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Abstract In 2012, the Centers for Disease Control and Prevention published a Framework for Elimination of Perinatal Transmission of HIV in the United States in Pediatrics, setting the goals of an incidence of

OBJECTIVE Describe sources of discrepancy between self-assessed LoMC (level of maternal care) and CDC LOCATe®-assessed (Levels of Care Assessment Tool) LoMC. STUDY DESIGN CDC LOCATe® was implemented at 480 facilities in 13 jurisdictions, including states, territories, perinatal regions, and hospital systems, in the U.S. Cross-sectional analyses were conducted to compare facilities' self-reported LoMC and LOCATe®-assessed LoMC. RESULT Among 418 facilities that self-reported an LoMC, 41.4% self-reported a higher LoMC than their LOCATe®-assessed LoMC. Among facilities with discrepancies, the most common elements lacking to meet self-reported LoMC included availability of maternal-fetal medicine (27.7%), obstetric-specializing anesthesiologist (16.2%), and obstetric ultrasound services (12.1%). CONCLUSION Two in five facilities self-report a LoMC higher than their LOCATe®-assessed LoMC, indicating discrepancies between perceived maternal care capabilities and those recommended in current LoMC guidelines. Results highlight an opportunity for states to engage with facilities, health systems, and other stakeholders about LoMC and collaborate to strengthen systems for improving maternal care delivery.

In this study, hospital discharge data from the 2016–2017 Healthcare Cost and Utilization Project were analyzed to describe national and, where data were available, state-specific prevalences of chronic hypertension and pregnancy-associated hypertension at delivery hospitalization. In 2016–2017, the prevalence of chronic hypertension was 216 per 10,000 delivery hospitalizations nationwide, ranging from 125 to 400 per 10,000 delivery hospitalizations in individual states. The prevalence of pregnancy-associated hypertension was 1021 per 10,000 delivery hospitalizations nationwide, ranging from 693 to 1382 per 10,000 delivery hospitalizations in individual states. The burden of hypertensive disorders in pregnancy remains high and varies considerably by jurisdiction.

Mobile technology allows delivery of sexual and reproductive health (SRH) information directly to youth. We tested the efficacy of Crush, a mobile application aimed at improving sexual health by promoting the use of SRH services and contraception among female adolescents.We recruited 1,210 women aged 14-18 years through social media advertising and randomized them into a Crush intervention group and a control group that received a wellness app. At 3 and 6 months post randomization, we compared changes from baseline in behaviors, attitudes, self-efficacy, perceived social norms, birth control knowledge, perceived control and use intentions, and SRH service utilization. Odds ratios were estimated with multivariable logistic regression and adjusted for baseline outcome, age, race/ethnicity, mother's education, and sexual experience.There was no difference in accessing SRH services according to study group. Three months post baseline, Crush users had higher odds (p.05) than control participants of reporting confidence in accessing SRH services (adjusted odds ratio [aOR] = 1.6, 95% confidence interval [CI]: 1.1-2.3) and of believing that it is a good thing to use birth control consistently (aOR = 2.3, 95% CI: 1.4-3.8). Six months after baseline, Crush users had higher odds than control participants of reporting they can control whether birth control is used every time they have sex (aOR = 1.8, 95% CI: 1.2-2.6) and perceiving they would get pregnant if they did not use birth control (aOR: 1.5, 95% CI: 1.1-2.2). Impacts on other behavioral constructs were also found.Crush was associated with improvements in knowledge, attitudes, and self-efficacy related to key SRH behaviors and may be a strategy to deliver SRH education to adolescent women. Studies including larger numbers of sexually active adolescents are needed to demonstrate behavioral impacts.

