Articles tagged as "Dominican Republic"

Intrauterine infections, but not obstetric complications, more common among pregnant women with HIV

HIV and the Risk of Direct Obstetric Complications: A Systematic Review and Meta-Analysis. 

Calvert C, Ronsmans C. PLoS One. 2013 Oct 4;8(10):e74848. doi:10.1371/journal.pone.0074848.

Background: Women of reproductive age in parts of sub-Saharan Africa are faced both with high levels of HIV and the threat of dying from the direct complications of pregnancy. Clinicians practicing in such settings have reported a high incidence of direct obstetric complications among HIV-infected women, but the evidence supporting this is unclear. The aim of this systematic review is to establish whether HIV-infected women are at increased risk of direct obstetric complications.

Methods and findings: Studies comparing the frequency of obstetric haemorrhage, hypertensive disorders of pregnancy, dystocia and intrauterine infections in HIV-infected and uninfected women were identified. Summary estimates of the odds ratio (OR) for the association between HIV and each obstetric complication were calculated through meta-analyses. In total, 44 studies were included providing 66 data sets; 17 on haemorrhage, 19 on hypertensive disorders, five on dystocia and 25 on intrauterine infections. Meta-analysis of the OR from studies including vaginal deliveries indicated that HIV-infected women had over three times the risk of a puerperal sepsis compared with HIV-uninfected women [pooled OR: 3.43, 95% confidence interval (CI): 2.00-5.85]; this figure increased to nearly six amongst studies only including women who delivered by caesarean (pooled OR: 5.81, 95% CI: 2.42-13.97). For other obstetric complications the evidence was weak and inconsistent.

Conclusions: The higher risk of intrauterine infections in HIV-infected pregnant and postpartum women may require targeted strategies involving the prophylactic use of antibiotics during labour. However, as the huge excess of pregnancy-related mortality in HIV-infected women is unlikely to be due to a higher risk of direct obstetric complications, reducing this mortality will require non obstetric interventions involving access to ART in both pregnant and non-pregnant women.

Abstract  Full-text [free] access

Editor’s notes: Women with HIV are thought to have a higher risk of adverse outcomes during pregnancy. This review is valuable in summarizing available data on this topic. Many of the included studies predated the wide availability of antiretroviral therapy. There was a clear association between HIV infection and intrauterine infections, but not with the other obstetric complications, e.g., obstetric haemorrhage, hypertensive disorders of pregnancy, dystocia, examined in the review. Considering individual conditions analysed, HIV infection was associated with antepartum haemorrhage, (but not postpartum haemorrhage). It was also found to be associated with pregnancy-induced hypertension (but not pre-eclampsia or eclampsia), and uterine rupture or prolonged labour (but not other complications of dystocia). The authors note that the studies were generally of low quality, and there were too few studies to examine the effect of antiretroviral therapy on these complications.  

Given the excess of intrauterine infections in women with HIV, the authors suggest that these might be preventable with prophylactic antibiotics. Overall, where causes of maternal mortality are documented, pregnant women with HIV are more likely to die of non-pregnancy related infections, than of obstetric complications. Specifically, non-pregnancy related infections are tuberculosis, pneumonia or meningitis. Pregnant women living with HIV need access to antenatal services and a skilled attendant at delivery. But, the top priority with respect to reducing maternal mortality is effective antiretroviral therapy.

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Encouraging results of community empowerment interventions among female sex workers

Community empowerment among female sex workers is an effective HIV prevention intervention: a systematic review of the peer-reviewed evidence from low- and middle-income countries.

Kerrigan DL, Fonner VA, Stromdahl S, Kennedy CE., AIDS Behav. 2013 Jul;17(6):1926-40. doi: 10.1007/s10461-013-0458-4.

We conducted a systematic review and meta-analysis of community empowerment interventions for HIV prevention among sex workers in low- and middle-income countries from 1990-2010. Two coders abstracted data using standardized forms. Of 6 664 citations screened, ten studies met inclusion criteria. For HIV infection, two observational studies showed a significantly protective combined effect [odds ratio (OR): 0.84, 95 % confidence interval (CI): 0.709-0.988]. For STI infection, one longitudinal study showed reduced gonorrhoea/chlamydia (OR: 0.51, 95 % CI: 0.26-0.99). Observational studies showed reduced gonorrhoea (OR: 0.65, 95 % CI: 0.47-0.90), but non-significant effects on chlamydia and syphilis. For condom use, one randomized controlled trial showed improvements with clients (ß: 0.3447, p = 0.002). One longitudinal study showed improvements with regular clients (OR: 1.9, 95 % CI: 1.1-3.3), but no change with new clients. Observational studies showed improvements with new clients (OR: 3.04, 95 % CI: 1.29-7.17), regular clients (OR: 2.20, 95 % CI: 1.41-3.42), and all clients (OR: 5.87, 95 % CI: 2.88-11.94), but not regular non-paying partners. Overall, community empowerment-based HIV prevention was associated with significant improvements across HIV outcomes and settings.

