HIV-1 and HIV-2 prevalence, risk factors and birth outcomes among pregnant women in Bissau, Guinea-Bissau: a retrospective cross-sectional hospital study

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Study Justification:
– The study aimed to assess changes in HIV prevalence, risk factors, and provision of prevention of mother-to-child transmission (PMTCT) antiretroviral treatment (ART) among pregnant women in Bissau, Guinea-Bissau.
– The study aimed to investigate the association between HIV infection, birth outcomes, and maternal characteristics.
– The study aimed to identify challenges and gaps in the continuity of care and ART coverage for optimal PMTCT in Guinea-Bissau.
Study Highlights:
– HIV prevalence among pregnant women in Bissau was 3.3% for HIV-1, 0.8% for HIV-2, and 0.9% for HIV-1/2.
– There was a significant decline in HIV-1, HIV-2, and HIV-1/2 prevalence over time.
– HIV infection was associated with age and ethnicity.
– 85% of HIV-infected women received ART as part of PMTCT, but overall treatment coverage during labor and delivery declined significantly for both mothers and infants.
– 22% of infants did not receive treatment, and ineffective non-nucleoside reverse transcriptase inhibitors were given to 67% of HIV-2-infected mothers and 77% of their infants for PMTCT.
– Maternal HIV was associated with low birth weight but not stillbirth.
– Inadequate continuity of care and ART coverage presented challenges to optimal PMTCT in Guinea-Bissau.
Recommendations:
– Strengthen and improve the continuity of care for pregnant women with HIV, ensuring that they receive appropriate ART throughout pregnancy, labor, and delivery.
– Enhance the coverage and effectiveness of PMTCT interventions, including the provision of effective antiretroviral drugs to HIV-infected mothers and their infants.
– Address the challenges and gaps in the provision of PMTCT services, including stock outages and logistical issues related to ART availability.
– Implement strategies to increase HIV testing rates among pregnant women and improve access to testing services.
– Promote awareness and education on HIV prevention and PMTCT among pregnant women and healthcare providers.
– Strengthen the capacity of healthcare facilities and healthcare workers to provide comprehensive obstetric care and PMTCT services.
Key Role Players:
– Bandim Health Project (BHP): Conducted the study and collected the data.
– Simão Mendes National Hospital (HNSM): The study was conducted at the HNSM maternity ward.
– Guinean Ministry of Health: Provided free HIV testing and ART.
– Italian-Guinean NGO-clinic, Ceu e Terras: Referred newly diagnosed women and their infants for follow-up, counseling, and further PMTCT ART.
Cost Items for Planning Recommendations:
– ART medications: Budget for the procurement and supply of antiretroviral drugs for pregnant women and infants.
– Training and capacity building: Allocate funds for training healthcare workers on PMTCT guidelines and best practices.
– HIV testing supplies: Budget for the procurement of HIV testing kits and related supplies.
– Infrastructure and equipment: Allocate funds for improving healthcare facilities and ensuring the availability of necessary equipment for PMTCT services.
– Awareness and education campaigns: Set aside a budget for promoting awareness and education on HIV prevention and PMTCT among pregnant women and healthcare providers.
Please note that the cost items provided are general categories and not actual cost estimates. The actual budget would depend on the specific context and requirements of the implementation.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a large sample size (24,107 women) and covers a significant time period (June 2008 to May 2013). The study was conducted at a reputable hospital in Guinea-Bissau and the data was collected through a well-established health and demographic surveillance system. The study provides valuable information on HIV prevalence, risk factors, provision of PMTCT treatment, and birth outcomes. However, to improve the evidence, the abstract could include more details on the methodology, such as the sampling technique and data analysis methods. Additionally, it would be helpful to mention any limitations of the study, such as potential biases or confounding factors.

The human immunodeficiency virus (HIV) remains a leading cause of maternal morbidity and mortality in Sub-Saharan Africa. Prevention of mother-to-child transmission (PMTCT) has proven an effective strategy to end paediatric infections and ensure HIV-infected mothers access treatment. Based on cross-sectional data collected from June 2008 to May 2013, we assessed changes in HIV prevalence, risk factors for HIV, provision of PMTCT antiretroviral treatment (ART), and the association between HIV infection, birth outcomes and maternal characteristics at the Simão Mendes National Hospital, Guinea-Bissau’s largest maternity ward. Among 24,107 women, the HIV prevalence was 3.3% for HIV-1, 0.8% for HIV-2 and 0.9% for HIV-1/2. A significant decline in HIV-1, HIV-2, and HIV-1/2 prevalence was observed over time. HIV infection was associated with age and ethnicity. A total of 85% of HIV-infected women received ART as part of PMTCT, yet overall treatment coverage during labour and delivery declined significantly for both mothers and infants. Twenty-two percent of infants did not receive treatment, and 67% of HIV-2-infected mothers and 77% of their infants received ineffective non-nucleoside reverse transcriptase inhibitors for PMTCT. Maternal HIV was associated with low birth weight but not stillbirth. Inadequate continuity of care and ART coverage present challenges to optimal PMTCT in Guinea-Bissau.

