Use of and adherence to antiretroviral therapy is associated with decreased sexual risk behavior in HIV clinic patients

Previous research suggested that the availability of highly active antiretroviral therapy (ART) was associated with increased risky sexual behavior. This study examined the relationship between unprotected anal or vaginal sex (UAV) and ART use and adherence in a cross-sectional survey conducted in 874 randomly selected, sexually active patients at 6 public HIV clinics in California. Patients completed a standardized interview in 1998-1999 regarding HIV history, sexual behavior, illicit drug use, and ART use and adherence. Thirty-four percent reported UAV, defined as anal or vaginal sex without a condom within the past 3 months. Of 79% on ART, 26% reported <95% adherence. Decreased odds for UAV were found for both ART use, odds ratio (OR) 0.5 (95% CI 0.4-0.7, P < 0.001) and adherence to ART of > or = 95%, OR 0.6 (95% CI 0.4-0.8, P < 0.001). These relationships persisted in most stratified analysis for both ART use and adherence but in multivariate analysis only for ART use. An undetectable HIV RNA was associated with decreased odds of UAV, OR 0.6 (95% CI 0.5-0.8, P < 0.001). Contrary to expectations, use of and adherence to ART and their consequent suppression of HIV were associated with a decreased prevalence of self-reported risky sexual behavior.     

Effect of maternal HIV and malaria infection on pregnancy and perinatal outcome in Zimbabwe

OBJECTIVE: To investigate the effect of isolated or concomitant infection with malaria and HIV on pregnancy and neonatal outcome. METHODS: Data were collected on pregnant women admitted during the rainy seasons in the obstetric division of a district referral hospital in northern Zimbabwe in 2000 and 2001. The effects of malaria and HIV infection were determined by multivariate analysis. RESULTS: The prevalence of HIV seropositivity and symptomatic malaria in 986 pregnant women was 8.3% and 14.7%, respectively. HIV-infected women were more likely to develop malaria attacks during pregnancy than seronegative women (odds ratio [OR] = 3.96, 95% confidence interval (CI): 2.42-6.46). Malaria and HIV infections were associated with increased risk of stillbirth (OR = 4.74, 95% CI: 1.34-16.78) and preterm delivery (OR = 4.10, 95% CI: 2.17-7.75), respectively. They were independently associated with increased risk of low birth weight (malaria: OR = 10.09, 95% CI: 6.50-15.65; HIV: OR = 3.16, 95% CI: 1.80-5.54) and very low birth weight (malaria: OR = 5.04, 95% CI: 1.00-25.43; HIV: OR = 10.74, 95% CI: 2.12-54.41), low Apgar score (malaria: OR = 4.45, 95% CI: 1.42-13.94; HIV: OR = 5.94, 95% CI: 1.66-21.30), and fetal growth restriction (malaria: OR = 3.98, 95% CI: 2.51-6.30; HIV: OR = 4.07, 95% CI: 2.40-6.92). Dual infection with malaria and HIV was associated with increased risk of maternal, perinatal, and early infant death. CONCLUSIONS: Women with single HIV or malaria infection have a significantly increased risk of adverse outcomes of pregnancy and childbirth. Dual infection has additional detrimental effects on maternal and infant survival in an area where HIV and malaria coexist.     

Maternal Prepregnancy Underweight and Risk of Early and Late Stillbirth in Black and White Gravidas

ObjectiveThe association between underweight and stillbirth remains poorly defined, especially across racial/ethnic sub-populations. We investigate the association of pre-pregnancy underweight on the risk for early and late stillbirth among black and white mothers.MethodsWe conducted analysis on the Missouri maternally linked data files covering the period 1989-1997 inclusive. Using body mass index (BMI), we categorized mothers as underweight (BMI >18.5) and normal weight (BMI = 18.5-24.9). By applying logistic regression modeling with adjustment for intracluster correlation, we estimated the risk for total, early (≤28 weeks of gestation), and late stillbirth (>28 weeks of gestation) among black and white mothers.ResultsA total of 1808 cases of stillbirth were registered. The rate of stillbirth among white mothers was 3.7 per 1000, while the rate among blacks was 7.1 per 1000. Underweight black mothers had comparable risk for total (OR, 0.9; 95% CI, 0.7-1.2), early (OR, 1.1; 95% CI, 0.8-1.5), and late stillbirth (OR, 0.8; 95% CI, 0.5-1.2) as compared to their normal-weight counterparts. By contrast, underweight white gravidas had a 30% reduced likelihood (OR, 0.7; 95% CI, 0.6-0.9) for late stillbirth as compared to normal-weight white mothers. However, the risks for total and early stillbirth among underweight white mothers were similar to those of normal-weight white mothers.ConclusionLow prepregnancy BMI has similar effects on fetal survival in both blacks and whites except for late stillbirth. The underweight white survival advantage over blacks in late pregnancy could probably be due to greater access for identified white at-risk groups to effective obstetrical interventions as previously reported.     

