The Impact of Structured Mentor Mother Programs on 6-Month Postpartum Retention and Viral Suppression among HIV-Positive Women in Rural Nigeria: A Prospective Paired Cohort Study

Interventions to improve primary healthcare in rural settings: A scoping review

BACKGROUND

Residents of rural areas have poorer health status, less healthy behaviours and higher mortality than urban dwellers, issues which are commonly addressed in primary care. Strengthening primary care may be an important tool to improve the health status of rural populations.

OBJECTIVE

Synthesize and categorize studies that examine interventions to improve rural primary care.

ELIGIBILITY CRITERIA

Experimental or observational studies published between January 1, 1996 and December 2022 that include an historical or concurrent control comparison.

SOURCES OF EVIDENCE

Pubmed, CINAHL, Cochrane Library, Embase.

CHARTING METHODS

We extracted and charted data by broad category (quality, access and efficiency), study design, country of origin, publication year, aim, health condition and type of intervention studied. We assigned multiple categories to a study where relevant.

RESULTS

372 papers met our inclusion criteria, divided among quality (82%), access (20%) and efficiency (13%) categories. A majority of papers were completed in the USA (40%), Australia (15%), China (7%) or Canada (6%). 35 (9%) papers came from countries in Africa. The most common study design was an uncontrolled before-and-after comparison (32%) and only 24% of studies used randomized designs. The number of publications each year has increased markedly over the study period from 1-2/year in 1997-99 to a peak of 49 papers in 2017.

CONCLUSIONS

Despite substantial inequity in health outcomes associated with rural living, very little attention is paid to rural primary care in the scientific literature. Very few studies of rural primary care use randomized designs.

Association of comprehensiveness of antiretroviral care and detectable HIV viral load suppression among pregnant and postpartum women in the Democratic Republic of the Congo: a cross-sectional study

Introduction

Worldwide, over two-thirds of people living with HIV are on antiretroviral therapy (ART). Despite increased ART access, high virological suppression prevalence remains out of reach. Few studies consider the quality of ART services and their impact on recipients' viral suppression. We assessed the association between ART service readiness and HIV viral load suppression among pregnant and breastfeeding women living with HIV (WLH) receiving ART in maternal and child health (MCH) clinics in Kinshasa, Democratic Republic of Congo.

Methods

We performed a cross-sectional analysis leveraging data from a continuous quality improvement intervention on WLH's long-term ART outcomes. From November 2016 to May 2020, we enrolled WLH from the three largest clinics in each of Kinshasa'Łs 35 health zones. We measured clinic's readiness using three WHO-identified ART care quality indicators: relevant guidelines in ART service area, stocks of essential ART medicines, and relevant staff training in ≥24 months, scoring clinics 0-3 based on observed indicators. We defined viral load suppression as ≤1,000 cp/ml. Multilevel mixed-effect logistic models were used to estimate prevalence odds ratios (ORs) measuring the strength of the association between ART service readiness and viral suppression.

Results

Of 2,295 WLH, only 1.9% received care from a clinic with a score of 3, 24.1% received care from a 0-scoring clinic, and overall, 66.5% achieved virologically suppression. Suppression increased from 65% among WLH receiving care in 0-scoring clinics to 66.9% in 1-scoring clinics, 65.8% in 2-scoring clinics, and 76.1% in 3-scoring clinics. We did not observe a statistically significant association between ART service readiness score and increased viral suppression prevalence, however we did find associations between other factors, such as the location of the health center and pharmacist availability with suppressed viral load.

Discussion

A lack of comprehensive ART care underscores the need for enhanced structural and organizational support to improve virological suppression and overall health outcomes for women living with HIV..

Preferences of Pregnant and Postpartum Women for Differentiated Service Delivery in Kenya

BACKGROUND

Differentiated service delivery models are implemented by HIV care programs globally, but models for pregnant and postpartum women living with HIV (PPWH) are lacking. We conducted a discrete choice experiment to determine women's preferences for differentiated service delivery.

SETTING

Five public health facilities in western Kenya.

METHODS

PPWH were enrolled from April to December 2022 and asked to choose between pairs of hypothetical clinics that differed across 5 attributes: clinic visit frequency during pregnancy (monthly vs. every 2 months), postpartum visit frequency (monthly vs. only with routine infant immunizations), seeing a mentor mother (each visit vs. as needed), seeing a clinician (each visit vs. as needed), and basic consultation cost (0, 50, or 100 Kenya Shillings [KSh]). We used multinomial logit modeling to determine the relative effects (β) of each attribute on clinic choice.

RESULTS

Among 250 PPWH (median age 31 years, 42% pregnant, 58% postpartum, 20% with a gap in care), preferences were for pregnancy visits every 2 months (β = 0.15), postpartum visits with infant immunizations (β = 0.36), seeing a mentor mother and clinician each visit (β = 0.05 and 0.08, respectively), and 0 KSh cost (β = 0.39). Preferences were similar when stratified by age, pregnancy, and retention status. At the same cost, predicted market choice for a clinic model with fewer pregnant/postpartum visits was 75% versus 25% for the standard of care (ie, monthly visits during pregnancy/postpartum).

CONCLUSION

PPWH prefer fewer clinic visits than currently provided within the standard of care in Kenya, supporting the need for implementation of differentiated service delivery for this population.

Augmenting progress on the elimination of vertical transmissions of HIV in India: Insights from Spectrum-based HIV burden estimations

The government of India has adopted the elimination of vertical transmission of HIV as one of the five high-level goals under phase V of the National AIDS and STD Control Programme (NACP). In this paper, we present the data from HIV estimations 2021 for India and select States detailing the progress as well as the attributable causes for vertical transmissions. The NACP spearheads work on mathematical modelling to estimate HIV burden based on the periodically conducted sentinel surveillance for guiding program implementation and policymaking. Using the results of the latest round of HIV Estimations in 2021, we analysed the mother-to-child transmission (MTCT) during the perinatal and postnatal (breastfeeding) period. In 2021, overall, around 5,000 [3,000-7,800] vertical transmissions were estimated nationally with 58% being perinatal infections and remaining during breastfeeding. MTCT at 6 weeks was around 12.95% [9.45-16.02] with the final transmission rate at 24.25% [18.50-29.50]. Overall, 57% of vertical transmissions were among HIV-positive mothers who did not receive ART during pregnancy or breastfeeding, 19% among mothers who dropped off ART during pregnancy or delivery, and 18% among mothers who were infected during pregnancy or breastfeeding. There were significant variations between States. Depending upon the States, the programme needs to focus on the intervention domains of timely engagement in antenatal care-HIV testing-ART initiation as well as programme retention and adherence support. Equally important would be strengthening the strategic information to generate related evidence for inputting India and State-specific parameters improving the MTCT-related modelled estimates.

The effects of revised peer-counselor support on the PMTCT cascade of care: results from a cluster-randomized trial in Kenya (the EMMA study)

BACKGROUND

This study evaluated the effect of revisions to existing peer-counselor services, called Mentor Mothers (MM), at maternal and child health clinics on medication adherence for women living with HIV (WLWH) in Kenya and on early infant HIV testing.

METHODS

The Enhanced Mentor Mother Program study was a 12-site, two-arm cluster-randomized trial enrolling pregnant WLWH from March 2017 to June 2018 (with data collection through September 2020). Six clinics were randomized to continued MM-supported standard care (SC). Six clinics were randomized to the intervention arm (INT = SC plus revised MM services to include more one-on-one interactions). Primary outcomes for mothers were defined as: (PO1) the proportion of days covered (PDC) with antiretroviral therapy (ART) ≥ 0.90 during the last 24-weeks of pregnancy; and (PO2) ≥ 0.90 PDC during the first 24-weeks postpartum. Secondary outcomes were infant HIV testing according to national guidelines (at 6, 24, and 48 weeks). Crude and adjusted risk differences between study arms are reported.

RESULTS

We enrolled 363 pregnant WLHV. After excluding known transfers and subjects with incomplete data extraction, data were analyzed for 309 WLWH (151 SC, 158 INT). A small share achieved high PDC during the prenatal and postnatal periods (0.33 SC/0.24 INT achieved PO1; 0.30 SC/0.31 INT achieved PO2; crude or adjusted risk differences were not statistically significant). In addition, ~ 75% in both study arms completed viral load testing during year two after enrollment, with > 90% suppressed in both arms. For infants, ≥ 90% in both arms had at least one HIV test through study follow up (76 weeks) but testing on schedule according to PMTCT guidelines was uncommon.

CONCLUSIONS

While national guidelines in Kenya recommended that all HIV-infected pregnant women take a daily antiretroviral regimen for life following a HIV diagnosis, results presented here indicate that a minor share achieved high medication coverage during the prenatal and postnatal periods analyzed. In addition, adjustments to Mentor-Mother services showed no improvement in study outcomes. The lack of effect for this behavioral intervention is relatively consistent with the existing literature to improve mother-infant outcomes along the PMTCT care cascade.

CLINICAL TRIAL NUMBER

NCT02848235. Date of first trial registration 28/07/2016.

The Mentor-Mothers program in the Nigeria Department of Defense: policies, processes, and implementation

BACKGROUND

Nigeria has the second largest HIV epidemic in the world and is one of the countries with the highest rates of new pediatric infections in sub-Saharan Africa. The country faces several challenges in the provision of healthcare services and coverage of Prevention of Mother to child transmission of HIV. In the Nigeria's Department of Defense, prevention of vertically transmitted HIV infections has been given a boost by utilizing Mentor Mothers to facilitate antiretroviral compliance and retention in care. The aim of this study was to explore those processes and policies that guide the implementation of the Mentor Mothers program for PMTCT of HIV in the Department of Defense in Nigeria as no studies have examined this so far.

