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author:("sonde, Prisca")
1.  Does free pregnancy testing reduce service denial in family planning clinics? A cluster-randomized experiment in Zambia and Ghana 
Pregnancy tests, which cost very little (∼US$0.10) and are often required for successful family planning service delivery, may reduce service denial, and should be available in all family planning clinics at no or minimal cost to clients.
Pregnancy tests, which cost very little (∼US$0.10) and are often required for successful family planning service delivery, may reduce service denial, and should be available in all family planning clinics at no or minimal cost to clients.
In many countries, pregnancy tests are not freely available in family planning clinics. As a result, providers sometimes deny services to non-menstruating clients due to uncertainty about pregnancy. Few clients are actually pregnant, yet denied clients run the risk of becoming pregnant, and those sent to pharmacies pay inflated prices for inexpensive tests. To assess the programmatic effect of free pregnancy testing, we conducted cluster-randomized trials in Ghana and Zambia, assessing clients' uptake of contraception in family planning clinics.
In each country, 5 clinics were randomized to intervention status and 5 to control. Service data from 2,028 new, non-menstruating clients in Zambia and 1,556 in Ghana were collected. Intervention clinics received supplies of pregnancy tests, and staff were instructed to use tests as needed to help exclude pregnancy. Control clinics received no intervention. The primary outcome was the proportion of non-menstruating clients denied an effective contraceptive method. Cost-effectiveness was also evaluated.
In Zambia, clients in intervention and control clinics faced a similar risk of service denial at baseline, 15% and 17%, respectively. At follow-up, denial remained unchanged at 17% in control clinics, but decreased significantly to 4% in intervention sites. Clients in Zambia were 4.4 (95% confidence interval [CI] = 1.3–14.4) times more likely to be denied a method in control sites versus intervention sites (P<.01). Results from Ghana were inconclusive. Cost of a “denial averted” in Zambia was estimated to be US$0.59.
Zambia results suggest that availability of free pregnancy testing significantly reduced contraceptive service denial, although results from Ghana preclude an unqualified recommendation. Authors conclude that free pregnancy testing in family planning clinics may make strong public health sense in those developing countries where denial to non-menstruating clients remains a problem. Although pregnancy can usually be excluded with a client history, pregnancy tests are often necessary.
PMCID: PMC4168583  PMID: 25276551
2.  Pregnancy loss and role of infant HIV status on perinatal mortality among HIV-infected women 
BMC Pediatrics  2012;12:138.
HIV-infected women, particularly those with advanced disease, may have higher rates of pregnancy loss (miscarriage and stillbirth) and neonatal mortality than uninfected women. Here we examine risk factors for these adverse pregnancy outcomes in a cohort of HIV-infected women in Zambia considering the impact of infant HIV status.
A total of 1229 HIV-infected pregnant women were enrolled (2001–2004) in Lusaka, Zambia and followed to pregnancy outcome. Live-born infants were tested for HIV by PCR at birth, 1 week and 5 weeks. Obstetric and neonatal data were collected after delivery and the rates of neonatal (<28 days) and early mortality (<70 days) were described using Kaplan-Meier methods.
The ratio of miscarriage and stillbirth per 100 live-births were 3.1 and 2.6, respectively. Higher maternal plasma viral load (adjusted odds ratio [AOR] for each log10 increase in HIV RNA copies/ml = 1.90; 95% confidence interval [CI] 1.10–3.27) and being symptomatic were associated with an increased risk of stillbirth (AOR = 3.19; 95% CI 1.46–6.97), and decreasing maternal CD4 count by 100 cells/mm3 with an increased risk of miscarriage (OR = 1.25; 95% CI 1.02–1.54). The neonatal mortality rate was 4.3 per 100 increasing to 6.3 by 70 days. Intrauterine HIV infection was not associated with neonatal morality but became associated with mortality through 70 days (adjusted hazard ratio = 2.76; 95% CI 1.25–6.08). Low birth weight and cessation of breastfeeding were significant risk factors for both neonatal and early mortality independent of infant HIV infection.
More advanced maternal HIV disease was associated with adverse pregnancy outcomes. Excess neonatal mortality in HIV-infected women was not primarily explained by infant HIV infection but was strongly associated with low birth weight and prematurity. Intrauterine HIV infection contributed to mortality as early as 70 days of infant age. Interventions to improve pregnancy outcomes for HIV-infected women are needed to complement necessary therapeutic and prophylactic antiretroviral interventions.
PMCID: PMC3480840  PMID: 22937874
Perinatal mortality; Infant mortality; Risk factors; Adverse pregnancy outcome; HIV infection; Vertical transmission
3.  Analysis of HIV Early Infant Diagnosis Data to Estimate Rates of Perinatal HIV Transmission in Zambia 
PLoS ONE  2012;7(8):e42859.
