Search

This study aims to determine whether a novel cervical cancer screening toolkit will increase rates of pap test completion and HPV vaccination among Somali women living in the United States. We conducted a randomized controlled, pilot trial from June 2021 to February 2022. Somali women aged 21 to 70 were randomized to either receive a toolkit (infographic, video and an in-person health seminar) or not. Health passports confirming a completed pap test and/or HPV vaccination by clinician signature were used to measure outcomes. The primary outcome was pap test completion and the secondary outcome was HPV vaccination. We enrolled 57 participants. Patients randomized to the treatment arm were significantly more likely to have had a pap test (53.7% vs. 3.7%, p

Objectives Few studies have addressed optimal follow-up for HIV-infected women after cervical treatment. This study aimed to compare performance of three available tests to detect posttreatment cervical disease in HIV-infected women in Kenya. Design This is a prospective cohort study. Methods At least 6 months following cryotherapy, 517 HIV-infected women were evaluated concurrently with visual inspection with acetic acid (VIA), papanicolaou (Pap) smear, and high-risk human papillomavirus (HR-HPV) testing. Women positive by any test (≥low-grade squamous intraepithelial lesion for Pap) were scheduled for colposcopy and biopsy. Among 248 with histological confirmation [and 174 assumed to be truly negative for cervical intraepithelial neoplasia (CIN)2+ after testing negative by all three tests], the ability of each test alone, or in combination, to detect CIN2+ was calculated to determine their utility in posttreatment follow-up. Results The median age of women was 35 years, 68% were WHO stage 1-2, with a median CD4 cell count of 410 cells/μl, and 87% were on combination antiretroviral therapy. At a median of 6.3 months posttreatment, 64% had an abnormal screen by VIA, Pap, and/or HR-HPV. Among women with histological confirmation, 72 (30%) had persistent/recurrent CIN2+. As single tests, Pap correctly classified the most cases (83%) and had the highest specificity [91% (88 and 95%); sensitivity 44% (35 and 53%)], whereas HR-HPV had the highest sensitivity [85% (75 and 96%); specificity 54% (49 and 58%)]. VIA was not sensitive [27% (18 and 36%)] for the detection of posttreatment CIN2+ [specificity 82% (79 and 86%)]. Conclusion With the goal to minimize the number of false negatives (e.g. not miss CIN2+ posttreatment) in this population that is high-risk due to both prior cervical disease and HIV infection, HR-HPV-based algorithms are recommended.

Background Many HIV-infected pregnant women identified during antenatal care (ANC) do not enroll in long-term HIV care, resulting in deterioration of maternal health and continued risk of HIV transmission to infants. Methods We performed a cluster randomized trial to evaluate the effect of integrating HIV care into ANC clinics in rural Kenya. Twelve facilities were randomized to provide either integrated services (ANC, prevention of mother-to-child transmission, and HIV care delivered in the ANC clinic; n = 6 intervention facilities) or standard ANC services (including prevention of mother-to-child transmission and referral to a separate clinic for HIV care; n = 6 control facilities). Results There were high patient attrition rates over the course of this study. Among study participants who enrolled in HIV care, there was 12-month follow-up data for 256 of 611 (41.8%) women and postpartum data for only 325 of 1172 (28%) women. By 9 months of age, 382 of 568 (67.3%) infants at intervention sites and 338 of 594 (57.0%) at control sites had tested for HIV [odds ratio (OR) 1.45, 95% confidence interval (CI): 0.71 to 2.82]; 7.3% of infants tested HIV positive at intervention sites compared with 8.0% of infants at control sites (OR 0.89, 95% CI: 0.56 to 1.43). The composite clinical/immunologic progression into AIDS was similar in both arms (4.9% vs. 5.1%, OR 0.83, 95% CI: 0.41 to 1.68). Conclusions Despite the provision of integrated services, patient attrition was substantial in both arms, suggesting barriers beyond lack of service integration. Integration of HIV services into the ANC clinic was not associated with a reduced risk of HIV transmission to infants and did not appear to affect short-term maternal health outcomes.