The study was conducted by the Bandim Health Project (BHP) (https://www.bandim.org) at the Simão Mendes National Hospital (HNSM) maternity ward located in Bissau. The BHP, a health and demographic surveillance site present in Guinea-Bissau for 4 decades, routinely collects demographic and clinical data on all deliveries at HSNM. This public facility is the principal provider of comprehensive obstetric care in Guinea-Bissau, and approximately 90% of women who deliver at the facility are residents of the country’s capital, Bissau. From June 2008 onwards, opt-out HIV counselling and testing has been offered to women admitted to the maternity ward for the management of labour- and delivery- and/or pregnancy-related complications when HIV tests were available. HIV testing and ART were free of charge and provided by the Guinean Ministry of Health, but all women paid a flat fee of 2000 XOF (3–4 USD) to give birth at HNSM14. All newly diagnosed women and their infants were referred to the Italian-Guinean NGO-clinic, Ceu e Terras, or to other local HIV centres for follow-up, counselling, and further PMTCT ART13. Data registration of testing for HIV at delivery ceased in May 2013 due to funding constraints. While HIV testing at labour and delivery was national policy at the time of the study, not all women were tested. We have previously described the characteristics of women tested compared with those not tested 14. We conducted a retrospective cross-sectional survey exploring HIV prevalence, risk factors for HIV, treatment provision, and birth outcomes (low birth weight, LBW, and stillbirth), drawing on data routinely collected through the BHP surveillance system at HNSM from June 2008 until May 2013. All women presenting to HNSM for delivery or immediate postpartum care who had been tested for HIV were included in this study. Data were recorded in the HNSM maternity ward registration system and included basic socio-demographic and clinical data. Data cleaning was performed daily (including weekends) by trained research assistants from BHP who also collected supplementary demographic and clinical information using separate case report forms (CRFs). We have previously described the data collected in detail14,16. During the study period, it was national policy that hospital midwives offer immediate HIV counselling and testing to all women presenting to the maternity for delivery or, as many women had not attended ANC or did not receive PMTCT testing or counselling during pregnancy. Midwives had been trained to complete a short CRF as part of the counselling and testing routine to collect data on previous HIV testing, known sero-status, and ART use14. HIV screening was performed using the Determine® HIV-1/2 rapid test (Abbot Diagnostics, Maidenhead, United Kingdom). To confirm infection and to discriminate between HIV types, women with positive and inconclusive screening results were subsequently tested with another rapid test, SD Bioline HIV-1/2 3.0 (Standard Diagnostics, Kyonggi-do, South Korea). Provision of PMTCT at the initiation of this survey was guided by the 2006 World Health Organization (WHO) recommendations, i.e., ART prophylaxis in the third trimester (28 weeks) of pregnancy consisting of a regimen of twice daily Zidovudine (AZT), single-dose nevirapine (sd NVP) at onset of labour and Zidovudine plus Lamivudine (AZT + 3TC) for 1 week from birth. Women diagnosed in labour were given a single-dose nevirapine followed by AZT + 3TC for 1 week starting in labour. For women who needed treatment for their own health, triple ART (cART) was initiated as soon as possible. For HIV-2 and HIV-1/2 dually infected mothers, a combination of (AZT + 3TC) + Lopinavir/Ritonavir was recommended. For infants, guidelines recommended sd NVP plus AZT twice a day for either 4 weeks if the mother had received less than 4 weeks AZT prophylaxis prior to labour or for 1 week if the mother had received at least 4 weeks AZT prophylaxis. Infants of mothers receiving cART were recommended AZT twice daily17. After 2010, in line with the revised WHO recommendations, all pregnant women with CD4 count levels < 350 cells/mm3, irrespective of clinical stage, and women with a WHO clinical stage 3 or 4 infection, were started on triple ART. In addition, women not receiving ART for their own health, received (Option A) prophylaxis with AZT as monotherapy from as early as 14 weeks of pregnancy plus a single dose NVP + AZT + 3TC during labour and delivery followed by AZT + 3TC for 7 days after delivery, or triple ART prophylaxis (Option B) from as early as 14 weeks of pregnancy. The infant regime consisted of daily NVP from birth for a minimum of 4–6 weeks, and until 1 week after all exposure to breastmilk had ended. For infants receiving replacement feeding only daily NVP or sd NVP + daily AZT from birth and until 4–6 weeks of age was recommended18. Due to logistical issues, treatment was often started without CD4 cell count measurements based on clinical assessment. Throughout the study period, repeated stock outages and lack of ART at times forced clinicians to switch treatment and often to provide more simple regimes than recommended9, 19. In 2015, Guinea-Bissau began implementing option B+, i.e., lifelong ART from diagnosis20,21. Maternity and HIV testing data were entered in password-secured databases (dBase 5.0, dataBased Inc, Vestal, NY, USA; Microsoft Access 2007, Microsoft, Redmond, WA, USA), and datasets were merged using unique birth numbers. The data were analysed using Stata 14.0 (Stata Corporation, College Station, TX, USA). Outcome variables such as LBW and stillbirths were dichotomized (0 = absent, 1 = present). Continuous explanatory variables were grouped categorically. Factors associated with HIV serostatus and birth outcomes were determined using univariate and multivariate logistical regression models. The multivariate analysis was fitted with statistically significant covariates (as determined by Wald’s test). Birth outcomes i.e., stillbirths and low birthweight (LBW) were examined according to HIV status and adjusted for significant covariates. In accordance with the WHO criteria, stillbirth was defined as a newborn at or above 1,000 g showing no vital signs immediately after birth (Apgar score = 0)22. Low birth weight was defined as birth weight of < 2,500 g23. Miscarriages (birth weight < 1,000 g) were excluded. In the birth outcome analysis, “births” pertain to the number of fetuses at risk. Therefore, the number of total births is higher than the number of pregnant women due to multiple pregnancies. In the logistic regression models, adjustment for birth outcomes was made for clustering of twins using a specific pair number. Inconclusive test results were categorized as HIV-negative. Missing values were included in the logistic regression models. Trends over time (calendar year) for HIV prevalence and treatment were determined using Pearson’s χ2 test. Due to a lack of data to confirm self-reported antenatal treatment regimens and reasons for selecting a given treatment at labour, we opted to assess antenatal and treatment at labour separately. A p value of < 0.05 was considered significant. All patient data were fully anonymised before being accessed. The use of government surveillance maternity data was approved by the National Ethical Committee in Guinea-Bissau (CNES-2010-018). A separate ethical approval was obtained for the analysis of HIV data and linkage of delivery and HIV databases (CNES-2011-030). The study was carried out in accordance with Guinea-Bissau Medical Research Ethics Committee requirements and the Helsinki declaration. All participants were counselled and asked for verbal informed consent before data collection and HIV testing. Newly diagnosed women were offered ART at labour and subsequently referred for follow-up. The manuscript was prepared in accordance with the STROBE guidelines (Supplemental Checklist 1).