Discontinuation and modification of highly active antiretroviral therapy in HIV-infected Ugandans: prevalence and associated factors

BACKGROUND: Data on discontinuation and modification of highly active antiretroviral therapy (HAART) are scarce among sub-Saharan African populations. We sought to estimate the prevalence and to identify factors associated with these phenomena in our resource-limited setting. METHODS: Patients were recruited into this cross-sectional study from 2 treatment centers in Kampala, Uganda. Discontinuation and modification were assessed by self-report using semistructured quantitative and unstructured qualitative interviews. Discontinuation was defined as the simultaneous stopping of all antiretrovirals for at least 1 month, and modification as the changing of at least 1 antiretroviral used in an initial HAART regimen. Factors independently associated with each outcome were assessed using multivariate logistic regression. RESULTS: Of 686 subjects evaluated, 94 (13.7%) had ever discontinued therapy, whereas 175 (25.5%) had ever modified their regimen. The median CD4 count was 175 (interquartile range: 66-297) cells/microL. Factors associated with discontinuation were HAART experience before starting the current regimen (odds ratio [OR] = 3.70, 95% confidence interval [CI]: 2.13 to 6.25), use of alternative medicines (OR = 2.18, 95% CI: 1.06 to 4.47), hospitalization (OR = 2.36, 95% CI: 1.32 to 4.20), and 1 year or less on HAART (OR = 11.11, 95% CI: 5.00 to 25.00). Modification was associated with more than 3 months' duration on HAART (OR = 3.13, 95% CI: 1.16 to 8.33) and being unmarried (OR = 1.64, 95% CI: 1.02 to 2.70). CONCLUSIONS: The proportions of discontinuation and modification of antiretroviral therapy (ART) observed in our resource-poor setting pose a challenge to the limited treatment options presently available. Drug cost as a major reason for discontinuation of HAART has major implications for ART programs that charge fees in resource-limited settings.     

Effectiveness and safety of abacavir, lamivudine, and zidovudine in antiretroviral therapy-naive HIV-infected patients: results from a large multicenter observational cohort

OBJECTIVE: To analyze the safety and effectiveness of abacavir, lamivudine, and zidovudine (ABC/3TC/ZDV) in antiretroviral therapy (ART)-naive HIV-infected patients. DESIGN: Retrospective observational cohort study. METHODS: We analyzed all consecutive ART-naive HIV-infected patients who initiated ABC/3TC/ZDV in 71 centers throughout Spain and had a clinical visit and laboratory data at least 16 weeks after initiating this regimen. We assessed safety, mortality, new AIDS-defining conditions (ADCs) and treatment failure, the latter defined by any of the following: (1) reduction in plasma HIV-1 viral load (pVL) <1 log during the first 12 weeks of ART, unless it was less than the lower limit of quantification (LOQ); (2) failure to achieve a pVL or = LOQ after achieving a pVL 相似文献   

Maternal characteristics associated with antenatal, intrapartum, and neonatal zidovudine use in four US cities, 1994-1998

