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We tested an intervention that aimed to increase retention in antiretroviral therapy (ART) among HIV-positive pregnant and postpartum women, a population shown to be vulnerable to poor ART outcomes. 133 pregnant women initiating ART at 2 hospitals in Uganda used real time-enabled wireless pill monitors (WPM) for 1 month, and were then randomized to receive text message reminders (triggered by late dose-taking) and data-informed counseling through 3 months postpartum or standard care. We assessed "full retention" (proportion attending all monthly clinic visits and delivering at a study facility; "visit retention" (proportion of clinic visits attended); and "postpartum retention" (proportion retained at 3 months postpartum). Intention-to-treat and per protocol analyses found that retention was relatively low and similar between groups, with no significant differences. Retention declined significantly post-delivery. The intervention was unsuccessful in this population, which experiences suboptimal ART retention and is in urgent need of effective interventions.

Objective: Previous studies have demonstrated that HIV-exposed uninfected (HEU) infants and children experience morbidity and mortality at rates exceeding those of their HIV-unexposed uninfected (HUU) counterparts. We sought to summarize the association between HEU vs. HUU infants and children for the outcomes of diarrhea and pneumonia., Design: Meta-analysis., Methods: We reviewed studies comparing infants and children in the 2 groups for these infectious disease outcomes, in any setting, from 1993 to 2018 from 6 databases., Results: We included 12 studies, and 17,955 subjects total [n = 5074 (28.3%) HEU and n = 12,881 (71.7%) HUU]. Random-effects models showed HEU infants and children had a 20% increase in the relative risk of acute diarrhea and a 30% increase in the relative risk of pneumonia when compared with their HUU counterparts. When stratifying by time since birth, we showed that HEU vs. HUU children had a 50% and 70% increased risk of diarrhea and pneumonia, respectively, in the first 6 months of life., Conclusions: We show an increased risk of diarrhea and pneumonia for HEU vs. HUU infants and children. Although we acknowledge, and commend, the immense public health success of prevention of mother-to-child transmission, we now have an enlarging population of children that seem to be vulnerable to not only death, but increased morbidity. We need to turn our attention to understanding the underlying mechanism and designing effective public health solutions. Further longitudinal research is needed to elucidate possible underlying immunological and/or sociological mechanisms that explain these differences in morbidity.

Background: To determine the timing of prevention of mother-to-child transmission cascade programmatic barriers to understand the service gaps in preparation for scale up of Option B+ in the Southern Province of Zambia., Methods: A database search of the National Dried Blood Spot Registry in Zambia for DNA polymerase chain reaction identified human immunodeficiency virus (HIV)-infected infants from 5 facilities in 2 districts in Southern Province, Zambia over a 6-month observation period (January 2013 to June 2013)., Results: Seventeen HIV-positive infants out of 459 infants tested were identified from 5 health facilities that provided antiretroviral therapy (ART) initiation within the antenatal care (ANC) clinic, for a transmission rate of 3.7%. Possible risk factors identified for mother to child transmission of HIV included late ANC presentation, home delivery, provision of maternal short course prophylaxis, maternal refusal to initiate treatment and loss to follow-up., Conclusions: As Zambia transitions to life-long combination ART initiation for HIV-positive pregnant women under Option B+, and subsequent ART integration into ANC facilities, it is crucial to understand prevention of mother-to-child transmission program gaps to achieve the goal of eliminating mother to child transmission of HIV in Zambia.

