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Naanyu V, Koros H, Goodrich S, Siika A, Toroitich-Ruto C, Bateganya M, Wools-Kaloustian K. Post-intervention perceptions on the antiretroviral therapy community group model in Trans Nzoia County, Kenya. Pan Afr Med J 2024; 47:113. [PMID: 38828427 PMCID: PMC11143075 DOI: 10.11604/pamj.2024.47.113.41843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/19/2024] [Indexed: 06/05/2024] Open
Abstract
Introduction the increasing number of people receiving antiretroviral therapy (ART) in sub-Saharan Africa has stressed already overburdened health systems. A care model utilizing community-based peer-groups (ART Co-ops) facilitated by community health workers (CHW) was implemented (2016-2018) to address these challenges. In 2018, a post-intervention study assessed perceptions of the intervention. Methods forty participants were engaged in focus group discussions consisting of ART Co-op clients, study staff, and health care providers from Kitale HIV clinic. Data were analyzed thematically for content on the intervention, challenges, and recommendations for improvement. Results all participants liked the intervention. However, some reported traveling long distances to attend ART Co-op meetings and experiencing stigma with ART Co-ops participation. The ART Co-op inclusion criteria were considered appropriate; however, additional outreach to deliberately include spouses living with HIV, the disabled, the poor, and HIV pregnant women was recommended. Participants liked CHW-directed quarterly group meetings which included ART distribution, adherence review, and illness identification. The inability of the CHW to provide full clinical care, inconvenient meeting venues, poor timekeeping, and non-attendance behaviors were noted as issues. Participants indicated that program continuation, regular CHW training, rotating meetings at group members´ homes, training ART Co-ops leaders to assume CHW tasks, use of pill diaries to check adherence, nutritional support, and economically empowering members through income generation projects would be beneficial. Conclusion the intervention was viewed positively by both clinic staff and clients. They identified specific challenges and generated actionable key considerations to improve access and acceptability of the community-based model of care.
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Affiliation(s)
- Violet Naanyu
- Department of Sociology Psychology and Anthropology, School of Arts and Social Sciences, Moi University, Eldoret, Kenya
- AMPATH Qualitative Research Core, Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Hillary Koros
- AMPATH Qualitative Research Core, Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Suzanne Goodrich
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Abraham Siika
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Cathy Toroitich-Ruto
- Division of Global HIV and TB (DGHT), Centers for Global Health (CGH), US Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | | | - Kara Wools-Kaloustian
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
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2
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Larson BA, Tsikhutsu I, Bii M, Halim N, Agaba P, Sugut W, Muli J, Sawe F. The effects of revised peer-counselor support on the PMTCT cascade of care: results from a cluster-randomized trial in Kenya (the EMMA study). BMC Infect Dis 2023; 23:257. [PMID: 37098468 PMCID: PMC10127503 DOI: 10.1186/s12879-023-08246-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/12/2023] [Indexed: 04/27/2023] Open
Abstract
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.
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Affiliation(s)
- Bruce A Larson
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02118, USA.
| | - Isaac Tsikhutsu
- Kenya Medical Research Institute, Kericho, Kenya/U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- HJF Medical Research International, Kericho, Kenya
| | - Margaret Bii
- Kenya Medical Research Institute, Kericho, Kenya/U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- HJF Medical Research International, Kericho, Kenya
| | - Nafisa Halim
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02118, USA
| | - Patricia Agaba
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - William Sugut
- Kenya Medical Research Institute, Kericho, Kenya/U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- HJF Medical Research International, Kericho, Kenya
| | - Jane Muli
- Kenya Medical Research Institute, Kericho, Kenya/U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- HJF Medical Research International, Kericho, Kenya
| | - Fredrick Sawe
- Kenya Medical Research Institute, Kericho, Kenya/U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- HJF Medical Research International, Kericho, Kenya
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3