OBJECTIVES: To investigate potential risk factors for perinatal (intrauterine and intrapartum) mother-to-child transmission of HIV (MTCT) in women unexposed to Antiretroviral Therapy (ART) during pregnancy. METHODS: We compared factors according to perinatal MTCT outcome among 2,275 ART-naïve (until the onset of labor) HIV-infected women in the Breastfeeding, Antiretrovirals and Nutrition study (2004–2010) in Lilongwe, Malawi. Factors included HIV viral load during pregnancy, food security, demographic characteristics, hematologic and blood chemistry measures, medical history and physical factors. Associations with perinatal MTCT and interactions with maternal viral load were assessed using simple and multivariable logistic regression. RESULTS: There were 119 (115 intrauterine, 4 intrapartum) cases of perinatal MTCT; only one to a mother with 10,000 copies/mL were common (63.1%). Lower maternal viral load (10,000 copies/mL. Low CD4+ T cell count (≤ 350 cells/μL) was only associated with perinatal MTCT in unadjusted models. Food shortage (aOR, 1.8; 95% CI; 1.2-2.6), sexually transmitted infection (past year) (aOR, 1.9; 95% CI; 1.0–3.7), histories of herpes zoster (aOR, 3.0; 95% CI; 1.6–5.6) and tuberculosis (aOR, 2.5; 95% CI; 1.1–5.7) were associated with increased odds of perinatal MTCT. CONCLUSIONS: These findings confirm that lowering maternal HIV viral load is most important in preventing perinatal MTCT, and support efforts to address food shortage, STD and TB prevention, while informing programs to improve ART coverage in pregnancy.

Describe sources of discrepancy between self-assessed LoMC (level of maternal care) and CDC LOCATeCDC LOCATeAmong 418 facilities that self-reported an LoMC, 41.4% self-reported a higher LoMC than their LOCATeTwo in five facilities self-report a LoMC higher than their LOCATe

Cotrimoxazole preventive therapy may lead to fewer prescriptions., Antimicrobial drug resistance is a serious health hazard driven by overuse. Administration of antimicrobial drugs to HIV-exposed, uninfected infants, a population that is growing and at high risk for infection, is poorly studied. We therefore analyzed factors associated with antibacterial drug administration to HIV-exposed, uninfected infants during their first year of life. Our study population was 2,152 HIV-exposed, uninfected infants enrolled in the Breastfeeding, Antiretrovirals and Nutrition study in Lilongwe, Malawi, during 2004–2010. All infants were breastfed through 28 weeks of age. Antibacterial drugs were prescribed frequently (to 80% of infants), and most (67%) of the 5,329 prescriptions were for respiratory indications. Most commonly prescribed were penicillins (43%) and sulfonamides (23%). Factors associated with lower hazard for antibacterial drug prescription included receipt of cotrimoxazole preventive therapy, receipt of antiretroviral drugs, and increased age. Thus, cotrimoxazole preventive therapy may lead to fewer prescriptions for antibacterial drugs for these infants.

Objective Using data from 2003-2012, we updated a previous analysis of trends in hospitalizations of HIV-infected children and adolescents in the United States. Methods We used data from the Kids´ Inpatient Database of the Healthcare Cost and Utilization Project to derive nationally representative estimates of the number of hospitalizations and the rates per 1000 hospitalizations of select discharge diagnoses and procedures in 2003, 2006, 2009 and 2012 among HIV-infected and HIV-uninfected children and adolescents ≤18 years, excluding hospitalizations for conditions related to pregnancy/delivery and neonatal diagnoses. We also examined trends in the prevalence of select discharge diagnoses and procedures using multivariable logistic regression models. Results During 2003-2012, the number of hospitalizations for HIV-infected children declined 58% versus 17% for uninfected, but the odds of having discharge codes for most of the diagnoses and procedures studied, including death during hospitalization, remained higher among HIV-infected compared with uninfected children. Among HIV-infected children, the prevalence of discharge diagnoses for pneumonia, pneumococcal disease and varicella/herpes zoster infections and odds of death during hospitalization decreased over time, while bacterial infections/sepsis and methicillin-resistant Staphylococcus aureus increased. Among HIV-uninfected children, there was no increase in diagnoses of bacterial infection/sepsis, but otherwise trends were similar. Conclusions The number of hospitalizations for HIV-infected children declined from 2003 to 2012. The decreased prevalence of several discharge diagnoses and lower risk of death during hospitalization likely reflect improvements in HIV therapies and increased uptake of other preventive strategies. However, the increasing prevalence of discharge diagnoses for bacterial infections/sepsis warrants further attention and monitoring.

Since 1969, CDC has conducted abortion surveillance to document the number and characteristics of women obtaining legal induced abortions in the United States.

