Implementation and Operational Research: Postpartum Transfer of Care Among HIV-Infected Women Initiating Antiretroviral Therapy During Pregnancy

Peripartum mobility and maternal/child separation among women living with HIV in South Africa

This prospective cohort study investigated the mobility patterns of 200 pregnant and postpartum women living with HIV in South Africa. Participants were enrolled during their third trimester from routine antenatal care near Cape Town, South Africa, and followed for six months postpartum. Quantitative data were collected at enrollment and follow-up. Mobility (self-reported) was common among the participants, despite the brief study period and the concurrent COVID-19 pandemic. While most reported stability in their current residence, 71% had a second main residence, primarily in the Eastern Cape (EC). Participants had a median of two lifetime moves, motivated by work, education, and family life. During the study period, 20% of participants met the study definition of travel (>7 days and >50 km), with trips predominantly to the EC, lasting a median duration of 30 days. Over one-third of participants with other living children reported that these children lived apart from them, with the mother's family being primary caregivers. These findings emphasize the need for targeted interventions to support continuity of care for mobile populations, particularly peripartum women living with HIV. The study contributes valuable insights into mobility dynamics and highlights unique barriers faced by this population, contributing to improved HIV care in resource-limited settings.

Experiences of transfer of care among postpartum women living with HIV attending primary healthcare services in South Africa

Transfers between health facilities for postpartum women living with HIV are associated with disengagement from care. In South Africa, women must transfer from integrated antenatal/HIV care to general HIV services post-delivery. Thereafter, women transfer frequently e.g. due to geographic mobility. To explore barriers to transfer, we conducted in-depth interviews >2 years post-delivery in 28 participants in a trial comparing postpartum HIV care at primary health care (PHC) antiretroviral therapy (ART) facilities versus a differentiated service delivery model, the adherence clubs, which are the predominant model implemented in South Africa. Data were thematically analysed using inductive and deductive approaches. Women lacked information including where they could transfer to and transfer processes. Continuity mechanisms were affected when women transferred silently i.e. without informing facilities or obtaining referral letters. Silent transfers often occurred due to poor relationships with healthcare workers and were managed inconsistently. Fear of disclosure to family and community stigma led to transfers from local PHC ART facilities to facilities further away affecting accessibility. Mobility and the postpartum period presented unique challenges requiring specific attention. Information regarding long-term care options and transfer processes, ongoing counselling regarding disclosure and social support, and increased health system flexibility are required.

Why do Integrated Maternal HIV and Infant Healthcare Services work? A Secondary Analysis of a Randomised Controlled Trial in South Africa

In a randomised trial, we found that integrated maternal HIV and infant health services through the end of breastfeeding were significantly associated with the primary outcome of engagement in HIV care and viral suppression at 12 months postpartum, compared to the standard of care. Here, we quantitatively explore potential psychosocial modifiers and mediators of this association. Our findings suggest that the intervention was significantly more effective among women experiencing an unintended pregnancy but did not improve outcomes among women reporting risky alcohol use. Although not statistically significant, our results suggest that the intervention may also be more effective among women experiencing higher levels of poverty and HIV-related stigma. We observed no definitive mediator of the intervention effect, but women allocated to integrated services reported better relationships with their healthcare providers through 12 months postpartum. These findings point to high-risk groups that may benefit the most from integrated care, as well as groups for whom these benefits are hampered and that warrant further attention in intervention development and evaluation.

Postnatal clubs: Implementation of a differentiated and integrated model of care for mothers living with HIV and their HIV-exposed uninfected babies in Cape Town, South Africa

BACKGROUND

Despite the overall reduction in the HIV mother-to-child transmission (MTCT) rate in South Africa, poor adherence and retention in care during breastfeeding contribute to this period being a major driver of MTCT in South Africa. To improve this retention, postnatal clubs were created as an integrated, differentiated model of care providing psychosocial support and comprehensive care for the mother-infant pairs (MIP), including HIV and under-5-child services. We describe the implementation of these facility-based clubs and examine its health outcomes in a peri-urban primary health care setting in Cape Town, South Africa.

METHODS

In this prospective cohort study, conducted between June 2016 and December 2019, MIPs were recruited into postnatal clubs between 6 weeks and 6 months of age and followed-up until 18 months of age. Outcomes including maternal Viral Load (VL), and children's HIV testing were compared to a historical control group. Children's immunizations and maternal sexual and reproductive health outcomes are also described.

RESULTS

During the implementation of the postnatal club study period, 484 MIP were recruited with 84% overall attendance, 95% overall viral load suppression, and 98% overall uptake of HIV infant testing. Compared to historical controls, the club infant rapid test uptake was 1.6 times higher (95% CI: 1.4-1.9) at 9 months and 2.0 times higher at 18 months (95% CI: 1.6-2.6). Through 12 months and between 12-18 months, maternal VL monitoring was higher in the club group compared to the historical control by 1.5 times (95% CI: 1.3-1.6) and 2.6 times (95% CI: 2.1-3.2), respectively, with similar maternal VL suppression. Of 105 infants attending the 12 months visit, 99% were fully vaccinated by one year.

CONCLUSION

MIP in the postnatal clubs showed better PMTCT outcomes than historical controls with high levels of retention in care. Other outcomes such as immunisation results suggest that integration of services, such as in the postnatal club, is feasible and beneficial for MIPs.