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Wang Y, Ramos-Gomez F, Kemoli A, John-Stewart G, Wamalwa D, Benki-Nugent S, Slyker J, Seminario A. Oral Diseases and Oral Health-Related Quality of Life among Kenyan Children and Adolescents with HIV. JDR Clin Trans Res 2023; 8:168-177. [PMID: 35354307 PMCID: PMC10026160 DOI: 10.1177/23800844221087951] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Children and adolescents living with HIV (CALHIV) have a higher risk of hard and soft oral tissue diseases as compared with their healthy peers. It is important to increase awareness regarding the need to integrate oral health within medical care among pediatric HIV populations. Studies on associations of oral diseases with oral health-related quality of life (OHRQoL) in CALHIV are lacking. This study examined the association between oral diseases and OHRQoL in Kenyan CALHIV. METHODS This cross-sectional analysis was nested in a longitudinal cohort study of CALHIV in Nairobi. CALHIV received oral examinations, and the World Health Organization's Oral Health Surveys and Record Form was administered. OHRQoL was measured with the Parental-Caregiver Perceptions Questionnaire, with the subdomains of global, oral symptoms, function limitations, and emotional and social well-being, with higher scores indicating poorer OHRQoL. Linear regression was used to model associations between OHRQoL and oral diseases, adjusting for age at the time of oral examination, CD4 counts, and caregiver's education. RESULTS Among 71 CALHIV, the mean age was 12.6 y (SD, 2.9; range, 10 to <21), and the mean composite OHRQoL score was 12.6 (SD, 11.2). Ulcers (not herpes simplex virus or aphthous) were associated with the worst overall OHRQoL (mean, 21.8; SD, 11.1; P = 0.055) and oral symptoms subdomain (mean, 7.0, SD, 2.5; P = 0.003). Children with dry mouth and untreated caries had significantly higher mean global OHRQoL scores than those without disease (P < 0.0001). In the multivariate analysis, the OHRQoL composite score was 6.3 units (95% CI, -0.3 to 12.9) higher for those who had dry mouth and untreated dental caries; dry mouth accounted for the highest percentage of variability of OHRQoL (9.6%) and the global subdomain (31.9%). Ulcers accounted for the highest percentage of variability of the oral symptoms domain (15.4%). CONCLUSIONS Oral ulcers, dry mouth, and untreated caries were associated with poorer OHRQoL in CALHIV. Integrating oral health into the primary care of CALHIV may improve their OHRQoL. KNOWLEDGE TRANSFER STATEMENT This study aimed to determine the association of oral diseases with the oral health-related quality of life of children and adolescents living with HIV (CALHIV). The findings will form part of the evidence to incorporate oral health protocols into care programs for CALHIV. Oral health monitoring has the potential to increase the surveillance of HIV clinical status, monitor the effectiveness of antiretroviral therapy, and improve the oral health-related quality of life of CALHIV.
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Affiliation(s)
- Y. Wang
- Division of Infectious Diseases,
University of California Los Angeles, Los Angeles, CA, USA
| | - F. Ramos-Gomez
- Division of Preventative and
Restorative Sciences, School of Dentistry, University of California Los Angeles, Los
Angeles, CA, USA
| | - A.M. Kemoli
- Department of Paediatric Dentistry and
Orthodontics, University of Nairobi, Nairobi, Kenya
| | - G. John-Stewart
- Departments of Global Health, Medicine,
and Pediatrics, University of Washington, Seattle, WA, USA
| | - D. Wamalwa
- Department of Pediatrics and Child
Health, University of Nairobi, Nairobi, Kenya
| | - S. Benki-Nugent
- Department of Global Health, University
of Washington, Seattle, WA, USA
| | - J. Slyker
- Departments of Epidemiology and Global
Health, University of Washington, Seattle, WA, USA
| | - A.L. Seminario
- UW Timothy A. DeRouen Center for Global
Oral Health, School of Dentistry, University of Washington, Seattle, WA, USA
- Department of Pediatric Dentistry,
Universidad Peruana Cayetano Heredia, Lima, Peru
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Lippman SA, de Kadt J, Ratlhagana MJ, Agnew E, Gilmore H, Sumitani J, Grignon J, Gutin SA, Shade SB, Gilvydis JM, Tumbo J, Barnhart S, Steward WT. Impact of short message service and peer navigation on linkage to care and antiretroviral therapy initiation in South Africa. AIDS 2023; 37:647-657. [PMID: 36468499 PMCID: PMC9994809 DOI: 10.1097/qad.0000000000003453] [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: 08/03/2022] [Revised: 11/18/2022] [Accepted: 11/25/2022] [Indexed: 12/07/2022]
Abstract