Mother-to-child transmission of HIV (MTCT) remains the most prevalent source of pediatric HIV infection. Most PMTCT (prevention of mother-to-child transmission of HIV) programs have concentrated monitoring and evaluation efforts on process rather than on outcome indicators. In this paper, we review service data from 28,320 children born to HIV-positive mothers to estimate MTCT rates.
This study analyzed DNA PCR results and PMTCT data from perinatally exposed children zero to 12 months of age from five Zambian provinces between September 2007 and July 2010.
The majority of children (58.6%) had a PCR test conducted between age six weeks and six months. Exclusive breastfeeding (56.8%) was the most frequent feeding method. An estimated 45.9% of mothers were below 30 years old and 93.3% had disclosed their HIV status. In terms of ARV regimen for PMTCT, 32.7% received AZT+single dose NVP (sdNVP), 30.9% received highly active antiretroviral treatment (HAART), 19.6% received sdNVP only and 12.9% received no ARVs. Transmission rates at six weeks when ARVs were received by both mother and baby, mother only, baby only, and none were 5.8%, 10.5%, 15.8% and 21.8% respectively. Transmission rates at six weeks where mother received HAART, AZT+sd NVP, sdNVP, and no intervention were 4.2%, 6.8%, 8.7% and 20.1% respectively. Based on adjusted analysis including ARV exposures and non ARV-related parameters, lower rates of positive PCR results were associated with 1) both mother and infant receiving prophylaxis, 2) children never breastfed and 3) mother being 30 years old or greater.
Overall between September 2007 and July 2010, 12.2% of PCR results were HIV positive. Between September 2007 and January 2009, then between February 2009 and July 2010, proportions of positive PCR results were 15.1% and 11% respectively, a significant difference.
The use of ARV drugs reduces vertical transmission of HIV in a program setting. Non-chemoprophylactic factors also play a significant role in HIV transmission. The overall change in the proportions of positive PCR results over time is more likely an indication of better PMTCT implementation. Determination of the outcomes of PMTCT in program settings is feasible but requires accurate documentation and analysis.
PMCID: PMC3422300  PMID: 22912752
4.  Lactation-associated postpartum weight changes among HIV-infected women in Zambia 
Background There are concerns about effects of lactation on postpartum weight changes among HIV-infected women because low weight may increase risks of HIV-related disease progression.
Methods This analysis of postpartum maternal weight change is based on a trial evaluating the effects of shortened breastfeeding on postpartum mother-to-child transmission of HIV in Lusaka, Zambia, in which 958 HIV-infected women were randomized to breastfeed for a short duration (4 months) or for a duration of their own informed choosing (median 16 months). Among 768 women who met inclusion criteria, we compared across the two groups change in weight (kg) and the percent underweight [body mass index (BMI) <18.5] through 24 months. We also examined the effect of breastfeeding in two high-risk groups: those with low BMI and those with low CD4 counts.
Results Overall, women in the long-duration group gained less weight compared with those in the short-duration group from 4–24 months {1.0 kg [95% confidence interval (CI): 0.3–1.7] vs 2.3 kg (95% CI: 1.6–2.9), P = 0.01}. No association was found between longer breastfeeding and being underweight (odds ratio 1.1; 95% CI: 0.8–1.6; P = 0.40). Effects of lactation in underweight women and women with low CD4 counts were similar to the effects in women with higher BMI and higher CD4 counts. Women with low baseline BMI tended to gain more weight from 4 to 24 months than those with higher BMI, regardless of breastfeeding duration (2.1 kg, 95% CI: 1.3–2.9; P < 0.01).
Conclusions In this study of HIV-infected breastfeeding women in a low-resource setting, the average change in weight from 4 to 24 months postpartum was a net gain rather than loss. Although longer duration breastfeeding was associated with less weight gain, breastfeeding duration was not associated with being underweight (BMI < 18.5). Weight change associated with longer breastfeeding may be metabolically regulated so that women with low BMI and at risk of wasting are protected from excess weight loss.
PMCID: PMC2972438  PMID: 20484334
Breast feeding; lactation; HIV infections; weight loss; metabolism; body mass index
5.  Elevations in mortality due to weaning persist into the second year of life among uninfected children born to HIV-infected mothers 
Early weaning has been recommended to reduce postnatal HIV transmission. We evaluated the safety of stopping breastfeeding at different ages for mortality of uninfected children born to HIV-infected mothers.
During a trial of early weaning, 958 HIV-infected mothers and their infants were recruited and followed from birth to 24 months in Lusaka, Zambia. Half of the cohort was randomized to wean abruptly at 4 months and the other half to continue breastfeeding. We examined associations between uninfected child mortality and actual breastfeeding duration investigating possible confounding and effect modification.
