Maternal HIV is associated with reduced growth in the first year of life among infants in the Eastern region of Ghana: The research to improve infant nutrition and growth (RIING) project

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Study Justification:
The study aimed to investigate the association between maternal HIV status and growth among infants in the first year of life in the Eastern region of Ghana. This research was important because there was limited understanding of the extent to which children of HIV-infected mothers are affected by poor growth. By examining this association, the study aimed to provide valuable insights into the impact of maternal HIV on infant nutrition and growth.
Highlights:
1. The study found that infants of HIV-negative mothers had significantly higher weight-for-age and length-for-age z-scores at birth compared to infants of HIV-positive mothers.
2. The prevalence of underweight and stunting at 12 months was significantly higher among infants of HIV-positive mothers compared to infants of HIV-negative mothers.
3. Maternal HIV was associated with reduced infant growth in weight and length throughout the first year of life.
4. The study highlighted the need for special support for children of HIV-positive mothers living in socioeconomically deprived communities to mitigate the negative effects on growth performance.
Recommendations:
1. Provide targeted support and interventions for children of HIV-positive mothers in socioeconomically deprived communities to improve their growth and nutrition outcomes.
2. Strengthen HIV prevention and treatment programs to reduce the transmission of HIV from mother to child.
3. Enhance access to antenatal care services and promote early HIV testing and counseling for pregnant women.
4. Improve the overall socioeconomic conditions in communities to support optimal growth and development of infants.
Key Role Players:
1. Healthcare professionals and organizations involved in antenatal care, HIV testing, and counseling.
2. Government agencies responsible for implementing HIV prevention and treatment programs.
3. Non-governmental organizations working in the field of maternal and child health.
4. Community leaders and organizations involved in community development and support.
Cost Items for Planning Recommendations:
1. Training and capacity building for healthcare professionals on HIV prevention, testing, and counseling.
2. Provision of antiretroviral therapy for pregnant women living with HIV.
3. Development and implementation of targeted interventions for children of HIV-positive mothers.
4. Community outreach and awareness campaigns on HIV prevention and maternal and child health.
5. Monitoring and evaluation of program implementation and impact.
Please note that the cost items provided are for planning purposes and do not represent actual costs. The actual budget will depend on the specific context and resources available for implementation.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because the study used a longitudinal study design and collected data on infant weight and length at birth and every month until 12 months of age. The study also compared weight-for-age, weight-for-length, and length-for-age z-scores between different groups. However, the evidence could be strengthened by providing more details on the statistical analysis methods used and addressing potential confounding factors such as breastfeeding and maternal nutrition. Additionally, the abstract could include information on the sample size and characteristics of the study population, as well as any limitations of the study.

Children of HIV-infected mothers experience poor growth, but not much is understood about the extent to which such children are affected. The Research to Improve Infant Nutrition and Growth (RIING) Project used a longitudinal study design to investigate the association between maternal HIV status and growth among Ghanaian infants in the first year of life. Pregnant women in their third trimester were enrolled into three groups: HIV-negative (HIV-N, n=185), HIV-positive (HIV-P, n=190) and HIV-unknown (HIV-U, n=177). Socioeconomic data were collected. Infant weight and length were measured at birth and every month until 12 months of age. Weight-for-age (WAZ), weight-for-length (WLZ) and length-for-age (LAZ) z-scores were compared using analysis of covariance. Infant HIV status was not known as most mothers declined to test their children’s status at 12 months. Adjusted mean WAZ and LAZ at birth were significantly higher for infants of HIV-N compared with infants of HIV-P mothers. The prevalence of underweight at 12 months in the HIV-N, HIV-P and HIV-U were 6.6%, 27.5% and 9.9% (P<0.05), respectively. By 12 months, the prevalence of stunting was significantly different (HIV-N=6.0%, HIV-P=26.5% and HIV-U=5.0%, P<0.05). The adjusted mean±SE LAZ (0.57±0.11 vs. -0.95±0.12; P<0.005) was significantly greater for infants of HIV-N mothers than infants of HIV-P mothers. Maternal HIV is associated with reduce infant growth in weight and length throughout the first year of life. Children of HIV-P mothers living in socioeconomically deprived communities need special support to mitigate any negative effect on growth performance.

