An investigation of maternal anaemia among hiv infected pregnant women on antiretroviral treatment in johannesburg, south africa

Pan African Medical Journal, Volume 37, No. 93, Year 2020

Interpretation

Introduction: maternal anaemia is a major public health problem in developing countries. Data suggests that anaemia contributes to the progression of Human Immunodeficiency Virus (HIV)-infection. The aim of this study was to investigate if pregnancy was an aggravating factor for anaemia among HIV-positive women on anti-retroviral treatment (ART). Methods: we analyzed data of all HIV-positive women aged 18-49 years receiving ART at Themba Lethu Clinic, Helen Joseph Hospital, Johannesburg, South Africa, from 1st April 2004-30t hApril 2011. HIV-positive pregnant women were matched with non-pregnant women using the year of initiation of treatment. The outcome of interest ´anaemia´ was defined as “no anaemia”, “anaemia” and “moderate/severe anaemia”. We fitted an ordered logistic regression model to predict the likelihood of having severe/moderate anaemia versus no anaemia. We included pregnancy status as a predictor of the outcome and controlled the effect of other covariates in the analysis. Results: the study included 236 HIV positive patients, of which half (n=118, 50%) were pregnant. At baseline, about (n=143, 60%) of patients were anaemic. The proportion of pregnant women classified as anaemic (anaemia, moderate/severe) differed significantly (p=0.02) from that of non-pregnant women. The following characteristics were significantly associated with anaemia at baseline: Body mass index (BMI) category (p=0.01); World Health Organization (WHO) stage (p=0.001) and CD4 count (p=0.001). Seven months after initiation of treatment, the proportion of HIV positive women with anaemia decreased significantly. Conclusion: anaemia is a significant risk factor for untoward health outcomes, especially among HIV-positive pregnant women. Early ART access might result in a significant decrease in anaemia in pregnancy. Study design: we analyzed secondary data of all HIV-positive women receiving ART at Themba Lethu Clinic, Helen Joseph Hospital in Johannesburg, South Africa. We included data of patients enrolled between 1stApril 2004 (baseline) to 30th April 2011 (end-line) and tracked anaemia among those patients seven months later. The Themba Lethu Clinic is the largest public sector ART site in the country [26]. Study population: our study included retrospective records for 236 HIV positive women aged 18-49 years on ART. Of these 118 were pregnant and 118 were non-pregnant HIV positive women. Patients included had the following parameters “baseline CD4 count, haemoglobin measurements and at least 7 months of follow-up time”. Both pregnant and non-pregnant study participants were offered similar first line ART regimens comprised of fixed dose combinations of stavudine (D4T), tenofovir (TDF), efavirenz (EFV), zidovudine (AZT), lamivudine (3TC) and neviropine (NVP). Specific triple therapy regimens included D4T/3TC/NVP; D4T/3TC/EFV; 3TC/TDF/EFV; 3TC/TDF/NVP; and AZT/3TC/NVP. Study variables: the outcome variable was anaemia. This was defined as the haemoglobin concentration as per the Demographic and Health Survey (DHS) [27]. Guidelines “severe anaemia (<7.0g/dl), moderate anaemia (7.0 - 9.9g/dl), anaemia (10.0 - 10.9g/dl)”. This allowed us to have a more flexible definition that considers the pregnancy status of half of the study participants. We combined moderate and severe anaemia into one single category because there were very few patients classified as having severe anaemia; either at baseline (n=7) or at end-line (n=2). The analyses took into account the sociodemographic characteristics of the patients i.e. “age” (in complete years), pregnancy status (Y/N), education (no education, primary or just literate, secondary and beyond), smoking status (Y/N), alcohol consumption (Y/N) and employment status (employed/unemployed). Clinical and anthropometric measurements included body weight and height, which were used to compute a body mass index (BMI). We categorized BMI into the following using the Centers for Disease Control and Prevention (CDC) cut-off points: underweight: BMI <18.5, normal: BMI 18.5-24.5, overweight: BMI 25-29.9, obese: BMI ≥30. Furthermore, we included patients´ “CD4 count at baseline WHO stage of HIV disease at baseline and 7 months follow-up time after initiation of treatment”. Statistical analysis: we performed data analysis using STATA 15. Patient´s demographics and clinical characteristics at baseline and end-line were described using percentages and frequencies for all categorical data. Means and standard deviation were used for all continuous variables. Given that our primary exposure was pregnancy and the two groups were balanced with respect to age and year of ART initiation, we also created a dichotomous variable for anaemia coded 1 for patients with any type of anaemia and 0 if otherwise. We then used the McNemar´s test to investigate the association between overall anaemia status (dichotomous) between the two data points (baseline and exit). For other categorical variables with more than 2 categories, we used Pearson Chi-square test to document any association between those characteristics and different levels of anaemia. An analysis of variance (one-way ANOVA) was used to test for equality of mean ‘CD4 count at baseline and end-line’ across the three levels of anaemia. A small proportion of patients had item missing data on CD4 count (n=7 at baseline and n=49 at end-line) and BMI (n=22 at baseline, n=36 at end-line). These item-missing values were replaced by the mean values in the series to reduce non-response bias. A sensitivity analysis was conducted with complete case analysis and we found no evidence that the mean imputation introduced a bias to the estimates. We used an ordered logistic regression model to predict the likelihood of these patients being in the higher versus the lower category of anaemia levels as a function of selected covariates, using pregnancy as the primary exposure variable. The final model excluded 10 patients with unknown status on history of alcohol use. Results from Brant test showed no violation of the proportional odds assumption. Ethical approval: ethical clearance was obtained from Monash University Human Research Ethics Committee (certificate number 2016-0696).

