Continuation of postpartum antiretroviral therapy in a cohort of women infected with human immunodeficiency virus

ART uptake and adherence among women who use drugs globally: A scoping review

OBJECTIVE

To assess the state of peer-reviewed literature surrounding uptake and adherence of antiretroviral therapy (ART) among HIV-positive women who use drugs (WWUD).

METHODS

Consistent with PRISMA-ScR guidelines, we conducted a scoping literature review on ART uptake and adherence among WWUD, searching PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting at least one ART uptake or adherence related result among WWUD aged 18 or older; peer-reviewed; published in English between 1996-2018.

RESULTS

Our search identified 6735 studies; 86 met eligibility requirements. ART uptake ranged from 30 % to 76 % and adherence ranged from 27 % to 95 %. Substance use, co-morbid psychiatric disorders, and side effects emerged as the primary ART uptake and adherence barriers among this population. Few facilitators were identified.

CONCLUSION

This study is the first scoping review to look at ART uptake and adherence among WWUD globally. The wide range in uptake and adherence outcomes indicates the need for gold standard assessments, which may differ between high and low resource settings. This study offers rich insight into uptake and adherence barriers and facilitators, primarily at the intrapersonal level. More research is needed to examine interventions that focus on additional levels of the SEM (e.g., community and policy levels). These review findings can inform ART interventions, future research, and offer guidance to other support services with WWUD, such as PrEP interventions.

Brief Report: Estimated Incidence of Perinatally Acquired HIV Infection in the United States, 1978-2013

BACKGROUND

An incidence of perinatally acquired HIV infection less than 1:100,000 live births is one of the Centers for Disease Control and Prevention (CDC) goals of the United States. Such an estimate has only been possible in recent years because regular nationwide data were lacking.

METHOD

Using previously published CDC estimates of the number of infants born with HIV infection in the United States (interpolating for years for which there was no published estimate), and census data on the annual number of live-born infants, estimated incidence was calculated for 1978-2013. Exact 95% confidence intervals (CIs) were calculated using the Poisson distribution.

RESULTS

Estimated incidence of perinatally acquired HIV infection peaked at 43.1 (95% CI: 41.1 to 45.1) in 1992 and declined rapidly after the use of zidovudine prophylaxis was recommended in 1994. In 2013, estimated incidence of perinatally acquired HIV infection in the United States was 1.8 (95% CI: 1.4 to 2.2), a 96% decline since the peak.

CONCLUSION

Estimated incidence of perinatally acquired HIV infection in the United States in 2013 was 1.8/100,000 live births.

Combination antiretroviral treatment for women previously treated only in pregnancy: week 24 results of AIDS clinical trials group protocol a5227

BACKGROUND

Women with HIV and prior exposure to combination antiretroviral therapy (cART) solely for prevention of mother-to-child transmission (pMTCT) need to know whether they can later be treated successfully with a commonly used regimen of efavirenz (EFV) and coformulated emtricitabine (FTC) and tenofovir disoproxil fumarate (TDF).

METHODS

Nonpregnant women with plasma HIV-1 RNA of ≥500 copies per milliliter, previously cART exposed for pMTCT only, were eligible if they were off ART for ≥24 weeks before entry, were without evidence of drug resistance on standard genotyping, and were ready to start EFV plus FTC/TDF. The primary endpoint was virologic response (defined as plasma HIV RNA <400 copies/mL) at 24 weeks.

RESULTS

Fifty-four women were enrolled between October 2007 and December 2009; 52 of 54 completed 24 weeks of follow-up. Median baseline CD4 T-cell count was 265/mm and baseline plasma HIV-1 RNA was 4.6 log10 copies per milliliter. Median prior cART duration was 14 weeks, and median time elapsed from the last pMTCT dose to entry was 22 months. Virologic response at 24 weeks was observed in 42 of 52 women or 81% (exact 95% confidence interval: 68% to 90%). There were no differences in response by country, by number, or class of prior pMTCT exposures. Although confirmed virologic failure occurred in 8 women, no virologic failures were observed in women reporting perfect early adherence.

CONCLUSIONS

In this first prospective clinical trial studying combination antiretroviral retreatment in women with a history of pregnancy-limited cART, the observed virologic response to TDF/FTC and EFV at 24 weeks was 81%. Virologic failures occurred and correlated with self-reported nonadherence.

