1
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Rosen JG, Ndyanabo A, Nakawooya H, Galiwango RM, Ssekubugu R, Ssekasanvu J, Kim S, Rucinski KB, Nakigozi G, Nalugoda F, Kigozi G, Quinn TC, Chang LW, Kennedy CE, Reynolds SJ, Kagaayi J, Grabowski MK. Incidence of Health Facility Switching and Associations With HIV Viral Rebound Among Persons on Antiretroviral Therapy in Uganda: A Population-based Study. Clin Infect Dis 2024; 78:1591-1600. [PMID: 38114162 PMCID: PMC11175689 DOI: 10.1093/cid/ciad773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/02/2023] [Accepted: 12/14/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND A substantial proportion of persons on antiretroviral therapy (ART) considered lost to follow-up have actually transferred their human immunodeficiency virus (HIV) care to other facilities. However, the relationship between facility switching and virologic outcomes, including viral rebound, is poorly understood. METHODS We used data from 40 communities (2015-2020) in the Rakai Community Cohort Study to estimate incidence of facility switching and viral rebound. Persons aged 15-49 years with serologically confirmed HIV who self-reported ART use and contributed ≥1 follow-up visit were included. Facility switching and virologic outcomes were assessed between 2 consecutive study visits (ie, index and follow-up visits, interval of approximately 18 months). Those who reported different HIV treatment facilities between index and follow-up study visits were classified as having switched facilities. Virologic outcomes included viral rebound among individuals initially suppressed (<200 copies/mL). Multivariable Poisson regression was used to estimate associations between facility switching and viral rebound. RESULTS Overall, 2257 persons who self-reported ART use (median age, 35 years; 65% female, 92% initially suppressed) contributed 3335 visit-pairs and 5959 person-years to the analysis. Facility switching was common (4.8 per 100 person-years; 95% confidence interval [CI], 4.2-5.5) and most pronounced in persons aged <30 years and fishing community residents. Among persons suppressed at their index visit (n = 2076), incidence of viral rebound was more than twice as high in persons who switched facilities (adjusted incidence rate ratio = 2.27; 95% CI, 1.16-4.45). CONCLUSIONS Facility switching was common and associated with viral rebound among persons initially suppressed. Investments in more agile, person-centered models for mobile clients are needed to address system inefficiencies and bottlenecks that can disrupt HIV care continuity.
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Affiliation(s)
- Joseph G Rosen
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | | | | | - Seungwon Kim
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Katherine B Rucinski
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | - Thomas C Quinn
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Larry W Chang
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Caitlin E Kennedy
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Steven J Reynolds
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | - M Kate Grabowski
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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2
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Wilkinson L, Grimsrud A. Enabling effective differentiated service delivery transitions for people on antiretroviral treatment. AIDS 2024; 38:615-622. [PMID: 38170470 PMCID: PMC10942239 DOI: 10.1097/qad.0000000000003826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 12/11/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Lynne Wilkinson
- IAS –International AIDS Society
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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3
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Urrio RF, Lyatuu GW, Sando D, Mahande MJ, Philipo E, Naburi H, Lyaruu P, Kimonge A, Mayogu K, Simba B, Kibao AM, Msangi M, Zeebari Z, Biberfeld G, Ekström AM, Kilewo C, Kågesten AE. Long-term retention on antiretroviral treatment after enrolment in prevention of vertical HIV transmission services: a prospective cohort study in Dar es Salaam, Tanzania. J Int AIDS Soc 2024; 27:e26186. [PMID: 38332522 PMCID: PMC10853596 DOI: 10.1002/jia2.26186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 10/09/2023] [Indexed: 02/10/2024] Open
Abstract
