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Parroco AM, Arcaio M, Mendola D. Does neighborhood matter? An analysis of HIV prevalence in Sub-Saharan African countries. BIODEMOGRAPHY AND SOCIAL BIOLOGY 2024; 69:149-162. [PMID: 39072483 DOI: 10.1080/19485565.2024.2384995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
Over two-thirds of the population living with HIV were concentrated in Eastern, Southern, Western, and Central Africa in 2021. This paper employs data from the Demographic and Health Survey to assess the relationship between HIV prevalence and its socio-economic and demographic drivers at the neighborhood (macro-cluster) level. Additionally, the study examines the existence of differences in such relationships among countries. The results of the fractional logistic regression models highlight that highly educated neighborhoods are less likely to be affected by HIV. A greater average number of children, potentially due to programs that promote access to preventive antenatal care and prevention, is associated with a lower likelihood of residents living with HIV. Notably, HIV testing coverage is prevalent in neighborhoods with a high prevalence of HIV. It is also evident that there are notable differences between countries, which demonstrate national context plays a crucial role in the association between education, number of children, testing coverage, and HIV prevalences.
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Affiliation(s)
- Anna Maria Parroco
- Department of Psychology, Educational Sciences and Human Movement, University of Palermo, Palermo, Italy
| | - Micaela Arcaio
- Department of Psychology, Educational Sciences and Human Movement, University of Palermo, Palermo, Italy
| | - Daria Mendola
- Department of Psychology, Educational Sciences and Human Movement, University of Palermo, Palermo, Italy
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de Azevedo AP, de Rezende Filho JF, Hofer CB, Rego F. The Childbirth Experiences of Pregnant Women Living with HIV Virus: Scoping Review. CHILDREN (BASEL, SWITZERLAND) 2024; 11:743. [PMID: 38929322 PMCID: PMC11202184 DOI: 10.3390/children11060743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 05/30/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE Understand and explore the childbirth experiences of pregnant women living with HIV (PWLWHIV). With the advent of several measures to decrease the intrapartum HIV infection and a strong emphasis on the humanization of childbirth, there is a growing focus on providing positive childbirth experiences for pregnant women. Indeed, a positive childbirth experience is even more important in the group of pregnant women living with HIV (PWLWHIV) as it plays a pivotal role in enhancing the mother's adherence to her postpartum treatment and the newborn's engagement in Infectious Disease services. METHODOLOGY A scoping review was conducted. Searches were performed on databases, such as MEDLINE, PUBMED, WEB OF SCIENCE and Cochrane Library, using the following keywords: childbirth, birth, parturition, HIV, humaniz*, perceived safety, experience, maternal satisfaction, healthcare professional and midwi*. Articles meeting pre-established criteria were selected within the timeframe of 2013 to 2023 for inclusion in the review. RESULTS Out of a total of 2,340,391 articles, 4 were chosen based on our defined criteria. Three primary themes emerged from the selected articles: the assessment of childbirth experience quality, vulnerability and autonomy. CONCLUSIONS The four studies identified had a small sample size and were not adequately conducted with a specific focus on studying the childbirth experience of pregnant women living with HIV (PWLWHIV). This scoping review revealed a gap in the existing literature, indicating a need for further research and clarification in the identified area.
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Affiliation(s)
- Andréa Paula de Azevedo
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- Institute of Childcare and Pediatrics Martagão Gesteira, Federal University of Rio de Janeiro, Rua Bruno Lobo, 50, Rio de Janeiro 21941-912, Brazil
| | - Jorge Fonte de Rezende Filho
- National Medicine Academy, Rio de Janeiro 20021-130, Brazil
- Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro 22240-001, Brazil
| | - Cristina Barroso Hofer
- Department Infectious Diseases, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro 21044-020, Brazil
| | - Francisca Rego
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
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Boisson-Walsh A, Ravelomanana NLR, Tabala M, Malongo F, Kawende B, Babakazo P, Yotebieng M. Association of comprehensiveness of antiretroviral care and detectable HIV viral load suppression among pregnant and postpartum women in the Democratic Republic of the Congo: a cross-sectional study. Front Glob Womens Health 2024; 5:1308019. [PMID: 38903153 PMCID: PMC11188341 DOI: 10.3389/fgwh.2024.1308019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 05/21/2024] [Indexed: 06/22/2024] Open
Abstract
Introduction Worldwide, over two-thirds of people living with HIV are on antiretroviral therapy (ART). Despite increased ART access, high virological suppression prevalence remains out of reach. Few studies consider the quality of ART services and their impact on recipients' viral suppression. We assessed the association between ART service readiness and HIV viral load suppression among pregnant and breastfeeding women living with HIV (WLH) receiving ART in maternal and child health (MCH) clinics in Kinshasa, Democratic Republic of Congo. Methods We performed a cross-sectional analysis leveraging data from a continuous quality improvement intervention on WLH's long-term ART outcomes. From November 2016 to May 2020, we enrolled WLH from the three largest clinics in each of Kinshasa'Łs 35 health zones. We measured clinic's readiness using three WHO-identified ART care quality indicators: relevant guidelines in ART service area, stocks of essential ART medicines, and relevant staff training in ≥24 months, scoring clinics 0-3 based on observed indicators. We defined viral load suppression as ≤1,000 cp/ml. Multilevel mixed-effect logistic models were used to estimate prevalence odds ratios (ORs) measuring the strength of the association between ART service readiness and viral suppression. Results Of 2,295 WLH, only 1.9% received care from a clinic with a score of 3, 24.1% received care from a 0-scoring clinic, and overall, 66.5% achieved virologically suppression. Suppression increased from 65% among WLH receiving care in 0-scoring clinics to 66.9% in 1-scoring clinics, 65.8% in 2-scoring clinics, and 76.1% in 3-scoring clinics. We did not observe a statistically significant association between ART service readiness score and increased viral suppression prevalence, however we did find associations between other factors, such as the location of the health center and pharmacist availability with suppressed viral load. Discussion A lack of comprehensive ART care underscores the need for enhanced structural and organizational support to improve virological suppression and overall health outcomes for women living with HIV..
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Affiliation(s)
- Alix Boisson-Walsh
- Department of Health Policy and Management, University of Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Martine Tabala
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Fathy Malongo
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Bienvenu Kawende
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Pélagie Babakazo
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Marcel Yotebieng
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, United States
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Zanré N, Carvalho S, Elwood C, Côté HCF, Kakkar F, Boucher M, Money D, Boucoiran I. Factors associated with HIV viral load control in the early postpartum period - a Canadian prospective cohort study. AIDS Care 2024:1-8. [PMID: 38500011 DOI: 10.1080/09540121.2024.2325082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 02/22/2024] [Indexed: 03/20/2024]
Abstract
Despite success in managing HIV during pregnancy, challenges remain around sustained adherence with antiretroviral therapy (ART), and the suboptimal viral load (VL) suppression during the postpartum period. The objective of this study was to compare VL levels at delivery and during the postpartum period and assess factors associated with lack of viral suppression during the postpartum period in Canada. We combined data from two Canadian prospective cohorts, which included 286 HIV-positive women (352 pregnancies) who delivered between 2012 and 2020. Delivery VL, postpartum VL, and potential factors associated with an undetectable VL (<50 copies/mL), 2-18 weeks after delivery were assessed. To account for the correlation between multiple pregnancies from the same woman, generalized estimating equations were used to assess bivariate associations. Ninety-nine per cent of pregnant women were on ART during pregnancy compared to 93% during the postpartum period. Of those with available VL results (n = 214 pregnancies), 94% of women achieved an undetectable VL at delivery compared to 87% during the postpartum period. The postpartum period is a challenging time for ART use and VL control. Qualitative studies are needed to better understand these challenges and guide us in designing adequate interventions.
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Affiliation(s)
- Nadège Zanré
- Department of Obstetrics and Gynecology, University of Montreal, Montreal, QC, Canada
| | - Sabrina Carvalho
- Faculty of Pharmacy, University of Montreal, Montreal, QC, Canada
- Mother and Children Infectious Disease Center, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | - Chelsea Elwood
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
- Women's Health Research Institute, BC Women's Hospital & Health Centre, Vancouver, BC, Canada
| | - Hélène C F Côté
- Women's Health Research Institute, BC Women's Hospital & Health Centre, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Fatima Kakkar
- Mother and Children Infectious Disease Center, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | - Marc Boucher
- Department of Obstetrics and Gynecology, University of Montreal, Montreal, QC, Canada
- Mother and Children Infectious Disease Center, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | - Deborah Money
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
- Women's Health Research Institute, BC Women's Hospital & Health Centre, Vancouver, BC, Canada
| | - Isabelle Boucoiran
- Department of Obstetrics and Gynecology, University of Montreal, Montreal, QC, Canada
- Mother and Children Infectious Disease Center, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, QC, Canada
- School of Public Health, University of Montreal, Montreal, QC, Canada
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Nordberg B, Kaguiri E, Chamorro de Angeles KJ, Gabriel EE, van der Kop ML, Mwangi W, Lester RT, Were E, Ekström AM, Rautiainen S. The use, adherence, and evaluation of interactive text-messaging among women admitted to prevention of mother-to-child transmission of HIV care in Kenya (WelTel PMTCT). BMC Pregnancy Childbirth 2024; 24:25. [PMID: 38172881 PMCID: PMC10763426 DOI: 10.1186/s12884-023-06194-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND To improve future mobile health (mHealth) interventions in resource-limited settings, knowledge of participants' adherence to interactive interventions is needed, but previous studies are limited. We aimed to investigate how women in prevention of mother-to-child transmission of HIV (PMTCT) care in Kenya used, adhered to, and evaluated an interactive text-messaging intervention. METHODS We conducted a cohort study nested within the WelTel PMTCT trial among 299 pregnant women living with HIV aged ≥ 18 years. They received weekly text messages from their first antenatal care visit until 24 months postpartum asking "How are you?". They were instructed to text within 48 h stating that they were "okay" or had a "problem". Healthcare workers phoned non-responders and problem-responders to manage any issue. We used multivariable-adjusted logistic and negative binomial regression to estimate adjusted odds ratios (aORs), rate ratios (aRRs) and 95% confidence intervals (CIs) to assess associations between baseline characteristics and text responses. Perceptions of the intervention were evaluated through interviewer-administered follow-up questionnaires at 24 months postpartum. RESULTS The 299 participants sent 15,183 (48%) okay-responses and 438 (1%) problem-responses. There were 16,017 (51%) instances of non-response. The proportion of non-responses increased with time and exceeded 50% around 14 months from enrolment. Most reported problems were health related (84%). Having secondary education was associated with reporting a problem (aOR:1.88; 95%CI: 1.08-3.27) compared to having primary education or less. Younger age (18-24 years) was associated with responding to < 50% of messages (aOR:2.20; 95%CI: 1.03-4.72), compared to being 35-44 years. Women with higher than secondary education were less likely (aOR:0.28; 95%CI: 0.13-0.64), to respond to < 50% of messages compared to women with primary education or less. Women who had disclosed their HIV status had a lower rate of non-response (aRR:0.77; 95%CI: 0.60-0.97). In interviews with 176 women, 167 (95%) agreed or strongly agreed that the intervention had been helpful, mainly by improving access to and communication with their healthcare providers (43%). CONCLUSION In this observational study, women of younger age, lower education, and who had not disclosed their HIV status were less likely to adhere to interactive text-messaging. The majority of those still enrolled at the end of the intervention reported that text-messaging had been helpful, mainly by improving access to healthcare providers. Future mHealth interventions aiming to improve PMTCT care need to be targeted to attract the attention of women with lower education and younger age.
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Affiliation(s)
- Björn Nordberg
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
- Department of Infectious Diseases, Helsingborg Hospital, Helsingborg, Sweden.
| | | | | | - Erin E Gabriel
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | | | - Winfred Mwangi
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Directorate of Reproductive Health, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Richard T Lester
- Department of Medicine, Division of Infectious Diseases, University of British Columbia, Vancouver, Canada
| | - Edwin Were
- Department of Reproductive Health, Moi University, Eldoret, Kenya
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, South General Hospital, Stockholm, Sweden
| | - Susanne Rautiainen
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
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Pellowski JA, Jensen D, Tsawe N, Colvin C, Cu-Uvin S, Operario D, Lurie M, Harrison A, Myer L, Knight L. Womandla Health: development and rationale of a behavioral intervention to support HIV treatment adherence among postpartum women in South Africa. BMC Womens Health 2023; 23:649. [PMID: 38057777 PMCID: PMC10701937 DOI: 10.1186/s12905-023-02817-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/28/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND While Option B + has made great strides in eliminating vertical transmission of HIV and improving access to lifelong antiretroviral therapy (ART) for women, the postpartum period remains a risk period for disengagement from HIV care and non-adherence. METHODS Longitudinal qualitative data was collected from 30 women living with HIV in Cape Town, South Africa from pregnancy through 1 year postpartum to examine key barriers and facilitators to HIV treatment adherence across this transition. Participants were also asked about their preferences for behavioral intervention content, format, and scope. The intervention development process was guided by Fernandez et al.'s Intervention Mapping process and was informed by the qualitative data, the wider literature on ART adherence, and Transition Theory. RESULTS The Womandla Health Intervention is a multicomponent intervention consisting of four individual sessions with a lay health worker and four peer group sessions, which span late pregnancy and early postpartum. These sessions are guided by Transition Theory and utilize motivational interviewing techniques to empower women to ascertain their own individual barriers to HIV care and identify solutions and strategies to overcome these barriers. CONCLUSIONS This intervention will be tested in a small scale RCT. If successful, findings will provide an innovative approach to HIV treatment by capitalizing on the transition into motherhood to bolster self-care behaviors, focusing on ART adherence and also women's overall postpartum health and psychosocial needs.
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Affiliation(s)
- Jennifer A Pellowski
- School of Public Health, Brown University, Providence, USA.
- School of Public Health, University of Cape Town, Cape Town, South Africa.
| | - Destry Jensen
- School of Public Health, Brown University, Providence, USA
| | - Nokwazi Tsawe
- School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Christopher Colvin
- School of Public Health, University of Cape Town, Cape Town, South Africa
- School of Medicine, University of Virginia, Charlottesville, USA
| | - Susan Cu-Uvin
- The Warren Alpert Medical School of Brown University, Providence,, USA
| | - Don Operario
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Mark Lurie
- School of Public Health, Brown University, Providence, USA
- School of Public Health, University of Cape Town, Cape Town, South Africa
| | | | - Landon Myer
- School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Lucia Knight
- School of Public Health, University of Cape Town, Cape Town, South Africa
- School of Public Health, University of the Western Cape, Cape Town, South Africa
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7
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Malaba T. Dolutegravir-based regimens in the post-partum period. Lancet HIV 2023:S2352-3018(23)00086-3. [PMID: 37167995 DOI: 10.1016/s2352-3018(23)00086-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/13/2023]
Affiliation(s)
- Thokozile Malaba
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town 7925, South Africa.