The study was conducted from 2003 to 2008 in the Yilo Krobo (population 93 586) and Manya Krobo (population 165 409) districts located about 80 km north of Accra, in the Eastern region of Ghana. The main adult occupations are trading, fishing, pottery and farming. The districts are served by three hospitals. The Eastern region where the two districts are located had an HIV prevalence of 3.7% compared with the national prevalence of 2.2% at the time of the study (GSS 2004). The prevalence of stunting among children under 5 years in the Eastern region was 27% (GSS 2004). Literacy rates among men and women in the region were 81% and 64%, respectively (GSS 2004). Most households in the districts had access to electricity and public pipe‐borne water within the community. The study was a prospective cohort involving pregnant women (n = 552) in their third trimester attending prenatal clinics in three hospitals in the districts. To be eligible, the participant had to be (1) pregnant; (2) at least 18 years of age; (3) undergo voluntary pre‐test counselling and if tested agree to have her HIV test results released to the project supervisor; (4) available for the entire duration of the study; and (5) free from clinical and physical conditions that would limit her ability to care for the infant. The women went through the regular Ghana Health Service (GHS) antenatal clinic procedures, which included voluntary pre‐test counselling to offer HIV testing (Okronipa et al. 2012). Women who agreed to be tested were identified as HIV‐P or HIV‐N those who refused testing were identified as HIV‐U. Recruitment into the study was done in partnership with the hospital nursing staff responsible for voluntary counselling and testing (VCT) in the three participating hospitals. After testing (or after pre‐test counselling if testing was refused), the GHS nurse informed women about the study. Recruitment of HIV‐N and HIV‐U (because refusal to be tested) women followed the identification of HIV‐P women to assure similar seasonal enrolment in the three groups. All HIV‐P women who consented were enrolled. If more HIV‐N and HIV‐U women were available at the time, participants were randomly chosen from those available that day. The GHS nurse approached 692 pregnant, of whom 653 expressed interest in the study. HIV status was released only to the project supervisor who personally visited each woman at her home to further explain the study. Informed written consent was obtained from 552 women: HIV‐N (n = 185), HIV‐P (n = 190) and HIV‐U (n = 177). HIV tests were routinely done by the recruiting hospitals using the Rapid Test Abbott Determine HIV‐1/2 (Abbott Laboratories, Abbott Park, IL, USA). At the time of the study, the administration of nevirapine to the pregnant woman at labour and to the infant at birth was the national protocol for the prevention of mother‐to‐child transmission (PMTCT). Sample size was determined based on estimates of effect sizes and individual‐level variability documented for anthropometric, breast milk intake and morbidity data from previous studies in similar low‐income communities (Marquis et al. 2002). Calculations used an effect ratio of 1, a one‐tailed test, a significance level of 0.05 and a power of 80% (Kelsey et al. 1986). Morbidity rates based on 20% and mean difference of 15% yielded the largest sample size of 151 per group. Assuming a loss to follow‐up of 25%, a total sample of 189 per group was considered to be adequate. Data were collected on socio‐demographic information (age, education, marital status), occupation, household characteristics (size and composition), food production, economic activities, household FI, maternal post‐natal depression and maternal stress. These data were collected at baseline, birth, 3, 6, 9 and 12 months after birth. Infant anthropometric measurements (weight and length) were taken within 24 h of birth, and then monthly thereafter until the infant reached 12 months. Infants were weighed naked to the nearest 100 g (Tanita Corporation of America Inc., Arlington Heights, IL, USA), and recumbent length was measured to the nearest 0.1 cm using an infant stadiometer at home (Shorr Productions, Olney, MD, USA). Maternal post‐natal depression was measured at birth and at 6 months after birth using the Edinburgh Post‐natal Depression Scale as described elsewhere (Okronipa et al. 2012). Maternal stress was measured at baseline, birth, 3, 6, 9 and 12 months using the Perceived Stress Scale as described elsewhere (Okronipa et al. 2012). Other data on infant morbidity and feeding, and maternal anthropometry, morbidity and social capital not reported in this paper were also collected. At 12 months of age, all mothers were given the opportunity through a separate informed consent process to have their infant tested for HIV. Those who agreed to testing (n = 81) had a finger prick blood taken on to a filter paper to determine the child's HIV status by DNA polymerase chain reaction (PCR) analysis (Fransen et al. 1994, 1998). Analyses were done using SAS v. 9.2 (SAS Institute, Cary, NC, USA). Background characteristics were assessed by using chi‐squared tests for categorical variables and analysis of variance (with Ryan–Einot–Gabriel–Weich for post hoc pair‐wise comparison) for continuous variables. As a proxy for household socioeconomic status, we created an ‘amenities’ factor from a set of 18 socioeconomic variables (house‐building materials, location of household water, toilet, access to electricity, cooking fuel, ownership of appliances) using factor analysis with varimax rotation. Lower values for amenities were assumed to indicate poorer households. Household‐level FI at birth, 3, 6, 9 and 12 months after birth was determined using a 14‐item scale derived from the US Household Food Security Survey Module. Rasch analyses confirmed the psychometric validity of the scale (R. Perez‐Escamilla, ‘unpublished observations’). Based on these analyses, households were classified as food secure if none of the questions were affirmed. The cut‐off points for classifying households into different FI levels based on adding the number of questions affirmed were: mild (0), moderate (1–6) and severe (7–14). Questions were asked in reference to the month preceding the survey. Eight questions were asked in reference to adult(s)/household and six in reference to children who were defined as individuals under 16 years of age living in the household. At each time point, household FI was assigned a score of 0 if they were food secure, 1 if they were mildly, 2 if they were moderately or 3 if they were severely food insecure. A mean FI score was calculated across time to obtain the final mean FI level for each household throughout the duration of the study. The mean FI level was considered as a continuous variable, and was used as a covariate in the analysis. Child anthropometric measurements were converted to weight‐for‐age (WAZ), length‐for‐age (LAZ) and weight‐for‐length z‐scores (WLZ) using the WHO Child Growth Standards (WHO Multicenter Growth Reference Study Group 2006). Mean WAZ, LAZ and WLZ for each group at each month from 1 to 12 months were calculated and compared using ANCOVA, adjusting for child sex and birthweight, and maternal age, education, marital status, household amenities (as a proxy for socioeconomic status) and mean household FI. These variables were selected because they were either different among the three groups at baseline, or were related to growth. We used a repeated measures analysis (SAS Proc Mixed) to determine whether the growth of children over time differed for children of mothers in the three HIV status categories with Tukey–Kramer post hoc test. A three‐way HIV–age–sex interaction term reflecting sex differences in the association between HIV and growth across the first year was tested and found to be not significant and therefore was not included in the final model. In all analyses involving growth, we controlled for the child and maternal characteristics mentioned earlier. The percentage of children with z‐scores <−2 standard deviation at 6 and 12 months was determined. Ethical approval for the study was obtained from the Institutional Review Boards of the University of Ghana, Iowa State University, University of Connecticut and McGill University.

