As the number of HIV-infected women initiating lifelong antiretroviral therapy (ART) during pregnancy increases globally, concerns have emerged regarding low levels of retention in HIV services and ...suboptimal adherence to ART during the postpartum period. We examined the impact of integrating postpartum ART for HIV+ mothers alongside infant follow-up within maternal and child health (MCH) services in Cape Town, South Africa.
We conducted a randomised trial among HIV+ postpartum women aged ≥18 years who initiated ART during pregnancy in the local antenatal care clinic and were breastfeeding when screened before 6 weeks postpartum. We compared an integrated postnatal service among mothers and their infants (the MCH-ART intervention) to the local standard of care (control)-immediate postnatal referral of HIV+ women on ART to general adult ART services and their infants to separate routine infant follow-up. Evaluation data were collected through medical records and trial measurement visits scheduled and located separately from healthcare services involved in either arm. The primary trial outcome was a composite endpoint of women's retention in ART care and viral suppression (VS) (viral load < 50 copies/ml) at 12 months postpartum; secondary outcomes included duration of any and exclusive breastfeeding, mother-to-child HIV transmission, and infant mortality. Between 5 June 2013 and 10 December 2014, a total of 471 mother-infant pairs were enrolled and randomised (mean age, 28.6 years; 18% nulliparous; 57% newly diagnosed with HIV in pregnancy; median duration of ART use at randomisation, 18 weeks). Among 411 women (87%) with primary endpoint data available, 77% of women (n = 155) randomised to the MCH-ART intervention achieved the primary composite outcome of retention in ART services with VS at 12 months postpartum, compared to 56% of women (n = 117) randomised to the control arm (absolute risk difference, 0.21; 95% CI: 0.12-0.30; p < 0.001). The findings for improved retention in care and VS among women in the MCH-ART intervention arm were consistent across subgroups of participants according to demographic and clinical characteristics. The median durations of any breastfeeding and exclusive breastfeeding were longer in women randomised to the intervention versus control arm (6.9 versus 3.0 months, p = 0.006, and 3.0 versus 1.4 months, p < 0.001, respectively). For the infants, overall HIV-free survival through 12 months of age was 97%: mother-to-child HIV transmission was 1.2% overall (n = 4 and n = 1 transmissions in the intervention and control arms, respectively), and infant mortality was 1.9% (n = 6 and n = 3 deaths in the intervention and control arms, respectively), and these outcomes were similar by trial arm. Interpretation of these findings should be qualified by the location of this study in a single urban area as well as the self-reported nature of breastfeeding outcomes.
In this study, we found that integrating ART services into the MCH platform during the postnatal period was a simple and effective intervention, and this should be considered for improving maternal and child outcomes in the context of HIV.
ClinicalTrials.gov NCT01933477.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
BACKGROUND:Several studies from sub-Saharan Africa have highlighted significant challenges in providing antiretroviral therapy (ART) to pregnant and postpartum women, with specific concerns around ...maintaining optimal levels of adherence to ART and/or retaining women in long-term services. However, there are few conceptual frameworks to help understand nonadherence and nonretention, as well as the drivers of these, among HIV-infected women, particularly in the postpartum period.
METHODS:This review provides an overview of the key issues involved in thinking about ART adherence, retention in care and engagement in ART services among pregnant and postpartum women.
RESULTS:The related behaviors of adherence and retention may be understood as components of effective engagement of patients in ART services, which share the goal of achieving and maintaining suppressed maternal viral load on ART. Under this framework, the existing literature indicates that disengagement from care is widespread among postpartum women, with strikingly similar data emerging from ART services around the globe and indications that similar challenges may be encountered by postpartum care services outside the context of HIV. However, the drivers of disengagement require further research, and evidence-based intervention strategies are limited.
CONCLUSIONS:The challenges of engaging women in ART services during pregnancy and the postpartum period seem pervasive, although the determinants of these are poorly understood. Looking forward, a host of innovative intervention approaches are needed to help improve womenʼs engagement, and in turn, promote maternal and child health in the context of HIV.