OBJECTIVES: To evaluate implementation of 1994 United States Public Health Service guidelines for zidovudine (ZDV) use in HIV-infected women and their newborns by describing the prevalence of use of perinatal ZDV and other antiretrovirals and by investigating determinants of not receiving perinatal ZDV. DESIGN/METHODS: The Perinatal AIDS Collaborative Transmission Study is a prospective cohort study designed to collect information related to mother-to-child HIV transmission that was conducted in New York City (NY), Newark (NJ), Baltimore (MD), and Atlanta (GA), U.S.A. The current analysis was restricted to infants born between July 1994 and June 1998. RESULTS: Utilization rates for antenatal, intrapartum, and neonatal ZDV increased from 41% to 70% during the 4-year period. Use of combination antiretrovirals increased from fewer than 2% of women in 1994 to 1995 to 35% in 1997 to 1998. Antenatal and neonatal ZDV use increased each year, but intrapartum ZDV use reached a plateau after 1996. Mother-infant pairs with the following characteristics were less likely to have received a complete 3-part ZDV regimen: older maternal age, CD4 count >500 cells/microl, preterm birth, cocaine or heroin use during pregnancy, positive newborn drug screen test result, and smoking or alcohol use during pregnancy. By multivariate logistic regression adjusted for hospital and year of birth, cocaine or heroin use during pregnancy (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.6-3.3), maternal CD4 count (OR, 0.4; 95% CI, 0.2-0.8; comparing <200 with >500 cells/microl), and preterm birth (OR, 1.6; 95% CI, 1.1-2.5) remained independently associated with not receiving the complete ZDV regimen. CONCLUSIONS: ZDV use by pregnant HIV-infected women and their infants has increased dramatically since publication of the 1994 guidelines. Nevertheless, women who abuse substances, give birth preterm, or have less advanced immunosuppression, were at substantial risk of not receiving the complete ZDV regimen.     

Prenatal paracetamol exposure and risk of asthma and elevated immunoglobulin E in childhood

BACKGROUND: We recently found that paracetamol (acetaminophen) use in late pregnancy was associated with an increased risk of early wheezing in the offspring. OBJECTIVE: To see whether use of paracetamol in late pregnancy is associated with an increased risk of asthma, wheezing and other atopic outcomes in the child at school age. METHODS: In the population-based Avon Longitudinal Study of Parents and Children, we measured associations of paracetamol and aspirin use in late pregnancy (20-32 weeks) with asthma, hayfever, eczema (n = 8511) and wheezing (8381) in the offspring at 69-81 months, and with atopy (positive skin prick test to Dermatophagoides pteronyssinus, cat or grass, n = 6527) and blood total IgE (n = 5148) at 7 years. We used logistic and linear regression to analyse binary outcomes and log-transformed IgE, respectively, controlling for potential confounders. RESULTS: Use of paracetamol, but not aspirin, in late pregnancy was positively associated with asthma (odds ratios (ORs), comparing children whose mothers took paracetamol 'sometimes' and 'most days/daily' with those whose mothers never took it, 1.22 (95% confidence interval (CI): 1.06-1.41) and 1.62 (95% CI: 0.86-3.04), respectively; P trend = 0.0037), wheezing (ORs 1.20 (95% CI: 1.02-1.40) and 1.86 (95% CI: 0.98-3.55), respectively; P trend = 0.011), and total IgE (geometric mean ratios 1.14 (95% CI: 1.03-1.26) and 1.52 (95% CI: 0.98-2.38), respectively; P trend = 0.0034), but not hayfever, eczema or skin test positivity. The proportion of asthma attributable to paracetamol use in late pregnancy, assuming a causal relation, was 7%. CONCLUSION: Paracetamol exposure in late gestation may cause asthma, wheezing and elevated IgE in children of school age.     

Exposure to antiretroviral therapy in utero or early life: the health of uninfected children born to HIV-infected women

Concerns have been raised over possible adverse effects of prophylactic antiretroviral therapy (ART) on the fetus and newborn. We analyzed data relating to uninfected children enrolled in the European Collaborative Study and investigated the association between ART exposure, perinatal problems, and major adverse health events later in life. Median length of follow-up was 2.2 (0-15.9) years. Of the 2414 uninfected children, 687 (28%) were exposed to ART in all three periods (antenatal, intrapartum, and neonatal). Of the 1008 infants exposed to ART at any time, 906 (90%) were exposed antenatally, 840 (83%) neonatally, and 750 (74%) both antenatally and neonatally. ART exposure was not significantly associated with pattern or prevalence of congenital abnormalities or low birth weight. In multivariate analysis, prematurity was associated with exposure to combination therapy without a protease inhibitor (PI) (OR = 2.66; 95% CI: 1.52-4.67) and with a PI (OR = 4.14; 95% CI: 2.36-7.23). ART exposure was associated with anemia in early life ( <.001). There was no evidence of an association with clinical manifestations suggestive of mitochondrial abnormalities. The absence of serious adverse events in this large cohort of uninfected children exposed to prophylactic ART in the short to medium term is reassuring.     