The mortality rate among 749 uninfected children was 9.4% by 12 months and 13.6% by 24 months. Weaning during the interval encouraged by the protocol (4-5 months) was associated with a 2.03-fold increased risk of mortality (95% CI: 1.13 - 3.65), weaning 6-11 months a 3.54-fold increase (95% CI: 1.68 - 7.46) and 12-18 months a 4.22-fold increase (95% CI: 1.59 - 11.24). Significant effect modification was detected such that risks associated with weaning were stronger among infants born to mothers with higher CD4 counts (>350 cells/mL).
Shortening the normal duration of breastfeeding for uninfected children born to HIV-infected mothers living in low resource settings is associated with significant increases mortality extending into the second year of life. Intensive nutritional and counseling interventions reduce, but do not eliminate, this excess mortality.
PMCID: PMC2805776  PMID: 20047479
6.  Mortality and virologic outcomes following access to antiretroviral therapy among a cohort of HIV-infected women who received single-dose nevirapine in Lusaka, Zambia 
Single-dose nevirapine (SDNVP) for prevention of mother-to-child HIV transmission selects mutations conferring resistance to non-nucleoside reverse transcriptase inhibitor (NNRTI)-based therapy. We investigated mortality and virologic and clinical outcomes following introduction of antiretroviral treatment (ART) among a cohort of women given SDNVP.
When ART programs were introduced in 2004 in Lusaka, Zambia, we were completing a trial of infant feeding which involved following HIV-infected women who received SDNVP between 2001 and 2005. Women still in follow-up or who could be contacted were evaluated for eligibility for ART (CD4 count <200 or <350 and WHO stage ≥ 3) and started on NNRTI-based therapy if eligible. We compared mortality in the cohort of women before and after ART access, and examined, among women initiating ART, whether virologic response was better allowing a longer time to elapse between SDNVP and treatment initiation.
In the cohort of 872 women, mortality more than halved after ART became available (relative hazard [RH] = 0.46 95% CI: 0.23–0.91 p=0.03). Of 161 SDNVP-exposed women followed on NNRTI-based ART, 70.8% suppressed (viral load <400 copies/ml). Only 3/8 (37.5%) women SDNVP-exposed <6 months of starting therapy suppressed compared to 13/22 (59.1%) who started 6–12 months, 44/61 (72.1 %) 12–24 months, and 54/70 (77.1%) >24 months post-exposure (chi-square trend p=0.01).
Most SDNVP-exposed women respond well to NNRTI-based therapy but there was an attenuation of therapy efficacy that persisted to 12 months after exposure. Women should be screened for ART eligibility during pregnancy and started on effective regimens before delivery.
PMCID: PMC2782481  PMID: 19506483
7.  Temporal and Lateral Dynamics of HIV Shedding and Elevated Sodium in Breast Milk Among HIV-Positive Mothers During the First 4 Months of Breast-Feeding 
To better understand the dynamics of breast milk HIV shedding and its relation to postnatal HIV transmission, we investigated the temporal and lateral relations of breast milk viral shedding and sodium concentrations in HIV-positive women.
This was a longitudinal cohort study in Lusaka, Zambia.
We examined patterns of HIV shedding in breast milk over the first 4 months of breast-feeding and their correlations with postnatal HIV transmission among 138 breast-feeding mothers. Sodium concentration in breast milk was also examined in the same samples and in breast milk from 23 HIV-negative controls.
Higher breast milk viral load at 1 week, 1 month, and 4 months and consistent viral shedding in breast milk were significantly associated with increased risk of HIV transmission. Elevated breast milk sodium concentration ($13 mmol/L) at 4 months was associated with HIV transmission, low maternal CD4 cell count, and high maternal plasma viral load. Elevated sodium concentration at 1 week postpartum was common and was not associated with any of these parameters.
Consistent viral shedding and high breast milk viral load are strong predictors of mother-to-child HIV transmission. Although sodium concentrations later in breast-feeding correlate with breast milk viral load, increased breast milk sodium is normal in early lactation and does not predict HIV transmission.
PMCID: PMC2821877  PMID: 18398972
breast-feeding; breast milk sodium; HIV; lactation; mastitis; mother-to-child transmission; viral load
8.  Increasing the uptake of prevention of mother-to-child transmission of HIV services in a resource-limited setting 
As in other resource limited settings, the Ministry of Health in Zambia is challenged to make affordable and acceptable PMTCT interventions accessible and available. With a 14.3% HIV prevalence, the MOH estimates over one million people are HIV positive in Zambia. Approximately 500,000 children are born annually in Zambia and 40,000 acquire the infection vertically each year if no intervention is offered. This study sought to review uptake of prevention of mother-to-child (PMTCT) services in a resource-limited setting following the introduction of context-specific interventions.
Interventions to improve PMTCT uptake were introduced into 38 sites providing PMTCT services in Zambia in July 2005. Baseline and follow up service data were collected on a monthly basis through September 2008. Data was checked for internal and external consistency using logic built into databases used for data management. Data audits were conducted to determine accuracy and reliability. Trends were analyzed pre- and post- intervention.