"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

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.

"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

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.

Investigating clinic transfers among HIV patients considered lost to follow-up to improve understanding of the HIV care cascade: Findings from a cohort study in rural north-eastern South Africa

Investigating clinical transfers of HIV patients is important for accurate estimates of retention and informing interventions to support patients. We investigate transfers for adults reported as lost to follow-up (LTFU) from eight HIV care facilities in the Agincourt health and demographic surveillance system (HDSS), South Africa. Using linked clinic and HDSS records, outcomes of adults more than 90 days late for their last scheduled clinic visit were determined through clinic and routine tracing record reviews, HDSS data, and supplementary tracing. Factors associated with transferring to another clinic were determined through Cox regression models. Transfers were graphically and geospatially visualised. Transfers were more common for women, patients living further from the clinic, and patients with higher baseline CD4 cell counts. Transfers to clinics within the HDSS were more likely to be undocumented and were significantly more likely for women pregnant at ART initiation. Transfers outside the HDSS clustered around economic hubs. Patients transferring to health facilities within the HDSS may be shopping for better care, whereas those who transfer out of the HDSS may be migrating for work. Treatment programmes should facilitate transfer processes for patients, ensure continuity of care among those migrating, and improve tracking of undocumented transfers.

Uninterrupted HIV treatment for women: Policies and practices for care transitions during pregnancy and breastfeeding in Côte d'Ivoire, Lesotho and Malawi

Transitions between services for continued antiretroviral treatment (ART) during and after pregnancy are a commonly overlooked aspect of the HIV care cascade, but ineffective transitions can lead to poor health outcomes for women and their children. In this qualitative study, we conducted interviews with 15 key stakeholders from Ministries of Health along with PEPFAR-supported and other in-country non-governmental organizations actively engaged in national programming for adult HIV care and prevention of mother-to-child-transmission of HIV (PMTCT) services in Côte d'Ivoire, Lesotho and Malawi. We aimed to understand perspectives regarding transitions into and out of PMTCT services for continued ART. Thematic analysis revealed that, although transitions of care are necessary and a potential point of loss from ART care in all three countries, there is a lack of clear guidance on transition approach and no formal way of monitoring transition between services. Several opportunities were identified to monitor and strengthen transitions of care for continued ART along the PMTCT cascade.

Patient Transfers and Their Impact on Gaps in Clinical Care: Differences by Gender in a Large Cohort of Adults Living with HIV on Antiretroviral Therapy in South Africa

For people living with HIV (PLWH), patient transfers may affect engagement in care. We followed a cohort of PLWH in Cape Town, South Africa who tested positive for HIV in 2012-2013 from ART initiation in 2012-2016 through December 2016. Patient transfers were defined as moving from one healthcare facility to another on a different day, considering all healthcare visits and recorded HIV-visits only. We estimated incidence rates (IR) for transfers by time since ART initiation, overall and by gender, and associations between transfers and gaps of > 180 days in clinical care. Overall, 4,176 PLWH were followed for a median of 32 months, and 8% (HIV visits)-17% (all healthcare visits) of visits were patient transfers. Including all healthcare visits, transfers were highest through 3 months on ART (IR 20.2 transfers per 100 visits, 95% CI 19.2-21.2), but increased through 36 months on ART when only HIV visits were included (IR 9.7, 95% CI 8.8-10.8). Overall, women were more likely to transfer than men, and transfers were associated with gaps in care (IR ratio [IRR] 3.06 95% CI 2.83-3.32; HIV visits only). In this cohort, patient transfers were frequent, more common among women, and associated with gaps in care.

"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

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.

Attitudes Toward a Proposed GPS-Based Location Tracking Smartphone App for Improving Engagement in HIV Care Among Pregnant and Postpartum Women in South Africa: Focus Group and Interview Study

Background

Peripartum women living with HIV in South Africa are at high risk of dropping out of care and are also a particularly mobile population, which may impact their engagement in HIV care. With the rise in mobile phone use worldwide, there is an opportunity to use smartphones and GPS location software to characterize mobility in real time.

Objective

The aim of this study was to propose a smartphone app that could collect individual GPS locations to improve engagement in HIV care and to assess potential users’ attitudes toward the proposed app.

Methods

We conducted 50 in-depth interviews (IDIs) with pregnant women living with HIV in Cape Town and Johannesburg, South Africa, and 6 focus group discussions (FGDs) with 27 postpartum women living with HIV in Cape Town. Through an open-ended question in the IDIs, we categorized “positive,” “neutral,” or “negative” reactions to the proposed app and identified key quotations. For the FGD data, we grouped the text into themes, then analyzed it for patterns, concepts, and associations and selected illustrative quotations.

Results

In the IDIs, the majority of participants (76%, 38/50) responded favorably to the proposed app. Favorable comments were related to the convenience of facilitated continued care, a sense of helpfulness on the part of the researchers and facilities, and the difficulties of trying to maintain care while traveling. Among the 4/50 participants (8%) who responded negatively, their comments were primarily related to the individual’s responsibility for their own health care. The FGDs revealed four themes: facilitating connection to care, informed choice, disclosure (intentional or unintentional), and trust in researchers.