METHODS

The descriptive, qualitative research approach was utilized. We conducted 7 key informants interviews with 7 purposively selected participants made up of 2 program Directors, 1 Doctor, 1 PMTCT focal Nurse, 1 PMTCT site coordinator, 1 Mentor Mother, and 1 patient from one each of the health facilities of the Army, Navy, Airforce and the Defence Headquarters Medical Centre. Open coding for major themes and sub-themes was done. Data were analyzed using thematic analysis.

RESULTS

Findings revealed that the program in the Department of Defense had been modelled after the WHO and implementing partners' guidelines. Foundational Factors; Leadership; Skill acquisition; and Service Characteristics emerged as processes guiding the implementation of the Mentor-Mothers program in the DoD. These findings supported the Mentor Mother Model, which empowers mothers living with HIV - through education and employment - to promote access to essential PMTCT services and medical care to HIV positive pregnant women.

CONCLUSION

We concluded that no definitive policy establishes the Mentor Mothers program in the DoD. Working with Doctors, Nurses, local & collaborating partners, and communities in which these hospitals are located, the Mentor Mothers play a pivotal role in the formation, facilitation, and implementation of the MM model to effectively decrease HIV infections in children and reduce child and maternal mortality in women and families they interact with.

Peer Approaches to Improve HIV Care Cascade Outcomes: a Scoping Review Focused on Peer Behavioral Mechanisms

PURPOSE OF REVIEW

There are three main components of peer-based approaches regardless of type: education, social support, and social norms. The purpose of this scoping review was to examine evidence in the literature among peer-based interventions and programs of components and behavioral mechanisms utilized to improve HIV care cascade outcomes.

RECENT FINDINGS

Of 522 articles found, 40 studies were included for data abstraction. The study outcomes represented the entire HIV care cascade from HIV testing to viral suppression. Most were patient navigator models and 8 of the studies included all three components. Social support was the most prevalent component. Role modeling of behaviors was less commonly described. This review highlighted the peer behavioral mechanisms that operate in various types of peer approaches to improve HIV care and outcomes in numerous settings and among diverse populations. The peer-based approach is flexible and commonly used, particularly in resource-poor settings.

A Scoping Review of Peer Navigation Programs for People Living with HIV: Form, Function and Effects

This scoping review maps recent research into peer navigation programs for people living with HIV. Four databases were systematically searched in June 2020. Results were screened according to defined criteria and were not restricted to any design, outcome or country. Six papers drew from randomised control trials, five from quasi-experimental or pragmatic trials, and four panel, eight qualitative, three mixed method and one cross-sectional designs were included for review. Programs incorporated health systems navigation and social support. Authors provided strong theoretical bases for peers to enhance program effects. Studies primarily reported program effects on continuum of care outcomes. Further research is required to capture the role HIV peer navigators play in preventing disease and promoting quality of life, mental health, and disease self-management in diverse settings and populations. Peer programs are complex, social interventions. Future work should evaluate detailed information about peer navigators, their activities, the quality of peer engagement as well as employee and community support structures to improve quality and impact.

The effect of a Mentor Mothers program on prevention of vertical transmission of HIV outcomes in Zambézia Province, Mozambique: a retrospective interrupted time series analysis

Introduction

Mentor Mothers (MM) provide peer support to pregnant and postpartum women living with HIV (PPWH) and their infants with perinatal HIV exposure (IPE) throughout the cascade of prevention of vertical transmission (PVT) services. MM were implemented in Zambézia Province, Mozambique starting in August 2017. This evaluation aimed to determine the effect of MM on PVT outcomes.

Methods

A retrospective interrupted time series analysis was done using routinely collected aggregate data from 85 public health facilities providing HIV services in nine districts of Zambézia. All PPWH (and their IPE) who initiated antiretroviral therapy (ART) from August 2016 through April 2019 were included. Outcomes included the proportion per month per district of: PPWH retained in care 12 months after ART initiation, PPWH with viral suppression and IPE with HIV DNA PCR test positivity by 9 months of age. The effect of MM on outcomes was assessed using logistic regression.

Results

The odds of 12‐month retention increased 1.5% per month in the pre‐MM period, compared to a monthly increase of 7.6% with‐MM (35–61% pre‐MM, 56–72% with‐MM; p < 0.001). The odds of being virally suppressed decreased by 0.9% per month in the pre‐MM period, compared to a monthly increase of 3.9% with‐MM (49–85% pre‐MM, 59–80% with‐MM; p < 0.001). The odds of DNA PCR positivity by 9 months of age decreased 8.9% per month in the pre‐MM period, compared to a monthly decrease of 0.4% with‐MM (0–14% pre‐MM, 4–10% with‐MM; p < 0.001). The odds of DNA PCR uptake (the proportion of IPE who received DNA PCR testing) by 9 months of age were significantly higher in the with‐MM period compared to the pre‐MM period (48–100% pre‐MM, 87–100% with‐MM; p < 0.001).

Conclusions

MM services were associated with improved retention in PVT services and higher viral suppression rates among PPWH. While there was ongoing but diminishing improvement in DNA PCR positivity rates among IPE following MM implementation, this might be explained by increased uptake of HIV testing among high‐risk IPE who were previously not getting tested. Additional efforts are needed to further optimize PVT outcomes, and MM should be one part of a comprehensive strategy to address this critical need.

Community health workers and health equity in low- and middle-income countries: systematic review and recommendations for policy and practice

Background

The deployment of Community Health Workers (CHWs) is widely promoted as a strategy for reducing health inequities in low- and middle-income countries (LMIC). Yet there is limited evidence on whether and how CHW programmes achieve this. This systematic review aimed to synthesise research findings on the following questions: (1) How effective are CHW interventions at reaching the most disadvantaged groups in LMIC contexts? and (2) What evidence exists on whether and how these programmes reduce health inequities in the populations they serve?

Methods

We searched six academic databases for recent (2014–2020) studies reporting on CHW programme access, utilisation, quality, and effects on health outcomes/behaviours in relation to potential stratifiers of health opportunities and outcomes (e.g., gender, socioeconomic status, place of residence). Quantitative data were extracted, tabulated, and subjected to meta-analysis where appropriate. Qualitative findings were synthesised using thematic analysis.

Results

One hundred sixty-seven studies met the search criteria, reporting on CHW interventions in 33 LMIC. Quantitative synthesis showed that CHW programmes successfully reach many (although not all) marginalized groups, but that health inequalities often persist in the populations they serve. Qualitative findings suggest that disadvantaged groups experienced barriers to taking up CHW health advice and referrals and point to a range of strategies for improving the reach and impact of CHW programmes in these groups. Ensuring fair working conditions for CHWs and expanding opportunities for advocacy were also revealed as being important for bridging health equity gaps.

Conclusion

In order to optimise the equity impacts of CHW programmes, we need to move beyond seeing CHWs as a temporary sticking plaster, and instead build meaningful partnerships between CHWs, communities and policy-makers to confront and address the underlying structures of inequity.

Trial registration

PROSPERO registration number CRD42020177333.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01615-y.

Interventions to improve early retention of patients in antiretroviral therapy programmes in sub-Saharan Africa: A systematic review

Background

Several interventions to improve long term retention (12 months and above) on treatment have been rigorously evaluated in Sub-Saharan Africa (SSA). However, research on interventions to improve retention of patients in the early stages of treatment (6 months) during this era of Universal Test and Treat has only recently emerged. The aim of this study is to systematically map evidence of interventions used to improve early retention of patients in antiretroviral therapy (ART) programmes in SSA.

Methods

We searched PubMed, EMBASE and Cochrane electronic databases to identify studies describing interventions aimed at improving early retention in ART treatment. We applied the methodological frameworks by Arksey and O’Malley (2005) and Levac et al. (2010). We also followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Interventions were categorized according to key broad areas in the existing literature.

Results

A total of 2,241 articles were identified of which 19 met the inclusion criteria and were eligible for this review, with the majority either being randomized control trials 32% (n = 6) or cohort studies 32% (n = 6). The studies reviewed were conducted in 11 SSA countries. The most common interventions described under key broad areas included: Health system interventions such as Universal Test-and-Treat, integration of ART initiation, HIV Testing and Counselling and Antenatal Care services and reduction of ART drug costs; Patient centered approaches such as fast track ART initiation, Differentiated Drug Delivery models and point of care HIV birth testing; Behavioral interventions and support through lay counselors, mentor mothers, nurse counselors and application of quality improvement interventions and financial incentives. Majority of the studies targeted the HIV positive adults and pregnant women.

Conclusion

With the introduction of Universal Test-and-Treat and same-day initiation of ART, findings suggest that adoption of policies that expand ART uptake with the goal of reducing HIV transmission at the population level, promoting patient centered approaches such as fast track ART initiation, Differentiated Service Delivery models and providing adequate support through Mentor Mothers, lay and nurse counselors may improve early retention in HIV care in SSA. However, these interventions have only been tested in few countries in the region which points to how hard evidence based HIV programming is. Further research investigating the impact of individual and a combination of interventions to improve early retention in HIV care, including for various groups at high risk of attrition, is warranted across SSA countries to fast track the achievement of 95-95-95 Joint United Nations Programme on HIV/AIDS (UNAIDS) targets by 2030.

