Publications by authors named "Lisa B Haddad"

95 Publications

Association of Delayed Treatment of Chlamydial Infection and Gonorrhea in Pregnancy and Preterm Birth.

Sex Transm Dis 2021 Jun 5. Epub 2021 Jun 5.

Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA Center for Biomedical Research, Population Council, New York, NY.

Background: Treating chlamydia and gonorrhea in pregnancy has been shown to decrease the associated risk of preterm birth in some studies. Delayed treatment of these infections among non-pregnant patients carries known consequences. It is unclear whether delayed treatment in pregnancy similarly increases adverse outcomes.

Methods: We conducted a retrospective cohort study of women who delivered at a safety-net hospital from July 2016 to June 2018. Women with at least one visit who were tested for chlamydia and gonorrhea were included. Women diagnosed after 36 weeks (preterm analysis) or 31 weeks (early preterm analysis) were excluded. We used multivariable logistic regression to examine the association between no infection, timely treatment (<1 week), and delayed treatment (>1 week, not treated) with preterm (<37 weeks) and early preterm (<32 weeks) birth.

Results: Among 3,154 deliveries, 389 (12%) were preterm. Among 3,107 deliveries, 74 (2%) were early preterm. In adjusted models, women with timely (aOR 1.7, 95% CI 1.0-2.7) and delayed (aOR 1.7, 95% CI 1.1-2.5) treatment had increased odds of preterm birth. Similarly, women with timely (aOR 2.5, 95% CI 1.0-6.2) and delayed (aOR 2.4, 95% CI 1.2-4.9) treatment had increased odds of early preterm birth. Among women who tested positive, multiple infections was not associated with an increase in preterm birth (preterm: 17% vs. 20%, p = 0.53; early preterm: 5% vs. 6%, p = 0.74).

Conclusions: Chlamydia and gonorrhea are associated with preterm and early preterm birth, regardless of time to treatment. Creative solutions are needed to improve prevention of these infections in pregnancy.
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http://dx.doi.org/10.1097/OLQ.0000000000001490DOI Listing
June 2021

Chronic Stress and Preconception Health Among Latina Women in Metro Atlanta.

Matern Child Health J 2021 Jul 28;25(7):1147-1155. Epub 2021 Apr 28.

Department of Epidemiology, Emory University Rollins School of Public Health, 1518 Clifton Road NE, Atlanta, GA, 30322, USA.

Background: Underserved subgroups are less likely to have optimal health prior to pregnancy. We describe preconception health indicators (behavior, pregnancy intention, and obesity) among pregnant Latina women with and without chronic stress in metro Atlanta.

Design: We surveyed 110 pregnant Latina women enrolled in prenatal care at three clinics in Atlanta. The survey assessed chronic stress, pregnancy intention, preconception behavior changes (taking folic acid or prenatal vitamins, seeking healthcare advice, any reduction in smoking or drinking), and previous trauma.

Results: Specific behaviors to improve health prior to pregnancy were uncommon (e.g., taking vitamins (25.5%) or improving nutrition (20.9%)). Just under half of women were experiencing a chronic stressor at the time of conception (49.5%). Chronically stressed women were more likely to be obese (aOR: 3.0 (1.2, 7.4)), less likely to intend their pregnancy (aOR: 0.3 (0.1, 0.7)), and possibly less likely to report any PHB (45.5% vs. 57.4%; aOR: 0.5 (0.2-1.1)).

Conclusions: Chronically stress women were less likely to enter prenatal care with optimal health. However, preconception behaviors were uncommon overall.
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http://dx.doi.org/10.1007/s10995-021-03164-wDOI Listing
July 2021

Addressing contraceptive needs exacerbated by COVID-19: A call for increasing choice and access to self-managed methods.

Contraception 2021 06 27;103(6):377-379. Epub 2021 Mar 27.

Population Council, New York, NY, USA.

The COVID-19 pandemic has exposed the vulnerability of global contraception provision, exacerbating the barriers to access reproductive health services, leading to suspension of clinical services and disruption of supply chains. Critical to combatting this crisis is the expansion of healthcare to include self-care approaches to de-medicalize contraception and increase an individual's agency in determining what method they use, when they use it, and where they obtain it. Expanding the mix of self-administered contraceptives is essential for ensuring choice, access, and availability. We highlight advances in the self-care movement and actions needed to strengthen self-management approaches to maximize our chances of preventing a reproductive health crisis.
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http://dx.doi.org/10.1016/j.contraception.2021.03.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7997847PMC
June 2021

Genital abnormalities, hormonal contraception, and HIV transmission risk in Rwandan serodifferent couples.

J Infect Dis 2021 Feb 9. Epub 2021 Feb 9.

Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.

Background: We explored the role of genital abnormalities and hormonal contraception in HIV transmission among heterosexual serodifferent couples in Rwanda.

Methods: From 2002-2011, non-antiretroviral treatment using HIV serodifferent couples were followed and sociodemographic and clinical data were collected, family planning provided, and HIV-negative partners retested. Couples were assessed for genital ulcers; non-ulcerative genital sexually transmitted infection (STI) including gonorrhea, chlamydia, and trichomoniasis; and non-STI vaginal infections including bacterial vaginosis and candida. Multivariable models evaluated associations between covariates and HIV transmission genetically linked to the index partner.

Results: Among 877 couples where the man was HIV-positive, 37 linked transmissions occurred. Factors associated with women's HIV acquisition included female partner genital ulceration (adjusted hazard ratio [aHR]=14.1) and male partner non-ulcerative STI (aHR=8.6). Among 955 couples where the woman was HIV-positive, 46 linked transmissions occurred. Factors associated with men's HIV acquisition included female partner non-ulcerative STI (aHR=4.4), non-STI vaginal dysbiosis (aHR=7.1), and male partner genital ulceration (aHR=2.6). Hormonal contraception use was not associated with HIV transmission or acquisition.

Conclusions: Our findings underscore the need for integrating HIV services with care for genital abnormalities. Barriers (e.g., cost for training, demand creation, advocacy, client education; provider time; clinic space) to joint HIV/STI testing need to be considered and addressed.
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http://dx.doi.org/10.1093/infdis/jiab071DOI Listing
February 2021

Interactions between Hormonal Contraception and Anti-Retroviral Therapy: An Updated Review.

Curr Obstet Gynecol Rep 2020 Sep 31;9(3):98-104. Epub 2020 May 31.

Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, GA, USA.

Purpose Of Review: Hormonal contraception provides women living with HIV the ability to control their fertility and avoid pregnancy-related morbidity. Due to shared metabolic pathways, there has been concern over drug-drug interactions between hormonal contraception and anti-retroviral therapy, which may affect the drugs' safety and efficacy. This article aims to provide an updated review of the most recent data around hormonal contraceptives and anti-retroviral therapy.

Recent Findings: Prior data have suggested possible pharmacologic interactions between certain hormonal contraceptives and anti-retroviral therapy. The most significant interactions implicated include those between progestin-based contraceptive implants and efavirenz as well as between combined hormonal contraceptives and protease inhibitors. Most past studies, however, feature small sample sizes with few clinical outcomes reported.

Summary: Recent data since 2017 have largely affirmed prior studies on this topic, showing possible pharmacokinetic relationships between certain contraceptives and anti-retrovirals. Notably, while the effectiveness of progestin-based contraceptives, specifically the implant, appears reduced with efavirenz use, the overall effectiveness may remain higher than most other contraceptive methods. Larger studies are needed to provide further guidance before contraceptive-prescribing recommendations can be changed.
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http://dx.doi.org/10.1007/s13669-020-00289-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864371PMC
September 2020

Pre-exposure Prophylaxis Implementation in Family Planning Services Across the Southern United States: Findings from a Survey Among Staff, Providers and Administrators Working in Title X-Funded Clinics.

