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1.  Infection with Hepatitis C Virus among HIV-Infected Pregnant Women in Thailand 
Objective. The purpose of this study was to describe the epidemiology of coinfection with hepatitis C virus (HCV) and HIV among a cohort of pregnant Thai women. Methods. Samples from 1771 pregnant women enrolled in three vertical transmission of HIV studies in Bangkok, Thailand, were tested for HCV. Results. Among HIV-infected pregnant women, HCV seroprevelance was 3.8% and the active HCV infection rate was 3.0%. Among HIV-uninfected pregnant women, 0.3% were HCV-infected. Intravenous drug use by the woman was the factor most strongly associated with HCV seropositivity. Among 48 infants tested for HCV who were born to HIV/HCV coinfected women, two infants were HCV infected for an HCV transmission rate of 4.2% (95% 0.51–14.25%). Conclusions. HCV seroprevalence and perinatal transmission rates were low among this Thai cohort of HIV-infected pregnant women.
PMCID: PMC2631650  PMID: 19190779
2.  The Health of HIV-exposed Children after Early Weaning 
Maternal & child nutrition  2011;9(2):217-232.
There are potential health risks associated with the use of early weaning to prevent mother-to-child transmission of HIV in resource-poor settings. Our objective was to examine growth and nutrient inadequacies among a cohort of children weaned early. Children participating in the Breastfeeding Antiretrovirals and Nutrition (BAN) Study in Lilongwe, Malawi, had HIV-infected mothers, were weaned at 6 months and fed LNS until 12 months. 40 HIV-negative, BAN-exited children were compared to 40 HIV-negative, community children matched on age, gender and local health clinic. Nutrient intake was calculated from 24-hour dietary recalls collected from BAN-exited children. Anthropometric measurements were collected from BAN-exited and matched community children at 15-16 months, and 2 months later. Longitudinal random effects sex-stratified models were used to evaluate anthropometric differences between the 2 groups. BAN-exited children consumed adequate energy, protein, and carbohydrates but inadequate amounts of fat. The prevalence of inadequate micronutrient intakes were: 46% for vitamin A; 20% for vitamin B6; 69% for folate; 13% for vitamin C; 19% for iron; 23% for zinc. Regarding growth, BAN-exited girls gained weight at a significantly lower rate (0.02g/kg/day [95%CI: 0.01, 0.03] than their matched comparison (0.05g/kg/day [95%CI: 0.03, 0.07]); BAN girls grew significantly slower (0.73cm/month [95%CI: 0.40,1.06]) than their matched comparison (1.55cm/month [95%CI: 0.98, 2.12]). Among this sample of BAN-exited children, early weaning was associated with dietary deficiencies and girls experienced reduced growth velocity. In resource-poor settings, HIV prevention programs must ensure that breastfeeding stop only once a nutritionally adequate and safe diet without breastmilk can be provided.
PMCID: PMC3787136  PMID: 22099216
LNS; early breastfeeding cessation; HIV; Malawi; child growth
3.  Maternal and infant antiretroviral regimens to prevent postnatal HIV-1 transmission: 48-week follow-up of the BAN randomised controlled trial 
Lancet  2012;379(9835):2449-2458.
In resource-limited settings where no safe alternative to breastfeeding exists, WHO recommends that antiretroviral prophylaxis be given to either HIV-infected mothers or infants throughout breastfeeding. We assessed the effect of 28 weeks of maternal or infant antiretroviral prophylaxis on postnatal HIV infection at 48 weeks.
The Breastfeeding, Antiretrovirals, and Nutrition (BAN) Study was undertaken in Lilongwe, Malawi, between April 21, 2004, and Jan 28, 2010. 2369 HIV-infected breastfeeding mothers with a CD4 count of 250 cells per μL or more and their newborn babies were randomly assigned with a variable-block design to one of three, 28-week regimens: maternal triple antiretroviral (n=849); daily infant nevirapine (n=852); or control (n=668). Patients and local clinical staff were not masked to treatment allocation, but other study investigators were. All mothers and infants received one dose of nevirapine (mother 200 mg; infant 2 mg/kg) and 7 days of zidovudine (mother 300 mg; infants 2 mg/kg) and lamivudine (mothers 150 mg; infants 4 mg/kg) twice a day. Mothers were advised to wean between 24 weeks and 28 weeks after birth. The primary endpoint was HIV infection by 48 weeks in infants who were not infected at 2 weeks and in all infants randomly assigned with censoring at loss to follow-up. This trial is registered with, number NCT00164736.