Objective To describe the experience at a single facility regarding single-use emergency medication kits to treat obstetric emergencies in a resource-poor setting. Methods A retrospective study was conducted between October 2009 and October 2010 using data from the medical records of all patients treated with a single-use obstetric emergency medical kit (E-kit) during admission at the Riley Mother and Baby Hospital Wing, Eldoret, Kenya. Descriptive analyses were performed to quantify proportions of emergencies treated using E-kits in the first year of implementation. Summary statistics regarding maternal mortality from October 2008 to October 2010 were also retrieved to evaluate differences in the maternal mortality rates in the year of E-kit implementation and the year preceding implementation in order to estimate maternal mortalities averted with E-kit implementation. Results In the first year of implementation, 192 patients were treated using E-kits. Overall, 144 kits were used for treating postpartum hemorrhage, 52 for treating severe pre-eclampsia/eclampsia, and 1 for treating cardiopulmonary shock. There was a 30% reduction in maternal mortality ratio with E-kit implementation; however, results did not reach statistical significance. Conclusion The results indicate that single-use E-kits may help to achieve a significant reduction in hospital rates of maternal mortality.

A cluster randomized controlled trial was initiated in Kenya to determine if full integration (FI) of HIV care, including HAART, into antenatal care (ANC) clinics improves health outcomes among HIV-infected women and exposed infants, compared to a non-integrated (NI) model. This article examines ANC clients' satisfaction with and preferences regarding HIV-integrated services. In this cross-sectional study, pregnant women attending five FI clinics (n=185) and four NI clinics (n=141) completed an interviewer-administered questionnaire following an ANC visit. By self-report, 55 women (17%) were HIV(+), 230 (71%) were HIV(-), and 40 (12%) did not know their HIV status. Among HIV-infected women, 79% attending FI clinics were very satisfied with their clinic visit compared to 54% of women attending NI clinics (P=0.044); no such difference was found among HIV-uninfected women. In multivariate analysis, overall satisfaction was also independently associated with satisfaction with administrative staff, satisfaction with health care providers, positive evaluation of wait time, and having encountered a receptionist. Full integration of HIV care into antenatal clinics can significantly increase overall satisfaction with care for HIV-infected women, with no significant decrease in satisfaction for HIV-uninfected women served in the same clinics.

We sought to examine racial/ethnic differences in deliveries by caesarean section (CS) over time, particularly among women at low risk for this procedure. To do so, we conducted a retrospective cohort study at the University of California, San Francisco, a tertiary care academic centre. Births occurring between 1980 and 2001 were included in the analyses. Women with multiple gestations, fetuses in other than the cephalic presentation or with other known contraindications to vaginal birth were excluded. A total of 28 493 African American, Asian, Latina and White women were studied. Risk-adjusted models were created to explore differences in CS risk by race/ethnicity. We also performed analyses of subgroups of women at relatively low risk of CS, and explored changes in observed disparities over time. The overall CS rate was 15.8%. The absolute rate was highest among Latinas (16.7%) and lowest among Asians (14.7%). After adjustment for known risk factors, African American women had a 1.48 times greater odds of having a CS than did White women [95% confidence interval (CI) 1.31, 1.68], and Latina women had a 1.19 times greater odds [95% CI 1.05, 1.34]. Stepwise adjustment for confounders showed that this variation is not entirely explained by known risk factors. These differences exist even for women at low risk of CS, and have persisted over time. We conclude that racial and ethnic disparities in CS delivery exist, even among women presumed to be at lower risk of CS; rates have not improved with time. Disparities in risk-adjusted CS should be considered as a quality metric for obstetric care, whether at the national, state, hospital or provider level.

