Increased fertility rates in HIV-infected women receiving antiretroviral therapy (ART) have been attributed to improved immunological function; it is unknown to what extent the rise in pregnancy ...rates is due to unintended pregnancies.
Non-pregnant women ages 18-35 from four public-sector ART clinics in Johannesburg, South Africa, were enrolled into a prospective cohort and followed from August 2009-March 2011. Fertility intentions, contraception and pregnancy status were measured longitudinally at participants' routine ART clinic visits.
Of the 850 women enrolled, 822 (97%) had at least one follow-up visit and contributed 745.2 person-years (PY) at-risk for incident pregnancy. Overall, 170 pregnancies were detected in 161 women (incidence rate IR: 21.6/100 PY 95% confidence interval (CI): 18.5-25.2). Of the 170 pregnancies, 105 (62%) were unplanned. Unmet need for contraception was 50% higher in women initiating ART in the past year as compared to women on ART>1 year (prevalence ratio 1.5 95% CI: 1.1-2.0); by two years post-ART initiation, nearly one quarter of women had at least one unplanned pregnancy. Cumulative incidence of pregnancy was equally high among recent ART initiators and ART experienced participants: 23.9% 95% CI: 16.4-34.1, 15.9% 12.0-20.8, and 21.0% 16.8-26.1 for women on ART 0-1 yr, >1 yr-2 yrs, and >2 yrs respectively (log-rank, p = 0.54). Eight hormonal contraceptive failures were detected IR: 4.4 95% CI: 2.2-8.9, 7/8 among women using injectable methods. Overall 47% (80/170) of pregnancies were not carried to term.
Rates of unintended pregnancies among women on ART are high, including women recently initiating ART with lower CD4 counts and higher viral loads. A substantial burden of pregnancy loss was observed. Integration of contraceptive services and counselling into ART care is necessary to reduce maternal and child health risks related to mistimed and unwanted pregnancies. Further research into injectable contraceptive failures on ART is warranted.
Gender inequity and adverse health outcomes continue to be of concern among women in sub-Saharan Africa. We determined prevalence of intimate partner violence and excess fertility (having more ...children than desired) in reproductive age women in Malawi. We also explored factors associated with these outcomes and with spousal fertility intentions.
In a cross-sectional study, a total of 360 women and 410 men were recruited using multi-stage sampling from communities in a peri-urban setting in Blantyre District, Southern Malawi in 2021. Women and men were separately interviewed by trained study workers using a structured questionnaire. In addition to descriptive analyses, we used univariate and multivariate logistic regression models to assess associations of risk factors with the outcomes of intimate partner violence and excess fertility.
Among women, lifetime prevalence of intimate partner violence was 23.1%, and excess fertility was experienced by 25.6%. Intimate partner violence was associated with male partners alcohol consumption (adjusted odds ratio 2.13; P = 0.019). Women were more likely to report excess fertility if they were older (adjusted odds ratio 2.0, P<0.001, for a 5-year increase). Alcohol consumption by the male partner (adjusted odds ratio 2.14; P = 0.025) and women being able to refuse sex with their male partner (adjusted odds ratio 0.50; P = 0.036) were associated with discordant fertility preferences.
Intimate partner violence, excess fertility, and social and health inequities continue to be prevalent in Malawi. These data suggest the underlying proximal and distal factors associated with these adverse outcomes such as alcohol consumption may be addressed through education, couple interactive communication, and community dialogue. To ensure sustainability and effectiveness, strong leadership involvement, both governmental and non-governmental, is needed.
The PROMOTE study aims to measure long-term antiretroviral treatment (ART) safety and adherence; compare HIV disease progression; assess subsequent adverse pregnancy outcomes; evaluate effect of ART ...exposure on growth and development in HIV-exposed uninfected children; and assess long-term survival of mothers and children. This report primarily describes cohort characteristics at baseline to better understand long-term outcomes.