Transitions between services for continued antiretroviral treatment (ART) during and after pregnancy are a commonly overlooked aspect of the HIV care cascade, but ineffective transitions can lead to ...poor health outcomes for women and their children. In this qualitative study, we conducted interviews with 15 key stakeholders from Ministries of Health along with PEPFAR-supported and other in-country non-governmental organizations actively engaged in national programming for adult HIV care and prevention of mother-to-child-transmission of HIV (PMTCT) services in Côte d'Ivoire, Lesotho and Malawi. We aimed to understand perspectives regarding transitions into and out of PMTCT services for continued ART. Thematic analysis revealed that, although transitions of care are necessary and a potential point of loss from ART care in all three countries, there is a lack of clear guidance on transition approach and no formal way of monitoring transition between services. Several opportunities were identified to monitor and strengthen transitions of care for continued ART along the PMTCT cascade.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
OBJECTIVE:Unintended pregnancies are common among women living with HIV, but there are no data on their long-term impact on treatment outcomes. In a cohort of women initiating antiretroviral therapy ...(ART) during pregnancy, we examined the association between the intendedness of the current pregnancy, measured antenatally, and elevated viral load up to 5 years postpartum.
DESIGN:Prospective study with enrolment at entry into antenatal care and follow-up at study visits separate from routine care.
METHODS:At enrolment women completed the London Measure of Unplanned Pregnancy. Mixed effects models examined the impact of the intendedness of the pregnancy (planned versus each of unplanned or ambivalent, respectively) on viral load 50 or more copies/ml across postpartum study visits.
RESULTS:Overall, 459 women were followed for a median of 43 months postpartum, contributing 2535 viral load measures (median per woman6). Ambivalent and unplanned pregnancy were commonly reported (20 and 60%, respectively), and the proportion of women with elevated viral load increased over time (16% at 6 weeks to 43% by 36–60 months postpartum). Compared with those reporting a planned pregnancy, elevated viral load was more common among women reporting an unplanned pregnancy (odds ratio2.87; 95% confidence interval1.46–5.64), with a trend towards a higher odds among those reporting ambivalence (odds ratio2.19; 95% confidence interval0.97–4.82); associations persisted after adjustment for a wide range of demographic, clinical and psychosocial factors.
CONCLUSION:These novel data suggest that unplanned pregnancy may be a prevalent and persistent predictor of poor ART outcomes among women initiating ART during pregnancy.
Introduction
Linkage to care and mobility postpartum present challenges to long‐term retention after initiating antiretroviral therapy (ART) in pregnancy, but there are few insights from sub‐Saharan ...Africa. We aimed to describe postpartum linkage to care, mobility, retention and viral suppression after ART initiation in pregnancy.
Methods
Using routine electronic data we assessed HIV‐specific health contacts and clinic movements among women initiating ART in an integrated antenatal care (ANC) and ART clinic in Cape Town, South Africa. The local care model includes mandatory transfer to general ART clinics postpartum. We investigated linkage to care after leaving the integrated clinic and mobility to new clinics until 30 months on ART. We used Poisson regression to explore predictors of linkage, retention (accessing care at least once at both 12 6 to <18 and 24 18 to <30 months on ART), and viral suppression (HIV viral load VL ≤50 and ≤1000 copies/mL after 12 months on ART).