AIDS Behav 2021 Jun 23;25(6):1901-1912. Epub 2021 Jan 23.

Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.

To improve women's access to pre-exposure prophylaxis (PrEP) in family planning (FP) clinics, we examined readiness to provide PrEP, and barriers and facilitators at the clinic level to integrate PrEP services into Title X-funded FP clinics across the Southern US. Title X-funded FP clinics across DHHS regions III (Mid-Atlantic), IV (Southeast), and VI (Southwest), comprising the Southern US. From February to June, 2018, we conducted a web-based, geographically targeted survey of medical staff, providers and administrators of Title X-funded FP clinics in DHHS regions III (Mid-Atlantic), IV (Southeast), and VI (Southwest). Survey items were developed using the Consolidated Framework for Implementation Research to assess constructs relevant to PrEP implementation. One-fifth of 283 unique Title X clinics across the South provided PrEP. Readiness for PrEP implementation was positively associated with a climate supportive of HIV prevention, leadership engagement, and availability of resources, and negatively associated with providers holding negative attitudes about PrEP's suitability for FP. The Title X FP network is a vital source of sexual health care for millions of individuals across the US. Clinic-level barriers to providing PrEP must be addressed to expand onsite PrEP delivery in Title X FP clinics in the Southern US.
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http://dx.doi.org/10.1007/s10461-020-03120-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8085117PMC
June 2021

Effect of efavirenz on levonorgestrel concentrations among Malawian levonorgestrel implant users for up to 30 months of concomitant use: a subanalysis of a randomized clinical trial.

Contracept X 2020 29;2:100027. Epub 2020 May 29.

US Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA.

Objectives: Our primary objective was to compare geometric mean levonorgestrel concentrations between levonorgestrel implant users who were or were not taking the antiretroviral efavirenz, for up to 30 months after implant initiation. Our secondary objective was to evaluate the pregnancy rate among levonorgestrel implant users on efavirenz.

Study Design: We performed a subanalysis of 42 Malawian women randomized to initiate the levonorgestrel implant as part of a parent randomized clinical trial. Our subset included 30 HIV-infected women taking efavirenz and 12 HIV-uninfected women not taking efavirenz. They underwent urine pregnancy testing every 3 months and serum levonorgestrel testing at day 3 and months 1, 3, 6, 12, 18, 24, 27 and 30 after implant initiation. Geometric mean levonorgestrel concentrations were calculated for efavirenz users and non-efavirenz users at each time point.

Results: The geometric mean levonorgestrel concentrations were lower for efavirenz users than non-efavirenz users at every time point; the geometric mean ratio for efavirenz users:non-efavirenz users ranged from 0.60 [90% confidence interval (CI) 0.46-0.79] at 1 month to 0.27 (90% CI 0.12-0.61) at 30 months after implant insertion. No pregnancies occurred over 60 woman-years of concomitant levonorgestrel implant and efavirenz use, although 11 women had levonorgestrel concentrations < 180 pg/mL (the previously suggested minimum threshold concentration for efficacy).

Conclusions: Efavirenz users had lower levonorgestrel concentrations than non-efavirenz users, and one third of our concomitant efavirenz and levonorgestrel implant users had concentrations < 180 pg/mL. Continued evaluation of the contraceptive efficacy of the levonorgestrel implant may be needed for efavirenz users.

Implications: Among 42 Malawian women using the levonorgestrel implant for contraception, women who were taking the antiretroviral efavirenz had lower serum levonorgestrel concentrations than women who were not taking efavirenz. However, none of the women who were taking efavirenz became pregnant over 60 women-years of follow-up.
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http://dx.doi.org/10.1016/j.conx.2020.100027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7752709PMC
May 2020

Chagas Disease Screening Using Point-of-Care Testing in an At-Risk Obstetric Population.

Am J Trop Med Hyg 2020 Dec 21. Epub 2020 Dec 21.

Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia.

Congenital transmission is the most important mode of transmission of Chagas disease (CD) in non-endemic countries. Identifying CD in reproductive-aged women is essential to reduce the risk of transmitting the disease to their children and offer treatment to women and their children, which could cure the disease. We evaluated the use of point-of-care (POC) testing for CD in postpartum patients. In our patient population, 16.7% (23/138) tested positive by POC testing, but confirmatory testing was negative for all patients. Among those considered high risk, 30% declined participation. Our results suggest limited utility of the point-of-care test used in our study and identify an opportunity for improvement to broaden diagnostic testing options. Our study also highlights the need to develop strategies to increase subject participation in future research.
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http://dx.doi.org/10.4269/ajtmh.20-0517DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7941822PMC
December 2020

Differences in maternal group B Streptococcus screening rates in Latin American countries.

Vaccine 2020 Dec 8. Epub 2020 Dec 8.

Yale Institute of Global Health, Department of Medicine (Section of Infectious Diseases), Yale School of Medicine. Department of Epidemiology of Microbial Diseases, Yale School of Public Health, 333 Cedar St, New Haven, CT 06510, USA. Electronic address:

Objective: To determine rates and results of maternal Group B streptococcus (GBS) screening during pregnancy and identify sociodemographic characteristics associated with GBS screening in Latin American countries.

Background: GBS is a primary cause of morbidity and mortality in neonates and is prevented by screening pregnant women for GBS before delivery and intrapartum antibiotic treatment. Yet, data regarding national GBS screening practices and the epidemiology of maternal GBS colonization in Latin America are limited.

Methods: We conducted a retrospective observational study using de-identified records of pregnant women in six Latin American countries from a regional database. 460,328 collected from January 1, 2009 through December 31, 2012 met study criteria and were included. Maternal screening rates for GBS were determined, association of demographic variables (ethnicity, age, education level, and civil status) with maternal GBS screening was determined using logistic regression, odds ratios were calculated comparing incidence of adverse neonatal outcomes (sepsis, pneumonia, and meningitis) between countries with high and low rates of GBS screening, maternal GBS colonization prevalence was determined by year and association of demographic variables with maternal GBS colonization was determined using logistic regression.

Results: Maternal GBS screening was less than 15% in each country, except Uruguay which screened greater than 65% of women. The final regression model examining maternal screening rates and demographic variables included the covariates ethnicity, maternal age group, education level and civil status. Countries with lower rates of maternal GBS screening had increased odds of neonatal sepsis [OR 23.3; 95% CI (15.2-35.9)] and pneumonia [OR 19.9; 95% CI (12.1-32.6)]. In Uruguay, GBS prevalence over the study period was 18.5%. Black women, older women and women without a primary education had higher rates of GBS colonization (21.3%, 20.4% and 21.9% respectively).

Conclusions: Our study highlights the need for national policy and investments to increase maternal GBS screening and better understand the prevalence of maternal GBS colonization in Latin America. Further research on the burden of neonatal GBS disease within Latin America is needed to inform the introduction of a maternal GBS vaccine, when available.
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http://dx.doi.org/10.1016/j.vaccine.2020.10.082DOI Listing
December 2020

Health Literacy and Associated Outcomes in the Postpartum Period at Grady Memorial Hospital.

Matern Child Health J 2021 Apr 16;25(4):599-605. Epub 2020 Nov 16.

Department of Obstetrics and Gynecology, Emory University School of Medicine, 550 Peachtree St NE, MOT 8th Floor, Atlanta, GA, 30308, USA.