676 mother–infant pairs completed follow-up to 48 weeks or reached an endpoint in the maternal-antiretroviral group, 680 in the infant-nevirapine group, and 542 in the control group. By 32 weeks post partum, 96% of women in the intervention groups and 88% of those in the control group reported no breastfeeding since their 28-week visit. 30 infants in the maternal-antiretroviral group, 25 in the infant-nevirapine group, and 38 in the control group became HIV infected between 2 weeks and 48 weeks of life; 28 (30%) infections occurred after 28 weeks (nine in maternal-antiretroviral, 13 in infant-nevirapine, and six in control groups). The cumulative risk of HIV-1 transmission by 48 weeks was significantly higher in the control group (7%, 95% CI 5–9) than in the maternal-antiretroviral (4%, 3–6; p=0·0273) or the infant-nevirapine (4%, 2–5; p=0·0027) groups. The rate of serious adverse events in infants was significantly higher during 29–48 weeks than during the intervention phase (1·1 [95% CI 1·0–1·2] vs 0·7 [0·7–0·8] per 100 person-weeks; p<0·0001), with increased risk of diarrhoea, malaria, growth faltering, tuberculosis, and death. Nine women died between 2 weeks and 48 weeks post partum (one in maternal-antiretroviral group, two in infant-nevirapine group, six in control group).
In resource-limited settings where no suitable alternative to breastfeeding is available, antiretroviral prophylaxis given to mothers or infants might decrease HIV transmission. Weaning at 6 months might increase infant morbidity
US Centers for Disease Control and Prevention.
PMCID: PMC3661206  PMID: 22541418
4.  Prevention of Perinatal Hepatitis B Virus Transmission 
Hepatitis B virus (HBV) infection, the most common form of chronic hepatitis worldwide, is a major public health problem affecting an estimated 360 million people globally. Mother-to-child transmission (MTCT) is responsible for more than one third of chronic HBV infections worldwide. An estimated 15%–40% of persons chronically infected develop HBV-related complications, such as cirrhosis and hepatic carcinoma, and 25% die from these complications. MTCT can occur during pregnancy or during delivery. Screening pregnant women for HBV infection, providing infant postexposure prophylaxis, and maternal treatment with antiviral medications are strategies for reducing MTCT transmission rates and the global burden of new chronic HBV infections. Administration of hepatitis B immune globulin (HBIG) and hepatitis B (HepB) vaccine within 24 hours of birth, followed by completion of the vaccine series, is 85%–95% efficacious for prevention of MTCT. Despite timely post-exposure prophylaxis, MTCT occurs in 5%–15% of infants. Hepatitis B surface antigen (HBsAg) positive, hepatitis e antigen (HBeAg) positive mothers with HBV DNA level ≥106 copies/mL (>200 000 IU/mL) are at greatest risk of transmitting HBV to their infants. Consensus recommendations and evidence-based guidelines for management of chronic HBV infection and screening of pregnant women have been developed. The safety and efficacy of antiviral drug use during pregnancy are areas of ongoing research. Substantial advances have been achieved globally in reducing MTCT, but MTCT remains an ongoing health problem. Attaining a better understanding of the mechanisms of MTCT, implementing existing policies on maternal screening and infant follow-up, and addressing research gaps are critical for further reductions in MTCT transmission.
PMCID: PMC4164184  PMID: 25232477
antivirals; hepatitis B; hepatitis B immune globulin; hepatitis B vaccine; hepatitis B virus; mother-to-child transmission; perinatal transmission
5.  CDC Pregnancy Flu Line: monitoring severe illness among pregnant women with influenza 
Maternal and child health journal  2014;18(7):1578-1582.
The Centers for Disease Control and Prevention implemented the Pregnancy Flu Line during the influenza A(H1N1)pdm09 (pH1N1) pandemic and continued operation through the 2010–11 influenza season to collect reports of intensive care unit (ICU) admissions and deaths among pregnant women with influenza. The system documented the severe impact of influenza on pregnant women during both seasons with 181 ICU/survivals and 37 deaths reported during the 2009 fall pandemic wave and 69 ICU/survivals and 10 deaths reported in the subsequent influenza season (2010–11). A health department survey suggests PFL participants perceived public health benefits and minimum time burdens.
PMCID: PMC4498262  PMID: 24368408
Influenza; Human; Influenza A Virus; H1N1 Subtype; Pregnancy; Surveillance
6.  What Obstetric Health Care Providers Need to Know About Measles and Pregnancy 
Obstetrics and gynecology  2015;126(1):163-170.