INTRODUCTION To prevent vertical HIV transmission and ensure healthy mothers and children, pregnant women with HIV must remain on antiretroviral treatment (ART) for life. However, motivation to remain on ART may decline beyond the standard 2-year breastfeeding/postpartum period. We assessed attrition and retention in ART care among women with HIV up to 6 years since enrolment in vertical transmission prevention services in Dar es Salaam, Tanzania. METHODS A prospective cohort of 22,631 pregnant women with HIV were enrolled in vertical transmission prevention services between January 2015 and December 2017 in routine healthcare settings and followed-up to July 2021. Kaplan-Meier was used to estimate time to ART attrition (died, stopped ART or was lost to follow-up [no show ≥90 days since scheduled appointment]) and the proportion retained in care. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR) of ART attrition in relation to predictors. RESULTS Participants were followed-up to 6 years for a median of 3 years (IQR: 0.1-4). The overall ART attrition rate was 13.8 per 100 person-years (95% CI: 13.5-14.1), highest in the first year of enrolment at 27.1 (26.3-27.9), thereafter declined to 9.5 (8.9-10.1) in year 3 and 2.7 (2.1-3.5) in year 6. The proportion of women retained in care were 78%, 69%, 63%, 60%, 57% and 56% at 1, 2, 3, 4, 5 and 6 years, respectively. ART attrition was higher in young women aged <20 years (aHR 1.63, 95% CI: 1.38-1.92) as compared to 30-39 year-olds and women enrolled late in the third versus first trimester (aHR 1.29, 95% CI: 1.16-1.44). In contrast, attrition was lower in older women ≥40 years, women who initiated ART before versus during the index pregnancy and women attending higher-level health facilities. CONCLUSIONS ART attrition among women with HIV remains highest in the first year of enrolment in vertical transmission prevention services and declines markedly following a transition to chronic HIV care. Targeted interventions to improve ART continuity among women with HIV during and beyond prevention of vertical transmission are vital to ending paediatric HIV and keeping women and children alive and healthy.
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Affiliation(s)
- Roseline Faustine Urrio
- Management and Development for HealthDar es SalaamTanzania
- Department of Obstetrics and GynacologyMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Goodluck Willey Lyatuu
- Management and Development for HealthDar es SalaamTanzania
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - David Sando
- Management and Development for HealthDar es SalaamTanzania
| | | | | | - Helga Naburi
- Department of Pediatric and Child HealthMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Peter Lyaruu
- Management and Development for HealthDar es SalaamTanzania
| | - Amanda Kimonge
- Management and Development for HealthDar es SalaamTanzania
| | - Kasasi Mayogu
- Management and Development for HealthDar es SalaamTanzania
| | - Brenda Simba
- Management and Development for HealthDar es SalaamTanzania
| | | | | | - Zangin Zeebari
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - Gunnel Biberfeld
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - Anna Mia Ekström
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
- Department of Infectious Disease/VenhälsanSouth General HospitalStockholmSweden
| | - Charles Kilewo
- Department of Obstetrics and GynacologyMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Anna E. Kågesten
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
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Brittain K, Brown K, Phillips T, Zerbe A, Pellowski J, Remien RH, Mellins CA, Abrams EJ, Myer L. Why do Integrated Maternal HIV and Infant Healthcare Services work? A Secondary Analysis of a Randomised Controlled Trial in South Africa. AIDS Behav 2023; 27:3831-3843. [PMID: 37306847 PMCID: PMC10598190 DOI: 10.1007/s10461-023-04097-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2023] [Indexed: 06/13/2023]
Abstract
In a randomised trial, we found that integrated maternal HIV and infant health services through the end of breastfeeding were significantly associated with the primary outcome of engagement in HIV care and viral suppression at 12 months postpartum, compared to the standard of care. Here, we quantitatively explore potential psychosocial modifiers and mediators of this association. Our findings suggest that the intervention was significantly more effective among women experiencing an unintended pregnancy but did not improve outcomes among women reporting risky alcohol use. Although not statistically significant, our results suggest that the intervention may also be more effective among women experiencing higher levels of poverty and HIV-related stigma. We observed no definitive mediator of the intervention effect, but women allocated to integrated services reported better relationships with their healthcare providers through 12 months postpartum. These findings point to high-risk groups that may benefit the most from integrated care, as well as groups for whom these benefits are hampered and that warrant further attention in intervention development and evaluation.