Objectives: Many studies correlate lower health literacy with poorer health outcomes and inferior provider-patient communication. Little is known about how impaired health literacy among women receiving prenatal care at inner city public hospitals may impact reproductive health behaviors and outcomes. The objective of this study was to assess health literacy among postpartum women receiving care at a public tertiary care center and to explore the association of impaired health literacy with prenatal care attendance and postpartum outcomes.

Methods: Written consent was obtained before completing the 7-item REALM-SF study tool to assess health literacy. A score of zero to three indicated low health literacy, four to six moderately low health literacy, and seven adequate health literacy. Patients completed a 25-item demographic questionnaire, and medical outcomes were obtained via this questionnaire and chart review. Descriptive statistics were generated, and bivariate and multivariate analyses evaluated the association between REALM-SF score and study outcomes.

Results: We recruited 300 adult English-speaking postpartum women and 293 were included in the final analysis. The majority of participants (53.9%) experienced impaired health literacy (score zero to six). Most respondents completed high school or higher education (77.1%), 17.8% had no prenatal care, and 83.6% reported that this pregnancy was unplanned. After adjusting for age, race, and education, women in the lowest health literacy group were less likely to indicate a plan to exclusively breastfeed (aRR = 0.54, p = 0.03).

Conclusions For Practice: Impaired health literacy affects a majority of our patients and is associated with reproductive health outcomes, including exclusive breastfeeding. Health care providers should attempt to overcome differences in health literacy through strong breastfeeding promotion. Verbal and written patient education materials should be tailored to the needs of patients with impaired health literacy.
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http://dx.doi.org/10.1007/s10995-020-03030-1DOI Listing
April 2021

Contraception methods used among women with HIV starting antiretroviral therapy in a large United States clinical trial, 2009-2011.

Contraception 2021 Apr 12;103(4):225-231. Epub 2020 Nov 12.

Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.

Objective(s): We describe contraception and dual method use among women with HIV initiating antiretroviral therapy (ART) in a U.S. clinical trial and examine associated factors.

Study Design: We analyzed data from ART-naïve women aged 45 years and under initiating one of 3 regimens as part of A5257 (May 2009-June 2011) which required that women at risk for pregnancy use contraception. We classified self-reported methods as more effective (Tier 1 [intrauterine device, hysterectomy, permanent contraception] and Tier 2 [hormonal rings, patches, injections, pills]) versus less effective (Tier 3 [condoms alone] and Tier 4 [withdrawal, none]). We used logistic regression models to assess associations with use of (a) more effective, and (b) dual methods (condoms with a more effective method).

Results: Of 285 women, majority were Black (59%), had annual income <$20,000 (54%), and had government insurance (68%). The most common contraceptive methods reported at baseline were permanent contraception (37%), male condoms alone (31%), and injectable progestin (8%); 41% and 16% reported Tier 1 and 2 use, respectively; 36% reported dual method use. Use of more effective and dual methods did not change 48 and 96 weeks after ART initiation (p > 0.05). In multivariable analyses, baseline use of more effective and dual methods was associated with age at least 40 years versus 18 to 29 years (odds ratio [OR] 4.46, 95% confidence interval [CI] 2.12, 9.35) and having at least one child (OR 2.31, 95%CI 1.27, 4.20).

Conclusions: In women initiating modern ART in a clinical trial, permanent contraception was common, while use of other more effective contraceptive methods was low and did not change after ART initiation. Efforts are needed to improve integration of family planning services for women within the context of HIV clinical trials.

Implications: The findings highlight the importance of improving integration of HIV and family planning services, including in the context of clinical trials.
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http://dx.doi.org/10.1016/j.contraception.2020.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7925358PMC
April 2021

Abortion restrictions in the state of Georgia: Anticipated impact on people seeking abortion.

Contraception 2021 Feb 17;103(2):121-126. Epub 2020 Oct 17.

Emory University School of Medicine, Division of Family Planning, 49 Jesse Hill Jr. Drive SE, Atlanta, GA 30303, USA. Electronic address:

Objective: To explore the impact of restrictive abortion policies in the state of Georgia on the lives of people seeking abortion and how they would manage unwanted pregnancies.

Study Design: We conducted a cross sectional study of English and Spanish-speaking people seeking abortion from three high-volume outpatient abortion clinics in Atlanta, Georgia from April 2019 through August 2019. Participants completed a multiple-choice questionnaire. We used bivariable and multivariable analysis to explore relationships between demographic characteristics and how people would manage their unwanted pregnancies if abortion were illegal in the state. Two researchers (EC and SC) conducted qualitative analysis on free response answers and coded them by key emotion.

Results: Of the 382 participants, 312 (81.9%) considered at least one way to end their pregnancy if abortion were illegal in Georgia: 252 (66.1%) by traveling to another state, 85 (22.3%) by self-management with medications and/or herbs, and 32 (8.4%) considered self-harm behaviors. When asked how they would feel about not being able to have a desired abortion, 94% reported negative emotions, ranging from "scared" to "enslaved."

Conclusions: Limiting access to legal abortion in Georgia would negatively impact the lives of people seeking abortion and has the potential to drive individuals to seek more costly and risky alternatives to end their pregnancy.

Implications: Restricting abortion in Georgia may cause medically unnecessary delays in care, increased travel time, cost and negative emotional responses to people seeking abortion. Mitigating strategies include legislative challenges to restrictive laws as well as harm reduction education.
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http://dx.doi.org/10.1016/j.contraception.2020.10.010DOI Listing
February 2021

A Prospective Study of Exposure to Gender-Based Violence and Risk of Sexually Transmitted Infection Acquisition in the Women's Interagency HIV Study, 1995-2018.

J Womens Health (Larchmt) 2020 10 30;29(10):1256-1267. Epub 2020 Sep 30.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.

Our objectives were to estimate the association of gender-based violence (GBV) experience with the risk of sexually transmitted infection (STI) acquisition in HIV-seropositive and HIV-seronegative women, to compare the STI risks associated with recent and lifetime GBV exposures, and to quantify whether these associations differ by HIV status. We conducted a multicenter, prospective cohort study in the Women's Interagency HIV Study, 1994-2018. Poisson models were fitted using generalized estimating equations to estimate the association of past 6-month GBV experience (physical, sexual, or intimate partner psychological violence) with subsequent self-reported STI diagnosis (gonorrhea, syphilis, chlamydia, pelvic inflammatory disease, or trichomoniasis). Data from 2868 women who reported recent sexual activity comprised 12,069 person-years. Higher STI risk was observed among HIV-seropositive women (incidence rate [IR] 5.5 per 100 person-years) compared with HIV-seronegative women (IR 4.3 per 100 person-years). Recent GBV experience was associated with a 1.28-fold (95% confidence interval [CI] 0.99, 1.65) risk after adjustment for HIV status and relevant demographic, socioeconomic, and sexual risk variables. Other important risk factors for STI acquisition included unstable housing (adjusted incidence rate ratio [AIRR] 1.81, 95% CI 1.32-2.46), unemployment (AIRR 1.42, 95% CI 1.14-1.76), transactional sex (AIRR 2.06, 95% CI 1.52-2.80), and drug use (AIRR 1.44, 95% CI 1.19-1.75). Recent physical violence contributed the highest risk of STI acquisition among HIV-seronegative women (AIRR 2.27, 95% CI 1.18-4.35), whereas lifetime GBV experience contributed the highest risk among HIV-seropositive women (AIRR 1.59, 95% CI 1.20-2.10). GBV prevention remains an important public health goal with direct relevance to women's sexual health.
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http://dx.doi.org/10.1089/jwh.2019.7972DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7583344PMC
October 2020

Pre-Exposure Prophylaxis Integration Into Family Planning Services at Title X Clinics in the Southeastern United States: Protocol for a Mixed Methods Hybrid Type I Effectiveness Implementation Study (Phase 2 ATN 155).