Loss to follow-up before and after delivery among women testing HIV positive during pregnancy in Johannesburg, South Africa

OBJECTIVE

HIV-positive pregnant women are at heightened risk of becoming lost to follow-up (LTFU) from HIV care. We examined LTFU before and after delivery among pregnant women newly diagnosed with HIV.

METHODS

Observational cohort study of all pregnant women ≥18 years (N = 300) testing HIV positive for the first time at their first ANC visit between January and June 2010, at a primary healthcare clinic in Johannesburg, South Africa. Women (n = 27) whose delivery date could not be determined were excluded.

RESULTS

Median (IQR) gestation at HIV testing was 26 weeks (21-30). Ninety-eight per cent received AZT prophylaxis, usually started at the first ANC visit. Of 139 (51.3%) patients who were ART eligible, 66.9% (95% CI 58.8-74.3%) initiated ART prior to delivery; median (IQR) ART duration pre-delivery was 9.5 weeks (5.1-14.2). Among ART-eligible patients, 40.5% (32.3-49.0%) were cumulatively retained through 6 months on ART. Of those ART-ineligible patients at HIV testing, only 22.6% (95% CI 15.9-30.6%) completed CD4 staging and returned for a repeat CD4 test after delivery. LTFU (≥1 month late for last scheduled visit) before delivery was 20.5% (95% CI 16.0-25.6%) and, among those still in care, 47.9% (95% CI 41.2-54.6%) within 6 months after delivery. Overall, 57.5% (95% CI 51.6-63.3%) were lost between HIV testing and 6 months post-delivery.

CONCLUSIONS

Our findings highlight the challenge of continuity of care among HIV-positive pregnant women attending antenatal services, particularly those ineligible for ART.

Adherence to antiretroviral therapy during and after pregnancy in low-income, middle-income, and high-income countries: a systematic review and meta-analysis

OBJECTIVE

To estimate antiretroviral therapy (ART) adherence rates during pregnancy and postpartum in high-income, middle-income, and low-income countries.

DESIGN

Systematic review and meta-analysis.

METHODS

MEDLINE, EMBASE, SCI Web of Science, NLM Gateway, and Google scholar databases were searched. We included all studies reporting adherence rates as a primary or secondary outcome among HIV-infected pregnant women. Two independent reviewers extracted data on adherence and study characteristics. A random-effects model was used to pool adherence rates; sensitivity, heterogeneity, and publication bias were assessed.

RESULTS

Of 72 eligible articles, 51 studies involving 20 153 HIV-infected pregnant women were included. Most studies were from United States (n =  14, 27%) followed by Kenya (n = 6, 12%), South Africa (n = 5, 10%), and Zambia (n = 5, 10%). The threshold defining good adherence to ART varied across studies (>80, >90, >95, 100%). A pooled analysis of all studies indicated a pooled estimate of 73.5% [95% confidence interval (CI) 69.3-77.5%] of pregnant women who had adequate (>80%) ART adherence. The pooled proportion of women with adequate adherence levels was higher during the antepartum (75.7%, 95% CI 71.5-79.7%) than during postpartum (53.0%, 95% CI 32.8-72.7%; P = 0.005). Selected reported barriers for nonadherence included physical, economic and emotional stresses, depression (especially postdelivery), alcohol or drug use, and ART dosing frequency or pill burden.

CONCLUSION

Our findings indicate that only 73.5% of pregnant women achieved optimal ART adherence. Reaching adequate ART adherence levels was a challenge in pregnancy, but especially during the postpartum period. Further research to investigate specific barriers and interventions to address them is urgently needed globally.

Effect of Postpartum HIV Treatment Discontinuation on Long-Term Maternal Outcome

Background. Long-term maternal outcomes after postpartum antiretroviral therapy (ART) discontinuation are unknown. Methods. Retrospective review of pregnancies in HIV-infected women on treatment between 1997 and 2005. Women were grouped by postpartum ART use and followed until new opportunistic infection (OI), death or last clinic visit. Results. Of 172 pregnancies, postpartum ART discontinuation occurred in 123 (71.5%) women and was associated with greater parity, no partner during pregnancy, and no indication for OI prophylaxis or preconception ART in multivariate analysis (P < .05). Median follow-up was 32.5 months after delivery. There were 12 OIs and 2 deaths; 10 OIs and both deaths occurred in women who had discontinued ART. Conclusion. Postpartum ART discontinuation is common, especially among those with less advanced HIV disease, but may leave women at increased risk of long term adverse outcomes. This study highlights the need for larger longitudinal studies to determine appropriate recommendations for postpartum ART administration.