OBJECTIVE We examine the efficacy of short message service (SMS) and SMS with peer navigation (SMS + PN) in improving linkage to HIV care and initiation of antiretroviral therapy (ART). DESIGN I-Care was a cluster randomized trial conducted in primary care facilities in North West Province, South Africa. The primary study outcome was retention in HIV care; this analysis includes secondary outcomes: linkage to care and ART initiation. METHODS Eighteen primary care clinics were randomized to automated SMS ( n = 7), automated and tailored SMS + PN ( n = 7), or standard of care (SOC; n = 4). Recently HIV diagnosed adults ( n = 752) were recruited from October 2014 to April 2015. Those not previously linked to care ( n = 352) contributed data to this analysis. Data extracted from clinical records were used to assess the days that elapsed between diagnosis and linkage to care and ART initiation. Cox proportional hazards models and generalized estimating equations were employed to compare outcomes between trial arms, overall and stratified by sex and pregnancy status. RESULTS Overall, SMS ( n = 132) and SMS + PN ( n = 133) participants linked at 1.28 [95% confidence interval (CI): 1.01-1.61] and 1.60 (95% CI: 1.29-1.99) times the rate of SOC participants ( n = 87), respectively. SMS + PN significantly improved time to ART initiation among non-pregnant women (hazards ratio: 1.68; 95% CI: 1.25-2.25) and men (hazards ratio: 1.83; 95% CI: 1.03-3.26) as compared with SOC. CONCLUSION Results suggest SMS and peer navigation services significantly reduce time to linkage to HIV care in sub-Saharan Africa and that SMS + PN reduced time to ART initiation among men and non-pregnant women. Both should be considered candidates for integration into national programs. TRIAL REGISTRATION NCT02417233, registered 12 December 2014; closed to accrual 17 April 2015.
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Affiliation(s)
- Sheri A. Lippman
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Julia de Kadt
- International Training and Education Center for Health (I-TECH), Pretoria, Republic of South Africa
| | - Mary J. Ratlhagana
- International Training and Education Center for Health (I-TECH), Pretoria, Republic of South Africa
| | - Emily Agnew
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Hailey Gilmore
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jeri Sumitani
- International Training and Education Center for Health (I-TECH), Pretoria, Republic of South Africa
| | - Jessica Grignon
- International Training and Education Center for Health (I-TECH), Pretoria, Republic of South Africa
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Sarah A. Gutin
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Starley B. Shade
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer M. Gilvydis
- International Training and Education Center for Health (I-TECH), Pretoria, Republic of South Africa
| | - John Tumbo
- Department of Family Medicine and Primary Health Care, Sefako Makgatho Health Sciences University, Pretoria, Republic of South Africa
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Wayne T. Steward
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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Etoori D, Kabudula CW, Wringe A, Rice B, Renju J, Gomez-Olive FX, Reniers G. Investigating clinic transfers among HIV patients considered lost to follow-up to improve understanding of the HIV care cascade: Findings from a cohort study in rural north-eastern South Africa. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000296. [PMID: 36962304 PMCID: PMC10022370 DOI: 10.1371/journal.pgph.0000296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 05/02/2022] [Indexed: 11/18/2022]
Abstract
Investigating clinical transfers of HIV patients is important for accurate estimates of retention and informing interventions to support patients. We investigate transfers for adults reported as lost to follow-up (LTFU) from eight HIV care facilities in the Agincourt health and demographic surveillance system (HDSS), South Africa. Using linked clinic and HDSS records, outcomes of adults more than 90 days late for their last scheduled clinic visit were determined through clinic and routine tracing record reviews, HDSS data, and supplementary tracing. Factors associated with transferring to another clinic were determined through Cox regression models. Transfers were graphically and geospatially visualised. Transfers were more common for women, patients living further from the clinic, and patients with higher baseline CD4 cell counts. Transfers to clinics within the HDSS were more likely to be undocumented and were significantly more likely for women pregnant at ART initiation. Transfers outside the HDSS clustered around economic hubs. Patients transferring to health facilities within the HDSS may be shopping for better care, whereas those who transfer out of the HDSS may be migrating for work. Treatment programmes should facilitate transfer processes for patients, ensure continuity of care among those migrating, and improve tracking of undocumented transfers.