JMIR Res Protoc 2020 Sep 25;9(9):e18784. Epub 2020 Sep 25.

Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA, United States.

Background: Adolescent and young adult women (AYAW), particularly racial and ethnic minorities, in the Southern United States are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is an effective, scalable, individual-controlled HIV prevention strategy that is grossly underutilized among women of all ages and requires innovative delivery approaches to optimize its benefit. Anchoring PrEP delivery to family planning (FP) services that AYAW already trust, access routinely, and deem useful for their sexual health may offer an ideal opportunity to reach women at risk for HIV and to enhance their PrEP uptake and adherence. However, PrEP has not been widely integrated into FP services, including Title X-funded FP clinics that provide safety net sources of care for AYAW. To overcome potential implementation challenges for AYAW, Title X clinics in the Southern United States are uniquely positioned to be focal sites for conceptually informed and thoroughly evaluated PrEP implementation science studies.

Objective: The objective of this study is two-fold: to evaluate multilevel factors associated with the level of PrEP adoption and implementation (eg, PrEP screening, counseling, and prescription) within and across 3 FP clinics and to evaluate PrEP uptake, persistence, and adherence among female patients in these clinics over a 6-month follow-up period.

Methods: Phase 2 of Planning4PrEP (Adolescent Medicine Trials Network for HIV/AIDS Interventions 155) is a mixed methods hybrid type 1 effectiveness implementation study to be conducted in three clinics in Metro Atlanta, Georgia, United States. Guided by the Exploration, Preparation, Implementation, and Sustainment framework, this study will prepare clinics for PrEP integration via clinic-wide trainings and technical assistance and will develop clinic-specific PrEP implementation plans. We will monitor and evaluate PrEP implementation as well as female patient PrEP uptake, persistence, and adherence over a 6-month follow-up period.

Results: Phase 2 of Planning4PrEP research activities began in February 2018 and are ongoing. Qualitative data analysis is scheduled to begin in Fall 2020.

Conclusions: This study seeks to evaluate factors associated with the level of PrEP adoption and implementation (eg, PrEP screening, counseling, and prescription) within and across 3 FP clinics following training and implementation planning and to evaluate PrEP uptake, persistence, and adherence among female patients over a 6-month follow-up period. This will guide future strategies to support PrEP integration in Title X-funded clinics across the Southern United States.

Trial Registration: ClinicalTrials.gov NCT04097834; https://clinicaltrials.gov/ct2/show/NCT04097834.

International Registered Report Identifier (irrid): DERR1-10.2196/18784.
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http://dx.doi.org/10.2196/18784DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7547391PMC
September 2020

Postpartum long-acting contraception uptake and service delivery outcomes after a multilevel intervention in Kigali, Rwanda.

BMJ Sex Reprod Health 2020 Sep 16. Epub 2020 Sep 16.

Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA

Introduction: Postpartum family planning (PPFP) is critical to reduce maternal-child mortality, abortion and unintended pregnancy. As in most countries, the majority of PP women in Rwanda have an unmet need for PPFP. In particular, increasing use of the highly effective PP long-acting reversible contraceptive (LARC) methods (the intrauterine device (IUD) and implant) is a national priority. We developed a multilevel intervention to increase supply and demand for PPFP services in Kigali, Rwanda.

Methods: We implemented our intervention (which included PPFP promotional counselling for clients, training for providers, and Ministry of Health stakeholder involvement) in six government health facilities from August 2017 to October 2018. While increasing knowledge and uptake of the IUD was a primary objective, all contraceptive method options were discussed and made available. Here, we report a secondary analysis of PP implant uptake and present already published data on PPIUD uptake for reference.

Results: Over a 15-month implementation period, 12 068 women received PPFP educational counselling and delivered at a study facility. Of these women, 1252 chose a PP implant (10.4% uptake) and 3372 chose a PPIUD (27.9% uptake). On average providers at our intervention facilities inserted 83.5 PP implants/month and 224.8 PPIUDs/month. Prior to our intervention, 30 PP implants/month and 8 PPIUDs/month were inserted at our selected facilities. Providers reported high ease of LARC insertion, and clients reported minimal insertion anxiety and pain.

Conclusions: PP implant and PPIUD uptake significantly increased after implementation of our multilevel intervention. PPFP methods were well received by clients and providers.
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http://dx.doi.org/10.1136/bmjsrh-2020-200741DOI Listing
September 2020

Factors that Lengthen Patient Hospitalizations Following Laparoscopic Hysterectomy.

JSLS 2020 Jul-Sep;24(3)

Emory University Health System, Atlanta, GA, USA.

Objective: To establish descriptive observations associated with prolonged hospitalization after laparoscopic hysterectomy prior to the implementation of a department-wide Enhanced Recovery After Surgery protocol.

Methods: A retrospective cohort study at three academic affiliated hospitals in the southeastern United States was conducted evaluating length of hospitalization by patient, surgical, and physician factors for 384 patients who underwent total laparoscopic hysterectomy, laparoscopic assisted vaginal hysterectomy, and robotic assisted total laparoscopic hysterectomy for benign conditions by general and subspecialized gynecologists from 2010 to 2015.

Results: Among 384 patients, 19.5% experienced prolonged hospitalization, defined as greater than one day. After adjusting for covariates, robotic assisted total laparoscopic hysterectomy (aOR 3.13), dietary restrictions on postoperative day 1 (aOR 4.42), postoperative nausea or vomiting (aOR 2.01), and postoperative complications (aOR 3.58) were associated with prolonged hospitalization.

Conclusion: Data from this study were collected prior to implementation of department-wide enhanced recovery after surgery protocols and highlights areas for improvement. Implementation of specific aspects of these protocols, including aggressive prevention of postoperative nausea and vomiting and early feeding, are easily made changes which may help to effectively decrease length of stay after laparoscopic hysterectomy. Patient and provider education on enhanced recovery protocols is also key to reducing length of stay.
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http://dx.doi.org/10.4293/JSLS.2020.00029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7362931PMC
January 2021

Repeat Pregnancies Among US Women Living With HIV in the SMARTT Study: Temporal Changes in HIV Disease Status and Predictors of Preterm Birth.

J Acquir Immune Defic Syndr 2020 11;85(3):346-354

Section of Infectious Diseases, Department of Pediatrics, Tulane University School of Medicine, New Orleans, LA.

Background: Birth rates among women living with HIV (WLHIV) have increased recently, with many experiencing multiple pregnancies. Yet, viral suppression is often not sustained between pregnancies. In addition, protease inhibitors (PIs) have been associated with preterm birth, but associations between integrase strand transfer inhibitors (INSTIs) and preterm birth are less well characterized.

Methods: We studied WLHIV with ≥2 live-born infants enrolled into the Pediatric HIV/AIDS Cohort Study Surveillance Monitoring for Antiretroviral Treatment Toxicities (SMARTT) study between 2007 and 2018, comparing CD4 counts and viral loads (VLs) between 2 consecutive SMARTT pregnancies. We evaluated associations of covariates with CD4 and viral suppression and the association of PI/INSTI use during pregnancy with odds of preterm birth.

Results: There were 736 women who had ≥2 live-born children enrolled in SMARTT (1695 pregnancies). Median CD4 counts remained stable over repeat pregnancies. Although >80% of women achieved VL suppression during pregnancy, more than half had a detectable VL early in their subsequent pregnancy. In adjusted models including all singleton pregnancies, an increased odds of preterm birth was observed for women with first trimester PI initiation (adjusted odds ratio: 1.97; 95% confidence interval: 1.27 to 3.07) compared with those not receiving PIs during pregnancy and for first trimester INSTI initiation (adjusted odds ratio: 2.39; 95% confidence interval: 1.04 to 5.46) compared with those never using INSTIs during pregnancy.