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Affiliation(s)
- Kirsty Brittain
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.
| | - Karryn Brown
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - Tamsin Phillips
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - Allison Zerbe
- Mailman School of Public Health, ICAP at Columbia University, Columbia University, New York, NY, USA
| | - Jennifer Pellowski
- Department of Behavioral & Social Sciences, Brown University School of Public Health, Providence, RI, USA
- International Health Institute, Brown University School of Public Health, Providence, RI, USA
| | - Robert H Remien
- New York State Psychiatric Institute, HIV Center for Clinical & Behavioral Studies, Columbia University, New York, NY, USA
| | - Claude A Mellins
- New York State Psychiatric Institute, HIV Center for Clinical & Behavioral Studies, Columbia University, New York, NY, USA
| | - Elaine J Abrams
- Mailman School of Public Health, ICAP at Columbia University, Columbia University, New York, NY, USA
- Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
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Ye J, Xiong S, Wang T, Li J, Cheng N, Tian M, Yang Y. The Roles of Electronic Health Records for Clinical Trials in Low- and Middle-Income Countries: Scoping Review. JMIR Med Inform 2023; 11:e47052. [PMID: 37991820 DOI: 10.2196/47052] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 09/10/2023] [Accepted: 09/22/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Clinical trials are a crucial element in advancing medical knowledge and developing new treatments by establishing the evidence base for safety and therapeutic efficacy. However, the success of these trials depends on various factors, including trial design, project planning, research staff training, and adequate sample size. It is also crucial to recruit participants efficiently and retain them throughout the trial to ensure timely completion. OBJECTIVE There is an increasing interest in using electronic health records (EHRs)-a widely adopted tool in clinical practice-for clinical trials. This scoping review aims to understand the use of EHR in supporting the conduct of clinical trials in low- and middle-income countries (LMICs) and to identify its strengths and limitations. METHODS A comprehensive search was performed using 5 databases: MEDLINE, Embase, Scopus, Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature. We followed the latest version of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guideline to conduct this review. We included clinical trials that used EHR at any step, conducted a narrative synthesis of the included studies, and mapped the roles of EHRs into the life cycle of a clinical trial. RESULTS A total of 30 studies met the inclusion criteria: 13 were randomized controlled trials, 3 were cluster randomized controlled trials, 12 were quasi-experimental studies, and 2 were feasibility pilot studies. Most of the studies addressed infectious diseases (15/30, 50%), with 80% (12/15) of them about HIV or AIDS and another 40% (12/30) focused on noncommunicable diseases. Our synthesis divided the roles of EHRs into 7 major categories: participant identification and recruitment (12/30, 40%), baseline information collection (6/30, 20%), intervention (8/30, 27%), fidelity assessment (2/30, 7%), primary outcome assessment (24/30, 80%), nonprimary outcome assessment (13/30, 43%), and extended follow-up (2/30, 7%). None of the studies used EHR for participant consent and randomization. CONCLUSIONS Despite the enormous potential of EHRs to increase the effectiveness and efficiency of conducting clinical trials in LMICs, challenges remain. Continued exploration of the appropriate uses of EHRs by navigating their strengths and limitations to ensure fitness for use is necessary to better understand the most optimal uses of EHRs for conducting clinical trials in LMICs.