From January 1 to April 3, 2015, 159 people from 18 states and the District of Columbia were reported as having measles. Most cases are part of an outbreak linked to a California amusement park. Because measles was eliminated in the United States in 2000, most U.S. clinicians are unfamiliar with the condition. We reviewed information on the current outbreak, measles manifestations, diagnostic methods, treatment, and infection-control recommendations. To identify information on measles and pregnancy, we reviewed reports with 20 or more measles cases during pregnancy that included data on effects on pregnant women or pregnancy outcomes. These reports were identified through MEDLINE from inception through February 2015 using the following strategy: (((pregnan*) AND measles) AND English[Language]) NOT review[Publication Type]. Reference lists also were reviewed to identify additional articles. Pregnant women infected with measles are more likely to be hospitalized, develop pneumonia, and die than nonpregnant women. Adverse pregnancy outcomes, including pregnancy loss, preterm birth, and low birth weight, are associated with maternal measles; however, the risk of congenital defects does not appear to be increased. No antiviral therapy is available; treatment is supportive. Early identification of possible cases is needed so that appropriate infection control can be instituted promptly. The recent measles outbreak highlights the role that obstetric health care providers play in vaccine-preventable illnesses; obstetrician–gynecologists should ensure that patients are up to date on all vaccines, including measles-containing vaccines, and should recommend and ideally offer a measles-containing vaccine to women without evidence of measles immunity before or after pregnancy.
PMCID: PMC4552307  PMID: 25899422
7.  Exploring Discordance Between Biologic and Self-Reported Measures of Semen Exposure: A Qualitative Study Among Female Patients Attending an STI Clinic in Jamaica 
AIDS and behavior  2013;17(2):728-736.
We explored the use of qualitative interviews to discuss discrepancies between two sources of information on unprotected sex: biomarker results and self-reported survey data. The study context was a randomized trial in Kingston, Jamaica examining the effect of STI counseling messages on recent sexual behavior using prostate-specific antigen (PSA) as the primary study outcome. Twenty women were interviewed. Eleven participants were selected because they tested positive for PSA indicating recent semen exposure, yet reported no unprotected sex in a quantitative survey (“discordant”): 5 reported abstinence and 6 reported condom use. Nine participants who also tested positive for PSA but reported unprotected sex in the survey were interviewed for comparison (“concordant”). Qualitative interviews with 6 of the 11 discordant participants provided possible explanations for their PSA test results, and 5 of those were prompted by direct discussion of those results. Rapid PSA testing combined with qualitative interviews provides a novel tool for investigating and complementing self-reported sexual behavior.
PMCID: PMC4544859  PMID: 22893195
Qualitative study; Self-reported data; Semen biomarker; Prostate-specific antigen; Jamaica
8.  Emerging and Zoonotic Infections in Women 
Emerging infections, many of them zoonotic, are caused by a wide variety of pathogens with global distribution. Their impact on women is similarly diverse. Pathogens that were previously rare are emerging in recent years to cause disease in new populations, and global travel facilitates their rapid spread across continents. Finally, human encroachment on previously remote areas has brought people into contact with zoonotic diseases and vectors never before characterized. Although systematic study of rare outbreaks can be challenging, our knowledge of emerging pathogens and their differential effects on women, including those who are pregnant, has started to accumulate. We discuss the effects on women of lymphocytic choriomeningitis virus, West Nile virus, SARS coronavirus, avian influenza A (H5N1), virus, and the viral hemorrhagic fevers. We also explore the spirochetal illnesses and Chagas disease as they pertain to the pregnant patient. Finally, we review the potential impact of candidate bioterror agents on the female population, and address related issues of prophylaxis and therapy.
PMCID: PMC2650502  PMID: 18954762
9.  Health outcomes of HIV-exposed uninfected African infants 
AIDS (London, England)  2013;27(5):749-759.
To evaluate severe (grade 3/4) morbidity and mortality in HIV-exposed, uninfected infants.
Secondary data analysis of The Breastfeeding, Antiretrovirals, and Nutrition (BAN) clinical trial.
BAN randomized 2369 mother–infant pairs to maternal, infant, or no extended antiretroviral prophylaxis during breastfeeding. Morbidity outcomes examined were pneumonia/serious febrile illness, diarrhea/growth faltering, and malaria. Infant death was defined as neonatal (≤ 30 days of life), and postneonatal (31 days to 48 weeks of life). Cox proportional hazards models were used to evaluate the effect of covariates on infant morbidity and mortality.
The rate of pneumonia/serious febrile illness was highest in the first 12 weeks (0.83/100 person-weeks) before rapidly decreasing; rates of all morbidity outcomes increased after 24 weeks. Rates of pneumonia/serious febrile illness and diarrhea/growth faltering were higher during the rainy season. Prophylactic infant cotrimoxazole significantly decreased the rates of all morbidity outcomes. White blood cell (WBC) count less than 9000/μl at birth was associated with increased diarrhea/growth faltering [adjusted hazard ratio (aHR) 1.73, P = 0.04] and malaria (aHR 2.18, P = 0.02). Low birth weight (2000–2499 g) was associated with neonatal death (aHR 12.3, P <0.001). Factors associated with postneonatal death included rainy season (aHR 4.24, P = 0.002), infant cotrimoxazole (aHR 0.48, P = 0.03), and low infant WBC count at birth (aHR 2.53, P = 0.02).
