Sustitución segura de la lactancia materna para prevenir la transmisión vertical del VIH en la Provincia Central de Kenia / Safe replacement of breast milk to prevent VIH vertical transmission in the Central Province of Kenia

Introducción: la lactancia materna es responsable de hasta un 40% de los contagios perinatales del virus de la inmunodeficiencia humana (VIH) en el África subsahariana. La OMS aconseja evitar por completo la lactancia materna solo si la lactancia artificial es aceptable, factible, asequible, segura y sostenible (AFASS). Material y métodos: se analizaron datos de tres programas del Ministerio de Salud para la prevención de la transmisión vertical (PTV) del VIH, en la Provincia Central de Kenia. Las gestantes VIH+ recibieron información y consejo sobre cómo proteger al bebé durante el embarazo, el parto y el periodo de lactancia. Se administró zidovudina (AZT) desde la vigésimo octava semana, más nevirapina –dosis única– (SD-NVP) intraparto si los linfocitos CD4 eran mayores de 350 cel/mm3, o tratamiento antirretroviral de gran actividad (TARGA) si eran menores de 350 cel/mm3. Los neonatos expuestos recibieron AZT + NVP. Se suministró lactancia artificial (LA), filtros de agua y termos a las madres que optaron por no lactar a sus hijos. Se realizó reacción en cadena de la polimerasa (PCR) para ADN-VIH-1 a las seis semanas de vida. Las madres incluidas en el programa recibían apoyo psicológico individualizado y a través de terapias de grupo. Resultados: la mayoría de las madres (66-96%) se decidieron por la LA; 881 lactantes recibieron leche artificial bien desde el nacimiento o tras un periodo inicial con lactancia materna o con leche de vaca; 515 (58%) fueron dados de alta a los seis meses de edad; 272 (31%) permanecían en el programa (niños < 6 meses) en el momento del análisis de datos. Hubo 59 (6,7%) pérdidas de seguimiento y 12 (1,4%) traslados a otros programas. Un total de 23 (2,6%) lactantes fallecieron. Los neonatos infectados por VIH tuvieron diez veces más probabilidades de morir antes de cumplir seis meses que los no infectados (odds ratio [OR]: 10,55; IC 95% [intervalo de confianza del 95%]: 2,51-41,5), p < 0,001). La morbilidad fue baja; la incidencia de diarrea y de infecciones respiratorias fue de 15,3 y de 42,4 por cada 100 personas/año, respectivamente. Conclusiones: es factible y seguro apoyar la lactancia artificial para madres seropositivas y sus bebés en entornos con escasos recursos en programas integrados en instituciones sanitarias del sector público (AU)

Background: breast feeding accounts for up to 40% of perinatally acquired HIV infection in sub-Saharan Africa. HIV infected mothers are advised by World Health Organization (WHO) to completely avoid breast feeding only if replacement feeding is acceptable, feasible, affordable, safe and sustainable (AFASS). Methods: data were obtained from 3 Ministry of Health PMTCT programs in Central Province, Kenya. HIV positive pregnant women received AZT starting at 28 weeks + intrapartum SD-NVP if CD4>350 or TARGA if CD4<350. HIV exposed infants received AZT + NVP. Infant formula, water filters and thermos flasks were provided to women opting not to breast-feed their infants. ADN-PCR for HIV was obtained at 6 weeks of age. Results: most mothers (66-96%) opted for replacement feeding (RF). Eight hundred and eighty one infants received RF either from birth or after initial breast feeding or cow’s milk. Five hundred and fifteen infants (58%) were discharged after reaching 6 months of age; 272 (31%) were still active (<6 months). There were 59 defaulters (6.7%) and 12 relocations (1.4%). Twenty three infants died (2.6%). HIV-infected infants were more than 10 times more likely to die before 6 months of age than HIV-uninfected infants [OR 10.55 (2.51-41.5) P < 0.001]. Morbidity was low; the incidence of diarrhoea and respiratory tract infection was 15.3 and 42.4 per 100 person-years respectively. Interpretation: it is possible to support safe replacement feeding in resource-limited contexts under routine program conditions within public sector health facilities by employing a feeding methodology that is feasible for mothers and safe for infants (AU)

Preventing IUCD-related pelvic infection: the efficacy of prophylactic doxycycline at insertion.

