Young Mothers: From pregnancy to early motherhood in adolescents with HIV

Transcription

1 Young Mothers: From pregnancy to early motherhood in adolescents with HIV Lisa L. Abuogi, MD, MSc Assistant Professor University of Colorado, Denver 8 th HIV and Women Workshop March 2, 2018 Boston, MA

2 Outline Demographics of AGYW with HIV Pregnancy Prevention Adolescent birth rates PMTCT care continuum among adolescent girls Young Motherhood Future

3 Adolescents HIV Demographics Globally, 2.1 million adolescents aged years were living with HIV in out of 4 new HIV infections in years in sub-saharan Africa in girls About one-third of perinatally HIV-infected children worldwide have reached adolescence Half are female UNAIDS Fact sheet HIV and Children 2017

4 Vulnerabilities of Adolescent Girls and Young Women (AGYW) Early marriage 15 million girls are married before 18 years of age every year 90% of births to girls aged years occur within marriage Lack of complete education In sub-saharan Africa, 75% of girls start primary school, 8% finish secondary school Girls are 6 times more likely to be a child bride without secondary school Poor contraception access, uptake, use Susceptibility to HIV infection 65% of new HIV infections in year old are in AGYW

5 Pregnancy Prevention for Adolescents Unmet need for modern contraception 23 million girls aged 15 to 19 years in developing regions Half of adolescent pregnancies are unintended Barriers to contraception Health care worker bias and lack of adolescent-friendly services Restrictive laws Adolescent knowledge, transportation, stigma, pressure to have children Sexual violence WHO Adolescent Pregnancy Factsheet Jan 2018

6 The HIV Contraceptive Conundrums and Controversies DMPA: Most commonly used more effective contraceptive method in developing countries may be associated with higher risk of HIV infection Progestin Implants: Long term contraception is becoming increasingly popular, but Efavirenz reduces effectiveness of contraception leading to accidental pregnancies Scarsi et al. Unintended Pregnancies Observed With Combined Use of the Levonorgestrel Contraceptive Implant and Efavirenz-based Antiretroviral Therapy: A Three-Arm Pharmacokinetic Evaluation Over 48 Weeks. Clinical Infectious Disease. 2016:62

7 Adolescent Birth Rates 21 million girls aged years become pregnant in LMIC every year 2 million girls aged under 15 years 16 million girls aged years give birth annually 11% of all births worldwide are to girls aged years Adolescent birth rate (per 1000 women age years)

8 Ganchimeg T, et al. Pregnancy and childbirth outcomes among adolescent mothers: a WHO multicountry study. Bjog. 2014;121(S Suppl 1):40-8 Pregnancy and Delivery in Adolescents Complications from pregnancy and childbirth are the leading cause of death for year-old girls globally Higher risks of Eclampsia Sepsis Low birthweight Preterm delivery Severe neonatal conditions

9 Conceptual framework of risk factors of adverse pregnancy outcome Ghyslain Mombo-Ngoma et al. BMJ Open 2016;6:e011783

10 Kenney, et al. HIV Med May: 13(5): perinatally infected HIV+ females >12 years of age in UK 30 AGYW experienced 42 pregnancies Age first conception years 81% were unplanned 33% had detectable viral load at delivery Prieto, et al. Plos One. 2017;12(8) 28 deliveries among 22 PHIV 1/3 deemed high risk for MTCT (MDR, detectable VL at delivery or last TM) 14% detectable at delivery

11 Lazenby, et al. Infect Dis Obstet Gynecol. 2016; 2016: US and Canada PHIV N=41 NPHIV N=41 P-value Any drug resistance 55% 17% OR 6.0 p=0.05 MDR 15% 0 p=0.03 Nonstandard ARV during pregnancy 27% 5% p=0.01 ART at conception 68% 23% P<0.0001

12 Perinatal Pregnancy outcomes in LMIC Brazil, PHIV pregnancies ART regimens 18% 1 st line 36% 2 nd Line 41% 3 rd line or salvage 77% had VL > 50 copies/ml at prenatal care entry 41% achieved VL< 50 at delivery 16/22 had genotyping- 69% had drug resistance Cruz, et al. Viral Suppression and Resistance in a Cohort of Perinatally-HIV Infected (PHIV+) Pregnant Women. Int J Environ Res Public Health Jun; 13(6): 568.

13 PMTCT Care Continuum among HIV+ adolescents HIV testing Linkage & engagement Viral suppression MTCT HIV exposed infants Retention

14 Lower rates of HIV testing at ANC in some settings (West and Central Africa, ) 4-19% gap But high universal testing rates in other settings (Kenya, ) 95.7% <19 year olds in ANC 91.6% adult women in ANC (OR 0.95, p=0.95) Lack of HIV preventive services in ANC for negative AGYW 1 Helleringer S. Understanding the adolescent gap in HIV testing among clients of antenatal care services in West and Central African countries. AIDS Behav Ronen K, et al. Gaps in adolescent engagement in antenatal care and prevention of mother-to child HIV transmission services in Kenya. JAIDS.