Conclusions: Most WLHIV achieved VL suppression by late pregnancy but many were viremic early in subsequent pregnancies. First trimester initiation of PIs or INSTIs was associated with a higher risk of preterm birth.
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http://dx.doi.org/10.1097/QAI.0000000000002445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8086749PMC
November 2020

Gabapentin as an adjunct to paracervical block for perioperative pain management for first-trimester uterine aspiration: a randomized controlled trial.

Am J Obstet Gynecol 2020 12 11;223(6):884.e1-884.e10. Epub 2020 Jun 11.

Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA.

Background: Pain management approaches during uterine aspiration vary, which include local anesthetic, oral analgesics, moderate sedation, deep sedation, or a combination of approaches. For local anesthetic approaches specifically, we continue to have suboptimal pain control. Gabapentin as an adjunct to pain management has proven to be beneficial in gynecologic surgery. We sought to evaluate the impact of gabapentin on perioperative pain during surgical management of first-trimester abortion or early pregnancy loss with uterine aspiration under local anesthesia.

Objective: We hypothesized that adding gabapentin to local anesthesia will reduce perioperative and postoperative pain associated with uterine aspiration. Secondary outcomes included tolerability of gabapentin and postoperative pain, nausea, vomiting, and anxiety.

Study Design: We conducted a randomized double-blinded placebo-controlled trial of gabapentin 600 mg given 1 to 2 hours preoperatively among subjects receiving a first-trimester uterine aspiration under paracervical block in an outpatient ambulatory surgery center. There were 111 subjects randomized. The primary outcome was pain at time of uterine aspiration as measured on a 100-mm visual analog scale. Secondary outcomes included pain at other perioperative time points. To assess changes in pain measures, an intention to treat mixed effects model was fit with treatment groups (gabapentin vs control) as a between-subjects factor and time point as a within-subjects factor plus their interaction term. Because of a non-normal distribution of pain scores, the area under the curve was calculated for secondary outcomes with comparison of groups utilizing Mann-Whitney U tests.

Results: Among the 111 randomized, most subjects were Black or African American (69.4%), mean age was 26 years (±5.5), and mean gestational age was 61.3 days (standard deviation, 14.10). Mean pain scores at time of uterine aspiration were 66.77 (gabapentin) vs 71.06 (placebo), with a mean difference of -3.38 (P=.51). There were no significant changes in pain score preoperatively or intraoperatively. Subjects who received gabapentin had significantly lower levels of pain at 10 minutes after surgery (mean difference [standard error (SE)]=-13.0 [-5.0]; P=.01) and 30 minutes after surgery (mean difference [SE]=-10.8 [-5.1]; P=.03) compared with subjects who received placebo. Median nausea scores and incidence of emesis pre- and postoperatively did not differ between groups. Similarly, anxiety scores did not differ between groups, before or after the procedure. At 10 and 30 minutes after the procedure, most participants reported no side effects or mild side effects, and this did not differ between groups.

Conclusion: Preoperative gabapentin did not reduce pain during uterine aspiration. However, it did reduce postoperative pain, which may prove to be a desired attribute of its use, particularly in cases where postoperative pain may be a greater challenge.
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http://dx.doi.org/10.1016/j.ajog.2020.06.011DOI Listing
December 2020

Abortion Trends in Georgia Following Enactment of the 22-Week Gestational Age Limit, 2007-2017.

Am J Public Health 2020 May 21:e1-e5. Epub 2020 May 21.

Kelli Stidham Hall, Sara Redd, Subasri Narasimhan, Elizabeth A. Mosley, Sophie A. Hartwig, Emily Lemon, and Roger Rochat are with the Rollins School of Public Health, Emory University, Atlanta, GA. Erin Berry, Eva Lathrop, Lisa B. Haddad, and Carrie Cwiak are with the Department of Obstetrics and Gynecology, School of Medicine, Emory University, Atlanta.

To measure trends before, during, and after implementation of Georgia House Bill 954, a limit on abortion at 22 or more weeks of gestation passed in 2012, in total abortions and abortions by gestational age and state residence. We analyzed aggregate year-level induced termination of pregnancy data from the Georgia Department of Public Health from 2007 to 2017. We used linear regression to describe annual trends in the number of abortions and χ analyses to describe changes in proportions of abortions by gestational age (< 20 weeks, 20-21 weeks, and > 21 weeks) across policy implementation periods (before, partial, and full implementation) for Georgia residents and nonresidents. Although the total number of abortions and abortions at 21 weeks or less remained stable from 2007 to 2017, the number of abortions at more than 21 weeks declined ( = .02). The decline in number of abortions at more than 21 weeks was steeper for nonresidents (31/year; Β = -31.3;  = .02) compared with Georgia residents (14/year; Β = -13.9;  = .06). Findings suggest that implementation of Georgia's 22-week gestational age limit has effectively limited access to needed abortion services in Georgia and beyond. (. Published online ahead of print May 21, 2020: e1-e5. doi:10.2105/AJPH.2020.305653).
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http://dx.doi.org/10.2105/AJPH.2020.305653DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7287556PMC
May 2020

Trichomonas vaginalis in Pregnancy: Patterns and Predictors of Testing, Infection, and Treatment.

Obstet Gynecol 2020 05;135(5):1136-1144

Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, and the Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts; and the Emory University School of Medicine, and the Department of Gynecology and Obstetrics, the Division of Infectious Disease, Department of Medicine, and the Division of Family Planning, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA.

Objective: To identify factors associated with testing for and diagnosis of trichomoniasis in pregnancy and to describe patterns of treatment and tests of reinfection or persistence.

Methods: We conducted a retrospective cohort study of women who delivered from July 2016 to June 2018 at one institution. Testing for Trichomonas vaginalis infection was done by wet mount microscopy or by nucleic acid amplification testing for routine prenatal testing or symptomatic visits. Poisson regression was used to identify factors associated with testing for trichomoniasis and testing positive in pregnancy. Treatment and re-testing patterns also were assessed.

Results: Among 3,265 pregnant women, 2,489 (76%) were tested for T vaginalis infection. Of the total sample, 1,808 (55%) were tested by wet mount microscopy, 1,661 (51%) by nucleic acid amplification testing, and 980 (30%) by both modalities. The sensitivity for microscopy compared with nucleic acid amplification testing was 26%, with a specificity of 99%. Factors associated with increased likelihood of being tested included younger age (adjusted risk ratio [aRR] 0.99, 95% CI 0.99-1.00) and bacterial vaginosis (aRR 1.17, 95% CI 1.01-1.37). Prevalence of trichomoniasis was 15% among those tested by any modality (wet mount or nucleic acid amplification testing). Risk factors for trichomoniasis included younger age (aRR 0.97, P<.01), being of black race (aRR 2.62, P<.01), abnormal vaginal discharge (aRR 1.45, P<.01), and chlamydia during the current pregnancy (aRR 1.70, P<.01). Women diagnosed by microscopy had a shorter time to treatment compared with those diagnosed by nucleic acid amplification testing. Most (75%) women with positive infections had a test of reinfection; 29% of these were positive. Bacterial vaginosis was associated with decreased risk of a positive test of reinfection.

Conclusion: Although testing for and treatment of trichomoniasis during pregnancy is not routinely recommended, the high burden of infection among some pregnant women demonstrates a need to further understand patterns of T vaginalis testing and infection. Opportunities exist for improving timely treatment of trichomoniasis and test of reinfection.
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http://dx.doi.org/10.1097/AOG.0000000000003776DOI Listing
May 2020

Impact of etonogestrel implant use on T-cell and cytokine profiles in the female genital tract and blood.