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Affiliation(s)
- Jiancheng Ye
- Weill Cornell Medicine, New York, NY, United States
- Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Shangzhi Xiong
- The George Institute for Global Health, Faulty of Medicine and Health, University of New South Wales, Sydney, Australia
- Global Health Research Centre, Duke Kunshan University, Kunshan, China
| | - Tengyi Wang
- School of Public Health, Harbin Medical University, Harbin, China
| | - Jingyi Li
- School of Basic Medicine, Harbin Medical University, Harbin, China
| | - Nan Cheng
- The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Maoyi Tian
- The George Institute for Global Health, Faulty of Medicine and Health, University of New South Wales, Sydney, Australia
- School of Public Health, Harbin Medical University, Harbin, China
| | - Yang Yang
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Brittain K, Zerbe A, Phillips TK, Gomba Y, Mellins CA, Myer L, Abrams EJ. Impact of adverse childhood experiences on women's psychosocial and HIV-related outcomes and early child development in their offspring. Glob Public Health 2022; 17:2779-2791. [PMID: 34613893 PMCID: PMC8983791 DOI: 10.1080/17441692.2021.1986735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 09/04/2021] [Indexed: 12/15/2022]
Abstract
Adverse childhood experiences (ACEs) may have a critical influence on adult outcomes and subsequent offspring development, but few data have explored the effects of ACEs in low-resource settings where the burdens of childhood adversity and HIV are high. Among mothers living with HIV in Cape Town, we examined the effects of ACEs on maternal psychosocial and HIV-related outcomes, as well as early child development in their offspring aged 36-60 months. The World Health Organization's Adverse Childhood Experiences International Questionnaire was used to measure maternal reports of ACEs, and the Ages & Stages Questionnaire to screen for developmental delays in their offspring. Among 353 women (median age: 32 years), 84% reported ≥1 ACEs. Increased report of ACEs was strongly associated with depressive symptoms, hazardous alcohol use, intimate partner violence and self-reported suboptimal adherence to antiretroviral therapy. These associations were driven by more severe childhood experiences, including abuse, neglect and exposure to collective violence. Among 255 women who reported on their child's development, maternal ACEs were associated with poorer socioemotional development. These data suggest that childhood adversity has long-term effects on maternal outcomes as well as their children's socioemotional development and point to ACEs that might be targeted for screening and intervention.
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Affiliation(s)
- Kirsty Brittain
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Allison Zerbe
- ICAP at Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Tamsin K. Phillips
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Yolanda Gomba
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Claude A. Mellins
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elaine J. Abrams
- ICAP at Columbia University, Mailman School of Public Health, New York, NY, USA
- Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
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Gawler N, Reynolds SJ, Hsiao NY, Clarke W, Maartens G, Abrams EJ, Myer L, Redd AD, Phillips TK. Routine Antiretroviral Pharmacy Refill Information Can Predict Failure Postpartum in Previously Suppressed South African Women With HIV. Open Forum Infect Dis 2022; 9:ofac483. [PMID: 36275867 PMCID: PMC9578152 DOI: 10.1093/ofid/ofac483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/14/2022] [Indexed: 11/14/2022] Open
Abstract
Background Detection of antiretrovirals (ARVs) in biological specimens is a reliable, objective way to measure adherence. However, routine ARV testing is not feasible in many high-burden settings. This study explored if pharmacy data could accurately predict HIV viremia postpartum in previously virally suppressed women. Methods South African women with HIV who initiated antiretroviral therapy (ART) during pregnancy and achieved viral suppression (VS; viral load [VL]≤50 copies/mL) were followed postpartum; during follow-up, plasma VL was measured and ARV adherence self-reported. A portion of samples were tested for the presence of ARV using mass spectrometry. Patient-level routine pharmacy data were used to classify if women should have the drug in hand for the past 7 days before the visit date. Logistic regressions were used to calculate associations between adherence and viral nonsuppression (VNS; VL > 50) or failure (VF; VL > 1000) at the first study visit of women who had ARV measured. Data for all women were examined for associations of self-reported adherence and drug in hand with VS and VF at 2, 6, and 12 months postpartum. Results Women with no ARV detected were significantly more likely to have VNS (odds ratio [OR], 26.4). Having no drug in hand for 7 days was also predictive of VNS in these same women (OR, 7.0) and the full cohort (n = 572) at 3 (OR, 2.9), 6 (OR, 8.7), and 12 months (OR, 14.5). Similar results were seen for VF. Conclusions These data show that routine pharmacy data can act as a highly predictive mechanism for identifying patients at risk of VNS and VF due to nonadherence.