Effect of peer-mother interactive programme on prevention of mother-to-child HIV transmission outcomes among pregnant women on anti-retroviral treatment in routine healthcare in Dar es Salaam, Tanzania

Peer support services are increasingly being integrated in programmes for the prevention of mother-to-child HIV transmission (PMTCT). We aimed to evaluate the effect of a peer-mother interactive programme on PMTCT outcomes among pregnant women on anti-retroviral treatment (ART) in routine healthcare in Dar es Salaam, Tanzania. Twenty-three health facilities were cluster-randomized to a peer-mother intervention and 24 to a control arm. We trained 92 ART experienced women with HIV to offer peer education, adherence and psychosocial support to women enrolling in PMTCT care at the intervention facilities. All pregnant women who enrolled in PMTCT care at the 47 facilities from 1st January 2018 to 31st December 2019 were identified and followed up to 31st July 2021. The primary outcome was time to ART attrition (no show >90 days since the scheduled appointment, excluding transfers) and any difference in one-year retention in PMTCT and ART care between intervention and control facilities. Secondary outcomes were maternal viral suppression (<400 viral copies/mL) and mother-to-child HIV transmission (MTCT) by ≥12 months post-partum. Analyses were done using Kaplan Meier and Cox regression (ART retention/attrition), generalized estimating equations (viral suppression) and random effects logistic regression (MTCT); reporting rates, proportions and 95% confidence intervals (CI). There were 1957 women in the peer-mother and 1384 in the control facilities who enrolled in routine PMTCT care during 2018-2019 and were followed for a median [interquartile range (IQR)] of 23 [10, 31] months. Women in both groups had similar median age of 30 [IQR 25, 35] years, but differed slightly with regard to proportions in the third pregnancy trimester (14% versus 19%); advanced HIV (22% versus 27%); and ART naïve (55% versus 47%). Peer-mother facilities had a significantly lower attrition rate per 1000 person months (95%CI) of 14 (13, 16) versus 18 (16, 19) and significantly higher one-year ART retention (95%CI) of 78% (76, 80) versus 74% (71, 76) in un-adjusted analyses, however in adjusted analyses the effect size was not statistically significant [adjusted hazard ratio of attrition (95%CI) = 0.85 (0.67, 1.08)]. Viral suppression (95%CI) was similar in both groups [92% (91, 93) versus 91% (90, 92)], but significantly higher among ART naïve women in peer-mother [91% (89, 92)] versus control [88% (86, 90)] facilities. MTCT (95%CI) was similar in both groups [2.2% (1.4, 3.4) versus 1.5% (0.7, 2.8)]. In conclusion, we learned that integration of peer-mother services in routine PMTCT care improved ART retention among all women and viral suppression among ART naïve women but had no significant influence on MTCT.

Effects of behavioural interventions on postpartum retention and adherence among women with HIV on lifelong ART: the results of a cluster randomized trial in Kenya (the MOTIVATE trial)

INTRODUCTION

Retention in HIV care and adherence to antiretroviral therapy (ART) during pregnancy and postpartum for women living with HIV (WLWH) are necessary to optimize health outcomes for women and infants. The objective of this study was to evaluate the impact of two evidenced-based behavioural interventions on postpartum adherence and retention in WLWH in Kenya.

METHODS

The Mother-Infant Visit Adherence and Treatment Engagement (MOTIVATE) study was a cluster-randomized trial enrolling pregnant WLWH from December 2015 to August 2017. Twenty-four health facilities in southwestern Kenya were randomized to: (1) standard care (control), (2) text-messaging, (3) community-based mentor mothers (cMM) or (4) text-messaging and cMM. Primary outcomes included retention in care and ART adherence at 12 months postpartum. Analyses utilized generalized estimating equations and competing risks regression. Per-protocol analyses examined differences in postpartum retention for women with high versus low levels of exposure to the interventions.

RESULTS

We enrolled 1331 pregnant WLWH (mean age 28 years). At 12 months postpartum, 1140 (85.6%) women were retained in care, 96 women (7.2%) were lost-to-follow-up (LTFU) and 95 (7.1%) were discontinued from the study. In intention-to-treat analyses, the relative risk of being retained at 12-months postpartum was not significantly higher in the intervention arms versus the control arm. In time-to-event analysis, the cMM and text arm had significantly lower rates of LTFU (hazard ratio 0.44, p = 0.019). In per-protocol analysis, the relative risk of 12-month postpartum retention was 24-29% higher for women receiving at least 80% of the expected intervention compared to the control arm; text message only risk ratio (RR) 1.24 (95% confidence interval [CI] 1.16-1.32, p<0.001), cMM only RR 1.29 (95% CI 1.21-1.37, p<0.001) and cMM plus text RR 1.29 (1.21-1.37, p<0.001). Women LTFU were younger (p<0.001), less likely to be married (p<0.001) and more likely to be newly diagnosed with HIV during pregnancy (p<0.001). Self-reported ART adherence did not vary by study arm.

CONCLUSIONS

Behavioural interventions using peer support and text messages did not appear to improve 12-month postpartum retention and adherence in intention-to-treat analyses. Higher levels of exposure to the interventions may be necessary to achieve the desired effects.

Machine Learning Algorithms Using Routinely Collected Data Do Not Adequately Predict Viremia to Inform Targeted Services in Postpartum Women Living With HIV

BACKGROUND

Adherence to antiretroviral treatment (ART) among postpartum women with HIV is essential for optimal health and prevention of perinatal transmission. However, suboptimal adherence with subsequent viremia is common, and adherence challenges are often underreported. We aimed to predict viremia to facilitate targeted adherence support in sub-Saharan Africa during this critical period.

METHODS

Data are from PROMISE 1077BF/FF, which enrolled perinatal women between 2011 and 2014. This analysis includes postpartum women receiving ART per study randomization or country-specific criteria to continue from pregnancy. We aimed to predict viremia (single and confirmed events) after 3 months on ART at >50, >400, and >1000 copies/mL within 6-month intervals through 24 months. We built models with routine clinical and demographic data using the least absolute shrinkage and selection operator and SuperLearner (which incorporates multiple algorithms).

RESULTS

Among 1321 women included, the median age was 26 years and 96% were in WHO stage 1. Between 0 and 24 months postpartum, 42%, 31%, and 28% of women experienced viremia >50, >400, and >1000 copies/mL, respectively, at least once. Across models, the cross-validated area under the receiver operating curve ranged from 0.74 [95% confidence interval (CI): 0.72 to 0.76] to 0.78 (95% CI: 0.76 to 0.80). To achieve 90% sensitivity predicting confirmed viremia >50 copies/mL, 64% of women would be classified as high risk.

CONCLUSIONS

Using routinely collected data to predict viremia in >1300 postpartum women with HIV, we achieved moderate model discrimination, but insufficient to inform targeted adherence support. Psychosocial characteristics or objective adherence metrics may be required for improved prediction of viremia in this population.

Experiences, perceptions and potential impact of community-based mentor mothers supporting pregnant and postpartum women with HIV in Kenya: a mixed-methods study

Introduction

Community‐based mentor mothers (cMMs) are women living with HIV who provide peer support to pregnant/postpartum women living with HIV (PWLWH) to enhance antiretroviral therapy (ART) adherence, retention in care and prevent perinatal transmission of HIV. The goal of this study was to explore the experiences, perceptions, mechanisms and health impact of cMMs on PWLWH in Kenya from the perspective of cMMs.

Methods

We conducted a prospective mixed‐methods study in southwestern Kenya in 2015–2018. In the qualitative phase, we completed in‐depth interviews with cMMs to explore their perceptions and experiences in supporting PWLWH. Transcripts were broad‐coded according to identified themes, then fine‐coded using an inductive approach. In the quantitative phase, we analysed medical record data from PWLWH who were randomized in the cMM intervention to examine the impact of cMM visits on optimal prevention of mother‐to‐child transmission (PMTCT). We used cluster‐adjusted generalized estimating equation models to examine relationships with a composite outcome (facility delivery, infant HIV testing, ART adherence and undetectable viral load at 6 weeks postpartum). Finally, qualitative and quantitative results were integrated.

Results

Convergence of findings from cMM interviews (n = 24) and PWLWH medical data (n = 589) revealed: (1) The cMM intervention was utilized and perceived as acceptable. PWLWH received, on average, 6.2 of 8 intended home visits through 6 weeks postpartum. (2) The cMMs reported serving as role models and confidantes, supporting PWLWH's acceptance of their HIV status, providing assurances about PMTCT and assisting with male partner disclosure and communication. cMMs also described benefits for themselves, including empowerment and increased income. (3) The cMM visits supported PWLWH's completion of PMTCT steps. Having ≥4 cMM home visits up to 6 weeks postpartum, as compared to <4 visits, was associated with higher likelihood of an optimal PMTCT composite outcome (adjusted relative risk 1.42, p = 0.044).

Conclusions

We found that peer support from cMMs during pregnancy through 6 weeks postpartum was associated with improved uptake of critical PMTCT services and health behaviours and was perceived as beneficial for cMMs themselves. CMM support of PWLWH may be valuable for other low‐resource settings to improve engagement with lifelong ART and HIV services among PWLWH.

Acceptability of mentor mother peer support for women living with HIV in North-Central Nigeria: a qualitative study

BACKGROUND

Mentor mothers provide psychosocial and other support to pregnant and post-partum women living with HIV (WLHIV), which has been shown to enhance maternal-infant outcomes in the prevention of mother-to-child transmission of HIV (PMTCT). Our objective was to assess the acceptability of mentor mothers as a PMTCT intervention, and to explore opinions on mentor mother program composition and delivery among stakeholders in North-Central Nigeria.

METHODS

We conducted nine focus group discussions and 31 in-depth interviews with 118 participants, including WLHIV, pregnant women, male partners, health workers, traditional birth attendants, community leaders, PMTCT program implementers, and policymakers. Participants were purposively recruited from health facilities and surrounding communities in the Federal Capital Territory and Nasarawa State. Transcripts were manually analysed using a Grounded Theory approach, where theory was derived from the data collected.

RESULTS

Most participants were female (n = 78, 67%), and married (n = 110, 94%). All participant groups found  mentor mothers acceptable as women providing care to pregnant and postpartum women, and as WLHIV supporting other WLHIV. Mentor mothers were uniquely relatable as role models for WLHIV because they were women, living with HIV, and had achieved an HIV-negative status for their HIV-exposed infants. Mentor mothers were recognized as playing major roles in maternal health education, HIV treatment initiation, adherence, and retention, HIV prevention for male partners and infants, and couple HIV disclosure. Most WLHIV preferred to receive mentor mothers' services at health facilities rather than at home, due to concerns about HIV-related stigma and discrimination through association with mentor mothers. Key mentor mother needs were identified as training, remuneration, and validation as lay health workers.