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8
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Stanton AM, Blyler AP, Mosery N, Goodman GR, Vanderkruik R, Sithole K, Bedoya CA, Smit J, Psaros C. "I am scared, I do not want to lie": exploring the impacts of COVID-19 on engagement in care, perceived health, relationship dynamics, and parenting among postpartum women with HIV in South Africa. BMC Pregnancy Childbirth 2023; 23:223. [PMID: 37013509 PMCID: PMC10068701 DOI: 10.1186/s12884-023-05520-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/15/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND COVID-19 and efforts to manage widespread infection may compromise HIV care engagement. The COVID-19-related factors linked to reduced HIV engagement have not been assessed among postpartum women with HIV, who are at heightened risk of attrition under non-pandemic circumstances. To mitigate the effects of the pandemic on care engagement and to prepare for future public health crises, it is critical to understand how COVID-19 has impacted (1) engagement in care and (2) factors that may act as barriers to care engagement. METHODS A quantitative assessment of COVID-19-related experiences was added to a longitudinal cohort study assessing predictors of postpartum attrition from HIV care among women in South Africa. Participants (N = 266) completed the assessment at 6, 12, 18, or 24 months postpartum between June and November of 2020. Those who endorsed one or more challenge related to engagement in care (making or keeping HIV care appointments, procuring HIV medications, procuring contraception, and/or accessing immunization services for infants; n = 55) were invited to complete a brief qualitative interview, which explored the specific factors driving these challenges, as well as other impacts of COVID-19 on care engagement. Within this subset, 53 participants completed an interview; qualitative data were analyzed via rapid analysis. RESULTS Participants described key challenges that reduced their engagement in HIV care and identified four other domains of COVID-19-related impacts: physical health, mental health, relationship with a partner or with the father of the baby, and motherhood/caring for the new baby. Within these domains, specific themes and subthemes emerged, with some positive impacts of COVID-19 also reported (e.g., increased quality time, improved communication with partner, HIV disclosure). Coping strategies for COVID-19-related challenges (e.g., acceptance, spirituality, distraction) were also discussed. CONCLUSIONS About one in five participants reported challenges accessing HIV care, medications, or services, and they faced complex, multilayered barriers to remaining engaged. Physical health, mental health, relationships with partners, and ability to care for their infant were also affected. Given the dynamic nature of the pandemic and general uncertainty about its course, ongoing assessment of pandemic-related challenges among postpartum women is needed to avoid HIV care disruptions and to support wellbeing.
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Affiliation(s)
- Amelia M Stanton
- Department of Psychological and Brain Sciences, Boston University, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
| | - Abigail P Blyler
- Department of Psychology, Positive Psychology Center, University of Pennsylvania, Pennsylvania, PA, USA
| | - Nzwakie Mosery
- Wits MatCH Research Unit (WMRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Georgia R Goodman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Rachel Vanderkruik
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kedibone Sithole
- Wits MatCH Research Unit (WMRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - C Andres Bedoya
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jennifer Smit
- Wits MatCH Research Unit (WMRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Christina Psaros
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Dovel K, Kalande P, Udedi E, Bruns L, Desmond C, Mbalanga C, Gupta S, Phiri S, Chivwala M, Richter L, Coates TJ. Triple Benefit: Impact of an Integrated Early Childhood Development and PMTCT Intervention on ART Outcomes Among Mothers Living with HIV and Infants in Malawi-An Endline Evaluation. AIDS Behav 2023:10.1007/s10461-022-03975-0. [PMID: 36746875 DOI: 10.1007/s10461-022-03975-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2022] [Indexed: 02/08/2023]
Abstract
We conducted a programmatic, observational cohort study with mother-infant pairs (MIPs) enrolled in prevention-of-mother-to-child-transmission (PMTCT) programs in Malawi to assess the feasibility and potential HIV-related benefits of integrating Early Childhood Development (ECD) services into PMTCT programs. Six health facilities were included in the intervention. We offered ECD counseling from the WHO/UNICEF Care for Child Development package in PMTCT waiting spaces while MIPs waited for PMTCT and broader treatment consultations. Primary outcomes were mothers' retention in HIV care at 12 months and infant HIV testing at 6 weeks and 12 months after birth. Routine facility-level data from six comparison health facilities were collected as an adhoc standard of care comparison and used to calculate the cost of delivering the intervention. A total of 607 MIPs were enrolled in the integrated ECD-PMTCT intervention between June 2018 and December 2019. The average age of MIPs was 30 years and 7 weeks respectively. We found that 86% of mothers attended ≥ 5 of the 8 ECD sessions over the course of 12 months; 88% of intervention mothers were retained in PMTCT versus 59% of mothers in comparison health facilities, and 96% of intervention infants were tested for HIV by six weeks compared to 66% of infants in comparison health facilities. Costing data demonstrated the financial feasibility of integrating ECD and PMTCT programs in government health facilities in Malawi. Integrating ECD into PMTCT programs was feasible, acceptable, resulted in better programmatic outcomes for both mothers and infants. Further investigation is required to determine optimal delivery design for scale-up.
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Affiliation(s)
- Kathryn Dovel
- Partners in Hope, Implementation Science, Lilongwe, Malawi.
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA.
| | | | - Evelyn Udedi
- University of California Global Health Institute, San Francisco, CA, USA
| | - Laurie Bruns
- University of California Global Health Institute, San Francisco, CA, USA
| | | | | | - Sundeep Gupta
- Partners in Hope, Implementation Science, Lilongwe, Malawi
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - Sam Phiri
- Partners in Hope, Implementation Science, Lilongwe, Malawi
| | | | - Linda Richter
- University of the Witwatersrand, Johannesburg, South Africa
| | - Thomas J Coates
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
- University of California Global Health Institute, San Francisco, CA, USA
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10
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Psaros C, Stanton AM, Raggio GA, Mosery N, Goodman GR, Briggs ES, Williams M, Bangsberg D, Smit J, Safren SA. Optimizing PMTCT Adherence by Treating Depression in Perinatal Women with HIV in South Africa: A Pilot Randomized Controlled Trial. Int J Behav Med 2023; 30:62-76. [PMID: 35260947 PMCID: PMC9452601 DOI: 10.1007/s12529-022-10071-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND South Africa (SA) has the greatest HIV prevalence in the world, with rates as high as 40% among pregnant women. Depression is a robust predictor of nonadherence to antiretroviral therapy (ART) and engagement in HIV care; perinatal depression may affect upwards of 47% of women in SA. Evidence-based, scalable approaches for depression treatment and ART adherence in this setting are lacking. METHOD Twenty-three pregnant women with HIV (WWH), ages 18-45 and receiving ART, were randomized to a psychosocial depression and adherence intervention or treatment as usual (TAU) to evaluate intervention feasibility, acceptability, and preliminary effect on depressive symptoms and ART adherence. Assessments were conducted pre-, immediately post-, and 3 months post-treatment, and included a qualitative exit interview. RESULTS Most (67.6%) eligible individuals enrolled; 71% completed at least 75% of sessions. Compared to TAU, intervention participants had significantly greater improvements in depressive symptoms at post-treatment, β = - 11.1, t(24) = - 3.1, p < 0.005, 95% CI [- 18.41, - 3.83], and 3 months, β = - 13.8, t(24) = - 3.3, p < 0.005, 95% CI [- 22.50, - 5.17]. No significant differences in ART adherence, social support, or stigma were found. Qualitatively, perceived improvements in social support, self-esteem, and problem-solving adherence barriers emerged as key benefits of the intervention; additional sessions were desired. CONCLUSION A combined depression and ART adherence intervention appears feasible and acceptable, and demonstrated preliminary evidence of efficacy in a high-need population. Additional research is needed to confirm efficacy and identify dissemination strategies to optimize the health of WWH and their children. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03069417. Protocol available at https://clinicaltrials.gov/ct2/show/NCT03069417.
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Affiliation(s)
- Christina Psaros
- Department of Psychiatry, Massachusetts General Hospital / Harvard Medical School, Boston, MA, USA.
- , Boston, USA.
| | - Amelia M Stanton
- Department of Psychiatry, Massachusetts General Hospital / Harvard Medical School, Boston, MA, USA
| | - Greer A Raggio
- Department of Psychiatry, Massachusetts General Hospital / Harvard Medical School, Boston, MA, USA
- National Center for Weight and Wellness, Washington, D.C., USA
| | - Nzwakie Mosery
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
| | - Georgia R Goodman
- Department of Psychiatry, Massachusetts General Hospital / Harvard Medical School, Boston, MA, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
| | - Elsa S Briggs
- Department of Health Systems & Population Health, University of Washington, Seattle, WA, USA
- Department of Community Health Science, Boston University, Boston, MA, USA
| | - Marcel Williams
- Howard University College of Medicine, Washington, D.C., USA
| | | | - Jenni Smit
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
| | - Steven A Safren
- Department of Psychology, University of Miami, Miami, FL, USA
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11
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Stanton AM, Blyler AP, Mosery N, Goodman GR, Vanderkruik R, Sithole K, Bedoya CA, Smit J, Psaros C. "I am scared, I do not want to lie": Exploring the impacts of COVID-19 on engagement in care, perceived health, relationship dynamics, and parenting among postpartum women with HIV in South Africa. RESEARCH SQUARE 2023:rs.3.rs-2463315. [PMID: 36711876 PMCID: PMC9882635 DOI: 10.21203/rs.3.rs-2463315/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background COVID-19 and efforts to manage widespread infection may compromise HIV care engagement. The COVID-19-related factors linked to reduced HIV engagement have not been assessed among postpartum women with HIV, who are at heightened risk of attrition under non-pandemic circumstances. To mitigate the effects of the pandemic on care engagement and to prepare for future public health crises, it is critical to understand how COVID-19 has impacted (1) engagement in care and (2) factors that may act as barriers to care engagement. Methods A quantitative assessment of COVID-19-related experiences was added to a longitudinal cohort study assessing predictors of postpartum attrition from HIV care among women in South Africa. Participants (N = 266) completed the assessment at 6, 12, 18, or 24 months postpartum between June and November of 2020. Those who endorsed one or more challenge related to engagement in care (making or keeping HIV care appointments, procuring HIV medications, procuring contraception, and/or accessing immunization services for infants; n = 55) were invited to complete a brief qualitative interview, which explored the specific factors driving these challenges, as well as other impacts of COVID-19 on care engagement. Within this subset, 53 participants completed an interview; qualitative data were analyzed via rapid analysis. Results Participants described key challenges that reduced their engagement in HIV care and identified four other domains of COVID-19-related impacts: physical health, mental health, relationship with a partner or with the father of the baby, and motherhood/caring for the new baby. Within these domains, specific themes and subthemes emerged, with some positive impacts of COVID-19 also reported (e.g., increased quality time, improved communication with partner, HIV disclosure). Coping strategies for COVID-19-related challenges (e.g., acceptance, spirituality, distraction) were also discussed. Conclusions About one in five participants reported challenges accessing HIV care, medications, or services, and they faced complex, multilayered barriers to remaining engaged. Physical health, mental health, relationships with partners, and ability to care for their infant were also affected. Given the dynamic nature of the pandemic and general uncertainty about its course, ongoing assessment of pandemic-related challenges among postpartum women is needed to avoid HIV care disruptions and to support wellbeing.
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12
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Geremew H, Wolde A, Kassa GM. Incidence and predictors of loss to follow-up among women on option B+ PMTCT program in northwest Ethiopia. A retrospective follow-up study. PLoS One 2023; 18:e0280546. [PMID: 36649312 PMCID: PMC9844877 DOI: 10.1371/journal.pone.0280546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Loss to follow-up from lifelong antiretroviral therapy continued to be a major challenge affecting virtual elimination of mother-to-child transmission of human immunodeficiency virus, especially in Sub-Saharan Africa. Although there was a study conducted in Ethiopia, loss to follow-up was not clearly defined and some important variables were not addressed. Thus, this study was conducted to determine the incidence of loss to follow-up and its predictors among women on option B+ lifelong antiretroviral therapy program in Pawi district health facilities, northwest Ethiopia. METHODS An institutional-based retrospective follow-up study was conducted among 365 women who were enrolled for option B+ prevention of mother-to-child transmission service between June 2013 and March 2021 in Pawi district health facilities. A standard pretested checklist was used to extract data from all eligible women's records. The Kaplan-Meier survival curve for estimating survival probability and Cox proportional hazards model to identify independent predictors of loss to follow-up were employed after checking for proportional hazards assumptions using STATA-14 statistical software. RESULT The overall incidence of loss to follow-up was 12.04 (95% CI: 9.50, 15.20) per 1000 person-months of observation time. Residing outside the catchment area (adjusted hazard ratio (AHR): 3.08, 95% CI: 1.59, 5.98), lactating at enrollment (AHR: 2.43, 95% CI: 1.24, 4.77), living in a sero-discordant relationship (AHR: 2.5, 95% CI: 1.13, 5.53), lack of sero-status disclosure (AHR: 2.59, 95% CI: 1.15, 5.85), new enrollment to lifelong antiretroviral therapy (AHR: 2.07, 95% CI: 1.05, 4.11), and fair (AHR: 2.69, 95% CI: 1.2, 6.04) or poor (AHR: 5.78, 95% CI: 2.76, 12.12) antiretroviral drug adherence level were independent predictors of loss to follow-up. CONCLUSION We found a higher incidence of loss to follow-up relative to previous studies in Ethiopia. Thus, strengthening adherence support interventions, and effective counseling on sero-status disclosure and male partner involvement are important to retain women in care.
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Affiliation(s)
- Habtamu Geremew
- College of Health Science, Oda Bultum University, Chiro, Ethiopia
| | - Awraris Wolde
- Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Getachew Mullu Kassa
- Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
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13
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Yang LH, Eschliman EL, Mehta H, Misra S, Poku OB, Entaile P, Becker TD, Melese T, Brooks MJ, Eisenberg M, Stockton MA, Choe K, Tal D, Li T, Go VF, Link BG, Rampa S, Jackson VW, Manyeagae GD, Arscott-Mills T, Goodman M, Opondo PR, Ho-Foster AR, Blank MB. A pilot pragmatic trial of a "what matters most"-based intervention targeting intersectional stigma related to being pregnant and living with HIV in Botswana. AIDS Res Ther 2022; 19:26. [PMID: 35739534 PMCID: PMC9219368 DOI: 10.1186/s12981-022-00454-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 06/08/2022] [Indexed: 01/21/2023] Open
Abstract
We conducted a pilot trial of an intervention targeting intersectional stigma related to being pregnant and living with HIV while promoting capabilities for achieving 'respected motherhood' ('what matters most') in Botswana. A pragmatic design allocated participants to the intervention (N = 44) group and the treatment-as-usual (N = 15) group. An intent-to-treat, difference-in-difference analysis found the intervention group had significant decreases in HIV stigma (d = - 1.20; 95% CI - 1.99, - 0.39) and depressive symptoms (d = - 1.96; 95% CI - 2.89, - 1.02) from baseline to 4-months postpartum. Some, albeit less pronounced, changes in intersectional stigma were observed, suggesting the importance of structural-level intervention components to reduce intersectional stigma.