This is a prospective study. HIV-infected mothers and their children originally recruited in a multisite randomized clinical trial for prevention of perinatal HIV transmission were re-enrolled in PROMOTE. A total of 1987 mothers and 1784 children were enrolled from eight sites in Uganda, Malawi, Zimbabwe and South Africa. Most women (≥75%) reported being married in Malawi and Zimbabwe compared to low proportions in South Africa (4.4% in Durban and 15% in Soweto), and 43.5% in Uganda (p<0.001). There were variabilities in contraceptive practices: injectable contraceptive was the commonest reported method (40.9% overall); implant was the second commonest (15.7% overall); oral contraceptives were common in Zimbabwe; and tubal ligation was common in Malawi and South Africa. At baseline, 97.8% of women reported currently using ART; 96.4% were in WHO clinical class 1 or 2; median CD4 cell count was 825 cells per uL; and viral load was undetectable in 1637 (~85%) of the women. Approximately, 14% of women did not inform their primary partners of their own HIV status, 18% reported that they knew their partners were not HIV tested, and 9% did not know if partner was tested. Overall mean age of children at enrollment was 3.5 years; and 5.7% and 25.0% had weight-for-age and height-for-age z-scores <2 standard deviations, respectively.
These baseline data show high adherence to ART use. However, issues of HIV disclosure and reproductive intentions remain important. In addition to ART and ensuring high adherence, other preventive measures should be included.
In this randomized, controlled trial in Africa and India, combination antiretroviral therapy was more effective than standard therapy in preventing mother-to-child transmission of HIV but was ...associated with increased toxic effects.
Antiretroviral regimens used for the prevention of mother-to-child transmission of the human immunodeficiency virus (HIV) have evolved from the first successful trial that used zidovudine single-drug prophylaxis in 1994 to current triple-drug regimens.
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Although there are clear benefits of combination antiretroviral therapy (ART) for the mother and infant, these do not come without risks; some studies have shown higher rates of adverse pregnancy outcomes with maternal ART than with regimens containing fewer antiretroviral agents.
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The Promoting Maternal and Infant Survival Everywhere (PROMISE) trial compared the relative efficacy and safety of various proven antiretroviral strategies for the prevention of . . .
HIV prevalence continues to be high among women of reproductive age in sub-Saharan Africa. In 2007 the HIV prevalence among pregnant women attending antenatal clinics was >
20% in the southern ...African counties of Botswana, Swaziland, South Africa and Lesotho. Mother-to-child transmission (MTCT) of HIV can occur in-utero, intrapartum or postnatally. Without any preventive measure the overall rate of the MTCT of HIV in breastfeeding women could be 25–45%. Prior to the discovery of successful antiretroviral interventions to prevent the MTCT of HIV in sub-Saharan Africa (before 1999), innovative research determined the magnitude of the problem, the impact of the HIV epidemic on mothers and children, and the main risk factors associated with MTCT. Non-antiretroviral interventions conducted before 1999 such as washing the birth canal with antiseptics and antenatal supplementation with vitamin A did not reduce the MTCT of HIV. However, during the period 1999 to present, major successes were made in the prevention of the MTCT of HIV. The use of single-dose nevirapine prophylaxis to the mother and infant reduced the MTCT of HIV to ~
12%. Subsequently, longer prophylaxis and combined antiretroviral regimens were shown to be highly effective and very low HIV transmission rates comparable to those in developed countries were reported in some clinical trial settings in sub-Saharan Africa. The future is promising but challenges remain. The current successful intervention modalities are entirely dependent on antiretrovirals and breastfeeding continues to be vital for the survival of the child in the African setting. Reviewing past and present achievements assists in focusing future research and development of prevention programs.
Optimal adherence to antiretroviral therapy (ART) is crucial to promoting maternal-infant health.
Fourteen sites in 7 countries within sub-Saharan Africa and India.
The multicomponent, open-label ...strategy PROMISE trial enrolled breastfeeding mother-infant pairs not meeting in-country criteria for maternal ART (mART) initiation in the postpartum component within 5 days of delivery. Randomization was to mART versus infant NVP (iNVP) prophylaxis. Infants in the mART arm also received 6 weeks of iNVP. Self-reported adherence was assessed in a secondary analysis. Time-to-event analyses were performed to explore the association between adherence and maternal viral load (mVL) in the mART arm.