CONCLUSIONS

Mentor mothers are an acceptable PMTCT intervention among stakeholders in North-Central Nigeria. However, stigma and discrimination for both mentor mothers and their clients remain a critical challenge, and mentor mother needs such as training, pay, and a sustainably supported niche in health systems require focused attention.

TRIAL REGISTRATION

Clinicaltrials.gov registration number ( NCT01936753 ), registered on September 3, 2013 (retrospectively registered).

Improving retention in antenatal and postnatal care: a systematic review of evidence to inform strategies for adolescents and young women living with HIV

INTRODUCTION

Young pregnant and postpartum women living with HIV (WLHIV) are at high risk of poor outcomes in prevention of mother-to-child transmission services. The aim of this systematic review was to collate evidence on strategies to improve retention in antenatal and/or postpartum care in this population. We also conducted a secondary review of strategies to increase attendance at antenatal care (ANC) and/or facility delivery among pregnant adolescents, regardless of HIV status, to identify approaches that could be adapted for adolescents and young WLHIV.

METHODS

Selected databases were searched on 1 December 2020, for studies published between January 2006 and November 2020, with screening and data abstraction by two independent reviewers. We identified papers that reported age-disaggregated results for adolescents and young WLHIV aged <25 years at the full-text review stage. For the secondary search, we included studies among female adolescents aged 10 to 19 years.

RESULTS AND DISCUSSION

Of 37 papers examining approaches to increase retention among pregnant and postpartum WLHIV, only two reported age-disaggregated results: one showed that integrated care during the postpartum period increased retention in HIV care among women aged 18 to 24 years; and another showed that a lay counsellor-led combination intervention did not reduce attrition among women aged 16 to 24 years; one further study noted that age did not modify the effectiveness of a combination intervention. Mobile health technologies, enhanced support, active follow-up and tracing and integrated services were commonly examined as standalone interventions or as part of combination approaches, with mixed evidence for each strategy. Of 10 papers identified in the secondary search, adolescent-focused services and continuity of care with the same provider appeared to be effective in improving attendance at ANC and/or facility delivery, while home visits and group ANC had mixed results.

CONCLUSIONS

This review highlights the lack of evidence regarding effective strategies to improve retention in antenatal and/or postpartum care among adolescents and young WLHIV specifically, as well as a distinct lack of age-disaggregated results in studies examining retention interventions for pregnant WLHIV of all ages. Identifying and prioritizing approaches to improve retention of adolescents and young WLHIV are critical for improving maternal and child health.

Social support and postpartum adherence to HIV treatment: a community-based participatory research study in Russia

BACKGROUND

There are over 1 million people living with HIV in Russia, and less than half of them are on antiretroviral treatment (ART). Earlier in the epidemic, Russia was successful in implementing prevention of mother-to-child transmission programmes; however, there is a gap in knowledge about postpartum adherence to ART among women living with HIV (WLHIV). The objective of our research study was to identify which factors are associated with postpartum engagement in HIV care and treatment in Russia.

METHODS

We conducted a community-based participatory research study in five Russian cities. We surveyed 200 WLHIV who had given birth within the previous 24 months about their use of ART. We used multivariable logistic regression to determine which types of social support are associated with adherence to ART in the postpartum period.

RESULTS

Less than half (40%) of mothers reported being adherent to ART. Multivariable analysis showed that having a supportive family environment [aOR = 2.64, 95% CI (1.91-5.83)], and active engagement with other HIV-positive mothers [aOR = 2.20, 95% CI (1.04-4.66)] were positively associated with postpartum adherence to ART. WLHIV who had more than one child were less likely to be adherent then WLHIV with just one child [aOR = 0.44, 95% CI (0.22-0.91)].

CONCLUSION

The support that new mothers have or do not have can play an important role in WLHIV adherence to ART. The findings from our study provide ideas for improving the likelihood that women will continue to engage in HIV treatment and care after pregnancy.

Retention-in-care in the PMTCT cascade: definitions matter! Analyses from the INSPIRE projects in Malawi, Nigeria and Zimbabwe

Introduction

Definitions of retention‐in‐care in Prevention of Mother‐to‐Child Transmission of HIV (PMTCT) vary substantially between studies and programmes. Some definitions are based on visits missed/made, others on a minimum total number of visits, or attendance at a final clinic visit at a specific time. An agreed definition could contribute to developing evidence‐based interventions for improving retention‐in‐care. In this paper, we estimated retention‐in‐care rates according to different definitions, and we quantified and visualized the degree of agreement between definitions.

Methods

We calculated retention in care rates using nine definitions in the six INSPIRE PMTCT intervention studies, conducted in three sub‐Saharan African countries between 2013 and 2017. With data from one of the studies (E4E), we estimated the agreement between definitions using Gwet’s agreement coefficient (AC1) and concordance. We calculated positive predictive values (PPV) and negative predictive values (NPV) for all definitions considering successively each definition as the reference standard. Finally, we used a Multiple Correspondence Analysis (MCA) to examine clustering of the way different definitions handle retention‐in‐care.

Results

Retention‐in‐care rates among 5107 women ranged from 30% to 76% in the complete dataset with Gwet’s AC1 being 0.56 [0.53; 0.59] indicating a moderate agreement between all definitions together. Two pairs of definitions with high inner concordance and agreement had either very high PPV or very high NPV, and appeared distinct from the other five definitions on the MCA figures. These pairs of definitions were also the ones resulting in the lowest and highest estimates of retention‐in‐care. The simplest definition, that only required a final clinic visit to classify women as retained in care, and classified 55% of women as retained in care, had a PPV ranging from 0.7 to 1 and a NPV ranging from 0.69 to 0.98 when excluding the two pairs afore‐mentioned; it resulted in a moderate to substantial agreement and a 70% to 90% concordance with all other definitions.

Conclusions

Our study highlights the variability of definitions in estimating retention‐in‐care. Some definitions are very stringent which may be required in some instances. A simple indicator such as attendance at a single time point may be sufficient for programme planning and evaluation.

Access to maternal-child health and HIV services for women in North-Central Nigeria: A qualitative exploration of the male partner perspective

BACKGROUND

In much of sub-Saharan Africa, male partners play influential roles in women's access to maternal-child healthcare, including prevention of mother-to-child transmission of HIV services. We explored male partner perspectives on women's access to maternal-child healthcare in North-Central Nigeria.

METHODS

Three focus groups were conducted with 30 men, purposefully-selected on the basis of being married, and rural or urban residence. Major themes explored were men's maternal-child health knowledge, gender power dynamics in women's access to healthcare, and peer support for pregnant and postpartum women. Data were manually analyzed using Grounded Theory, which involves constructing theories out of data collected, rather than applying pre-formed theories.

RESULTS

Mean participant age was 48.3 years, with 36.7% aged <40 years, 46.7% between 41 and 60 years, and 16.6% over 60 years old. Religious affiliation was self-reported; 60% of participants were Muslim and 40% were Christian. There was consensus on the acceptability of maternal-child health services and their importance for optimal maternal-infant outcomes. Citing underlying patriarchal norms, participants acknowledged that men had more influence in family health decision-making than women. However, positive interpersonal couple relationships were thought to facilitate equitable decision-making among couples. Financial constraints, male-unfriendly clinics and poor healthcare worker attitudes were major barriers to women's access and male partner involvement. The provision of psychosocial and maternal peer support from trained women was deemed highly acceptable for both HIV-positive and HIV-negative women.

CONCLUSIONS

Strategic engagement of community leaders, including traditional and religious leaders, is needed to address harmful norms and practices underlying gender inequity in health decision-making. Gender mainstreaming, where the needs and concerns of both men and women are considered, should be applied in maternal-child healthcare education and delivery. Clinic fee reductions or elimination can facilitate service access. Finally, professional organizations can do more to reinforce respectful maternity care among healthcare workers.

Assessing the acceptability of village health workers' roles in improving maternal health care in Gombe State, Nigeria a qualitative exploration from women beneficiaries

Introduction

Maternal, and under-five mortality rates in Gombe State are disproportionately high. The Society for Family Health (a Non-Governmental Organization) in collaboration with Gombe State Primary Health Care Development Agency implemented the Village Health Worker (VHW) Program in Gombe to address the low uptakes of maternal neonatal and child health (MNCH) services and reduced the impact of healthcare worker insufficiency. VHWs are lay indigenous women trained to educate and encourage women to use MNCH services, provide simple community-based maternal and new-born care through home visits, and facilitate facility linkage. We assessed the acceptability of VHW services among women beneficiaries of the Program.

Methods

Qualitative data were obtained through six focus group discussions with 58 women beneficiaries of the VHW program who delivered within the last 12 months preceding study period (October–November 2018). Themes explored were roles and acceptability of VHWs, and the influence of VHWs on the uptake of MNCH services. We analyzed data with NVivo 12, using Grounded Theory.

Results

Participants’ mean age was 25.1 (± 5.3) years old. Most participants 39 (67%), had been in contact with a VHW for at least 10 months. VHWs visited pregnant women at home and registered them for antenatal care, provided them basic maternal healthcare, health education, and facilitated facility linkage. Participants generally accepted the VHW Program because it was community-based, VHWs were indigenous community members, delivered clear messages, and influenced husbands and mothers-in-law to support women’s’ use of MNCH services. VHWs’ interventions were perceived to have improved health literacy and the uptake of MNCH services. Participants generally admired the VHW occupation and recommended VHW program scale-up, and for VHWs to be offered basic obstetric training and employment by health facilities or the government.

Conclusion

The general acceptance and positive views of VHWs from beneficiaries of the program demonstrates the feasibility of the program to improve the uptake of MNCH services.

