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Browsing by Author "Keiser, Olivia"
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Item Clinical and programmatic outcomes of HIV-exposed infants enrolled in care at geographically diverse clinics, 1997-2021: A cohort study(Public Library of Science, 2022-09-15) Edmonds, Andrew; Brazier, Ellen; Musick, Beverly S.; Yotebieng, Marcel; Humphrey, John; Abuogi, Lisa L.; Adedimeji, Adebola; Keiser, Olivia; Msukwa, Malango; Carlucci, James G.; Maia, Marcelle; Pinto, Jorge A.; Leroy, Valériane; Davies, Mary-Ann; Wools-Kaloustian, Kara K.; IeDEA; Biostatistics, School of Public HealthBackground: Although 1·3 million women with HIV give birth annually, care and outcomes for HIV-exposed infants remain incompletely understood. We analyzed programmatic and health indicators in a large, multidecade global dataset of linked mother-infant records from clinics and programs associated with the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. Methods and findings: HIV-exposed infants were eligible for this retrospective cohort analysis if enrolled at <18 months at 198 clinics in 10 countries across 5 IeDEA regions: East Africa (EA), Central Africa (CA), West Africa (WA), Southern Africa (SA), and the Caribbean, Central, and South America network (CCASAnet). We estimated cumulative incidences of DNA PCR testing, loss to follow-up (LTFU), HIV diagnosis, and death through 24 months of age using proportional subdistribution hazard models accounting for competing risks. Competing risks were transfer, care withdrawal, and confirmation of negative HIV status, along with LTFU and death, when not the outcome of interest. In CA and EA, we quantified associations between maternal/infant characteristics and each outcome. A total of 82,067 infants (47,300 EA, 10,699 CA, 6,503 WA, 15,770 SA, 1,795 CCASAnet) born from 1997 to 2021 were included. Maternal antiretroviral therapy (ART) use during pregnancy ranged from 65·6% (CCASAnet) to 89·5% (EA), with improvements in all regions over time. Twenty-four-month cumulative incidences varied widely across regions, ranging from 12·3% (95% confidence limit [CL], 11·2%,13·5%) in WA to 94·8% (95% CL, 94·6%,95·1%) in EA for DNA PCR testing; 56·2% (95% CL, 55·2%,57·1%) in EA to 98·5% (95% CL, 98·3%,98·7%) in WA for LTFU; 1·9% (95% CL, 1·6%,2·3%) in WA to 10·3% (95% CL, 9·7%,10·9%) in EA for HIV diagnosis; and 0·5% (95% CL, 0·2%,1·0%) in CCASAnet to 4·7% (95% CL, 4·4%,5·0%) in EA for death. Although infant retention did not improve, HIV diagnosis and death decreased over time, and in EA, the cumulative incidence of HIV diagnosis decreased substantially, declining to 2·9% (95% CL, 1·5%,5·4%) in 2020. Maternal ART was associated with decreased infant mortality (subdistribution hazard ratio [sdHR], 0·65; 95% CL, 0·47,0·91 in EA, and sdHR, 0·51; 95% CL, 0·36,0·74 in CA) and HIV diagnosis (sdHR, 0·40; 95% CL, 0·31,0·50 in EA, and sdHR, 0·41; 95% CL, 0·31,0·54 in CA). Study limitations include potential misclassification of outcomes in real-world service delivery data and possible nonrepresentativeness of IeDEA sites and the population of HIV-exposed infants they serve. Conclusions: While there was marked regional and temporal heterogeneity in clinical and programmatic outcomes, infant LTFU was high across all regions and time periods. Further efforts are needed to keep HIV-exposed infants in care to receive essential services to reduce HIV infection and mortality.Item Sub optimal HIV status ascertainment at antenatal clinics and the impact on HIV prevalence estimates: A cross sectional study(PLOS, 2022-12-01) Wangara, Fatihiyya; Estill, Janne; Kipruto, Hillary; Wools-Kaloustian, Kara; Chege, Wendy; Manguro, Griffins; Keiser, Olivia; Medicine, School of MedicineBackground While many countries including Kenya transitioned from sentinel surveillance to the use of routine antenatal care (ANC) data to estimate the burden of HIV, countries in Sub Saharan Africa reported several challenges of this transition, including low uptake of HIV testing and sub national / site-level differences in HIV prevalence estimates. In Kenya voluntary HIV testing is offered to all 1st ANC clients. However, some women may decline testing. We aim to predict the HIV positivity (as a proxy of prevalence) at ANC assuming 100% uptake of HIV testing and compare this to the observed positivity. Methods Using a cross sectional study design, we examine routine data on HIV testing among all women attending ANC in Kwale County, Kenya, for the period January 2015 to December 2019.We used a generalized estimating equation with binomial distribution to model the observed HIV prevalence as explained by HIV status ascertainment. We then used marginal standardization to predict the HIV prevalence at 100% HIV status ascertainment and make recommendations to improve the utility of ANC routine data for HIV surveillance. Results HIV testing at ANC was at 91.3%, slightly above the global target of 90%. If there was 100% HIV status ascertainment at ANC, the HIV prevalence would be 2.7% (95% CI 2.3–3.2). This was 0.3% lower than the observed prevalence. Across the yearly predictions, there was no difference between the observed and predicted values except for 2018 where the HIV prevalence was underestimated with an absolute bias of -0.2 percent. This implies missed opportunities for identifying new HIV infections in the year 2018. Conclusions Imperfect HIV status ascertainment at ANC overestimates HIV prevalence among women attending ANC in Kwale County. However, the use of ANC routine data may underestimate the true population prevalence. There is need to address both community level and health facility level barriers to the uptake of ANC services.