Marijuana use and its association with adherence to antiretroviral therapy among HIV-infected persons with moderate to severe nausea

BACKGROUND: Adherence to antiretroviral therapy (ART) is essential to successful treatment of HIV infection. Two recent studies reported a negative correlation between marijuana use and adherence to ART. Some patients, however, report that smoking marijuana improves adherence to ART. This study therefore sought to identify which subgroups of patients may have differential adherence to ART in association with recent marijuana use. METHODS: Cross-sectional survey design within a public health care system for HIV/AIDS. RESULTS: With a 5% refusal rate, 252 patients completed the interview, 175 (69%) were on ART, and 168 (67%) provided ART adherence data. Forty-one subjects (24%), predominantly whites, used marijuana. In bivariate analysis, no association between ART adherence and marijuana use was found (odds ratio [OR] = 0.92, 95% CI = 0.4-1.9). Adherence was positively associated with undetectable plasma virus and negatively associated with alcohol and other illicit drug use. Examining subgroups of patients, among those with nausea, marijuana users were more likely to show an association with adherence than nonusers (OR = 3.3), while among those without nausea, marijuana use was lower associated with adherence (OR = 0.52, P for homogeneity 0.02). This relationship was confirmed in multivariate analyses controlling for the interactions between nausea and marijuana use, in which other illicit drug use remained a factor related to nonadherence. DISCUSSION: These data suggest that medicinal use of marijuana may facilitate, rather than impede, ART adherence for patients with nausea, in contrast to the use of other illicit substances, which were associated with lower rates of ART adherence. To demonstrate any causal relationship between marijuana and adherence would require a longitudinal or controlled study.     

Home-based antiretroviral care is associated with positive social outcomes in a prospective cohort in Uganda

BACKGROUND: Home-based antiretroviral therapy (ART) care in Africa has expanded; but social outcomes of home-based ART programs are unknown. METHODS: Social experiences of participants in an antiretroviral therapy program involving weekly home visits in Uganda were assessed through interviews at enrollment and after 3 months and analyzed using generalized estimating equations. RESULTS: Of 654 participants, 72% were women; median baseline CD4 cell-count was 123 cells/muL. At follow-up, participants were more likely to report community support (adjusted odds ratio [OR] 2.10, 95% confidence interval [CI]: 1.46 to 3.03, P < 0.001), family support (OR 2.65, CI: 2.01 to 3.49, P < 0.001), and relationship strengthening (OR 2.10, CI: 1.46 to 3.03, P = 0.001) than at baseline; 84% attributed these experiences to antiretroviral therapy program participation. There was no change in incidence of negative experiences (P = 0.3). Forty-six percent of women reported a history of partner abuse, but abuse rates 3 months before and after program initiation were low (1% vs. 2%, OR 3.20, CI: 0.94 to 10.9, P = 0.063). Of five women who reported abuse associated with program participation, all had history of domestic violence. Of all participants reporting outcomes associated with antiretroviral therapy program participation at follow-up, 464 (79%) had only positive experiences, 35 (6%) had both positive and negative experiences, and <1% had only negative experiences. CONCLUSIONS: Participation in a home-based antiretroviral therapy program was associated with multiple positive social outcomes.     

Recurrent miscarriage--an aspirin a day?