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Affiliation(s)
- Lawrence H Yang
- Department of Social and Behavioral Sciences, School of Global Public Health, New York University, 708 Broadway, New York, NY, 10003, USA.
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
| | - Evan L Eschliman
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Haitisha Mehta
- Department of Clinical and Counseling Psychology, Teachers College, Columbia University, New York, NY, USA
| | - Supriya Misra
- Department of Public Health, San Francisco State University, San Francisco, CA, USA
| | - Ohemaa B Poku
- Division of Gender, Sexuality, and Health, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute, New York, NY, USA
| | | | - Timothy D Becker
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tadele Melese
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Merrian J Brooks
- Botswana-UPenn Partnership, Gaborone, Botswana
- Department of Pediatrics, Craig Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Pediatrics and Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Marlene Eisenberg
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Melissa A Stockton
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons & New York State Psychiatric Institute, New York, USA
| | - Karen Choe
- Department of Clinical and Counseling Psychology, Teachers College, Columbia University, New York, NY, USA
| | - Danielle Tal
- Department of Clinical and Counseling Psychology, Teachers College, Columbia University, New York, NY, USA
| | - Tingyu Li
- Department of Clinical and Counseling Psychology, Teachers College, Columbia University, New York, NY, USA
| | - Vivian F Go
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Bruce G Link
- School of Public Policy, University of California Riverside, Riverside, CA, USA
- Department of Sociology, University of California Riverside, Riverside, CA, USA
| | - Shathani Rampa
- Department of Psychology, University of Botswana, Gaborone, Botswana
| | - Valerie W Jackson
- Department of Anesthesia, University of California San Francisco, San Francisco, CA, USA
| | - Gorata D Manyeagae
- Department of Statistics, Faculty of Social Sciences, University of Botswana, Gaborone, Botswana
| | - Tonya Arscott-Mills
- Department of Pediatrics and Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Melody Goodman
- Department of Biostatistics, School of Global Public Health, New York University, New York, NY, USA
| | - Philip R Opondo
- Department of Psychiatry, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Ari R Ho-Foster
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Office of Research and Graduate Studies, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Michael B Blank
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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14
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DiClemente-Bosco K, Weber AZ, Harrison A, Tsawe N, Rini Z, Brittain K, Colvin CJ, Myer L, Pellowski JA. Empowerment in pregnancy: ART adherence among women living with HIV in Cape Town, South Africa. Soc Sci Med 2022; 296:114738. [PMID: 35078104 PMCID: PMC8882130 DOI: 10.1016/j.socscimed.2022.114738] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 12/14/2021] [Accepted: 01/19/2022] [Indexed: 11/17/2022]
Abstract
RATIONALE Adherence to antiretroviral therapy (ART) is a global concern among pregnant and postpartum women living with HIV (WLHIV). Research focusing on peripartum WLHIV and how they balance adherence, engaging in HIV care, and other forms of self-care is limited. Women's empowerment theories have been applied to myriad health behaviors to understand patterns, establish mechanisms, and develop interventions; yet empowerment theory as applied to ART is under-researched. OBJECTIVE Seeking deeper insight into peripartum health behaviors, we examine these factors using Naila Kabeer's (1999) women's empowerment theory, which denotes resources, agency, and achievements as three primary and interrelated components of empowerment. METHODS Data were collected in Gugulethu, South Africa, between March and July 2018. Thirty in-depth interviews were conducted with WLHIV at 32-35 weeks of pregnancy, with topics including experiences related to ART adherence and meanings of empowerment in motherhood. Analyses had two phases: (1) inductive open-coding for emergent themes; and (2) classifying themes into Kabeer's empowerment theory. RESULTS Participants expressed that resources play a critical role in adherence, ranging from practical support to motivational support provided by both family and partners. Agency is experienced as a desire to be an independent mother in the often-expected event that partners withdraw support. Participants described achievements as time-oriented goals, ranging from having a baby born without HIV to living a long and productive life. CONCLUSIONS These findings suggest that a promising and innovative approach to improving ART adherence across the peripartum transition would focus on understanding resources as an enabling environment, build on existing feelings of agency, and highlight the lifelong goals achievable with high levels of adherence. A better understanding of how women's empowerment evolves over the course of pregnancy and into the postpartum period will support intervention development aimed at improving ART adherence and potentially additional peripartum health behaviors.
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Affiliation(s)
- Kira DiClemente-Bosco
- Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main St, Box G-S121-3, Providence, RI, 02912, USA.
| | - Alison Z. Weber
- Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main St., Box G-S121-3, Providence, RI 02912, USA
| | - Abigail Harrison
- Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main St, Box G-S121-3, Providence, RI, 02912, USA.
| | - Nokwazi Tsawe
- Division of Epidemiology and Biostatistics, University of Cape Town School of Public Health and Family Medicine, Falmouth 3.46, UCT Health Sciences Campus, Observatory, Cape Town, 7925, South Africa.
| | - Zanele Rini
- Division of Epidemiology and Biostatistics, University of Cape Town School of Public Health and Family Medicine, Falmouth 3.46, UCT Health Sciences Campus, Observatory, Cape Town, 7925, South Africa.
| | - Kirsty Brittain
- Division of Epidemiology and Biostatistics, University of Cape Town School of Public Health and Family Medicine, Falmouth 3.46, UCT Health Sciences Campus, Observatory, Cape Town, 7925, South Africa.
| | - Christopher J Colvin
- Division of Social and Behavioural Sciences, University of Cape Town School of Public Health and Family Medicine, Falmouth 3.46, UCT Health Sciences Campus, Observatory, Cape Town, 7925, South Africa; Public Health Sciences, University of Virginia, 200 Jeanette Lancaster Way, Charlottesville, VA, 22903, USA; Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main St, Box G-S121-3, Providence, RI, 02912, USA.
| | - Landon Myer
- Division of Epidemiology and Biostatistics, University of Cape Town School of Public Health and Family Medicine, Falmouth 3.46, UCT Health Sciences Campus, Observatory, Cape Town, 7925, South Africa.
| | - Jennifer A. Pellowski
- Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main St., Box G-S121-3, Providence, RI 02912, USA,Division of Epidemiology and Biostatistics, University of Cape Town School of Public Health and Family Medicine, Falmouth 3.46, UCT Health Sciences Campus, Observatory, Cape Town, 7925, South Africa
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15
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Abuogi LL, Castillo-Mancilla J, Hampanda K, Owuor K, Odwar T, Onono M, Helova A, Turan JM, Anderson PL. Tenofovir Diphosphate in Dried Blood Spots in Pregnant and Postpartum Women With HIV in Kenya: A Novel Approach to Measuring Peripartum Adherence. J Acquir Immune Defic Syndr 2022; 89:310-317. [PMID: 34889866 PMCID: PMC8837670 DOI: 10.1097/qai.0000000000002859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adherence to antiretroviral therapy (ART) among pregnant and postpartum women with HIV (PWLWH) is critical to promote maternal health and prevent HIV transmission. Tenofovir diphosphate (TFV-DP) in dried blood spots (DBS) is an objective assessment of cumulative ART adherence that has not been fully assessed in PWLWH. SETTING Southwestern Kenya. METHODS PWLWH receiving tenofovir disoproxil fumarate-based ART from 24 health facilities provided DBS samples at 3 time points [pregnancy/early postpartum (PP), 6 months PP, and 9-12 months PP]. Thresholds for daily adherence were defined as TFV-DP in DBS ≥650 fmol/punch in pregnancy and ≥950 PP. Descriptive analysis is presented. Cluster adjusted χ2 and t-tests were used to test for association with clinical and demographic factors. RESULTS A total of 419 DBS samples were collected from 150 PWLWH. Median TFV-DP in DBS was lowest, 552 fmol/punch [interquartile range (IQR), 395-759] in pregnancy and declined over time [914 (IQR, 644-1176) fmol/punch; early PP; 838 (IQR, 613-1063) fmol/punch 6 months PP; and 785 (IQR, 510-1009) fmol/punch 9-12 months; P < 0.001]. Only 42% of samples in pregnancy and 38.5% of samples in PP met thresholds for daily adherence. Clinical or demographic factors were not associated with suboptimal adherence levels. CONCLUSION Cumulative ART exposure in PWLWH, quantified by TFV-DP in DBS, demonstrated a stepwise decrease (ie, adherence) PP. Most women demonstrated less than daily adherence throughout the peripartum period. Use of TFV-DP in DBS as a measure of cumulative ART adherence could help optimize health outcomes in PWLWH and their infants.
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Affiliation(s)
- Lisa L. Abuogi
- Department of Pediatrics, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jose Castillo-Mancilla
- Department of Medicine, Division of Infectious Diseases, Kenya Medical Research Institute, Nairobi, Kenya
| | - Karen Hampanda
- School of Public Health, Kenya Medical Research Institute, Nairobi, Kenya
| | - Kevin Owuor
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Tobias Odwar
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Maricianah Onono
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Anna Helova
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Janet M. Turan
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Peter L. Anderson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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16
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Atukunda EC, Owembabazi M, Pratt MC, Psaros C, Muyindike W, Chitneni P, Bwana MB, Bangsberg D, Haberer JE, Marrazzo J, Matthews LT. A qualitative exploration to understand barriers and facilitators to daily oral PrEP uptake and sustained adherence among HIV-negative women planning for or with pregnancy in rural Southwestern Uganda. J Int AIDS Soc 2022; 25:e25894. [PMID: 35324081 PMCID: PMC8944216 DOI: 10.1002/jia2.25894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 02/08/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Antiretroviral pre-exposure prophylaxis (PrEP) may reduce periconception and pregnancy HIV incidence among women in settings, where gender power imbalances limit HIV testing, engagement in care and HIV viral suppression. We conducted qualitative interviews to understand factors influencing periconception and pregnancy PrEP uptake and use in a cohort of women (Trial registration: NCT03832530) offered safer conception counselling in rural Southwestern Uganda, where PrEP uptake was high. METHODS Between March 2018 and January 2019, in-depth interviews informed by conceptual frameworks for periconception risk reduction and PrEP adherence were conducted with 37 women including those with ≥80% and <80% adherence to PrEP doses measured by electronic pill cap, those who never initiated PrEP, and seven of their male partners. Content and dyadic analyses were conducted to identify emergent challenges and facilitators of PrEP use within individual and couple narratives. RESULTS The median age for women was 33 years (IQR 28, 35), 97% felt likely to acquire HIV and 89% initiated PrEP. Individual-level barriers included unwillingness to take daily pills while healthy, side effects and alcohol use. Women overcame these barriers through personal desires to have control over their HIV serostatus, produce HIV-negative children and prevent HIV transmission within partnerships. Couple-level barriers included nondisclosure, mistrust and gender-based violence; facilitators included shared goals and perceived HIV protection, which improved communication, sexual intimacy and emotional support within partnerships through a self-controlled method. Community-level barriers included multi-level stigma related to HIV, ARVs/PrEP and serodifference; facilitators included active peer, family or healthcare provider support as women aspired to safely meet socio-cultural expectations to conceive and preserve serodifferent relationships. Confidence in PrEP effectiveness was promoted by positive peer experiences with PrEP and ongoing HIV testing. CONCLUSIONS Multi-level forms of HIV-, serodifference- and disclosure-related stigma, side effects, pill burden, alcohol use, relationship dynamics, social, professional and partnership support towards adaptation and HIV risk reduction influence PrEP uptake and adherence among HIV-negative women with plans for pregnancy in rural Southwestern Uganda. Confidence in PrEP, individually controlled HIV prevention and improved partnership communication and intimacy promoted PrEP adherence. Supporting individuals to overcome context-specific barriers to PrEP use may be an important approach to improving uptake and prolonged use.
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Affiliation(s)
| | | | - Madeline Claire Pratt
- Division of Infectious DiseasesUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Christina Psaros
- Behavioral Medicine ProgramDepartment of PsychiatryMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | | | - Pooja Chitneni
- Division of Infectious Diseases and General Internal MedicineBrigham and Women's HospitalBostonMassachusettsUSA
| | | | - David Bangsberg
- School of Public HealthOregon Health Sciences University – Portland State UniversityPortlandOregonUSA
| | - Jessica Elizabeth Haberer
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Jeanne Marrazzo
- Division of Infectious DiseasesUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Lynn Turner Matthews
- Division of Infectious DiseasesUniversity of Alabama at BirminghamBirminghamAlabamaUSA
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17
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Sabin LL, Gifford AL, Haberer JE, Harvey K, Sarkisova N, Martin K, West RL, Stephens J, Killian C, Halim N, Berkowitz N, Jennings K, Jennings L, Orrell C. Patients' and Providers' Views on Optimal Evidence-Based and Scalable Interventions for Individuals at High Risk of HIV Treatment Failure: Sequential Explorations Among Key Stakeholders in Cape Town, South Africa. AIDS Behav 2022; 26:2783-2797. [PMID: 35190943 DOI: 10.1007/s10461-022-03623-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/25/2022]
Abstract
To support translation of evidence-based interventions into practice for HIV patients at high risk of treatment failure, we conducted qualitative research in Cape Town, South Africa. After local health officials vetted interventions as potentially scalable, we held 41 in-depth interviews with patients with elevated viral load or a 3-month treatment gap at community clinics, followed by focus group discussions (FGDs) with 20 providers (physicians/nurses, counselors, and community health care workers). Interviews queried treatment barriers, solutions, and specific intervention options, including motivational text messages, data-informed counseling, individual counseling, peer support groups, check-in texts, and treatment buddies. Based on patients' preferences, motivational texts and treatment buddies were removed from consideration in subsequent FGDs. Patients most preferred peer support groups and check-in texts while individual counseling garnered the broadest support among providers. Check-in texts, peer support groups, and data-informed counseling were also endorsed by provider sub-groups. These strategies warrant attention for scale-up in South Africa and other resource-constrained settings.