Based on the provided information, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide pregnant women with information on maternal health, including HIV prevention and treatment options. These apps can also send reminders for antenatal care appointments and provide access to telemedicine consultations.

2. Community Health Workers: Train and deploy community health workers to provide education and support to pregnant women in remote areas. These workers can conduct home visits, offer counseling on HIV prevention and treatment, and facilitate referrals to healthcare facilities.

3. Point-of-Care Testing: Implement point-of-care HIV testing in maternity wards to ensure timely diagnosis and initiation of treatment for HIV-positive pregnant women. This can help reduce the number of women who are lost to follow-up and improve access to antiretroviral therapy.

4. Integrated Maternal Health Services: Integrate HIV testing, prevention, and treatment services into routine antenatal care visits. This approach can streamline care and ensure that all pregnant women have access to comprehensive maternal health services, including HIV-related care.

5. Task Shifting: Train and empower nurses and midwives to provide HIV testing and counseling, as well as initiate and manage antiretroviral therapy for pregnant women. This can help alleviate the burden on doctors and increase access to HIV services in resource-limited settings.

6. Supply Chain Management: Strengthen supply chain management systems to ensure consistent availability of antiretroviral drugs and other essential maternal health commodities. This can help prevent stockouts and ensure that pregnant women receive the necessary medications and supplies.

7. Public-Private Partnerships: Foster collaborations between government health systems and private sector organizations to improve access to maternal health services. This can involve leveraging private sector expertise and resources to enhance service delivery and expand coverage.

8. Health Information Systems: Enhance health information systems to enable real-time monitoring of maternal health indicators, including HIV prevalence, treatment coverage, and birth outcomes. This data can inform decision-making and help identify areas for improvement in maternal health services.

9. Community Engagement: Engage communities in maternal health programs through awareness campaigns, community dialogues, and involvement of community leaders. This can help reduce stigma associated with HIV and promote uptake of maternal health services.

10. Policy and Advocacy: Advocate for policies that prioritize maternal health and ensure equitable access to care, including HIV prevention and treatment services. This can involve working with policymakers to allocate resources and implement evidence-based interventions.

