Use of HIV pre-exposure prophylaxis during the preconception, antepartum and postpartum periods at two United States medical centers.

BACKGROUND: Pregnancy may increase a woman's susceptibility to HIV. Maternal HIV acquisition during pregnancy and lactation is associated with increased perinatal and lactational HIV transmission. There are no published reports of preexposure prophylaxis use after the first trimester of pregnancy or during lactation. OBJECTIVE: The purpose of this study was to report the use of preexposure prophylaxis and to identify gaps in HIV prevention services for women who were at substantial risk of HIV preconception and during pregnancy and lactation at 2 United States medical centers. STUDY DESIGN: Chart review was performed on women who were identified as "at significant risk" for HIV acquisition preconception (women desiring pregnancy) and during pregnancy and lactation at 2 medical centers in San Francisco and New York from 2010-2015. Women were referred to specialty clinics for women who were living with or were at substantial risk of HIV. RESULTS: Twenty-seven women who were identified had a median age of 27 years. One-half of the women had unstable housing, 22% of the women had ongoing intimate partner violence, and 22% of the women had active substance use. Twenty-six women had a male partner living with HIV, and 1 woman had a male partner who had sex with men. Of the partners who were living with HIV, 73% (19/26) were receiving antiretroviral therapy, and 42% (11/26) had documented viral suppression. Thirty-nine percent (10/26) of partners had known detectable virus, and 19% (5/26) had unknown viral loads. Women were identified by clinicians, health educators, and health departments. Approximately one-third of the women were identified preconception (8/27); the majority of the women were identified during pregnancy (18/27) with a median gestational age of 20 weeks (interquartile range, 11-23), and 1 woman was identified in the postpartum period. None of the pregnant referrals had received safer conception counseling to reduce HIV transmission. Twenty-six percent of all women (7/27) were eligible for postexposure prophylaxis at referral, of whom 57% (4/7) were offered postexposure prophylaxis. In 30% (8/27), the last HIV exposure was not assessed and postexposure prophylaxis was not offered. The median time from identification as "at substantial risk" to consultation was 30 days (interquartile range, 2-62). Two women were lost to follow up before consultation. One woman who was identified as "at significant risk" was not referred because of multiple pregnancy complications. She remained in obstetrics care and was HIV-negative at delivery but was lost to follow up until 10 months after delivery when she was diagnosed with HIV. No other seroconversions were identified. Of referrals who presented and were offered preexposure prophylaxis, 67% women (16/24) chose to take it, which was relatively consistent whether the women were preconception (5/8), pregnant (10/15), or after delivery (1/1). Median length of time on preexposure prophylaxis was 30 weeks (interquartile range, 20-53). One-half of women (10/20) who were in care at delivery did not attend a postpartum visit. CONCLUSION: Women at 2 United States centers frequently chose to use preexposure prophylaxis for HIV prevention when it was offered preconception and during pregnancy and lactation. Further research and education are needed to close critical gaps in screening for women who are at risk of HIV for pre- and postexposure prophylaxis eligibility and gaps in care linkage before and during pregnancy and lactation. Postpartum women are particularly vulnerable to loss-to-follow-up and miss opportunities for safe and effective HIV prevention.

Household food insecurity, maternal nutritional status, and infant feeding practices among HIV-infected Ugandan women receiving combination antiretroviral therapy.

Household food insecurity (HHFI) may be a barrier to both optimal maternal nutritional status and infant feeding practices, but few studies have tested this relationship quantitatively, and never among HIV-infected individuals. We therefore described the prevalence of HHFI and explored if it was associated with poorer maternal nutritional status, shorter duration of exclusive breastfeeding (EBF) and fewer animal-source complementary foods. We assessed these outcomes using bivariate and multivariate analyses among 178 HIV-infected pregnant and breastfeeding (BF) women receiving combination antiretroviral therapy in the PROMOTE trial (NCT00993031), a prospective, longitudinal cohort study in Tororo, Uganda. HHFI was common; the prevalence of severe, moderate, and little to no household hunger was 7.3, 39.9, and 52.8 %, respectively. Poor maternal nutritional status was common and women in households experiencing moderate to severe household hunger (MSHH) had statistically significantly lower body mass index (BMIs) at enrollment (21.3 vs. 22.5, p < 0.01) and prior to delivery (22.6 vs. 23.8, p < 0.01). BMI across time during pregnancy, but not gestational weight gain, was significantly lower for MSHH [adjusted beta (95 % CI) -0.79 (-1.56, -0.02), p = 0.04; -2.06 (-4.31, 0.19), p = 0.07], respectively. The prevalence (95 % CI) of EBF at 6 months was 67.2 % (59.7-73.5 %), and the proportion of women BF at 12 months was 80.4 % (73.3-85.7 %). MSHH was not associated with prevalence of EBF at 6 months or BF at 12 months. However, among those women still EBF at 4 months (81.4 % of population), those experiencing MSHH were significantly more likely to cease EBF between 4 and 6 months (aHR 2.38, 95 % CI 1.02-5.58). The prevalence of HHFI, maternal malnutrition, and suboptimal infant feeding practices are high and the causal relationships among these phenomena must be further explored.