Adherence among women with HIV infection in Puerto Rico: the potential use of modified directly observed therapy (MDOT) among pregnant and postpartum women

Women are the fastest growing segment of the adult population acquiring HIV, and most women infected with HIV are in their reproductive years. The success of HAART is highly dependent upon the ability and willingness of the individual to adhere to complex antiretroviral regimens. Improved adherence among HIV-infected pregnant women will delay disease progression in the mother and should also reduce HIV transmission to the baby. Modified directly observed therapy (MDOT), may benefit this population. MDOT has been shown to be an acceptable and feasible intervention among HIV substance users; however, no-one has yet evaluated the use of MDOT in pregnant and postpartum women. Based on semi-structured interviews with 17 Latina women with HIV infection, we explored women's adherence patterns and barriers to adherence and their perceptions of a hypothetical MDOT program. The vast majority of women positively appraised the MDOT program as an effective means to increase and reinforce adherence to demanding drug regimens. Respondents cited the face-to-face contact, the supportive nature of the relationship, and the practical approach of the program as the primary reasons for the effectiveness of MDOT. Results indicate that MDOT could be an acceptable intervention for pregnant and postpartum Latina women to improve adherence to HAART.

Relationship of Emotional Intelligence and Adherence to Combination Antiretroviral Medications by Individuals Living With HIV Disease

Medications are an intentional and purposeful means to the successful management of many chronic diseases. In the treatment of disease caused by HIV, adherence to medication is of particular concern because any level of nonadherence, often a few missed doses, will lead eventually to the development of drug resistance. Many predictors of poor adherence to HIV medications have been identified as significant factors in adherence. Among these is the emotional aspect. The purpose of this study was to examine emotional intelligence (EI) and adherence to combination antiretroviral therapy in individuals who are infected with HIV. EI is defined as the ability to perceive and express emotions, facilitate emotions, understand and reason with emotion, and manage emotions. EI has been correlated with various aspects of success in life. In this study, EI was measured by the Mayer, Salovey, Caruso Emotional Intelligence Test. Adherence to medications was measured by self-report and defined as less than 10% missed doses of medications. Eighty-two participants were recruited from an urban hospital-based HIV clinic. Pearson's r was used to analyze the data for significance, and no correlation was reported. This data set was not large enough to prove significance, statistically, of the research question. However, an unexpected result of this study was that the overall EI scores for this particular population were markedly lower than the test norms. Further study would be warranted and recommended to explore El measurement in people at risk for HIV disease or in those who have the disease to further understand the impact of emotions and EI in this specific population.

Cost-effectiveness of HIV screening for incarcerated pregnant women

Antiretroviral therapy (ART) initiated on a prenatal basis in HIV-infected pregnant women is a highly effective method for preventing mother-to-child HIV transmission. We developed a decision analytic model to project the clinical and economic outcomes of alternative HIV screening strategies (voluntary prenatal screening [VPS], routine prenatal screening [RPS], and mandatory newborn screening [MNS]) for a high-risk population of incarcerated pregnant women. Data for the decision model came from the HIV voluntary counseling and testing program at Connecticut's sole correctional facility for women and a comprehensive anonymously linked serosurvey of all inmates who entered the facility during the 2-year period beginning in October 1994. Based on serosurvey results, in the absence of any HIV screening program, 2.5 cases of pediatric HIV infection would be expected per 1000 pregnancies. Multiplied by the discounted lifetime cost per case of $247,000, this translates to a cost of $624 per testing-eligible prison entrant. Entrants were considered eligible if they were pregnant and their HIV status was unknown. MNS would save money, cost $364 per eligible entrant, and simultaneously reduce the rate of infections to 1.1 per 1000 pregnancies. Doing both MNS and RPS is most effective in reducing the rate of new infections (down to 0.2 per 1000 pregnancies). It would, however, increase costs to $430 per eligible entrant. This would result in an incremental cost of $73,603 per additional pediatric HIV case averted when compared with MNS alone. If mandatory newborn testing was not considered a feasible option, RPS would dominate VPS and would be cost-saving compared with no screening. RPS compares favorably with alternative uses of HIV prevention and treatment resources. In correctional facilities where voluntary newborn screening is already in place, our findings show that there remains a small marginal benefit to be realized from switching to RPS. In settings where HIV screening policies are not in place, however, the implementation of RPS can be expected to significantly reduce pediatric HIV cases and net health care expenditures.