Lisa Rahangdale

Stigma as experienced by women accessing prevention of parent-to-child transmission of HIV services in Karnataka, India

Abstract In Karnataka, India only one-third of HIV-infected pregnant women received antiretroviral prophylaxis at delivery in 2007 through the state governments prevention of parent-to-child HIV transmission (PPTCT) program. The current qualitative study explored the role of HIV-associated stigma as a barrier to access 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 toward HIV-infected 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.

Reproductive Health and Family Planning Needs Among HIV-Infected Women in Sub-Saharan Africa

OBJECTIVE Review key topics and recent literature regarding reproductive health and family planning needs for HIV-infected women in Sub-Saharan Africa. METHODS Electronic searches performed in PubMed, JSTOR, and Web of Science; identified articles reviewed for inclusion. FINDINGS Most HIV-infected women in Sub-Saharan Africa bear children, and access to antiretroviral therapy may increase childbearing desires and/or fertility, resulting in greater need for contraception. Most contraceptive options can be safely and effectively used by HIV-infected women. Unmet need for contraception is high in this population, with 66- 92% of women reporting not wanting another child (now or ever), but only 20-43% using contraception. During pregnancy and delivery, HIV-infected women need access to prevention of mother-to-child transmission (PMTCT) services, a skilled birth attendant, and quality post-partum care to prevent HIV infection in the infant and maximize maternal health. Providers may lack resources as well as appropriate training and support to provide such services to women with HIV. Innovations in biomedical and behavioral interventions may improve reproductive healthcare for HIV-infected women, but in Sub-Saharan Africa, models of integrating HIV and PMTCT services with family planning and reproductive health services will be important to improve reproductive outcomes. CONCLUSIONS HIV-infected women in Sub-Saharan Africa have myriad needs related to reproductive health, including access to high-quality family planning information and options, high-quality pregnancy care, and trained providers. Integrated services that help prevent unintended pregnancy and optimize maternal and infant health before, during and after pregnancy will both maximize limited resources as well as provide improved reproductive outcomes.

Pregnancy intentions among women living with HIV in the United States.

Background:The number of HIV-infected women giving birth in the United States 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 before conception at 12 US 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% 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 (aRR) = 0.67, 95% confidence interval (CI): 0.47 to 0.94, P = 0.02], had seen a medical provider in the year before the index pregnancy (aRR = 0.60, 95% CI: 0.46 to 0.77, P < 0.01), or had a patient-initiated discussion of pregnancy intentions in the year before the index pregnancy (aRR = 0.63, 95% CI: 0.46 to 0.77, P < 0.01). Unplanned or ambivalent pregnancy was not associated with age, race/ethnicity, or educational level. Conclusions:In this multisite US cohort, patient-initiated pregnancy counseling and being engaged in medical care before pregnancy were associated with a decreased probability of unplanned or ambivalent pregnancy. Interventions that promote healthcare 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 United States.

Frequency of cervical cancer and breast cancer screening in HIV-infected women in a county-based HIV clinic in the Western United States.

BACKGROUND Womens primary-care services are frequently dispensed to HIV-infected women through HIV specialty clinics. Our objective was to evaluate cervical cancer and breast cancer screening practices in a county-based HIV clinic in San Mateo, California. METHODS This was a retrospective cohort study of medical records of HIV-infected women obtaining HIV care at this site. RESULTS Between January 1, 2002 and December 31, 2006, 69 women were documented to have at least 12 months of medical care at the clinic. Median followup time was 51 months. Over 253 person-years of followup, there were 656 pap smears performed per 1,000 person-years; 77.9% of women had at least one Pap smear during the study time period. A total of 59.5% (47/79) of normal pap smears had a followup pap smear within 18 months; 62.0% of abnormal pap smears had a followup pap smear within 12 months. A CD4 count of less than 200 cells/mm(3) was associated with not receiving a pap smear in multivariable analysis. Mammogram screening was performed on 64.7% of women aged 40 or older. CONCLUSIONS Based on the results of this study, the majority of HIV-infected women at this clinic received cervical and breast cancer screening at some point during their care. Only two-thirds of abnormal pap smear results had followup pap smear screening within a year. With the increased risk of cervical cancer in HIV-infected women, efforts should be made to promote cervical cancer screening, particularly in high-risk women.