Infant morbidity rates increased after 24 weeks, when BAN infants weaned. Introduction of prophylactic cotrimoxazole was associated with reduced rates of morbidity and mortality in HIV-exposed uninfected infants. Unexpectedly, a low WBC count at birth was significantly associated with later infant morbidity and mortality in this cohort.
PMCID: PMC4493890  PMID: 23719347
Africa; HIV; HIV-exposed; infant; morbidity; mortality; pediatric
10.  Orphaned and abused youth are vulnerable to pregnancy and suicide risk☆, ☆☆ 
Child abuse & neglect  2013;37(5):310-319.
Little is known about the magnitude and consequences of violence against children for those living outside family care. We sought to estimate the frequency of childhood abuse and examine its association with lifetime pregnancy involvement (LPI) and past year suicide ideation among orphaned youth.
We analyzed data collected via cross-sectional interviewer-administered surveys completed by 293 orphaned youth aged 16–23 years living outside of family care in St. Petersburg, Russia. We used multivariable logistic regression to estimate adjusted odds ratios (AORs) of LPI and past year suicide ideation associated with childhood physical and sexual abuse. Other risk factors were also examined (e.g., social vulnerability, sexual and substance use behaviors), and characteristics of orphaned youth with LPI and past year suicide ideation were described.
The prevalence of childhood abuse was higher among females than among males (23.3% versus 15.6% for physical abuse, and 20.3% versus 5.6% for sexual abuse), as was the prevalence of LPI and past year suicide ideation among those with histories of abuse. Experiences of childhood abuse were strong risk factors for both LPI and past year suicide ideation, with significant variation by gender. While both types of abuse were significantly associated with LPI and past year suicide ideation among females, physical abuse was significantly associated with LPI and sexual abuse was associated with suicide ideation for males. Of the other characteristics examined, strong modifiable risk factors included having no one to turn to for help and no involvement in activities outside of class. Among those with LPI (n = 36), nearly 20% had been pregnant or gotten someone pregnant ≥2 times, most (61.8%) reported at least one induced abortion, and current use of effective contraception was nearly non-existent. Among those with past year suicide ideation (n = 30), nearly half (44.8%) reported attempting suicide.
There is an urgent need for interventions to prevent and mitigate the negative influence of childhood abuse experiences. Programs providing services to orphaned youth should increase access to sexual education, effective contraceptives, and mental health counseling.
PMCID: PMC4465590  PMID: 23290621
Orphans; Abuse; Pregnancy; Suicide ideation; Risk factors; Protective factors
11.  Pregnancy and Infection 
The New England journal of medicine  2014;370(23):2211-2218.
PMCID: PMC4459512  PMID: 24897084
12.  Optimal methods for collecting and storing vaginal specimens for prostate-specific antigen testing in research studies☆ 
Contraception  2012;87(6):830-835.
Prostate-specific antigen (PSA) detected in vaginal fluid can be used in studies of HIV/sexually transmitted infection (STI) and pregnancy prevention as an alternative to relying on participant reports of exposure to semen. Optimal methods for collecting and storing specimens for this testing have not been determined.
Study Design
We conducted a controlled, in vitro experiment of 550 specimens spiked with semen to determine the effects of swab type (five types), storage conditions of the swabs (room temperature with or without desiccant or at −80°C without desiccant) and time from collection to testing (seven intervals over the course of 12 months) on the identification of PSA. We performed factorial analysis of variance to identify factors influencing PSA detection.
Concentrations of PSA detected in the swabs declined with time of storage over the 1-year experiment (p<.01). The 1-mL, rayon-tipped swab stored immediately at −80°C following collection performed best.
If immediate testing or freezer storage is not feasible, investigators should use a swab with 1-mL capacity with processing and testing as soon as possible after specimen collection.
PMCID: PMC4452941  PMID: 23121826
Biomarker; In vitro experiment; Prostate-specific antigen
13.  HIV–HBV Coinfection — A Global Challenge 
The New England journal of medicine  2012;366(19):1749-1752.
PMCID: PMC4453872  PMID: 22571198
14.  Evaluation of a volunteer community-based health worker program for providing contraceptive services in Madagascar☆ 
Contraception  2013;88(5):657-665.
Madagascar recently scaled up their volunteer community health worker (CHW) program in maternal health and family planning to reach remote and underserved communities.
