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Hunt JH, Peay HL, Henderson GE. Facilitators and Barriers to Adherence to Anti-Retroviral Treatment Among Pregnant or Breastfeeding Women Living with HIV and Perinatally Infected Infants: A Scoping Review. AIDS Behav 2024; 28:2910-2925. [PMID: 38767727 DOI: 10.1007/s10461-024-04373-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2024] [Indexed: 05/22/2024]
Abstract
In 2022, 54% of 1.5 million children (age 0-14) living with HIV had access to anti-retroviral medication (ART). Adherence to ART for pregnant or breastfeeding HIV + women is critical for maintaining their personal health and to prevent mother-to-child-transmission (MTCT). For HIV + infants, adherence is essential to establish early viremic control and is contingent on caregiver administration. We conducted a scoping review to systematically identify and categorize the influences on ART adherence for pregnant or breastfeeding HIV + women and their HIV + infants. We searched databases in June 2023 and employed the Social-Ecological Model (SEM) to organize facilitators and barriers to adherence referenced in published articles. All articles published before 2016 were excluded due to updated guidelines from WHO on MTCT and ART. Our analysis included 52 articles. 50/52 took place in Africa and used cross-sectional and mixed-methods design. Barriers to adherence for pregnant or breastfeeding HIV + women included maternal education, self-efficacy, social support, and social/economic context. Barriers to infant adherence included development, nutrition, age of treatment initiation, disclosure, and ART side effects. Additional facilitators and barriers to adherence are presented at family, extra-familial, and socio-cultural SEM levels. Stigma was the most salient barrier referenced across the entire continuum of HIV care and all SEM levels. This review revealed a dearth of literature focusing on HIV + infants who are dependent on their caregivers for ART adherence and lack of a standard adherence measure. We identified multi-leveled influences on adherence impacting both the mother and infant and are amenable to public health intervention.
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Affiliation(s)
- Joanne H Hunt
- Department of Sociology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Holly L Peay
- Research Triangle International, Durham, NC, USA
| | - Gail E Henderson
- Department of Social Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
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Stoner MCD, Mathebula F, Sedze N, Seyama L, Mohuba R, Fabiano Z, Etima J, Young A, Scheckter R, van der Straten A, Piper J, Noguchi L, Montgomery ET, Balán IC. Depression Among Pregnant and Breastfeeding Persons Participating in Two Randomized Trials of the Dapivirine Vaginal Ring and Oral Pre-Exposure Prophylaxis (PrEP) in Malawi, South Africa, Uganda, and Zimbabwe. AIDS Behav 2024; 28:2264-2275. [PMID: 38526641 DOI: 10.1007/s10461-024-04321-2] [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] [Accepted: 03/11/2024] [Indexed: 03/27/2024]
Abstract
Depression is associated with lower adherence to oral pre-exposure prophylaxis (PrEP) to prevent HIV, but data are not currently available on how depression may affect use of other HIV prevention methods including the dapivirine vaginal ring (DVR). We conducted a mixed methods study using data from the Microbicide Trials Network (MTN) 042/DELIVER (n = 558) and MTN-043/B-PROTECTED (n = 197) studies to describe the prevalence of depressive symptoms and explore how depressive symptoms may have influenced attitudes about use of the monthly DVR and once-daily oral PrEP tablet among pregnant and breastfeeding persons, respectively, in Malawi, South Africa, Uganda, and Zimbabwe. Eleven participants had high Edinburgh Postnatal Depression scores ≥ 10 in MTN-042/DELIVER (2%) and four participants (2%) in MTN-043/B-PROTECTED. In interviews with 9 participants who had high scores (6 DVR, 3 oral PrEP), those with depressive symptoms described overlapping stressors which were magnified by job loss and economic instability during the COVID-19 pandemic, and by experiences of pregnancy/postpartum. These participants experienced a lack of support from partners or family members, and conflict with partners related to trust, and infidelity. While we did not find evidence of a change in product adherence, there was a strong sense of commitment and motivation to use the study products for protection from HIV for participants themselves and their baby. Although lack of social support is usually an obstacle to adherence, in this study, the participants' lives and relationships seemed to have reinforced the need for HIV prevention and motivated women to protect themselves and their babies from HIV.