Uptake among pregnant women increased across the 13 quarters (39 months) of observation, particularly in the case of acceptance of counseling and HIV testing from 45% to 90% (p value = 0.00) in the first year and 99% by year 3 (p value = 0.00). Receipt of complete course of antiretroviral (ARV) prophylaxis increased from 29% to 66% (p = 0.00) in the first year and 97% by year 3 (p value = 0.00). There was also significant improvement in the percentage of HIV positive pregnant women referred for clinical care.
Uptake of PMTCT services in resource-limited settings can be improved by utilizing innovative alternatives to mitigate the effects of human resource shortage such as by providing technical assistance and mentorship beyond regular training courses, integrating PMTCT services into existing maternal and child health structures, addressing information gaps, mobilizing traditional and opinion leaders and building strong relationships with the government. These health system based approaches provide a sustainable improvement in the capacity and uptake of services.
PMCID: PMC2835703  PMID: 20109210
9.  Prevention of mother-to-child transmission of HIV in Zambia: implementing efficacious ARV regimens in primary health centers 
BMC Public Health  2009;9:314.
Safety and effectiveness of efficacious antiretroviral (ARV) regimens beyond single-dose nevirapine (sdNVP) for prevention of mother-to-child transmission (PMTCT) have been demonstrated in well-controlled clinical studies or in secondary- and tertiary-level facilities in developing countries. This paper reports on implementation of and factors associated with efficacious ARV regimens among HIV-positive pregnant women attending antenatal clinics in primary health centers (PHCs) in Zambia.
Blood sample taken for CD4 cell count, availability of CD4 count results, type of ARV prophylaxis for mothers, and additional PMTCT service data were collected for HIV-positive pregnant women and newborns who attended 60 PHCs between April 2007 and March 2008.
Of 14,815 HIV-positive pregnant women registered in the 60 PHCs, 2,528 (17.1%) had their CD4 cells counted; of those, 1,680 (66.5%) had CD4 count results available at PHCs; of those, 796 (47.4%) had CD4 count ≤ 350 cells/mm3 and thus were eligible for combination antiretroviral treatment (cART); and of those, 581 (73.0%) were initiated on cART. The proportion of HIV-positive pregnant women whose blood sample was collected for CD4 cell count was positively associated with (1) blood-draw for CD4 count occurring on the same day as determination of HIV-positive status; (2) CD4 results sent back to the health facilities within seven days; (3) facilities without providers trained to offer ART; and (4) urban location of PHC. Initiation of cART among HIV-positive pregnant women was associated with the PHC's capacity to provide care and antiretroviral treatment services. Overall, of the 14,815 HIV-positive pregnant women registered, 10,015 were initiated on any type of ARV regimen: 581 on cART, 3,041 on short course double ARV regimen, and 6,393 on sdNVP.
Efficacious ARV regimens beyond sdNVP can be implemented in resource-constrained PHCs. The majority (73.0%) of women identified eligible for ART were initiated on cART; however, a minority (11.3%) of HIV-positive pregnant women were assessed for CD4 count and had their test results available. Factors associated with implementation of more efficacious ARV regimens include timing of blood-draw for CD4 count and capacity to initiate cART onsite where PMTCT services were being offered.
PMCID: PMC2739530  PMID: 19712454
10.  Differential Effects of Early Weaning for HIV-Free Survival of Children Born to HIV-Infected Mothers by Severity of Maternal Disease 
PLoS ONE  2009;4(6):e6059.
We previously reported no benefit of early weaning for HIV-free survival of children born to HIV-infected mothers in intent-to-treat analyses. Since early weaning was poorly accepted, we conducted a secondary analysis to investigate whether beneficial effects may have been hidden.
958 HIV-infected women in Lusaka, Zambia, were randomized to abrupt weaning at 4 months (intervention) or to continued breastfeeding (control). Children were followed to 24 months with regular HIV PCR tests and examinations to determine HIV infection or death. Detailed behavioral data were collected on when all breastfeeding ended. Most participants were recruited before antiretroviral treatment (ART) became available. We compared outcomes among mother-child pairs who weaned earlier or later than intended by study design adjusting for potential confounders.
Of infants alive, uninfected and still breastfeeding at 4 months in the intervention group, 16.1% who weaned as instructed acquired HIV or died by 24 months compared to 16.0% who did not comply (p = 0.98). Children of women with less severe disease during pregnancy (not eligible for ART) had worse outcomes if their mothers weaned as instructed (RH = 2.60 95% CI: 1.06–6.36) compared to those who continued breastfeeding. Conversely, children of mothers with more severe disease (eligible for ART but did not receive it) who weaned early had better outcomes (p-value interaction = 0.002). In the control group, weaning before 15 months was associated with 3.94-fold (95% CI: 1.65–9.39) increase in HIV infection or death among infants of mothers with less severe disease.