Study design
We conducted a cross-sectional evaluation using a systematic sample of 100 CHWs trained to provide contraceptive counseling and short-acting contraceptive services at the community level. CHWs were interviewed on demographics, recruitment, training, supervision, commodity supply, and other measures of program functionality; tested on knowledge of injectable contraception; and observed by an expert while completing five simulated client encounters with uninstructed volunteers. We developed a CHW performance score (0–100%) based on the number of counseling activities adequately met during the client encounters and used multivariable linear regression to identify correlates of the score.
CHWs had a mean performance score of 73.9% (95% confidence interval [CI]: 70.3–77.6%). More education, more weekly volunteer hours, and receiving a refresher training correlated with a higher performance score. We found no other associations between measures of the components previously identified as essential for effective CHW programs and performance score.
Although areas of deficiency were identified, CHWs proved capable of providing high-quality contraception services.
PMCID: PMC4453873  PMID: 23850074
Community health workers; Contraception; Evaluation; Multivariable linear regression
15.  Trends and Correlates of Good Perinatal Outcomes in Assisted Reproductive Technology 
Obstetrics and gynecology  2012;120(4):843-851.
To estimate trends in good perinatal outcomes (singleton live births at term with birthweight more than 2,500 g) among live births after assisted reproductive technology in the United States from 2000 to 2008, and associated factors among singletons in 2008.
Using retrospective cohort data from the National Assisted Reproductive Technology Surveillance System from 2000 to 2008, we calculated relative change and χ2 tests for trend in the proportion of good perinatal outcomes among assisted reproductive technology live births (n=444,909) and liveborn singletons (n=222,500). We conducted univariable analyses followed by multiple logistic regression to estimate the effects of various characteristics on the outcome among singletons born in 2008 after fresh, nondonor assisted reproductive technology cycles (n=20,780).
The proportion of good perinatal outcomes among all liveborn neonates increased from 38.6% in 2000 to 42.5% in 2008, whereas it declined marginally among singletons from 83.6% to 83.4%. One previous birth, transfer of fewer than three embryos, and the presence of fewer than three fetal hearts on 6-week ultrasound examination were associated with good perinatal outcome among singletons. Non-Hispanic black race, tubal factor infertility, uterine factor infertility, ovulatory disorder, and 5-day embryo culture were associated with reduced odds for a good outcome. The strongest association was the presence of one fetal heart compared with more than two (adjusted odds ratio 2.43, 95% confidence interval 1.73–3.42).
From 2000 to 2008, good perinatal outcomes increased among assisted reproductive technology live births. Among singleton live births, odds for good outcome were greatest with the presence of a single fetal heart and lowest in women of non-Hispanic black race.
PMCID: PMC4454287  PMID: 22996102
16.  Does Autism Diagnosis Age or Symptom Severity Differ Among Children According to Whether Assisted Reproductive Technology was Used to Achieve Pregnancy? 
Previous studies report associations between conception with assisted reproductive technology (ART) and autism. Whether these associations reflect an ascertainment or biologic effect is undetermined. We assessed diagnosis age and initial autism symptom severity among >30,000 children with autism from a linkage study of California Department of Developmental Services records, birth records, and the National ART Surveillance System. Median diagnosis age and symptom severity levels were significantly lower for ART-conceived than non-ART-conceived children. After adjustment for differences in the socio-demographic profiles of the two groups, the diagnosis age differentials were greatly attenuated and there were no differences in autism symptomatology. Thus, ascertainment issues related to SES, not ART per se, are likely the driving influence of the differences we initially observed.
PMCID: PMC4553150  PMID: 25997596
Infantile autism; Symptom severity; Diagnosis age; Assisted reproductive technology
17.  Hepatitis B virus infection among HIV-infected pregnant women in Malawi and transmission to infants 
Journal of hepatology  2013;60(3):508-514.
Background & Aims
The extent of HBV infection to infants of HBV/HIV-coinfected pregnant women in sub-Saharan Africa is unknown. The aim of this study was to assess prevalence of HBV infection among antiretroviral-naïve, HIV-infected pregnant women in Malawi and examine HBV transmission to their infants.
Plasma from 2048 HIV-infected, Malawian women and their infants were tested for markers of HBV infection. Study participants were provided standard-of-care health services, which included administration of pentavalent vaccine to infants at 6, 10, and 14 weeks of age.
One-hundred and three women (5%) were HBsAg-positive; 70 of these HBsAg-positive women were also HBV-DNA-positive. Sixteen women (0.8%) were HBV-DNA-positive but HBsAg-negative. Five of 51 infants (9.8%) born to HBsAg-positive and/or HBV-DNA-positive women were HBV-DNA-positive by 48 weeks of age. HBV DNA concentrations of two infants of mothers who received extended lamivudine-containing anti-HIV prophylaxis were <4 log10 IU/ml compared to ≥8 log10 IU/ml in three infants of mothers who did not.