PLoS One 2020 26;15(3):e0230473. Epub 2020 Mar 26.

Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia.

Background: While prior epidemiologic studies have suggested that injectable progestin-based contraceptive depot medroxyprogesterone acetate (DMPA) use may increase a woman's risk of acquiring HIV, recent data have suggested that DMPA users may be at a similar risk for HIV acquisition as users of the copper intrauterine device and levonorgestrel implant. Use of the etonogestrel Implant (Eng-Implant) is increasing but there are currently no studies evaluating its effect on HIV acquisition risk.

Objective: Evaluate the potential effect of the Eng-Implant use on HIV acquisition risk by analyzing HIV target cells and cytokine profiles in the lower genital tract and blood of adult premenopausal HIV-negative women using the Eng-Implant.

Methods: We prospectively obtained paired cervicovaginal lavage (CVL) and blood samples at 4 study visits over 16 weeks from women between ages 18-45, with normal menses (22-35 day intervals), HIV uninfected with no recent hormonal contraceptive or copper intrauterine device (IUD) use, no clinical signs of a sexually transmitted infection at enrollment and who were medically eligible to initiate Eng-Implant. Participants attended pre-Eng-Implant study visits (week -2, week 0) with the Eng-Implant inserted at the end of the week 0 study visit and returned for study visits at weeks 12 and 14. Genital tract leukocytes (enriched from CVL) and peripheral blood mononuclear cells (PBMC) from the study visits were evaluated for markers of activation (CD38, HLA-DR), retention (CD103) and trafficking (CCR7) on HIV target cells (CCR5+CD4+ T cells) using multicolor flow cytometry. Cytokines and chemokines in the CVL supernatant and blood plasma were measured in a Luminex assay. We estimated and compared study endpoints among the samples collected before and after contraception initiation with repeated-measures analyses using linear mixed models.

Results: Fifteen of 18 women who received an Eng-Implant completed all 4 study visits. The percentage of CD4+ T cells in CVL was not increased after implant placement but the percentage of CD4+ T cells expressing the HIV co-receptor CCR5 did increase after implant placement (p = 0.02). In addition, the percentage of central memory CD4+ T-cells (CCR7+) in CVL increased after implant placement (p = 0.004). The percentage of CVL CD4+, CCR5+ HIV target cells expressing activation markers after implant placement was either reduced (HLA-DR+, p = 0.01) or unchanged (CD38+, p = 0.45). Most CVL cytokine and chemokine concentrations were not significantly different after implant placement except for a higher level of the soluble lymphocyte activation marker (sCD40L; p = 0.04) and lower levels of IL12p70 (p = 0.02) and G-CSF (p<0.001). In systemic blood, none of the changes noted in CVL after implant placement occurred except for decreases in the percentage CD4 T-cells expressing HLA-DR+ T cells (p = 0.006) and G-CSF (p = 0.02).

Conclusions: Eng-Implant use was associated with a moderate increase in the availability of HIV target cells in the genital tract, however the percentage of these cells that were activated did not increase and there were minimal shifts in the overall immune environment. Given the mixed nature of these findings, it is unclear if these implant-induced changes alter HIV risk.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0230473PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7098611PMC
June 2020

Patterns of Screening, Infection, and Treatment of Chlamydia trachomatis and Neisseria gonorrhea in Pregnancy.

Obstet Gynecol 2020 04;135(4):799-807

Department of Gynecology and Obstetrics, Emory University School of Medicine, and the Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; and the Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Objective: To describe factors associated with not being tested for Chlamydia trachomatis and Neisseria gonorrhea infection during pregnancy and for testing positive and to describe patterns of treatment and tests of reinfection.

Methods: We conducted a retrospective cohort study of women who delivered at an urban teaching hospital from July 1, 2016 to June 30, 2018. Women with at least one prenatal care or triage visit were included. The index delivery was included for women with multiple deliveries. We used logistic regression to analyze factors associated with not being tested and for testing positive for these infections in pregnancy. Cox proportional hazards models were used to examine factors associated with time to treatment and tests of reinfection. We reviewed medical records to determine reasons for delays in treatment longer than 1 week.

Results: Among 3,265 eligible deliveries, 3,177 (97%) women were tested during pregnancy. Of these, 370 (12%) tested positive (287 chlamydia, 35 gonorrhea, 48 both), and 15% had repeat infections. Prenatal care adequacy and insurance status were risk factors for not being tested. Age, race and ethnicity, alcohol use, and sexually transmitted infection history were associated with testing positive. Time to treatment ranged from 0 to 221 days, with the majority (55%) of patients experiencing delays of more than 1 week. Common reasons for delays included lack of clinician recognition and follow-up of abnormal results (65%) and difficulty contacting the patient (33%).

Conclusion: Traditional risk factors are associated with increased risk of infection during pregnancy. Prenatal care adequacy and insurance status were associated with the likelihood of being tested. Delays in treatment and tests of reinfection were common. Point-of-care testing and expedited partner therapy should be explored as ways to improve the management of these infections in pregnancy.
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http://dx.doi.org/10.1097/AOG.0000000000003757DOI Listing
April 2020

Fertility intentions and long-acting reversible contraceptive use among HIV-negative single mothers in Zambia.

Am J Obstet Gynecol 2020 04 14;222(4S):S917.e1-S917.e15. Epub 2020 Jan 14.

Rwanda Zambia Emory HIV Research Group, Department of Pathology, Emory University School of Medicine, Atlanta, GA.

Background: Integrating family planning interventions with HIV studies in developing countries has been shown to prevent mother-to-child HIV transmission and simultaneously reduce HIV and unintended pregnancy in high-risk populations. As part of a prospective cohort study on HIV incidence and risk factors in Zambian women having unprotected sex, we also offered family planning counseling and immediate access to long-acting reversible contraceptives. Although long-acting reversible contraceptives are the most effective form of contraception, many Zambian women are limited to oral or injectable methods because of a lack of knowledge or method availability. This project offers to single mothers who are enrolled in a cohort study information about and access to long-acting reversible contraceptives at enrollment and at each follow-up visit.

Objective: This study evaluates how fertility intentions affect long-acting reversible contraceptive use in HIV-negative single mothers in Zambia. Our primary outcome was long-acting reversible contraceptive use throughout the study participation. We also estimated rates of long-acting reversible contraceptive uptake and discontinuation. We specifically studied single mothers because they are at high risk for unintended pregnancy, which can have significant negative ramifications on their financial, social, and psychologic circumstances.

Study Design: From 2012-2017, Zambia Emory HIV Research Project recruited 521 HIV-negative single mothers ages 18-45 years from government clinics in Lusaka and Ndola, Zambia's 2 largest cities. Participants were followed every 3 months for up to 5 years. At each visit, we discussed fertility goals and contraceptive options and offered a long-acting reversible method to any woman who was not pregnant or who already was using a long-acting reversible or permanent contraceptive method. Data were collected on demographic factors, sexual behavior, and reproductive history. Multivariable logistic regression was used to model baseline fertility intentions with long-acting reversible contraceptive use.

