ci6rvZ

By: Carolyn Othieno^15*, Joseph B. Babigumira²³ and Barbra Richardson⁴

¹Department of Health Services, Executive MPH Program, University of Washington, Seattle, WA, USA

²Department of Global Health, Global Medicines Program, University of Washington, Seattle, WA, USA

³Department of Pharmacy, Pharmaceutical Outcomes Research and Policy Program, University of Washington, Seattle, WA, USA

⁴Department of Biostatistics, University of Washington, Seattle, WA, USA

⁵Tacoma 98409, WA, USA

   

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Targeting an Alcohol Intervention Cost-Effectively to Persons Living with HIV/AIDS in East Africa

In the current report, we ask if targeting a cognitive behavioral therapy (CBT)-based intervention aimed at reducing hazardous alcohol consumption to HIV-infected persons in East Africa would have a favorable value at costs that are feasible for scale-up.

Using a computer simulation to inform HIV prevention decisions in East Africa, we compared 4 different strategies for targeting a CBT intervention-(i) all HIV-infected persons attending clinic; (ii) only those patients in the pre-antiretroviral therapy (ART) stages of care; (iii) only those patients receiving ART; and (iv) only those patients with detectable viral loads (VLs) regardless of disease stage. We define targeting as screening for hazardous alcohol consumption (e.g., using the Alcohol Use Disorders Identification Test and offering the CBT intervention to those who screen positive). We compared these targeting strategies to a null strategy (no intervention) or a hypothetical scenario where an alcohol intervention was delivered to all adults regardless of HIV status.

An intervention targeted to HIV-infected patients could prevent 18,000 new infections, add 46,000 quality-adjusted life years (QALYs), and yield an incremental cost-effectiveness ratio of $600/QALY compared to the null scenario. Narrowing the prioritized population to only HIV-infected patients in pre-ART phases of care results in 15,000 infections averted, the addition of 21,000 QALYs and would be cost-saving, while prioritizing based on an unsuppressed HIV-1 VL test results in 8,300 new infections averted, adds 6,000 additional QALYs, and would be cost-saving as well.

Our results suggest that targeting a cognitive-based treatment aimed at reducing hazardous alcohol consumption to subgroups of HIV-infected patients provides favorable value in comparison with other beneficial strategies for HIV prevention and control in this region. It may even be cost-saving under certain circumstances.

Full article at:  http://goo.gl/k7hpwt

By: Kessler J1, Ruggles K1, Patel A1,2, Nucifora K1, Li L1, Roberts MS3, Bryant K4, Braithwaite RS1.

• 1Department of Population Health, NYU School of Medicine, New York, New York.
• 2Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
• 3Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania.
• 4National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland.  

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Rapid Antiretroviral Therapy Initiation for Women in an HIV-1 Prevention Clinical Trial Experiencing Primary HIV-1 Infection during Pregnancy or Breastfeeding

During an HIV-1 prevention clinical trial in East Africa, we observed 16 cases of primary HIV-1 infection in women coincident with pregnancy or breastfeeding. Nine of eleven pregnant women initiated rapid combination antiretroviral therapy (ART), despite having CD4 counts exceeding national criteria for ART initiation; breastfeeding women initiated ART or replacement feeding. Rapid ART initiation during primary HIV-1 infection during pregnancy and breastfeeding is feasible in this setting...

Primary HIV-1 infection carries a high risk of maternal-to-child HIV-1 transmission (MTCT) when occurring during pregnancy or breastfeeding [1, 2]. HIV-1 acquisition during pregnancy is often not identified because of limited repeat HIV-1 testing, although high HIV-1 incidence during this period has been observed [2, 3, 4]. Initiation of antiretroviral therapy (ART) reduces the risk of MTCT; however, few countries have policies which specifically address primary HIV-1 infection during pregnancy or breastfeeding or prioritize treatment in this situation. Women with primary HIV-1 infection are likely to have higher CD4 counts and thus not qualify for combination ART under many national guidelines for routine ART initiation, or may not be prioritized for urgent initiation where policies for universal treatment during pregnancy (Option B/B+) have been adopted.

Randomized clinical trials of novel HIV-1 prevention strategies frequently enroll reproductive-age women at high HIV-1 risk, who may also become pregnant during study follow-up. Frequent, scheduled HIV-1 testing presents an opportunity to identify HIV-1 acquisition, potentially permitting initiation of combination ART to reduce the risk of MTCT. However, HIV-1 prevention trial sites do not typically provide direct HIV-1 care, instead referring HIV-1 seroconverters to local institutions.

Full article at: http://goo.gl/QIneEb

By: 

Susan Morrison, Grace John-Stewart, Elizabeth A. Bukusi, Connie Celum, Jared M. Baeten

Department of Global Health, University of Washington, Seattle, WA, United States of America

Grace John-Stewart, Connie Celum, Jared M. Baeten

Department of Medicine, University of Washington, Seattle, WA United States of America

Grace John-Stewart, Connie Celum, Jared M. Baeten

Department of Epidemiology, University of Washington, Seattle, United States of America

John J. Egessa, Sylvia Kusemererwa, Jonathan Wangisi

The AIDS Support Organization, Kampala, Uganda

Sezi Mubezi, Nulu Bulya

Infectious Disease Institute, Makerere University, Kampala, Uganda

Dennis K. Bii, Elizabeth A. Bukusi

Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya

Francis Mugume

Kabwohe Clinical Research Center, Kabwohe, Uganda

James D. Campbell

Centers for Disease Control and Prevention, Entebbe, Uganda

  

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Estimation of Mortality among HIV-Infected People on Antiretroviral Therapy Treatment in East Africa

Below:  Mortality among a sample of patients lost to follow-up. Incidence and the hazard of mortality among a random sample of patients lost to follow-up and successfully sought in the community, stratified by program.

We evaluated in HIV-infected adults on ART in 14 clinics in five settings in Kenya, Uganda and Tanzania using a sampling-based approach in which we intensively traced a random sample of lost patients (> 90 days late for last scheduled visit) and incorporated their vital status outcomes into analyses of the entire clinic population through probability-weighted survival analyses.

We followed 34,277 adults on ART from Mbarara and Kampala, Uganda; Eldoret and Kisumu, Kenya; and Morogoro, Tanzania. The median age was 35 years, 34% were men, and median pre-therapy CD4 count was 154 cells/μl. Overall 5,780 (17%) were LTFU, 991 (17%) were randomly selected for tracing and vital status was ascertained in 860 of 991 (87%). Incorporating outcomes among the lost increased estimated 3-year mortality from 3.9% (95% CI: 3.6%-4.2%) to 12.5% (95% CI: 11.8%-13.3%). The sample-corrected, unadjusted 3-year mortality across settings ranged from 7.2% in Mbarara to 23.6% in Morogoro. After adjustment for age, sex, pre-therapy CD4 value, and WHO stage, the sample-corrected hazard ratio comparing the setting with highest vs. lowest mortality was 2.2 (95% CI: 1.5-3.4) and the risk difference for death at 3 years was 11% (95% CI: 5.0%-17.7%).

A sampling based approach is widely feasible and important for understanding mortality after starting ART. After adjustment for measured biological drivers, mortality differs substantially across settings despite delivery of a similar clinical package of treatment. Implementation research to understand the systems, community, and patient behaviors driving these differences is urgently needed.

Via:   http://ht.ly/QnW0w HT @UCSF