Incomplete adherence did not mask a benefit of early weaning. On the contrary, for women with less severe disease, early weaning was harmful and continued breastfeeding resulted in better outcomes. For women with more advanced disease, ART should be given during pregnancy for maternal health and to reduce transmission, including through breastfeeding.
Trial Registration
Clinical NCT00310726
PMCID: PMC2698120  PMID: 19557167
11.  Task-shifting HIV counselling and testing services in Zambia: the role of lay counsellors 
The human resource shortage in Zambia is placing a heavy burden on the few health care workers available at health facilities. The Zambia Prevention, Care and Treatment Partnership began training and placing community volunteers as lay counsellors in order to complement the efforts of the health care workers in providing HIV counselling and testing services. These volunteers are trained using the standard national counselling and testing curriculum. This study was conducted to review the effectiveness of lay counsellors in addressing staff shortages and the provision of HIV counselling and testing services.
Quantitative and qualitative data were collected by means of semistructured interviews from all active lay counsellors in each of the facilities and a facility manager or counselling supervisor overseeing counseling and testing services and clients. At each of the 10 selected facilities, all counselling and testing record books for the month of May 2007 were examined and any recordkeeping errors were tallied by cadre. Qualitative data were collected through focus group discussions with health care workers at each facility.
Lay counsellors provide counselling and testing services of quality and relieve the workload of overstretched health care workers. Facility managers recognize and appreciate the services provided by lay counsellors. Lay counsellors provide up to 70% of counselling and testing services at health facilities. The data review revealed lower error rates for lay counsellors, compared to health care workers, in completing the counselling and testing registers.
Community volunteers, with approved training and ongoing supervision, can play a major role at health facilities to provide counselling and testing services of quality, and relieve the burden on already overstretched health care workers.
PMCID: PMC2692981  PMID: 19480710
12.  Effects of Early, Abrupt Weaning on HIV-free Survival of Children in Zambia 
The New England journal of medicine  2008;359(2):130-141.
In low-resource settings, many programs recommend that women who are infected with the human immunodeficiency virus (HIV) stop breast-feeding early. We conducted a randomized trial to evaluate whether abrupt weaning at 4 months as compared with the standard practice has a net benefit for HIV-free survival of children.
We enrolled 958 HIV-infected women and their infants in Lusaka, Zambia. All the women planned to breast-feed exclusively to 4 months; 481 were randomly assigned to a counseling program that encouraged abrupt weaning at 4 months, and 477 to a program that encouraged continued breast-feeding for as long as the women chose. The primary outcome was either HIV infection or death of the child by 24 months.
In the intervention group, 69.0% of the mothers stopped breast-feeding at 5 months or earlier; 68.8% of these women reported the completion of weaning in less than 2 days. In the control group, the median duration of breast-feeding was 16 months. In the overall cohort, there was no significant difference between the groups in the rate of HIV-free survival among the children; 68.4% and 64.0% survived to 24 months without HIV infection in the intervention and control groups, respectively (P = 0.13). Among infants who were still being breast-fed and were not infected with HIV at 4 months, there was no significant difference between the groups in HIV-free survival at 24 months (83.9% and 80.7% in the intervention and control groups, respectively; P = 0.27). Children who were infected with HIV by 4 months had a higher mortality by 24 months if they had been assigned to the intervention group than if they had been assigned to the control group (73.6% vs. 54.8%, P = 0.007).
Early, abrupt cessation of breast-feeding by HIV-infected women in a low-resource setting, such as Lusaka, Zambia, does not improve the rate of HIV-free survival among children born to HIV-infected mothers and is harmful to HIV-infected infants. ( number, NCT00310726.)
PMCID: PMC2577610  PMID: 18525036
13.  Predictors of Nonadherence to Single-Dose Nevirapine Therapy for the Prevention of Mother-to-Child HIV Transmission 
Adequate adherence is required for prevention of mother-to-child transmission of HIV (pMTCT) programs to be effective. We investigated predictors and extent of nonadherence to single-dose nevirapine.
Data on nevirapine intake and possible predictors were collected among 760 HIV-positive women with liveborn babies enrolled in a study in Lusaka, Zambia.
Most (94%) women took nevirapine before delivery, and most (91%) newborns received it soon after delivery. Maternal nonadherence was associated with home births (odds ratio [OR]: 3.2; 95% confidence interval [CI]: 1.3 to 7.4), no high school education (OR: 2.4; 95% CI: 1.1 to 5.3), and low newborn birth weight (OR: 4.6; 95% CI: 1.3 to 20.1). Disclosure of HIV status and couples counseling was only associated with adherence among home births. Failure to administer nevirapine to the newborn was associated with birth at the tertiary hospital (OR: 7.2; 95% CI: 3.7 to 13.8), lower 5-minute Apgar scores (OR: 0.5; 95% CI: 0.4 to 0.7), and neonatal death (OR: 5.8; 95% CI: 2.0 to 16.3).
