In Karnataka, India only one-third of HIV-infected pregnant women received antiretroviral prophylaxis at delivery in 2007 through the state government's prevention of parent-to-child HIV transmission (PPTCT) program. The current qualitative study explored the role of HIV-associated stigma as a barrier to accessing PPTCT services in the rural northern Karnataka district of Bagalkot using in depth interviews and focus group discussions with HIV-infected women who had participated in the PPTCT program, male and female family members, and HIV service providers. Participants discussed personal experiences, community perceptions of HIV, and decision-making related to accessing PPTCT services. They described stigma towards HIVinfected individuals from multiple sources: healthcare workers, community members, family and self. Stigma-related behaviors were based on fears of HIV transmission through personal contact and moral judgment. Experience and/or fears of discrimination led pregnant women to avoid using PPTCT interventions. Government, cultural and historical factors are described as the roots of much the stigma-related behavior in this setting. Based on these formative data, PPTCT program planners should consider further research and interventions aimed at diminishing institutional and interpersonal HIV-associated stigma experienced by pregnant women.
Background The number of HIV-infected women giving birth in the U.S. is increasing. Research on pregnancy planning in HIV-infected women is limited. Methods Between January 1 and December 30, 2012, pregnant women with a known HIV diagnosis prior to conception at 12 U.S. urban medical centers completed a survey including the London Measure of Unplanned Pregnancy (LMUP) scale. We assessed predictors of LMUP category (unplanned/ambivalent versus planned pregnancy) using bivariate and multivariable analyses. Results Overall, 172 women met inclusion criteria and completed a survey. Based on self-report using the LMUP scale, 23% of women had an unplanned pregnancy, 58% were ambivalent and 19% reported a planned pregnancy. Women were at lower risk for an unplanned or ambivalent pregnancy if they had previously given birth since their HIV diagnosis (adjusted Relative Risk = 0.67, 95% CI 0.47-0.94, p=0.02), had seen a medical provider in the year before the index pregnancy (aRR 0.60, 95% CI 0.46-0.77, p<0.01), or had a patient-initiated discussion of pregnancy intentions in the year prior to the index pregnancy (aRR = 0.63, 95% CI 0.46-0.77, p<0.01). Unplanned or ambivalent pregnancy was not associated with age, race/ethnicity, or educational level. Conclusions In this multi-site U.S. cohort, patient-initiated pregnancy counseling as well as being engaged in medical care prior to pregnancy were associated with a decreased probability of unplanned or ambivalent pregnancy. Interventions that promote health-care engagement among HIV-infected women and integrate contraception and preconception counseling into routine HIV care may decrease the risk of unplanned pregnancy among HIV-infected women in the U.S.
Background Minimizing time to Human Immunodeficiency Virus (HIV) viral suppression is critical in pregnancy. Integrase strand transfer inhibitors (INSTIs), like raltegravir, are known to rapidly suppress plasma HIV ribonucleic acid (RNA) in nonpregnant adults. There is limited data in pregnant women. Objective We describe time to clinically relevant reduction in HIV RNA in pregnant women using INSTI-containing and non-INSTI-containing ART options. Study Design We conducted a retrospective cohort study of pregnant HIV-infected women in the U.S. from 2009 to 2015. We included women who initiated antiretroviral therapy (ART), intensified their regimen or switched to a new regimen due to detectable viremia (HIV RNA > 40c/mL) at ≥ 20 weeks gestation. Among women with a baseline HIV RNA permitting one-log reduction, we estimated time to one-log RNA reduction using the Kaplan-Meier estimator comparing women starting/adding an INSTI in their regimen versus other ART. To compare groups with similar follow-up time, we also conducted a subgroup analysis limited to women with ≤14 days between baseline and follow-up RNA data. Results This study describes 101 HIV-infected pregnant women from 11 U.S. clinics. Seventy-five percent (76/101) women were not taking ART at baseline; 24 were taking non-INSTI containing ART, and 1 received zidovudine monotherapy. Thirty-nine percent (39/101) of women started an INSTI-containing regimen or added an INSTI to their ART regimen. Among 90 women with a baseline HIV RNA permitting one-log reduction, the median time to one-log RNA reduction was 8 days [Interquartile Range (IQR): 7, 14] in the INSTI group versus 35 days [IQR: 20, 53] in the non-INSTI ART group (p<0.01). In a subgroup of 39 women with first and last RNA measurements ≤14 days apart, median time to one-log reduction was 7 days [IQR: 6, 10] in the INSTI group versus 11 days [IQR: 10, 14] in the non-INSTI group (p<0.01). Conclusion ART that includes INSTIs appears to induce more rapid viral suppression than other ART regimens in pregnancy. Inclusion of an INSTI may play a role in optimal reduction of HIV-RNA for HIV-infected pregnant women presenting late to care or failing initial therapy. Larger studies are urgently needed to assess the safety and effectiveness of this approach.
Background Little is known about fertility choices and pregnancy outcome rates among HIV-infected women in the current combination ART era. Objective To describe trends and factors associated with live-birth and abortion rates among HIV-positive and high-risk HIV-negative women enrolled in the Women’s Interagency HIV Study (WIHS) in the United States. Study Design We analyzed longitudinal data collected from October 1st 1994 to September 30th 2012 through WIHS. Age-adjusted rates per 100 person-years (PY) live-births, and induced abortions were calculated by HIV serostatus over four time periods. Poisson mixed effects models containing variables associated with live-births and abortions in bivariable analyses (p<0.05) generated adjusted incidence rate ratios (aIRRs) and 95% confidence intervals. Results There were 1,356 pregnancies among 2,414 women. Among HIV-positive women, age-adjusted rates of live-birth increased from 1994-1997 to 2006-2012 (2.85/100PY to 7.27/100PY, p-trend<0.0001). Age-adjusted rates of abortion in HIV-positive women remained stable over these time periods (4.03/100PY to 4.29/100PY, p-trend=0.09). Significantly lower live-birth rates occurred among HIV-positive compared to HIV-negative women in 1994-1997 and 1997-2001, however rates were similar during 2002-2005 and 2006-2012. Higher CD4+ T cells/mm3 (≥350 aIRR=1.39 [1.03-1.89] versus <350) was significantly associated with increased live-birth rates, while combination antiretroviral treatment (cART) use (aIRR=1.35 [0.99-1.83]) was marginally associated with increased live-birth rates. Younger age, having a prior abortion, condom use and increased parity were associated with increased abortion rates among both HIV-positive and HIV-negative women. CD4+ T-cell count, cART use, and viral load were not associated with abortion rates. Conclusions Unlike earlier periods (pre-2001) when live-birth rates were lower among HIV-positive women, rates are now similar to HIV-negative women, potentially due to improved health status and cART. Abortion rates remain unchanged illuminating a need to improve contraceptive services.
Clinical research to inform the evidence base to guide nonobstetrical care during pregnancy is critically important for the well-being of women and their future offspring. Conversations about regulations for such research, including whether paternal consent should ever be required, should be informed by the perspectives of those most affected, namely, pregnant women. We conducted in-depth interviews with 140 pregnant women living with or at risk of HIV-70 in Malawi, 70 in the United States-exploring their views on requiring paternal consent for pregnant women's participation in trials offering the prospect of direct benefit solely to the fetus. The majority of women supported such a requirement; others raised concerns. A trio of themes-the father's or pregnant woman's rights, fetal protection, and gender/relationship dynamics-characterized views both supporting and against a paternal consent requirement, expanding the range of considerations that should inform approaches to paternal involvement in research with pregnant women.
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