Patterns of Genital Examination and Vulvovaginal Graft-Versus-Host Disease in a Pediatric Post-Hematopoietic Stem Cell Transplant Population.

STUDY OBJECTIVE: To determine vulvovaginal graft-versus-host disease (vvGVHD) incidence among pediatric patients who have received hematopoietic stem cell transplantation (HSCT) and who already have graft-versus-host disease (GVHD) involving any organ system and characterize patterns of genital examination and referral to pediatric and adolescent gynecology (PAG) in the post-HSCT population. DESIGN: Retrospective chart review. SETTING: Large tertiary children's hospital in Texas. PARTICIPANTS: Eighty-six post-HSCT female patients 21 years old and younger with GVHD involving any organ system. INTERVENTIONS: None. MAIN OUTCOME MEASURES: vvGVHD among post-HSCT children, referrals to PAG, genital examinations documented by any clinician. RESULTS: Eighty-six patients met inclusion criteria. Most HSCTs were bone marrow transplants, typically for leukemia. Median ages of indication diagnosis and HSCT were 5.1 and 7.5 years, respectively. Median time from HSCT to first GVHD diagnosis (eg, skin, intestine) was 96 days. Nearly all patients had at least 1 genital exam documented in the first 2 years post-HSCT, with a median of 17 exams. Twenty-eight patients were seen by PAG post-HSCT, with 7 of these patients seen within the first 2 years post-HSCT. Four symptomatic patients were diagnosed with vvGVHD. Median time from HSCT to vvGVHD was 398 days. CONCLUSION: The small number of vvGVHD cases in our study population is likely because of lack of symptom reporting from patients and families and difficulty with vvGVHD diagnosis. Further training for non-PAG physicians, including pediatricians and oncologists, in identifying and managing vvGVHD might prevent delayed diagnosis and severe sequelae. Earlier referral to PAG or a gynecologist versed in post-HSCT survivorship is also recommended.

Incidence of abnormal cervical and vaginal cytology among women over age 65 years living with human immunodeficiency virus.

BACKGROUND: Women with human immunodeficiency virus have higher rates of abnormal cervical and vaginal cytology and, subsequently, of cervical and vaginal cancers. Although professional bodies currently advocate for indefinite cytology screening for women living with human immunodeficiency virus, these recommendations are based on expert opinion, not evidence-based. In the general population, women who have never had an abnormal cytology result can cease screening at age 65 years. This is due to the relatively low incidence of dysplasia in this group and the risk of false-positive results as women age, invasive follow-up testing, and destructive treatments of lesions that are unlikely to progress to cancer. What is unclear, however, is how human immunodeficiency virus-infected women over age 65 years who have no history of abnormal cytology should be screened to maximize benefit while reducing harms of overscreening. This is a crucial question, as women over age 65 years who are living with human immunodeficiency virus comprise a rapidly growing population. OBJECTIVE: To describe the incidence of abnormal cervical and vaginal cytology results in women over the age of 65 years living with human immunodeficiency virus, with the goal of providing evidence for screening recommendations. MATERIALS AND METHODS: A retrospective chart review was performed, identifying 69 women who received gynecologic follow-up in a county hospital system in Houston, Texas, between 2000 and 2018 and who met study criteria. Incidence of abnormal cytology after age 65 was determined by analyzing all available cytology results after age 65. Demographic and clinical risk factors, including human immunodeficiency virus-specific clinical risk factors, were analyzed. Matched cervical and vaginal pathology results, if conducted, were also evaluated. Statistical analyses were conducted using Stata 15, including χ2 tests and Wilcoxon rank-sum tests for categorical and continuous variables, respectively. Estimates of the cumulative probability of developing an abnormal cytology result was calculated using the Kaplan-Meier method. RESULTS: Among 69 women with no history of abnormal cervical cytology, 12 (17%) went on to develop abnormal cytology results, including 3 (4%) showing high-grade squamous intraepithelial lesions. The incidence rate was 3.5 cases per 100 woman-years (95% confidence interval, 1.58, 7.81). No demographic or gynecologic characteristics were associated with abnormal cytology. A CD4 count of <200 at the time of human immunodeficiency virus diagnosis or at the time of cytology was associated with an abnormal Papanicolaou test result (P < .0001, P = .031). Of women with pathology results in the county hospital system (n = 8), 4 (50%) had cervical intraepithelial neoplasia 2+ or vaginal intraepithelial neoplasia 2+. No women developed invasive cancer. However, 50% of women who had an abnormal Papanicolaou test result in the study period were lost to follow-up; outcomes for these patients are unknown. CONCLUSION: Given the relatively high proportion (4%) of women with high-grade squamous intraepithelial lesions/cervical intraepithelial neoplasia 2+/vaginal intraepithelial neoplasia 2+ during the study period, we agree with current screening recommendations for continued routine Papanicolaou testing after the age of 65 years in women with human immunodeficiency virus. More evidence from larger studies is needed to solidify evidence-based screening recommendations in this unique and growing population.

