Natasha Parekh

Highly Active Antiretroviral Therapy and Adverse Birth Outcomes Among HIV-Infected Women in Botswana

BACKGROUND It is unknown whether adverse birth outcomes are associated with maternal highly active antiretroviral therapy (HAART) in pregnancy, particularly in resource-limited settings. METHODS We abstracted obstetrical records at 6 sites in Botswana for 24 months. Outcomes included stillbirths (SBs), preterm delivery (PTD), small for gestational age (SGA), and neonatal death (NND). Among human immunodeficiency virus (HIV)-infected women, comparisons were limited to HAART exposure status at conception, and those with similar opportunities for outcomes. Comparisons were adjusted for CD4(+) lymphocyte cell count. RESULTS Of 33,148 women, 32,113 (97%) were tested for HIV, of whom 9504 (30%) were HIV infected. Maternal HIV was significantly associated with SB, PTD, SGA, and NND. Compared with all other HIV-infected women, those continuing HAART from before pregnancy had higher odds of PTD (adjusted odds ratio [AOR], 1.2; 95% confidence interval [CI], 1.1, 1.4), SGA (AOR, 1.8; 95% CI, 1.6, 2.1) and SB (AOR, 1.5; 95% CI, 1.2, 1.8). Among women initiating antiretroviral therapy in pregnancy, HAART use (vs zidovudine) was associated with higher odds of PTD (AOR, 1.4; 95% CI, 1.2, 1.8), SGA (AOR, 1.5; 95% CI, 1.2, 1.9), and SB (AOR, 2.5; 95% CI, 1.6, 3.9). Low CD4(+) was independently associated with SB and SGA, and maternal hypertension during pregnancy with PTD, SGA, and SB. CONCLUSIONS HAART receipt during pregnancy was associated with increased PTD, SGA, and SB.

Risk factors for very preterm delivery and delivery of very-small-for-gestational-age infants among HIV-exposed and HIV-unexposed infants in Botswana.

To evaluate risk factors for very preterm delivery (VPTD) and very‐small‐for‐gestational‐age (VSGA) births in a country with a high HIV prevalence.

Knowledge of HPV among United States Hispanic women: opportunities and challenges for cancer prevention.

In the United States, Hispanic women contribute disproportionately to cervical cancer incidence and mortality. This disparity, which primarily reflects lack of access to, and underutilization of, routine Pap smear screening may improve with increased availability of vaccines to prevent Human Papillomavirus (HPV) infection, the principal cause of cervical cancer. However, limited research has explored known determinants of HPV vaccine acceptability among Hispanic women. The current study examines two such determinants, HPV awareness and knowledge, using data from the 2007 Health Interview National Trends Survey (HINTS) and a cross-section of callers to the National Cancer Institutes (NCI) Cancer Information Service (CIS). Study data indicate that HPV awareness was high in both samples (69.5% and 63.8% had heard of the virus) but that knowledge of the virus and its association with cervical cancer varied between the two groups of women. The CIS sample, which was more impoverished and less acculturated than their HINTS counterparts, were less able to correctly identify that HPV causes cervical cancer (67.1% vs. 78.7%) and that it is a prevalent sexually transmitted infection (STI; 66.8% vs. 70.4%). Such findings imply that future research may benefit from disaggregating data collected with Hispanics to reflect important heterogeneity in this population subgroups ancestries, levels of income, educational attainment, and acculturation. Failing to do so may preclude opportunity to understand, as well as to attenuate, cancer disparity.

High Prevalence of Hypertension and Placental Insufficiency, but No In Utero HIV Transmission, among Women on HAART with Stillbirths in Botswana

Background Increased stillbirth rates occur among HIV-infected women, but no studies have evaluated the pathological basis for this increase, or whether highly active antiretroviral therapy (HAART) influences the etiology of stillbirths. It is also unknown whether HIV infection of the fetus is associated with stillbirth. Methods HIV-infected women and a comparator group of HIV-uninfected women who delivered stillbirths were enrolled at the largest referral hospital in Botswana between January and November 2010. Obstetrical records, including antiretroviral use in pregnancy, were extracted at enrollment. Verbal autopsies; maternal HIV, CD4 and HIV RNA testing; stillbirth HIV PCR testing; and placental pathology (blinded to HIV and treatment status) were performed. Results Ninety-nine stillbirths were evaluated, including 62 from HIV-infected women (34% on HAART from conception, 8% on HAART started in pregnancy, 23% on zidovudine started in pregnancy, and 35% on no antiretrovirals) and 37 from a comparator group of HIV-uninfected women. Only 2 (3.7%) of 53 tested stillbirths from HIV-infected women were HIV PCR positive, and both were born to women not receiving HAART. Placental insufficiency associated with hypertension accounted for most stillbirths. Placental findings consistent with chronic hypertension were common among HIV-infected women who received HAART and among HIV-uninfected women (65% vs. 54%, p = 0.37), but less common among HIV-infected women not receiving HAART (28%, p = 0.003 vs. women on HAART). Conclusions In utero HIV infection was rarely associated with stillbirths, and did not occur among women receiving HAART. Hypertension and placental insufficiency were associated with most stillbirths in this tertiary care setting.