Two thousand four hundred thirty-one mother-infant pairs were enrolled between 2011 and 2014; the baseline maternal median CD4 was 686 (IQR 553-869), and the median mVL was 322 copies/mL (IQR 40-1422). Self-reported adherence was lower in the mART arm compared with the iNVP arm (no missed doses within 4 weeks of all study visits: 66% vs 83%; within 2 weeks: 71% vs 85%; P < 0.0001). The iNVP adherence at week 6 was high in both arms: 97% in mART arm; 95% in iNVP arm. Time-to-event analyses showed that adherence to mART was associated with time to first mVL ≥400 copies/mL ( P < 0.0001). Missing 1 full day of doses over 3 days was associated with a 66% risk of mVL ≥1000 copies/mL (HR: 1.66; 95% CI: 1.37, 1.99).
Postpartum women were less adherent to their own ART than mothers providing their infant's nevirapine prophylaxis. The self-reported missed mART doses were associated with high mVL. Strategies to optimize postpartum mART adherence are urgently needed.
ClinicalTrials.gov: NCT01061151; closed to follow-up.
BACKGROUND:No randomized trial has directly compared the efficacy of prolonged infant antiretroviral prophylaxis versus maternal antiretroviral therapy (mART) for prevention of mother-to-child ...transmission throughout the breastfeeding period.
SETTING:Fourteen sites in Sub-Saharan Africa and India.
METHODS:A randomized, open-label strategy trial was conducted in HIV-1–infected women with CD4 counts ≥350 cells/mm (or ≥country-specific ART threshold if higher) and their breastfeeding HIV-1–uninfected newborns. Randomization at 6–14 days postpartum was to mART or infant nevirapine (iNVP) prophylaxis continued until 18 months after delivery or breastfeeding cessation, infant HIV-1 infection, or toxicity, whichever occurred first. The primary efficacy outcome was confirmed infant HIV-1 infection. Efficacy analyses included all randomized mother–infant pairs except those with infant HIV-1 infection at entry.
RESULTS:Between June 2011 and October 2014, 2431 mother–infant pairs were enrolled; 97% of women were World Health Organization Clinical Stage I, median screening CD4 count 686 cells/mm. Median infant gestational age/birth weight was 39 weeks/2.9 kilograms. Seven of 1219 (0.57%) and 7 of 1211 (0.58%) analyzed infants in the mART and iNVP arms, respectively, were HIV-infected (hazard ratio 1.0, 96% repeated confidence interval 0.3–3.1); infant HIV-free survival was high (97.1%, mART and 97.7%, iNVP, at 24 months). There were no significant differences between arms in median time to breastfeeding cessation (16 months) or incidence of severe, life-threatening, or fatal adverse events for mothers or infants (14 and 42 per 100 person-years, respectively).
CONCLUSIONS:Both mART and iNVP prophylaxis strategies were safe and associated with very low breastfeeding HIV-1 transmission and high infant HIV-1–free survival at 24 months.
The incidence of melanoma, the most serious form of skin cancer, has been increasing rapidly in recent years. Early diagnosis is crucial for successful treatment. Dermoscopy, a reliable medical ...technique, utilizes specialized devices to examine the skin and detect melanoma. With advancements in digital imaging, high-quality images of these examinations can now be captured and stored. These images are being standardized and used for automated melanoma detection. However, the presence of hair on the skin poses a challenge to accurate diagnosis. Thus, it is essential to remove hair to obtain precise results. In this paper, we propose a simple yet effective method for hair removal using deep learning. Our approach leverages the architecture of generative adversarial networks (GAN) combined with convolutional neural networks (CNN) to reconstruct hair-free images. The GAN consists of a generator and a discriminator. The generator takes a dermoscopy image as input and aims to generate a latent distribution that eliminates hair, considering it as noise. Simultaneously, the discriminator detects changes in the generated image. This iterative process continues until the discriminator fails to identify any changes, considering the generated image as the original hairless image. To evaluate our proposed model, a dataset comprising both hair-covered and hairless images is required. As such a dataset does not currently exist, we introduce a new dataset called Modified-HAM10000 (M-HAM10000), inspired by the scientifically curated dermoscopy dataset HAM10000. Experimental results demonstrate the improved performance of our technique on the M-HAM10000 dataset. Furthermore, we employ various evaluation metrics including Peak Signal-to-Noise Ratio (PSNR), Mean Squared Error (MSE), Structural Similarity Index (SSIM), and Multiscale Structural Similarity Index (MS-SSIM) to assess our model's effectiveness. Through experiments conducted on the publicly available M-HAM10000 dataset, our proposed method demonstrates high efficiency in hair removal, enhancing the accuracy of skin disease diagnostics compared to other existing methods.