15 Lower service uptake among adolescents Tanzania 1 (2011 pre- Treat All ) 61% AGYW <24 years declined ARV during pregnancy compared to 18% of adult women (p=0.01) Kenya 2 (2017) Adolescents were less likely than adults to be on ARVs (65.0% vs. 85.8%, P = 0.01) prior to pregnancy South Africa 3 (2008) Interaction with HTC counselor profoundly impacted engagement and adherence to PMTCT 1 Kirsten I, et al. Adherence to combination prophylaxis for prevention of mother-to-child transmission of HIV in Tanzania. PLoS One. 2011;6(6):e Ronen K, et al. Lower ANC attendance and PMTCT uptake in adolescent versus adult pregnant women in Kenya. Geneva (Switzerland): Int Aids Society; JIAS

16 Adolescent vs. Adult Mothers, Kwa Zulu Natal, SA 2013 Horwood C, et al.. HIV-infected adolescent mothers and their infants: low coverage of HIV services and high risk of HIV transmission in KwaZulu-Natal, South Africa. PLoS One. 2013

17 Adolescents lower rates of viral suppression than adults PHIV adolescents with pregnancy have higher rates of drug resistance and detectable VL at delivery

18 In high-income countries, no association with increased rates of MTCT South Africa % MTCT in adolescents vs. 6.1% in adult mothers (OR 1.7%, 95%CI ) Note, only 46% of pregnancies with infant testing Poor engagement in care Adherence concerns Suboptimal viral suppression Horwood C, et al.. HIV-infected adolescent mothers and their infants: low coverage of HIV services and high risk of HIV transmission in KwaZulu-Natal, South Africa. PLoS One. 2013

19 South Africa (2013) More adolescent vs. adult mothers reported exclusive breastfeeding 1,065/1,808 [58.9%] vs. 2,922/5,839 [50.0%] OR 1.4 (95% CI ), p< Adolescents much more likely to self-report HIV negative when actually positive 17 vs. 5% Kenya (2017) Adolescent less likely than adult women to have infants on ARVs (85.7% vs. 97.7%, p= 0.005) Horwood C, et al.. HIV-infected adolescent mothers and their infants: low coverage of HIV services and high risk of HIV transmission in KwaZulu-Natal, South Africa. PLoS One Ronen K, Mcgrath C, Langat A, Kinuthia J, Omolo D, Singa B, et al. editors. Lower ANC attendance and PMTCT uptake in adolescent versus adult pregnant women in Kenya. Geneva Int Aids Society; JIAS

20 Ethiopia, 2016 ahr to 24 years vs. 30 to 40 years: 95% CI: 1.2 to 4.5 Uganda, 2017 LTFU was higher < 25 years (59.3%) compared to >25 years (40.7%) (p=0.02) Malawi, 3 year follow up Option B Younger age was associated with increased defaulting from care at any point during follow-up

21 Young Motherhood School drop out Up to 33% of girls who drop out do so due to pregnancy Lack of social and counseling support to return to school Mental Health Increased distress At risk for depression Repeat pregnancies Lack of contraception Social pressure

22 The Future Age disaggregation of all ongoing studies is a must Adolescent SRH, pregnancy prevention and pregnancy support studies needed

23 What Works and What Doesn t Work in Adolescent SRH Doesn t Work Youth friendly centers Peer education One-off meetings Does Work Comprehensive SRH education Youth friendly services Trained providers Welcoming and appealing Demand creation/outreach Community support

24 Ethiopia- Factors promoting contraceptive use among adolescents Ethiopia Health Extension Worker Program Paid CHW Trained and supervised Provide modern contraception in community

25 Game Change in Colorado: Widespread Use Of Long Acting Reversible Contraceptives and Rapid Decline in Births Among Young, Low Income Women Free LARC (IUD and implant) for teens LARC use among yrs from 5% to 19% Teen birth rate 29% lower among low-income yrs Update % drop in teen birthrate between 2009 and % drop abortions among teens Averted up to $69.6 million that would have been spent Colorado Department of Public Health and Environment Jan 2017 Abortion rates fell 34% Perspectives on Sexual and Reproductive Health Volume 46, Issue 3, pages , 24 JUN 2014 DOI: /46e1714

26 Financial Incentives Malawi Conditional cash transfers provided to girls attending school OR recent school dropouts School fees and ~$10/month if 75% attendance 30% decrease pregnancy rate for dropout group Western Kenya Multicomponent intervention Free school uniform for each year stay in school 17% less early childbearing Duflo E., et al. Education, HIV, and Early Fertility: Experimental Evidence from Kenya. No. w20784: National Bureau of Economic Research. Baird S., et al. The short-term impacts of a schooling conditional cash transfer program on the sexual behavior of young women. Health Econ 2010; 19: pp

27 Adolescents are able to obtain the services that are provided Health services are provided in ways adolescents want to obtain them All adolescents, not just certain groups, are able to obtain the health services they need The health services that adolescents need are provided Accessible- Acceptable- Equitable- Appropriate- Effective- The right health services are provided in the right way and make a positive contribution to the health of adolescents

28 More combination prevention approaches need testing Active participation of AGYW Education completion Long acting contraception HIV prevention Community attitudes Child marriage Sexual violence

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