A Multicenter Analysis of Elvitegravir Use During Pregnancy on HIV Viral Suppression and Perinatal Outcomes.

BACKGROUND: There is a knowledge gap on the clinical use of elvitegravir (EVG) during pregnancy and maternal viral suppression. Our objective was to evaluate the effects of EVG use in pregnancy on rates of HIV virologic suppression and perinatal outcomes. METHODS: We conducted a retrospective, multicenter study of pregnant women living with HIV (WLHIV) who used EVG-containing antiretroviral therapy (ART) between January 2014 and March 2017 at 9 tertiary care centers in the United States. WLHIV were included if they took EVG at any time during pregnancy. We described the characteristics of the WLHIV using EVG during the study period and evaluated the rates of HIV suppression and perinatal outcomes. RESULTS: Among 134 pregnant WLHIV who received EVG at any time during pregnancy, viral suppression at delivery (HIV-1 RNA < 40 copies/mL) occurred in 81.3%. In WLHIV who initiated EVG before pregnancy and continued through delivery (n = 68), the rate of viral suppression at delivery was 88.2%. The average gestational age at the time of delivery was 37 weeks 6 days, and the overall rate of preterm birth was 20%. No cases of open neural tube defects were noted in women on EVG at the time of conception (n = 82). The perinatal HIV transmission rate was 0.8%. CONCLUSIONS: EVG use was associated with high sustained levels of HIV suppression during pregnancy and a low rate of perinatal HIV transmission.

Measuring facility capability to provide routine and emergency childbirth care to mothers and newborns: An appeal to adjust for delivery caseload of facilities.

BACKGROUND: Measurement of Emergency Obstetric Care capability is common, and measurement of newborn and overall routine childbirth care has begun in recent years. These assessments of facility capabilities can be used to identify geographic inequalities in access to functional health services and to monitor improvements over time. This paper develops an approach for monitoring the childbirth environment that accounts for the delivery caseload of the facility. METHODS: We used data from the Kenya Service Provision Assessment to examine facility capability to provide quality childbirth care, including infrastructure, routine maternal and newborn care, and emergency obstetric and newborn care. A facility was considered capable of providing a function if necessary tracer items were present and, for emergency functions, if the function had been performed in the previous three months. We weighted facility capability by delivery caseload, and compared results with those generated using traditional "survey weights". RESULTS: Of the 403 facilities providing childbirth care, the proportion meeting criteria for capability were: 13% for general infrastructure, 6% for basic emergency obstetric care, 3% for basic emergency newborn care, 13% and 11% for routine maternal and newborn care, respectively. When the new caseload weights accounting for delivery volume were applied, capability improved and the proportions of deliveries occurring in a facility meeting capability criteria were: 51% for general infrastructure, 46% for basic emergency obstetric care, 12% for basic emergency newborn care, 36% and 18% for routine maternal and newborn care, respectively. This is because most of the caseload was in hospitals, which generally had better capability. Despite these findings, fewer than 2% of deliveries occurred in a facility capable of providing all functions. CONCLUSION: Reporting on the percentage of facilities capable of providing certain functions misrepresents the capacity to provide care at the national level. Delivery caseload weights allow adjustment for patient volume, and shift the denominator of measurement from facilities to individual deliveries, leading to a better representation of the context in which facility births take place. These methods could lead to more standardized national datasets, enhancing their ability to inform policy at a national and international level.