Results
Among 617 women, 23% never linked to care; 71% and 65% were retained at 12 and 24 months on ART respectively, with 59% retained in care at both times. Those who linked (n = 485) accessed HIV care at 98 different clinics and 21% attended ≥2 clinics. Women >25 years, married/cohabiting or presenting early for ANC were more likely to link. Younger and unemployed women were more likely to attend ≥2 clinics (adjusted risk ratio aRR 1.10 95% confidence interval CI 1.02 to 1.18 and aRR 1.06 95% CI 0.99 to 1.12 respectively). Age >25 years (aRR 1.17 95% CI 1.02 to 1.33) and planned pregnancy (aRR 1.20 95% CI 1.09 to 1.33) were associated with being retained. Among 338 retained women with VL available, attending ≥2 clinics reduced the likelihood of viral suppression when defined as ≤50 copies/mL (aRR 0.81 95% CI 0.69 to 0.95). Distance moved was not associated with VL.
Conclusions
These data show that a substantial proportion of women do not link to postpartum ART care in this setting and, among those that do, long‐term retention remains a challenge. Women move to a variety of clinics and young women appear particularly vulnerable to attrition. Interventions promoting linkage and continued retention for women initiating ART during pregnancy warrant urgent consideration.
OBJECTIVES:To assess neurodevelopment of breastfed HIV-exposed uninfected (HEU) and breastfed HIV-unexposed children in the context of universal maternal antiretroviral therapy (ART).
...DESIGN:Prospective study with antenatal enrolment and follow-up of breastfeeding HEU and HIV-unexposed mother–infant pairs through 12–18 months postpartum.
SETTING:Peri-urban community, Cape Town, South Africa.
PARTICIPANTS:HEU (n = 215) and HIV-unexposed (n = 306) children.
MAIN OUTCOME MEASURES:Cognitive, motor and language development at median 13 (interquartile range 12–14) months of agecontinuous and dichotomous Bayley Scales of Infant and Toddler Development Third Edition (delay defined as composite score <85).
RESULTS:Incidence of preterm delivery (<37 weeks) was similar among HEU and HIV-unexposed children (11 vs. 9%, P = 0.31; median gestation 39 weeks); 48% were boys. Median breastfeeding duration was shorter among HEU vs. HIV-unexposed children (6 vs. 10 months). All HIV-infected mothers initiated lifelong ART (tenofovir–emtricitabine–efavirenz) antenatally. HEU (vs. HIV-unexposed) children had higher odds of cognitive delay odds ratio (OR) 2.28 (95% confidence interval (CI) 1.13–4.60) and motor delay OR 2.10 (95% CI 1.03–4.28), but not language delay, in crude and adjusted analysis. Preterm delivery modified this relationship for motor developmentcompared with term HIV-unexposed children, term HEU children had similar odds of delay, preterm HIV-unexposed children had five-fold increased odds of delay (adjusted OR 4.73, 95% CI 1.32; 16.91) and preterm HEU children, 16-fold increased odds of delay (adjusted OR 16.35, 95% CI 5.19; 51.54).
CONCLUSION:Young HEU children may be at increased risk for cognitive and motor delay despite universal maternal ART and breastfeeding; those born preterm may be particularly vulnerable.
OBJECTIVES:Measuring retention is critical for antiretroviral therapy (ART) management and program monitoring; however, many definitions and data sources, usually from single health facilities, are ...used. We used routine electronic data, linked across facilities, to examine the impact of definitions and data sources on retention estimates among women in Cape Town, South Africa.
DESIGN:Retrospective cohort study.
METHODS:We compiled routine electronic laboratory, pharmacy and clinic visit data for 617 women who started ART during pregnancy (2013–2014) and estimated 24-month retention using different definitions and data sources. We used logistic regression to assess consistency of associations between risk factors and retention, and receiver operating characteristics analyses to describe how different retention estimates predict viremia at 12 months on ART.
RESULTS:Using all available data sources, retention ranged from 41% (no gap >180 days) to 72% (100% 12-month visit constancy). Laboratory data (expected infrequently) underestimated retention compared with clinic visit data that identified more than 80% of women considered retained in all definitions. In all estimates, associations with known risk factors for nonretention remained consistent and retention declined over time77, 65 and 58% retained using all data sources in months 6–12, 12–18 and 18–24, respectively (P < 0.001). The 180-day gap definition was most strongly associated with viremia (odds ratio 24.3 95% confidence interval 12.0–48.9, all data sources).
