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Prenatal Transmission of Syphilis and Human Immunodeficiency Virus in Brazil: Achieving Regional Targets for Elimination.

Cerda R, Perez F, Domingues RM, Luz PM, Grinsztejn B, Veloso VG, Caffe S, Francke JA, Freedberg KA, Ciaranello AL - Open Forum Infect Dis (2015)

Bottom Line: Background.  The Pan-American Health Organization has called for reducing (1) human immunodeficiency virus (HIV) mother-to-child transmission (MTCT) to ≤0.30 infections/1000 live births (LB), (2) HIV MTCT risk to ≤2.0%, and (3) congenital syphilis (CS) incidence to ≤0.50/1000 LB in the Americas by 2015.Results.  With current access, we projected 2.95 CS cases/1000 LB, 0.29 HIV infections/1000 LB, 7.1% HIV MTCT risk, and 11.11 intrauterine fetal demises (IUFD)/1000 pregnancies, with significant regional variation.With ideal access, we projected improved outcomes: 1.00 CS cases/1000 LB, 0.10 HIV infections/1000 LB, HIV MTCT risk of 2.4%, and 10.65 IUFD/1000 pregnancies.

View Article: PubMed Central - PubMed

Affiliation: Divisions of General Medicine.

ABSTRACT
Background.  The Pan-American Health Organization has called for reducing (1) human immunodeficiency virus (HIV) mother-to-child transmission (MTCT) to ≤0.30 infections/1000 live births (LB), (2) HIV MTCT risk to ≤2.0%, and (3) congenital syphilis (CS) incidence to ≤0.50/1000 LB in the Americas by 2015. Methods.  Using published Brazilian data in a mathematical model, we simulated a cohort of pregnant women from antenatal care (ANC) through birth. We investigated 2 scenarios: "current access" (89.1% receive one ANC syphilis test and 41.1% receive 2; 81.7% receive one ANC HIV test and 18.9% receive birth testing; if diagnosed, 81.0% are treated for syphilis and 87.5% are treated for HIV) and "ideal access" (95% of women undergo 2 HIV and syphilis screenings; 95% receive appropriate treatment). We conducted univariate and multivariate sensitivity analyses on key inputs. Results.  With current access, we projected 2.95 CS cases/1000 LB, 0.29 HIV infections/1000 LB, 7.1% HIV MTCT risk, and 11.11 intrauterine fetal demises (IUFD)/1000 pregnancies, with significant regional variation. With ideal access, we projected improved outcomes: 1.00 CS cases/1000 LB, 0.10 HIV infections/1000 LB, HIV MTCT risk of 2.4%, and 10.65 IUFD/1000 pregnancies. Increased testing drove the greatest improvements. Even with ideal access, only HIV infections/1000 LB met elimination goals. Achieving all targets required testing and treatment >95% and reductions in prevalence and incidence of HIV and syphilis. Conclusions.  Increasing access to care and HIV and syphilis antenatal testing will substantially reduce HIV and syphilis MTCT in Brazil. In addition, regionally tailored interventions reducing syphilis incidence and prevalence and supporting HIV treatment adherence are necessary to completely meet elimination goals.

No MeSH data available.


Related in: MedlinePlus

Three-way sensitivity analysis, showing impact of maternal syphilis prevalence, maternal syphilis incidence, and uptake prevention of mother-to-child transmission (PMTCT) services. The vertical axis shows cases of congenital syphilis (CS)/1000 live births (LB). The horizontal axis shows the prevalence of maternal syphilis in Brazil. The black arrow indicates the base case input of 0.2% incidence with a prevalence of 1.0%. Projected results at base-case and “ideal” uptakes are shown. It is not possible to meet the Pan American Health Organization (PAHO) goals for elimination (defined as ≤0.50 cases of CS/1000 LB) unless syphilis incidence drops to 0.0% and prevalence drops below 0.5% for current levels of uptake. If uptake increases to 95%, incidence and prevalence still need to drop to at least 0.1% and 0.5%, respectively, to meet elimination targets. Transmission of syphilis still occurs at “ideal access” rates due to remaining gaps in testing and treatment, 88% sensitivity of syphilis testing (Venereal Disease Research Laboratory), and imperfect treatment efficacy (97%). Although incidence and prevalence are varied independently in the figure, in reality they will increase or decrease together.
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OFV073F3: Three-way sensitivity analysis, showing impact of maternal syphilis prevalence, maternal syphilis incidence, and uptake prevention of mother-to-child transmission (PMTCT) services. The vertical axis shows cases of congenital syphilis (CS)/1000 live births (LB). The horizontal axis shows the prevalence of maternal syphilis in Brazil. The black arrow indicates the base case input of 0.2% incidence with a prevalence of 1.0%. Projected results at base-case and “ideal” uptakes are shown. It is not possible to meet the Pan American Health Organization (PAHO) goals for elimination (defined as ≤0.50 cases of CS/1000 LB) unless syphilis incidence drops to 0.0% and prevalence drops below 0.5% for current levels of uptake. If uptake increases to 95%, incidence and prevalence still need to drop to at least 0.1% and 0.5%, respectively, to meet elimination targets. Transmission of syphilis still occurs at “ideal access” rates due to remaining gaps in testing and treatment, 88% sensitivity of syphilis testing (Venereal Disease Research Laboratory), and imperfect treatment efficacy (97%). Although incidence and prevalence are varied independently in the figure, in reality they will increase or decrease together.

