J.D. Makin

The impact of structured support groups for pregnant South African women recently diagnosed HIV positive.

The authors of this study evaluated a structured 10-session psychosocial support group intervention for newly HIV-diagnosed pregnant South African women. Participants were expected to display increases in HIV disclosure, self-esteem, active coping and positive social support, and decreases in depression, avoidant coping, and negative social support. Three hundred sixty-one pregnant HIV-infected women were recruited from four antenatal clinics in Tshwane townships from April 2005 to September 2006. Using a quasi-experimental design, assessments were conducted at baseline and two and eight months post-intervention. A series of random effects regression analyses were conducted, with the three assessment points treated as a random effect of time. At both follow-ups, the rate of disclosure in the intervention group was significantly higher than that of the comparison group (p < 0.001). Compared to the comparison group at the first follow-up, the intervention group displayed higher levels of active coping (t = 2.68, p < 0.05) and lower levels of avoidant coping (t = −2.02, p < 0.05), and those who attended at least half of the intervention sessions exhibited improved self-esteem (t = 2.11, p < 0.05). Group interventions tailored for newly HIV positive pregnant women, implemented in resource-limited settings, may accelerate the process of adjusting to ones HIV status, but may not have sustainable benefits over time.

Where are the men? Targeting male partners in preventing mother-to-child HIV transmission

Abstract Involvement of male partners may increase adherence to and improve outcomes of programs to prevent mother-to-child HIV transmission (PMTCT). Greater understanding of factors impeding male voluntary HIV counseling and testing (VCT) is needed. A cross-sectional study was conducted in Tshwane, South Africa. Semi-structured interviews were completed with men whose partners had recently been pregnant. Of 124 men who participated, 94% believed male HIV testing was important, but 40% had never been tested. Of those tested, 32% were tested during the pregnancy, while 37% were tested afterward. Fifty-eight percent of men reported that their female partners had disclosed their test results during pregnancy. A mans likelihood of testing during pregnancy was associated with prior discussion of testing in PMTCT, knowing the female partner had tested, and her disclosure of the test result (all p<0.05). In terms of increasing male-partner HIV testing rates, 74% of the men reported they would respond favorably to a written invitation for VCT from their partners. Based on themes that emerged during the interviews, six partner invitation cards to encourage male involvement in PMTCT were designed. Responses to the cards were elicited from 158 men and 409 women. One invitation card framed by the themes of fatherhood and the baby was selected by 41% of men and 31% of women as the most likely for women undergoing PMTCT to bring to their male partners and the most successful at encouraging men to be tested. In conclusion, this study found that a substantial proportion of men whose partners were recently pregnant had never been tested themselves; of those who had tested, most had done so only after the pregnancy. Encouraging partner communication and clinic attendance using an invitation card could facilitate increased male testing and participation in PMTCT.

A pilot study using interactive SMS support groups to prevent mother-to-child HIV transmission in South Africa

We investigated the feasibility of using mobile phone text messaging (SMS) to promote adherence to antiretroviral therapy among HIV-infected pregnant women recently diagnosed with HIV. Seven HIV-positive women (15–33 weeks gestation) from two urban antenatal clinics received mobile phones and were invited to use text messaging to discuss HIV, health and pregnancy over a 12-week period. All participants were connected to each other and to a clinician who guided the group and answered questions via group SMS messaging. A total of 1018 individual messages were sent regarding medical and psychosocial topics related to HIV and mother-to-child HIV transmission. Participants sent an average of 16 messages per enrolled, technology-problem-free week. Half the messages (51%) concerned medical information, and the remainder concerned social comments or addressed psychological matters. Four post-intervention interviews with participants revealed overall satisfaction and participants recommended that the group be offered in the future. The pilot projects anonymity, non-rigid nature and remote access allowed it to overcome stigma and logistical challenges where a conventional support intervention would probably have failed.

