Browsing by Author "Myer, Benjamin"

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    Anaemia in early childhood pneumonia ? prevalence, predictors, and associated growth in the Drakenstein child health study (DCHS)
    (2023) Prentice, Carley; Myer, Benjamin
    Background: Concurrent anaemia and pneumonia in under-fives living in LMICs is a complex relationship associated with high morbidity and mortality. Ascertaining whether there is an increased prevalence of anaemia among pneumonia infected under-fives can provide valuable insights for more effective treatments. Additionally, highlighting individual and maternal risk factors of anaemia as well as associated adverse growth outcomes among under-fives can bring about findings to prioritise resource allocation for anaemia prevention and treatment. Methods: This cross-sectional sub-study analysed data from the Drakenstein Child Health Study (DCHS), a South African population-based birth cohort which enrolled pregnant women. Mother-child pairs were followed prospectively, and a subgroup of children had additional data collected (including haemoglobin (g/dL) measurements) during episodes of LRTI/pneumonia. Prevalence ratios were used to assess the impact of LRTI/pneumonia severity on anaemia status. Binary logistic regression models were used to analyze the effects of predictors on risk of child anaemia and linear regression models were used to analyze the effect of anaemia on adverse growth outcomes (WAZ and HAZ). Results: 28% of first LRTI/pneumonia episodes co-occurred with anaemia (95% CI, 24.9 - 31.8), and median child age was 8.4 months during the episode. When all LRTI/pneumonia episodes were included, anaemia prevalence was higher among under-fives treated in hospital compared to those treated in ambulatory care (38.9% compared to 30.3% respectively, p=0.04). Additionally, children who experienced recurrent LRTI/pneumonia (2+ episodes) were 1.28 times as likely to have anaemia compared to children experiencing a first episode (95% CI, 1.03 - 1.59, p=0.023). Overall, children aged 6-59 months, with low socioeconomic status, and were exclusively breastfed for more than 1 month were strongly associated with anaemia (p<0.05). Children with concurrent LRTI/pneumonia and anaemia were found to be at increased risk of wasting (WAZ) and decreased risk of stunting (HAZ). Conclusions: This study provides evidence of a high prevalence of concurrent LRTI/pneumonia and anaemia among under-fives in South Africa. It demonstrates the complex interplay between these conditions and various risk factors including older child age, maternal anaemia, exclusive breastfeeding, low socioeconomic status, and food insecurity. These findings highlight the need for multi-sectoral approaches to address the medical treatment and underlying social determinants of health that contribute to the burden of LRTI/pneumonia and anaemia in under-fives.
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    Economic evaluation of models of prevention of mother-to-child transmission of HIV intervention for large scale implementation
    (2021) Cunnama, Lucy; Sinanovic, Edina; Myer, Benjamin
    Background: Huge successes have been seen in the prevention of mother-to-child transmission of HIV (PMTCT) towards its elimination. Now amidst a landscape of universal antiretroviral therapy (ART), focus has been placed on different models of care to support and retain mother-infant pairs in the vulnerable postpartum phase. Methods The aim was to establish economic evidence for scaling-up approaches and models of care for PMTCT particularly during the postpartum period in Southern Africa. The economic data were collected during three studies, Safe Generations (Eswatini), MCH-ART and PACER (South Africa), using mixed bottom-up and top-down methodology. Outcomes of these studies were used to estimate the cost-effectiveness using an incremental cost effectiveness ratio (ICER, calculated by the difference in cost divided by the difference in effects) of lifelong ART in comparison to Option A (the standard of care at the time) in Eswatini; and to estimate the annual costs, costeffectiveness and budget impact of three models of care (Model I: Routine Care - mothers in general ART and infants in well-baby clinics; Model II: Integrated Care - mothers-infant pairs in integrated care in midwife obstetric unit; and Model III: Community Care - mothers in community adherence clubs and infants in well-baby clinics) in South Africa, from the provider and patient's perspectives. Costs are presented in 2019 United States Dollars (US $). Results Lifelong ART can be considered cost-effective in Eswatini with an ICER of US $984 per mother retained in care to six months postpartum. In Cape Town, South Africa, Routine Care cost US $226 per mother-infant pair per annum; Integrated Care cost US $341; and Community Care cost US $254. Annual patient costs (direct and indirect costs) for Models I-III, were US $30-55, US $23-45 and US $76 per mother-infant pair respectively. Comparatively Community Care was the most cost-effective model with an ICER of US $97 per mother-infant pair retained and mother virally suppressed. Scaling-up Community Care nationally in South Africa would require US $5 720 096 more than Routine Care, 0.2% of the total health budget for 2020/21. Conclusions This work has generated novel empirical data in the form of new cost estimates and cost comparisons across different models of care. It has also provided a unique comparison of the different models of care using a cost-effectiveness analysis; and further a novel budget impact analysis of different approaches to rolling these strategies out. This data has helped to fill the gap in the evidence base for instance lifelong ART was implemented in Eswatini as a direct result of the Safe Generations study findings. Community Care was found to be cost-effective and if scaled up nationally in South Africa would only require a small increment of the total health budget. However, we recommend a mixture of models of care to cater for the needs and preferences of patients. Decision makers can use the empirical findings to help set realistic budgets in Southern Africa and explore ideal model implementation to support mother-infant pairs in the crucial postpartum phase.