Mentions: The number of cases of CS was highly sensitive to maternal syphilis prevalence and incidence. The CS goal was only reached in the current access scenario when maternal syphilis incidence was set at zero and maternal syphilis prevalence was 0.3%; this led to a CS rate of 0.48 cases/1000 LB (Figure 3). When maternal syphilis incidence was assumed to be 0.1%, it was not possible to reach elimination goals with current access. Even with ideal access and maternal syphilis incidence of zero, a syphilis prevalence of ≤0.5% was needed to reach PAHO goals. The base-case maternal syphilis incidence of 0.2% required a prevalence of <0.2% to reach the regional goals at ideal access. If we simultaneously assumed ideal access, improved syphilis test sensitivity (99.0%), greater efficacy of syphilis treatment on transmission risk (1.0% syphilis transmission risk after treatment, compared with 3.0% in the base case), and a lower maternal syphilis incidence of 0.1%, projected syphilis “elimination” was possible at the current syphilis prevalence (projected CS rate 0.36 cases/1000 LB). Figures 1–3 and the Supplementary Appendix report additional sensitivity analyses; all other sensitivity analyses for which ranges are shown in Table 1 did not have a substantial effect on model results.Figure 3.


Prenatal Transmission of Syphilis and Human Immunodeficiency Virus in Brazil: Achieving Regional Targets for Elimination.

Cerda R, Perez F, Domingues RM, Luz PM, Grinsztejn B, Veloso VG, Caffe S, Francke JA, Freedberg KA, Ciaranello AL - Open Forum Infect Dis (2015)

Three-way sensitivity analysis, showing impact of maternal syphilis prevalence, maternal syphilis incidence, and uptake prevention of mother-to-child transmission (PMTCT) services. The vertical axis shows cases of congenital syphilis (CS)/1000 live births (LB). The horizontal axis shows the prevalence of maternal syphilis in Brazil. The black arrow indicates the base case input of 0.2% incidence with a prevalence of 1.0%. Projected results at base-case and “ideal” uptakes are shown. It is not possible to meet the Pan American Health Organization (PAHO) goals for elimination (defined as ≤0.50 cases of CS/1000 LB) unless syphilis incidence drops to 0.0% and prevalence drops below 0.5% for current levels of uptake. If uptake increases to 95%, incidence and prevalence still need to drop to at least 0.1% and 0.5%, respectively, to meet elimination targets. Transmission of syphilis still occurs at “ideal access” rates due to remaining gaps in testing and treatment, 88% sensitivity of syphilis testing (Venereal Disease Research Laboratory), and imperfect treatment efficacy (97%). Although incidence and prevalence are varied independently in the figure, in reality they will increase or decrease together.
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Related In: Results  -  Collection

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getmorefigures.php?uid=PMC4498254&req=5