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Editor’s notes: In contrast to individual behaviour change interventions, community empowerment is a structural intervention which seeks to address and alter social, political and material conditions surrounding sex work in a given setting.  This is the first systematic review to evaluate the impact of community empowerment as an HIV prevention strategy among sex worker in low- and middle-income countries. This systematic review was conducted as part of a larger World Health Organization (WHO) effort to develop technical guidelines for HIV/STI prevention among sex workers. The results were encouraging, with positive effects of empowerment interventions on outcomes including HIV/STI infection and consistent condom use with clients (but not with regular partners, with whom condom use is generally low).  Encouragingly, all of the studies involved included not only the community empowerment intervention elements as described above, but also core HIV prevention elements: HIV/STI peer education, some form of condom distribution (free or via social marketing), and STI screening, treatment and management. Of the 10 included studies, seven were from India, two from Brazil and one from the Dominican Republic.  The lack of such studies in southeast Asia, or Africa, is striking, and a rigorous evaluation of community empowerment among sex workers in sub-Saharan Africa is warranted.

Asia, Latin America
Brazil, Dominican Republic, India
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Increasing HIV testing among male partners in PMTCT settings

Increasing HIV testing among male partners. The Prenahtest ANRS 12127 multi-country randomised trial.

Orne-Gliemann J, Balestre E, Tchendjou P, Miric M, Darak S, Butsashvili M, Perez-Then E, Eboko F, Plazy M, Kulkarni S, Loû AD, Dabis F; for the Prenahtest ANRS 12127 Study Group. AIDS. 2013 Jan 22. [Epub ahead of print]

Couple-oriented post-test HIV counselling (COC) provides pregnant women with tools and strategies to invite her partner to HIV counselling and testing. A randomised trial of the efficacy of COC on partner HIV testing in low/medium HIV prevalence settings (Cameroon, Dominican Republic, Georgia, India) was conducted. Pregnant women were randomised to receive standard post-test HIV counselling (SC) or COC and followed until six months postpartum. Partner HIV testing events were notified by site laboratories, self-reported by women or both combined. Impact of COC on partner HIV testing was measured in intention-to-treat analysis. Socio-behavioural factors associated with partner HIV testing were evaluated using multivariable logistic regression. Among 1943 pregnant women enrolled, partner HIV testing rates (combined indicator) were 24.7% among women from COC group vs 14.3% in SC group in Cameroon (Odds Ratio [OR] = 2.0 95%CI [1.2-3.1]), 23.1% vs 20.3% in Dominican Republic (OR = 1.2 [0.8-1.8]), 26.8% vs 1.2% in Georgia (OR = 29.6 [9.1-95.6]) and 35.4% vs 26.6% in India (OR = 1.5 [1.0-2.2]). Women having received COC did not report more conjugal violence or union break-ups than in the SC group. The main factors associated with partner HIV testing were a history of HIV testing among men in Cameroon, Dominican Republic and Georgia and the existence of couple communication around HIV testing in Georgia and India. A simple prenatal intervention taking into account the couple relationship increases the uptake of HIV testing among men in different socio-cultural settings. COC could contribute to the efforts towards eliminating mother-to-child transmission of HIV.

Abstract access 

Editor’s notes: Programmes geared towards the elimination of new HIV infections in children and keeping their mothers alive worldwide have grappled with the challenge to increase partner testing. Partner HIV discordancy is common, and interventions can be tailored to the couple status categories. Antenatal care settings have not necessarily oriented their programming to be male-friendly. It is notable that generally couples-oriented counseling and testing (COC) did increase uptake of HIV testing by male partners, though there was wide variation between countries. In addition, male testing rates remained relatively low in the intervention couples.   It is clear that additional strategies to augment partner testing will need to be implemented and evaluated. This study did provide some reassuring information that conjugal violence and union break-ups were not more common in the COC group. The study sites were in low and medium HIV prevalence settings and these results need to be compared to similar interventions in high prevalence settings.

Africa, Asia, Latin America
Cameroon, Dominican Republic, Georgia, India
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