Cervical Precancer Risk in HIV-Infected Women Who Test Positive for Oncogenic Human Papillomavirus Despite a Normal Pap Test

BACKGROUND Determining cervical precancer risk among human immunodeficiency virus (HIV)-infected women who despite a normal Pap test are positive for oncogenic human papillomavirus (oncHPV) types is important for setting screening practices. METHODS A total of 2791 HIV-infected and 975 HIV-uninfected women in the Womens Interagency HIV Study were followed semiannually with Pap tests and colposcopy. Cumulative risks of cervical intraepithelial neoplasia grade 2 or greater (CIN-2+; threshold used for CIN treatment) and grade 3 or greater (CIN-3+; threshold to set screening practices) were measured in HIV-infected and HIV-uninfected women with normal Pap tests, stratified by baseline HPV results, and also in HIV-infected women with a low-grade squamous intraepithelial lesion (LSIL; benchmark indication for colposcopy). RESULTS At baseline, 1021 HIV-infected and 518 HIV-uninfected women had normal Pap tests, of whom 154 (15%) and 27 (5%), respectively, tested oncHPV positive. The 5-year CIN-2+ cumulative risk in the HIV-infected oncHPV-positive women was 22% (95% confidence interval [CI], 9%-34%), 12% (95% CI, 0%-22%), and 14% (95% CI, 2%-25%) among those with CD4 counts <350, 350-499, and ≥500 cells/µL, respectively, whereas it was 10% (95% CI, 0%-21%) in those without HIV. For CIN-3+, the cumulative risk averaged 4% (95% CI, 1%-8%) in HIV-infected oncHPV-positive women, and 10% (95% CI, 0%-23%) among those positive for HPV type 16. In HIV-infected women with LSIL, CIN-3+ risk was 7% (95% CI, 3%-11%). In multivariate analysis, HIV-infected HPV16-positive women had 13-fold (P = .001) greater CIN-3+ risk than oncHPV-negative women (referent), and HIV-infected women with LSIL had 9-fold (P < .0001) greater risk. CONCLUSIONS HIV-infected women with a normal Pap result who test HPV16 positive have high precancer risk (similar to those with LSIL), possibly warranting immediate colposcopy. Repeat screening in 1 year may be appropriate if non-16 oncHPV is detected.

Patient Acceptance of and Satisfaction with Rapid HIV Testing in a Labor and Delivery Setting

OBJECTIVE To evaluate womens acceptance of and satisfaction with rapid human immunodeficiency virus (HIV) testing in a labor and delivery (L&D) setting. METHODS We conducted a cross-sectional survey of pregnant women who underwent counseling for rapid HIV testing in an L&D unit at a university-affiliated urban hospital from April 1, 2005, to July 15, 2006. Medical chart abstractions were performed for all 158 eligible women, and a convenience sample of 46 women also completed a survey evaluating their satisfaction using a validated decisional conflict scale. RESULTS Uptake of rapid HIV testing was 98.1% (155 of 158). Overall, 89.1% of the 46 surveyed women reported feeling satisfied with their testing experience, and 82.6% of women reported no decisional conflict in making decisions for rapid testing; 9% of women reported decisional conflict. The median decisional conflict score on a scale of 0-100 was 5 (mean 11.6, SD 16). In addition, most women reported feeling certain about their decision to test (87.0%), feeling informed about testing (76.1%), having high levels of clarity about their values regarding testing (76.1%), and feeling supported in their decision-making process (76.1%). CONCLUSIONS In this study population, there was a high level of acceptance and satisfaction with rapid HIV testing in the L&D setting. Rapid HIV testing is a vital component of perinatal HIV transmission prevention, as well as being an opportunity for women, some of whom have little contact with the healthcare system, to learn their HIV status.

Topical 5-fluorouracil for treatment of cervical intraepithelial neoplasia 2: a randomized controlled trial.

OBJECTIVE The objective of the study was to evaluate the efficacy of intravaginal application of 5% 5-fluorouracil (5-FU) for the treatment of cervical intraepithelial neoplasia (CIN) 2 in women. STUDY DESIGN Women aged 18-29 years with CIN 2 were recruited for this randomized controlled trial of observation vs treatment with intravaginal 5-FU. Women in the observation group returned in 6 months for a Papanicolaou smear, colposcopy, and a human papillomavirus (HPV) deoxyribonucleic acid test. Women in the 5-FU group were treated with intravaginal 5-FU once every 2 weeks for a total of 16 weeks and were similarly evaluated at 6 months. All women who had a baseline visit were included in the intention-to-treat analysis. Values of P < .05 were considered statistically significant. RESULTS Between August 2010 and June 2013, 60 women were randomized and had a baseline visit for intervention (n = 31) vs observation (n = 29). Of women who had cervical biopsy results at 6 months, regression of disease was demonstrated in 93% of women in the 5-FU group (26 of 28) and 56% of women in the observation group (15 of 27). Under the intention-to-treat analysis, a relative risk for cervical disease regression of 1.62 (95% confidence interval [CI], 1.10-2.56) was found between the 5-FU and observation arms (P = .01). When the cervical biopsy, Papanicolaou smear, and HPV results were combined for the 6 month follow-up visit, 50% of the 5-FU group (14 of 28) had a documented normal biopsy, normal Papanicolaou smear, and negative HPV test compared with 22% in the observation group (6 of 27) (relative risk, 2.25; 95% confidence interval, 1.05-5.09; P < .05). There were no moderate or severe side effects in the intervention group. CONCLUSION Topical 5-FU appears to be an effective medical therapy for CIN 2 in young women. 5-FU is readily available and may be considered as an off-label treatment option for young women with CIN 2 who are interested in the treatment of disease but want to avoid excisional procedures.