Conclusions

Women living with HIV were overwhelmingly positive about the idea of a GPS-based smartphone app to improve engagement in HIV care. Participants reported that they would welcome a tool to facilitate connection to care when traveling and expressed trust in researchers and health care facilities. Within the context of the rapid increase of smartphone use in South Africa, these early results warrant further exploration and critical evaluation following real-world experience with the app.

Approaches to transitioning women into and out of prevention of mother-to-child transmission of HIV services for continued ART: a systematic review

INTRODUCTION

Women living with HIV are required to transition into the prevention of mother-to-child transmission of HIV (PMTCT) services when they become pregnant and back to ART services after delivery. Transition can be a vulnerable time when many women are lost from HIV care yet there is little guidance on the optimal transition approaches to ensure continuity of care. We reviewed the available evidence on existing approaches to transitioning women into and out of PMTCT, outcomes following transition and factors influencing successful transition.

METHODS

We searched PubMed and SCOPUS, as well as abstracts from international HIV-focused meetings, from January 2006 to July 2020. Studies were included that examined three points of transition: pregnant women already on ART into PMTCT (transition 1), pregnant women living with HIV not yet on ART into treatment services (transition 2) and postpartum women from PMTCT into general ART services after delivery (transition 3). Results were grouped and reported as descriptions of transition approach, comparison of outcomes following transition and factors influencing successful transition.

RESULTS & DISCUSSION

Out of 1809 abstracts located, 36 studies (39 papers) were included in this review. Three studies included transition 1, 26 transition 2 and 17 transition 3. Approaches to transition were described in 26 studies and could be grouped into the provision of information at the point of transition (n = 8), strengthened communication or linkage of data between services (n = 4), use of transition navigators (n = 12), and combination approaches (n = 4). Few studies were designed to directly assess transition and only nine compared outcomes between transition approaches, with substantial heterogeneity in study design, setting and outcomes. Four themes were identified in 25 studies reporting on factors influencing successful transition: fear, knowledge and preparedness, clinic characteristics and the transition requirements and process.

CONCLUSIONS

This review highlights that, despite the need for women to transition into and out of PMTCT services for continued ART in many settings, there is very limited evidence on optimal transition approaches. Ongoing operational research is required to identify sustainable and acceptable transition approaches and service delivery models that support continuity of HIV care during and after pregnancy.

Implementation and experiences of integrated prevention of mother-to-child transmission services in Tanzania, Malawi and South Africa: A mixed methods study

Although integration of HIV and maternal health services is recommended by the World Health Organization, evidence to guide implementation is limited. We describe facility-level implementation of policies for integrating HIV care within maternal health services and explore experiences of service users and providers in rural Tanzania (Ifakara), South Africa (uMkhanyakude) and Malawi (Karonga). Policy in all countries included HIV testing during antenatal care (ANC), same-day antiretroviral therapy (ART) initiation for HIV-positive pregnant women, and postpartum referral to ART clinics, between six weeks (Malawi, South Africa) and two years after delivery (Tanzania). All facilities offered HIV testing within ANC, most commonly during the first visit. Although most women were comfortable with HIV testing, some felt that opting out would lead to sub-standard services. Some facilities conducted group post-test counselling for HIV-negative women, raising concerns of unintended HIV status disclosure. ART initiation was offered on the same day, the same room as an HIV diagnosis in >90% of facilities. Women’s worries around postpartum referral included having unknown providers, insufficient privacy and queues. Adoption and implementation of policies on integrated HIV and maternal health services varied across settings. Patients’ experiences of these policies may influence uptake and retention in care.

Long-Term Outcomes of HIV-Infected Women Receiving Antiretroviral Therapy After Transferring Out of an Integrated Maternal and Child Health Service in South Africa

BACKGROUND

Integrated maternal and child health (MCH) services improve women's postpartum antiretroviral therapy (ART) outcomes during breastfeeding; however, long-term outcomes after transfer to general ART services remain unknown.

METHODS

The MCH-ART trial demonstrated that maternal retention and viral suppression at 12-months postpartum were improved significantly among women randomized to integrated MCH services continued in the antenatal clinic through cessation of breastfeeding (MCH-ART arm) compared with immediate transfer to general ART services postpartum (standard of care). We reviewed electronic health records for all women who participated in the MCH-ART trial to ascertain retention and gaps in care and invited all women for a study visit 36- to 60-months postpartum including viral load testing.

RESULTS

Of 471 women in MCH-ART, 450 (96%) contributed electronic health record data and 353 (75%) completed the study visit (median 44-month postpartum). At this time, outcomes were identical in both trial arms: 67% retained in care (P = 0.994) and 56% with viral loads <50 copies/mL (P = 0.751). Experiencing a gap in care after delivery was delayed in the MCH-ART arm with 17%, 36%, and 45% of women experienced a gap in care by 12-, 24-, and 36-months postpartum compared with 35%, 48%, and 57% in the standard of care arm, respectively.

CONCLUSIONS

The benefits of integrated maternal HIV and child health care did not persist after transfer to general ART services. The transfer of women postpartum to routine adult care is a critical period requiring interventions to support continuity of HIV care.

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

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.

CareConekta: study protocol for a randomized controlled trial of a mobile health intervention to improve engagement in postpartum HIV care in South Africa

BACKGROUND

South Africa is home to the world's largest antiretroviral therapy program but sustaining engagement along the HIV care continuum has proven challenging in the country and throughout the wider region. Population mobility is common in South Africa, but there are important research gaps in describing this mobility and its impact on engagement in HIV care. Postpartum women and their infants in South Africa are known to be at high risk of dropping out of HIV care after delivery and are frequently mobile.