Results: We enrolled 518 women; 57 women did not return for any follow-up visits. There was a significant increase in long-acting reversible contraceptive use during the study. At baseline, 93 of 518 women (18%) were using a long-acting reversible method, and 151 of 461 women (33%) used a long-acting reversible method at the end of follow-up period (P<.0001). Four women chose an intrauterine device, and 91 women chose an implant for their first uptake event. After we adjusted the data for other confounders, we found that women in Ndola who did not desire any more children were more likely to use a long-acting reversible contraceptive (adjusted prevalence ratio, 2.02; 95% confidence interval, 1.88-3.42). During follow up, 37 of 183 long-acting reversible contraceptive users (20%) discontinued their method; women who desired future children at baseline were more likely to discontinue earlier (P=.016).

Conclusion: This study demonstrates that integrated family planning services can increase long-acting reversible contraceptive use successfully among Zambian single mothers, who are a vulnerable population that disproportionately is affected by unintended pregnancy. A steady increase in use over time confirms the importance of repeated messaging about these unfamiliar methods. Thus, it is imperative that family planning interventions target single mothers in developing countries to promote effective contraceptive use.
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http://dx.doi.org/10.1016/j.ajog.2019.12.269DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138749PMC
April 2020

Factors associated with condom use among HIV-positive women living in Atlanta, Georgia.

PLoS One 2019 13;14(12):e0225406. Epub 2019 Dec 13.

Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia, United States of America.

Objectives: Consistent condom use is essential to reducing heterosexual transmission of HIV. African Americans are disproportionately affected by HIV in the United States despite comprising a small percentage of the population. Our objectives were to evaluate factors associated with self-reported condom use in a cohort of predominantly African American women receiving HIV care in Atlanta, Georgia.

Methods: A cross-sectional study of reproductive knowledge, attitudes, and practices among adult, sexually-active, HIV-positive women attending the Grady Infectious Disease Clinic in Atlanta, Georgia was conducted from July, 2013 to November, 2014 to evaluate factors associated with self-reported condom use. Primary outcomes included: condom use at last vaginal intercourse and consistent condom use with vaginal intercourse over the last six months. Descriptive, bivariable, and multivariable logistic regression analyses were performed.

Results: Of 187 women enrolled, 170 reported having vaginal intercourse in the last six months. Seventy-four percent used condoms at last vaginal intercourse, whereas 53% reported consistent condom use over the last six months. In adjusted analyses, factors associated with condom use at last intercourse included decreased frequency of sex, no history of drug use, and confidence to discuss condom use with sexual partners (p<0.05). Factors associated with consistent condom use in the past six months were older age, being single/dating, and confidence to discuss condom use with sexual partners. History of drug use, having HIV-positive partners, and unprotected anal intercourse were associated with inconsistent use (p<0.05).

Conclusions: Improved strategies are needed to educate women on the importance of safe sexual practices and condom negotiation. Healthcare providers should strive to have an open dialogue with patients about condom use, whether they engage in anal sex, and its risks.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0225406PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6910822PMC
March 2020

Combination Antiretroviral Therapy and Hypertensive Disorders of Pregnancy.

Obstet Gynecol 2019 12;134(6):1205-1214

Emory University School of Medicine, the Department of Gynecology and Obstetrics, and the Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; and the Departments of Obstetrics and Gynecology and Pediatrics, Northwestern Feinberg School of Medicine, Chicago, Illinois.

Objective: To compare the incidence of hypertensive disorders of pregnancy among women living with human immunodeficiency virus (HIV) on combination antiretroviral therapy (ART) to women without HIV, and to evaluate the association of hypertensive disorders of pregnancy with ART regimens or timing of ART initiation.

Methods: We conducted a retrospective cohort study among two overlapping pregnancy cohorts using preexisting databases at a single tertiary care hospital: all pregnant women who delivered during years 2016-2018 (cohort 1) and all women living with HIV who delivered during years 2011-2018 (cohort 2). The primary outcome for both cohorts was any hypertensive disorder of pregnancy; gestational hypertension and preeclampsia were also examined separately. The primary exposure variables were HIV status for cohort 1 and ART regimen (integrase strand transfer inhibitor-containing, protease inhibitor-containing, or non-nucleoside reverse transcriptase inhibitor-containing) for cohort 2. For estimation of risk ratios (RRs), we used a modified Poisson regression with robust error variances. Multivariate models among the women living with HIV in cohort 2 were tested for a statistical interaction between ART regimen and timing of initiation.

Results: In cohort 1, among 80 women living with HIV compared with 3,464 women without HIV, there was no difference in the risk of hypertensive disorders of pregnancy (29% in women living with HIV vs 30% in women without HIV, adjusted RR 0.9, 95% CI 0.6-1.3). In cohort 2, among 265 women living with HIV, integrase strand transfer inhibitor-containing regimens were associated with an increased risk for any hypertensive disorder of pregnancy (25% among integrase strand transfer inhibitor vs 10% among protease inhibitor, adjusted RR 2.8, 95% CI 1.5-5.1) and gestational hypertension (20% among integrase strand transfer inhibitor vs 8% among protease inhibitor, adjusted RR 2.8, 95% CI 1.3-5.9) compared with protease inhibitor-containing regimens. Timing of ART initiation was not associated with hypertensive disorders of pregnancy, nor did it significantly alter the associations between ART regimen and hypertensive disorders of pregnancy outcomes.

Conclusion: Overall the risk of hypertensive disorders of pregnancy was similar among women living with HIV on ART and women without HIV. With greater integrase strand transfer inhibitor use, the greater frequency of hypertensive disorders of pregnancy with these regimens compared with protease inhibitor-containing regimens warrants future evaluation using cohorts with greater sample size.
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http://dx.doi.org/10.1097/AOG.0000000000003584DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7036166PMC
December 2019

Interleukin-36γ Is Elevated in Cervicovaginal Epithelial Cells in Women With Bacterial Vaginosis and In Vitro After Infection With Microbes Associated With Bacterial Vaginosis.

J Infect Dis 2020 03;221(6):983-988

Department of Basic Medical Sciences, College of Medicine-Phoenix, University of Arizona, Phoenix, Arizona, USA.

In recent studies, the interleukin (IL)-36 cytokines were shown to be elevated in women with non-Lactobacillus-dominated vaginal microbiomes. In this study, we evaluated IL36G expression in clinical samples from women with and without bacterial vaginosis (BV) and a human 3-dimensional cervical epithelial cell model. IL36G expression was significantly elevated in cervicovaginal epithelial cells isolated from BV-positive women and corresponded with increased neutrophil counts relative to BV-negative women. In addition, specific BV-associated bacterial species as well as a polymicrobial cocktail significantly induced IL36G expression in vitro. These findings suggest that IL-36γ may exhibit an important function in the host response to BV and other sexually transmitted infections.
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http://dx.doi.org/10.1093/infdis/jiz514DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7325615PMC
March 2020

Combined antiretroviral therapy for HIV and the risk of hypertensive disorders of pregnancy: A systematic review.

Pregnancy Hypertens 2019 Jul 17;17:178-190. Epub 2019 May 17.

Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Feinberg School of Medicine, Northwestern University, 250 E. Superior Street, Chicago, IL 60611, USA.

Objective: To assess if there is a relationship between use of combined antiretroviral therapy among pregnant women living with HIV and hypertensive disorders of pregnancy (HDP).

Design: Due to the heterogeneity of study designs in the literature and the utilization of different outcome measures in regards to assessing the presence of HDP, a systematic review was performed.

Methods: ClinicalTrials.gov and MEDLINE, via PubMed, EMBASE, Scopus, CINAHL, ProQuest Dissertations & Theses Global, EBSCOHost, DARE, and the Cochrane Library, were queried from January 1997 to October 2017. Studies were included if they reported HDP and focused on pregnant women living with HIV who used combined antiretroviral therapy. The Cochrane Collaboration's tool for assessment of risk of bias and the U.S. Preventive Services Task Force grading scale were used to assess the studies.