Background The objective of this study was to estimate the prevalence of current (past 30 days) marijuana use and its associations with demographic, other substance use, chronic disease, physical health and mental health measures among women of reproductive age (18–44 years) in 12 US states. Methods This analysis used 2016 Behavioral Risk Factor Surveillance System (BRFSS) data from 16,556 women of reproductive age in 12 US states. Women self-reported current marijuana use and covariates. Weighted χ2 statistics and adjusted prevalence ratios (aPR) were calculated accounting for the complex survey design. Results Among women of reproductive age, 9.9 % reported current marijuana use. Current cigarette use (aPR: 2.0, 95 % CI: 1.6, 2.6), current e-cigarette use (aPR: 1.9, 95 % CI: 1.4, 2.6), binge drinking (aPR: 2.6, 95 % CI: 1.9, 3.6), ever having received a depression diagnosis (aPR: 1.6, 95 % CI: 1.2, 2.1), and ≥14 days of poor mental health in the past 30 days (aPR: 1.8, 95 % CI: 1.3, 2.4) were all associated with higher adjusted prevalence of current marijuana use. Reporting ≥14 days of poor physical health within the last 30 was associated with a 40 % lower adjusted prevalence of current marijuana use (aPR: 0.6, 95 % CI: 0.4, 0.8). Conclusion Current marijuana use among women of reproductive age was associated with other substance use, poor mental health, and depression. As state laws concerning marijuana use continue to change, it is important to monitor usage patterns and to assess associated health risks in this population.

BACKGROUND: Maternal mortality rates in the United States appear to be increasing. One potential reason may be increased identification of maternal deaths after the addition of a pregnancy checkbox to the death certificate. In 2016, four state health departments (Georgia, Louisiana, Michigan, Ohio) implemented a pregnancy checkbox quality assurance pilot, with technical assistance provided by the Centers for Disease Control and Prevention. The pilot aimed to improve accuracy of the pregnancy checkbox on death certificates and resultant state maternal mortality estimates. OBJECTIVE(S): To estimate the validity of the pregnancy checkbox on the death certificate and describe characteristics associated with errors using 2016 data from a four state quality assurance pilot. STUDY DESIGN: Potential pregnancy-associated deaths were identified by linking death certificates with birth or fetal death certificates from within a year preceding death or by pregnancy checkbox status. Death certificates which indicated the decedent was pregnant within a year of death via the pregnancy checkbox, but that did not link to a birth or fetal death certificate, were referred for active follow-up to confirm pregnancy status by either death certifier confirmation or medical record review. Descriptive statistics and 95% confidence intervals were used to examine the distributions of demographic characteristics by pregnancy confirmation category (i.e., confirmed pregnant, confirmed not pregnant, and unable to confirm). We compared the proportion confirmed pregnant and confirmed not pregnant within age, race/ethnicity, pregnancy checkbox category, and certifier type categories using a Wald test of proportions. Binomial and Poisson regression models were used to estimate prevalence ratios for having an incorrect pregnancy checkbox (false positive, false negative) by age group, race/ethnicity, pregnancy checkbox category, and certifier type. RESULTS: Among 467 potential pregnancy-associated deaths, 335 (72%) were confirmed pregnant either via linkage to a birth or fetal death certificate, certifier confirmation, or review of medical records. Ninety-seven (21%) women were confirmed not pregnant (false positives) and 35 (7%) were unable to be confirmed. Women confirmed pregnant were significantly younger than women confirmed not pregnant (p

Background Given the potential of cotrimoxazole preventive therapy (CPT) to prevent bacterial and malarial infections in HIV-exposed, uninfected (HEU) infants, it is important to evaluate the effects of its concurrent use with antiretroviral agents that have overlapping toxicity profiles. Methods We used data from the Breastfeeding, Antiretrovirals, and Nutrition study (2004-2010) to evaluate the association of CPT and antiretrovirals with hematologic measures (hemoglobin, neutrophil, and alanine aminotransferase levels) from 6 to 48 weeks of age in 2006 HEU infants in Lilongwe, Malawi. Hazards of severe outcomes (anemia, neutropenia, and elevated alanine aminotransferase), as defined by the National Institutes of Health, were compared using Cox regression models, according to time-varying CPT (implemented June 2006), antiretroviral treatment arm (maternal triple antiretroviral, infant nevirapine, or none during 6 months of breastfeeding), and their interaction. The effects of these treatments on hemoglobin, neutrophil, and alanine aminotransferase levels were assessed using linear mixed models. Results In Cox models, CPT was associated with an increase in severe neutropenia [hazard ratio 1.97 (1.01, 3.86)] and a decrease in severe anemia (hazard ratio 0.65 (0.48, 0.88)]. Interactions between CPT and antiretroviral treatment were not significant. By 36 weeks, there was a significant association of CPT with increased hemoglobin levels regardless of antiretroviral drug exposure. Conclusions In addition to expected associations with increased hazard of severe neutropenia and decreased neutrophil count, CPT was associated with reduced hazard of severe anemia and higher infant blood hemoglobin. This provides further support for CPT use in HEU infants in malaria-endemic resource-limited settings where anemia is prevalent.