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Affiliation(s)
| | - Florence Mathebula
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Natasha Sedze
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Linly Seyama
- Johns Hopkins Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Rebone Mohuba
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Zayithwa Fabiano
- Johns Hopkins Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Juliane Etima
- Makerere University - Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | | | | | | | - Jeanna Piper
- National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, USA
| | - Lisa Noguchi
- Division of Reproductive, Maternal, Newborn, Child and Adolescent Health, Jhpiego/Johns Hopkins University, Washington, DC, USA
| | | | - Iván C Balán
- Florida State University College of Medicine, Tallahassee, FL, USA
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Bengtson AM, Filipowicz TR, Mphonda S, Udedi M, Kulisewa K, Meltzer-Brody S, Gaynes BN, Go VF, Chibanda D, Verhey R, Hosseinipour MC, Pence BW. An Intervention to Improve Mental Health and HIV Care Engagement Among Perinatal Women in Malawi: A Pilot Randomized Controlled Trial. AIDS Behav 2023; 27:3559-3570. [PMID: 37084104 PMCID: PMC10119837 DOI: 10.1007/s10461-023-04070-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 04/22/2023]
Abstract
Perinatal depression (PND) is common and an important barrier to engagement in HIV care for women living with HIV (WLHIV). Accordingly, we adapted and enhanced The Friendship Bench, an evidence-based counseling intervention, for perinatal WLHIV. In a pilot randomized trial (NCT04143009), we evaluated the feasibility, acceptability, fidelity, and preliminary efficacy of the Enhanced Friendship Bench (EFB) intervention to improve PND and engagement in HIV care outcomes. Eighty pregnant WLHIV who screened positive for PND symptoms on the Self-Report Questionnaire (≥ 8) were enrolled, randomized 1:1 to EFB or usual care, and followed through 6 months postpartum. Overall, 100% of intervention participants were satisfied with the intervention and 93% found it beneficial to their overall health. Of 82 counseling sessions assessed for fidelity, 83% met or exceeded the fidelity threshold. At 6 months postpartum, intervention participants had improved depression remission (59% versus 36%, RD 23%, 95% CI 2%, 45%), retention in HIV care (82% versus 69%, RD 13%, -6%, 32%), and viral suppression (96% versus 90%, RD 7%, -7%, 20%) compared to usual care. Adverse events did not differ by arm. These results suggest that EFB intervention should be evaluated in a fully powered randomized trial to evaluate its efficacy to improve PND and engagement in HIV care outcomes for WLHIV.
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Affiliation(s)
- Angela M Bengtson
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA.
| | - Teresa R Filipowicz
- Department of Epidemiology, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | | | - Michael Udedi
- Mental Health Unit, Malawi Ministry of Health, Lilongwe, Malawi
| | - Kazione Kulisewa
- Department of Psychiatry and Mental Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Samantha Meltzer-Brody
- Department of Psychiatry, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Bradley N Gaynes
- Department of Epidemiology, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
- Department of Psychiatry, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Vivian F Go
- Department of Health Behavior, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Dixon Chibanda
- Department of Psychiatry & Research Support Centre, University of Zimbabwe, Harare, Zimbabwe
| | | | - Mina C Hosseinipour
- UNC Project Malawi, Lilongwe, Malawi
- Division of Infectious Diseases, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Brian Wells Pence
- Department of Epidemiology, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
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Davies A, Mullin S, Chapman S, Barnard K, Bakhbakhi D, Ion R, Neuberger F, Standing J, Merriel A, Fraser A, Burden C. Interventions to enhance medication adherence in pregnancy- a systematic review. BMC Pregnancy Childbirth 2023; 23:135. [PMID: 36864375 PMCID: PMC9979410 DOI: 10.1186/s12884-022-05218-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 11/15/2022] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Sub-optimal medication adherence in pregnant women with chronic disease and pregnancy-related indications has the potential to adversely affect maternal and perinatal outcomes. Adherence to appropriate medications is advocated during and when planning pregnancy to reduce risk of adverse perinatal outcomes relating to chronic disease and pregnancy-related indications. We aimed to systematically identify effective interventions to promote medication adherence in women who are pregnant or planning to conceive and impact on perinatal, maternal disease-related and adherence outcomes. METHODS Six bibliographic databases and two trial registries were searched from inception to 28th April 2022. We included quantitative studies evaluating medication adherence interventions in pregnant women and women planning pregnancy. Two reviewers selected studies and extracted data on study characteristics, outcomes, effectiveness, intervention description (TIDieR) and risk of bias (EPOC). Narrative synthesis was performed due to study population, intervention and outcome heterogeneity. RESULTS Of 5614 citations, 13 were included. Five were RCTs, and eight non-randomised comparative studies. Participants had asthma (n = 2), HIV (n = 6), inflammatory bowel disease (IBD; n = 2), diabetes (n = 2) and risk of pre-eclampsia (n = 1). Interventions included education +/- counselling, financial incentives, text messaging, action plans, structured discussion and psychosocial support. One RCT found an effect of the tested intervention on self-reported antiretroviral adherence but not objective adherence. Clinical outcomes were not evaluated. Seven non-randomised comparative studies found an association between the tested intervention and at least one outcome of interest: four found an association between receiving the intervention and both improved clinical or perinatal outcomes and adherence in women with IBD, gestational diabetes mellitus (GDM), and asthma. One study in women with IBD reported an association between receiving the intervention and maternal outcomes but not for self-reported adherence. Two studies measured only adherence outcomes and reported an association between receiving the intervention and self-reported and/or objective adherence in women with HIV and risk of pre-eclampsia. All studies had high or unclear risk of bias. Intervention reporting was adequate for replication in two studies according to the TIDieR checklist. CONCLUSIONS There is a need for high-quality RCTs reporting replicable interventions to evaluate medication adherence interventions in pregnant women and those planning pregnancy. These should assess both clinical and adherence outcomes.