Results: Of 1055 abstracts, 28 articles met inclusion criteria. The data are marked by multiple biases and poor study design. All studies demonstrate an increased risk of HDP among pregnant women living with HIV who used combined antiretroviral therapy when compared to seropositive pregnant women not using antiretroviral therapy. Three studies suggest protease inhibitors may be associated with a higher risk of HDP.

Conclusion: Despite all studies indicating a higher frequency of HDP among pregnant women living with HIV using combined antiretroviral therapy when compared with seropositive pregnant women not using antiretroviral therapy, the quality of the studies is mixed, necessitating further research.
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http://dx.doi.org/10.1016/j.preghy.2019.05.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6733581PMC
July 2019

Predictors of tetanus, diphtheria, acellular pertussis and influenza vaccination during pregnancy among full-term deliveries in a medically underserved population.

Vaccine 2019 09 27;37(41):6054-6059. Epub 2019 Aug 27.

Department of Gynecology and Obstetrics, Emory University School of Medicine, 69 Jesse Hill Jr. Drive SE, Atlanta, GA 30303, United States. Electronic address:

Objective: To evaluate predictors of vaccination among women who received tetanus, diphtheria, and acellular pertussis vaccination (Tdap), influenza vaccination, and Tdap and influenza vaccinations.

Study Design: In a retrospective cohort study of all full-term (≥37 weeks gestation) deliveries between July 1, 2016 and June 30, 2018 at a single, safety-net institution, we used multinomial logistic regression models to compare predictors of vaccination among women who received Tdap only, influenza only, and both Tdap and influenza vaccines.

Results: Among 3132 full-term deliveries, women were primarily non-Hispanic black (67.5%), between the ages of 21-34 (65.3%), and multiparous (76.0%). The rates of only influenza or Tdap vaccination were 10.3% and 21.6%, respectively; 43.3% of women received both vaccines, and 24.9% of women did not receive either vaccine. In the adjusted models, Hispanic ethnicity was positively associated with receipt of all types of vaccination and non-Spanish language interpreter use was positively associated with receipt of Tdap vaccination and Tdap and influenza vaccination. A parity of greater than three and inadequate and unknown prenatal care adequacy were negative predictors of all types of vaccination. Pre-existing hypertension was negatively associated with Tdap vaccination, and HIV-positive status was negatively associated with influenza vaccination and Tdap and influenza vaccination.

Conclusion: Compared to the national rate of both Tdap and influenza vaccination (32.8%), a higher proportion of women received both vaccines in our study population. Vaccine uptake may be affected by race/ethnicity, use of interpreter services, parity, pre-existing comorbidities, and prenatal care adequacy. The lower rate of influenza vaccination compared to Tdap vaccination suggests that other factors, such as vaccine hesitancy and mistrust, may be differentially impacting influenza vaccination uptake in our predominantly minority population. Future provider and public health approaches to vaccine promotion should incorporate culturally appropriate strategies that address vaccine-related beliefs and misconceptions.
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http://dx.doi.org/10.1016/j.vaccine.2019.08.044DOI Listing
September 2019

Hormonal Contraception and Vaginal Infections Among Couples Who Are Human Immunodeficiency Virus Serodiscordant in Lusaka, Zambia.

Obstet Gynecol 2019 09;134(3):573-580

Department of Gynecology and Obstetrics, Emory University, School of Medicine, the Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, and the Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; the Department of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Gynecology and Obstetrics, School of Medicine, University of Zambia, and the Ministry of Community Development, Mother and Child Health, Lusaka, Zambia.

Objective: To examine the relationship between hormonal contraception and vaginal infections with bacterial vaginosis, vaginal candidiasis, or trichomoniasis.

Methods: Couples who were human immunodeficiency virus (HIV) serodiscordant in Zambia were enrolled in a longitudinal cohort study. From 1994 to 2002, both partners were seen quarterly and received physical exams including genital examinations. Separate rates for three outcome infections of interest (bacterial vaginosis, vaginal candidiasis, and trichomoniasis) were calculated. Bivariate associations between baseline and time-varying covariates and outcome infections of interest were evaluated using unadjusted Anderson-Gill survival models. Adjusted hazard ratios (aHRs) were generated using multivariable Anderson-Gill survival models that included demographic and clinical factors associated with both hormonal contraceptive use and each infection of interest.

Results: There were 1,558 cases of bacterial vaginosis, 1,529 cases of vaginal candidiasis, and 574 cases of trichomoniasis over 2,143 person-years of observation. Depot medroxyprogesterone acetate (DMPA) users had significantly lower rates of trichomoniasis and bacterial vaginosis. In adjusted models, DMPA was protective for bacterial vaginosis (aHR=0.72; 95% CI 0.54-0.95), candidiasis (aHR 0.75, 95% CI 0.57-1.00) and trichomoniasis (aHR=0.43, 95% CI 0.25-0.74). Oral contraceptive pills were protective for candidiasis (aHR=0.79, 95% CI 0.65-0.97).

Conclusion: We confirm that DMPA use was associated with reduced rates of the three most common causes of vaginitis, and oral contraceptive pill use was associated with reduced rates of candidiasis among women in couples who were HIV discordant.
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http://dx.doi.org/10.1097/AOG.0000000000003404DOI Listing
September 2019

Gabapentin for Perioperative Pain Management for Uterine Aspiration: A Randomized Controlled Trial.

Obstet Gynecol 2019 09;134(3):611-619

Department of Obstetrics and Gynecology, Duke University Medical Center, and the Duke Office of Clinical Research and the Department of Biostatistics & Bioinformatics, BERD Methods Core, Duke University School of Medicine, Durham, North Carolina; and the Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia.

Objective: To evaluate the effect of oral gabapentin in conjunction with usual oral pain management regimens of lorazepam, ibuprofen, oxycodone, and acetaminophen for surgical abortion on pain 5 minutes postprocedure.

Methods: This was a randomized, double-blind, placebo-controlled trial of patients from 6 0/7-14 6/7 weeks of gestation scheduled to undergo surgical abortion at the Duke Family Planning Clinic. Participants were administered 600 mg of oral gabapentin compared with placebo with usual oral pain management. Pain score was assessed using a 100-mm visual analog scale, with the primary outcome being pain score 5 minutes after the procedure. The effect of gabapentin was assessed using a linear regression model controlling for baseline pain. We also measured pain perception 24 hours after the procedure. Secondary outcome measures included anxiety, side effects, and usage of opiate pain medication in the 24-hour postoperative period.

Results: Out of 113 women screened for this study; 96 women were recruited, enrolled, and randomized to study treatment arm from August 2016 to June 2018. Pain at 5 minutes after the procedure was similar between the gabapentin and placebo groups ((Equation is included in full-text article.)=3.40; 95% CI -8.20 to 15.0; P=.56). Gabapentin and placebo were well tolerated, with no statistically significant difference in side effects or anxiety levels. Although prescription of opioids after the procedure was not standardized among patients, 73% of women received a short-term prescription for oxycodone. A lower percentage of women in the gabapentin group self-reported taking opioids in the 24 hours postprocedure (18% vs 47%; odds ratio 0.26; 95% CI 0.09-0.75).

Conclusion: The addition of gabapentin to usual oral pain management regimens with paracervical block did not reduce postoperative pain for patients undergoing outpatient surgical abortion. Although the addition of gabapentin was well tolerated and reduced oral opiate use 24 hours postprocedure, it did not affect the experience of pain during and immediately after the procedure.

Clinical Trial Registration: ClinicalTrials.gov, NCT02725710.
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http://dx.doi.org/10.1097/AOG.0000000000003398DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7187900PMC
September 2019