Objectives Sexually transmitted infections (STIs) are associated with adverse outcomes in pregnancy, including mother-to-child HIV transmission. Yet there are limited data on the prevalence and correlates of STI in pregnant women by HIV status in low- and middle-income countries, where syndromic STI management is routine. Methods Between November 2017 and July 2018, we conducted a cross-sectional study of consecutive pregnant women making their first visit to a public sector antenatal clinic (ANC) in Cape Town. We interviewed women ≥18 years and tested them for Chlamydia trachomatis (CT), Neisseria gonorrhoea (NG) and Trichomonas vaginalis (TV) using Xpert assays (Cepheid, USA); results of syphilis serology came from routine testing records. We used multivariable logistic regression to identify correlates of STI in pregnancy. Results In 242 women (median age 29 years [IQR = 24–34], median gestation 19 weeks [IQR = 14–24]) 44% were HIV-infected. Almost all reported vaginal sex during pregnancy (93%). Prevalence of any STI was 32%: 39% in HIV-infected women vs. 28% in HIV-uninfected women (p = 0.036). The most common infection was CT (20%) followed by TV (15%), then NG (5.8%). Of the 78 women diagnosed with a STI, 7 (9%) were identified and treated syndromically in ANC. Adjusting for age and gestational age, HIV-infection (aOR = 1.89; 95% CI = 1.02–3.67), being unmarried or not cohabiting with the fetus’ father (aOR = 2.19; 95% CI = 1.16–4.12), and having STI symptoms in the past three days (aOR = 6.60; 95% CI = 2.08–20.95) were associated with STI diagnosis. Conclusion We found a high prevalence of treatable STIs in pregnancy among pregnant women, especially in HIV-infected women. Few women were identified and treated in pregnancy.

Background-Tenofovir-diphosphate (TFV-DP) in dried blood spots (DBS) is an objective longterm adherence measure but data are limited on its ability to predict virologic suppression (VS) in people on antiretroviral (ARV) treatment. There are also no data comparing DBS TFV-DP with plasma ARV concentrations as predictors of VS.Methods-Women who were on a first-line regimen of tenofovir, emtricitabine, and efavirenz (EFV) were enrolled in a cross-sectional study. Plasma EFV and tenofovir (TFV), DBS TFV-DP assays, and 30-day self-reported adherence were evaluated as predictors of VS (<50 copies/mL) with area under the curve (AUC) of receiver operating characteristics (ROC) and logistic regression.Results-We enrolled 137 women; mean age 33 years; median 4 years on ART; 88 (64%) had VS. In ROC analyses: DBS TFV-DP (0.926 [95%CI 0.876-0.976]) had a higher AUC than plasma TFV (0.864 [0.797-0.932]; p=0.006), while plasma EFV (0.903 [0.839-0.967]) was not significantly different from DBS TFV-DP (p=0.138) or plasma TFV (p=0.140

BackgroundHIV acquisition in pregnancy and breastfeeding contributes significantly toward pediatric HIV infection. However, little is known about how sexual behavior changes during pregnancy and postpartum periods which will help develop targeted HIV prevention and transmission interventions, including pre-exposure prophylaxis (PrEP).MethodsCross-sectional study in HIV-infected and uninfected pregnant and postpartum women in Cape Town, South Africa. Interviewers collected survey data on demographic, sexual behaviors, and alcohol use among pregnant and post-partum women. We report descriptive results of sexual behavior by trimester and postpartum period, and results of multivariable logistic regression stratified by pregnancy status.ResultsWe enrolled 377 pregnant and postpartum women (56% pregnant, 40% HIV-infected). During pregnancy, 98% of women reported vaginal sex (8% anal sex, 44% oral sex) vs. 35% and 88% during the periods 0–6 and 7–12 months postpartum, respectively (p<0.05). More pregnant women reported having >1 partner in the past 12-months compared to postpartum women (18% vs. 13%, respectively, p<0.05). Sex frequency varied by trimester with greatest mean sex acts occurring during first trimester and >6-months postpartum (13 mean sex acts in first trimester; 17 mean sex acts >6-months postpartum). Pregnant women had increased odds of reporting condomless sex at last sex (aOR = 2.96;95%CI = 1.84–4.78) and ever having condomless sex in past 3-months (aOR = 2.65;95%CI = 1.30–5.44) adjusting for age, HIV status, and sex frequency compared to postpartum women.ConclusionWe identified that sexual behaviors and risk behaviors were high and changing during pregnancy and postpartum periods, presenting challenges to primary and secondary HIV prevention efforts, including PrEP delivery to pregnant and breastfeeding women.

Objective: HIV-uninfected pregnant and breastfeeding women are at high risk of HIV acquisition, contributing to vertical transmission. Pre-exposure prophylaxis (PrEP) is safe in pregnancy, but PrEP in pregnancy is not policy in many countries including South Africa (SA). We evaluated the potential impact of providing PrEP for pregnant/breastfeeding women using a HIV model for SA. Methods: Our model considers two scenarios: a conservative scenario that matches the experience reported in the Kenyan PrEP programme for pregnant women (probability of uptake=32% and 11% in high-risk and low-risk women, respectively); and an optimistic scenario with PrEP initiated by 80% of all pregnant women. We compared this with PrEP for female sex workers (FSWs), men who have sex with men (MSM), and adolescent girls/young women (AGYW). Women are assumed to remain on PrEP throughout pregnancy and breastfeeding, and an equivalent average PrEP duration (2 years) is assumed in other scenarios. Results: Between 2020-2030, if PrEP is provided to pregnant/breastfeeding mothers, we project a 2.5% reduction in total HIV transmission (95%CI:2.4-2.6%) in the conservative scenario and 7.2% (95%CI:6.8-7.5%) in the optimistic scenario, which is similar to that in the FSW and MSM PrEP scenarios (1.9% and 3.0% respectively). Without PrEP, 76,000 (95%CI: 64,000-90,000) new cases of vertical transmission are expected; PrEP provision may reduce these infections by 13% (95%CI:13-14%) in the conservative scenario and 41% (95%CI:39-44%) in the optimistic scenario. Conclusion: High levels of uptake of and adherence to PrEP among pregnant/breastfeeding women could substantially reduce maternal and infant HIV acquisition in SA.

Background: Integrated maternal and child health (MCH) services improve women's postpartum antiretroviral therapy (ART) outcomes during breastfeeding; however, long-term outcomes after transfer to general ART services remain unknown. Methods: The MCH-ART trial demonstrated that maternal retention and viral suppression at 12-months postpartum were improved significantly among women randomized to integrated MCH services continued in the antenatal clinic through cessation of breastfeeding (MCH-ART arm) compared with immediate transfer to general ART services postpartum (standard of care). We reviewed electronic health records for all women who participated in the MCH-ART trial to ascertain retention and gaps in care and invited all women for a study visit 36- to 60-months postpartum including viral load testing. Results: Of 471 women in MCH-ART, 450 (96%) contributed electronic health record data and 353 (75%) completed the study visit (median 44-month postpartum). At this time, outcomes were identical in both trial arms: 67% retained in care (P = 0.994) and 56% with viral loads <50 copies/mL (P = 0.751). Experiencing a gap in care after delivery was delayed in the MCH-ART arm with 17%, 36%, and 45% of women experienced a gap in care by 12-, 24-, and 36-months postpartum compared with 35%, 48%, and 57% in the standard of care arm, respectively. Conclusions: The benefits of integrated maternal HIV and child health care did not persist after transfer to general ART services. The transfer of women postpartum to routine adult care is a critical period requiring interventions to support continuity of HIV care.