In this large, international study of HIV-1–serodiscordant couples, the receipt of antiretroviral therapy by the infected partner decreased transmission to the uninfected partner as well as rates of ...clinical events in the HIV-1–infected partner.
Combination antiretroviral therapy decreases the replication of human immunodeficiency virus type 1 (HIV-1) and improves the survival of infected persons.
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Such therapy has been shown to reduce the amount of HIV-1 in genital secretions.
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Because the sexual transmission of HIV-1 from infected persons to their partners is strongly correlated with concentrations of HIV-1 in blood
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and in the genital tract,
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it has been hypothesized that antiretroviral therapy could reduce sexual transmission of the virus. Several observational studies have reported decreased acquisition of HIV-1 by sexual partners of patients receiving antiretroviral therapy.
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These results have been extrapolated to . . .
SARS-CoV-2 seropositivity data in women living with HIV (WLHIV), their infants and associated factors in this subpopulation remain limited. We retrospectively measured SARS-CoV-2 seropositivity from ...07/2020-11/2021 among WLHIV and their children in the PROMOTE observational cohort in Uganda, Malawi, and Zimbabwe prior to widespread SARS-CoV-2 vaccination in those countries. Plasma stored during 3 waves of the COVID-19 pandemic in East/Southern Africa were tested for SARS-CoV-2 specific IgG antibodies (Ab) using serological assays that detect adaptive immune responses to SARS-CoV-2 spike protein. (EUROIMMUN, Mountain Lakes, New Jersey and Roche Diagnostics, Indianapolis, IN). Modified-Poisson regression models were used to calculate prevalence rate ratios (PRR) and 95% confidence intervals (CI) to identify sociodemographic and clinical risk factors. PROMOTE samples from 918 mothers and 1237 children were analysed. Overall, maternal SARS-CoV-2 seropositivity was 60.1% (95% CI: 56.9 -63.3) and 41.5% (95%CI: 38.8 - 44.2) for children. Non-breastfeeding mothers had a 31% higher risk of SARS-CoV-2 seropositivity compared to breastfeeding mothers (aPRR=1.31, 95%CI: 1.08-1.59). WLHIV with undetectable viral load had a 10% increased risk of SARS-CoV-2 seropositivity (aPRR=1.10, 95%CI: 0.89-1.37). Moreover, those who were normotensive had 12% increased risk SARS-CoV-2 seropositivity (aPRR= 1.12, 95% CI: 0.68-1.85) compared to women with hypertension. Children between 2 and 5 years had a 19% reduced risk of SARS-CoV-2 seropositivity (aPRR=0.81, 95%CI: 0.64-1.02) when compared to younger children. Mother/infant SARS-CoV-2 serostatuses were discordant in 346/802 (43.1%) families tested: mothers+/children- in 72.3%; mothers-/children+ in 26.3%; child+/sibling+ concordance was 34.6%. These SARS-CoV-2 seropositivity data indicate that by late 2021, about 60% of mothers and about 40% of children in a cohort of HIV-affected families in eastern/southern Africa had been infected with SARS-CoV-2. More mothers than their infants tested SARS-CoV-2+, likely due to a greater external exposure for mothers linked to daily routines/employment, and school closures. Breastfeeding was protective for mothers, likely because of higher likelihood of staying home with young children, and thus less exposure. Discordant results between children within the same families underscores the need to further understand transmission dynamics within households.
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