AI Digest

Study Justification:

This study aimed to investigate if pregnancy is an aggravating factor for anaemia among HIV-positive women on antiretroviral treatment (ART). Maternal anaemia is a major public health problem in developing countries, and data suggests that anaemia contributes to the progression of HIV infection. Understanding the relationship between pregnancy, HIV infection, and anaemia is crucial for improving the health outcomes of HIV-positive pregnant women.

Study Highlights:

– The study analyzed data from 236 HIV-positive women aged 18-49 years receiving ART at Themba Lethu Clinic, Helen Joseph Hospital in Johannesburg, South Africa.
– Half of the participants were pregnant, and the other half were non-pregnant HIV-positive women.
– At baseline, 60% of patients were anaemic, and the proportion of pregnant women classified as anaemic differed significantly from that of non-pregnant women.
– Factors significantly associated with anaemia at baseline included body mass index (BMI) category, World Health Organization (WHO) stage, and CD4 count.
– Seven months after initiation of treatment, the proportion of HIV-positive women with anaemia decreased significantly.
– The study concluded that anaemia is a significant risk factor for untoward health outcomes, especially among HIV-positive pregnant women, and early ART access may result in a significant decrease in anaemia during pregnancy.

Recommendations for Lay Reader and Policy Maker:

1. Increase awareness and education about the importance of early ART access for HIV-positive pregnant women to reduce the risk of anaemia.
2. Implement strategies to improve nutrition and address factors associated with anaemia, such as low BMI, among HIV-positive pregnant women.
3. Strengthen antenatal care services to include regular monitoring and management of anaemia in HIV-positive pregnant women.
4. Enhance collaboration between HIV/AIDS programs and maternal health programs to ensure comprehensive care for HIV-positive pregnant women.

Key Role Players:

1. Healthcare providers: Including doctors, nurses, and midwives who provide antenatal care and ART services.
2. Public health officials: Responsible for developing and implementing policies related to HIV/AIDS and maternal health.
3. Non-governmental organizations (NGOs): Involved in providing support and resources for HIV-positive pregnant women.
4. Community leaders and advocates: Engaged in raising awareness and promoting access to healthcare services for HIV-positive pregnant women.

Cost Items for Planning Recommendations:

1. Training and capacity building for healthcare providers on managing anaemia in HIV-positive pregnant women.
2. Development and dissemination of educational materials for HIV-positive pregnant women and their families.
3. Procurement and distribution of nutritional supplements and iron-folic acid tablets for pregnant women.
4. Strengthening antenatal care services, including infrastructure, equipment, and staffing.
5. Monitoring and evaluation activities to assess the impact of interventions on reducing anaemia among HIV-positive pregnant women.
Please note that the provided cost items are general suggestions and may vary based on the specific context and resources available.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. To improve the evidence, the study could have included a larger sample size and a control group of HIV-positive women not on antiretroviral treatment. Additionally, the study could have provided more detailed information on the statistical analysis methods used and the results of the ordered logistic regression model. Finally, the abstract could have included information on the limitations of the study and suggestions for future research.