Most of the small increased risk in pelvic inflammatory disease (PID) associated with the intrauterine contraceptive device (IUCD) appears to be caused by bacterial contamination of the endometrial cavity at the time of insertion. This randomized clinical trial of 1813 women in Nairobi, Kenya, assessed the effectiveness of 200 mg of doxycycline given orally at the time of insertion in reducing the occurrence of PID. The rate of this infection in the doxycycline-treated group was 31% lower than that in the placebo-treated group (1.3 and 1.9%, respectively; RR 0.69; 95% CI 0.32 to 1.5). The rate of an unplanned IUCD-related visit to the clinic was also 31% lower in the doxycycline-treated group (RR 0.69; 95% CI 0.52 to 0.91). Although the significance level (P = 0.17) for the reduction is PID does not meet the conventional standard of 0.05, the results may be suggestive of an effect. Moreover, the reduction in IUCD-related visits (P = 0.004) not only represents an important decrease in morbidity but also substantiates the reduction found for PID. Further studies are needed to corroborate these results. Consideration should be given to the prophylactic use of doxycycline at the time of IUCD insertion as an approach to preventing PID and other IUCD-related morbidity.

PIP: This double-blind, randomized clinical trial was conducted to investigate whether the use of prophylactic doxycycline at intrauterine contraceptive device (IUCD) insertion can reduce the incidence of pelvic inflammatory disease (PID) in women. 1813 women in Nairobi, Kenya, were given 200 mg of doxycycline, taken orally at the time of IUCD insertion. Analysis of the data collected show that the rate of PID infection in the doxycycline-treated group was 31% lower than that in the placebo-treated group. The rate of an unplanned IUCD-related visit to the clinic was also 31% lower in the doxycycline-treated group. Although the significance level (P = 0.17) for the reduction in PID does not meet the conventional standard of 0.05, the results may be suggestive of an effect. In addition, the reduction in IUCD-related visits (P = 0.004) not only represents an important decrease in morbidity, but also substantiates the reduction found for PID. To conclude, the prophylactic use of doxycycline at the time of IUCD insertion appears effective, well tolerated, and cost-effective. Further studies are needed to corroborate these results and consideration should be given to the prophylactic use of doxycycline at the time of IUCD insertion as an approach in preventing PID and other IUCD-related morbidity.

The prevalence of Neisseria gonorrhoea and Chlamydia trachomatis in intra-uterine contraceptive acceptors in Kenya.

PIP: The 1725 women presenting at Kenyatta National Hospital in 1984-86 for IUD insertion were screened for cervical Chlamydia trachomatis and Neisseria gonorrhoea before the IUD insertion. 207 (12%) cases of chlamydia trachomatis and 61 (3.5%) cases of Neisseria gonorrhoea were detected. There was no association between the ages of the women and the prevalence of these 2 sexually transmitted pathogens; however, there was a significant relationship between the prevalence of N gonorrhoea and marital status. N gonorrhoea was detected in 6.2% of never-married and 5.2% of formerly married women compared with 2.3% of currently married subjects (p0.001). Although there was no significant relationship between parity and the rate of isolation of the 2 pathogens, infection tended to be lower in women with 5 or more children. Educational attainment was significantly associated with N gonorrhoea infection: 5.1% in women who had 0-7 years of schooling compared with 3.0% in those with 8 or more years of education (p0.05). 12 women with C trachomatis infection were also positive for N gonorrhoea. There was no significant relationship between C trachomatis infection and any of the demographic variables examined. Given the finding that the greatest risk of pelvic inflammatory disease occurs in the 1st month of IUD use, it can be speculated that pathogens are inserted into the uterine cavity at the time of IUD insertion. It is therefore recommended that clients--especially the unmarried, the formerly unmarried, and those with low levels of education--be screened and treated for N gonorrhoea and C trachomatis before an IUD is inserted.^ieng