Mortality and Health Outcomes in HIV-Infected and HIV-Uninfected Mothers at 18–20 Months Postpartum in Zomba District, Malawi
Malawi. PLoS ONE 7(9): e44396. doi:10.1371/journal.pone.0044396
Mortality and Health Outcomes in HIV-Infected and HIV- Uninfected Mothers at 18-20 Months Postpartum in Zomba District, Malawi
Megan Landes 0
Monique van Lettow 0
Richard Bedell 0
Isabell Mayuni 0
Adrienne K. Chan 0
Lyson Tenthani 0
Erik Schouten 0
Kara K. Wools-Kaloustian, Indiana University, United States of America
0 1 Dignitas International, Zomba, Malawi, 2 Department of Family and Community Medicine, University of Toronto , Toronto, Ontario , Canada , 3 Dalla Lana School of Public Health, University of Toronto , Toronto, Ontario , Canada , 4 St. Michael's Hospital, University of Toronto , Toronto, Ontario , Canada , 5 Department of HIV and AIDS, Ministry of Health , Lilongwe, Malawi, 6 Management Sciences for Health, Lilongwe , Malawi
Background: Maternal morbidity and mortality among HIV-infected women is a global concern. This study compared mortality and health outcomes of HIV-infected and HIV-uninfected mothers at 18-20 months postpartum within routine prevention of mother-to-child transmission of HIV (PMTCT) services in a rural district in Malawi. Methods: A retrospective cohort study of mother-child dyads at 18-20 months postpartum in Zomba District. Data on socio-demographic characteristics, service uptake, maternal health outcomes and biometric parameters were collected. Results: 173 HIV-infected and 214 HIV-uninfected mothers were included. HIV-specific cohort mortality at 18-20 months postpartum was 42.4 deaths/1000 person-years; no deaths occurred among HIV-uninfected women. Median time to death was 11 months post-partum (range 3-19). Women ranked their health on a comparative qualitative scale; HIV-infected women perceived their health to be poorer than did HIV-uninfected women (RR 2.4; 95% CI 1.6-3.7). Perceived maternal health status was well correlated with an objective measure of functional status (Karnofsky scale; p,0.001). HIV-infected women were more likely to report minor (RR 3.8; 95% CI 2.3-6.4) and major (RR 6.2; 95% CI 2.2-17.7) signs or symptoms of disease. In multivariable analysis, HIV-infected women remained twice as likely to report poorer health [adjusted OR (aOR) 2.3; 95% CI 1.4-3.6], as did women with low BMI (aOR 2.1; 95% CI 1.1-4.0) and scoring lowest on the welfare scale (aOR 2.0; 95% CI 1.1-3.8). Conclusions: HIV-infected women show increased mortality and morbidity at 18-20 months postpartum. In our rural Malawian operational setting, where there is documented under-application of ART and poor adherence to PMTCT services, these results support attention to optimizing maternal participation in PMTCT programs.
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The reduction of maternal mortality remains one of the greatest
challenges in global health [1]. In particular, countries in
subSaharan Africa (SSA) continue to report alarmingly high maternal
mortality rates [2] and this has been, in part, attributed to the HIV
epidemic. HIV-infection has been shown to increase a womans
risk for obstetrical complications, as well as for illness during the
postpartum period [2,3,4]. During the 1990s, a 10-fold increase in
the prevalence of HIV-infection among women was reported in
Malawi, along with a concurrent doubling of the overall
pregnancy-related mortality risk [5].
During the past decade, there has been considerable progress in
SSA to scale up prevention of mother-to-child transmission of HIV
(PMTCT) services aimed to identify HIV-infection in pregnancy
for the prevention of vertical transmission, but also to refer
mothers for appropriate antiretroviral treatment (ART) services
when available and indicated.[68] Despite these efforts to
increase access to ART for women, several studies still show
considerable increased risk of mortality amongst HIV-infected
women in the postpartum period as well as an elevated incidence
of morbidity [913].
From 2003 to 2010, the primary prophylaxis regimen within the
Malawian PMTCT strategy was single dose nevirapine (sd-NVP).
At the time of study (20082009), PMTCT services included:
routine opt-out HIV testing and counselling (HTC) for women
presenting to antenatal clinics (ANC) and maternity wards, WHO
clinical staging and CD4 count if indicated (for WHO clinical
stage I or II) and available, initiation of highly active antiretroviral
treatment (ART) for women in WHO clinical stages III or IV or in
stages I and II if CD4 count ,250 cells/mm3, single dose
nevirapine (sd-NVP) for women not initiated on ART and for all
HIV-exposed infants, and follow-up of exposed infants up to 18
months.
We previously report within an operational research study
evaluating the uptake of PMTCT services in Zomba District, the
suboptimal coverage of PMTCT services including only 66%
percent of women taking sd-NVP at the time of delivery and 28%
of exposed infants being tested for HIV [14]. As part of this
previously reported study, we additionally collected data on
maternal deaths and health outcomes at 1820 months
postpartum for which (...truncated)