The cost-effectiveness of repeat HIV testing during pregnancy in a resource-limited setting.

OBJECTIVE: To estimate the cost-effectiveness of HIV screening strategies for the prevention of perinatal transmission in Uganda, a resource-limited country with high HIV prevalence and incidence. STUDY DESIGN: We designed a decision analytic model from a health care system perspective to assess the vertical transmission rates and cost-effectiveness of 4 different HIV screening strategies in pregnancy: (1) rapid HIV antibody (Ab) test at initial visit (current standard of care), (2) strategy 1 + HIV RNA at initial visit (adds detection of acute HIV), (3) strategy 1 + repeat HIV Ab at delivery (adds detection of incident HIV), and (4) strategy 3 + HIV RNA at delivery (adds detection of acute HIV at delivery). Model estimates were derived from the literature and local sources, and life years saved were discounted at a rate of 3% per year. Based on World Health Organization guidelines, we defined our cost-effectiveness threshold as ≤3 times the gross domestic product per capita, which for Uganda was US$3300 in 2008. RESULTS: Using base case estimates of 10% HIV prevalence among women entering prenatal care and 3% incidence during pregnancy, strategy 3 was incrementally the cost-effective option that led to the greatest total life years. CONCLUSIONS: Repeat rapid HIV Ab testing at the time of labor is a cost-effective strategy even in a resource-limited setting such as Uganda.

Contraceptive use and barriers to access among newly arrested women.

Incarcerated women report high rates of prior unintended pregnancies as well as low contraceptive use. Because jail could be a site of contraception care, this study aimed to assess women's access to contraception prior to their arrest. A cross-sectional survey was administered to 228 reproductive-aged, nonpregnant women arrested in San Francisco. Twenty-one percent were currently using contraception. More than half (61%) had not used contraception in the last year, yet 11% wanted to have used it. Women in this latter subset reported greater difficulty with payment, finding a clinic, and transportation compared to women who had used contraception. In addition, 60% of all women in the sample would accept contraception if offered to them in jail. Thus, jail is a potentially important and acceptable point of access to contraception, which can circumvent some preincarceration logistical barriers.

Emergency contraception for newly arrested women: evidence for an unrecognized public health opportunity.

Incarceration affords an opportunity to provide health care to populations with limited access to care. Women in this population are at high risk for experiencing unintended pregnancies. It is not known what proportion of these women engage in unprotected intercourse in the days prior to incarceration and therefore may benefit from being offered emergency contraception upon their arrest to decrease their risk of unintended pregnancies. We sought to describe the proportion and characteristics of newly arrested women who are eligible for and interested in taking emergency contraception by conducting a cross-sectional study in an urban county jail booking facility. A 63-item survey was administered to women ages 18-44 within 24 h of being arrested in San Francisco. Eighty-four (29%) women were eligible for emergency contraception. Of these, 48% indicated a willingness to take emergency contraception if offered. Half of the women eligible for emergency contraception expressed ambivalent attitudes about pregnancy. Women who had taken emergency contraception in the past were more likely to say they would accept it (45%) than women who had never used it (25%, p = .05). The strongest predictor of willingness to take emergency contraception was not having a misperception about its safety, efficacy, or mechanism of action (RR = 1.9, 95% CI 1.2-3.0). Seventy-one percent of all women indicated that they would accept an advance supply of emergency contraception upon release from jail. Emergency contraception counseling and provision should be offered to newly arrested women as a key reproductive and public health intervention for a traditionally marginalized, high-risk population.