Reduction of Maternal Mortality with Highly Active Antiretroviral Therapy in a Large Cohort of HIV-Infected Pregnant Women in Malawi and Mozambique

Liotta, Giuseppe; Mancinelli, Sandro; Nielsen‐Saines, Karin; Gennaro, Elisabetta; Scarcella, P; Magid, Nurja Abdul; Germano, Paola; Jere, Haswell; Guidotti, G; Buonomo, E; Ciccacci, Fausto; Palombi, Leonardo; Marazzi, Maria Cristina

doi:10.1371/journal.pone.0071653

Cited by 25 publications

(38 citation statements)

References 14 publications

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“…In our study, the maternal prevalence of HIV infection was high (17%), similar to a previously reported study performed in metropolitan Maputo . Not unexpectedly, HIV infection was associated with high maternal mortality, also reported by others for this region . Remarkably, though, HIV‐related mortality was exacerbated by PPH.…”

Section: Discussionsupporting

confidence: 91%

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Maternal death and postpartum hemorrhage in sub‐Saharan Africa – A pilot study in metropolitan Mozambique

Lancaster

Barnes

Correia

et al. 2020

Research and Practice in Thrombosis and Haemostasis

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Background Maternal mortality in sub‐Saharan Africa is approximately 500 to 1000 per 100 000 births (vs. approximately 5‐20 in developed countries). Postpartum hemorrhage (PPH) is deemed responsible for 30% to 50% of the deaths. Objective To study PPH, risk factors, and mortality in metropolitan Mozambique to inform future studies and intervention strategies. Materials/Methods Retrospective cross‐sectional data extraction from all charts available to us (n = 495) recording deliveries between January and June 2018 at Maputo Central Hospital. Data included age, maternal survival, HIV status, parity, delivery mode, complications, vital signs, laboratory values, and maternal/fetal data. PPH was determined by charted diagnosis, interventions for hemorrhaging, placental abruption, transfusion, or blood loss. Autopsy reports from all deceased patients (n = 35) were examined. Results Median age was 29 years with 17% HIV prevalence. Risk factors for PPH (frequency, 12%) included parity (adjusted odds ratios (AORs) for 3+ versus nulliparity, 7.20 (95% confidence interval [CI], 2.46‐21.10), gestation length (AOR, 0.86; CI, 0.81‐0.92 per week), and body temperature (AOR, 1.10; CI, 1.04‐1.16 per 0.1°C). Maternal mortality was strongly associated with PPH (AOR, 5.22; 95% CI, 2.26‐12.08) and HIV (AOR, 11.66; 95% CI, 4.72‐28.78). Laboratory values (n = 241) were available from mothers experiencing complications (approximately 50%). Anemia (prevalence 54%) was a strong predictor of PPH with an inverse relationship between hemoglobin levels on admission (AOR, 0.62; 95% CI, 0.50‐0.77 per g/dL higher hemoglobin) and the probability of later suffering from PPH. Mothers who died following PPH had lower median hemoglobin (6.2 g/dL) than mothers who survived (9.2 g/dL). Protocols to estimate peripartum blood loss were not used; antifibrinolytics and/or cryoprecipitate were unavailable. Conclusion Postpartum hemorrhage is a serious problem even in metropolitan areas of sub‐Saharan Africa, and anemia influenced bleeding and death substantially. To address this problem, it is critical to raise awareness and region‐specific prevention and intervention protocols.

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Section: Discussionsupporting

confidence: 91%

“…32 Not unexpectedly, HIV infection was associated with high maternal mortality, also reported by others for this region. 29,33,34 Remarkably, though, HIV-related mortality was exacerbated by PPH. The probability of maternal mortality from PPH when the mother was infected with HIV was well over 50%.…”

Section: Discussionmentioning

confidence: 99%

Maternal death and postpartum hemorrhage in sub‐Saharan Africa – A pilot study in metropolitan Mozambique

Lancaster

Barnes

Correia

et al. 2020

Research and Practice in Thrombosis and Haemostasis

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“…In the model, pregnant women with CD4 cell counts > 350 started IPTp-SP in the second trimester and thus received no malaria prophylaxis in the first trimester [27]. Annual mortality due to malaria during pregnancy 0.33% Beta(0.033,9.967) [30] Annual mortality due to anaemia in pregnancy 1.0% Beta(0.1,9.9) [30] Annual HIV mortality among HIV-infected pregnant women 0.0161% Beta(0.16,9.84) [50] Annual HIV mortality among HIV-infected pregnant women on ART 0.007% Beta(0.07,9.93) [47,50] In all simulated strategies, it was assumed that all women were eligible to receive Option B+, the current recommended strategy for prevention of mother-tochild HIV transmission [28]. Under Option B+, all HIVinfected pregnant women receive ART regardless of their CD4 cell counts.…”

Section: Treatment Strategiesmentioning

confidence: 99%

Cost-effectiveness of malaria preventive treatment for HIV-infected pregnant women in sub-Saharan Africa