Specialization training in Malawi: a qualitative study on the perspectives of medical students graduating from the University of Malawi College of Medicine.

BackgroundThere is a critical shortage of healthcare workers in sub-Saharan Africa, and Malawi has one of the lowest physician densities in the region. One of the reasons for this shortage is inadequate retention of medical school graduates, partly due to the desire for specialization training. The University of Malawi College of Medicine has developed specialty training programs, but medical school graduates continue to report a desire to leave the country for specialization training. To understand this desire, we studied medical students’ perspectives on specialization training in Malawi.MethodsWe conducted semi-structured interviews of medical students in the final year of their degree program. We developed an interview guide through an iterative process, and recorded and transcribed all interviews for analysis. Two independent coders coded the manuscripts and assessed inter-coder reliability, and the authors used an “editing approach” to qualitative analysis to identify and categorize themes relating to the research aim. The University of Pittsburgh Institutional Review Board and the University of Malawi College of Medicine Research and Ethics Committee approved this study and authors obtained written informed consent from all participants.ResultsWe interviewed 21 medical students. All students reported a desire for specialization training, with 12 (57%) students interested in specialties not currently offered in Malawi. Students discussed reasons for pursuing specialization training, impressions of specialization training in Malawi, reasons for staying or leaving Malawi to pursue specialization training and recommendations to improve training.ConclusionsGraduating medical students in Malawi have mixed views of specialization training in their own country and still desire to leave Malawi to pursue further training. Training institutions in sub-Saharan Africa need to understand the needs of the country’s healthcare workforce and the needs of their graduating medical students to be able to match opportunities and retain graduating students.

Birth weight for gestational age norms for a large cohort of infants born to HIV-negative women in Botswana compared with norms for U.S.-born black infants

BackgroundStandard values for birth weight by gestational age are not available for sub-Saharan Africa, but are needed to evaluate incidence and risk factors for intrauterine growth retardation in settings where HIV, antiretrovirals, and other in utero exposures may impact birth outcomes.MethodsBirth weight data were collected from six hospitals in Botswana. Infants born to HIV-negative women between 26-44 weeks gestation were analyzed to construct birth weight for gestational age charts. These data were compared with published norms for black infants in the United States.ResultsDuring a 29 month period from 2007-2010, birth records were reviewed in real-time from 6 hospitals and clinics in Botswana. Of these, 11,753 live infants born to HIV-negative women were included in the analysis. The median gestational age at birth was 39 weeks (1st quartile 38, 3rd quartile 40 weeks), and the median birth weight was 3100 grams (1st quartile 2800, 3rd quartile 3400 grams). We constructed estimated percentile curves for birth weight by gestational age which demonstrate increasing slope during the third trimester and leveling off beyond 40 weeks. Compared with black infants in the United States, Botswana-born infants had lower median birth weight for gestational age from weeks 37 through 42 (p < .02).ConclusionsWe present birth weight for gestational age norms for Botswana, which are lower at term than norms for black infants in the United States. These findings suggest the importance of regional birth weight norms to identify and define risk factors for higher risk births. These data serve as a reference for Botswana, may apply to southern Africa, and may help to identify infants at risk for perinatal complications and inform comparisons among infants exposed to HIV and antiretrovirals in utero.

Cultural implications of mentoring in sub-Saharan Africa: a qualitative study.

Although many studies have demonstrated the benefits of mentoring in academic medicine, conceptual understanding has been limited to studies performed in North America and Europe. An ecological model of mentoring in academic medicine can provide structure for a broader understanding of the role of culture in mentoring.