Correlates of loss to follow-up and missed diagnosis among HIV-exposed infants throughout the breastfeeding period in southern Mozambique

Introduction

Complete follow-up of human immunodeficiency virus (HIV)-exposed infants (HEI) is crucial for a successful prevention of mother-to-child HIV transmission. This study analyzed the HEI follow-up and factors associated with loss to follow-up (LTFU) in southern Mozambique.

Methods

This retrospective cohort study used the data of HEI enrolled between June 2017 and June 2018, followed-up for 18 months. The outcomes were the proportion of infants with completed follow-up and a definitive diagnosis, and the presence of clinical events. Kaplan–Meier survival analysis was used to calculate the cumulative probability of LTFU and of clinical events. Factors associated with LTFU and clinical events were analyzed using Cox regression to calculate the hazard ratio (HR) and adjusted HR (AHR), with a 95% confidence interval (CI) and a significance cutoff of p<0.05.

Results

1413 infants were enrolled (49% males) at a median age of 32 days (IQR 31–41); the median follow-up time was 12 months (IQR 8.2–14.2); 1129 (80%) completed follow-up and had a definitive diagnosis, 58 (4%) were HIV-positive, 225 (16%) were LTFU; 266 (19%) presented a clinical event. Factors associated with LTFU were: age >2 months at entry (AHR, 1.58; 95% CI, 1.12–2.23), non-exclusive breastfeeding (AHR, 1.44; 95% CI, 1.01–2.06), poor cotrimoxazole adherence (AHR, 3.42; 95% CI, 1.59–7.35), and clinical events (AHR, 0.51; 95% CI, 0.34–0.77). Factors associated with clinical events were: malnutrition (AHR, 10.06; 95% CI, 5.92–17.09), non-exclusive breastfeeding (AHR, 1.98; 95% CI, 1.34–2.93), no nevirapine prophylaxis (AHR, 1.67; 95% CI, 1.18–2.36), and poor cotrimoxazole adherence (AHR, 2.62; 95% CI, 1.10–6.22).

Conclusion

The high rate of HEI LTFU, associated with delayed linkage to postnatal care, poor prophylaxis adherence, non-exclusive breastfeeding, indicates the need to design a differentiated service delivery model that is tailored to the mothers’ and infants’ specific needs.

Accelerating progress towards the elimination of mother-to-child transmission of HIV: a narrative review

INTRODUCTION

Findings from biomedical, behavioural and implementation studies provide a rich foundation to guide programmatic efforts for the prevention of mother-to-child HIV transmission (PMTCT).

METHODS

We summarized the current evidence base to support policy makers, programme managers, funding agencies and other stakeholders in designing and optimizing PMTCT programmes. We searched the scientific literature for PMTCT interventions in the era of universal antiretroviral therapy for pregnant and breastfeeding women (i.e. 2013 onward). Where evidence was sparse, relevant studies from the general HIV treatment literature or from prior eras of PMTCT programme implementation were also considered. Studies were organized into six categories: HIV prevention services for women, timely access to HIV testing, timely access to ART, programme retention and adherence support, timely engagement in antenatal care and services for infants at highest risk of HIV acquisition. These were mapped to specific missed opportunities identified by the UNAIDS Spectrum model and embedded in UNICEF operational guidance to optimize PMTCT services.

RESULTS AND DISCUSSION

From May to November 2019, we identified numerous promising, evidence-based strategies that, properly tailored and adopted, could contribute to population reductions in vertical HIV transmission. These spanned the HIV and maternal and child health literature, emphasizing the importance of continued alignment and integration of services. We observed overlap between several intervention domains, suggesting potential for synergies and increased downstream impact. Common themes included integration of facility-based healthcare; decentralization of health services from facilities to communities; and engagement of partners, peers and lay workers for social support. Approaches to ensure early HIV diagnosis and treatment prior to pregnancy would strengthen care across the maternal lifespan and should be promoted in the context of PMTCT.

CONCLUSIONS

A wide range of effective strategies exist to improve PMTCT access, uptake and retention. Programmes should carefully consider, prioritize and plan those that are most appropriate for the local setting and best address existing gaps in PMTCT health services.

A mixed-methods assessment of disclosure of HIV status among expert mothers living with HIV in rural Nigeria

BACKGROUND

Peer support provided by experienced and/or trained "expert" women living with HIV has been adopted by prevention of mother-to-child transmission of HIV (PMTCT) programs across sub-Saharan Africa. While there is ample data on HIV status disclosure among non-expert women, there is little data on disclosure among such expert women, who support other women living with HIV.

OBJECTIVE

This study compared HIV disclosure rates between expert and non-expert mothers living with HIV, and contextualized quantitative findings with qualitative data from expert women.

METHODS

We compared survey data on HIV disclosure to male partners and family/friends from 37 expert and 100 non-expert mothers living with HIV in rural North-Central Nigeria. Four focus group discussions with expert mothers provided further context on disclosure to male partners, extended family and peers. Chi square and Fisher's exact tests were applied to quantitative data. Qualitative data were manually analyzed using a Grounded Theory approach.

RESULTS

Two-thirds of the 137 participants were 21-30 years old; 89.8% were married, and 52.3% had secondary-level education. Disclosure to male partners was higher among expert (100.0%) versus non-expert mothers (85.0%), p = 0.035. Disclosure to anyone (93.1% vs 80.8%, p = 0.156), and knowledge of male partners' HIV status were similar (75.7% versus 66.7%, p = 0.324) between expert and non-expert mothers, respectively. With respect to male partners, HIV serodiscordance rates were also similar (46.4% vs 55.6%, p = 0.433). Group discussions indicated that expert mothers did not consistently disclose to their mentored clients, with community-level stigma and discrimination stated as major reasons for this non-disclosure.

CONCLUSIONS

Expert mothers experience similar disclosure barriers as their non-expert peers, especially regarding disclosure outside of intimate relationships. Thus, attention to expert mothers' coping skills and disclosure status, particularly to mentored clients is important to maximize the impact of peer support in PMTCT.

CLINICAL TRIALS REGISTRATION

Clinicaltrials.gov registration number NCT01936753 (retrospective), September 3, 2013.

Measuring retention in HIV care: the impact of data sources and definitions using routine data

OBJECTIVES

Measuring retention is critical for antiretroviral therapy (ART) management and program monitoring; however, many definitions and data sources, usually from single health facilities, are used. We used routine electronic data, linked across facilities, to examine the impact of definitions and data sources on retention estimates among women in Cape Town, South Africa.

DESIGN

Retrospective cohort study.

METHODS

We compiled routine electronic laboratory, pharmacy and clinic visit data for 617 women who started ART during pregnancy (2013-2014) and estimated 24-month retention using different definitions and data sources. We used logistic regression to assess consistency of associations between risk factors and retention, and receiver operating characteristics analyses to describe how different retention estimates predict viremia at 12 months on ART.

RESULTS

Using all available data sources, retention ranged from 41% (no gap >180 days) to 72% (100% 12-month visit constancy). Laboratory data (expected infrequently) underestimated retention compared with clinic visit data that identified more than 80% of women considered retained in all definitions. In all estimates, associations with known risk factors for nonretention remained consistent and retention declined over time: 77, 65 and 58% retained using all data sources in months 6-12, 12-18 and 18-24, respectively (P < 0.001). The 180-day gap definition was most strongly associated with viremia (odds ratio 24.3 95% confidence interval 12.0-48.9, all data sources).

CONCLUSION

Researchers must carefully consider the most appropriate retention definition and data source depending on available data. Presenting more than one approach may be warranted to obtain estimates that are context-appropriate and comparable across settings.

The Video intervention to Inspire Treatment Adherence for Life (VITAL Start): protocol for a multisite randomized controlled trial of a brief video-based intervention to improve antiretroviral adherence and retention among HIV-infected pregnant women in Malawi

BACKGROUND

Improving maternal antiretroviral therapy (ART) retention and adherence is a critical challenge facing prevention of mother-to-child transmission (PMTCT) of HIV programs. There is an urgent need for evidence-based, cost-effective, and scalable interventions to improve maternal adherence and retention that can be feasibly implemented in overburdened health systems. Brief video-based interventions are a promising but underutilized approach to this crisis. We describe a trial protocol to evaluate the effectiveness and implementation of a standardized educational video-based intervention targeting HIV-infected pregnant women that seeks to optimize their ART retention and adherence by providing a VITAL Start (Video intervention to Inspire Treatment Adherence for Life) before committing to lifelong ART.

METHODS

This study is a multisite parallel group, randomized controlled trial assessing the effectiveness of a brief facility-based video intervention to optimize retention and adherence to ART among pregnant women living with HIV in Malawi. A total of 892 pregnant women living with HIV and not yet on ART will be randomized to standard-of-care pre-ART counseling or VITAL Start. The primary outcome is a composite of retention and adherence (viral load < 1000 copies/ml) 12 months after starting ART. Secondary outcomes include assessments of behavioral adherence (self-reported adherence, pharmacy refill, and tenofovir diphosphate concentration), psychosocial impact, and resource utilization. We will also examine the implementation of VITAL Start via surveys and qualitative interviews with patients, partners, and health care workers and conduct cost-effectiveness analyses.

DISCUSSION

This is a robust evaluation of an innovative facility-based video intervention for pregnant women living with HIV, with the potential to improve maternal and infant outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03654898. Registered on 31 August 2018.