Choi

Brandeau

Bendavid

2017

Malar J

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Background: Malaria is a leading cause of morbidity and mortality among HIV-infected pregnant women in subSaharan Africa: at least 1 million pregnancies among HIV-infected women are complicated by co-infection with malaria annually, leading to increased risk of premature delivery, severe anaemia, delivery of low birth weight infants, and maternal death. Current guidelines recommend either daily cotrimoxazole (CTX) or intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) for HIV-infected pregnant women to prevent malaria and its complications. The cost-effectiveness of CTX compared to IPTp-SP among HIV-infected pregnant women was assessed.Methods: A microsimulation model of malaria and HIV among pregnant women in five malaria-endemic countries in sub-Saharan Africa was constructed. Four strategies were compared: (1) 2-dose IPTp-SP at current IPTp-SP coverage of the country ("2-IPT Low"); (2) 3-dose IPTp-SP at current coverage ("3-IPT Low"); (3) 3-dose IPTp-SP at the same coverage as antiretroviral therapy (ART) in the country ("3-IPT High"); and (4) daily CTX at ART coverage. Outcomes measured include maternal malaria, anaemia, low birth weight (LBW), and disability-adjusted life years (DALYs). Sensitivity analyses assessed the effect of adherence to CTX. Results:Compared with the 2-IPT Low Strategy, women receiving CTX had 22.5% fewer LBW infants (95% CI 22.3-22.7), 13.5% fewer anaemia cases (95% CI 13.4-13.5), and 13.6% fewer maternal malaria cases (95% CI 13.6-13.7). In all simulated countries, CTX was the preferred strategy, with incremental cost-effectiveness ratios ranging from costsaving to $3.9 per DALY averted from a societal perspective. CTX was less effective than the 3-IPT High Strategy when more than 18% of women stopped taking CTX during the pregnancy. Conclusion:In malarious regions of sub-Saharan Africa, daily CTX for HIV-infected pregnant women regardless of CD4 cell count is cost-effective compared with 3-dose IPTp-SP as long as more than 82% of women adhere to daily dosing.

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“…4,5 Most studies of postpartum mortality among HIV-infected women were performed before widespread use of antiretroviral therapy (ART) for prevention of mother to child transmission (PMTCT) and for maternal treatment, both of which would be expected to improve maternal outcomes. [5][6][7] Our aims were to determine the impact of HIV infection on 24-month postpartum mortality and evaluate risk factors for mortality among HIV-infected women in a setting with widespread uptake of ART and PMTCT services. We prospectively followed both HIV-infected and HIV-uninfected women in Botswana and ascertained maternal vital status at 24 months postpartum.…”

Section: Introductionmentioning

confidence: 99%

High Proportion of Deaths Attributable to HIV Among Postpartum Women in Botswana Despite Widespread Uptake of Antiretroviral Therapy

Zash

Souda

Leidner³

et al. 2017

AIDS Patient Care and STDs

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Mortality in the postpartum period may be impacted by antiretroviral therapy (ART) received in pregnancy, and whether ART is continued in the postpartum period. HIV-infected and HIV-uninfected mothers were enrolled within 48 h of delivery at five public hospital maternity wards throughout Botswana and followed for 24 months. Maternal deaths were reported by one of the approved contacts given by the mother at enrollment. Detailed information on the cause of death was not available. Risk factors for 24-month mortality were assessed using Cox proportional hazard models. From February 2012 to March 2013, 3000 mothers (1499 HIV infected and 1501 HIV uninfected) were enrolled, and 2985 (99.5%) were followed to 24 months or death, or until the death of their child. There were 26 total maternal deaths through 24 months postpartum [439 per 100,000 person-years (p-y)], 22 among HIV-infected women (758 per 100,000 p-y) and 4 among HIV-uninfected women (132 per 100,000 p-y). Maternal HIV-infection (aHR 5.0, 95% CI 1.6-15.2) and infant birth injury (aHR 3.8, 95% CI 1.3-11.4) were independent risk factors for maternal death. Universal ART in pregnancy became the standard-of-care after June 2012, and 978 (65%) women received ART in pregnancy; by 24 months postpartum or end of follow-up, 1148 (79%) had started ART overall. There was no significant difference in 24-month mortality among HIV-infected women who took ART in pregnancy and continued throughout the follow-up period compared with HIV-infected women who took ART or zidovudine in pregnancy and stopped postpartum (aHR 0.6, 95% CI 0.2-1.7). Despite high uptake of ART in pregnancy and postpartum, women with HIV infection in Botswana are five times more likely to die than HIV-uninfected women in the 24 months postpartum.

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Reduction of Maternal Mortality with Highly Active Antiretroviral Therapy in a Large Cohort of HIV-Infected Pregnant Women in Malawi and Mozambique

Cited by 25 publications

References 14 publications

Maternal death and postpartum hemorrhage in sub‐Saharan Africa – A pilot study in metropolitan Mozambique

Maternal death and postpartum hemorrhage in sub‐Saharan Africa – A pilot study in metropolitan Mozambique

Cost-effectiveness of malaria preventive treatment for HIV-infected pregnant women in sub-Saharan Africa

High Proportion of Deaths Attributable to HIV Among Postpartum Women in Botswana Despite Widespread Uptake of Antiretroviral Therapy

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