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Affiliation(s)
- Lora L Sabin
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA.
| | - Allen L Gifford
- Section of General Internal Medicine, Boston University School of Medicine and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, 02118, USA
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, 02130, USA
| | - Jessica E Haberer
- Center of Global Health, Massachusetts General Hospital, Boston, MA, 02114, USA
- Department of Medicine, Harvard Medical School, Boston, MA, 02114, USA
| | - Kelsee Harvey
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Natalya Sarkisova
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Kyle Martin
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Rebecca L West
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Jessie Stephens
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Clare Killian
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Nafisa Halim
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | | | - Karen Jennings
- City of Cape Town Health Department, Cape Town, South Africa
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18
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Chandiwana NC, Serenata CM, Owen A, Rannard S, Pérez Casas C, Scott C, Hill A, Clayden P, Flexner C. Impact of long-acting therapies on the global HIV epidemic. AIDS 2021; 35:S137-S143. [PMID: 34848580 DOI: 10.1097/qad.0000000000003102] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Long-acting antiretroviral drugs have emerged as exciting treatment and preexposure prophylaxis (PrEP) options for people with HIV and at risk of HIV. Long-acting regimens may improve dosing convenience, tolerability and cost compared with current daily-based oral therapy. They can also circumvent stigma associated with oral therapy for both treatment and PrEP, thereby improving adherence and outcomes. Yet, multiple challenges remain, many specific to low-income and middle-income countries (LMICs), where the epidemic is most concentrated and HIV prevention and treatment options are limited. To optimize the use of long-acting formulations, key outstanding questions must be addressed. Uncertain costing, scale-up manufacturing, complex delivery systems and implementation challenges are potential barriers when considering the scalability of long-acting ARVs for global use.
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Affiliation(s)
- Nomathemba C Chandiwana
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Celicia M Serenata
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Owen
- Department of Molecular and Clinical Pharmacology
| | - Steve Rannard
- Department of Chemistry, Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool, United Kingdom
| | | | | | - Andrew Hill
- Department of Translational Medicine, Liverpool University, Liverpool
| | | | - Charles Flexner
- Divisions of Clinical Pharmacology and Infectious Diseases, School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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19
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Okhai H, Tariq S, Burns F, Gilleece Y, Dhairyawan R, Hill T, Peters H, Thorne C, Sabin CA. Association of pregnancy with engagement in HIV care among women with HIV in the UK: a cohort study. Lancet HIV 2021; 8:e747-e754. [PMID: 34762836 DOI: 10.1016/s2352-3018(21)00194-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/12/2021] [Accepted: 08/18/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Women with HIV face challenges in engaging in HIV care post partum. We aimed to examine changes in engagement in HIV care through clinic attendance before, during, and after pregnancy, compared with matched women with HIV who had never had a recorded pregnancy. METHODS In this cohort study, we describe changes in engagement in HIV care before, during, and after pregnancy among women with HIV from the UK Collaborative HIV Cohort (CHIC) study from 25 HIV clinics in the UK with a livebirth reported to the National Surveillance of HIV in Pregnancy and Childhood between Jan 1, 2000, and Dec 31, 2017. To investigate whether changes were specific to HIV, we compared these changes to those over equivalent periods among non-pregnant women with HIV in the UK CHIC study matched for ethnicity, year of conception, age, CD4 cell count, viral suppression, and antiretroviral therapy use. Analyses were via logistic regression using generalised estimated equations with an interaction between case-control status (pregnant women vs non-pregnant women) and pregnancy or pseudo pregnancy (for non-pregnant women) stage. FINDINGS 1116 matched pairs of pregnant and non-pregnant women were included (median age 34 years [IQR 30-38], 80·1% Black African, 12·5% white). 69 330 person-months of follow-up were recorded, 25 412 in the before stage, 18 897 during, and 25 021 after pregnancy or pseudo pregnancy stages. Among pregnant women, the proportion of time engaged in care increased during pregnancy (8477 [90·5%] of 9371 person-months) and after pregnancy (10 501 [84·6%] of 12 407), compared with before pregnancy (9979 [78·5%] of 12 707). Among non-pregnant women in the control group, engagement in HIV care remained stable across the three equivalent stages (9688 [76·3%] of 12 705 person-months before pseudo pregnancy; 7463 [78·3%] of 9526 during pseudo pregnancy; and 9892 [78·4%] of 12 614 after pseudo pregnancy). The association of engagement in HIV care with pregnancy or pseudo pregnancy stage differed significantly by case-control status (pinteraction<0·0001); the odds of engagement in HIV care were higher during pregnancy (odds ratio [OR] 3·32, 95% CI 2·68-4·12) and after pregnancy (OR 1·49, 1·24-1·79) only among pregnant women, and not among non-pregnant women, when compared with the before pseudo pregnancy stage. INTERPRETATION Women with HIV and a pregnancy resulting in a livebirth were more likely to engage in HIV care post partum when compared with before pregnancy. A detailed understanding of the reason for this finding could support interventions to maximise engagement in HIV care for all women with HIV. FUNDING Medical Research Council and National Institute for Health Research.
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Affiliation(s)
- Hajra Okhai
- Institute for Global Health, University College London, London, UK; National Institute for Health Research Health Protection Research Unit in Blood-borne and Sexually Transmitted Infections, University College London, London, UK.
| | - Shema Tariq
- Institute for Global Health, University College London, London, UK
| | - Fiona Burns
- Institute for Global Health, University College London, London, UK
| | - Yvonne Gilleece
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK; Brighton and Sussex Medical School, Brighton, UK
| | | | - Teresa Hill
- Institute for Global Health, University College London, London, UK
| | - Helen Peters
- Institute for Global Health, University College London, London, UK; Integrated Screening Outcomes Surveillance Service, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Claire Thorne
- Institute for Global Health, University College London, London, UK; Integrated Screening Outcomes Surveillance Service, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Caroline A Sabin
- Institute for Global Health, University College London, London, UK; National Institute for Health Research Health Protection Research Unit in Blood-borne and Sexually Transmitted Infections, University College London, London, UK
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20
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Psaros C, Stanton AM. Patterns of post-partum HIV care engagement. Lancet HIV 2021; 8:e730-e731. [PMID: 34762837 PMCID: PMC10929616 DOI: 10.1016/s2352-3018(21)00270-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/23/2021] [Indexed: 06/13/2023]
Affiliation(s)
- Christina Psaros
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
| | - Amelia M Stanton
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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21
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Knippler ET, Mwamba RN, Coleman JN, Knettel BA, Minja LM, Kisigo GA, Ngocho JS, Cichowitz C, Mmbaga BT, Watt MH. Attitudes Toward Pregnancy Among Women Enrolled in Prevention of Mother-to-Child Transmission of HIV (PMTCT) Services in Moshi, Tanzania. AIDS Behav 2021; 25:4008-4017. [PMID: 34125322 DOI: 10.1007/s10461-021-03339-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2021] [Indexed: 11/30/2022]
Abstract
For pregnant women living with HIV (WLWH), feelings about pregnancy may influence their emotional well-being and health seeking behaviors. This study examined attitudes toward pregnancy and associated factors among women enrolled in prevention of mother-to-child transmission of HIV (PMTCT) services in Moshi, Tanzania. 200 pregnant WLWH were enrolled during their second or third trimester of pregnancy and completed a structured survey. Univariable and multivariable regression models examined factors associated with attitudes toward pregnancy, including demographics, interpersonal factors, and emotional well-being. Attitudes toward the current pregnancy were generally positive, with 87% of participants reporting feeling happy about being pregnant. In the final multivariable model, having higher levels of partner support, being newly diagnosed with HIV, and having fewer children were significantly associated with more positive attitudes toward their pregnancy. Findings point to a need for tailored psychosocial support services in PMTCT, as well as comprehensive reproductive health care for WLWH.
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Affiliation(s)
- Elizabeth T Knippler
- Duke Global Health Institute, Duke University, Durham, NC, USA.
- Gillings School of Global Public Health, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA.
- UNC Gillings School of Global Public Health, 104 Rosenau Hall 135 Dauer Dr, Chapel Hill, NC, 27599, USA.
| | - Rimel N Mwamba
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Jessica N Coleman
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Psychology and Neuroscience, Duke University, Durham, NC, USA
| | | | - Linda M Minja
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Godfrey A Kisigo
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - James S Ngocho
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Cody Cichowitz
- Department of Medicine, Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
| | - Blandina T Mmbaga
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Melissa H Watt
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
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22
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Kiirya Y, Musoke P, Adobea Odei Obeng-Amoako G, Kalyango J. Loss to follow up after pregnancy among mothers enrolled on the option B+ program in Uganda. PUBLIC HEALTH IN PRACTICE 2021; 2:100085. [PMID: 36101573 PMCID: PMC9461603 DOI: 10.1016/j.puhip.2021.100085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 01/19/2021] [Indexed: 11/04/2022] Open
Abstract
Objective Option-B+ programs in Uganda have reported high levels of loss to follow up (LTFU) after cessation of breastfeeding, and this remains unknown beyond this period. In this study, we assessed the incidence and factors associated with LTFU two to four years after delivery among Option-B+ mothers. Study design Retrospective cohort. Methods We reviewed files of 452 mothers who enrolled on Option-B+ between January 1st, 2013 and December 31st, 2014 at Kisenyi Health Centre IV in Kampala district. We assessed factors associated with LTFU using Cox proportional hazards regression. We also explored the reasons for LTFU using three focus group discussions, five in-depth and three key informant interviews. Results Of the 452 mothers, 131(29%) were LTFU after delivery. The incidence of LTFU after delivery was 17/1000 person months (95% CI, 14–30/1000) with a median follow up of 32 months. The risk of LTFU was higher among mothers who started ART on the day they tested HIV positive (aHR = 1.66, 95% CI; 1.25–2.20, p-value< 0.001). Reasons for LFTU included transport costs, stigma, poor human resource policies and non-disclosure. Conclusion LTFU after delivery among Option-B+ mothers is higher than the global target of 15%. ART initiation on the day a mother tests positive increases the risk of LTFU. The major reasons for LTFU were stigma and non-disclosure. To reduce the risk of LTFU, we recommend approaches that encourage disclosure to sexual partners and ongoing specific support to mothers who are initiated on ART-the day of positive test. Loss to follow up (LTFU) among Option-B+ mothers after delivery is high. ART initiation on the day a mother tests positive increases the risk of LTFU. Non-disclosure is a major contributor to LTFU among Option-B+ mothers.
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"This is My Life We are Talking About": Adaptive Strategies for HIV Care Retention and Treatment Adherence Among Postpartum Women Living with HIV in Cape Town, South Africa. Matern Child Health J 2021; 24:1454-1463. [PMID: 32816255 DOI: 10.1007/s10995-020-02995-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Retaining postpartum women living with HIV in ongoing care is critical for the health of the mother-child dyad but low adherence to antiretroviral therapy (ART) and retention in HIV care are a global concern. This issue is particularly salient in South Africa, where approximately 50% of women fall out of the care cascade by 6 months postpartum. The purpose of this secondary analysis is to understand the strategies that women use to navigate HIV care during the postpartum period. METHODS This study was conducted in Gugulethu, in Cape Town, South Africa. In-depth interviews were conducted with 21 study participants at 18-months postpartum. Participants were interviewed about their perceptions and experiences of their postpartum HIV care, and barriers and facilitators to their adherence and retention. RESULTS All participants reported using care navigation strategies across a spectrum of individual, interpersonal and structural levels to remain retained in care and adherent to ART. Participants expressed the importance of individual empowerment and knowledge of treatment benefits for their HIV care. Interpersonal relationships were discussed as a pathway to access both psychosocial and tangible support. Participants described overcoming structural barriers to care through creative problem solving and identified opportunities for care delivery improvement. DISCUSSION Participants described a wide range of overlapping and interconnected care navigation strategies. Consistent with the assets model, participants discussed their own capacity and that of their communities to engage in lifelong HIV care. Better understanding of potentially successful individual care navigation strategies should guide future intervention work. TRIAL REGISTRATION ClinicalTrials.gov NCT01933477.
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24
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Ahonkhai AA, Aliyu MH, Audet CM, Bravo M, Simmons M, Claquin G, Memiah P, Fernando AN, Carlucci JG, Shepherd BE, Van Rompaey S, Yu Z, Gong W, Vermund SH, Wester CW. Poor retention and care-related sex disparities among youth living with HIV in rural Mozambique. PLoS One 2021; 16:e0250921. [PMID: 34019582 PMCID: PMC8139489 DOI: 10.1371/journal.pone.0250921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/16/2021] [Indexed: 11/18/2022] Open
Abstract
Background There are few studies that characterize sex-related differences in HIV outcomes among adolescents and young adults (AYA) 15–24 years of age. Methods We conducted a retrospective cohort study among AYA who enrolled in a comprehensive HIV program in Mozambique between 2012–2016. We assessed patients by sex and pregnancy/lactation status, comparing time to combination antiretroviral therapy (ART) initiation using Cox proportional hazard models. We employed multivariable logistic regression to investigate pre- and post-ART retention. Patients were defined as ‘retained pre-ART’ if they attended at least 3 of 4 required visits or started ART in the 6 months after enrollment, and ‘retained post-ART’ if they had any ART pickup or clinical visit during the last 90 days of the one-year follow-up period. Results Of 47,702 patients in the cohort, 81% (n = 38,511) were female and 19% (n = 9,191) were male. Of the females, 57% (n = 21,770) were non-pregnant and non-lactating (NPNL) and 43% (n = 16,741) were pregnant or lactating (PL). PL (aHR 2.64, 95%CI:2.47–2.81) and NPNL females (aHR 1.36, 95%CI:1.30–1.42) were more likely to initiate ART than males. PL females had higher odds of pre-ART retention in care (aOR 3.56, 95%CI: 3.30–3.84), as did NPNL females (aOR 1.71, 95%CI: 1.62–1.81), compared to males. This was also true for retention post-ART initiation, with higher odds for both PL (aOR 1.78, 95%CI:1.63–1.94) and NPNL females (aOR 1.50, 95%CI:1.35–1.65) compared to males. Conclusions PL females were most likely to initiate ART and remain in care post-ART in this AYA cohort, likely reflecting expansion of Option B+. Despite pregnancy and policy driven factors, we observed important sex-related disparities in this cohort. NPNL females were more likely to initiate ART and be retained in care before and after ART initiation than males. These data suggest that young males need targeted interventions to improve these important care continuum outcomes.