Objective To describe the uptake of and factors associated with HIV prevalence among pregnant women in a large-scale home-based HIV counseling and testing (HBCT) program in western Kenya. Methods In 2007, the Academic Model Providing Access to Healthcare Program (AMPATH) initiated HBCT to all individuals aged ≥13 years and high-risk children

BACKGROUND: Integrating antenatal care (ANC) and HIV care may improve uptake and retention in services along the prevention of mother-to-child transmission (PMTCT) cascade. This study aimed to determine whether integration of HIV services into ANC settings improves PMTCT service utilization outcomes. METHODS: ANC clinics in rural Kenya were randomized to integrated (6 clinics 569 women) or nonintegrated (6 clinics 603 women) services. Intervention clinics provided all HIV services including highly active antiretroviral therapy (HAART) whereas control clinics provided PMTCT services but referred women to HIV care clinics within the same facility. PMTCT utilization outcomes among HIV-infected women (maternal HIV care enrollment HAART initiation and 3-month infant HIV testing uptake) were compared using generalized estimating equations and Cox regression. RESULTS: HIV care enrollment was higher in intervention compared with control clinics [69% versus 36%; odds ratio = 3.94 95% confidence interval (CI): 1.14 to 13.63]. Median time to enrollment was significantly shorter among intervention arm women (0 versus 8 days hazard ratio = 2.20 95% CI: 1.62 to 3.01). Eligible women in the intervention arm were more likely to initiate HAART (40% versus 17%; odds ratio = 3.22 95% CI: 1.81 to 5.72). Infant testing was more common in the intervention arm (25% versus 18%) however not statistically different. No significant differences were detected in postnatal service uptake or maternal retention. CONCLUSIONS: Service integration increased maternal HIV care enrollment and HAART uptake. However PMTCT utilization outcomes were still suboptimal and postnatal service utilization remained poor in both study arms. Further improvements in the PMTCT cascade will require additional research and interventions.

Objective To describe the challenges and successes of integrating a public-sector cervical screening program into a large HIV care system in western Kenya. Methods The present study was a programmatic description and a retrospective chart review of data collected from a cervical screening program based on visual inspection with acetic acid (VIA) between June 2009 and October 2011. Results In total, 6787 women were screened: 1331 (19.6%) were VIA-positive, of whom 949 (71.3%) had HIV. Overall, 206 women underwent cryotherapy, 754 colposcopy, 143 loop electrical excision procedure (LEEP), and 27 hysterectomy. Among the colposcopy-guided biopsies, 27.9% had severe dysplasia and 10.9% had invasive cancer. There were 68 cases of cancer, equating to approximately 414 per 100 000 women per year. Despite aggressive strategies, the overall loss to follow-up was 31.5%: 27.9% were lost after a positive VIA screen, 49.3% between biopsy and LEEP, and 59.6% between biopsy and hysterectomy/chemotherapy. Conclusion The established infrastructure of an HIV treatment program was successfully used to build capacity for cervical screening in a low-resource setting. By using task-shifting and evidence-based, low-cost approaches, population-based cervical screening in a rural African clinical network was found to feasible; however, loss to follow-up and poor pathology infrastructure remain important obstacles.