METHODS

In 2017, we developed a beta version of a smartphone application (app) - CareConekta - that detects a user's smartphone location to allow for prospective characterization of mobility. Now we will adapt and test CareConekta to conduct essential formative work on mobility and evaluate an intervention - the CareConekta app plus text notifications and phone calls and/or WhatsApp messages - to facilitate engagement in HIV care during times of mobility. During the 3-year project period, our first objective is to evaluate the feasibility, acceptability, and initial efficacy of using CareConekta as an intervention to improve engagement in HIV care. Our second objective is to characterize mobility among South African women during the peripartum period and its impact on engagement in HIV care. We will enroll 200 eligible pregnant women living with HIV and receiving care at the Gugulethu Midwife Obstetric Unit in Cape Town, South Africa.

DISCUSSION

This work will provide critical information about mobility during the peripartum period and the impact on engagement in HIV care. Simultaneously, we will pilot test an intervention to improve engagement with rigorously assessed outcomes. If successful, CareConekta offers tremendous potential as a research and service tool that can be adapted and evaluated in multiple geographic regions, study contexts, and patient populations.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03836625. Registered on 8 February 2019.

Acceptability of Interventions to Improve Engagement in HIV Care Among Pregnant and Postpartum Women at Two Urban Clinics in South Africa

INTRODUCTION

Pregnant women initiating antiretroviral therapy (ART) in sub-Saharan Africa have been shown to have sub-optimal engagement in care, particularly after delivery, and interventions to improve engagement in care for this unique population are urgently needed.

METHODS

We enrolled 25 pregnant women living with HIV at each of two large antenatal clinics in Johannesburg and Cape Town, South Africa (n = 50), and conducted in-depth interviews. We assessed participants' reported acceptability of the following proposed interventions to improve engagement in care and retention monitoring data systems: financial incentives, educational toys, health education, combined maternal/infant visits, cell phone text reminders, mobility tracking, fingerprint/biometric devices, and smartcards.

RESULTS

Acceptability overall for interventions was high, with mixed responses for some interventions. Overall themes identified included (i) the intersection of individual and facility responsibility for a patient's health, (ii) a call for more health education, (iii) issues of disclosure and concerns about privacy, and (iv) openness to interventions that could improve health systems.

DISCUSSION

These findings provide insight into the preferences and concerns of potential users of interventions to improve engagement in HIV care for pregnant women, and support the development of tools that specifically target this high-risk group.

Protocol for a prospective evaluation of postpartum engagement in HIV care among women living with HIV in South Africa

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).

Engagement in care among women and their infants lost to follow-up under Option B+ in eSwatini

Background

Universal antiretroviral treatment (ART) for pregnant women with HIV, Option B+, has been adopted widely for prevention of mother-to-child HIV transmission (PMTCT). Some evidence shows high loss to follow-up (LTF) under this model. However, gaps in data systems limit this evidence. We collected additional information for women and infants LTF from Option B+ in Eswatini to assess more accurate outcomes.

Methods

LTF at 6-months postpartum was assessed using facility data. Additional data was gathered from: 1) the national ART database and paper records; 2) patient tracing; and 3) interviews and abstraction from patient-held records. Engagement in care was defined as any clinic visit within 91 days before or after 6-months postpartum or completion of a documented transfer; or, for those traced but not completing study interviews, visits at 6-months postpartum or later (for infants), or visits within 3-months of tracing (for women). Multivariable loglinear models were used to identify correlates of engagement.

Results

One-hundred-ninety-four (44.7%) of 434 LTF women had outcomes ascertained, including 122 (62.9%) women engaged in care. Among 510 LTF infants, 265 (52.0%) had ascertained outcomes, including 143 (54.0%) engaged in care, 47 (17.7%) pregnancy losses, and 18 (6.8%) deaths. Seventy-two of 189 live infants (38.1%) with ascertained outcomes had a 6-week early infant diagnostic (EID) test. Among women with ascertained outcomes, gestational age of 20+ weeks (vs. fewer than 20 weeks, aRR 0.80; 95% CI 0.68–0.94) and age 25–29 years (vs. 15–24 years, aRR 0.81; 95% CI 0.67–0.97), were associated with lower engagement; initiating ART after first ANC visit was associated with higher engagement (vs. at first ANC visit, aRR 1.12; 95% CI 1.04–1.21). Among infants with ascertained outcomes, mother not initiating ART was associated with lower engagement (vs. ART at first ANC visit, aRR 0.71; 95% CI 0.54–0.91).

Conclusion

Substantial numbers of women and infants classified as LTF under Option B+ were engaged in care, though a suboptimal level of 6-week EID testing was observed. These findings highlight a need to improve coverage of routine EID testing, and improve data systems to better capture PMTCT patient outcomes.

"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

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.

Shifting to the long view: engagement of pregnant and postpartum women living with HIV in lifelong antiretroviral therapy services

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.

