Acceptability of routine HIV testing ("opt-out") in antenatal services in two rural districts of Zimbabwe

Low uptake of prevention of mother-to-child transmission of HIV (PMTCT) services in resource-limited settings requires new approaches to prevent missed opportunities. Routine HIV testing ("opt-out" testing) in antenatal care (ANC) should be considered. An exploratory cross-sectional survey was conducted in 6 PMTCT sites in rural Zimbabwe. Women who had attended ANC in health centers where PMTCT was provided were surveyed in postnatal services. Of 520 women sampled, 285 (55%) had been HIV tested during their last pregnancy. Primary education or no education (P = 0.02), reporting receiving neither group education in the ANC clinic (P < 0.001) nor individual pretest counseling (P < 0.001), and having attended <6 ANC visits (P < 0.03) were associated with not having been HIV tested. Among the 235 women not HIV tested in ANC, 79% would accept HIV testing if opt-out testing was introduced. Factors associated with accepting the opt-out approach were being <20 years old (P = 0.005), having secondary education or more (P = 0.03), living with a partner (P = 0.001), and the existence of a PMTCT service where the untested women delivered. Thirty-seven women of 235 (16%) would decline routine HIV testing, mainly because of their fear of knowing their HIV status and the need to have their partner's consent. Among the women already tested in ANC (n = 285), 97% would accept the opt-out approach. In Zimbabwe, where 25% of pregnant women are HIV infected, introducing the opt-out strategy for HIV testing may have a far-reaching public health impact on PMTCT. Issues regarding, stigma, quality of post-testing counseling and staffing must be considered, however.     

Sex Differences in the Management and Outcomes of Ontario Patients With Cardiogenic Shock Complicating Acute Myocardial Infarction

Background

Sex differences in the management of acute myocardial infarction (AMI) patients with cardiogenic shock (CS) have not been well studied.

Methods

We examined mortality and revascularization rates of 9750 patients with CS between 1992 and 2008 in the Ontario Myocardial Infarction Database. Men and women were compared in the entire cohort and in subgroups divided by age (aged < 75 years vs aged ≥ 75 years) and revascularization availability at presenting hospital. Logistic regression was used to determine the adjusted effect of sex on mortality and to determine predictors of revascularization.

Results

The incidence of CS was higher in women (3.7% of female vs 2.7% of male AMI patients; P < 0.001). Women with CS were older than men (mean age: 75.5 vs 71.1 years; P < 0.001) and less likely to present to revascularization-capable sites (16% vs 19.2%; P < 0.001). Unadjusted 1-year mortality rates were higher in women (80.3% vs 75.4%; P < 0.001). Women were less likely to be revascularized (12.6% vs 17.6%; P < 0.001) and less likely to be transferred when they presented to nonrevascularization sites (11.3% vs 14.2%; P < 0.001). The strongest predictor of revascularization was presentation to a revascularization-capable site (odds ratio, 17.69; P < 0.001). After regression adjustment, there were no significant differences in mortality or revascularization between the sexes.

Conclusion

Women with CS are older than men with CS and are less likely to present to revascularization-capable sites. This accounts for the lower unadjusted revascularization rates among women compared with men. However, there are no significant sex-based differences in adjusted mortality rates.     

Prevalence of immunity to hepatitis viruses A and B in a large cohort of HIV/HCV-coinfected patients, and factors associated with HAV and HBV vaccination

Hepatitis A (HAV) and B (HBV) vaccination is strongly recommended for HIV-infected patients, especially those with hepatitis C coinfection. The aim of this study was to determine the prevalence of antibodies directed against HAV and HBV in a large cohort of HIV/HCV-coinfected patients, and to identify factors associated with HAV and HBV vaccination.

Patients and methods

We studied 1175 HIV/HCV-coinfected patients enrolled in the ANRS CO13 HEPAVIH cohort, whose HAV and HBV serostatus was known.

Results

1056 patients (89.9%) have been tested for anti-HBc IgG, anti-HBs, and HbsAg. Only 10.9% of patients had received HBV vaccination and 70% of the patients with no HBV immunity (231/265) had never received HBV vaccination. In multivariate analysis, male sex (OR 2.0. 95% CI 1.1-3.8; p = 0.02), a higher level of school education (OR 2.5, 95% CI 1.3-4.5; p = 0.003), a higher CD4 cell nadir (OR 1.05, 95% CI 1.009-1.103; p = 0.018) and no cirrhosis (OR 2.7, 95% CI 1.2-6.4; p = 0.02) were associated with HBV vaccination.Only 368 patients (31.3%) were tested for immunity to HAV. Despite a frequent lack of HAV immunity (48.3%), a low rate of HAV vaccination (6%) was observed. In multivariate analysis, a higher level of school education (OR 3.6, 95% CI 1.03-12.4; p = 0.045) was the only factor associated with HAV vaccination.HAV screening rates and HAV and HBV vaccination rates were low in this population of HIV/HCV-coinfected patients. The benefits of routine HAV and HBV screening, vaccination and post-vaccination testing should be emphasized.     

Severe asthma in children—a review of definitions,epidemiology, and treatment options in 2019

Severe asthma is a relatively uncommon condition in children but one which causes morbidity, occasionally mortality, and is a challenging condition to manage. There are several definitions of severe asthma, which have a common theme of poor control despite high dose inhaled corticosteroid treatment. Depending on the definition chosen, the prevalence of severe childhood asthma may be up to 5% within populations with asthma. Collectively, there is some evidence that the treatments used in severe asthma are beneficial, but a solid evidence‐base is lacking for many treatments and some treatments have recognized side effects. Evidence supporting the use of maintenance oral prednisolone and intramuscular triamcinolone is weak. Response to systemic corticosteroids is heterogeneous and recognizing phenotypes or endotypes may identify those most likely to gain maximal benefit from treatment. For children aged 6 to 11 years, the anti‐IgE biologic omalizumab is effective and anti‐IL‐5 agent (mepolizumab) has recently been licenced in Europe (but not the US). Biologics, which are licenced for >11 year olds include omalizumab, mepolizumab, benralizumab, reslizumab, and dupilumab. There is plenty that the clinician can offer to the child and adolescent with severe asthma in 2019, including nontherapeutic and therapeutic interventions. To manage severe asthma, practitioners from broad specialities must establish and maintain a close therapeutic relationship with patients. Looking beyond 2019, more treatment options will emerge for severe childhood asthma, and clinical teams will need to continue weighing up benefits and harms.