The effect of Pretoria Pasteurization on bacterial contamination of hand-expressed human breastmilk

One of the challenges facing the development of programs to reduce mother to child transmission of HIV in developing countries remains the problem of infant feeding. One of the alternative feeding methods under investigation for infants of HIV-infected mothers is heat treatment of expressed breastmilk by Pretoria Pasteurization. The objective of this study was to determine the effect of Pretoria Pasteurization on commensal and pathogenic bacteria in hand-expressed human breastmilk, and to determine the duration of time for which milk can be kept safely without refrigeration after Pretoria Pasteurization. Samples of milk were hand expressed by lactating women in the postnatal ward. The samples were split into control and pasteurized specimens. The pasteurized specimens underwent Pretoria Pasteurization. All samples were stored at room temperature and were sampled for bacterial culture every 4 h, up to 12 h. Clinically significant levels of bacterial contamination occurred in 59 per cent of control and 7.8 per cent of pasteurized samples. Four pasteurized samples showed significant contamination. There is strong evidence that the contaminating organisms in these samples were introduced by handling after pasteurization. The 53 (91 per cent) pasteurized samples that had no contamination at 4 h remained sterile for the remainder of the standing period of 12 h. Forty-one per cent of control samples already had significant growth after standing at room temperature for 4 h. In conclusion, Pretoria Pasteurization kills pathogenic and commensal bacteria in hand-expressed breastmilk. Expressed breastmilk that has undergone Pretoria Pasteurization can be kept without refrigeration for up to 12 h with minimal probability of bacterial contamination provided that it is kept in the pasteurization container and is not handled.

The coping strategies used over a two-year period by HIV-positive women who had been diagnosed during pregnancy.

Structured interviews were conducted with 224 HIV-positive women diagnosed during pregnancy, at antenatal clinics in Tshwane, South Africa, in order to investigate the use of coping strategies during the first two years after diagnosis. Interviews were conducted between one and four weeks after diagnosis during pregnancy, with three follow-up interviews conducted post-partum. Coping strategies were assessed with an adapted version of the Brief COPE. It was found that active coping was used more often than avoidant coping throughout the study period. Active coping increased over time, while avoidant coping decreased at first but increased again between 6 and 21 months after diagnosis. The most frequently used coping strategies included acceptance, direct action, positive reframing, religion and distraction. At first, women coped through internalised strategies. Over time, outward-focused strategies developed. Avoidant coping patterns differed from previous research indicating that women diagnosed during pregnancy deal with the consequences of HIV after the baby is born. Recommendations for mental health services are made.

Behavior and psychological functioning of young children of HIV-positive mothers in South Africa

Adults with HIV are living longer due to earlier diagnosis and increased access to antiretroviral medications. Therefore, fewer young children are being orphaned and instead, are being cared for by parents who know they are HIV positive, although they may be asymptomatic. Presently, it is unclear whether the psychological functioning of these young children is likely to be affected or, alternatively, whether it is only when a mother is ill, that children suffer adverse effects. We, thus, aimed to compare the behavior and psychological functioning of young children (aged 6–10 years) of HIV-positive and HIV-negative mothers. We also aimed to examine the association between HIV status disclosure and child outcomes. This study uses cross-sectional data from the baseline assessment of a randomized controlled trial conducted in Tshwane, South Africa. Participants (n=509) and their children were recruited from area health clinics. Among the 395 mothers with HIV, 42% reported symptoms of HIV disease. Multivariate linear regression models suggested that after adjusting for socio-demographic characteristics, children of HIV-positive mothers had significantly greater externalizing behaviors than children of HIV-negative mothers. Importantly, children whose mothers were symptomatic had greater internalizing and externalizing behaviors compared with children of HIV-negative mothers, but this was not true for children of asymptomatic mothers. Additionally, among children of HIV-positive mothers, those who had been told their mothers were sick compared with children who had been told nothing had less internalizing and externalizing behaviors and improved daily living skills. This study, therefore, provides evidence that maternal HIV disease can affect the behaviors of young children in South Africa but, importantly, only when the mothers are symptomatic from their disease. Furthermore, results suggest that disclosure of maternal illness but not HIV status was associated with improved behavior and psychological functioning among young children.

Barriers to early prenatal care in South Africa

To understand the barriers delaying early prenatal care for women in South Africa.