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Affiliation(s)
- Nicola Gawler
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Steven J Reynolds
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Intramural Research, NIAID, NIH, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Nei-Yuan Hsiao
- Division of Medical Virology, University of Cape Town and National Health Laboratory Service, Cape Town, South Africa
| | - William Clarke
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Elaine J Abrams
- ICAP at Columbia University, Mailman School of Public Health, and Department of Paediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Andrew D Redd
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Intramural Research, NIAID, NIH, Baltimore, Maryland, USA
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Tamsin K Phillips
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
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8
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van der Hoven J, Allen E, Cois A, de Waal R, Maartens G, Myer L, Malaba T, Madlala H, Nyemba D, Phelanyane F, Boulle A, Mehta U, Kalk E. Determining antenatal medicine exposures in South African women: a comparison of three methods of ascertainment. BMC Pregnancy Childbirth 2022; 22:466. [PMID: 35658841 PMCID: PMC9164333 DOI: 10.1186/s12884-022-04765-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/17/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In the absence of clinical trials, data on the safety of medicine exposures in pregnancy are dependent on observational studies conducted after the agent has been licensed for use. This requires an accurate history of antenatal medicine use to determine potential risks. Medication use is commonly determined by self-report, clinician records, and electronic pharmacy data; different data sources may be more informative for different types of medication and resources may differ by setting. We compared three methods to determine antenatal medicine use (self-report, clinician records and electronic pharmacy dispensing records [EDR]) in women attending antenatal care at a primary care facility in Cape Town, South Africa in a setting with high HIV prevalence. METHODS Structured, interview-administered questionnaires recorded self-reported medicine use. Data were collected from clinician records and EDR on the same participants. We determined agreement between these data sources using Cohen's kappa and, lacking a gold standard, used Latent Class Analysis to estimate sensitivity, specificity and positive predictive value (PPV) for each data source. RESULTS Between 55% and 89% of 967 women had any medicine use documented depending on the data source (median number of medicines/participant = 5 [IQR 3-6]). Agreement between the datasets was poor regardless of class except for antiretroviral therapy (ART; kappa 0.6-0.71). Overall, agreement was better between the EDR and self-report than with either dataset and the clinician records. Sensitivity and PPV were higher for self-report and the EDR and were similar for the two. Self-report was the best source for over-the-counter, traditional and complementary medicines; clinician records for vaccines and supplements; and EDR for chronic medicines. CONCLUSIONS Medicine use in pregnancy was common and no single data source included all the medicines used. ART was the most consistently reported across all three datasets but otherwise agreement between them was poor and dependent on class. Using a single data collection method will under-estimate medicine use in pregnancy and the choice of data source should be guided by the class of the agents being investigated.
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Affiliation(s)
- Jani van der Hoven
- grid.7836.a0000 0004 1937 1151Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Elizabeth Allen
- grid.7836.a0000 0004 1937 1151Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Annibale Cois
- grid.11956.3a0000 0001 2214 904XDivision of Health Systems and Public Health, Department of Global Health, Stellenbosch University, Tygerberg, South Africa ,grid.7836.a0000 0004 1937 1151Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Renee de Waal
- grid.7836.a0000 0004 1937 1151Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- grid.7836.a0000 0004 1937 1151Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- grid.7836.a0000 0004 1937 1151Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Thokozile Malaba
- grid.7836.a0000 0004 1937 1151Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Hlengiwe Madlala
- grid.7836.a0000 0004 1937 1151Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Dorothy Nyemba
- grid.7836.a0000 0004 1937 1151Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Florence Phelanyane
- grid.7836.a0000 0004 1937 1151Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa ,Provincial Health Data Centre, HealthIntelligence, Western Cape Government Health, Cape Town, South Africa
| | - Andrew Boulle