HBV DNA was detected in nearly 10% of infants born to HBV/HIV-coinfected women. Antenatal testing for HIV and HBV, if instituted, can facilitate implementation of prophylactic measures against infant infection by both viruses. Published by Elsevier B.V. on behalf of the European Association for the Study of the Liver.
PMCID: PMC4411040  PMID: 24211737
Hepatitis; HIV; Mother-to-child transmission; Sub-Saharan Africa; Antiviral therapy
18.  Emerging Infections and Pregnancy 
Emerging Infectious Diseases  2006;12(11):1638-1643.
Immunologic changes of pregnancy may increase susceptibility to certain intracellular pathogens.
A key component of the response to emerging infections is consideration of special populations, including pregnant women. Successful pregnancy depends on adaptation of the woman's immune system to tolerate a genetically foreign fetus. Although the immune system changes are not well understood, a shift from cell-mediated immunity toward humoral immunity is believed to occur. These immunologic changes may alter susceptibility to and severity of infectious diseases in pregnant women. For example, pregnancy may increase susceptibility to toxoplasmosis and listeriosis and may increase severity of illness and increase mortality rates from influenza and varicella. Compared with information about more conventional disease threats, information about emerging infectious diseases is quite limited. Pregnant women's altered response to infectious diseases should be considered when planning a response to emerging infectious disease threats.
PMCID: PMC3372330  PMID: 17283611
emerging infectious diseases; pregnancy; immunology; synopsis
19.  Contraceptive Availability During an Emergency Response in the United States 
Journal of women's health (2002)  2013;22(3):189-193.
This article provides the evidence for contraceptive need to prevent unintended pregnancy during an emergency response, discusses the most appropriate types of contraceptives for disaster situations, and details the current provisions in place to provide contraceptives during an emergency response.
PMCID: PMC4388024  PMID: 23421580
20.  Pregnancy Prevention and Condom Use Practices among HIV-Infected Women on Antiretroviral Therapy Seeking Family Planning in Lilongwe, Malawi 
PLoS ONE  2015;10(3):e0121039.
Programs for integration of family planning into HIV care must recognize current practices and desires among clients to appropriately target and tailor interventions. We sought to evaluate fertility intentions, unintended pregnancy, contraceptive and condom use among a cohort of HIV-infected women seeking family planning services within an antiretroviral therapy (ART) clinic.
200 women completed an interviewer-administered questionnaire during enrollment into a prospective contraceptive study at the Lighthouse Clinic, an HIV/ART clinic in Lilongwe, Malawi, between August and December 2010.
Most women (95%) did not desire future pregnancy. Prior reported unintended pregnancy rates were high (69% unplanned and 61% unhappy with timing of last pregnancy). Condom use was inconsistent, even among couples with discordant HIV status, with lack of use often attributed to partner’s refusal. Higher education, older age, lower parity and having an HIV negative partner were factors associated with consistent condom usage.
High rates of unintended pregnancy among these women underscore the need for integ rating family planning, sexually transmitted infection (STI) prevention, and HIV services. Contraceptive access and use, including condoms, must be improved with specific efforts to enlist partner support. Messages regarding the importance of condom usage in conjunction with more effective modern contraceptive methods for both infection and pregnancy prevention must continue to be reinforced over the course of ongoing ART treatment.
PMCID: PMC4374940  PMID: 25811849
21.  Tubal Factor Infertility and Perinatal Risk After Assisted Reproductive Technology 
Obstetrics and gynecology  2013;121(6):1263-1271.
To assess trends of tubal factor infertility and to evaluate risk of miscarriage and delivery of preterm or low birth weight (LBW) neonates among women with tubal factor infertility using assisted reproductive technology (ART).
We assessed trends of tubal factor infertility among all fresh and frozen, donor, and nondonor ART cycles performed annually in the United States between 2000 and 2010 (N=1,418,774) using the National ART Surveillance System. The data set was then limited to fresh, nondonor in vitro fertilization cycles resulting in pregnancy to compare perinatal outcomes for cycles associated with tubal compared with male factor infertility. We performed bivariate and multivariable analyses controlling for maternal characteristics and calculated adjusted risk ratios (RRs) and 95% confidence intervals (CI).