Background Despite strong evidence for the effectiveness of anti-retroviral therapy for improving the health of women living with HIV and for the prevention of mother-to-child transmission (PMTCT), HIV persists as a major maternal and child health problem in sub-Saharan Africa. In most settings antenatal care (ANC) services and HIV treatment services are offered in separate clinics. Integrating these services may result in better uptake of services, reduction of the time to treatment initiation, better adherence, and reduction of stigma. Methodology/Principal Findings A prospective cluster randomized controlled trial design was used to evaluate the effects of integrating HIV treatment into ANC clinics at government health facilities in rural Kenya. Twelve facilities were randomized to provide either fully integrated services (ANC, PMTCT, and HIV treatment services all delivered in the ANC clinic) or non-integrated services (ANC clinics provided ANC and basic PMTCT services and referred clients to a separate HIV clinic for HIV treatment). During June 2009– March 2011, 1,172 HIV-positive pregnant women were enrolled in the study. The main study outcomes are rates of maternal enrollment in HIV care and treatment, infant HIV testing uptake, and HIV-free infant survival. Baseline results revealed that the intervention and control cohorts were similar with respect to socio-demographics, male partner HIV testing, sero-discordance of the couple, obstetric history, baseline CD4 count, and WHO Stage. Challenges faced while conducting this trial at low-resource rural health facilities included frequent staff turnover, stock-outs of essential supplies, transportation challenges, and changes in national guidelines. Conclusions/Significance This is the first randomized trial of ANC and HIV service integration to be conducted in rural Africa. It is expected that the study will provide critical evidence regarding the implementation and effectiveness of this service delivery strategy, with important implications for programs striving to eliminate vertical transmission of HIV and improve maternal health. Trial Registration ClinicalTrials.gov NCT00931216 NCT00931216.

The rate of cesarean delivery in the United States has increased from 4.5 percent in 1965 (1) to 31.8 percent in 2007 (2). Although much of this rise occurred in the 1970s and 1980s, the cesarean delivery rate has continued to rise by 1 percent per year over the past decade (3). Clinical conditions such as obesity, gestational hypertension, preeclampsia, gestational diabetes, and other chronic diseases have been shown to contribute to higher rates of cesarean deliveries, (4–10), in addition to nonclinical factors including patient and provider preferences, insurance type, socioeconomic status, regional differences, legal climate, and increasing maternal age (9–15). Numerous studies have focused on racial and ethnic differences in cesarean delivery rates, demonstrating that black women have the highest rates nationwide (16–19), even after adjustment for level of education, income, insurance status, and regional practice differences (1, 17, 20, 21). Many hypotheses have been suggested to explain the higher cesarean rates in black women including provider-level practices, hospital-level practices, patient-provider communication, patient preferences, and racial or ethnic discrimination (20–24). However, few studies have examined specific medical indications as a means to explain the differential rates in cesarean delivery across race (16). Although the documented medical indication for cesarean delivery is the most readily available source of information about the reason for this surgery, its assignment can be somewhat subjective and dependent on the perspective of the medical provider. Comparison of the indications for cesarean delivery may help to clarify potential patient-level differences and specific provider-level practices that may underlie racial and ethnic differences in cesarean delivery rates Our study attempts to examine differences in indications for cesarean section as a means of further elucidating the relationship between race and ethnicity and primary cesarean delivery risk among primiparous women.

Background In the US, an unacceptably high percentage of pregnant women do not undergo prenatal HIV testing. Previous studies have found increased uptake of prenatal HIV testing with abbreviated pre-test counseling, however little is known about patient decision making, testing satisfaction and knowledge in this setting. Methodology/Findings A randomized-controlled, non-inferiority trial was conducted from October 2006 through February 2008 at San Francisco General Hospital (SFGH), the public teaching hospital of the City and County of San Francisco. A total of 278 English- and Spanish-speaking pregnant women were randomized to receive either abbreviated or standard nurse-performed HIV test counseling at the initial prenatal visit. Patient decision making experience was compared between abbreviated versus standard HIV counseling strategies among a sample of low-income, urban, ethnically diverse prenatal patients. The primary outcome was the decisional conflict score (DCS) using O'Connor low-literacy scale and secondary outcomes included satisfaction with test decision, basic HIV knowledge and HIV testing uptake. We conducted an intention-to-treat analysis of 278 women – 134 (48.2%) in the abbreviated arm (AA) and 144 (51.8%) in the standard arm (SA). There was no significant difference in the proportion of women with low decisional conflict (71.6% in AA vs. 76.4% in SA, p = .37), and the observed mean difference between the groups of 3.88 (95% CI: −0.65, 8.41) did not exceed the non-inferiority margin. HIV testing uptake was very high (97. 8%) and did not differ significantly between the 2 groups (99.3% in AA vs. 96.5% in SA, p = .12). Likewise, there was no difference in satisfaction with testing decision (97.8% in AA vs. 99.3% in SA, p = .36). However, women in AA had significantly lower mean HIV knowledge scores (78.4%) compared to women in SA (83.7%, p