Factors Associated with Postpartum Loss to Follow-Up and Detectable Viremia After Delivery Among Pregnant Women Living with HIV

Pregnant women living with HIV are at risk for loss to follow-up and viral rebound after delivery. We conducted a retrospective cohort study of women with HIV who delivered at Parkland Hospital, Dallas, to identify factors associated with postpartum loss to HIV care 1 year after delivery. Logistic regression was used to identify factors predicting loss to follow-up. For a subset of women, we compared odds of viremia detectable at delivery and postpartum among women with higher versus lower pill burden regimens. We included 604 women with HIV who delivered between 2005 and 2015. Three hundred ninety-one (65%) women completed at least one visit with an HIV provider within 1 year of delivery. The follow-up rate among black, non-Hispanic women was 65%; 57% for white, non-Hispanic women; and 78% for Hispanic women. Women without follow-up presented for prenatal care later (17 vs. 11 weeks, p < 0.001), and were less likely to be on antiretroviral therapy at initial prenatal visit (29% vs. 49%, p < 0.001). Factors predicting loss to follow-up in multivariate analysis included low-level viremia at delivery [adjusted odds ratio (aOR) = 2.85, 95% confidence interval (CI) = 1.73-4.71] and failure to return for a postpartum visit (aOR = 3.19, 95% CI = 2.07-4.94). High antiretroviral pill burden (≥6 pills daily) was associated with viremia (>1000 copies/mL) at the first prenatal visit (OR = 8.7, 95% CI = 4.6-16.6) through 1 year postpartum (OR = 2.3, 95% CI = 1.2-4.4). Viremia at delivery, failure to return for a postpartum visit, and high pill burden during pregnancy are predictors of postpartum loss to HIV care.

'If she gave birth to a healthy child, then she may forget about her own health': Postpartum engagement in HIV care and treatment among women living with HIV in Russia

There is a dearth of information about the factors influencing postpartum engagement in HIV treatment and care in Russia, a country with an expanding HIV epidemic and poor treatment coverage. The goal of our community-based study was to identify and explore the factors influencing engagement in care after pregnancy. We conducted in-depth interviews with 50 women living with HIV who had recently given birth, and with 20 health care and social service providers in two locations: a large metropolitan city (St. Petersburg) and a semi-urban town near the Ural Mountains. Thematic analysis led us to identify the following themes in regard to factors influencing postpartum engagement in care: feeling overwhelmed with caring for an infant; sense of responsibility for child's health and well-being; misinformation and AIDS denialism; HIV-related stigma and fear; benefits versus side-effects of ART; professional and personal support; drug and alcohol use; and structural factors. Structural factors include poverty, continued provision of ART after pregnancy, dosage, obtaining necessary documents, and distance to clinic. These findings are important to consider in developing much-needed interventions to promote women's longer-term engagement in HIV care and treatment in Russia.

Adolescent pregnancy at antiretroviral therapy (ART) initiation: a critical barrier to retention on ART

INTRODUCTION

Adolescence and pregnancy are potential risk factors for loss to follow-up (LTFU) while on antiretroviral therapy (ART). We compared adolescent and adult LTFU after ART initiation to quantify the impact of age, pregnancy, and site-level factors on LTFU.

METHODS

We used routine clinical data for patients initiating ART as young adolescents (YA; 10 to 14 years), older adolescents (OA; 15 to 19 years) and adults (≥20 years) from 2000 to 2014 at 52 health facilities affiliated with the International epidemiology Databases to Evaluate AIDS (IeDEA) East Africa collaboration. We estimated cumulative incidence (95% confidence interval, CI) of LTFU (no clinic visit for ≥6 months after ART initiation) and identified patient and site-level correlates of LTFU, using multivariable Cox proportional hazards models for all patients as well as individual age groups.

RESULTS

A total of 138,387 patients initiated ART, including 2496 YA, 2955 OA and 132,936 adults. Of these, 55%, 78% and 66%, respectively, were female and 0.7% of YA, 22.3% of OA and 8.3% of adults were pregnant at ART initiation. Cumulative incidence of LTFU at five years was 26.6% (24.6 to 28.6) among YA, 44.1% (41.8 to 46.3) among OA and 29.3% (29.1 to 29.6) among adults. Overall, compared to adults, the adjusted hazard ratio, aHR, (95% CI) of LTFU for OA was 1.54 (1.41 to 1.68) and 0.77 (0.69 to 0.86) for YA. Compared to males, pregnant females had higher hazard of LTFU, aHR 1.20 (1.14 to 1.27), and nonpregnant women had lower hazard aHR 0.90 (0.88 to 0.93). LTFU hazard among the OA was primarily driven by both pregnant and nonpregnant females, aHR 2.42 (1.98 to 2.95) and 1.51 (1.27 to 1.80), respectively, compared to men. The LTFU hazard ratio varied by IeDEA program. Site-level factors associated with overall lower LTFU hazard included receiving care in tertiary versus primary-care clinics aHR 0.61 (0.56 to 0.67), integrated adult and adolescent services and food ration provision aHR 0.93 (0.89 to 0.97) versus nonintegrated clinics with food ration provision, having patient support groups aHR 0.77 (0.66 to 0.90) and group adherence counselling aHR 0.61 (0.57 to 0.67).

CONCLUSIONS

Older adolescents experienced higher risk of LTFU compared to YA and adults. Interventions to prevent LTFU among older adolescents are critically needed, particularly for female and/or pregnant adolescents.