Abstract

Study design: we analyzed secondary data of all HIV-positive women receiving ART at Themba Lethu Clinic, Helen Joseph Hospital in Johannesburg, South Africa. We included data of patients enrolled between 1stApril 2004 (baseline) to 30th April 2011 (end-line) and tracked anaemia among those patients seven months later. The Themba Lethu Clinic is the largest public sector ART site in the country [26]. Study population: our study included retrospective records for 236 HIV positive women aged 18-49 years on ART. Of these 118 were pregnant and 118 were non-pregnant HIV positive women. Patients included had the following parameters “baseline CD4 count, haemoglobin measurements and at least 7 months of follow-up time”. Both pregnant and non-pregnant study participants were offered similar first line ART regimens comprised of fixed dose combinations of stavudine (D4T), tenofovir (TDF), efavirenz (EFV), zidovudine (AZT), lamivudine (3TC) and neviropine (NVP). Specific triple therapy regimens included D4T/3TC/NVP; D4T/3TC/EFV; 3TC/TDF/EFV; 3TC/TDF/NVP; and AZT/3TC/NVP. Study variables: the outcome variable was anaemia. This was defined as the haemoglobin concentration as per the Demographic and Health Survey (DHS) [27]. Guidelines “severe anaemia (<7.0g/dl), moderate anaemia (7.0 – 9.9g/dl), anaemia (10.0 – 10.9g/dl)”. This allowed us to have a more flexible definition that considers the pregnancy status of half of the study participants. We combined moderate and severe anaemia into one single category because there were very few patients classified as having severe anaemia; either at baseline (n=7) or at end-line (n=2). The analyses took into account the sociodemographic characteristics of the patients i.e. “age” (in complete years), pregnancy status (Y/N), education (no education, primary or just literate, secondary and beyond), smoking status (Y/N), alcohol consumption (Y/N) and employment status (employed/unemployed). Clinical and anthropometric measurements included body weight and height, which were used to compute a body mass index (BMI). We categorized BMI into the following using the Centers for Disease Control and Prevention (CDC) cut-off points: underweight: BMI <18.5, normal: BMI 18.5-24.5, overweight: BMI 25-29.9, obese: BMI ≥30. Furthermore, we included patients´ “CD4 count at baseline WHO stage of HIV disease at baseline and 7 months follow-up time after initiation of treatment”. Statistical analysis: we performed data analysis using STATA 15. Patient´s demographics and clinical characteristics at baseline and end-line were described using percentages and frequencies for all categorical data. Means and standard deviation were used for all continuous variables. Given that our primary exposure was pregnancy and the two groups were balanced with respect to age and year of ART initiation, we also created a dichotomous variable for anaemia coded 1 for patients with any type of anaemia and 0 if otherwise. We then used the McNemar´s test to investigate the association between overall anaemia status (dichotomous) between the two data points (baseline and exit). For other categorical variables with more than 2 categories, we used Pearson Chi-square test to document any association between those characteristics and different levels of anaemia. An analysis of variance (one-way ANOVA) was used to test for equality of mean ‘CD4 count at baseline and end-line’ across the three levels of anaemia. A small proportion of patients had item missing data on CD4 count (n=7 at baseline and n=49 at end-line) and BMI (n=22 at baseline, n=36 at end-line). These item-missing values were replaced by the mean values in the series to reduce non-response bias. A sensitivity analysis was conducted with complete case analysis and we found no evidence that the mean imputation introduced a bias to the estimates. We used an ordered logistic regression model to predict the likelihood of these patients being in the higher versus the lower category of anaemia levels as a function of selected covariates, using pregnancy as the primary exposure variable. The final model excluded 10 patients with unknown status on history of alcohol use. Results from Brant test showed no violation of the proportional odds assumption. Ethical approval: ethical clearance was obtained from Monash University Human Research Ethics Committee (certificate number 2016-0696).

Materials

N/A

Innovations

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 anaemia prevention and management. These apps can also send reminders for prenatal appointments and medication adherence.

2. Telemedicine Services: Implement telemedicine services to provide remote consultations and follow-up care for pregnant women, especially those in rural or underserved areas. This can help overcome geographical barriers and improve access to healthcare professionals.

3. Community Health Workers: Train and deploy community health workers to provide education, support, and monitoring for pregnant women. These workers can conduct home visits, provide health counseling, and assist with referrals to healthcare facilities.

4. Integrated Antenatal Care: Establish integrated antenatal care services that combine maternal health services with HIV treatment and prevention. This approach can ensure comprehensive care for HIV-positive pregnant women, addressing both their HIV and anaemia needs.

5. Point-of-Care Testing: Introduce point-of-care testing for anaemia during antenatal visits. This allows for immediate diagnosis and appropriate management, reducing the time and resources required for laboratory testing.