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Affiliation(s)
- David Etoori
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chodziwadziwa Whiteson Kabudula
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Alison Wringe
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Brian Rice
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jenny Renju
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Francesc Xavier Gomez-Olive
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Georges Reniers
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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Outcomes After Being Lost to Follow-up Differ for Pregnant and Postpartum Women When Compared With the General HIV Treatment Population in Rural South Africa. J Acquir Immune Defic Syndr 2021; 85:127-137. [PMID: 32520907 PMCID: PMC7495979 DOI: 10.1097/qai.0000000000002413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is Available in the Text. Undetermined attrition prohibits full understanding of the coverage and effectiveness of HIV programs. Outcomes following loss to follow-up (LTFU) among antiretroviral therapy (ART) patients may differ according to their reasons for ART initiation.
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Humphrey J, Alera M, Kipchumba B, Pfeiffer EJ, Songok J, Mwangi W, Musick B, Yiannoutsos C, Wachira J, Wools-Kaloustian K. A qualitative study of the barriers and enhancers to retention in care for pregnant and postpartum women living with HIV. PLOS GLOBAL PUBLIC HEALTH 2021; 1:e0000004. [PMID: 36962063 PMCID: PMC10021710 DOI: 10.1371/journal.pgph.0000004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/15/2021] [Indexed: 11/18/2022]
Abstract
Retention in care is a major challenge for pregnant and postpartum women living with HIV (PPHIV) in the prevention of mother-to-child HIV transmission (PMTCT) continuum. However, the factors influencing retention from the perspectives of women who have become lost to follow-up (LTFU) are not well described. We explored these factors within an enhanced sub-cohort of the East Africa International Epidemiology Databases to Evaluate AIDS Consortium. From 2018-2019, a purposeful sample of PPHIV ≥18 years of age were recruited from five maternal and child health clinics providing integrated PMTCT services in Kenya. Women retained in care were recruited at the facility; women who had become LTFU (last visit >90 days) were recruited through community tracking. Interview transcripts were analyzed thematically using a social-ecological framework. Forty-one PPHIV were interviewed. The median age was 27 years, 71% were pregnant, and 39% had become LTFU. In the individual domain, prior PMTCT experience and desires to safeguard infants' health enhanced retention but were offset by perceived lack of value in PMTCT services following infants' immunizations. In the peer/family domain, male-partner financial and motivational support enhanced retention. In the community/society domain, some women perceived social pressure to attend clinic while others perceived pressure to utilize traditional birth attendants. In the healthcare environment, long queues and negative provider attitudes were prominent barriers. HIV-related stigma and fear of disclosure crossed multiple domains, particularly for LTFU women, and were driven by perceptions of HIV as a fatal disease and fear of partner abandonment and abuse. Both retained and LTFU women perceived that integrated HIV services increased the risk of disclosure. Retention was influenced by multiple factors for PPHIV. Stigma and fear of disclosure were prominent barriers for LTFU women. Multicomponent interventions and refining the structure and efficiency of PMTCT services may enhance retention for PPHIV.
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Affiliation(s)
- John Humphrey
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Marsha Alera
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Bett Kipchumba
- Department of Reproductive Health, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Elizabeth J Pfeiffer
- Department of Anthropology, Rhode Island College, Providence, RI, United States of America
| | - Julia Songok
- Department of Child Health and Paediatrics, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Winfred Mwangi
- Department of Reproductive Health, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Beverly Musick
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Constantin Yiannoutsos
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Juddy Wachira
- Department of Behavioral Sciences, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Kara Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