"I will leave the baby with my mother": Long-distance travel and follow-up care among HIV-positive pregnant and postpartum women in South Africa

INTRODUCTION

It is common in urban African settings for postpartum women to temporarily return to family in distant settings. We sought to explore mobility among peripartum HIV-positive women to understand the timing and motivation of travel, particularly vis-à-vis delivery, and how it may affect healthcare access.

METHODS

Using the same mobility measurements within three different studies, we examined long-distance travel of mother and infant before and after delivery in three diverse clinics within greater Johannesburg, South Africa (n = 150). Participants were interviewed prior to delivery at two sites (n = 125) and after delivery at one (n = 25). Quantitative and qualitative results are reported.

RESULTS

Among 150 women, median age was 29 years (IQR: 26 to 34) and 36.3% were employed. Overall, 76.7% of the participants were born in South Africa: 32.7% in Gauteng Province (Johannesburg area) and 44.0% in other South African provinces, but birthplace varied greatly by site. Almost half (44.0%) planned to travel around delivery; nearly all after delivery. Median duration of stay was 30 days (IQR: 24 to 90) overall, but varied from 60 days at two sites to just 7 days at another. Participants discussed travel to eight of South Africa's nine provinces and four countries. Travel most frequently was to visit family, typically to receive help with the new baby. Nearly all the employed participants planned to return to work in Johannesburg after delivery, sometimes leaving the infant in the care of family outside of Johannesburg. All expressed their intent to continue HIV care for themselves and their infant, but few planned to seek care at the destination site, and care for the infant was emphasized over care for the mother.

CONCLUSIONS

We identified frequent travel in the peripartum period with substantial differences in travel patterns by site. Participants more frequently discussed seeking care for the infant than for themselves. HIV-exposed children often were left in the care of family members in distant areas. Our results show the frequent mobility of women and infants in the peripartum period. This underscores the challenge of ensuring a continuity of HIV care in a fragmented healthcare system that is not adapted for a mobile population.

Achieving Viral Suppression in 90% of People Living With Human Immunodeficiency Virus on Antiretroviral Therapy in Low- and Middle-Income Countries: Progress, Challenges, and Opportunities

Although significant progress has been made, the latest data from low- and middle-income countries show substantial gaps in reaching the third "90%" (viral suppression) of the UNAIDS 90-90-90 goals, especially among vulnerable and key populations. This article discusses critical gaps and promising, evidence-based solutions. There is no simple and/or single approach to achieve the last 90%. This will require multifaceted, scalable strategies that engage people living with human immunodeficiency virus, motivate long-term treatment adherence, and are community-entrenched and ‑supported, cost-effective, and tailored to a wide range of global communities.

Integration of postpartum healthcare services for HIV-infected women and their infants in South Africa: A randomised controlled trial

BACKGROUND

As the number of HIV-infected women initiating lifelong antiretroviral therapy (ART) during pregnancy increases globally, concerns have emerged regarding low levels of retention in HIV services and suboptimal adherence to ART during the postpartum period. We examined the impact of integrating postpartum ART for HIV+ mothers alongside infant follow-up within maternal and child health (MCH) services in Cape Town, South Africa.

METHODS AND FINDINGS

We conducted a randomised trial among HIV+ postpartum women aged ≥18 years who initiated ART during pregnancy in the local antenatal care clinic and were breastfeeding when screened before 6 weeks postpartum. We compared an integrated postnatal service among mothers and their infants (the MCH-ART intervention) to the local standard of care (control)-immediate postnatal referral of HIV+ women on ART to general adult ART services and their infants to separate routine infant follow-up. Evaluation data were collected through medical records and trial measurement visits scheduled and located separately from healthcare services involved in either arm. The primary trial outcome was a composite endpoint of women's retention in ART care and viral suppression (VS) (viral load < 50 copies/ml) at 12 months postpartum; secondary outcomes included duration of any and exclusive breastfeeding, mother-to-child HIV transmission, and infant mortality. Between 5 June 2013 and 10 December 2014, a total of 471 mother-infant pairs were enrolled and randomised (mean age, 28.6 years; 18% nulliparous; 57% newly diagnosed with HIV in pregnancy; median duration of ART use at randomisation, 18 weeks). Among 411 women (87%) with primary endpoint data available, 77% of women (n = 155) randomised to the MCH-ART intervention achieved the primary composite outcome of retention in ART services with VS at 12 months postpartum, compared to 56% of women (n = 117) randomised to the control arm (absolute risk difference, 0.21; 95% CI: 0.12-0.30; p < 0.001). The findings for improved retention in care and VS among women in the MCH-ART intervention arm were consistent across subgroups of participants according to demographic and clinical characteristics. The median durations of any breastfeeding and exclusive breastfeeding were longer in women randomised to the intervention versus control arm (6.9 versus 3.0 months, p = 0.006, and 3.0 versus 1.4 months, p < 0.001, respectively). For the infants, overall HIV-free survival through 12 months of age was 97%: mother-to-child HIV transmission was 1.2% overall (n = 4 and n = 1 transmissions in the intervention and control arms, respectively), and infant mortality was 1.9% (n = 6 and n = 3 deaths in the intervention and control arms, respectively), and these outcomes were similar by trial arm. Interpretation of these findings should be qualified by the location of this study in a single urban area as well as the self-reported nature of breastfeeding outcomes.