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Affiliation(s)
- Aima A. Ahonkhai
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- * E-mail:
| | - Muktar H. Aliyu
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Carolyn M. Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Friends in Global Health (FGH), Maputo, Mozambique
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Melynda Simmons
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Gael Claquin
- Friends in Global Health (FGH), Maputo, Mozambique
| | - Peter Memiah
- Division of Epidemiology and Prevention, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | | | - James G. Carlucci
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Bryan E. Shepherd
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | | | - Zhihong Yu
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Wu Gong
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Sten H. Vermund
- Yale School of Public Health, Yale University, New Haven, Connecticut, United States of America
| | - C. William Wester
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
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25
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Dovel K, Kalande P, Udedi E, Temelkovska T, Hubbard J, Mbalanga C, Bruns L, Mulungu S, Gupta S, Richter L, Coates TJ. Integrated early childhood development services improve mothers' experiences with prevention of mother to child transmission (PMTCT) programs in Malawi: a qualitative study. BMC Health Serv Res 2021; 21:348. [PMID: 33858394 PMCID: PMC8048322 DOI: 10.1186/s12913-021-06342-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV-positive mothers who face the dual burden of HIV-positive status and motherhood, may benefit from holistic services that include early childhood development (ECD). We evaluated the acceptability and impact of integrated ECD-PMTCT interventions for mothers and their children. METHODS We implemented an integrated ECD-PMTCT intervention in 4 health facilities in Malawi for HIV-positive mothers and their infants. WHO/UNICEF Care for Child Development (CCD) education and counseling sessions were offered during routine PMTCT visits between infant age 1.5-24 months. From June-July 2019, we conducted in-depth interviews with 29 mothers enrolled in the intervention for ≥6 months across 4 health facilities. The interview guide focused on perceived impact of the intervention on mothers' ECD and PMTCT practices, including barriers and facilitators, and unmet needs related to the program. Data were coded and analyzed using constant comparison methods in Atlas ti.8. RESULTS The vast majority of mothers believed the ECD-PMTCT intervention improved their overall experience with the PMTCT services, strengthened their relationship with providers, and excited and motivated them to attend PMTCT services during the postpartum period. Unlike prior experience, mothers felt more welcome at the health facility, and looked forward to the next visit in order to interact with other mothers and learn new ECD skills. Mothers formed new social support networks with other mothers engaged in ECD sessions, and they provided emotional and financial support to one another, including encouragement regarding ART adherence. Mothers believed their infants reached developmental milestones faster compared to non-intervention children they observed at the same age, and they experienced improved engagement in caregiving activities among male caregivers. Nearly half of women requested additional support with depression or anxiety, coping mechanisms to deal with the stresses of life, or support in building positive dynamics with their male partner. CONCLUSION The integrated ECD-PMTCT intervention improved mother's experiences with PMTCT programs and health care providers, increased ECD practices such as responsive and stimulating parenting, and created social support networks for women with other PMTCT clients.
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Affiliation(s)
- Kathryn Dovel
- Partners in Hope, Lilongwe, Malawi.
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | | | | | - Tijana Temelkovska
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Julie Hubbard
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Laurie Bruns
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- University of California Global Health Institute, San Francisco, USA
| | | | - Sundeep Gupta
- Partners in Hope, Lilongwe, Malawi
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Linda Richter
- DSI-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa
| | - Thomas J Coates
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- University of California Global Health Institute, San Francisco, USA
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26
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Watt MH, Minja L, Knettel BA, Mwamba RN, Osaki H, Ngocho JS, Kisigo GA, Renju J, Vissoci JRN, Sao SS, Mmbaga BT. Pilot Outcomes of Maisha: An HIV Stigma Reduction Intervention Developed for Antenatal Care in Tanzania. AIDS Behav 2021; 25:1171-1184. [PMID: 33180253 PMCID: PMC7979435 DOI: 10.1007/s10461-020-03093-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2020] [Indexed: 12/15/2022]
Abstract
HIV stigma is a persistent barrier to curbing the spread of HIV and improving quality of life for people living with HIV. We developed and pilot tested Maisha, an HIV stigma reduction intervention in antenatal care (ANC) with two objectives: 1) among individuals living with HIV, reduce internalized and anticipated HIV stigma, with subsequent improvements in HIV care engagement, and 2) among individuals who are HIV-seronegative, reduce HIV stigmatizing attitudes. We enrolled and baselined 1039 women and 492 male partners presenting to a first ANC appointment and randomized them to standard of care or the Maisha intervention. All women living with HIV (WLHIV) and a subset of HIV-negative participants completed a 3-month follow-up assessment. Participation in the three Maisha sessions was high (99.6%, 92.8%, 89.3%), and nearly all participants noted satisfaction with the intervention content (99.8%) and counselor (99.8%). Among 55 WLHIV, care engagement outcomes did not differ by condition. Among 293 HIV-negative participants, Maisha participants had significantly greater reductions in the moral judgment sub-scale of the stigma attitudes measure (p < .001), but not the social distancing subscale. The ANC setting, where women and their partners are routinely tested for HIV, is an ideal venue for addressing HIV stigma. The Maisha intervention was feasible and acceptable, and had an impact on HIV stigma attitudes. A full trial is needed to examine impacts on HIV outcomes; modifications to the intervention should be considered to reduce social alienation of PLWH.
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27
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Saleska JL, Turner AN, Gallo MF, Shoben A, Kawende B, Ravelomanana NLR, Thirumurthy H, Yotebieng M. Role of temporal discounting in a conditional cash transfer (CCT) intervention to improve engagement in the prevention of mother-to-child transmission (PMTCT) cascade. BMC Public Health 2021; 21:477. [PMID: 33691667 PMCID: PMC7944635 DOI: 10.1186/s12889-021-10499-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 02/24/2021] [Indexed: 11/22/2022] Open
Abstract
Background Temporal discounting, the tendency of individuals to discount future costs and benefits relative to the present, is often associated with greater engagement in risky behaviors. Incentives such as conditional cash transfers (CCTs) have the potential to counter the effects of high discount rates on health behaviors. Methods With data from a randomized trial of a CCT intervention among 434 HIV-positive pregnant women in the Democratic Republic of Congo, we used binomial models to assess interactions between discount rates (measured using a delay-discounting task) and the intervention. The analysis focused on two outcomes: 1) retention in HIV care, and 2) uptake of prevention of mother-to-child transmission (PMTCT) services. Results The effect of high discount rates on retention was small, and we did not observe evidence of interaction between high discount rates and CCT on retention. However, our findings suggest that CCT may mitigate the negative effect of high discount rates on uptake of PMTCT services (interaction contrast (IC): 0.18, 95% CI: − 0.09, 0.44). Conclusions Our findings provide evidence to support the continued use of small, frequent incentives, to motivate improved uptake of PMTCT services, especially among women exhibiting high rates of temporal discounting. Trial registration Clinicaltrials.gov number NCT01838005, April 23, 2013. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-10499-0.
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Affiliation(s)
- Jessica Londeree Saleska
- Division of Epidemiology, Cunz Hall, The Ohio State University, College of Public Health, 1841 Neil Avenue, Columbus, OH, 43210, USA. .,The University of California Los Angeles, Global Center for Children and Families, Semel Institute for Neuroscience and Human Behavior, 10920 Wilshire Blvd, Los Angeles, CA, 90024, USA.
| | - Abigail Norris Turner
- Division of Infectious Disease, Doan Hall, The Ohio State University, College of Medicine, 410 W. 10th Avenue, Columbus, OH, 43210, USA
| | - Maria F Gallo
- Division of Epidemiology, Cunz Hall, The Ohio State University, College of Public Health, 1841 Neil Avenue, Columbus, OH, 43210, USA
| | - Abigail Shoben
- Division of Epidemiology, Cunz Hall, The Ohio State University, College of Public Health, 1841 Neil Avenue, Columbus, OH, 43210, USA
| | - Bienvenu Kawende
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Noro Lantoniaina Rosa Ravelomanana
- Division of Epidemiology, Cunz Hall, The Ohio State University, College of Public Health, 1841 Neil Avenue, Columbus, OH, 43210, USA.,The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.,Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, USA
| | - Marcel Yotebieng
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, USA
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28
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Kwena Z, Kimbo L, Darbes LA, Hatcher AM, Helova A, Owino G, Thirumurthy H, Bukusi EA, Braun T, Kilgore M, Pisu M, Tamhane A, Nghiem VT, Agot K, Neilands TB, Turan JM. Testing strategies for couple engagement in prevention of mother-to-child transmission of HIV and family health in Kenya: study protocol for a randomized controlled trial. Trials 2021; 22:19. [PMID: 33407784 PMCID: PMC7788905 DOI: 10.1186/s13063-020-04956-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/08/2020] [Indexed: 11/10/2022] Open
Abstract
Background HIV-related maternal deaths and HIV infection among infants remain unacceptably high across sub-Saharan Africa despite increased antenatal care attendance and provision of antiretroviral therapy to pregnant women. In the Jamii Bora (“Better Family” in Swahili) Study, we seek to test the efficacy of an interdependence theory-based couple intervention. The intervention reaches pregnant women and male partners through home visits by male-female pairs of lay health workers. The aim is to increase access to home-based couples’ HIV testing and counseling services to improve family health. Methods This is a three-arm randomized control trial among 1080 pregnant women 15 years of age or older, living with their male partners, and who have not undergone couples’ HIV testing and counseling in Kisumu and Migori Counties in Kenya. Couples will be randomized into three groups: home-based couple visits, HIV self-testing kits for couple use, or standard care (male partner clinic invitation letters). Participants will be followed up to 18 months postpartum. The study has three aims: in aim 1, we will determine the effects of the intervention on our primary outcome of couple HIV testing, compared to HIV self-testing kits and standard care; in aim 2, we will examine the intervention impact on HIV prevention behaviors, facility delivery, and postnatal healthcare utilization, as well as secondary health outcomes of maternal viral suppression and HIV-free child survival up to 18 months for couples living with HIV; and in aim 3, we will compare the cost-effectiveness of the home-based couple intervention to the less resource-intensive strategies used in the other two study arms. Assessments with couples are conducted at baseline, late pregnancy, and at months 3, 6, 12, and 18 after birth. Discussion The results from this study will inform decision-makers about the cost-effective strategies to engage pregnant couples in the prevention of mother-to-child transmission and family health, with important downstream benefits for maternal, paternal, and infant health. Trial registration ClinicalTrials.gov NCT03547739. Registered on May 9, 2018 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-020-04956-1.
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Affiliation(s)
- Zachary Kwena
- Research, Care and Treatment Programme, Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya.
| | - Liza Kimbo
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lynae A Darbes
- Center for Sexuality and Health Disparities, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Abigail M Hatcher
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Anna Helova
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - George Owino
- Research, Care and Treatment Programme, Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Harsha Thirumurthy
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth A Bukusi
- Research, Care and Treatment Programme, Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Thomas Braun
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Meredith Kilgore
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Maria Pisu
- Division of Preventive Medicine, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ashutosh Tamhane
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Van T Nghiem
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Torsten B Neilands
- Division of Prevention Sciences, Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Janet M Turan
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
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Watt MH, Knettel BA, Knippler ET, Kisigo G, Ngocho JS, Renju J, Rogathi J, Sao SS, Minja L, Osaki H, Mwamba RN, Mmbaga BT. The development of Maisha, a video-assisted counseling intervention to address HIV stigma at entry into antenatal care in Tanzania. EVALUATION AND PROGRAM PLANNING 2020; 83:101859. [PMID: 32795711 PMCID: PMC7686260 DOI: 10.1016/j.evalprogplan.2020.101859] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 02/10/2020] [Accepted: 07/30/2020] [Indexed: 06/11/2023]
Abstract
HIV stigma has a profound impact on clinical outcomes and undermines the quality of life of people living with HIV (PLWH). Among HIV-negative individuals, misinformation and prejudicial attitudes about HIV can fuel stigma and contribute to discrimination against PLWH. Antenatal care (ANC), with its focus on universal HIV testing, provides a unique entry point to address HIV stigma. This study describes the development of a counseling intervention to address HIV stigma among women and their partners attending a first ANC appointment in Tanzania. Formative work to inform the intervention consisted of qualitative interviews with 32 pregnant and postpartum women (both women living with HIV and HIV-negative women) and 20 healthcare workers. Data were analyzed iteratively, using a thematic analysis approach, to identify intervention targets. The resulting intervention, Maisha (Swahili for "Life"), includes three sessions informed by the HIV Stigma Framework and Cognitive-Behavioral Therapy: a video and brief counseling session prior to HIV testing and, for those who test seropositive for HIV, two additional sessions building on the video content. A pilot test of the intervention is in process. Addressing HIV stigma at the first ANC visit can help individuals living with HIV to overcome stigma-related barriers to the initiation and maintenance of HIV care, and can reduce stigmatizing attitudes among those who test negative for HIV.
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Affiliation(s)
- Melissa H Watt
- Duke Global Health Institute, Duke University, Durham, NC, USA; Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA.
| | | | - Elizabeth T Knippler
- Duke Global Health Institute, Duke University, Durham, NC, USA; Gilling School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
| | - Godfrey Kisigo
- Duke Global Health Institute, Duke University, Durham, NC, USA; Kilimanjaro Clinical Research Institute, Moshi, Tanzania.
| | - James S Ngocho
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Moshi, Tanzania.
| | - Jenny Renju
- Kilimanjaro Christian Medical University College, Moshi, Tanzania; London School of Hygiene and Tropical Medicine, London, UK.
| | - Jane Rogathi
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Moshi, Tanzania.
| | - Saumya S Sao
- Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Linda Minja
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania.
| | - Haika Osaki
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania.
| | - Rimel N Mwamba
- Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Blandina T Mmbaga
- Duke Global Health Institute, Duke University, Durham, NC, USA; Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Moshi, Tanzania.
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Retention in HIV Care Among HIV-Seropositive Pregnant and Postpartum Women in Uganda: Results of a Randomized Controlled Trial. AIDS Behav 2020; 24:3164-3175. [PMID: 32314120 DOI: 10.1007/s10461-020-02875-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We tested an intervention that aimed to increase retention in antiretroviral therapy (ART) among HIV-positive pregnant and postpartum women, a population shown to be vulnerable to poor ART outcomes. 133 pregnant women initiating ART at 2 hospitals in Uganda used real time-enabled wireless pill monitors (WPM) for 1 month, and were then randomized to receive text message reminders (triggered by late dose-taking) and data-informed counseling through 3 months postpartum or standard care. We assessed "full retention" (proportion attending all monthly clinic visits and delivering at a study facility; "visit retention" (proportion of clinic visits attended); and "postpartum retention" (proportion retained at 3 months postpartum). Intention-to-treat and per protocol analyses found that retention was relatively low and similar between groups, with no significant differences. Retention declined significantly post-delivery. The intervention was unsuccessful in this population, which experiences suboptimal ART retention and is in urgent need of effective interventions.