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

1. Mobile Health (mHealth) Applications: Develop and implement mobile applications that provide pregnant women with access to information and resources related to maternal health. These apps can provide guidance on prenatal care, nutrition, and breastfeeding, as well as reminders for appointments and medication.

2. Telemedicine: Establish telemedicine services that allow pregnant women in remote or underserved areas to consult with healthcare professionals remotely. This can help overcome geographical barriers and provide access to prenatal care and consultations without the need for travel.

3. Community Health Workers: Train and deploy community health workers who can provide education, support, and basic healthcare services to pregnant women in their communities. These workers can help bridge the gap between healthcare facilities and pregnant women, ensuring they receive necessary care and support.

4. Maternal Health Vouchers: Implement a voucher system that provides pregnant women with access to essential maternal health services, such as prenatal check-ups, delivery, and postnatal care. These vouchers can be distributed to women in need, enabling them to access quality care without financial barriers.

5. Public-Private Partnerships: Foster collaborations between public and private healthcare providers to improve access to maternal health services. This can involve leveraging private sector resources and expertise to enhance the availability and quality of care for pregnant women.

6. Maternal Health Education Programs: Develop and implement comprehensive maternal health education programs that target both pregnant women and their families. These programs can focus on promoting healthy behaviors, raising awareness about the importance of prenatal care, and addressing common misconceptions about pregnancy and childbirth.

7. Transportation Support: Establish transportation support systems to ensure pregnant women can easily access healthcare facilities for prenatal check-ups, delivery, and postnatal care. This can involve providing subsidized transportation services or organizing community-based transportation networks.

8. Maternal Health Hotlines: Set up dedicated hotlines staffed by trained healthcare professionals who can provide information, support, and guidance to pregnant women. These hotlines can address concerns, provide advice, and connect women to appropriate healthcare services.

9. Maternal Health Clinics: Establish specialized maternal health clinics that offer comprehensive care for pregnant women, including prenatal check-ups, counseling, and support services. These clinics can provide a one-stop-shop for maternal health needs, ensuring women receive holistic care throughout their pregnancy journey.