Recurrent miscarriage and later pregnancy complications are in some cases associated with placental thrombosis and infarction. The aim of this study was to assess the value of low dose aspirin (75 mg daily) in improving the subsequent livebirth rate amongst women with either unexplained recurrent early miscarriage (<13 weeks gestation; n = 805) or unexplained late pregnancy loss (n = 250). Amongst women with recurrent early miscarriages, there was no significant difference in the livebirth rate between those who took aspirin (251/367; 68.4%) compared with those who did not take aspirin [278/438; 63.5%; odds ratio (OR) 1.24; 95% confidence interval (CI) 0.93-1.67]. This relationship was independent of the number of previous early miscarriages. In contrast, women with a previous late miscarriage who took aspirin had a significantly higher livebirth rate (122/189; 64.6%) compared with those who did not take aspirin (30/61; 49.2%: OR 1.88; 95% CI 1.04-3.37). The empirical use of low dose aspirin amongst women with unexplained recurrent early miscarriage is not justified. We are currently investigating the role of incremental doses of aspirin in the treatment of women both with early miscarriages associated with thrombophilic abnormalities and in those with late pregnancy losses.     

A meta-analysis of pregnancy outcomes in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common reproductive disorder associated with many characteristic features, including hyperandrogenaemia, insulin resistance and obesity which may have significant implications for pregnancy outcomes and long-term health of the woman. This meta-analysis was conducted to evaluate the risk of pregnancy and neonatal complications in women with PCOS. Electronic databases were searched for the following MeSH headings: PCOS, hyperandrogenism, pregnancy outcome, pregnancy complications, diabetes mellitus, type II. A handsearch of human reproduction and fertility and sterility was also conducted. Studies in which pregnancy outcomes in women with PCOS were compared with controls were considered for inclusion in this meta-analysis. Fifteen of 525 identified studies were included, involving 720 women presenting with PCOS and 4505 controls. Women with PCOS demonstrated a significantly higher risk of developing gestational diabetes [odds ratio (OR) 2.94; 95% confidence interval (CI): 1.70-5.08], pregnancy-induced hypertension (OR 3.67; 95% CI: 1.98-6.81), pre-eclampsia (OR 3.47; 95% CI: 1.95-6.17) and preterm birth (OR 1.75; 95% CI: 1.16-2.62). Their babies had a significantly higher risk of admission to a neonatal intensive care unit (OR 2.31; 95% CI: 1.25-4.26) and a higher perinatal mortality (OR 3.07; 95% CI: 1.03-9.21), unrelated to multiple births. In conclusion, women with PCOS are at increased risk of pregnancy and neonatal complications. Pre-pregnancy, antenatal and intrapartum care should be aimed at reducing these risks.     

First-trimester bleeding and pregnancy outcome in singletons after assisted reproduction

BACKGROUND: First-trimester bleeding is frequent in assisted reproductive technique (ART) pregnancies. It is unknown whether first-trimester bleeding, if not ending in a spontaneous abortion, negatively influences further pregnancy outcome in ART in singletons. METHODS: Data were obtained from our ART database (1993-2002), with 1432 singleton ongoing pregnancies being included in this study. The outcome measures-second-trimester and third-trimester bleeding, preterm contraction rates, pregnancy duration, birthweight, Caesarean section rates, intrauterine growth retardation (IUGR), preterm prelabour rupture of membranes (P-PROM), neonatal intensive care unit (NICU) admission and perinatal mortality-were compared in the groups with and without first-trimester bleeding. RESULTS: Significantly more singleton pregnancies resulted from a vanishing twin in the group with first-trimester bleeding (8.7%) than in the controls (4.0%). A correlation was found between the incidence of first-trimester bleeding and the number of embryos transferred. First-trimester bleeding led to increased second-trimester [odds ratio (OR)=4.56; confidence interval (CI)=2.76-7.56] and third-trimester bleeding rates (OR=2.85; CI=1.42-5.73), P-PROM (OR=2.44; CI=1.38-4.31), preterm contractions (OR=2.27; CI=1.48-3.47) and NICU admissions (OR=1.75; CI=1.21-2.54). First-trimester bleeding increased the risk for preterm birth (OR=1.64; CI=1.05-2.55) and extreme preterm birth (OR=3.05; CI=1.12-8.31). CONCLUSIONS: First-trimester bleeding in an ongoing singleton pregnancy following ART increases the risk for pregnancy complications. The association between first-trimester bleeding, the number of embryos transferred and adverse pregnancy outcome provides a further argument in favour of single-embryo transfer.