Excellent adherence to single-dose nevirapine for pMTCT can be achieved. Nonadherence seems to be affected by place of birth and by poor health status of the newborn. Procedures to ensure that viable yet ill neonates receive nevirapine should be part of clinical protocols and training within pMTCT programs.
PMCID: PMC1855628  PMID: 16340483
perinatal HIV transmission; nevirapine; adherence; prevention
14.  Post-Weaning Breast Milk HIV-1 Viral Load, Blood Prolactin Levels and Breast Milk Volume 
AIDS (London, England)  2006;20(11):1539-1547.
The effect of abrupt weaning, advocated as a safe transition from exclusive breastfeeding in HIV-exposed children, on the quantity of HIV viral load in breast milk (BMVL) is not known.
To determine the effect of abrupt cessation of breastfeeding on serum prolactin, pumped breast milk volume and BMVL obtained 2 weeks after rapid weaning in HIV-infected women.
Women enrolled in a prospective study (ZEBS) were randomized to abruptly wean at 20 weeks postpartum or continue exclusive breastfeeding. Breast milk was obtained at 22 weeks by electric breast pump over 10 min from 222 women who had either weaned or continued to breastfeed. Pre- and post-pumping prolactin was measured. BMVL was measured at 20 and 22 weeks in 71 randomly selected women from both groups.
Baseline prolactin and breast milk volume was significantly lower among women who had weaned. Detectable (68 versus 42%; P 0.03) and median BMVL (448 versus < 50 copies/ml; P = 0.005) was significantly higher = among those who had weaned in comparison with those who were still breastfeeding and was significantly higher in the same women after weaning compared with 2 weeks earlier (P = 0.001). Conclusions: BMVL is substantially higher after rapid weaning and this may pose an increased risk of HIV transmission if children resume breastfeeding after a period of cessation. Increases in BMVL with differing degrees of mixed feeding needs to be assessed.
PMCID: PMC1773053  PMID: 16847409
HIV; breastfeeding; breast milk; viral load; weaning; prolactin mother-to-child transmission; postnatal HIV transmission
16.  Reduction in Preterm Delivery and Neonatal Mortality after the Introduction of Antenatal Cotrimoxazole Prophylaxis among HIV-Infected Women with Low CD4 Cell Counts 
The Journal of infectious diseases  2006;194(11):1510-1518.
Cotrimoxazole prophylaxis is recommended for subgroups of human immunodeficiency virus (HIV)-infected adults and children to reduce all-cause morbidity and mortality. We investigated whether antenatal cotrimoxazole prophylaxis begun during pregnancy for HIV-infected pregnant women with low CD4 cell counts would affect birth outcomes.
Cotrimoxazole prophylaxis was introduced as a routine component of antenatal care for HIV-infected women with CD4 cell counts <200 cells/μL during the course of a trial of mother-to-child HIV transmission in Lusaka, Zambia. Rates of preterm delivery, low birth weight, and neonatal mortality were compared for women with low CD4 cell counts before and after its introduction.
Among 255 women with CD4 cell counts <200 cells/μL, the percentage of preterm births (≤34 weeks of gestation) was lower (odds ratio [OR], 0.49 [95% confidence interval {CI}, 0.24-0.98]) after cotrimoxazole prophylaxis was introduced than before; there was a significant decrease in neonatal mortality (9% to 0%; P = .01) and a trend toward increased birth weight (β = 114 g [95% CI, -42 to 271 g]). In contrast, there were no significant changes in these parameters over the same time interval among women with CD4 cell counts ≥200 cells/μL.
Antenatal provision of cotrimoxazole for HIV-infected pregnant women with low CD4 cell counts may have indirect benefits for neonatal health.
PMCID: PMC1773010  PMID: 17083035
17.  Impact of Chloroquine on Viral Load in Breast Milk 
The anti-malarial agent chloroquine has activity against HIV. We compared the effect of chloroquine (n = 18) to an anti-malarial agent without known anti-HIV-activity, sulfadoxine-pyrimethamine (n = 12), on breast milk HIV RNA levels among HIV-infected breastfeeding women in Zambia. After adjusting for CD4 count and plasma viral load, chloroquine was associated with a trend towards lower levels of HIV RNA in breast milk compared with sulfadoxine-pyrimethamine (P 0.05). Higher breastmilk viral load was also observed among women receiving presumptive treatment = for symptomatic malaria compared with asymptomatic controls and among controls reporting fever in the prior week. Further research is needed to determine the potential role of chloroquine in prevention of HIV transmission through breastfeeding.