- grid.7836.a0000 0004 1937 1151Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa ,Provincial Health Data Centre, HealthIntelligence, Western Cape Government Health, Cape Town, South Africa
| | - Ushma Mehta
- grid.7836.a0000 0004 1937 1151Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Emma Kalk
- grid.7836.a0000 0004 1937 1151Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
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9
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Davey DJ. Long-term use of ART in African women of reproductive age. THE LANCET HIV 2022; 9:e369-e370. [DOI: 10.1016/s2352-3018(22)00061-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 10/18/2022]
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10
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Brittain K, Teasdale CA, Ngeno B, Odondi J, Ochanda B, Brown K, Langat A, Modi S, Abrams EJ. Improving retention in antenatal and postnatal care: a systematic review of evidence to inform strategies for adolescents and young women living with HIV. J Int AIDS Soc 2021; 24:e25770. [PMID: 34449121 PMCID: PMC8395389 DOI: 10.1002/jia2.25770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/17/2021] [Accepted: 06/01/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Kirsty Brittain
- Division of Epidemiology & BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Chloe A Teasdale
- Mailman School of Public HealthICAP‐Columbia UniversityNew YorkNYUSA
- Department of EpidemiologyMailman School of Public HealthNew YorkNYUSA
- Department of Epidemiology and BiostatisticsCUNY Graduate School of Public Health & Health PolicyNew YorkNYUSA
| | - Bernadette Ngeno
- Division of Global HIV and Tuberculosis (DGHT)US Centers for Disease Control and PreventionAtlantaGAUSA
| | - Judith Odondi
- Mailman School of Public HealthICAP‐Columbia UniversityNew YorkNYUSA
| | - Boniface Ochanda
- Division of Global HIV and Tuberculosis (DGHT)US Centers for Disease Control and PreventionNairobiKenya
| | - Karryn Brown
- Division of Epidemiology & BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Agnes Langat
- Division of Global HIV and Tuberculosis (DGHT)US Centers for Disease Control and PreventionNairobiKenya
| | - Surbhi Modi
- Division of Global HIV and Tuberculosis (DGHT)US Centers for Disease Control and PreventionAtlantaGAUSA
| | - Elaine J Abrams
- Mailman School of Public HealthICAP‐Columbia UniversityNew YorkNYUSA
- Department of EpidemiologyMailman School of Public HealthNew YorkNYUSA
- Department of PediatricsVagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
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Early post-partum viremia predicts long-term non-suppression of viral load in HIV-positive women on ART in Malawi: Implications for the elimination of infant transmission. PLoS One 2021; 16:e0248559. [PMID: 33711066 PMCID: PMC7954347 DOI: 10.1371/journal.pone.0248559] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/01/2021] [Indexed: 12/03/2022] Open
Abstract
Background Long-term viral load (VL) suppression among HIV-positive, reproductive-aged women on ART is key to eliminating mother-to-child transmission (MTCT) but few data exist from sub-Saharan Africa. We report trends in post-partum VL in Malawian women on ART and factors associated with detectable VL up to 24 months post-partum. Methods 1–6 months post-partum mothers, screened HIV-positive at outpatient clinics in Malawi, were enrolled (2014–2016) with their infants. At enrollment, 12- and 24-months post-partum socio-demographic and PMTCT indicators were collected. Venous samples were collected for determination of maternal VL (limit of detection 40 copies/ml). Results were returned to clinics for routine management. Results 596/1281 (46.5%) women were retained in the study to 24 months. Those retained were older (p<0.01), had higher parity (p = 0.03) and more likely to have undetectable VL at enrollment than those lost to follow-up (80.0% vs 70.2%, p<0.01). Of 590 women on ART (median 30.1 months; inter-quartile range 26.8–61.3), 442 (74.9%) with complete VL data at 3 visits were included in further analysis. Prevalence of detectable VL at 12 and 24 months was higher among women with detectable VL at enrollment than among those with undetectable VL (74 detectable VL results/66 women vs. 19/359; p<0.001). In multivariable analysis (adjusted for age, parity, education, partner disclosure, timing of ART start and self-reported adherence), detectable VL at 24 months was 9 times more likely among women with 1 prior detectable VL (aOR 9.0; 95%CI 3.5–23.0, p<0.001) and 226 times more likely for women with 2 prior detectable VLs (aOR 226.4; 95%CI 73.0–701.8, p<0.001). Conclusions Detectable virus early post-partum strongly increases risk of ongoing post-partum viremia. Due to high loss to follow-up, the true incidence of detectable VL over time is probably underestimated. These findings have implications for MTCT, as well as for the mothers, and call for intensified VL monitoring and targeted adherence support for women during pregnancy and post-partum.