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Affiliation(s)
- Anna Davies
- Academic Women's Health Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1QU, UK.
| | - Sadie Mullin
- grid.5337.20000 0004 1936 7603Academic Women’s Health Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1QU UK
| | - Sarah Chapman
- grid.7340.00000 0001 2162 1699Department of Pharmacy and Pharmacology, University of Bath, Bath, BA2 7AY UK
| | - Katie Barnard
- grid.416201.00000 0004 0417 1173North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, BS10 5NB UK
| | - Danya Bakhbakhi
- grid.5337.20000 0004 1936 7603Academic Women’s Health Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1QU UK
| | - Rachel Ion
- grid.416201.00000 0004 0417 1173North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, BS10 5NB UK
| | - Francesca Neuberger
- grid.416201.00000 0004 0417 1173North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, BS10 5NB UK
| | - Judith Standing
- grid.416201.00000 0004 0417 1173North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, BS10 5NB UK
| | - Abi Merriel
- grid.5337.20000 0004 1936 7603Academic Women’s Health Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1QU UK ,grid.5337.20000 0004 1936 7603Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1QU UK
| | - Abigail Fraser
- grid.5337.20000 0004 1936 7603Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1QU UK ,grid.410421.20000 0004 0380 7336National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN UK
| | - Christy Burden
- grid.5337.20000 0004 1936 7603Academic Women’s Health Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1QU UK
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Stanton AM, O'Cleirigh C, Knight L, Davey DLJ, Myer L, Joska JA, Mayer KH, Bekker L, Psaros C. The importance of assessing and addressing mental health barriers to PrEP use during pregnancy and postpartum in sub-Saharan Africa: state of the science and research priorities. J Int AIDS Soc 2022; 25:e26026. [PMID: 36251124 PMCID: PMC9575939 DOI: 10.1002/jia2.26026] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 09/28/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Pregnant and postpartum women (PPW) in sub‐Saharan Africa are at disproportionately high risk of HIV infection compared to non‐pregnant women. When used consistently, pre‐exposure prophylaxis (PrEP) can prevent HIV acquisition and transmission to the foetus or infant during these critical periods. Recent studies have demonstrated associations between mental health challenges (e.g. depression and traumatic stress associated with intimate partner violence) and decreased PrEP adherence and persistence, particularly among adolescents, younger women and women in the postpartum period. However, mental health is not currently a major focus of PrEP implementation research and programme planning for PPW. Discussion PrEP implementation programmes for PPW need to assess and address mental health barriers to consistent PrEP use to ensure effectiveness and sustainability in routine care. We highlight three key research priorities that will support PrEP adherence and persistence: (1) include mental health screening tools in PrEP implementation research with PPW, both to assess the feasibility of integrating these tools into routine antenatal and postpartum care and to ensure that limited resources are directed towards women whose symptoms may interfere most with PrEP use; (2) identify cross‐cutting, transdiagnostic psychological mechanisms that affect consistent PrEP use during these periods and can realistically be targeted with intervention in resource‐limited settings; and (3) develop/adapt and test interventions that target those underlying mechanisms, leveraging strategies from existing interventions that have successfully mitigated mental health barriers to antiretroviral therapy use among people with HIV. Conclusions For PPW, implementation of PrEP should be guided by a robust understanding of the unique psychological difficulties that may act as barriers to uptake, adherence and persistence (i.e. sustained adherence over time). We strongly encourage PrEP implementation research in PPW to incorporate validated mental health screening tools and ultimately treatment in routine antenatal and postnatal care, and we stress the potential public health benefits of identifying women who face mental health barriers to PrEP use.