CONCLUSIONS

In this study, we found that integrating ART services into the MCH platform during the postnatal period was a simple and effective intervention, and this should be considered for improving maternal and child outcomes in the context of HIV.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01933477.

What is new in perinatal HIV prevention?

PURPOSE OF REVIEW

The purpose of this review is to describe recent clinical trial, laboratory and observational findings that highlight both the progress that can be achieved in elimination of new pediatric infections in international clinical trial settings among HIV-infected breastfeeding women while also describing recent safety concerns related to currently used antiretroviral regimens. The article will also address the ongoing adherence challenges for HIV-infected mothers in taking their antiretroviral drugs. This information is timely and relevant as new regimens are being considered for both prevention of mother-to-child transmission (PMTCT) of HIV and HIV treatment options worldwide.

RECENT FINDINGS

The main themes described in this article include both efficacy of different antiretroviral therapy (ART) regimens currently being rolled out internationally for PMTCT as well as safety findings from recent research including a large multisite international trial, PROMISE.

SUMMARY

The findings from the IMPAACT PROMISE trial as well as other recent trial and observational findings suggest that while progress has been steady in reducing PMTCT worldwide, the goal of virtual elimination of pediatric HIV worldwide will require careful attention to optimizing safety of new regimens which are less dependent on maternal daily ART adherence and safer in preventing certain toxicities.

Maximizing adherence and retention for women living with HIV and their infants in Kenya (MOTIVATE! study): study protocol for a randomized controlled trial

BACKGROUND

Successful completion and retention throughout the multi-step cascade of prevention of mother-to-child HIV transmission (PMTCT) remains difficult to achieve. The Mother and Infant Visit Adherence and Treatment Engagement study aims to evaluate the effect of mobile text messaging, community-based mentor mothers (cMMs), or both on increasing antiretroviral therapy (ART) adherence, retention in HIV care, maternal viral load suppression, and mother-to-child HIV transmission for mother-infant pairs receiving lifelong ART.

METHODS/DESIGN

This study is a cluster randomized, 2 × 2 factorial, controlled trial. The trial will be undertaken in the western Kenyan counties of Migori, Kisumu, and Homa Bay. Study sites will be randomized into one of four groups: six sites will implement both text messaging and cMM, six sites will implement cMM only, six sites will implement text messaging only, and six sites will implement the existing standard of care. The primary analysis will be based on the intention-to-treat principle and will compare maternal ART adherence and maternal retention in care.

DISCUSSION

This study will determine the impact of long-term (up to 12 months postpartum) text messaging and cMMs on retention in and adherence to ART among pregnant and breastfeeding women living with HIV in Kenya. It will address key gaps in our understanding of what interventions may successfully promote long-term retention in the PMTCT cascade of care.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02491177 . Registered on 11 March 2015.

Differentiated models of care for postpartum women on antiretroviral therapy in Cape Town, South Africa: a cohort study

Background: The numbers of women initiating lifelong antiretroviral therapy (ART) during pregnancy and postpartum is increasing rapidly, presenting a burden on health systems and an urgent need for scalable models of care for this population. In a pilot project, we referred postpartum women who initiated ART during pregnancy to a community-based model of differentiated ART services.

Methods: Eligible women (on ART for at least 3 months with viral load (VL)<1000 copies/mL) were offered a choice of two ART models of care: (i) referral to an existing system of community-based ‘adherence clubs’, operated by lay counsellors with medication collection every 2–4 months; or (ii) referral to local primary healthcare clinics (PHC) with services provided by clinicians and medication collection every 1–2 months (local standard of care for postpartum ART). For evaluation, women were followed through 6-months postpartum with VL testing separate from either ART service.

Results: Through September 2015, n = 129 women were enrolled (median age, 28 years; median time postpartum, 10 days). Overall, 65% (n = 84) chose adherence clubs and 35% (n = 45) chose PHCs; there were no demographic or clinical predictors of this choice. Location of service delivery was commonly cited as a reason for choice by women selecting either model of care; shorter waiting times, ability to receive ART from lay counsellors and less frequent appointments were motivations for choosing adherence clubs. Among women choosing adherence clubs, 15% never attended the service and another 11% attended the service but were not retained through six months postpartum. Overall, 86% of women (n = 111) remained in the evaluation through 6 months postpartum; in this group, there were no differences in VL<1000 copies/mL at six months postpartum between women choosing PHCs (88%) vs. adherence clubs (92%; p = 0.483), but women who were not retained in adherence clubs were more likely to have VL≥1000 copies/mL compared to those who remained (p = 0.002).

Discussion: Adherence clubs may be a valuable model for postpartum women initiating ART in pregnancy, with good short-term outcomes observed during this critical period. To support optimal implementation, further research is needed into patient preferences for models of care, with consideration of integration of maternal and child health services, while ART adherence and retention require ongoing consideration in this population.

Optimizing Antiretroviral Therapy (ART) for Maternal and Child Health (MCH): Rationale and Design of the MCH-ART Study

Background:

Prevention of mother-to-child transmission of HIV implementation faces significant challenges globally, particularly in the context of universal lifelong antiretroviral therapy (ART) for all HIV-infected pregnant women.

Methods:

We describe the rationale and methods of the Maternal and Child Health-Antiretroviral Therapy (MCH-ART) study, an implementation science project examining strategies for providing HIV care and treatment to HIV-infected women who initiate ART during pregnancy and their HIV-exposed infants.