Background: Early initiation of combination antiretroviral therapy (cART) for HIV-positive pregnant women can decrease vertical transmission to less than 5%. Programmatic barriers to early cART include decentralized care, disease-stage assessment delays, and loss to follow-up., Intervention: Our intervention had 3 components: integrated HIV and antenatal services in 1 location with 1 provider, laboratory courier to expedite CD4 counts, and community-based follow-up of women-infant pairs to improve prevention of mother-to-child transmission attendance. Preintervention HIV-positive pregnant women were referred to HIV clinics for disease-stage assessment and cART initiation for advanced disease (CD4 count <350 cells/μL or WHO stage >2)., Methods: We used a quasi-experimental design with preintervention/postintervention evaluations at 6 government antenatal clinics (ANCs) in Southern Province, Zambia. Retrospective clinical data were collected from clinic registers during a 7-month baseline period. Postintervention data were collected from all antiretroviral therapy-naive, HIV-positive pregnant women and their infants presenting to ANC from December 2011 to June 2013., Results: Data from 510 baseline women-infant pairs were analyzed and 624 pregnant women were enrolled during the intervention period. The proportion of HIV-positive pregnant women receiving CD4 counts increased from 50.6% to 77.2% [relative risk (RR) = 1.81; 95% confidence interval (CI): 1.57 to 2.08; P < 0.01]. The proportion of cART-eligible pregnant women initiated on cART increased from 27.5% to 71.5% (RR = 2.25; 95% CI: 1.78 to 2.83; P < 0.01). The proportion of eligible HIV-exposed infants with documented 6-week HIV PCR test increased from 41.9% to 55.8% (RR = 1.33; 95% CI: 1.18 to 1.51; P < 0.01)., Conclusions: Integration of HIV care into ANC and community-based support improved uptake of CD4 counts, proportion of cART-eligible women initiated on cART, and infants tested.

Objective: To evaluate the impact of rapid syphilis tests (RSTs) on syphilis testing and treatment in pregnant women in Kalomo District, Zambia., Methods: In March 2012, health workers at all 35 health facilities in Kalomo Distract were trained in RST use and penicillin treatment. In March 2013, data were retrospectively abstracted from 18 randomly selected health facilities and stratified into three time intervals: baseline (6months prior to RST introduction), midline (0-6 months after RST introduction), and endline (7-12 months after RST introduction)., Results: Data collected on 4154 pregnant women showed a syphilis-reactive seroprevalence of 2.7%. The proportion of women screened improved from baseline (140/1365, 10.6%) to midline (976/1446, 67.5%), finally decreasing at endline (752/1337, 56.3%) (P<0.001). There was no significant difference in the proportion of syphilis-seroreactive pregnant women who received 1 dose of penicillin before (1/2, 50%) or after (5/48, 10.4%; P=0.199) RST introduction with low treatment rates throughout., Conclusion: With RST scale-up in Zambia and other resource-limited settings, same-day test and treatment with penicillin should be prioritized to achieve the goal of eliminating congenital syphilis., (Copyright © 2015 International Federation of Gynecology and Obstetrics. All rights reserved.)

Background: In March 2012, The Elizabeth Glaser Pediatric AIDS Foundation trained maternal and child health workers in Southern Province of Zambia to use a new rapid syphilis test (RST) during routine antenatal care. A recent study by Bonawitz et al. (2014) evaluated the impact of this roll out in Kalomo District. This paper estimates the costs and cost-effectiveness from the provider's perspective under the actual conditions observed during the first year of the RST roll out., Methods: Information on materials used and costs were extracted from program records. A decision-analytic model was used to evaluate the costs (2012 USD) and cost-effectiveness. Basic parameters needed for the model were based on the results from the evaluation study., Results: During the evaluation study, 62% of patients received a RST, and 2.8% of patients tested were positive (and 10.4% of these were treated). Even with very high RST sensitivity and specificity (98%), true prevalence of active syphilis would be substantially less (estimated at <0.7%). For 1,000 new ANC patients, costs of screening and treatment were estimated at $2,136, and the cost per avoided disability-adjusted-life year lost (DALY) was estimated at $628. Costs change little if all positives are treated (because prevalence is low and treatment costs are small), but the cost-per-DALY avoided falls to just $66. With full adherence to guidelines, costs increase to $3,174 per 1,000 patients and the cost-per-DALY avoided falls to $60., Conclusions: Screening for syphilis is only useful for reducing adverse birth outcomes if patients testing positive are actually treated. Even with very low prevalence of syphilis (a needle in the haystack), cost effectiveness improves dramatically if those found positive are treated; additional treatment costs little but DALYs avoided are substantial. Without treatment, the needle is essentially found and thrown back into the haystack.