The percentage of ART cycles associated with tubal factor infertility diagnoses decreased from 2000 to 2010 (26.02–14.81%). Compared with male factor infertility, tubal factor portended an increased risk of miscarriage (14.0% compared with 12.7%, adjusted RR 1.08, 95% CI 1.04–1.12); risk was increased for both early and late miscarriage. Singleton neonates born to women with tubal factor infertility had an increased risk of pre-term birth (15.8% compared with 11.6%, adjusted RR 1.27, 95% CI 1.20–1.34) and LBW (10.9% compared with 8.5%, adjusted RR 1.28, 95% CI 1.20–1.36). Significant increases in risk persisted for early and late preterm delivery and very low and moderately LBW delivery. A significantly elevated risk was also detected for twin, but not triplet, pregnancies.
Tubal factor infertility, which is decreasing in prevalence in the United States, is associated with an increased risk of miscarriage, preterm birth, and LBW delivery as compared with couples with male factor infertility using ART.
PMCID: PMC4292839  PMID: 23812461
22.  Trends and Outcomes for Donor Oocyte Cycles in the United States, 2000–2010 
JAMA  2013;310(22):2426-2434.
The prevalence of oocyte donation for in vitro fertilization (IVF) has increased in the United States, but little information is available regarding maternal or infant outcomes to improve counseling and clinical decision making.
To quantify trends in donor oocyte cycles in the United States and to determine predictors of a good perinatal outcome among IVF cycles using fresh (noncryopreserved) embryos derived from donor oocytes.
Analysis of data from the Centers for Disease Control and Prevention’s National ART Surveillance System, to which fertility centers are mandated to report and which includes data on more than 95% of all IVF cycles performed in the United States. Data from 2000 to 2010 described trends. Data from 2010 determined predictors.
Good perinatal outcome, defined as a singleton live-born infant delivered at 37 weeks or later and weighing 2500 g or more.
From 2000 to 2010, data from 443 clinics (93% of all US fertility centers) were included. The annual number of donor oocyte cycles significantly increased, from 10 801 to 18 306. Among all donor oocyte cycles, an increasing trend was observed from 2000 to 2010 in the proportion of cycles using frozen (vs fresh) embryos (26.7% [95% CI, 25.8%–27.5%] to 40.3% [95% CI, 39.6%–41.1%]) and elective single-embryo transfers (vs transfer of multiple embryos) (0.8% [95% CI, 0.7%–1.0%]to 14.5% [95% CI, 14.0%–15.1%]). Good perinatal outcomes increased from 18.5% (95% CI, 17.7%–19.3%) to 24.4% (95% CI, 23.8%–25.1%) (P < .001 for all listed trends). Mean donor and recipient ages remained stable at 28 (SD, 2.8) years and 41 (SD, 5.3) years, respectively. In 2010, 396 clinics contributed data. For donor oocyte cycles using fresh embryos (n = 9865), 27.5% (95% CI, 26.6%–28.4%) resulted in good perinatal outcome. Transfer of an embryo at day 5 (adjusted odds ratio [OR], 1.17 [95% CI, 1.04–1.32]) and elective single-embryo transfers (adjusted OR, 2.32 [95% CI, 1.92–2.80]) were positively associated with good perinatal outcome; tubal (adjusted OR, 0.72 [95% CI, 0.60–0.86]) or uterine (adjusted OR, 0.74 [95% CI, 0.58–0.94]) factor infertility and non-Hispanic black recipient race/ethnicity (adjusted OR, 0.48 [95% CI, 0.35–0.67]) were associated with decreased odds of good outcome. Recipient age was not associated with likelihood of good perinatal outcome.
In the United States from 2000 to 2010, there was an increase in number of donor oocyte cycles, accompanied by an increase in good outcomes. Further studies are needed to understand the mechanisms underlying the factors associated with less successful outcomes.
PMCID: PMC4307377  PMID: 24135860
23.  Trends in Use of and Reproductive Outcomes Associated With Intracytoplasmic Sperm Injection 
JAMA  2015;313(3):255-263.
Intracytoplasmic sperm injection (ICSI) is increasingly used in patients without severe male factor infertility without clear evidence of a benefit over conventional in vitro fertilization (IVF).
To assess national trends and reproductive outcomes for fresh IVF cycles (embryos transferred without being frozen) following the use of ICSI compared with conventional IVF with respect to clinical indications for ICSI use.
Retrospective cohort study using data on fresh IVF and ICSI cycles reported to the US National Assisted Reproductive Technology Surveillance System during 1996-2012.
Trends in ICSI use during 1996-2012 with respect to male factor infertility, unexplained infertility, maternal age 38 years or older, low oocyte yield, and 2 or more prior assisted reproductive technology cycles; reproductive outcomes for conventional IVF and ICSI cycles during 2008-2012, stratified by the presence or absence of male factor infertility.