It is important to note that the implementation of these innovations should be context-specific and tailored to the local healthcare system and needs of the population.
AI Innovations Description
Based on the description provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthening Continuity of Care: To address the challenges of inadequate continuity of care and ART coverage, it is recommended to develop an innovative system that ensures seamless coordination and follow-up of HIV-infected pregnant women throughout the entire maternal health journey. This can be achieved through the use of digital health technologies, such as mobile applications or electronic health records, that enable healthcare providers to track and monitor the progress of pregnant women, ensure timely provision of ART, and facilitate referrals to specialized HIV clinics for follow-up and counseling.

2. Enhancing PMTCT Treatment Coverage: To improve treatment coverage during labor and delivery, innovative strategies should be implemented to ensure that both mothers and infants receive the necessary PMTCT antiretroviral treatment. This can include the establishment of dedicated PMTCT clinics within maternity wards, where trained healthcare providers can administer ART and closely monitor the adherence and effectiveness of the treatment. Additionally, the use of point-of-care testing devices can enable rapid HIV testing and immediate initiation of treatment, reducing delays in accessing care.

3. Addressing Stock Outages and Logistical Issues: To overcome the challenges of stock outages and logistical issues that often result in the provision of suboptimal treatment regimens, innovative supply chain management systems should be implemented. This can involve the use of real-time inventory tracking systems, automated reordering processes, and improved coordination between healthcare facilities and suppliers to ensure a consistent and uninterrupted supply of essential PMTCT medications.

4. Community Engagement and Education: To increase awareness and uptake of PMTCT services, innovative community engagement and education programs should be developed. This can include the use of mobile health campaigns, community health workers, and peer support groups to disseminate information about the importance of HIV testing, PMTCT treatment, and the benefits of early antenatal care. Additionally, innovative approaches, such as interactive mobile applications or SMS-based reminders, can be utilized to provide ongoing education and support to pregnant women throughout their pregnancy journey.

By implementing these recommendations, it is possible to develop innovative solutions that improve access to maternal health, enhance the effectiveness of PMTCT programs, and ultimately reduce maternal morbidity and mortality related to HIV infection.
AI Innovations Methodology
To improve access to maternal health, here are some potential recommendations:

1. Strengthening Antenatal Care (ANC) Services: Enhance ANC services by providing comprehensive and regular check-ups for pregnant women, including HIV testing, counseling, and education on prevention of mother-to-child transmission (PMTCT) of HIV.

2. Increasing Availability of PMTCT Antiretroviral Treatment (ART): Ensure that all HIV-positive pregnant women have access to PMTCT ART, following the latest WHO guidelines. This includes providing appropriate antiretroviral drugs during pregnancy, labor, delivery, and breastfeeding.

3. Improving Continuity of Care: Establish systems to ensure that HIV-positive pregnant women receive continuous care throughout the pregnancy, delivery, and postpartum period. This can be achieved through effective referral systems and coordination between healthcare facilities.

4. Enhancing Health Education and Awareness: Conduct community-based health education programs to raise awareness about maternal health, HIV prevention, and PMTCT. This can help reduce stigma, increase knowledge, and encourage early testing and treatment.

5. Strengthening Health Infrastructure: Invest in improving healthcare infrastructure, including maternity wards, laboratories, and supply chains for essential medicines and equipment. This will ensure that pregnant women have access to quality maternal health services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Data Collection: Gather baseline data on maternal health indicators, such as HIV prevalence, ANC coverage, PMTCT ART coverage, and birth outcomes. This can be done through retrospective cross-sectional studies, surveys, or analysis of existing data sources.

2. Modeling the Impact: Use mathematical modeling techniques to simulate the impact of the recommendations on improving access to maternal health. This can involve creating a simulation model that incorporates various factors, such as population demographics, healthcare utilization rates, and the effectiveness of interventions.

3. Sensitivity Analysis: Conduct sensitivity analysis to assess the robustness of the model and explore the potential impact of different scenarios or variations in key parameters. This can help identify the most influential factors and uncertainties in the model.

4. Projection and Evaluation: Project the potential impact of the recommendations over a specific time period and evaluate the outcomes. This can include estimating changes in HIV prevalence, ANC coverage, PMTCT ART coverage, and birth outcomes, such as reductions in mother-to-child transmission of HIV and improvements in maternal and infant health.

5. Policy Recommendations: Based on the simulation results, provide evidence-based policy recommendations to stakeholders, such as government agencies, healthcare providers, and international organizations. These recommendations can guide decision-making and resource allocation to improve access to maternal health.

It is important to note that the methodology may vary depending on the available data, resources, and specific context. Collaboration with experts in epidemiology, public health, and data analysis can help ensure the accuracy and validity of the simulation model.

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