Towards the elimination of mother-to-child transmission of HIV in Nigeria: a health system perspective of the achievements and challenges

Despite its scaled-up response for prevention of mother-to-child transmission of HIV (PMTCT), Nigeria still contributes the greatest number of infants infected with HIV worldwide. Drawing on our knowledge, and review of policy documents and research papers, we explored the achievements and challenges in the elimination of mother-to-child transmission of HIV in Nigeria using the WHO's health systems framework. We found that Nigeria has increased the number of PMTCT sites, decentralized and integrated PMTCT care for expanded service delivery, adopted task-shifting to address the shortage of skilled healthcare providers, explored alternative sources of domestic funding to bridge the funding gap and harmonized the health management information system to improve data quality. Some of the challenges we identified included: difficulty in identifying HIV-infected pregnant women because of low uptake of antenatal care; interrupted supplies of medical commodities; knowledge gaps among healthcare workers; and lack of a national unique identifying system to enhance data quality. While there have been some achievements in the PMTCT program, gaps still exist in the different blocks of the health system. Elimination of mother-to-child transmission of HIV in Nigeria will require the implementation of feasible, culturally acceptable and sustainable interventions to address the health system-related challenges.

Effect of a Mentor Mother Programme on retention of mother-baby pairs in HIV care: A secondary analysis of programme data in Uganda

Background

Community healthcare workers (CHWs) play an important role in promoting HIV-care retention. Notwithstanding inconsistencies in the outcomes of CHW programmes, these programmes are known to have a positive effect on retention of mother-baby pairs in HIV-care in sub-Saharan Africa.

Aim

The aim of this analysis was to assess the effect of mothers2mothers (m2m) Ugandan Mentor Mother (MM) programme on the retention of mother-baby pairs in HIV-care.

Methods

We conducted a secondary analysis of data obtained from the m2m Uganda MM programme in nine East Central districts. The primary data was generated through a quasi-experimental study of women attending prevention of mother to child transmission of HIV (PMTCT) clinics in Uganda between January 2011 and March 2014; where those who were enrolled at PMTCT sites with the MM intervention (n = 1161) were compared with those who received standard PMCTCT services without the MM intervention (n = 1143). Frequencies and descriptive statistics were calculated for categorical and continuous measures respectively. Risk factors for retention in care were determined by clustered generalised estimating equations and reported as adjusted odds ratios (AOR) with 95% confidence intervals (95% CI).

Results

Retention in the PMTCT cascade was significantly higher for mother-baby pairs in the intervention arm compared to those in the control arm across all measured time points (96.7% vs 65.8% at 6 weeks after birth, p<0.001; 81.5% vs 42% at 6 weeks after cessation of breastfeeding, p<0.001; and 71.2% vs 20.6% at 18 months after birth, p<0.001). Relative to the control group, women in the intervention group were less likely to be lost to follow up following treatment initiation (AOR 0.05, 95% CI: 0.02, 0.15). There was no difference in the proportion of the retained mother-baby pairs who received prescribed PMTCT interventions at different time points but a significantly higher number of mother-baby pairs in the intervention arm were retained at different time points.

Conclusion

HIV positive mothers and their HIV exposed children in the mothers2mothers Ugandan Mentor Mother programme had higher retention in HIV care at every step along the PMTCT cascade. We therefore recommend adoption of this peer-to-peer model in sub-Saharan Africa to complement retention in care strategies and health system interventions especially among priority and key populations.

Acceptability of community-based mentor mothers to support HIV-positive pregnant women on antiretroviral treatment in western Kenya: a qualitative study

BACKGROUND

Option B+ is a comprehensive antiretroviral treatment (ART) designed for HIV-infected pregnant/ postpartum women. However, barriers to implementing Option B+ and establishing long-term ART adherence while facilitating retention in prevention of mother to child transmission of HIV (PMTCT) services remain. Community-based mentor mothers (cMMs) who can provide home-based support for PMTCT services may address some of the barriers to successful adoption and retention in Option B+. Thus, we evaluated the acceptability of using cMMs as home-based support for PMTCT services.

METHODS

Gender-matched in-depth interviews were conducted between September-November 2014 for HIV-infected pregnant/postpartum women and their male partners living in southwestern Kenya (n = 40); additionally, we conducted four focus groups involving 30 health workers (n = 70) within four health facilities. Audio-recordings were transcribed, translated, and then coded using a thematic analytical approach in which data were deductively and inductively coded with support from prior literature, identified themes within the interview guides, and emerging themes from the transcripts utilizing Dedoose software.

RESULTS

Overall, the study results suggest high acceptability of cMMs among individual participants and health workers. Stigma reduction, improvement of utilization of health care services, as well as ART adherence were most frequently discussed potential benefits of cMMs. Participants pictured a cMM as someone acting as a role model and confidant, and who was over 30 years old. Many respondents raised concerns about breaches of confidentiality and inadvertent disclosure. Respondent suggestions to overcome these issues included the cMM working in different communities than where she lives and attending home-visits with no identifying clothing as an HIV-related health worker.

CONCLUSIONS

The home-based cMM approach may be a beneficial and acceptable strategy for promoting ART adherence and retention within PMTCT services for pregnant/postpartum women living with HIV. Considering the risks of inadvertent disclosure of HIV-infected status and related negative consequences for pregnant/postpartum women living with HIV, similar cMM program designs may benefit from recognizing and addressing these risks.

TRIAL REGISTRATION

The MOTIVATE! study was registered on July 7, 2015 at the ClinicalTrials.gov ( NCT02491177 ).

Missed opportunities for early infant diagnosis of HIV in rural North-Central Nigeria: A cascade analysis from the INSPIRE MoMent study

Background

Early identification of HIV-infected infants for treatment is critical for survival. Efficient uptake of early infant diagnosis (EID) requires timely presentation of HIV-exposed infants, same-day sample collection, and prompt release of results. The MoMent (Mother Mentor) Nigeria study investigated the impact of structured peer support on EID presentation and maternal retention. This cascade analysis highlights missed opportunities for EID and infant treatment initiation during the study.

Methods

HIV-infected pregnant women and their infants were recruited at 20 rural Primary Healthcare Centers. Routine infant HIV DNA PCR testing was performed at centralized laboratories using dried blood spot (DBS) samples ideally collected by age two months. EID outcomes data were abstracted from study case report forms and facility registers. Descriptive statistics summarized gaps and missed opportunities in the EID cascade.

Results

Out of 497 women enrolled, delivery data was available for 445 (90.8%), to whom 415 of 455 (91.2%) infants were live-born. Out of 408 live-born infants with available data, 341 (83.6%) presented for DBS sampling at least once. Only 75.4% (257/341) were sampled, with 81.7% (210/257) sampled at first presentation. Only 199/257 (77.4%) sampled infants had results available up to 28 months post-collection. Two (1.0%) of the 199 infants tested HIV-positive; one infant died before treatment initiation and the other was lost to follow-up.

Conclusions

While nearly 85% of infants presented for sampling, there were multiple missed opportunities, largely due to health system and not necessarily patient-level failures. These included infants presenting without being sampled, presenting multiple times before samples were collected, and getting sampled but results not forthcoming. Finally, neither of the two HIV-positive infants were linked to treatment within the follow-up period, which may have led to the death of one. To facilitate patient compliance and HIV-free infant survival, quality improvement approaches should be optimized for EID commodity availability, consistent DBS sample collection, efficient processing/result release, and prompt infant treatment initiation.

Assessing the Acceptability of a Peer Mentor Mother Intervention to Improve Retention in Care of Postpartum Women Living with HIV

Background: Many women living with HIV (WLWH) experience poor postpartum retention in HIV care. There are limited evidence-based interventions in the United States aimed at increasing retention of WLWH postpartum; however, evidence from low-resource settings suggest that women who receive peer mentoring experience higher retention and viral suppression postpartum.

Methods: We conducted 15 semistructured interviews with pregnant or postpartum women from an urban U.S. clinic to assess factors influencing maternal adherence to antiretroviral therapy (ART) and retention in HIV care. We then assessed the acceptability of a peer intervention in mitigating barriers to sustain adherence and retention in care postpartum. Interviews were audio taped, transcribed, and analyzed. Codes were developed and applied to all transcripts, and matrices were used to facilitate comparisons across different types of participants.

Results: Participants included low-income black and Hispanic women with a mean age of 31 years (range 22–42). Social support and concern for infants' well-being were strong facilitators for engaging in care. Psychosocial challenges, such as stigma and isolation, fear of disclosure, and depression, negatively influenced adherence to ART and engagement in care. Regardless of their level of adherence to ART, women felt that peer mentoring would be an acceptable intervention to reinforce skill-related ART adherence and sustain engagement in care after delivery.

Conclusion: A peer mentor mother program is a promising intervention that can improve the care continuum of pregnant and postpartum women in the United States. Messaging that maximizes maternal support and women's motivation to keep their infant healthy may leverage retention in care postpartum.

Cell Phone Counseling Improves Retention of Mothers With HIV Infection in Care and Infant HIV Testing in Kisumu, Kenya: A Randomized Controlled Study

BACKGROUND

We evaluated the effectiveness of a cell phone counseling intervention to promote retention in care and HIV testing of infants among women with HIV accessing prevention of mother-to-child services in Kisumu, Kenya.

METHODS

Between May 2013 and September 2015, we recruited 404 pregnant women with HIV who were between 14 and 36 weeks of gestation and randomly assigned them to the intervention (n=207) or control arm (n=197). Retention was assessed at delivery and at 6 and 14 weeks postpartum. We also measured uptake of infant HIV testing. The intervention comprised a fixed protocol of counselor-delivered phone calls to provide one-to-one need-based support. The number of calls made varied depending on when participants presented for antenatal care services; the maximum number was 42. The control group received routine care. We evaluated retention at 3 time points using the complementary log-log regression model taking into account factors associated with retention and loss to follow-up time. We calculated the incidence rate for HIV transmission among infants and used binary logistic regression to identify predictors of HIV infection among infants.