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Matthews LT, Orrell C, Bwana MB, Tsai AC, Psaros C, Asiimwe S, Amanyire G, Musinguzi N, Bell K, Bangsberg DR, Haberer JE. Adherence to HIV antiretroviral therapy among pregnant and postpartum women during the Option B+ era: 12-month cohort study in urban South Africa and rural Uganda. J Int AIDS Soc 2020; 23:e25586. [PMID: 32820622 PMCID: PMC7441010 DOI: 10.1002/jia2.25586] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 06/18/2020] [Accepted: 07/01/2020] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION We conducted a cohort study to understand patterns of anti-retroviral therapy (ART) adherence during pregnancy, postpartum and non-pregnancy follow-up among women initiating ART in public clinics offering Option B+ in rural Uganda and urban South Africa. METHODS We collected survey data, continuously monitored ART adherence (Wisepill), HIV-RNA and pregnancy tests at zero, six and twelve months from women initiating ART in Uganda and South Africa, 2015 to 2017. The primary predictor of interest was follow-up time categorized as pregnant (pregnancy diagnosis to pregnancy end), postpartum (pregnancy end to study exit) or non-pregnancy-related (neither pregnant nor postpartum). Fractional regression models included demographics and socio-behavioural factors informed by the Behavioral Model for Vulnerable Populations. We evaluated HIV-RNA at 12 months by ever- versus never-pregnant status. RESULTS In Uganda, 247 women contributed 676, 900 and 1274 months of pregnancy, postpartum and non-pregnancy-related follow-up. Median ART adherence was consistently ≥90%: pregnancy, 94% (interquartile range [IQR] 78,98); postpartum, 90% (IQR 70,97) and non-pregnancy, 90% (IQR 80,98). Poorer adherence was associated with younger age (0.98% [95% CI 0.33%, 1.62%] average increase per year of age) and higher CD4 cell count (1.01% [0.08%, 1.94%] average decrease per 50 cells/mm3 ). HIV-RNA was suppressed among 91% (N = 135) ever-pregnant and 86% (N = 85) never-pregnant women. In South Africa, 190 women contributed 259, 624 and 1247 months of pregnancy, postpartum and non-pregnancy-related follow-up. Median adherence was low during pregnancy, 74% (IQR 31,96); postpartum, 40% (IQR 4,65) and non-pregnancy, 77% (IQR 47,92). Poorer adherence was associated with postpartum status (22.3% [95%CI 8.6%, 35.4%] average decrease compared to non-pregnancy-related follow-up) and less emotional support (1.4% [0.22%, 2.58%] average increase per unit increase). HIV-RNA was suppressed among 57% (N = 47) ever-pregnant and 86% (N = 93) never-pregnant women. CONCLUSIONS Women in rural Uganda maintained high adherence with 91% of ever-pregnant and 86% of never-pregnant women suppressing HIV-RNA at 12 months. Women in urban South Africa struggled with adherence, particularly during postpartum follow-up with median adherence of 40% and 57% of women with HIV-RNA suppression at one year, suggesting a crisis for postpartum women with HIV in South Africa. Findings suggest that effective interventions should promote emotional support.
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Affiliation(s)
- Lynn T Matthews
- Department of MedicineUniversity of Alabama at BirminghamBirminghamALUSA
- Department of MedicineMassachusetts General HospitalBostonMAUSA
| | | | | | - Alexander C Tsai
- Mbarara University of Science and TechnologyMbararaUganda
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
- Harvard Center for Population and Development StudiesBostonMAUSA
| | - Christina Psaros
- Department of PsychiatryMassachusetts General HospitalBostonMAUSA
| | - Stephen Asiimwe
- Mbarara University of Science and TechnologyMbararaUganda
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
- Kabwohe Clinical Research Center (KCRC)KabwoheUganda
| | - Gideon Amanyire
- Makerere‐Mbarara Universities Joint AIDS Program (MJAP)MbararaUganda
| | - Nicholas Musinguzi
- Mbarara University of Science and TechnologyMbararaUganda
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
| | - Kathleen Bell
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
| | - David R Bangsberg
- School of Public HealthOregon Health and Science University/Portland State UniversityPortlandORUSA
| | - Jessica E Haberer
- Department of MedicineMassachusetts General HospitalBostonMAUSA
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
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Sakyi KS, Lartey MY, Kennedy CE, Dension JA, Mullany LC, Owusu PG, Sacks E, Hurley EA, Surkan PJ. Barriers to maternal retention in HIV care in Ghana: key differences during pregnancy and the postpartum period. BMC Pregnancy Childbirth 2020; 20:398. [PMID: 32677910 PMCID: PMC7366890 DOI: 10.1186/s12884-020-03067-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 06/18/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maternal retention in HIV care is lower for women in the postpartum period than during pregnancy, but the reasons are poorly understood. We examined key differences in barriers to retention in HIV care during and after pregnancy. METHODS We conducted semi-structured, in-depth interviews with 30 postpartum women living with HIV. Participants were recruited from two tertiary facilities implementing Option B+ for prevention of mother-to-child HIV transmission in Accra, Ghana. We collected data from mothers who had disengaged from HIV care and those who were still engaged in care. The interviews were analyzed using principles adapted from grounded theory. RESULTS Participants' experiences and narratives showed that retention in HIV care was more challenging during the postpartum period than during pregnancy. Poor maternal physical health (from birth complications and cesarean section), socio-cultural factors (norms about newborn health and pregnancy), and economic difficulties linked to childbirth (such as unemployment, under-employment, and debt) made the costs of retention in HIV care more economically and socially expensive in the postpartum period than during pregnancy. Some participants also shared that transportation costs and resulting dependence on a partner to pay increased during the postpartum period because of a strong shift in maternal preference for private modes of transportation due to HIV stigma and the desire to protect the newborn. These factors played a larger role in the postpartum period than during pregnancy and created a significant barrier to retention. A conceptual model of how these factors interrelate, the synergy between them, and how they affect retention in the postpartum period is presented. CONCLUSIONS In Ghana, lower retention in HIV care in the postpartum period compared to in pregnancy may be primarily driven by social, economic, and newborn health factors. Multifaceted economic-based and stigma-reduction interventions are needed to increase retention in maternal HIV care after childbirth.
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Affiliation(s)
- Kwame S Sakyi
- Department of Public and Environmental Wellness, Oakland University, School of Health Sciences, 3101 Human Health Building, 433 Meadow Brook Rd, Rochester, MI, 48309-4452, USA.
- Center for Learning and Childhood Development-Ghana, AF, 3190, Adenta Flats, Accra, Ghana.
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Margaret Y Lartey
- Department of Medicine & Therapeutics, University of Ghana School of Medicine & Dentistry, CHS, P.O. Box GP 4236, Accra, Ghana
| | - Caitlin E Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Julie A Dension
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Luke C Mullany
- Department of Public and Environmental Wellness, Oakland University, School of Health Sciences, 3101 Human Health Building, 433 Meadow Brook Rd, Rochester, MI, 48309-4452, USA
- Center for Learning and Childhood Development-Ghana, AF, 3190, Adenta Flats, Accra, Ghana
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Prince G Owusu
- Center for Learning and Childhood Development-Ghana, AF, 3190, Adenta Flats, Accra, Ghana
| | - Emma Sacks
- Department of Public and Environmental Wellness, Oakland University, School of Health Sciences, 3101 Human Health Building, 433 Meadow Brook Rd, Rochester, MI, 48309-4452, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Emily A Hurley
- Health Services and Outcomes Research, Children's Mercy, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Pamela J Surkan
- Center for Learning and Childhood Development-Ghana, AF, 3190, Adenta Flats, Accra, Ghana
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
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Kerkhoff AD, Sikombe K, Eshun-Wilson I, Sikazwe I, Glidden DV, Pry JM, Somwe P, Beres LK, Simbeza S, Mwamba C, Bukankala C, Hantuba C, Moore CB, Holmes CB, Padian N, Geng EH. Mortality estimates by age and sex among persons living with HIV after ART initiation in Zambia using electronic medical records supplemented with tracing a sample of lost patients: A cohort study. PLoS Med 2020; 17:e1003107. [PMID: 32401797 PMCID: PMC7219718 DOI: 10.1371/journal.pmed.1003107] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 04/10/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Men in sub-Saharan Africa have lower engagement and retention in HIV services compared to women, which may result in differential survival. However, the true magnitude of difference in HIV-related mortality between men and women receiving antiretroviral therapy (ART) is incompletely characterized. METHODS AND FINDINGS We evaluated HIV-positive adults ≥18 years old newly initiating ART in 4 Zambian provinces (Eastern, Lusaka, Southern, and Western). In addition to mortality data obtained from routine electronic medical records, we intensively traced a random sample of patients lost to follow-up (LTFU) and incorporated tracing outcomes through inverse probability weights. Sex-specific mortality rates and rate differences were determined using Poisson regression. Parametric g-computation was used to estimate adjusted mortality rates by sex and age. The study included 49,129 adults newly initiated on ART between August 2013 and July 2015; overall, the median age among patients was 35 years, the median baseline CD4 count was 262 cells/μl, and 37.2% were men. Men comprised a smaller proportion of individuals starting ART (37.2% versus 62.8%), tended to be older (median age 37 versus 33 years), and tended to have lower CD4 counts (median 220 versus 289 cells/μl) at the time of ART initiation compared to women. The overall rate of mortality among men was 10.3 (95% CI 8.2-12.4) deaths/100 person-years (PYs), compared to 5.5 (95% CI 4.3-6.8) deaths/100 PYs among women (difference +4.7 [95% CI 2.3-7.2] deaths/100 PYs; p < 0.001). Compared to women in the same age groups, men's mortality rates were particularly elevated among those <30 years old (+6.7 deaths/100 PYs difference), those attending rural health centers (+9.4 deaths/100 PYs difference), those who had an initial CD4 count < 100 cells/μl (+9.2 deaths/100 PYs difference), and those who were unmarried (+8.0 deaths/100 PYs difference). After adjustment for potential confounders and mediators including CD4 count, a substantially higher mortality rate was predicted among men <30 years old compared to women of the same age, while women ≥50 years old had a mortality rate similar to that of age-matched men, but considerably higher than that predicted among young women (<30 years old). No clinically significant differences were evident with respect to rates of facility transfer or care disengagement between men and women. The main study limitations were the inability to successfully ascertain outcomes in all patients selected for tracing and missing clinical and laboratory data due to the use of medical records. CONCLUSIONS In this study, we found that among HIV-positive adults newly initiating ART, mortality among men exceeded mortality among women; disparities were most pronounced among young patients. Older women, however, also experienced high mortality. Specific interventions for men and older women at highest mortality risk are needed to improve HIV treatment outcomes.
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Affiliation(s)
- Andrew D. Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, United States of America
| | | | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Department of Medicine, Washington University, St. Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - David V. Glidden
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, United States of America
| | - Jake M. Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, Department of Medicine, Washington University, St. Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Laura K. Beres
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Chama Bukankala
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Cardinal Hantuba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Charles B. Holmes
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
- Georgetown University, Washington, District of Columbia, United States of America
| | - Nancy Padian
- University of California, Berkeley, Berkeley, California, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, Department of Medicine, Washington University, St. Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
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Cruz Zonenschein AC, João Filho EC, Cruz MLS, Gouvea MI, Teixeira MDLB, Fuller T, Dias MAB. Treatment dropout after pregnancy: a study of women living with HIV in Rio de Janeiro. AIDS Care 2020; 32:1283-1289. [PMID: 32338056 DOI: 10.1080/09540121.2020.1755011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Despite the investment in prevention of mother-to-child transmission of HIV, there is still little data about the proportion of women that are retained in treatment after pregnancy in Brazil. Research worldwide shows that a significant proportion of women drop out of treatment after pregnancy. The aim of this study was to identify factors associated with treatment dropout of women that received prenatal care at a federal hospital in Rio de Janeiro between 2016 and 2017 and abandoned treatment after pregnancy. This was a retrospective cohort study using data on prescription refills and hospital medical records. Cross-sectional analysis of data from 454 women showed that 18% were not on cART after pregnancy. Illicit drug use during pregnancy, being less than 35 years old, and being aware of HIV diagnosis before conceiving but not taking cART were factors associated with treatment interruption postpartum. The high prevalence of interruption of HIV treatment after pregnancy suggests that there is a need for better post-natal care to increase adherence in this population.
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Affiliation(s)
- Ana Clara Cruz Zonenschein
- Infectious Diseases Department, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil.,Instituto Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Esaú Custódio João Filho
- Infectious Diseases Department, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
| | | | - Maria Isabel Gouvea
- Infectious Diseases Department, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil.,Instituto Nacional de Infectologia, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Maria de Lourdes Benamor Teixeira
- Infectious Diseases Department, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil.,Instituto Nacional de Infectologia, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Trevon Fuller
- Institute of the Environment and Sustainability, University of California, Los Angeles, CA, USA
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Pastick KA, Nalintya E, Tugume L, Ssebambulidde K, Stephens N, Evans EE, Ndyetukira JF, Nuwagira E, Skipper C, Muzoora C, Meya DB, Rhein J, Boulware DR, Rajasingham R. Cryptococcosis in pregnancy and the postpartum period: Case series and systematic review with recommendations for management. Med Mycol 2020; 58:282-292. [PMID: 31689712 PMCID: PMC7179752 DOI: 10.1093/mmy/myz084] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/03/2019] [Accepted: 07/18/2019] [Indexed: 01/21/2023] Open
Abstract
Cryptococcal meningitis causes 15% of AIDS-related deaths. Optimal management and clinical outcomes of pregnant women with cryptococcosis are limited to case reports, as pregnant women are often excluded from research. Amongst pregnant women with asymptomatic cryptococcosis, no treatment guidelines exist. We prospectively identified HIV-infected women who were pregnant or recently pregnant with cryptococcosis, screened during a series of meningitis research studies in Uganda from 2012 to 2018. Among 571 women screened for cryptococcosis, 13 were pregnant, one was breastfeeding, three were within 14 days postpartum, and two had recently miscarried. Of these 19 women (3.3%), 12 had cryptococcal meningitis, six had cryptococcal antigenemia, and one had a history of cryptococcal meningitis and was receiving secondary prophylaxis. All women with meningitis received amphotericin B deoxycholate (0.7-1.0 mg/kg). Five were exposed to 200-800 mg fluconazole during pregnancy. Of these five, three delivered healthy babies with no gross physical abnormalities at birth, one succumbed to meningitis, and one outcome was unknown. Maternal meningitis survival rate at hospital discharge was 75% (9/12), and neonatal/fetal survival rate was 44% (4/9) for those mothers who survived. Miscarriages and stillbirths were common (n = 4). Of six women with cryptococcal antigenemia, two received fluconazole, one received weekly amphotericin B, and three had unknown treatment courses. All women with antigenemia survived, and none developed clinical meningitis. We report good maternal outcomes but poor fetal outcomes for cryptococcal meningitis using amphotericin B, without fluconazole in the first trimester, and weekly amphotericin B in place of fluconazole for cryptococcal antigenemia.