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Phillips TK, Teasdale CA, Geller A, Ng'eno B, Mogoba P, Modi S, Abrams EJ. Approaches to transitioning women into and out of prevention of mother-to-child transmission of HIV services for continued ART: a systematic review. J Int AIDS Soc 2021; 24:e25633. [PMID: 33372730 PMCID: PMC7771153 DOI: 10.1002/jia2.25633] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 09/22/2020] [Accepted: 10/08/2020] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Women living with HIV are required to transition into the prevention of mother-to-child transmission of HIV (PMTCT) services when they become pregnant and back to ART services after delivery. Transition can be a vulnerable time when many women are lost from HIV care yet there is little guidance on the optimal transition approaches to ensure continuity of care. We reviewed the available evidence on existing approaches to transitioning women into and out of PMTCT, outcomes following transition and factors influencing successful transition. METHODS We searched PubMed and SCOPUS, as well as abstracts from international HIV-focused meetings, from January 2006 to July 2020. Studies were included that examined three points of transition: pregnant women already on ART into PMTCT (transition 1), pregnant women living with HIV not yet on ART into treatment services (transition 2) and postpartum women from PMTCT into general ART services after delivery (transition 3). Results were grouped and reported as descriptions of transition approach, comparison of outcomes following transition and factors influencing successful transition. RESULTS & DISCUSSION Out of 1809 abstracts located, 36 studies (39 papers) were included in this review. Three studies included transition 1, 26 transition 2 and 17 transition 3. Approaches to transition were described in 26 studies and could be grouped into the provision of information at the point of transition (n = 8), strengthened communication or linkage of data between services (n = 4), use of transition navigators (n = 12), and combination approaches (n = 4). Few studies were designed to directly assess transition and only nine compared outcomes between transition approaches, with substantial heterogeneity in study design, setting and outcomes. Four themes were identified in 25 studies reporting on factors influencing successful transition: fear, knowledge and preparedness, clinic characteristics and the transition requirements and process. CONCLUSIONS This review highlights that, despite the need for women to transition into and out of PMTCT services for continued ART in many settings, there is very limited evidence on optimal transition approaches. Ongoing operational research is required to identify sustainable and acceptable transition approaches and service delivery models that support continuity of HIV care during and after pregnancy.
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Affiliation(s)
- Tamsin K Phillips
- Division of Epidemiology and BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
- Centre for Infectious Diseases Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Chloe A Teasdale
- ICAP‐Columbia UniversityMailman School of Public HealthNew YorkNYUSA
- Department of EpidemiologyMailman School of Public HealthNew YorkNYUSA
- Department of Epidemiology and BiostatisticsCUNY Graduate School of Public Health & Health PolicyNew YorkNYUSA
| | - Amanda Geller
- US Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | | | - Pheposadi Mogoba
- Centre for Infectious Diseases Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Surbhi Modi
- US Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | - Elaine J Abrams
- ICAP‐Columbia UniversityMailman School of Public HealthNew YorkNYUSA
- Department of EpidemiologyMailman School of Public HealthNew YorkNYUSA
- College Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
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Hassan F, Renju J, Songo J, Chimukuche RS, Kalua T, McLean E, Luwanda L, Geubbels E, Seeley J, Moshabela M, Kajoka D, Wringe A. Implementation and experiences of integrated prevention of mother-to-child transmission services in Tanzania, Malawi and South Africa: A mixed methods study. Glob Public Health 2020; 16:201-215. [PMID: 33119433 PMCID: PMC7612851 DOI: 10.1080/17441692.2020.1839927] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although integration of HIV and maternal health services is recommended by the World Health Organization, evidence to guide implementation is limited. We describe facility-level implementation of policies for integrating HIV care within maternal health services and explore experiences of service users and providers in rural Tanzania (Ifakara), South Africa (uMkhanyakude) and Malawi (Karonga). Policy in all countries included HIV testing during antenatal care (ANC), same-day antiretroviral therapy (ART) initiation for HIV-positive pregnant women, and postpartum referral to ART clinics, between six weeks (Malawi, South Africa) and two years after delivery (Tanzania). All facilities offered HIV testing within ANC, most commonly during the first visit. Although most women were comfortable with HIV testing, some felt that opting out would lead to sub-standard services. Some facilities conducted group post-test counselling for HIV-negative women, raising concerns of unintended HIV status disclosure. ART initiation was offered on the same day, the same room as an HIV diagnosis in >90% of facilities. Women’s worries around postpartum referral included having unknown providers, insufficient privacy and queues. Adoption and implementation of policies on integrated HIV and maternal health services varied across settings. Patients’ experiences of these policies may influence uptake and retention in care.