Of the 1 395 634 fresh IVF cycles from 1996 through 2012, 908 767 (65.1%) used ICSI and 499 135 (35.8%) reported male factor infertility. Among cycles with male factor infertility, ICSI use increased from 76.3% (10 876/14 259) to 93.3% (32 191/34 506) (P < .001) during 1996-2012; for those without male factor infertility, ICSI use increased from 15.4% (4197/27 191) to 66.9% (42 321/63 250) (P < .001). During 2008-2012, male factor infertility was reported for 35.7% (176 911/494 907) of fresh cycles. Among those cycles, ICSI use was associated with a lower multiple birth rate compared with conventional IVF (30.9% vs 34.2%; adjusted relative risk [RR], 0.87; 95% CI, 0.83-0.91). Among cycles without male factor infertility (n = 317 996), ICSI use was associated with lower rates of implantation (23.0% vs 25.2%; adjusted RR, 0.93; 95% CI, 0.91-0.95), live birth (36.5% vs 39.2%; adjusted RR, 0.95; 95% CI, 0.93-0.97), and multiple live birth (30.1% vs 31.0%; adjusted RR, 0.93; 95% CI, 0.91-0.95) vs conventional IVF.
Among fresh IVF cycles in the United States, ICSI use increased from 36.4% in 1996 to 76.2% in 2012, with the largest relative increase among cycles without male factor infertility. Compared with conventional IVF, ICSI use was not associated with improved postfertilization reproductive outcomes, irrespective of male factor infertility diagnosis.
PMCID: PMC4343214  PMID: 25602996
24.  Antiretroviral pharmacokinetics in mothers and breastfeeding infants from 6 to 24 weeks post partum: results of the BAN Study 
Antiviral therapy  2014;19(6):587-595.
An intensive, prospective, open-label pharmacokinetic (PK) study in a subset of HIV-infected mothers and their uninfected infants enrolled in the Breastfeeding, Antiretroviral, and Nutrition study was performed to describe drug exposure and antiviral response.
Women using Combivir®[zidovudine (ZDV)+ lamivudine (3TC)]+Aluvia®[lopinavir/ritonavir(LPV/RTV)] were enrolled. Breast milk (BM) and mother and infant plasma (MP, IP) samples were obtained over 6hrs after observed dosing at 6, 12, or 24wks post-partum for drug concentrations and HIV RNA.
30 mother/infant pairs (10 each at 6, 12,and 24wks post-partum) were enrolled. Relative to MP, BM concentrations of ZDV and 3TC were 35% and 21% higher, while LPV and RTV were 80% lower. Only 3TC was detected in IP with concentrations 96% and 98% lower than MP and BM, respectively. Concentrations in all matrices were similar at 6-24wks. The majority (98.3%) of BM concentrations were >HIVwt IC50, with one having detectable virus. There was no association between PK parameters and MP or BM HIV RNA.
ZDV and 3TC concentrated in BM while LPV and RTV did not, possibly due to protein binding and drug transporter affinity. Undetectable to low ARV concentrations in IP suggests prevention of transmission while breast feeding may be due to ARV effects on systemic or BM HIV RNA in the mother. Low IP 3TC exposure may predispose an infected infant to HIV resistance, necessitating testing and treating infants early.
PMCID: PMC4110187  PMID: 24464632
25.  Dietary Patterns and Maternal Anthropometry in HIV-Infected, Pregnant Malawian Women 
Nutrients  2015;7(1):584-594.
Diet is a modifiable factor that can contribute to the health of pregnant women. In a sample of 577 HIV-positive pregnant women who completed baseline interviews for the Breastfeeding, Antiretrovirals, and Nutrition Study in Lilongwe, Malawi, cluster analysis was used to derive dietary patterns. Multiple regression analysis was used to identify associations between the dietary patterns and mid-upper arm circumference (MUAC), arm muscle area (AMA), arm fat area (AFA), and hemoglobin at baseline. Three key dietary patterns were identified: animal-based, plant-based, and grain-based. Women with relatively greater wealth were more likely to consume the animal-based diet, which had the highest intake of energy, protein, and fat and was associated with higher hemoglobin levels compared to the other diets. Women with the lowest wealth were more likely to consume the grain-based diet with the lowest intake of energy, protein, fat, and iron and were more likely to have lower AFA than women on the animal-based and plant-based diets, but higher AMA compared to women on the animal-based diet. Pregnant, HIV-infected women in Malawi could benefit from nutritional support to ensure greater nutrient diversity during pregnancy, when women face increased nutrient demands to support fetal growth and development.
PMCID: PMC4303855  PMID: 25594441
maternal diet; nutrition; pregnancy; HIV; anthropometry; Malawi; cluster analysis

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