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Affiliation(s)
- Katelyn A Pastick
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Elizabeth Nalintya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Nicole Stephens
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Emily E Evans
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jane Frances Ndyetukira
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Edwin Nuwagira
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Caleb Skipper
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Conrad Muzoora
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - David B Meya
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joshua Rhein
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Radha Rajasingham
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Phillips TK, Orrell C, Brittain K, Zerbe A, Abrams EJ, Myer L. Measuring retention in HIV care: the impact of data sources and definitions using routine data. AIDS 2020; 34:749-759. [PMID: 32004202 PMCID: PMC7109335 DOI: 10.1097/qad.0000000000002478] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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 time: 77, 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.
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Affiliation(s)
- Tamsin K Phillips
- Division of Epidemiology & Biostatistics
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kirsty Brittain
- Division of Epidemiology & Biostatistics
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Allison Zerbe
- ICAP at Columbia University, Mailman School of Public Health
| | - Elaine J Abrams
- ICAP at Columbia University, Mailman School of Public Health
- Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
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Predictors of Mortality Among HIV-exposed Infants Through 18 Months of Age in Kenya: A Retrospective Review of Programmatic Data. Pediatr Infect Dis J 2020; 39:134-136. [PMID: 31738324 DOI: 10.1097/inf.0000000000002511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We identified mortality predictors among HIV-exposed uninfected infants and infants living with HIV in Kenyan early infant diagnosis services between 2012 and 2017. Younger maternal age and absence of antenatal antiretroviral therapy among HIV-exposed uninfected infants (n = 2366) and travel time to hospital and delayed infant testing among infants living with HIV (n = 130) predicted mortality, highlighting the importance of supporting engagement in maternal/pediatric HIV services.
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Psaros C, Stanton AM, Bedoya CA, Mosery N, Evans S, Matthews LT, Haberer J, Vangel M, Safren S, Smit JA. Protocol for a prospective evaluation of postpartum engagement in HIV care among women living with HIV in South Africa. BMJ Open 2020; 10:e035465. [PMID: 31924641 PMCID: PMC6955573 DOI: 10.1136/bmjopen-2019-035465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION KwaZulu-Natal (KZN), South Africa (SA) has the highest prevalence of pregnant women living with HIV in the world. Pregnancy and the postpartum period offer opportunities to engage women in HIV care, to prevent perinatal transmission and to optimise maternal and infant well-being. However, research suggests that remaining engaged in HIV care during this time can be challenging. METHODS AND ANALYSIS We are conducting a 5-year prospective cohort study among pregnant women living with HIV in KZN to estimate the rates and factors associated with attrition from HIV care during this critical period. To determine who is most likely to fall out of care, we are examining a range of relevant variables informed by a socioecological model of HIV care, including individual, relational, community and healthcare system variables. We are enrolling 18-45-year-old women, at 28 weeks or more of pregnancy, who are living with HIV and currently taking antiretroviral therapies. Participants complete quantitative assessments at baseline (pregnancy) and at 6, 12, 18 and 24 months postpartum. A subset of women and their partners are invited to complete qualitative interviews to further explore their experiences in HIV care. The main study outcomes are suppressed HIV RNA and retention in care at each study assessment. Our understanding of the factors that drive postpartum attrition from HIV care will ultimately inform the development of interventions to facilitate continued engagement in postpartum HIV care. ETHICS AND DISSEMINATION This protocol has been approved by the Human Research Ethics Committee (Medical) at The University of the Witwatersrand (Johannesburg, SA) and the Partners Human Research Committee at Partners HealthCare (Boston, Massachusetts, USA). Site support and approval were obtained from the District Hospital and the KZN Provincial Department of Health. Results will be disseminated through peer-reviewed manuscripts, reports and both local and international presentations (Ethics Registration #170 212).
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Affiliation(s)
- Christina Psaros
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amelia M Stanton
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - C Andres Bedoya
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nzwakie Mosery
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
| | - Shannon Evans
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
| | - Lynn Turner Matthews
- Department of Medicine, Division of Infectious Diseases, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jessica Haberer
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Global Health, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mark Vangel
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Steven Safren
- Department of Psychology, University of Miami, Coral Gables, Florida, USA
| | - Jennifer A Smit
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
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Decreases in Self-Reported ART Adherence Predict HIV Viremia Among Pregnant and Postpartum South African Women. J Acquir Immune Defic Syndr 2019; 80:247-254. [PMID: 30422906 DOI: 10.1097/qai.0000000000001909] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Routine HIV viral load (VL) monitoring is recommended for patients on antiretroviral therapy, but frequent VL testing, required in pregnant and postpartum women, is often not feasible. Self-reported adherence can be valuable, but little is known about its longitudinal characteristics. METHODS We followed women living with HIV from antiretroviral therapy initiation in pregnancy through 18-month postpartum in Cape Town, South Africa, with repeated measurement of VL and self-reported adherence using a 3-item scale. We used generalized estimating equations [with results presented as odds ratios (ORs) with 95% confidence intervals (CIs)] to investigate the association between viremia and change in adherence over pairs of consecutive visits. RESULTS Among 2085 visit pairs from 433 women, a decrease in self-reported adherence relative to the previous visit on any of the 3 self-report items, or the combined scale, was associated with VL >50 and >1000 copies per milliliter. The best-performing thresholds to predict VL >50 copies per milliliter were a single-level decrease on the Likert response item "how good a job did you do at taking your HIV medicines in the way that you were supposed to?" (OR 2.08, 95% CI: 1.48 to 2.91), and a decrease equivalent to ≥5 missed doses or a one-level decrease in score on either of 2 Likert items (OR 1.34, 95% CI: 1.06 to 1.69). CONCLUSIONS Longitudinal changes in self-reported adherence can help identify patients with viremia. This approach warrants consideration in settings where frequent VL monitoring or other objective adherence measures are not possible.
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Odeny TA, Hughes JP, Bukusi EA, Akama E, Geng EH, Holmes KK, McClelland RS. Text messaging for maternal and infant retention in prevention of mother-to-child HIV transmission services: A pragmatic stepped-wedge cluster-randomized trial in Kenya. PLoS Med 2019; 16:e1002924. [PMID: 31577792 PMCID: PMC6774469 DOI: 10.1371/journal.pmed.1002924] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 08/29/2019] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Timely diagnosis of infant HIV infection is essential for antiretroviral therapy (ART) initiation. In a randomized controlled trial, we found the Texting Improves Testing (TextIT) intervention (a theory-based text messaging system) to be efficacious for improving infant HIV testing rates and maternal retention in prevention of mother-to-child HIV transmission (PMTCT) programs. Using an implementation science approach, we aimed to evaluate real-world effectiveness of the intervention. METHODS AND FINDINGS In a pragmatic, cluster-randomized, stepped-wedge trial with 2 time periods of observation, we randomly allocated 10 clinics to begin implementing the intervention immediately and 10 clinics to begin implementing 6 months later. To approximate real-world conditions, inclusion criteria were broad. Women at clinics implementing the intervention received up to 14 text messages during pregnancy and after delivery and had the option to respond to text messages, call, or send inquiry text messages to a designated clinic phone. The primary outcomes were infant HIV testing and maternal retention in care during the first 8 weeks after delivery. We used modified Poisson regression with robust variance estimation to estimate the relative risk and 95% confidence intervals (CIs). Generalized estimating equations were applied on individual-level data to account for clustering by site. Between February 2015 and December 2016, 4,681 women were assessed for study participation, and 2,515 were included. Participant characteristics at enrollment did not differ by study arm. Overall median age was 27 years (interquartile range [IQR] 23-30), median gestational age was 30 weeks (IQR 28-34), 99% were receiving ART, and 87% who enrolled during intervention phases owned a phone. Of 2,326 infants analyzed, 1,466 of 1,613 (90.9%) in the intervention group and 609 of 713 (85.4%) in the control group met the primary outcome of HIV virologic testing performed before 8 weeks after birth (adjusted relative risk [aRR] 1.03; 95% CI 0.97-1.10; P = 0.3). Of 2,472 women analyzed, 1,548 of 1,725 (90%) in the intervention group and 571 of 747 (76%) in the control group met the primary outcome of retention in care during the first 8 weeks after delivery (aRR 1.12; 95% CI 0.97-1.30; P = 0.1). This study had two main limitations. Staff at all facilities were aware of ongoing observation, which may have contributed to increased rates of infant HIV testing and maternal retention in care at both intervention and control facilities, and programmatic initiatives to improve maternal and infant retention in care were ongoing at all facilities at the time of this study, which likely limited the ability to demonstrate effectiveness of the trial intervention. CONCLUSIONS In this study, a larger proportion of infants in the intervention group received HIV testing compared with the control group, but the difference was small and not statistically significant. There was also a nonsignificant increase in maternal postpartum retention in the intervention periods. Despite the lack of a significant effect of the intervention, key lessons emerged, both for strengthening PMTCT and for implementation research in general. Perhaps most important, improving the implementation of usual care may have been sufficient to substantially improve infant HIV testing rates. TRIAL REGISTRATION ClinicalTrials.gov Trial Number NCT02350140.
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Affiliation(s)
- Thomas A. Odeny
- Department of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, United States of America
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| | - James P. Hughes
- Department of Biostatistics, University of Washington, Seattle, Washington, United States of America
| | - Elizabeth A. Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
| | - Eliud Akama
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Elvin H. Geng
- University of California San Francisco, San Francisco, California, United States of America
| | - King K. Holmes
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Center for AIDS Research, University of Washington, Seattle, Washington, United States of America
- Department of Microbiology, University of Washington, Seattle, Washington, United States of America
| | - R. Scott McClelland
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
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Pellowski JA, Weber AZ, Phillips TK, Brittain K, Zerbe A, Abrams EJ, Myer L. "You must leave but I didn't want to leave": qualitative evaluation of the integration of ART into postnatal maternal and child health services in Cape Town, South Africa. AIDS Care 2019; 32:480-485. [PMID: 31455090 DOI: 10.1080/09540121.2019.1659913] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Postpartum HIV care retention rates are well below retention rates of the general adult population. The Maternal-Child Health Antiretroviral Therapy (MCH-ART) trial tested the benefit of integrating postpartum maternal ART and pediatric care through the end of breastfeeding compared to the standard of care of immediate postpartum referral of mother and infant to separate services. After the trial, twenty-one participants completed in-depth interviews to understand the acceptability of the service integration and the potentially differing "lived" experiences of the women randomized to the two conditions. Key findings include: (1) the MCH-ART integrated service was found to be acceptable, (2) women in the intervention condition expressed more negative feelings around the need to be transferred to general ART services and (3) women in the intervention condition perceived that they had more influence in selecting the clinic to which they would be transferred compared to those in the control group, although there was no actual difference by study design. Future work should more directly evaluate the impact of shared decision-making and long-term relationships with clinic staff on patient engagement and retention in HIV care.
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Affiliation(s)
- Jennifer A Pellowski
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA.,International Health Institute, Brown University School of Public Health, Providence, RI, USA
| | - Alison Z Weber
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Tamsin K Phillips
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Diseases Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kirsty Brittain
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Diseases Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Allison Zerbe
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Elaine J Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA.,Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Diseases Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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A Systematic Review and Meta-analysis of Antiretroviral Therapy (ART) Adherence Interventions for Women Living with HIV. AIDS Behav 2019; 23:1998-2013. [PMID: 30443806 DOI: 10.1007/s10461-018-2341-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
A systematic review and meta-analysis was conducted to determine the efficacy of women-focused ART adherence interventions. Included studies (a) reported on a behavioral ART adherence intervention for cis-women living with HIV, (b) measured ART adherence as an outcome, and (c) employed a randomized controlled trial design. Thirteen studies were included in the meta-analysis. Overall, interventions significantly improved ART adherence compared to control conditions (random-effects d = 0.82, 95% CI [0.18, 1.45], p = 0.01), however, this was largely driven by two studies that had effect sizes greater than 3 standard errors above the mean effect size. Key moderators were location, recruitment method, group-based intervention, and alteration of the healthcare system. Innovative behavioral interventions that focus on young women and adolescents, target the critical periods of pregnancy and postpartum and test the integration of multiple levels of intervention to create lasting effects on ART adherence are needed.
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Vulnerable at Each Step in the PMTCT Care Cascade: High Loss to Follow Up During Pregnancy and the Postpartum Period in Tanzania. AIDS Behav 2019; 23:1824-1832. [PMID: 30327997 DOI: 10.1007/s10461-018-2298-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In 2013, Tanzania adopted the World Health Organization's Option B+ guidelines for prevention of mother-to-child transmission of HIV (PMTCT), whereby all HIV-infected pregnant women initiate lifelong antiretroviral therapy. This study examined retention in PMTCT across critical junctures in the care continuum. This was a retrospective study of patient-level data for a cohort of women enrolled in PMTCT during the first year of Option B+ in Tanzania. Retention in care was described across three periods: (1) the first month of antenatal care (ANC), (2) pregnancy, and (3) the postpartum period. Logistic regression was used to identify factors associated with loss to follow up (LTFU) during the first month of ANC. Survival analyses were used to identify factors associated with LTFU during pregnancy and the postpartum periods. 650 participants were included in the cohort; 262 (40.3%) were newly diagnosed with HIV. Two years after delivery, 383/650 (58.7%) were LTFU. Of the 383 LTFU, 73 (19.1%) were lost during the first month of ANC, 44 (11.5%) during pregnancy, and 266 (69.5%) after delivery. Being newly diagnosed with HIV predicted higher LTFU during the first month of ANC (aOR 1.76; 95% CI 1.06-2.94) and faster time to LTFU during the postpartum period (adjusted relative time, 0.68; 95% CI 0.51-0.89). High LTFU occurred across the PMTCT continuum, including immediately after enrollment into ANC and the postpartum period. Ongoing research is needed to encourage treatment uptake and sustained engagement after delivery.
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Nyati-Jokomo Z, Chitsike I, Mbizvo E, January J. 'If nurses were in our shoes would they breastfeed their own babies?' A qualitative inquiry on challenges faced by breastfeeding mothers on the PMTCT programme in a rural community in Zimbabwe. BMC Pregnancy Childbirth 2019; 19:191. [PMID: 31146725 PMCID: PMC6543664 DOI: 10.1186/s12884-019-2336-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 05/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Prevention of Mother to Child Transmission (PMTCT) of HIV programme in Zimbabwe has had remarkable success despite the country's economic challenges. The aim of this study was to explore the challenges faced by breastfeeding mothers on the PMTCT programme. METHOD Narratives from 15 women (age range 19-35 years) were collected at two rural health facilities in Zimbabwe through in-depth interviews over a period of 6 months. Thematic analysis was used to describe breastfeeding mothers' experiences and challenges of being on the PMTCT programme. RESULTS The findings suggest that breastfeeding women on the PMTCT programme face challenges that include internal, external and institutional stigma and discrimination. Women reported a sense of powerlessness in decision making on following through with the PMTCT programme and were ambivalent regarding disclosure of their HIV status to their partners and significant others. CONCLUSION HIV and AIDS programmes should pay attention to women's readiness for interventions. There is need to understand women's life experiences to ensure informed and targeted programming for PMTCT.