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    Maternal and neonatal outcomes of women with CHD in pregnancy
    (2023) Muller, Elani; Myer, Benjamin
    Introduction Although pregnancy is generally well tolerated in women with congenital heart disease (CHD), little is known about maternal and neonatal outcomes of these pregnancies in sub-Saharan Africa. This study aimed to describe the maternal and neonatal outcomes as stratified by cyanotic vs. acyanotic CHD, previous surgically repaired vs. unrepaired CHD, and between the different Modified World Health Organisation risk stratification (mWHO) classes. Methods A nested retrospective cohort study was conducted that included 83 women with CHD out of the 243 women with CVD enrolled to a Cape Town-based registry from patients seen at a tertiary referral healthcare centre by November 2015. This study analysed poor maternal and neonatal outcomes in women with CHD. Poor maternal outcome was defined as maternal death, antenatal hospitalisation, and/or perinatal ICU admission. Poor neonatal outcome was defined as preterm birth, low birth weight, NICU admission, general ward admission over 2 days, neonatal death, and/or miscarriage. Data were collected using REDCap, and statistical analyses included descriptive statistics, non-parametric tests, and logistic regressions to assess associations. Risk factors were adjusted for, and a two-tailed p-value <0.05 was considered significant. Results This cohort had a median age of 27 years (IQR 23 – 32) and gravidity of 2 (IQR 1 – 2). Women were enrolled with a median gestational age of 24 weeks (IQR 19 – 30). There were no statistically significant differences in clinical presentation at enrolment between those who had cyanotic CHD or not, and those who had surgically repaired CHD or not. More than half (54.2%) of women required either antenatal hospitalisation and/or perinatal intensive care unit (ICU) admission. Women classified as mWHO class II, II-III, III or IV were at increased risk of poor maternal outcome (OR 4.239, 95% CI 1.4 – 12.5), even when corrected for confounders. Neonates born from mothers from mWHO classes II-III, III and IV had an odds ratio of 3.1 (95% CI 1.8 – 8.2) for poor neonatal outcome but did not show significance when corrected for confounders. Univariable and multivariable regression analysis showed that the risk for poor neonatal outcome increased with maternal age. Conclusion As more women with CHD are reaching child-bearing age, risk stratification is imperative to ensure optimal care and favourable maternal and neonatal outcomes. We found the mWHO classification a useful tool to predict poor outcomes and recommend its use to tailor appropriate level of care for women with CHD in pregnancy.