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Affiliation(s)
- Farida Hassan
- Health System, Impact Evaluation and Policy, Ifakara Health Institute, United Republic of Tanzania
| | - Jenny Renju
- Department of population studies, London School of Hygiene and Tropical Medicine, London, UK.,Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - John Songo
- Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
| | | | | | - Estelle McLean
- Department of population studies, London School of Hygiene and Tropical Medicine, London, UK.,Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
| | - Lameck Luwanda
- Health System, Impact Evaluation and Policy, Ifakara Health Institute, United Republic of Tanzania
| | - Eveline Geubbels
- Health System, Impact Evaluation and Policy, Ifakara Health Institute, United Republic of Tanzania
| | - Janet Seeley
- Department of population studies, London School of Hygiene and Tropical Medicine, London, UK.,Africa Health Research Institute, Durban, South Africa
| | - Mosa Moshabela
- Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Deborah Kajoka
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Alison Wringe
- Department of population studies, London School of Hygiene and Tropical Medicine, London, UK
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Redd AD, Mukonda E, Hu NC, Philips TK, Zerbe A, Lesosky M, Hsiao NY, Clarke W, Reynolds SJ, Abrams EJ, Myer L. ART Adherence, Resistance, and Long-term HIV Viral Suppression in Postpartum Women. Open Forum Infect Dis 2020; 7:ofaa346. [PMID: 33072803 DOI: 10.1093/ofid/ofaa346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 08/10/2020] [Indexed: 02/05/2023] Open
Abstract
HIV+ South African women who achieved viral suppression during routine antenatal care, but later experienced a viremic episode (viral load >1000 copies/mL), were examined for presence of antiretrovirals and classified as "nonadherers" or "suboptimal adherers." Women were tested for drug resistance mutations (DRMs) at several time points and underwent viral load testing 36-60 months postpartum. Suboptimal adherers were more likely to have DRM detected during their viremic episode (P = .03) and at a subsequent viremic time point (P = .05). There was no difference in levels of viral suppression 36-60 months later in women with DRM detected vs women who had no evidence of DRM (P = .5).
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Affiliation(s)
- Andrew D Redd
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, Maryland, USA.,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Elton Mukonda
- Division of Epidemiology and Biostatistics, University of Cape Town, Cape Town, South Africa
| | - Nai-Chung Hu
- Division of Epidemiology and Biostatistics, University of Cape Town, Cape Town, South Africa
| | - Tamsin K Philips
- Division of Epidemiology and Biostatistics, University of Cape Town, Cape Town, South Africa
| | - Allison Zerbe
- ICAP at Columbia University Mailman School of Public Health, New York, New York, USA
| | - Maia Lesosky
- Division of Epidemiology and Biostatistics, University of Cape Town, Cape Town, South Africa
| | - Nei-Yuan Hsiao
- Division of Medical Virology, Department of Pathology, University of Cape Town, Cape Town, South Africa.,National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa
| | - William Clarke
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Steven J Reynolds
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, Maryland, USA.,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Rakai Health Sciences Program, Kalisizo, Uganda
| | - Elaine J Abrams
- ICAP at Columbia University Mailman School of Public Health, New York, New York, USA.,Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Diseases Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Chi BH, Mbori‐Ngacha D, Essajee S, Mofenson LM, Tsiouris F, Mahy M, Luo C. Accelerating progress towards the elimination of mother-to-child transmission of HIV: a narrative review. J Int AIDS Soc 2020; 23:e25571. [PMID: 32820609 PMCID: PMC7440973 DOI: 10.1002/jia2.25571] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/28/2020] [Accepted: 06/08/2020] [Indexed: 01/16/2023] Open
Abstract
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.
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Affiliation(s)
- Benjamin H Chi
- University of North Carolina at Chapel HillChapel HillNCUSA
| | | | | | | | | | - Mary Mahy
- Joint United Nations Programme on HIV/AIDS (UNAIDS)GenevaSwitzerland
| | - Chewe Luo
- United Nations Children’s Fund (UNICEF)New YorkNYUSA
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