RESULTS

Participants attended on average 63% of the required number of counseling calls during the study period. Retention was higher in the intervention arm than the control arm at delivery (95.2% vs. 77.7%, respectively); 6 weeks postpartum (93.9% vs. 72.9%, respectively); and 14 weeks postpartum (83.3% vs. 66.5%, respectively) (P<.001). The counseling intervention (hazard ratio [HR]=0.29; 95% confidence interval [CI]=0.12, 0.69) and positive health perceptions (HR=0.99; 95% CI=0.98, 1.00) were associated with lower hazards of being lost to follow-up. HIV testing of infants was higher in the intervention than control arm (93% vs. 68%, respectively; P<.001). In total, 9 of 308 (2.9%) infants tested positive for HIV infection (incidence rate=0.39 infections/100 infant-weeks). Medication Possession Ratio (MPR) >90%, used to assess adherence to ART, was associated with lower odds of a positive HIV test among infants (adjusted odds ratio=0.20; 95% CI=0.04, 0.99). Attendance at antenatal and postnatal care visits was higher among participants in the intervention arm than the control arm.

CONCLUSIONS

The one-on-one tailored counseling delivered via cell phone was effective in retaining mothers with HIV infection in care and promoting uptake of infant HIV testing and antenatal and postnatal care services. Phone counseling offers a practical approach to reach and retain pregnant women with HIV infection and postpartum mothers in care, but greater emphasis on collection of medications and adherence is required.

Retention in HIV Care During Pregnancy and the Postpartum Period in the Option B+ Era: Systematic Review and Meta-Analysis of Studies in Africa

BACKGROUND

Under Option B+ guidelines for prevention of mother-to-child transmission of HIV, pregnant and breastfeeding women initiate antiretroviral therapy for lifelong use. The objectives of this study were: (1) to synthesize data on retention in care over time in option B+ programs in Africa, and (2) to identify factors associated with retention in care.

METHODS

PubMed, EMBASE, and African Index Medicus were systematically searched from January 2012 to June 2017. Pooled estimates of the proportion of women retained were generated and factors associated with retention were analyzed thematically.

RESULTS

Thirty-five articles were included in the final review; 22 reported retention rates (n = 60,890) and 25 reported factors associated with retention. Pooled estimates of retention were 72.9% (95% confidence interval: 66.4% to 78.9%) at 6 months for studies reporting <12 months of follow-up and 76.4% (95% confidence interval: 69.0% to 83.1%) at 12 months for studies reporting ≥12 months of follow-up. Data on undocumented clinic transfers were largely absent. Risk factors for poor retention included younger age, initiating antiretroviral therapy on the same day as diagnosis, initiating during pregnancy versus breastfeeding, and initiating late in the pregnancy. Retention was compromised by stigma, fear of disclosure, and lack of social support.

CONCLUSIONS

Retention rates in prevention of mother-to-child transmission under option B+ were below those of the general adult population, necessitating interventions targeting the complex circumstances of women initiating care under option B+. Improved and standardized procedures to track and report retention are needed to accurately represent care engagement and capture undocumented transfers within the health system.

Correlates of reported modern contraceptive use among postpartum HIV-positive women in rural Nigeria: an analysis from the MoMent prospective cohort study

Background

Nigeria has an annual population of ~ 200,000 women who are both pregnant and HIV-positive. High unmet need for family planning in this population could lead to unintended pregnancies, along with the increased risk of mother-to-child transmission of HIV (MTCT). To identify modifiable barriers and facilitators in effective family planning, we examined correlates of modern contraceptive use among HIV-positive women enrolled in the MoMent prevention of MTCT (PMTCT) implementation research study in rural North-Central Nigeria.

Methods

In this prospective cohort study, HIV-positive pregnant women were enrolled at 20 Primary Healthcare Centers and followed up to 12 months postpartum. Baseline socio-demographic, clinical and obstetric data were collected at enrollment. Participants were to receive routine family planning counselling from healthcare workers during postnatal visits. Analysis utilized baseline data linked to available family planning information collected from each woman at the first postpartum visit. Multivariate logistic regression was performed to determine factors associated with modern contraceptive use.

Results

Out of 497 women enrolled, family planning data was available for 399 (80.3%) women, of whom 349 (87.5%) received family planning counselling, and 321 (80.5%) were 30 years old or less. Two-thirds (268, 67.2%) of the cohort analyzed had 1–2 children at baseline; 24.8% (n = 99) had 3–4 children, and 8.0% (n = 32) had > 4 children. Approximately half (199, 49.9%) of the women reported no modern contraceptive use in the postpartum period. Male condoms (116, 29.1%) were the most reported method of contraception; other methods reported included oral hormones (71, 17.8%) and intrauterine devices (13, 3.2%). Only disclosure of HIV status to male partner or relative (aOR = 2.0, 95% CI: 1.2–3.3; p = 0.01) and receipt of family planning counselling (aOR = 2.3, 95% CI: 1.1–4.8; p = 0.03) were positively associated with reported modern contraceptive use. Age, marital or educational status, religious affiliation, employment status, gravidity and parity were non-correlates.

Conclusions

Family planning counselling and disclosure of HIV status are modifiable positive predictors of contraceptive use among our cohort of postpartum HIV-positive women in rural Nigeria. Rates of unintended pregnancy and concomitant risk of MTCT could be significantly reduced through strategies that facilitate these correlates.

Clinical trials registration

Clinicaltrials.gov registration number: NCT 01936753; registered September 3, 2013.

Exploring the acceptability of Option B plus among HIV-positive Nigerian women engaged and not engaged in the prevention of mother-to-child transmission of HIV cascade: a qualitative study

The acceptability of lifelong antiretroviral therapy (ART) among HIV-positive women in high-burden Nigeria, is not well-known. We explored readiness of users and providers of prevention of mother-to-child transmission of HIV (PMTCT) services to accept lifelong ART -before Option B plus was implemented in Nigeria. We conducted 142 key informant interviews among 100 PMTCT users (25 pregnant-newly-diagnosed, 26 pregnant-in-care, 28 lost-to-follow-up (LTFU) and 21 postpartum women living with HIV) and 42 PMTCT providers in rural North-Central Nigeria. Qualitative data were manually analyzed via Grounded Theory. PMTCT users had mixed views about lifelong ART, strongly influenced by motivation to prevent infant HIV and by presence or absence of maternal illness. Newly-diagnosed women were most enthusiastic about lifelong ART, however postpartum and LTFU women expressed conditionalities for acceptance and adherence, including minimal ART side effects and potentially serious maternal illness. Providers corroborated user findings, identifying the postpartum period as problematic for lifelong ART acceptability/adherence. Option B plus scale-up in Nigeria will require proactively addressing PMTCT user fears about ART side effects, and continuous education on long-term maternal and infant benefits. Structural barriers such as the availability of trained providers, long clinic wait times and patient access to ART should also be addressed.

"They do not see us as one of them": a qualitative exploration of mentor mothers' working relationships with healthcare workers in rural North-Central Nigeria

BACKGROUND

In HIV programs, mentor mothers (MMs) are women living with HIV who provide peer support for other women to navigate HIV care, especially in the prevention of mother-to-child transmission of HIV (PMTCT). Nigeria has significant PMTCT program gaps, and in this resource-constrained setting, lay health workers such as MMs serve as task shifting resources for formal healthcare workers and facility-community liaisons for their clients. However, challenging work conditions including tenuous working relationships with healthcare workers can reduce MMs' impact on PMTCT outcomes. This study explores the experiences and opinions of MMs with respect to their work conditions and relationships with healthcare workers.

METHODS

This study was nested in the prospective two-arm Mother Mentor (MoMent) study, which evaluated structured peer support in PMTCT. Thirty-six out of the 38 MMs who were ever engaged in the MoMent study were interviewed in seven focus group discussions, which focused on MM workload and stipends, scope of work, and relationships with healthcare workers. English and English-translated Hausa-language transcripts were manually analyzed by theme and content in a grounded theory approach.

RESULTS

Both intervention and control-arm MMs reported positive and negative relationships with healthcare workers, modulated by individual healthcare worker and structural factors. Issues with facility-level scope of work, workplace hierarchy, exclusivism and stigma/discrimination from healthcare workers were discussed. MMs identified clarification, formalization, and health system integration of their roles and services as potential mitigations to tenuous relationships with healthcare workers and challenging working conditions.

CONCLUSIONS

MMs function in multiple roles, as task shifting resources, lay community health workers, and peer counselors. MMs need a more formalized, well-defined niche that is fully integrated into the health system and is responsive to their needs. Additionally, the definition and formalization of MM roles have to take healthcare worker orientation, sensitization, and acceptability into consideration.

TRIAL REGISTRATION

Clinicaltrials.gov number NCT01936753 , registered September 3, 2013.

HIV treatment in pregnancy

Almost 25 years since antiretroviral therapy (ART) was first shown to prevent mother-to-child transmission of HIV, 76% of pregnant women living with HIV (over 1 million women) receive ART annually. This number is the result of successes in universal ART scale-up in low-income and middle-income countries. Despite unprecedented ART-related benefits to maternal and child health, challenges remain related to ART adherence, retention in care, and unequal access to ART. Implementation research is ongoing to understand and to address obstacles that lead to loss to follow-up. The biological mechanisms that underlie observed associations between antenatal ART and adverse outcomes in pregnancy and birth are not completely understood, with further research needed as well as strengthening of the systems to assess safety of antiretroviral drugs for the mother and HIV-exposed child. In the treat-all era, as duration of treatment and options for ART expand, pregnant women will remain a priority population for treatment optimisation to promote their health and that of their ART-exposed children.

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.

Generating evidence for health policy in challenging settings: lessons learned from four prevention of mother-to-child transmission of HIV implementation research studies in Nigeria

BACKGROUND

Implementation research (IR) facilitates health systems strengthening and optimal patient outcomes by generating evidence for scale-up of efficacious strategies in context. Thus, difficulties in generating IR evidence, particularly in limited-resource settings with wide disease prevention and treatment gaps, need to be anticipated and addressed. Nigeria is a priority country for the prevention of mother-to-child transmission of HIV (PMTCT). This paper analyses the experiences of four PMTCT IR studies in Nigeria, and proffers solutions to major challenges encountered during implementation.