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Affiliation(s)
- Zibusiso Nyati-Jokomo
- Department of Community Medicine, College of Health Sciences, University of Zimbabwe, PO Box A178, Avondale, Harare, Zimbabwe
| | - Inam Chitsike
- Department of Paediatrics and Child Health, University of Zimbabwe, Harare, Zimbabwe
| | - Elizabeth Mbizvo
- Department of Community Medicine, College of Health Sciences, University of Zimbabwe, PO Box A178, Avondale, Harare, Zimbabwe.
| | - James January
- Department of Community Medicine, College of Health Sciences, University of Zimbabwe, PO Box A178, Avondale, Harare, Zimbabwe
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Phillips TK, Myer L. Shifting to the long view: engagement of pregnant and postpartum women living with HIV in lifelong antiretroviral therapy services. Expert Rev Anti Infect Ther 2019; 17:349-361. [PMID: 30978126 DOI: 10.1080/14787210.2019.1607296] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Tamsin K Phillips
- a Division of Epidemiology & Biostatistics and Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa
| | - Landon Myer
- a Division of Epidemiology & Biostatistics and Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa
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Retention in HIV Care During Pregnancy and the Postpartum Period in the Option B+ Era: Systematic Review and Meta-Analysis of Studies in Africa. J Acquir Immune Defic Syndr 2019; 77:427-438. [PMID: 29287029 DOI: 10.1097/qai.0000000000001616] [Citation(s) in RCA: 156] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Under Option B+ guidelines for prevention of mother-to-child transmission of HIV, pregnant and breastfeeding women initiate antiretroviral therapy for lifelong use. The objectives of this study were: (1) to synthesize data on retention in care over time in option B+ programs in Africa, and (2) to identify factors associated with retention in care. METHODS PubMed, EMBASE, and African Index Medicus were systematically searched from January 2012 to June 2017. Pooled estimates of the proportion of women retained were generated and factors associated with retention were analyzed thematically. RESULTS Thirty-five articles were included in the final review; 22 reported retention rates (n = 60,890) and 25 reported factors associated with retention. Pooled estimates of retention were 72.9% (95% confidence interval: 66.4% to 78.9%) at 6 months for studies reporting <12 months of follow-up and 76.4% (95% confidence interval: 69.0% to 83.1%) at 12 months for studies reporting ≥12 months of follow-up. Data on undocumented clinic transfers were largely absent. Risk factors for poor retention included younger age, initiating antiretroviral therapy on the same day as diagnosis, initiating during pregnancy versus breastfeeding, and initiating late in the pregnancy. Retention was compromised by stigma, fear of disclosure, and lack of social support. CONCLUSIONS Retention rates in prevention of mother-to-child transmission under option B+ were below those of the general adult population, necessitating interventions targeting the complex circumstances of women initiating care under option B+. Improved and standardized procedures to track and report retention are needed to accurately represent care engagement and capture undocumented transfers within the health system.
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Sakyi KS, Lartey MY, Dension JA, Kennedy CE, Mullany LC, Owusu PG, Kwara A, Surkan PJ. Low Birthweight, Retention in HIV Care, and Adherence to ART Among Postpartum Women Living with HIV in Ghana. AIDS Behav 2019; 23:433-444. [PMID: 29968140 PMCID: PMC6710623 DOI: 10.1007/s10461-018-2194-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Care for low birthweight (LBW) infants can contribute to psychological difficulties and stigma among mothers living with HIV, creating challenges for antiretroviral therapy (ART) adherence and retention in HIV care. We explored how caring for LBW infants affects maternal ART adherence and retention in care. We conducted 30 in-depth interviews with postpartum women living with HIV in Accra, Ghana: 15 with LBW infants and 15 with normal birthweight (NBW) infants. Compared to mothers with NBW infants, mothers with LBW infants described how caring for their newborns led to increased caregiver burden, prolonged hospital stays, and stigma-contributing to incomplete ART adherence and missed clinical appointments. For a few women, care for LBW infants created opportunities for re-engagement in HIV care and motivation to adhere to ART. Results suggest women living with HIV and LBW babies in Ghana face increased challenges that impact their adherence to care and ART.
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Affiliation(s)
- Kwame S Sakyi
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
- Center for Learning and Childhood Development Ghana, AF 3190 Adenta Flats, Accra, Ghana.
- Department of Public and Environmental Wellness, School of Health Sciences, Oakland University, 3101 Human Health Building, 433 Meadow Brook Rd, Rochester, MI, 48309-4452, USA.
| | - Margaret Y Lartey
- Department of Medicine & Therapeutics, University of Ghana School of Medicine & Dentistry, CHS, P.O. Box GP 4236, Accra, Ghana
| | - Julie A Dension
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Caitlin E Kennedy
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Luke C Mullany
- Center for Learning and Childhood Development Ghana, AF 3190 Adenta Flats, Accra, Ghana
- Department of International Health, Global Epidemiology and Disease Control, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Prince G Owusu
- Center for Learning and Childhood Development Ghana, AF 3190 Adenta Flats, Accra, Ghana
| | - Awewura Kwara
- Division of Infectious Disease and Global Medicine, Department of Medicine, University of Florida, 2055 Mowry Road, Ste 250, PO Box 103600, Gainesville, FL, USA
| | - Pamela J Surkan
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
- Center for Learning and Childhood Development Ghana, AF 3190 Adenta Flats, Accra, Ghana
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Mogoba P, Phillips TK, Myer L, Ndlovu L, Were MC, Clouse K. Smartphone usage and preferences among postpartum HIV-positive women in South Africa. AIDS Care 2018; 31:723-729. [PMID: 30596261 DOI: 10.1080/09540121.2018.1563283] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In South Africa, HIV-positive women receiving antiretroviral therapy often are lost to care postpartum; strategies to support long-term engagement are needed. Mobile health (mHealth) interventions are emerging as a possible solution for supporting long-term engagement in the prevention of mother-to-child transmission (PMTCT) of HIV care continuum. In order to explore acceptability and feasibility of mobile health (mHealth) interventions in this context, we conducted focus group discussions (FGDs) to assess trends in smartphone usage in postpartum women. In six FGDs, we interviewed 27 HIV-positive, postpartum women who attended regular care at the Gugulethu Community Health Centre in Cape Town, South Africa, and who use a smartphone. Questions assessed the respondent's general trends in smartphone use, as well as their exposure to and perceptions of mHealth interventions. We found little turnover in phones and phone numbers, and about half the participants shared their devices with family and friends. Respondents reported high familiarity with smartphone applications, including WhatsApp, Facebook, YouTube, and Twitter, with WhatsApp as their preferred method of smartphone communication. Data bundles were most often used to connect to the internet, motivated by the perception that data bundles last longer and are cheaper than airtime, but respondents were adept at locating Wi-Fi sources at work or other public spaces. Nearly all participants were familiar with MomConnect, a national mHealth text support service in South Africa, and most described it positively. Respondents expressed interest in future HIV mHealth applications including complementary health information on physical activity, nutrition, mental health and basic social services. Participants were active and engaged smartphone users with reliable internet connections and a positive attitude towards mHealth platforms. Future mHealth interventions show promise in this population.
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Affiliation(s)
- Phepo Mogoba
- a Centre for Infectious Disease Epidemiology and Research , School of Public Health and Family Medicine, University of Cape Town , Cape Town , South Africa.,b Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine , University of Cape Town Cape Town , South Africa
| | - Tamsin K Phillips
- a Centre for Infectious Disease Epidemiology and Research , School of Public Health and Family Medicine, University of Cape Town , Cape Town , South Africa.,b Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine , University of Cape Town Cape Town , South Africa
| | - Landon Myer
- a Centre for Infectious Disease Epidemiology and Research , School of Public Health and Family Medicine, University of Cape Town , Cape Town , South Africa.,b Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine , University of Cape Town Cape Town , South Africa
| | - Linda Ndlovu
- a Centre for Infectious Disease Epidemiology and Research , School of Public Health and Family Medicine, University of Cape Town , Cape Town , South Africa
| | - Martin C Were
- c Vanderbilt Institute for Global Health , Vanderbilt University , Nashville , TN , USA.,d Department of Biomedical Informatics , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Kate Clouse
- c Vanderbilt Institute for Global Health , Vanderbilt University , Nashville , TN , USA.,e Vanderbilt University Department of Medicine , Division of Infectious Diseases , Nashville , TN , USA
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49
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Watt MH, Cichowitz C, Kisigo G, Minja L, Knettel BA, Knippler ET, Ngocho J, Manavalan P, Mmbaga BT. Predictors of postpartum HIV care engagement for women enrolled in prevention of mother-to-child transmission (PMTCT) programs in Tanzania. AIDS Care 2018; 31:687-698. [PMID: 30466304 DOI: 10.1080/09540121.2018.1550248] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Prevention of mother-to-child transmission of HIV (PMTCT) is a foundational component of a comprehensive HIV treatment program. In addition to preventing vertical transmission to children, PMTCT is an important catch-point for universal test-and-treat strategies that can reduce community viral load and slow the epidemic. However, systematic reviews suggest that care engagement in PMTCT programs is sub-optimal. This study enrolled a cohort of 200 women initiating PMTCT in Kilimanjaro, Tanzania, and followed them to assess HIV care engagement and associated factors. Six months after delivery, 42/200 (21%) of participants were identified as having poor care engagement, defined as HIV RNA >200 copies/mL or, if viral load was unavailable, being lost-to-follow-up in the clinical records or self-reporting being out of care. In a multivariable risk factor analysis, younger women were more likely to have poor postpartum care engagement; with each year of age, women were 7% less likely to have poor care engagement (aRR: 0.93; 95% CI: 0.89, 0.98). Additionally, women who had told at least one person about their HIV status were 47% less likely to have poor care engagement (aRR: .53; 95% CI: 0.29, 0.97). Among women who entered antenatal care with an established HIV diagnosis, those who were pregnant for the first time had increased risk of poor care engagement (aRR 4.16; 95% CI 1.53, 11.28). The findings suggest that care engagement remains a concern in PMTCT programs, and must be addressed to realize the goals of PMTCT. Comprehensive counseling on HIV disclosure, along with community-based stigma reduction programs to provide a supportive environment for people living with HIV, are crucial to address barriers to care engagement and support long-term treatment. Women presenting to antenatal care with an established HIV status require support for care engagement during the crucial period surrounding childbirth, particularly those pregnant for the first time.
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Affiliation(s)
- Melissa H Watt
- a Duke Global Health Institute , Duke University , Durham , NC , USA
| | - Cody Cichowitz
- a Duke Global Health Institute , Duke University , Durham , NC , USA.,b School of Medicine, Johns Hopkins University , Baltimore , MD , USA
| | - Godfrey Kisigo
- a Duke Global Health Institute , Duke University , Durham , NC , USA.,c Kilimanjaro Clinical Research Institute , Moshi , Tanzania
| | - Linda Minja
- c Kilimanjaro Clinical Research Institute , Moshi , Tanzania
| | - Brandon A Knettel
- a Duke Global Health Institute , Duke University , Durham , NC , USA
| | | | - James Ngocho
- d Kilimanjaro Christian Medical Centre , Moshi , Tanzania.,e Kilimanjaro Christian Medical University College , Moshi , Tanzania
| | - Preeti Manavalan
- a Duke Global Health Institute , Duke University , Durham , NC , USA
| | - Blandina T Mmbaga
- a Duke Global Health Institute , Duke University , Durham , NC , USA.,c Kilimanjaro Clinical Research Institute , Moshi , Tanzania.,d Kilimanjaro Christian Medical Centre , Moshi , Tanzania.,e Kilimanjaro Christian Medical University College , Moshi , Tanzania
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50
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Knettel BA, Minja L, Chumba LN, Oshosen M, Cichowitz C, Mmbaga BT, Watt MH. Serostatus disclosure among a cohort of HIV-infected pregnant women enrolled in HIV care in Moshi, Tanzania: A mixed-methods study. SSM Popul Health 2018; 7:007-7. [PMID: 30560196 PMCID: PMC6289955 DOI: 10.1016/j.ssmph.2018.11.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 10/10/2018] [Accepted: 11/11/2018] [Indexed: 11/16/2022] Open
Abstract
HIV-infected pregnant women face complex decisions about whether and how to disclose their serostatus. Previous studies have shown that HIV disclosure is associated with better care engagement, emotional adjustment to the disease, and reduced risk of HIV transmission, but women face both real and perceived barriers to disclosure. We examined patterns and predictors of HIV disclosure in a cohort of 200 women diagnosed or confirmed to have HIV during antenatal care in the Kilimanjaro region of Tanzania and followed participants to three months postpartum. Twenty women also completed qualitative in-depth interviews during pregnancy and three months postpartum. During the pregnancy period (at least 30 days post-diagnosis), 79.5% of women had disclosed to at least one other person, with disclosures generally restricted to the father of the child and/or a small number of close family members. By three months postpartum, 11.9% of women had still not disclosed to anyone. Women who presented to antenatal care with an established HIV diagnoses and married women were more likely to report disclosures. Social support was positively associated with disclosure. In qualitative interviews, women pointed to community gossip and stigma as barriers to disclosure. Those who had not disclosed to the father of the child noted fears of abandonment during the vulnerable pregnancy period. Despite expressed fears, participants reported overall positive experiences of disclosure that led to increased support. Taken together, these results point to the need for comprehensive, flexible, and culturally informed interventions that assist pregnant and postpartum women in deciding when and how to disclose. Such interventions should acknowledge and explore common barriers to disclosure, including fears of public stigma and personal consequences. Given the strong associations between disclosure, social support, and community stigma, interventions for disclosure should be nested in broader efforts of public education and HIV stigma reduction.
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Affiliation(s)
| | - Linda Minja
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Lilian N Chumba
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Martha Oshosen
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Cody Cichowitz
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Kilimanjaro Clinical Research Institute, Moshi, Tanzania.,Johns Hopkins University School of Medicine, Baltimore, MD
| | - Blandina T Mmbaga
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Kilimanjaro Clinical Research Institute, Moshi, Tanzania.,Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Melissa H Watt
- Duke Global Health Institute, Duke University, Durham, NC, USA
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