Rapid human immunodeficiency virus testing on labor and delivery.

CASE: A 20-year-old primigravida presented at 37 weeks of gestation to labor and delivery after spontaneous rupture of membranes. She denied any complications, medical problems, or substance use during prenatal care. She did not have a human immunodeficiency virus (HIV) test during pregnancy. On examination, her cervix was dilated to 6 cm. The physician offered a rapid HIV test during labor, which the patient accepted. An hour later, her rapid HIV test result returned as “preliminary positive.” The physician relayed the rapid HIV test result in a confidential manner and, although confirmatory testing was pending, strongly recommended that both she and the infant be given antiretroviral prophylaxis to decrease the risk of HIV transmission. The patient delivered a 2,690-g male infant with Apgar scores of 9 and 9 before the ordered intravenous zidovudine and oral nevirapine and lamivudine arrived from the pharmacy. The infant began HIV antiretroviral prophylaxis within 2 hours of birth. On the day of delivery, the patient’s CD4 count was 490 cells/mm3. She remained hospitalized until postpartum day 3, when her confirmatory HIV tests (Western blot assay and immunofluorescent antibody test) returned as positive. Her HIV viral load at the time of delivery was 32,000 copies/mL. When results were disclosed to the patient, she requested that her results be kept confidential from her partner, who was also the father of the newborn. She was discharged, with follow-up scheduled with an HIV provider. Her infant continued on zidovudine prophylaxis for 6 weeks after birth. His subsequent HIV DNA polymerase chain reaction tests at birth and at 2 weeks were negative.

Trends of and factors associated with live-birth and abortion rates among HIV-positive and HIV-negative women

BACKGROUND: Little is known about fertility choices and pregnancy outcome rates among HIV‐infected women in the current combination antiretroviral treatment era. OBJECTIVE: We sought to describe trends and factors associated with live‐birth and abortion rates among HIV‐positive and high‐risk HIV‐negative women enrolled in the Womens Interagency HIV Study in the United States. STUDY DESIGN: We analyzed longitudinal data collected from Oct. 1, 1994, through Sept. 30, 2012, through the Womens Interagency HIV Study. Age‐adjusted rates per 100 person‐years live births and induced abortions were calculated by HIV serostatus over 4 time periods. Poisson mixed effects models containing variables associated with live births and abortions in bivariable analyses (P < .05) generated adjusted incidence rate ratios and 95% confidence intervals. RESULTS: There were 1356 pregnancies among 2414 women. Among HIV‐positive women, age‐adjusted rates of live birth increased from 1994 through 1997 to 2006 through 2012 (2.85‐7.27/100 person‐years, P trend < .0001). Age‐adjusted rates of abortion in HIV‐positive women remained stable over these time periods (4.03‐4.29/100 person‐years, P trend = .09). Significantly lower live‐birth rates occurred among HIV‐positive compared to HIV‐negative women in 1994 through 1997 and 1997 through 2001, however rates were similar during 2002 through 2005 and 2006 through 2012. Higher CD4+ T cells/mm3 (≥350 adjusted incidence rate ratio, 1.39 [95% CI 1.03‐1.89] vs <350) were significantly associated with increased live‐birth rates, while combination antiretroviral treatment use (adjusted incidence rate ratio, 1.35 [95% CI 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, combination antiretroviral treatment use, and viral load were not associated with abortion rates. CONCLUSION: 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 combination antiretroviral treatment. Abortion rates remain unchanged, illuminating a need to improve contraceptive services.

Provider attitudes toward discussing fertility intentions with HIV-infected women and serodiscordant couples in the USA

Background Recent research suggests that pregnancy is a potentially safe option for couples with at least one HIV-infected adult. Data regarding provider discussion of fertility intentions with women living with HIV (WLWH) or in serodiscordant relationships is limited. Methods We conducted a cross-sectional self-administered survey of health professionals who provide HIV services to women in order to assess knowledge and behaviors regarding family planning options for HIV-infected women and serodiscordant couples. Results Of 77 respondents, 47(61%) met the inclusion criteria (health care provider who cares for WLWH). Approximately half (57%) of the participants indicated that they always or usually discuss contraception or fertility intentions with their HIV+ female patients of reproductive age. When asked to indicate their awareness of techniques to decrease HIV transmission risk among serodiscordant couples attempting pregnancy, most participants reported awareness of multiple options. Discussion of contraception or fertility intentions was not associated with provider gender, age, and experience in caring for HIV-infected patients, previous training in women’s health or provider’s awareness of options to decrease transmission risk. Conclusions HIV providers in this study were knowledgeable of practices that can lead to safer conception and prevent HIV transmission among individuals in serodiscordant relationships but did not always discuss this information with their patients. Further research is needed to explore optimal methods for encouraging such conversations.