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    Postnatal Clubs: Implementation Of A Differentiated And Integrated Model Of Care For Mothers Living With Hiv And Their HIV-Exposed Uninfected Babies
    (2023) Nelson, Aurelie; Myer, Benjamin
    Background Despite the reduction in the HIV mother-to-child transmission (MTCT) rate in South Africa, there are ongoing concerns in the breastfeeding period, linked to poor retention in care. To improve this retention, Post Natal Clubs (PNC) were created as an integrated, differentiated model of care providing psychosocial support and comprehensive care for the mother-infant pairs (MIP). We describe the implementation of PNC and examine its health outcomes in a peri-urban primary health care setting in Cape Town, South Africa. Methods In this cohort study, conducted between June 2016 and December 2019, MIPs were recruited into PNC between 6 weeks and 6 months of age and followed-up until 18 months of age. PNC MIPs were compared to a historical control group from the same setting. Outcomes included maternal Viral Load (VL), HIV testing at 9 and 18 months of age, and other maternal and child health outcomes. Results During the implementation of PNC study period, n=484 MIP were recruited with 84% overall attendance, 95% overall viral load suppression, and 98% overall uptake of HIV infant testing. Compared to historical controls, the PNC infant rapid test completion was 1.6 times higher (95% CI: 1.4-1.9) at 9 months and 2.0 times higher at 18 months (95% CI: 1.6-2.6). Through 12 months and between 12-18 months, maternal VL completion was higher in the PNC group compared to the historical control by 1.5 times (95% CI: 1.3-1.6) and 2.6 times (95% CI: 2.1- 3.2), respectively, with similar maternal VL suppression. Of 105 infants attending the 12 months visit, 99% were fully vaccinated by one year. Conclusion MIP in the PNC showed better PMTCT outcomes than historical controls with high levels of retention in care. Other outcomes such as immunisation results suggest that integration of services, such as in the PNC, is feasible and beneficial for MIPs.
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    The effect of low birth weight on timing to BCG vaccination in a rural district of Northern Ghana
    (2023) Ayamba, Emmanuel; Myer, Benjamin
    Introduction: Early Bacille Calmette-Guérin (BCG) vaccination of low birthweight (LBW) infants has been shown to have heterologous immunological effects by increasing the in vitro cytokine responses which contribute to the maturation of the infant immune system and thereby protecting against fatal infections in the neonatal period. It has been noted to also reduce neonatal mortality in these LBW infants. In some low-income countries, BCG vaccination is usually postponed for children born with a low birthweight (LBW). This has resulted in delayed timing to BCG vaccination. Ghana, however, does not have any restrictions on receiving BCG vaccination for LBW infants. This study therefore assessed the effects of low birthweight on timing to BCG vaccination in a context where there are no restrictions on vaccinations. Methods: The study used maternal and child health data collected from the Navrongo Health and Demographic Surveillance System (NHDSS). Age at BCG vaccination was the main outcome variable of interest whilst the weight at birth of the child was the main primary exposure variable. Frequencies, proportions, median and inter-quartile ranges (IQR) were used to describe the participants. Lognormal accelerated failure time (AFT) models were conducted, and time ratios obtained to assess the effect of birthweight on timing to BCG vaccination. Logistic regression models were also used to assess the factors associated with delays to BCG vaccination. Results: About 12% of the infants were low birthweights (less than 2500 grams) with 17% weighing less than 2000 grams and 83% weighing between 2000 and 2490 grams. The results showed than low birth weight infants had a median vaccination age of 2 days compared with normal birth weight (≥2500 grams) infants who had a median of 3 days. No statistically significant difference in time to BCG vaccination by birthweight status was observed. However, other characteristics which were statistically significantly associated with time to BCG included level of education of mother, place of delivery, socio-economic status of family and the age of mother. Conclusions: The study shows that low birthweight infants in the study area receive BCG vaccination as timely as normal birthweight infants with several maternal and infant characteristics as well as socio-demographic and health system factors been associated with the timing. It demonstrates that low birthweight infants can receive BCG vaccination on time if there are no restrictions regarding vaccination schedules.
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    The predictors and patterns of alcohol use in HIV positive women during their postpartum period, and how these impact viral load.