Impacte de la chloroquine sur la charge virale dans le lait maternelle
La chloroquine, agent antimalarique, a une activité contre le VIH. Nous avons comparé l’effet de la chloroquine à celui d’un autre agent antimalarique, la sulfadoxine-pyrimethamine, dont l’activité sur le VIH n’est pas connue, en mesurant les taux d’ARN de VIH dans le lait maternel de femmes allaitantes infectées par le VIH en Zambie. Après ajustement pour les taux de CD4 et la charge virale dans le plasma, la chloroquine comparée à la sulfadoxine pyrimethamine était associée à une tendance vers des teneurs plus bas en ARN de VIH dans le lait maternel (P = 0,05). Des charges virales plus élevées dans le lait maternel étaient aussi observées chez des femmes recevant un traitement présomptif pour des symptômes de malaria par rapport aux contrôles asymptomatiques et par rapport à des contrôles rapportant de la fièvre durant la première semaine. Des études supplémentaires sont nécessaires pour déterminer le rôle potentiel de la chloroquine dans la prévention de la transmission du VIH par l’allaitement maternel.
mots clésVIH, malaria, allaitement maternel, chloroquine, sulfadoxine-pyrimethamine, charge virale du lait maternel, fièvre
Impacto de la cloroquina en la carga viral de la leche materna
El antimalárico cloroquina tiene actividad frente al VIH. Comparamos el efecto de la cloroquina (n = 18) frente a un antimalárico sin actividad anti-VIH conocida, la sulfadoxina-pirimetamina (n = 12), en los niveles de ARN en la leche materna de mujeres infectadas con VIH, en Zambia. Después de ajustar para recuento de CD4 y la carga viral en plasma, se asoció a la cloroquina con una tendencia hacia menores niveles de ARN del VIH en leche materna, comparado con la sulfadoxina pirimetamina (P = 0.05). También se observó una mayor carga viral en la leche materna de mujeres recibiendo tratamiento presuntivo para malaria sintomática, que en los controles asintomáticos y controles que habáan reportado fiebre la semana anterior. Es necesario realizar más estudios para determinar el papel potencial de la cloroquina en la prevención de la trasmisión de VIH a través de la lactancia materna.
palabras claveVIH, malaria, lactancia materna, cloroquina, sulfadoxina pirimetamina, transmisión vertical, leche materna, carga viral, fiebre
PMCID: PMC1765922  PMID: 16772000
breastfeeding; breastmilk viral load; chloroquine; fever; HIV; malaria; mtct; sulfadoxine-pyrimethamine
18.  α-Defensins in the Prevention of HIV Transmission Among Breastfed Infants 
α-Defensins have been observed to have anti-HIV activity but have not been investigated in relation to mother-to-child HIV transmission. We measured the concentration of α-defensins in breast milk of HIV-positive mothers and tested whether the concentrations were associated with HIV transmission. A nested case-control study of 32 HIV-positive women who transmitted HIV to their infants and 52 randomly selected HIV-positive women who did not transmit HIV to their infants was conducted in Lusaka, Zambia. α-Defensins were detected in most (79%) of the milk samples tested. Concentrations of α-defensins increased as breast milk HIV RNA quantity increased, and breast milk HIV RNA quantity was, in turn, a strong and significant predictor of HIV transmission. After adjustment for milk HIV RNA quantity, however, α-defensin concentration was significantly associated with a decreased risk of intrapartum and postnatal HIV transmission (odds ratio = 0.3, 95% confidence interval: 0.09-0.93). Our data suggest that there may be a role for α-defensins in prevention of HIV transmission to breastfed infants.
PMCID: PMC1765920  PMID: 15905728
breast milk; HIV; defensins; transmission
19.  Prolonged breast-feeding and mortality up to two years post-partum among HIV-positive women in Zambia 
AIDS (London, England)  2005;19(15):1677-1681.
A previously reported association between prolonged lactation and maternal mortality has generated concern that breast-feeding may be detrimental for HIV-positive women.
As part of a trial conducted in Lusaka, Zambia, 653 HIV-positive women were randomly assigned either to a counseling program that encouraged abrupt cessation of breast-feeding at 4 months (group A) or to a program that encouraged prolonged breast-feeding for the duration of the woman’s own informed choice (group B). We examined whether mortality up to 2 years post-partum increased with breast-feeding for a longer duration.
There was no difference in mortality 12 months after delivery between 326 HIV-positive women randomly assigned to short breast-feeding [group A: 4.93%; 95% confidence interval (CI), 2.42–7.46] versus 327 women assigned to long breast-feeding (group B: 4.89%; 95% CI, 2.38–7.40). Analysis based on actual practice, rather than random assignment, also demonstrated no increased mortality due to breast-feeding.
Although HIV-related mortality was high in this cohort of untreated HIV-positive women, prolonged lactation was not associated with increased mortality.
PMCID: PMC1393280  PMID: 16184038
maternal mortality; HIV/AIDS; breastfeeding; women; lactation; prognosis; Zambia
20.  Does Severity of HIV Disease in HIV-Infected Mothers Affect Mortality and Morbidity among Their Uninfected Infants? 
Rates of perinatal human immunodeficiency virus (HIV) transmission are higher among HIV-infected mothers with more advanced disease, but effects of maternal disease on HIV-uninfected offspring are unclear. We investigated the hypothesis that the severity of HIV disease and immune dysfunction among mothers is associated with increased morbidity and mortality among their uninfected infants.