Rethinking How to Measure the Appropriateness of Cervical Cancer Screening

Background: Health care systems use performance measures based on guidelines from such organizations as the American College of Obstetricians and Gynecologists to monitor the appropriateness of cervical cancer screening. According to the performance measure currently in the Healthcare Effectiveness Data and Information Set, satisfactory cervical cancer screening involves at least 1 Papanicolaou (Pap) test every 3 years for average-risk women aged 21 to 64 years or at least 1 Pap and human papillomavirus test every 5 years for average-risk women aged 30 to 64 years (1). These performance measures have notable flaws. They do not allow for brief and clinically nonsignificant delays in screening. For example, a 29-year-old woman 3 years and 1 day after her last screening is considered nonadherent. These measures also fail to recognize overscreening. For example, an average-risk woman screened 3 times in 3 years is considered adherent despite evidence showing no benefit and potential harms of overscreening due to unnecessary follow-up procedures and other treatments (2). Objective: To show how changes in the performance measures for cervical cancer screening can address these 2 flaws. Methods and Findings: We determined how frequently screening practices were adherent to traditional performance measures and to alternative measures that incorporated 2 changes. We accepted existing categories of underscreening and appropriate screening and added a new category for overscreening that applied when intervals between screenings were shorter than guideline-recommended ones. We also replaced the single interval for adherence with ranges (3 months and6 months). To calculate actual frequencies, we used Pennsylvania Medicaid administrative data for women aged 18 to 64 years between 2007 and 2013. We used 2009 American College of Obstetricians and Gynecologists guidelines, because our data did not provide enough follow-up information to use more recent guidelines. The 2009 guidelines recommended beginning Pap testing at age 21 years and screening at 2-year intervals for women younger than 30 years and at 3-year intervals for women aged 30 years or older (3). To ensure adequate follow-up information, we required continuous enrollment of at least 3 years among women younger than 30 years and at least 4 years among women aged 30 years or older and included only women who had an initial Pap test during the 6 months after November 2009, the month that the guidelines were released. We excluded women who did not have at least 1 office visit; were dually enrolled in Medicare; and had preexisting conditions requiring different screening frequencies, such as cervical cancer, abnormal findings on cervical cytologic evaluation, total hysterectomy, HIV, and immunosuppression. We classified 27076 screening intervals among 14786 women using traditional and alternative measures. According to traditional measures, 29% of intervals among women younger than 30 years and 35% of intervals among women aged 30 years or older represented underscreening (Table). Most intervals that were appropriate under traditional measures were classified as overscreening under alternative ones. After we incorporated ranges of3 months and6 months, underscreening declined slightly; however, most intervals still represented overscreening. Table. Percentage of Intervals, by Category of Adherence and Type of Performance Measure* Discussion: We observed an up to 11% increase in appropriate cervical cancer screening when including 6-month ranges instead of a single interval in the definition of performance measures. We believe that incorporating this flexibility is reasonable and unlikely to negatively affect health. Most important, we found that most Pap screening classified as appropriate actually represented overscreening, even when adding ranges to the adherence intervals. Current performance measures that classify overscreening as appropriate may incentivize providers to overscreen, to the detriment of patients and the health care system. We believe that changing cervical cancer screening performance measures to align better with clinical guidelines will help reduce the frequency of unnecessary procedures (4, 5) and more accurately measure the quality of womens health care.

Impact of community pharmacist-provided preventive services on clinical, utilization, and economic outcomes: An umbrella review

Preventable diseases and late diagnosis of disease impose great clinical and economic burden for health care systems, especially in the current juncture of rising medical expenditures. Under these circumstances, community pharmacies have been identified as accessible venues to receive preventive services. This umbrella review aims to examine existing evidence on the impact of community pharmacist-provided preventive services on clinical, utilization, and economic outcomes in the United States (US). We included systematic reviews, narrative reviews and meta-analyses published in English between January 2007 and October 2017. Of 2742 references identified by our search strategy, a total of 13 research syntheses met our inclusion criteria. Included reviews showed that community pharmacists are effective at increasing immunization rates, supporting smoking cessation, managing hormonal contraception therapies, and identifying patients at high risk for certain diseases. Moreover, evidence suggests that community pharmacies are especially well-positioned for the provision of preventive services due to their convenient location and extended hours of operation. There is general agreement on the positive impact of community pharmacists in increasing access to preventive health, particularly among patients who otherwise would not be reached by other healthcare providers. The provision of preventive services at US community pharmacies is feasible and effective, and has potential for improving patient outcomes and health system efficiency. However, high-quality evidence is still lacking. As the healthcare landscape shifts towards a value-based framework, it will be important to conduct robust studies that further evaluate the impact of community pharmacist-provided preventive services on utilization and economic outcomes.

Prenatal and Postpartum Care Disparities in a Large Medicaid Program

Objectives Pennsylvania’s maternal mortality, infant mortality, and preterm birth rates rank 24th, 35th, and 25th in the country, and are higher among racial and ethnic minorities. Provision of prenatal and postpartum care represents one way to improve these outcomes. We assessed the extent of disparities in the provision and timeliness of prenatal and postpartum care for women enrolled in Pennsylvania Medicaid. Methods We performed a cross-sectional evaluation of representative samples of women who delivered live births from November 2011 to 2015. Our outcomes were three binary effectiveness-of-care measures: prenatal care timeliness, frequency of prenatal care, and postpartum care timeliness. Pennsylvania’s Managed Care Organizations (MCOs) were required to submit these outcomes to the state after reviewing administrative and medical records through a standardized, validated sampling process. We assessed for differences in outcomes by race, ethnicity, region, year, and MCO using logistic regression. Results We analyzed data for 12,228 women who were 49% White, 31% Black/African American, 4% Asian, and 15% Hispanic/Latina. Compared to Black/African American women, white and Asian women had higher odds of prenatal and postpartum care. Hispanic/Latina women had higher frequency of prenatal care than non-Hispanic women. Pennsylvania’s Southeast had lower prenatal care and Northwest had lower postpartum care than other regions. Prenatal care significantly decreased in 2014 and increased in 2015. We observed differences between MCOs, and as MCO performance diminished, racial disparities within each plan widened. We explored hypotheses for observed disparities in secondary analyses. Conclusions for Practice Our data demonstrate that interventions should address disparities by race, region, and MCO in equity-promoting measures.