Results:

MCH-ART is composed of 3 interrelated study designs across the antenatal and postnatal periods. Phase 1 is a cross-sectional evaluation of consecutive HIV-infected pregnant women seeking antenatal care; phase 2 is an observational cohort of all women from phase 1 who are eligible for initiation of ART following local guidelines; and phase 3 is a randomized trial of strategies for delivering ART to breastfeeding women from phase 2 during the postpartum period. During each phase, a set of study measurement visits is carried out separately from antenatal care and ART services; a maximum of 9 visits takes place from the beginning of antenatal care through 12 months postpartum. In parallel, in-depth interviews are used to examine issues of ART adherence and retention qualitatively, and costs and cost-effectiveness of models of care are examined. Separate substudies examine health outcomes in HIV-uninfected women and their HIV-unexposed infants, and the role of the adherence club model for long-term adherence and retention.

Discussion:

Combining observational and experimental components, the MCH-ART study presents a novel approach to understand and optimize ART delivery for MCH.

Understanding Antiretroviral Treatment Adherence Among HIV-Positive Women at Four Postpartum Time Intervals: Qualitative Results from the Kabeho Study in Rwanda

As lifelong antiretroviral therapy (ART) for pregnant women is implemented, it is important to understand the attitudes and norms affecting women's postpartum ART adherence. This is a qualitative cross-sectional study of HIV-positive postpartum women (n = 112) enrolled in a 2-year observational prospective cohort in Rwanda. Informed by the Theory of Reasoned Action (TRA), we conducted in-depth interviews with women whose children were 0-6, 7-12, 13-18, or 21-24 months of age to describe factors contributing to adherence and changes over time. Positive ART attitudes reported by women included mothers' health promotion, prevention of infant HIV infection, higher CD4 count, and improved physical appearance. Negative attitudes were few, but included side effects and the lifelong nature of treatment. Learning from people living with HIV (PLHIV) was identified as a norm facilitating adherence; ART adherence was inhibited by fear of disclosure or stigmatization in communities and clinics. Poor adherence behaviors were common immediately after HIV diagnosis, not necessarily during prevention of mother-to-child transmission (PMTCT). Women with older children, most of whom stopped breastfeeding by 13-18 months, reported more barriers and missed doses than women with younger children. The TRA was useful in identifying the collective influence of attitudes, norms, and intentions on behavior. Findings suggest that HIV-positive women are vulnerable to poor adherence following HIV diagnosis and around the time of breastfeeding cessation. Lifelong treatment adherence can be supported through PLHIV exemplifying long-term ART use, fewer and less stigmatizing clinic visits, and counseling messages highlighting the benefits of drugs on appearance and illness prevention and incorporating biological feedback.

Mother and child both matter: reconceptualizing the prevention of mother-to-child transmission care continuum

PURPOSE OF REVIEW

To propose a prevention of mother-to-child transmission (PMTCT) care continuum that defines the programmatic steps necessary to provide HIV care to the HIV-infected pregnant woman and her infant during the risk period for HIV transmission.

RECENT FINDINGS

There are several complexities of PMTCT care that should be considered in the care continuum, including the evolution in the population of women entering PMTCT care, various models of PMTCT service delivery and patterns of PMTCT care, and the critical step of transfer of women's HIV care from PMTCT programs to adult HIV clinics.

SUMMARY

We propose a reconceptualized PMTCT care continuum that accounts for the complexities of PMTCT care. We also propose a combined outcome for pregnant women and their infants across an interlinked PMTCT continuum to measure both maternal and child health outcomes.

90-90-90--Charting a steady course to end the paediatric HIV epidemic

INTRODUCTION

The new "90-90-90" UNAIDS agenda proposes that 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression by 2020. By focusing on children, the global community is in the unique position of realizing an end to the paediatric HIV epidemic.

DISCUSSION

Despite vast scientific advances in the prevention and treatment of paediatric HIV infection over the last two decades, in 2014 there were an estimated 220,000 new paediatric infections attributed to mother-to-child HIV transmission (MTCT) and 150,000 HIV-related paediatric deaths. Furthermore, adolescents remain at particularly high risk for acquisition of new HIV infections, and HIV/AIDS remains the second leading cause of death in this age group. Among the estimated 2.6 million children less than 15 years of age living with HIV infection, only 32% were receiving life-saving antiretroviral treatment. After decades of languishing, good progress is now being made to prevent MTCT. Unfortunately, efforts to scale up HIV treatment services have been less robust for children and adolescents compared with adult populations. These discrepancies reflect substantial gaps in essential services and numerous missed opportunities to prevent HIV transmission and provide effective life-saving antiretroviral treatment to children, adolescents and families. The road to an AIDS-free generation will require bridging the gaps in HIV services and addressing the particular needs of children across the developmental spectrum from infancy through adolescence. To reach the ambitious new targets, innovations and service improvements will need to be rapidly escalated at each step along the prevention-treatment cascade.

CONCLUSIONS

Charting a successful course to reach the 90-90-90 targets will require sustained political and financial commitment as well as the rapid implementation of a broad set of systematic improvements in service delivery. The prospect of a world where HIV no longer threatens the lives of infants, children and adolescents may finally be within reach.