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Zerbe A, Brittain K, Phillips TK, Iyun VO, Allerton J, Nofemela A, Kalombo CD, Myer L, Abrams EJ. Community-based adherence clubs for postpartum women on antiretroviral therapy (ART) in Cape Town, South Africa: a pilot study. BMC Health Serv Res 2020; 20:621. [PMID: 32641032 PMCID: PMC7341610 DOI: 10.1186/s12913-020-05470-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 06/25/2020] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND With an increasing number of countries implementing Option B+ guidelines of lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women, there is urgent need to identify effective approaches for retaining this growing and highly vulnerable population in ART care. METHODS Newly postpartum, breastfeeding women who initiated ART in pregnancy and met eligibility criteria were enrolled, and offered the choice of two options for postpartum ART care: (i) referral to existing network of community-based adherence clubs or (ii) referral to local primary health care clinic (PHC). Women were followed at study measurement visits conducted separately from either service. Primary outcome was a composite endpoint of retention in ART services and viral suppression [VS < 50 copies/mL based on viral load (VL) testing at measurement visits] at 12 months postpartum. Outcomes were compared across postpartum services using chi-square, Fisher's exact tests and Poisson regression models. The primary outcome was compared across services where women were receiving care at 12 months postpartum in exploratory analyses. RESULTS Between February and September 2015, 129 women (median age: 28.9 years; median time postpartum: 10 days) were enrolled with 65% opting to receive postpartum HIV care through an adherence club. Among 110 women retained at study measurement visits, 91 (83%) achieved the composite endpoint, with no difference between those who originally chose clubs versus those who chose PHC services. Movement from an adherence club to PHC services was common: 31% of women who originally chose clubs and were engaged in care at 12 months postpartum were attending a PHC service. Further, levels of VS differed significantly by where women were accessing ART care at 12 months postpartum, regardless of initial choice: 98% of women receiving care in an adherence club and 76% receiving care at PHC had VS < 50 copies/mL at 12 months postpartum (p = 0.001). CONCLUSION This study found comparable outcomes related to retention and VS at 12 months postpartum between women choosing adherence clubs and those choosing PHC. However, movement between postpartum services among those who originally chose adherence clubs was common, with poorer VS outcomes among women leaving clubs and returning to PHC services. TRIAL REGISTRATION ClinicalTrials.gov NCT02417675 , April 16, 2015 (retrospectively registered).
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Affiliation(s)
- Allison Zerbe
- ICAP, Mailman School of Public Health, Columbia University, 722 W. 168th street, 13th floor, New York, 10032 USA
| | - Kirsty Brittain
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Tamsin K. Phillips
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Victoria O. Iyun
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Joanna Allerton
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Andile Nofemela
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Cathy D. Kalombo
- Provincial Government of the Western Cape, Cape Town, South Africa
| | - Landon Myer
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elaine J. Abrams
- ICAP, Mailman School of Public Health, Columbia University, 722 W. 168th street, 13th floor, New York, 10032 USA
- Vagelos College of Physicians & Surgeons, Columbia University, New York, USA
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9
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Clouse K, Phillips TK, Camlin C, Noholoza S, Mogoba P, Naidoo J, Langford R, Weiss M, Seebregts CJ, Myer L. CareConekta: study protocol for a randomized controlled trial of a mobile health intervention to improve engagement in postpartum HIV care in South Africa. Trials 2020; 21:258. [PMID: 32164771 PMCID: PMC7068940 DOI: 10.1186/s13063-020-4190-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND South Africa is home to the world's largest antiretroviral therapy program but sustaining engagement along the HIV care continuum has proven challenging in the country and throughout the wider region. Population mobility is common in South Africa, but there are important research gaps in describing this mobility and its impact on engagement in HIV care. Postpartum women and their infants in South Africa are known to be at high risk of dropping out of HIV care after delivery and are frequently mobile. METHODS In 2017, we developed a beta version of a smartphone application (app) - CareConekta - that detects a user's smartphone location to allow for prospective characterization of mobility. Now we will adapt and test CareConekta to conduct essential formative work on mobility and evaluate an intervention - the CareConekta app plus text notifications and phone calls and/or WhatsApp messages - to facilitate engagement in HIV care during times of mobility. During the 3-year project period, our first objective is to evaluate the feasibility, acceptability, and initial efficacy of using CareConekta as an intervention to improve engagement in HIV care. Our second objective is to characterize mobility among South African women during the peripartum period and its impact on engagement in HIV care. We will enroll 200 eligible pregnant women living with HIV and receiving care at the Gugulethu Midwife Obstetric Unit in Cape Town, South Africa. DISCUSSION This work will provide critical information about mobility during the peripartum period and the impact on engagement in HIV care. Simultaneously, we will pilot test an intervention to improve engagement with rigorously assessed outcomes. If successful, CareConekta offers tremendous potential as a research and service tool that can be adapted and evaluated in multiple geographic regions, study contexts, and patient populations. TRIAL REGISTRATION ClinicalTrials.gov: NCT03836625. Registered on 8 February 2019.