Objectives The magnitude, characteristics, and morbidity of term (≥37 weeks gestation) newborns that are small-for-gestational-age (SGA) in the U.S. are underexplored. We sought to examine characteristics and trends for SGA-coded term newborns in the U.S. Methods Data were obtained from the Nationwide Inpatient Sample, a nationally representative database of hospital stays in the U.S. from 2002 to 2011. Term, singleton newborns with SGA codes were identified and examined over the study period. Demographic characteristics were compared for term newborns according to presence of SGA codes using χ2 tests. Odds ratios (OR) were calculated to compare morbidities between the two groups, adjusting for relevant demographic and clinical variables. Results In 2011, 15 per 1000 term newborns in the U.S. were coded as SGA, a 29.9 % increase since 2002. Compared with other term newborns, SGA term newborns were significantly (p

Background African American adolescent females are at elevated risk for unintended pregnancy and sexually transmitted infections (STIs). Dual protection (DP) is defined as concurrent prevention of pregnancy and STIs. This can be achieved by abstinence, consistent condom use, or the dual methods of condoms plus an effective non-barrier contraceptive. Previous clinic-based interventions showed short-term effects on increasing dual method use, but evidence of sustained effects on dual method use and decreased incident pregnancies and STIs are lacking. Methods/design This manuscript describes the 2GETHER Project. 2GETHER is a randomized controlled trial of a multi-component intervention to increase dual protection use among sexually active African American females aged 14–19 years not desiring pregnancy at a Title X clinic in Atlanta, GA. The intervention is clinic-based and includes a culturally tailored interactive multimedia component and counseling sessions, both to assist in selection of a DP method and to reinforce use of the DP method. The participants are randomized to the study intervention or the standard of care, and followed for 12 months to evaluate how the intervention influences DP method selection and adherence, pregnancy and STI incidence, and participants' DP knowledge, intentions, and self-efficacy. Discussion The 2GETHER Project is a novel trial to reduce unintended pregnancies and STIs among African American adolescents. The intervention is unique in the comprehensive and complementary nature of its components and its individual tailoring of provider-patient interaction. If the trial interventions are shown to be effective, then it will be reasonable to assess their scalability and applicability in other populations.

With the development and widespread use of combination antiretroviral therapy, HIV-infected women live longer, healthier lives. Previous research has shown that, since the adoption of combination antiretroviral therapy in the United States, rates of morbidity and adverse obstetric outcomes remained higher for HIV-infected pregnant women compared with HIV-uninfected pregnant women. Monitoring trends in the outcomes these women experience is essential, as recommendations for this special population continue to evolve with the progress of HIV treatment and prevention options.We conducted an analysis comparing rates of hospitalizations and associated outcomes among HIV-infected and HIV-uninfected pregnant women in the United States from 2004 through 2011.We used cross-sectional hospital discharge data for girls and women age 15-49 from the 2004, 2007, and 2011 Nationwide Inpatient Sample, a nationally representative sample of US hospital discharges. Demographic characteristics, morbidity outcomes, and time trends were compared using χ(2) tests and multivariate logistic regression. Analyses were weighted to produce national estimates.In 2011, there were 4751 estimated pregnancy hospitalizations and 3855 delivery hospitalizations for HIV-infected pregnant women; neither increased since 2004. Compared with those of HIV-uninfected women, pregnancy hospitalizations of HIV-infected women were more likely to be longer, be in the South and Northeast, be covered by public insurance, and incur higher charges (all P.005). Hospitalizations among pregnant women with HIV infection had higher rates for many adverse outcomes. Compared to 2004, hospitalizations of HIV-infected pregnant women in 2011 had higher odds of gestational diabetes (adjusted odds ratio, 1.81; 95% confidence interval, 1.16-2.84), preeclampsia/hypertensive disorders of pregnancy (adjusted odds ratio, 1.58; 95% confidence interval, 1.12-2.24), viral/mycotic/parasitic infections (adjusted odds ratio, 1.90; 95% confidence interval, 1.69-2.14), and bacterial infections (adjusted odds ratio, 2.54; 95% confidence interval, 1.53-4.20). Bacterial infections did not increase among hospitalizations of HIV-uninfected pregnant women.The numbers of hospitalizations during pregnancy and delivery have not increased for HIV-infected women since 2004, a departure from previously estimated trends. Pregnancy hospitalizations of HIV-infected women remain more medically complex than those of HIV-uninfected women. An increasing trend in infections among the delivery hospitalizations of HIV-infected pregnant women warrant further attention.