STUDIES INCLUDED AND FINDINGS

Multicentre PMTCT IR studies conducted in Nigeria during the Global Plan's assessment period (2011 to 2015) were included. Four studies were identified, namely The Baby Shower Trial, Optimizing PMTCT, MoMent and Lafiyan Jikin Mata. Major common challenges encountered were categorised as 'External' (beyond the control of study teams) and 'Internal' (amenable to rectification by study teams). External challenges included healthcare worker strikes and turnover, acts and threats of ethnic and political violence and terrorism, and multiplicity of required local ethical reviews. Internal challenges included limited research capacity among study staff, research staff turnover and travel restrictions hindering study site visits. Deliberate research capacity-building was provided to study staff through multiple opportunities before and during study implementation. Post-study employment opportunities and pathways for further research career-building are suggested as incentives for study staff retention. Engagement of study community-resident personnel minimised research staff turnover in violence-prone areas.

CONCLUSIONS

The IR environment in Nigeria is extremely diverse and challenging, yet, with local experience and anticipatory planning, innovative solutions can be implemented to modulate internal challenges. Issues still remain with healthcare worker strikes and often unpredictable insecurity. There is a dire need for cooperation between institutional review boards across Nigeria in order to minimise the multiplicity of reviews for multicentre studies. External challenges need to be addressed by high-level stakeholders, given Nigeria's crucial regional and global position in the fight against the HIV epidemic.

HIV status disclosure to male partners among rural Nigerian women along the prevention of mother-to-child transmission of HIV cascade: a mixed methods study

Background

HIV status disclosure to male partners is important for optimal outcomes in the prevention of mother-to-child transmission of HIV (PMTCT). Depending on timing of HIV diagnosis or pregnancy status, readiness to disclose and disclosure rates may differ among HIV-positive women. We sought to determine rates, patterns, and experiences of disclosure among Nigerian women along the PMTCT cascade.

Methods

HIV-positive women in rural North-Central Nigeria were purposively recruited according to their PMTCT cascade status: pregnant-newly HIV-diagnosed, pregnant-in care, postpartum, and lost-to-follow-up (LTFU). Participants were surveyed to determine rates of disclosure to male partners and others; in-depth interviews evaluated disclosure patterns and experiences. Tests of association were applied to quantitative data. Qualitative data were manually analysed by theme and content using the constant comparative method in a Grounded Theory approach.

Results

We interviewed 100 women; 69% were 21–30 years old, and 86% were married. There were 25, 26, 28 and 21 women in the newly-diagnosed, in-care, postpartum, and LTFU groups, respectively. Approximately 81% of all participants reported disclosing to anyone; however, family members were typically disclosed to first. Ultimately, more women had disclosed to male partners (85%) than to family members (55%). Rates of disclosure to anyone varied between groups: newly-diagnosed and LTFU women had the lowest (56%) and highest (100%) rates, respectively (p = 0.001). However, family (p = 0.402) and male partner (p = 0.218) disclosure rates were similar between cascade groups. Across all cascade groups, fear of divorce and intimate partner violence deterred women from disclosing to male partners. However, participants reported that with assistance from healthcare workers, disclosure and post-disclosure experiences were mostly positive.

Conclusion

In our study cohort, although disclosure to male partners was overall higher, family members appeared more approachable for initial disclosure. Across cascade groups, male partners were ultimately disclosed to at rates > 75%, with no significant inter-group differences. Fear appears to be a major reason for non-disclosure or delayed disclosure by women to male partners. Augmentation of healthcare workers’ skills and involvement can mediate gender power differentials, minimize fear and shorten time to male partner disclosure among women living with HIV, regardless of their PMTCT cascade status.

Trial registration

Clinicaltrials.gov registration number NCT 01936753, September 3, 2013 (retrospectively registered).

Improving postpartum retention in care for women living with HIV in the United States

: Research findings have consistently demonstrated that women living with HIV in the United States and globally experience declines in medication adherence and retention in care after giving birth. A number of studies have identified factors associated with postpartum retention in care, but the evidence base for interventions to address the problem and close this gap in the HIV care continuum is limited. Furthermore, the majority of studies have been conducted in low-resource or moderate-resource countries and may be less applicable or require adaptation for use in high resource countries. In the United States, up to two-thirds of women drop out of care after delivery and are unable to maintain or achieve viral suppression postpartum, at a time when maternal and pediatric health are closely linked. We conducted a critical review of the literature to identify existing gaps regarding maternal retention in the United States and conceptualize the problem through the lens of the integrated and ecological models of health behavior. This review describes existing barriers and facilitators to retention in HIV care postpartum from published studies and suggests steps that can be taken, using a multilevel approach, to improve maternal retention. We propose five core action steps related to increasing awareness of the problem of poor postpartum retention, addressing needs for improved care coordination and case management, and using novel approaches to adapt and implement peer support and technology-based interventions to improve postpartum retention and clinical outcomes of women living with HIV.

A Socio-Ecological Examination of Treatment Access, Uptake and Adherence Issues Encountered By HIV-Positive Women in Rural North-Central Nigeria

BACKGROUND

In spite of the global decline in HIV infections, sub-Saharan Africa still accounts for a non-proportional majority of global new infections. While many studies have documented the importance of facilitating access to anti-retroviral therapy (ART) as a means of reducing infections, the relationship between interpersonal, community, healthcare facility, and policy-level factors and treatment adherence in Africa have not been well-described. The authors examined these factors in the context of prevention of mother-to-child transmission (PMTCT) of HIV in rural north-central Nigeria, where HIV burden is high and service coverage is low.

METHODS

Eleven focus groups (n = 105) were conducted among PMTCT clients, male partners, young women, and other community members from 39 rural and semi-rural communities to explore factors related to HIV and antenatal care service use. Data were analyzed using the Constant Comparative Method.

RESULTS

Irrespective of HIV status, participants reported barriers to access including long clinic wait times, transportation availability and cost, and the lack of HIV treatment medications. For HIV-positive women, stigma from family members, providers, and the local community affected their ability to obtain care and remain ART-adherent. In the face of these barriers, these women reflected on the importance of peer and community support, as well as the passage of laws to combat barriers to treatment access, uptake, and adherence.

CONCLUSIONS

Facilitating treatment adherence may require not only focusing on the medical treatment needs of these women but also structural issues, such as the availability of providers and drugs, and systemic stigmatization of HIV-positive patients.

Improving Retention in Care Among Pregnant Women and Mothers Living With HIV: Lessons From INSPIRE and Implications for Future WHO Guidance and Monitoring

Identifying women living with HIV, initiating them on lifelong antiretroviral treatment (ART), and retaining them in care are among the important challenges facing this generation of health care managers and public health researchers. Implementation research attempts to solve a wide range of implementation problems by trying to understand and work within real-world conditions to find solutions that have a measureable impact on the outcomes of interest. Implementation research is distinct from clinical research in many ways yet demands similar standards of conceptual thinking and discipline to generate robust evidence that can be, to some extent, generalized to inform policy and service delivery. In 2011, the World Health Organization (WHO), with funding from Global Affairs Canada, began support to 6 implementation research projects in Malawi, Nigeria, and Zimbabwe. All focused on evaluating approaches for improving rates of retention in care among pregnant women and mothers living with HIV and ensuring their continuation of ART. This reflected the priority given by ministries of health, program implementers, and researchers in each country to the importance of women living with HIV returning to health facilities for routine care, adherence to ART, and improved health outcomes. Five of the studies were cluster randomized controlled trials, and 1 adopted a matched cohort design. Here, we summarize some of the main findings and key lessons learned. We also consider some of the broader implications, remaining knowledge gaps, and how implementation research is integral to, and essential for, global guideline development and to inform HIV/AIDS strategies.

Correlates of facility delivery for rural HIV-positive pregnant women enrolled in the MoMent Nigeria prospective cohort study

BACKGROUND

Low rates of maternal healthcare service utilization, including facility delivery, may impede progress in the prevention of mother-to-child transmission of HIV (PMTCT) and in reducing maternal and infant mortality. The MoMent (Mother Mentor) study investigated the impact of structured peer support on early infant diagnosis presentation and postpartum maternal retention in PMTCT care in rural Nigeria. This paper describes baseline characteristics and correlates of facility delivery among MoMent study participants.

METHODS

HIV-positive pregnant women were recruited at 20 rural Primary Healthcare Centers matched by antenatal care clinic volume, client HIV prevalence, and PMTCT service staffing. Baseline and delivery data were collected by participant interviews and medical record abstraction. Multivariate logistic regression with generalized estimating equation analysis was used to evaluate for correlates of facility delivery including exposure to structured (closely supervised Mentor Mother, intervention) vs unstructured (routine, control) peer support.

RESULTS

Of 497 women enrolled, 352 (71%) were between 21 and 30 years old, 319 (64%) were Christian, 245 (49%) had received secondary or higher education, 402 (81%) were multigravidae and 299 (60%) newly HIV-diagnosed. Delivery data was available for 445 (90%) participants, and 276 (62%) of these women delivered at a health facility. Facility delivery did not differ by type of peer support; however, it was positively associated with secondary or greater education (aOR 1.9, CI 1.1-3.2) and Christian affiliation (OR 1.4, CI 1.0-2.0) and negatively associated with primigravidity (OR 0.5; 0.3-0.9) and new HIV diagnosis (OR 0.6, CI 0.4-0.9).

CONCLUSIONS

Primary-level or lesser-educated HIV-infected pregnant women and those newly-diagnosed and primigravid should be prioritized for interventions to improve facility delivery rates and ultimately, healthy outcomes. Incremental gains in facility delivery from structured peer support appear limited, however the impact of duration of pre-delivery support needs further investigation. Religious influences on facility delivery and on general maternal healthcare service utilization need to be further explored.

TRIAL REGISTRATION

ClinicalTrials.gov number NCT01936753 , registered September 2013.