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Affiliation(s)
- Amelia M. Stanton
- Department of Psychological and Brain SciencesBoston UniversityBostonMassachusettsUSA,Massachusetts General HospitalBostonMassachusettsUSA,Fenway HealthBostonMassachusettsUSA
| | - Conall O'Cleirigh
- Massachusetts General HospitalBostonMassachusettsUSA,Fenway HealthBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
| | - Lucia Knight
- School of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Dvora L. Joseph Davey
- School of Public HealthUniversity of Cape TownCape TownSouth Africa,Division of Infectious Diseases, Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Landon Myer
- School of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - John A. Joska
- HIV Mental Health Research Unit, Division of Neuropsychiatry, Department of Psychiatry and Mental HealthUniversity of Cape TownCape TownSouth Africa
| | - Kenneth H. Mayer
- Fenway HealthBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA,HIV Mental Health Research Unit, Division of Neuropsychiatry, Department of Psychiatry and Mental HealthUniversity of Cape TownCape TownSouth Africa,Beth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | | | - Christina Psaros
- Massachusetts General HospitalBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA
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Spelke MB, Paul R, Blette BS, Meltzer-Brody S, Schiller CE, Ncheka JM, Kasaro MP, Price JT, Stringer JSA, Stringer EM. Interpersonal therapy versus antidepressant medication for treatment of postpartum depression and anxiety among women with HIV in Zambia: a randomized feasibility trial. J Int AIDS Soc 2022; 25:e25959. [PMID: 35803896 PMCID: PMC9270230 DOI: 10.1002/jia2.25959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 06/14/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Postpartum depression (PPD) is a prevalent and debilitating disease that may affect medication adherence and thus maternal health and vertical transmission among women with HIV. We assessed the feasibility of a trial of interpersonal psychotherapy (IPT) versus antidepressant medication (ADM) to treat PPD and/or anxiety among postpartum women with HIV in Lusaka, Zambia. Methods Between 29 October 2019 and 8 September 2020, we pre‐screened women 6–8 weeks after delivery with the Edinburgh Postnatal Depression Scale (EPDS) and diagnosed PPD or anxiety with the Mini International Neuropsychiatric Interview. Consenting participants were randomized 1:1 to up to 11 sessions of IPT or daily self‐administered sertraline and followed for 24 weeks. We assessed EPDS score, Clinical Global Impression‐Severity of Illness (CGI‐S) and medication side effects at each visit and measured maternal HIV viral load at baseline and final study visit. Retention, visit adherence, change in EPDS, CGI‐S and log viral load were compared between groups with t‐tests and Wilcoxon signed rank tests; we report mean differences, relative risks and 95% confidence intervals. A participant satisfaction survey assessed trial acceptability. Results 78/80 (98%) participants were retained at the final study visit. In the context of the COVID‐19 pandemic, visit adherence was greater among women allocated to ADM (9.9 visits, SD 2.2) versus IPT (8.9 visits, SD 2.4; p = 0.06). EPDS scores decreased from baseline to final visit overall, though mean change was greater in the IPT group (−13.8 points, SD 4.7) compared to the ADM group (−11.4 points, SD 5.5; p = 0.04). Both groups showed similar changes in mean log viral load from baseline to final study visit (mean difference −0.43, 95% CI −0.32, 1.18; p = 0.48). In the IPT group, viral load decreased significantly from baseline (0.9 log copies/ml, SD 1.7) to final visit (0.2 log copies/ml, SD 0.9; p = 0.01). Conclusions This pilot study demonstrates that a trial of two forms of PPD treatment is feasible and acceptable among women with HIV in Zambia. IPT and ADM both improved measures of depression severity; however, a full‐scale trial is required to determine whether treatment of PPD and anxiety improves maternal–infant HIV outcomes.
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Affiliation(s)
- M Bridget Spelke
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,University of North Carolina - Global Projects Zambia, Lusaka, Zambia
| | - Ravi Paul
- Department of Psychiatry, University of Zambia School of Medicine, Lusaka, Zambia
| | - Bryan S Blette
- Department of Biostatistics, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Samantha Meltzer-Brody
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Crystal E Schiller
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - J M Ncheka
- Department of Psychiatry, University of Zambia School of Medicine, Lusaka, Zambia
| | - Margaret P Kasaro
- University of North Carolina - Global Projects Zambia, Lusaka, Zambia
| | - Joan T Price
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,University of North Carolina - Global Projects Zambia, Lusaka, Zambia
| | - Jeffrey S A Stringer
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,University of North Carolina - Global Projects Zambia, Lusaka, Zambia
| | - Elizabeth M Stringer
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,University of North Carolina - Global Projects Zambia, Lusaka, Zambia
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