    (2023) Mazubane, Thandeka; Myer, Benjamin
    Introduction Although alcohol use among HIV-positive pregnant women in South Africa has been extensively researched, few studies have attempted to understand the longitudinal patterns and predictors of alcohol use when HIV-positive status intersects with the postpartum period. We examined the patterns of alcohol consumption during the postpartum period among HIV-positive women from Gugulethu, Cape Town; explored predictors associated with any alcohol consumption; and lastly, examined the association between alcohol use and HIV viral load. Methods Participants were recruited at the Gugulethu Community Health Centre while receiving prevention of mother to child transmission (PMTCT) services, obstetric, or postnatal care. The Alcohol Use Disorder Identification Test (AUDIT) screening tool was used to assess the alcohol use of eligible women. Participants were also assessed for hazardous alcohol use using the AUDIT-C scoring system during the analysis. The factors associated with patterns of alcohol use were then investigated using multiple logic regression and Generalised Mixed Effect Models. Using Generalised Mixed Effect Models, we also investigated the relationship between alcohol consumption and HIV viral load. Results Among 360 women (median age: 33 years), 10–28% reported alcohol use during the 24-month postpartum period, with alcohol use characterised by hazardous, binge drinking, and risky/dependency behaviour and associated with single relationship status and depression, whereas strong social support and patient-provider relationship was protective against risky/dependent alcohol use. We also found an association between hazardous, risky/dependent alcohol use and viral load, where hazardous drinkers and risky/dependent were 3 and 5 times more likely to have a suboptimal (>1000 copies/ml) viral load, respectively. Conclusion These unique data sheds light on the trajectories of alcohol use during the postpartum period in this vulnerable population, emphasizing the critical support and attention needed by this population and the strong focus public health needs to put on screening and interventions at a primary care level.
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    The prognostic value of HIV viral load in predicting viraemic outcomes of post-partum women on antiretroviral therapy: a secondary analysis of two randomised controlled trials from Gugulethu, Cape Town
    (2023) Egan, Daniel; Myer, Benjamin
    Background: Vertical transmission of HIV continues to be a significant health concern for HIV-infected women in pregnancy and postpartum, especially in Southern Africa, despite decreasing rates of infection. While better access to effective and acceptable antiretroviral therapy (ART) regimens has helped to improve control of viraemia in this group, ongoing vertical transmission continues despite being entirely preventable. The dynamics of transient viraemia, even in previously well-controlled individuals on ART, are not fully understood and may contribute to ongoing mother-to-child transmission (MTCT) despite therapy that is otherwise optimal. Methodology: Two randomised controlled trials (RCTs), the MCH-ART and PACART trials, were conducted in an antenatal clinic in Cape Town, South Africa, between 2013-2016 and 2016-2019 to investigate improvements to postnatal HIV care through use of integrated postnatal maternal and child clinics and adherence clubs, respectively. The present study conducted a pooled secondary analysis of data from these two trials to investigate the dynamics of HIV viraemia in these women and to estimate the prognostic strength of viral load (VL) measurements during the postpartum period. Sensitivity, specificity, predictive values, likelihood ratios and odds ratios for VL measurements were calculated at different cut-offs to predict later VL >1000 copies/ml. Cox proportional hazards models were used to estimate the risk of two consecutive measurements of VL >1000 copies/ml over the study period, based on starting viral load. Results: 883 HIV-infected pregnant women were followed-up for a median of 22.1 months (IQR: 17.7- 24.1), with a longer median length of follow-up in the PACART cohort (24.0 months) compared to the MCH-ART group (17.9 months). 826 (93.5%) of participants recorded at least one episode of VL <50 copies/ml, with 694 (78.6%) demonstrating VL <50 at the first study visit postpartum. 306 women (37%) demonstrated at least one episode of viraemia in the range of 50-999, while 307 (37.2%) experienced one or more episodes of VL >1000. As a predictor of future VL >1000, measurable viraemia >50 copies/ml was a specific (87.5%) but not sensitive (68%) test, with a clinical odds ratio of 14.8 (95% CI: 12.4-17.8). Similarly, current VL >200 was a good predictor of VL >1000 at the next visit, with an odds ratio of 26.1 (95% CI: 21.4-31.8), a sensitivity of 64%, and specificity of 94%. Cox proportional hazards analysis found that viraemia in the range of 50-999 copies/ml at the first study visit post-partum was associated with an increased hazard of two consecutive VL >1000 over the study period, when compared to participants with VL <50 at the same timepoint (HR: 1.75; 95% CI: 1.3-2.4; p<0.001). Conclusion: Episodes of viraemia in HIV-infected postpartum women remain common despite improving ART regimens and public HIV services. These represent windows of increased risk during which vertical transmission is more likely to occur. VL testing remains a useful tool in monitoring viraemia and may be helpful for identifying those who are more likely to develop substantial and prolonged viraemic episodes. These findings highlight one of the remaining problems perpetuating vertical transmission of HIV: unmeasured, untreated viraemia.