BACKGROUND: The provision of food supplementation to food-insecure patients initiating antiretroviral therapy (ART) may improve adherence to medications. METHODS: A home-based adherence support program at 8 government clinics assessed patients for food insecurity. Four clinics provided food supplementation and 4 acted as controls. The analysis compared adherence (assessed by medication possession ratio) CD4 and weight gain outcomes among food-insecure patients enrolled at the food clinics with those enrolled at the control clinics. RESULTS: Between May 1 2004 and March 31 2005 636 food- insecure adults were enrolled. Food supplementation was associated with better adherence to therapy. Two hundred fifty-eight of 366 (70%) patients in the food group achieved a medication possession ratio of 95% or greater versus 79 of 166 (48%) among controls (relative risk = 1.5; 95% confidence interval: 1.2 to 1.8). This finding was unchanged after adjustment for sex age baseline CD4 count baseline World Health Organization stage and baseline hemoglobin. We did not observe a significant effect of food supplementation on weight gain or CD4 cell response. CONCLUSIONS: This analysis suggests that providing food to food-insecure patients initiating ART is feasible and may improve adherence to medication. A large randomized study of the clinical benefits of food supplementation to ART patients is urgently needed to inform international policy.

5107 Background: To compare HIV+ and HIV- women with operable cervical cancer in a low resource contemporary setting. Methods: A retrospective study using well-matched controls from a Kenyan teaching and referral hospital. Results: 183 women were treated for cervical cancer between October 2007 and June 2011. The histologic subtype was squamous cell in all but one case. At presentation, 28 had operable lesions (Stage IA1–IIB1); 7 more received neoadjuvant chemotherapy prior to surgery. HIV seroprevalence was 54% (18/33) among initial operative cases and 57% among the neoadjuvant group (p=ns). Mean age was 42 (HIV+), and 43 (HIV-), (range 25-64). HIV- vs. HIV+ cervical cancer patients (mean CD4 count 373, 50%

MAY EXPLAIN DISPARITIES IN CESAREAN DELIVERY RISK SIERRA WASHINGTON, ALLISON BRYANT, YVONNE CHENG, ANJALI KAIMAL, AARON CAUGHEY, University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California OBJECTIVE: Racial and ethnic minorities have a higher risk of cesarean delivery (CD). We sought to examine possible medical indications for this higher risk. STUDY DESIGN: We conducted a retrospective cohort study of 15,366 nulliparous women delivering at one institution between 1980 and 2001. Black, White,AsianandLatinawomendelivering singletongestations at greater than24 weeks were included. Univariate andmultivariate analyses were used to evaluate the ethnic variation in risks of and indications for CD.We adjusted for insurance type, maternal age, smoking status, gestational age, birth weight, diabetes, hypertensive disorders,meconium stained amniotic fluid, and induction of labor. RESULTS: The overall rate of CD in our population was 20.6%. The adjusted odds for CD were 1.4 (p!0.001) and 1.3 (p!0.001) times greater for Black and Latina women, respectively, compared to White women. After adjustment, Black women had nearly twice the odds of having a CD for fetal distress. The adjusted odds ratios (AOR) for CD indications, stratified by race/ ethnicity, are presented in the Table. CONCLUSION: The climbing rate of CD is an important public health problem that differentially affects minority women. Black and Latina patients are more likely than other women to have a CD even after adjusting for chronic diseases, complications of pregnancy, and sociodemographic factors. After adjusting for such factors, Black women are more likely to have CD for fetal distress. These findings suggest that physician bias or racially/ethnically specific biologic factors may influence the rates of CD. These disparities in CD rates need to be addressed.