10. Maternal Health Awareness Campaigns: Launch targeted awareness campaigns to educate communities about the importance of maternal health and encourage early and regular prenatal care. These campaigns can use various media channels, including radio, television, and social media, to reach a wide audience and promote positive health-seeking behaviors.

It’s important to note that the specific implementation of these innovations would require careful planning, coordination, and evaluation to ensure their effectiveness and sustainability in improving access to maternal health.
AI Innovations Description
Based on the research findings, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Implement targeted support programs: Develop and implement targeted support programs for pregnant women living with HIV in socioeconomically deprived communities. These programs should focus on providing comprehensive care and support to mitigate the negative effects of HIV on maternal and infant health.

2. Strengthen antenatal care services: Enhance antenatal care services by integrating HIV testing and counseling into routine prenatal care. This will ensure that all pregnant women have access to HIV testing and can receive appropriate care and treatment if diagnosed with HIV.

3. Improve access to prevention of mother-to-child transmission (PMTCT) services: Strengthen PMTCT services by ensuring that all HIV-positive pregnant women have access to antiretroviral therapy (ART) to prevent mother-to-child transmission of HIV. This includes providing nevirapine to HIV-positive mothers during labor and to infants at birth, as per the national protocol.

4. Enhance community awareness and education: Conduct community awareness campaigns and education programs to increase knowledge and understanding of maternal HIV and its impact on infant growth. This will help reduce stigma and discrimination associated with HIV and encourage more pregnant women to seek testing and treatment.

5. Improve healthcare infrastructure: Invest in improving healthcare infrastructure, particularly in rural areas, to ensure that pregnant women have access to quality maternal health services. This includes strengthening healthcare facilities, training healthcare providers, and ensuring the availability of essential medical supplies and equipment.

6. Strengthen data collection and monitoring: Enhance data collection and monitoring systems to track the progress and impact of interventions aimed at improving access to maternal health. This will enable policymakers and healthcare providers to make informed decisions and allocate resources effectively.

By implementing these recommendations, it is possible to develop innovative solutions that can improve access to maternal health for women living with HIV and ultimately contribute to better maternal and infant health outcomes.
AI Innovations Methodology
To improve access to maternal health, here are some potential recommendations:

1. Strengthening healthcare infrastructure: Investing in healthcare facilities, equipment, and trained healthcare professionals in areas with limited access to maternal health services can improve access and quality of care.

2. Mobile health (mHealth) interventions: Utilizing mobile technology to provide maternal health information, reminders for prenatal and postnatal care appointments, and access to telemedicine consultations can help overcome geographical barriers and improve access to care.

3. Community-based interventions: Implementing community health worker programs to provide education, counseling, and support to pregnant women and new mothers in remote or underserved areas can improve access to maternal health services.

4. Financial incentives: Providing financial incentives such as cash transfers or subsidies for transportation, healthcare services, and medications can help overcome financial barriers and improve access to maternal health services.

5. Telemedicine and teleconsultations: Using telemedicine platforms to connect pregnant women and healthcare providers remotely can improve access to specialized care, especially in rural or remote areas.

Methodology to simulate the impact of these recommendations on improving access to maternal health:

1. Define the target population: Identify the specific population that will benefit from the recommendations, such as pregnant women in rural areas or low-income communities.

2. Collect baseline data: Gather data on the current access to maternal health services, including the number of healthcare facilities, healthcare professionals, and utilization rates.

3. Define indicators: Determine the key indicators that will be used to measure the impact of the recommendations, such as the number of prenatal care visits, percentage of women receiving skilled birth attendance, or reduction in maternal mortality rates.

4. Develop a simulation model: Create a simulation model that incorporates the recommendations and their potential impact on the defined indicators. This model should consider factors such as population size, geographical distribution, healthcare infrastructure, and financial resources.

5. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to assess the potential impact of the recommendations on the defined indicators. Adjust the parameters of the recommendations, such as the number of healthcare facilities or the coverage of mobile health interventions, to explore different scenarios.

6. Analyze results: Analyze the results of the simulations to determine the potential impact of the recommendations on improving access to maternal health services. Compare the outcomes of different scenarios to identify the most effective strategies.

7. Refine and validate the model: Continuously refine and validate the simulation model by incorporating new data and feedback from stakeholders. This will ensure that the model accurately reflects the real-world context and can be used to inform decision-making and resource allocation.

8. Communicate findings: Present the findings of the simulation study to policymakers, healthcare providers, and other relevant stakeholders to advocate for the implementation of the recommended strategies and support evidence-based decision-making.

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