CONCLUSION:Researchers must carefully consider the most appropriate retention definition and data source depending on available data. Presenting more than one approach may be warranted to obtain estimates that are context-appropriate and comparable across settings.
We examined the longitudinal association between women's exposure to intimate partner violence (IPV) and HIV viral load during pregnancy and postpartum.
Secondary analysis of an HIV-positive cohort ...enrolled during pregnancy at a South African antenatal clinic.
Viral load was assessed at 10 study visits and analyzed continuously as log10 copies/ml and suppression at less than 50 copies/ml. IPV was measured at three timepoints using behaviorally specific items. We used multivariate logistic regression to examine the association between IPV and viral suppression, and cross-lagged dynamic panel modeling (DPMs) to estimate the longitudinal association between IPV (lagged by 3-6 months) and log10 viral load.
Of 471 women, 84% were virally suppressed by 6 weeks postpartum and 67% at 12 months postpartum. One-third reported IPV exposure. IPV victimization was not associated with viral suppression at delivery, but was associated with a reduced odds of viral suppression at 12 months postpartum (aOR = 0.48, 95% CI = 0.27-0.85). Findings were robust to sensitivity analyses at different timepoints and clinical cut-points. In DPMs, lagged IPV exposure was associated with higher log10 viral load after controlling for past viral load, duration on ART, age, alcohol use, and gestation at study enrolment. Each standardized increase in IPV intensity was associated with higher log10 viral load (standardized coefficient = 0.12, 95% CI = 0.05-0.23).
Although viral suppression was widely achieved during pregnancy, suppression rates declined postpartum in this South African cohort. These data suggest IPV is longitudinally associated with elevated viral load postpartum. Interventions for reducing exposure to IPV are important for the health of women and may improve HIV care and treatment.
Introduction: The advent of policies promoting lifelong antiretroviral therapy (ART) for all pregnant and postpartum women living with HIV has shifted focus from short-term prevention of ...mother-to-child transmission (PMTCT) to lifelong engagement in ART services. However, disengagement from care threatens the long-term treatment and prevention benefits of lifelong ART.
Areas covered: A framework for considering the unique aspects of ART for pregnant and postpartum women is presented along with a review of the literature on maternal engagement in care in sub-Saharan Africa and a discussion of potential interventions to sustain engagement in lifelong ART.
Expert opinion: Engaging women and mothers in ART services for life is critical for maternal health, PMTCT, and prevention of sexual transmission. Evidence-based interventions exist to support engagement in care but most focus on periods of mother-to-child transmission risk. In the long term, life transitions and health-care transfers are inevitable. Thus, interventions that can reach beyond a single facility or provide a bridge between health services should be prioritized. Multicomponent interventions will also be essential to address the numerous intersecting barriers to sustained engagement in ART services.
This prospective cohort study investigated the mobility patterns of 200 pregnant and postpartum women living with HIV in South Africa. Participants were enrolled during their third trimester from ...routine antenatal care near Cape Town, South Africa, and followed for six months postpartum. Quantitative data were collected at enrollment and follow-up. Mobility (self-reported) was common among the participants, despite the brief study period and the concurrent COVID-19 pandemic. While most reported stability in their current residence, 71% had a second main residence, primarily in the Eastern Cape (EC). Participants had a median of two lifetime moves, motivated by work, education, and family life. During the study period, 20% of participants met the study definition of travel (>7 days and >50 km), with trips predominantly to the EC, lasting a median duration of 30 days. Over one-third of participants with other living children reported that these children lived apart from them, with the mother's family being primary caregivers. These findings emphasize the need for targeted interventions to support continuity of care for mobile populations, particularly peripartum women living with HIV. The study contributes valuable insights into mobility dynamics and highlights unique barriers faced by this population, contributing to improved HIV care in resource-limited settings.
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