Psychosocial and economic determinants of infant feeding intent by pregnant HIV infected women in Tshwane/Pretoria

Objectives . To determine the extent to which stigma, disclosure, coping and socio-economic factors would affect infant feeding choices made antenatally by pregnant HIV-positive women after the routine prevention of mother-to-child transmission counselling process. Patients and methods. The antenatal feeding choices and determinants of these choices of HIV-infected women were studied at four antenatal clinics in two Tshwane townships, between June 2003 and December 2005. Results . Seventy-four per cent of the 293 study participants intended to formula feed their babies, while 26% planned to breastfeed or mixed feed. The women who intended to breastfeed had lower active coping ability (adjusted odds ratio (AOR) 0.88, 95% confidence interval (CI) 0.82 - 0.94), were less likely to have disclosed their status to partners or husbands (AOR 0.54, 95% CI 0.30 - 0.99), were twice as likely to be married (AOR 2.06, 95% CI 1.03 - 4.12) and were twice as knowledgeable about HIV transmission through breastfeeding (AOR 2.11, 95% CI 1.14 - 3.90). Conclusion . Counselling on infant feeding choices among HIV-infected women should be sensitive to the numerous internal and external factors that influence the decision. The support that HIV-infected women need in making their infant feeding decisions will entail psychosocial, community-wide interventions, and frequent counselling sessions to assist them in coping with and disclosing their status.

Symphysis-fundal measurement as a predictor of low birthweight

OBJECTIVE To prospectively test the value of a symphysis-fundal measurement in labor of less than or equal to 29 cm as a predictor of birth mass below 2000 g. METHOD Women admitted to Kalafong Hospital in labor with a singleton pregnancy were included in the study. Symphysis-fundal measurement according to the method of Westin was performed on two separate occasions and recorded together with other pertinent details. A receiver-operator curve was constructed to test various cut-off measurements. RESULTS A total of 1216 women were included in the study. One hundred twenty-one fetuses had a birth mass less than 2000 g (10%). A measurement of less than or equal to 29 cm had a sensitivity of 69% and a specificity of 98% with a positive predictive value of 81% and a negative predictive value of 97%. On the receiver-operator curve a cutoff of 30 cm showed a better sensitivity with little loss of specificity. CONCLUSION A symphysis-fundal measurement of less than or equal to 29 cm is a good predictor of birth mass less than 2000 g and can be used as an indication for referral to centres with neonatal facilities.

Cerebral white matter lesions after pre-eclampsia

BACKGROUND Women who have had pre-eclampsia in their previous pregnancies demonstrate a greater prevalence of cerebral white matter lesions several years after the pregnancy than women who have been normotensive during their pregnancy. Both the pathophysiology and the timing of development of these lesions are uncertain. White matter lesions, in the general population, are associated with an increased risk of stroke, dementia and death. AIMS AND OBJECTIVES The objective of the study was to determine the prevalence of cerebral white matter lesions amongst women with severe pre-eclampsia at delivery, 6months and 1year postpartum and to establish the possible pathophysiology and risks factors. METHODS This was a longitudinal study performed at Steve Biko Academic Hospital, a tertiary referral hospital in Pretoria South Africa. Ninety-four women with severe pre-eclampsia were identified and recruited during the delivery admission. Magnetic resonance imaging (MRI) of the brain was performed post - delivery and at 6months and 1year postpartum. RESULTS Cerebral white matter lesions were demonstrated in 61.7% of women at delivery, 56.4% at 6months and 47.9% at 1year. Majority of the lesions were found in the frontal lobes of the brain. The presence of lesions at 1year post-delivery was associated with the number of drugs needed to control blood pressure during pregnancy (OR 5.1, 95% CI 2.3-11.3, p<0.001). The prevalence of WMLs at 1year was double in women with chronic hypertension at 1year compared to those women who were normotensive (65.1% vs 32.3%). CONCLUSION Women who require 2 or more drugs to control blood pressure during pregnancy have an increased risk of developing cerebral white matter lesions after delivery.