Background Antibiotic resistance is a serious health hazard driven by overuse. Antibiotic usage in low-income countries is poorly studied. HIV-exposed, uninfected (HEU) infants are a growing population at high risk for infection and resulting antibiotic use. Methods We described antibiotic usage among 2,152 HEU infants in the Breastfeeding, Antiretrovirals and Nutrition (BAN) Study in Lilongwe, Malawi, 2004–2010. Factors were tested for associations with antibiotic prescription using a repeated-measures Cox proportional hazards model and included cotrimoxazole preventive therapy (CPT) exposure, malaria season, antiretroviral (ARV) treatment, receipt of maternal nutritional supplement, maternal CD4+ T-cell count, HIV viral load, maternal age, infant sex and birthweight. Results Overall, 80% of HEU infants in the BAN study received an antibiotic prescription during follow-up (median length: 336 days). The majority (67%) of the 5,107 antibiotic prescriptions were for respiratory indications. Penicillins (43%) were the most commonly prescribed type of antibiotics, followed by sulfonamides (23%). The median number of prescriptions received per infant-month was 0.2 (interquartile range (IQR): 0.1, 0.3). Factors associated with lower hazard of antibiotic prescription included CPT exposure (hazard ratio (HR): 0.57 [95% confidence interval (CI): 0.52, 0.61]), maternal ARV (HR: 0.85, 95% CI: [0.78, 0.93]), and infant ARV (HR: 0.90, 95% CI: [0.82, 0.98]). Hazard of antibiotic prescription also decreased as participants aged (HR for ages 6–12 months vs. 0–1 month: 0.48, 95% CI: [0.40, 0.58]). Male sex (HR: 1.09, 95% CI: [1.02, 1.17]) and log maternal viral load (copies/mL) (HR: 1.02, 95% CI: 1.003, 1.04) were associated with increased hazard of antibiotic prescription. Conclusion This study provides an estimate of antibiotic use by HEU infants in a low-income country and evidence that CPT may lead to reduced antibiotic use. Disclosures All authors: No reported disclosures.

Background In settings where pneumonia, diarrhea, and malnutrition are significant causes of infant mortality, breastfeeding for 12 months combined with antiretroviral and cotrimoxazole preventive therapy (CPT) offers infants of HIV-infected mothers the greatest chance for HIV-free survival. Both maternal and infant antiretroviral (ARV) prophylaxis and CPT have been independently associated with reports of neutropenia and anemia, so it is important to evaluate the impact of their concurrent use. Methods We used data from the breastfeeding, antiretrovirals, and nutrition study (conducted 2004–2010) to evaluate the impact of CPT and ARV treatment on hematologic outcomes from 6 to 48 weeks of age for 2,006 HIV-exposed, uninfected infants in Lilongwe, Malawi. Using Cox proportional hazards models, we compared the hazard of severe (grade 3 and higher) anemia and neutropenia (as defined by the NIAID Division of AIDS, 2014) according to time-varying CPT, implemented mid-way through the study, and antiretroviral treatment arm exposure (maternal zidovudine/lamivudine/lopinavir-ritonavir, daily infant nevirapine, or none during 6 months of breastfeeding) and checked for statistical interaction between the two. Results CPT was associated with an increase in severe neutropenia (hazard ratio [95% CI]: 1.97 [1.01, 3.86]) (Figure 1a) and a decrease in severe anemia hazard (HR: 0.65 [0.48, 0.88]) (Figure 1b). The hazard of severe anemia is significantly lower in the infant nevirapine arm compared with the control arm (HR: 0.68 [0.48, 0.96]). The interaction between CPT and ARV treatment arm was not significant for either severe neutropenia (P = 0.22) or severe anemia (P = 0.32). Conclusion In addition to an expected association with increased hazard of severe neutropenia, CPT was associated with a reduced hazard of severe anemia, possibly due to the drug’s antimalarial effect. This provides further support for CPT use in HIV-exposed, uninfected infants in malaria-endemic resource-limited settings. Disclosures All Author: No reported disclosures.