In a birth cohort of 620 HIV-uninfected infants born to HIV-infected mothers in Lusaka, Zambia, we investigated associations between markers of more advanced maternal HIV disease and child mortality, hospital admissions, and infant weight through 4 months of age.
Mortality in the cohort of uninfected infants was 4.6% (95% confidence interval [CI], 2.8–6.3) through 4 months of age. Infants of mothers with CD4+ T cell counts of <350 cells/μL were more likely to die (hazard ratio [HR], 2.87; 95% CI, 1.03–8.03) and were more likely to be hospitalized (HR, 2.28; 95% CI, 1.17–4.45), after adjusting for other factors, including maternal death and low birth weight. The most common cause of infant death and hospitalization was pneumonia and/or sepsis. A maternal viral load of >100,000 copies/mL was associated with significantly lower child weight through 4 months of age.
Children born to HIV-infected mothers with advanced disease who escaped perinatal or early breastfeeding-related HIV infection are nonetheless at high risk of mortality and morbidity during the first few months of life. HIV-related immunosuppression appears to have adverse consequences for the health of infants, in addition to risks of vertical transmission.
PMCID: PMC1351118  PMID: 16267740
21.  Women in couples antenatal HIV counseling and testing are not more likely to report adverse social events 
AIDS (London, England)  2005;19(6):603-609.
Couple counseling has been promoted as a strategy to improve uptake of interventions to prevent mother-to-child HIV transmission (pMTCT) and to minimize adverse social outcomes associated with disclosure of HIV status.
We tested whether women counseled antenatally as part of a couple were more likely to accept HIV testing and nevirapine in a pMTCT program, and whether they would be less likely to experience later adverse social events than women counseled alone.
A pMTCT program that included active community education and outreach to encourage couple counseling and testing was implemented in two antenatal clinics in Lusaka, Zambia. A subset of HIV-positive women was asked to report their experience of adverse social events 6 months after delivery. Couple-counseled women were compared with individual-counseled women stratified by whether or not they had disclosed their HIV status to their partners.
Nine percent (868) of 9409 women counseled antenatally were counseled with their husband. Couple-counseled women were more likely to accept HIV testing (96%) than women counseled alone (79%); however uptake of nevirapine was not improved. Six months after delivery, 28% of 324 HIV-positive women reported at least one adverse social event (including physical violence, verbal abuse, divorce or separation). There were no significant differences in reported adverse social events between couple- and individual-counseled women.
Couple counseling did not increase the risk of adverse social events associated with HIV disclosure. Support services and interventions to improve social situations for people living with HIV need to be further evaluated.
PMCID: PMC1201374  PMID: 15802979
HIV/AIDS; prevention of mother-to-child transmission; voluntary counseling and testing; couples
22.  High Uptake of Exclusive Breastfeeding and Reduced Early Post-Natal HIV Transmission 
PLoS ONE  2007;2(12):e1363.
Empirical data showing the clear benefits of exclusive breastfeeding (EBF) for HIV prevention are needed to encourage implementation of lactation support programs for HIV-infected women in low resource settings among whom replacement feeding is unsafe. We conducted a prospective, observational study in Lusaka, Zambia, to test the hypothesis that EBF is associated with a lower risk of postnatal HIV transmission than non-EBF.
Methods and Results
As part of a randomized trial of early weaning, 958 HIV-infected women and their infants were recruited and all were encouraged to breastfeed exclusively to 4 months. Single-dose nevirapine was provided to prevent transmission. Regular samples were collected from infants to 24 months of age and tested by PCR. Detailed measurements of actual feeding behaviors were collected to examine, in an observational analysis, associations between feeding practices and postnatal HIV transmission. Uptake of EBF was high with 84% of women reporting only EBF cumulatively to 4 months. Post-natal HIV transmission before 4 months was significantly lower (p = 0.004) among EBF (0.040 95% CI: 0.024–0.055) than non-EBF infants (0.102 95% CI: 0.047–0.157); time-dependent Relative Hazard (RH) of transmission due to non-EBF = 3.48 (95% CI: 1.71–7.08). There were no significant differences in the severity of disease between EBF and non-EBF mothers and the association remained significant (RH = 2.68 95% CI: 1.28–5.62) after adjusting for maternal CD4 count, plasma viral load, syphilis screening results and low birth weight.
Non-EBF more than doubles the risk of early postnatal HIV transmission. Programs to support EBF should be expanded universally in low resource settings. EBF is an affordable, feasible, acceptable, safe and sustainable practice that also reduces HIV transmission providing HIV-infected women with a means to protect their children's lives.
Trial Registration NCT00310726
PMCID: PMC2137948  PMID: 18159246

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