6. Health Information Systems: Implement electronic health information systems to improve data collection, analysis, and monitoring of maternal health indicators. This can help identify trends, track progress, and inform evidence-based decision-making.

7. Maternal Health Education Campaigns: Launch targeted education campaigns to raise awareness about the importance of maternal health, including anaemia prevention and treatment. These campaigns can be conducted through various channels, such as mass media, community events, and social media.

8. Collaborative Partnerships: Foster collaborations between healthcare providers, researchers, policymakers, and community organizations to address the complex challenges of maternal health. This can lead to innovative solutions, resource sharing, and coordinated efforts to improve access and outcomes.

It’s important to note that these recommendations are general and may need to be tailored to the specific context and needs of the population being served.

AI Innovations Description

Based on the provided description, the recommendation to improve access to maternal health based on the study findings would be to implement early access to antiretroviral treatment (ART) for HIV-positive pregnant women. This recommendation is supported by the study’s conclusion that anaemia is a significant risk factor for untoward health outcomes, especially among HIV-positive pregnant women, and that early ART access may result in a significant decrease in anaemia during pregnancy.

Implementing early access to ART for HIV-positive pregnant women can help improve their overall health and reduce the risk of anaemia. This can be achieved by ensuring that pregnant women are promptly identified as HIV-positive and provided with appropriate ART regimens. Additionally, healthcare providers should closely monitor the haemoglobin levels of pregnant women on ART and provide necessary interventions, such as iron supplementation or blood transfusions, to manage anaemia effectively.

To ensure successful implementation, it is crucial to strengthen healthcare systems and infrastructure in areas with high HIV prevalence and limited resources. This includes increasing the availability of ART medications, improving access to antenatal care services, and providing adequate training and support to healthcare providers involved in maternal health.

Furthermore, raising awareness among pregnant women about the importance of early HIV testing and ART initiation can help reduce stigma and encourage more women to seek timely healthcare services. This can be achieved through community outreach programs, educational campaigns, and involving local community leaders and organizations in promoting maternal health.

Overall, implementing early access to ART for HIV-positive pregnant women is a crucial innovation that can significantly improve access to maternal health and reduce the burden of anaemia among this vulnerable population.

AI Innovations Methodology

Based on the provided study, here are some potential recommendations to improve access to maternal health:

1. Early initiation of antiretroviral treatment (ART): The study found that early access to ART resulted in a significant decrease in anaemia among HIV-positive pregnant women. Promoting early initiation of ART can help improve maternal health outcomes.

2. Regular monitoring of haemoglobin levels: Regular monitoring of haemoglobin levels during pregnancy can help identify and address anaemia early on. This can be done through routine antenatal care visits and ensuring access to necessary laboratory tests.

3. Nutritional support: Addressing nutritional deficiencies, such as iron deficiency, can help prevent and manage anaemia during pregnancy. Providing nutritional support and education on balanced diets can contribute to improved maternal health.

4. Integrated antenatal care: Integrating maternal health services with HIV care can improve access and coordination of care for HIV-positive pregnant women. This can include providing comprehensive antenatal care services at HIV treatment centers.

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

1. Define the target population: Identify the specific population that will be affected by the recommendations, such as HIV-positive pregnant women receiving ART.

2. Collect baseline data: Gather data on the current access to maternal health services, including rates of anaemia among HIV-positive pregnant women, ART initiation timing, and availability of monitoring and nutritional support.

3. Introduce the recommendations: Simulate the implementation of the recommendations by adjusting the variables related to early ART initiation, regular monitoring, nutritional support, and integrated antenatal care.

4. Analyze the impact: Compare the simulated data with the baseline data to assess the impact of the recommendations on access to maternal health. This can include measuring changes in anaemia rates, improvements in ART initiation timing, and increased utilization of integrated antenatal care services.

5. Evaluate outcomes: Assess the outcomes of the simulation, such as improvements in maternal health outcomes, reduction in anaemia rates, and increased access to necessary services. This evaluation can help determine the effectiveness of the recommendations in improving access to maternal health.

6. Refine and iterate: Based on the evaluation of outcomes, refine the recommendations and simulation methodology as needed. Iterate the process to further optimize the impact on improving access to maternal health.

It is important to note that the specific methodology for simulating the impact may vary depending on the available data, resources, and context of the study.

Authors & Co-Authors

Statistics:

Citations: 2

Authors: 5

Identifiers:

DOI: 10.11604/pamj.2020.37.93.22244

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Substance Abuse

Study Countries:

South Africa

Study Design:

Cohort Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female