OFV073F3: Three-way sensitivity analysis, showing impact of maternal syphilis prevalence, maternal syphilis incidence, and uptake prevention of mother-to-child transmission (PMTCT) services. The vertical axis shows cases of congenital syphilis (CS)/1000 live births (LB). The horizontal axis shows the prevalence of maternal syphilis in Brazil. The black arrow indicates the base case input of 0.2% incidence with a prevalence of 1.0%. Projected results at base-case and “ideal” uptakes are shown. It is not possible to meet the Pan American Health Organization (PAHO) goals for elimination (defined as ≤0.50 cases of CS/1000 LB) unless syphilis incidence drops to 0.0% and prevalence drops below 0.5% for current levels of uptake. If uptake increases to 95%, incidence and prevalence still need to drop to at least 0.1% and 0.5%, respectively, to meet elimination targets. Transmission of syphilis still occurs at “ideal access” rates due to remaining gaps in testing and treatment, 88% sensitivity of syphilis testing (Venereal Disease Research Laboratory), and imperfect treatment efficacy (97%). Although incidence and prevalence are varied independently in the figure, in reality they will increase or decrease together.
Mentions: The number of cases of CS was highly sensitive to maternal syphilis prevalence and incidence. The CS goal was only reached in the current access scenario when maternal syphilis incidence was set at zero and maternal syphilis prevalence was 0.3%; this led to a CS rate of 0.48 cases/1000 LB (Figure 3). When maternal syphilis incidence was assumed to be 0.1%, it was not possible to reach elimination goals with current access. Even with ideal access and maternal syphilis incidence of zero, a syphilis prevalence of ≤0.5% was needed to reach PAHO goals. The base-case maternal syphilis incidence of 0.2% required a prevalence of <0.2% to reach the regional goals at ideal access. If we simultaneously assumed ideal access, improved syphilis test sensitivity (99.0%), greater efficacy of syphilis treatment on transmission risk (1.0% syphilis transmission risk after treatment, compared with 3.0% in the base case), and a lower maternal syphilis incidence of 0.1%, projected syphilis “elimination” was possible at the current syphilis prevalence (projected CS rate 0.36 cases/1000 LB). Figures 1–3 and the Supplementary Appendix report additional sensitivity analyses; all other sensitivity analyses for which ranges are shown in Table 1 did not have a substantial effect on model results.Figure 3.

Bottom Line: Background.  The Pan-American Health Organization has called for reducing (1) human immunodeficiency virus (HIV) mother-to-child transmission (MTCT) to ≤0.30 infections/1000 live births (LB), (2) HIV MTCT risk to ≤2.0%, and (3) congenital syphilis (CS) incidence to ≤0.50/1000 LB in the Americas by 2015.Results.  With current access, we projected 2.95 CS cases/1000 LB, 0.29 HIV infections/1000 LB, 7.1% HIV MTCT risk, and 11.11 intrauterine fetal demises (IUFD)/1000 pregnancies, with significant regional variation.With ideal access, we projected improved outcomes: 1.00 CS cases/1000 LB, 0.10 HIV infections/1000 LB, HIV MTCT risk of 2.4%, and 10.65 IUFD/1000 pregnancies.

View Article: PubMed Central - PubMed

Affiliation: Divisions of General Medicine.

ABSTRACT
Background.  The Pan-American Health Organization has called for reducing (1) human immunodeficiency virus (HIV) mother-to-child transmission (MTCT) to ≤0.30 infections/1000 live births (LB), (2) HIV MTCT risk to ≤2.0%, and (3) congenital syphilis (CS) incidence to ≤0.50/1000 LB in the Americas by 2015. Methods.  Using published Brazilian data in a mathematical model, we simulated a cohort of pregnant women from antenatal care (ANC) through birth. We investigated 2 scenarios: "current access" (89.1% receive one ANC syphilis test and 41.1% receive 2; 81.7% receive one ANC HIV test and 18.9% receive birth testing; if diagnosed, 81.0% are treated for syphilis and 87.5% are treated for HIV) and "ideal access" (95% of women undergo 2 HIV and syphilis screenings; 95% receive appropriate treatment). We conducted univariate and multivariate sensitivity analyses on key inputs. Results.  With current access, we projected 2.95 CS cases/1000 LB, 0.29 HIV infections/1000 LB, 7.1% HIV MTCT risk, and 11.11 intrauterine fetal demises (IUFD)/1000 pregnancies, with significant regional variation. With ideal access, we projected improved outcomes: 1.00 CS cases/1000 LB, 0.10 HIV infections/1000 LB, HIV MTCT risk of 2.4%, and 10.65 IUFD/1000 pregnancies. Increased testing drove the greatest improvements. Even with ideal access, only HIV infections/1000 LB met elimination goals. Achieving all targets required testing and treatment >95% and reductions in prevalence and incidence of HIV and syphilis. Conclusions.  Increasing access to care and HIV and syphilis antenatal testing will substantially reduce HIV and syphilis MTCT in Brazil. In addition, regionally tailored interventions reducing syphilis incidence and prevalence and supporting HIV treatment adherence are necessary to completely meet elimination goals.

No MeSH data available.


Related in: MedlinePlus