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Affiliation(s)
- Kate Clouse
- Vanderbilt University School of Nursing, Nashville, TN USA
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN USA
| | - Tamsin K. Phillips
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Carol Camlin
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA USA
- Center for AIDS Prevention Studies, Division of Prevention Science, Department of Medicine, University of California, San Francisco, CA USA
| | - Sandisiwe Noholoza
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Phepo Mogoba
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | | | | | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Kyaw KWY, Mon AA, Phyo KH, Kyaw NTT, Kumar AMV, Lwin TT, Aung ZZ, Aung TK, Oo MM, Htun T, Ya SST, Satyanarayana S, Oo HN. Initiation of antiretroviral therapy or antiretroviral prophylaxis in pregnant women living with HIV registered in five townships of Mandalay, Myanmar: A cross sectional study. BMC Pregnancy Childbirth 2019; 19:475. [PMID: 31805892 PMCID: PMC6896496 DOI: 10.1186/s12884-019-2627-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 11/22/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND A series of interventions are required to prevent mother to child transmission (PMTCT) of Human Immunodeficiency Virus (HIV) starting from HIV testing of pregnant women, initiating antiretroviral therapy (ART) or antiretroviral prophylaxis to HIV-positive pregnant women to providing HIV prophylaxis to newborn babies. Gaps in each step can significantly affect the effectiveness of PMTCT interventions. We aimed to determine the gap in initiation of ART/antiretroviral prophylaxis for pregnant women living with HIV, delay in initiation of ART/antiretroviral prophylaxis and factors associated with the delay. METHODS This is a cross sectional study using routinely collected programme data from five health facilities providing PMTCT services located at Township Health Departments (THD) of Mandalay, Myanmar. RESULTS There were 363 pregnant women living with HIV enrolled between January 2012 and December 2017. Sixty (16%) women were excluded from the study due to missing data on dates of HIV diagnosis. Of 303 (84%) women included in the study, 89/303 (29%) and 214/303 (71%) were diagnosed with HIV before and during current pregnancy respectively. Among 214 women, 180 (84%) women were started on ART by the censor date (31st March 2018). Among those who started ART, 109 (61%) women had a delay of starting ART > 2 weeks from diagnosis. Women residing in township 4 had a significantly higher risk of delay in initiation of ART/antiretroviral prophylaxis compared to women residing in township 1 [adjusted prevalence ratio 4.2 (95% confidence interval 1.2-14.8]. CONCLUSIONS We found that one in four women living with HIV knew their HIV status before current pregnancy. Although the rate of ART/antiretroviral prophylaxis initiation was high among pregnant women living with HIV, there was a delay. Early initiation of ART/antiretroviral prophylaxis among newly HIV diagnosed pregnant women needs to be strengthened.
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Affiliation(s)
- Khine Wut Yee Kyaw
- Department of Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Mandalay, Myanmar
| | - Aye Aye Mon
- HIV unit, International Union Against Tuberculosis and Lung Disease (The Union), Mandalay, Myanmar
| | - Khaing Hnin Phyo
- HIV unit, International Union Against Tuberculosis and Lung Disease (The Union), Mandalay, Myanmar
| | - Nang Thu Thu Kyaw
- Department of Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Mandalay, Myanmar
- Center for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Ajay M. V. Kumar
- Center for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
- Yenepoya Medical College, Yenepoya (Deemed to be University), Mangaluru, India
| | - Than Than Lwin
- National AIDS Programme, Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Zaw Zaw Aung
- National AIDS Programme, Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Thet Ko Aung
- HIV unit, International Union Against Tuberculosis and Lung Disease (The Union), Mandalay, Myanmar
| | - Myo Minn Oo
- Department of Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Mandalay, Myanmar
| | - Thurain Htun
- Monitoring, Evaluation, Accountability and Learning Unit (HIV), International Union Against Tuberculosis and Lung Disease (The Union), Mandalay, Myanmar
| | - Sai Soe Thu Ya
- Monitoring, Evaluation, Accountability and Learning Unit (HIV), International Union Against Tuberculosis and Lung Disease (The Union), Mandalay, Myanmar
| | - Srinath Satyanarayana
- Center for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Htun Nyunt Oo
- National AIDS Programme, Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
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11
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Larson BA, Bii M, Tsikhutsu I, Halim N, Wolfman V, Coakley P, Sugut W, Sawe F. The Enhanced Mentor Mother ProgrAm (EMMA) for the prevention of mother-to-child transmission of HIV in Kenya: study protocol for a cluster randomized controlled trial. Trials 2018; 19:594. [PMID: 30376872 PMCID: PMC6208066 DOI: 10.1186/s13063-018-2975-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 10/10/2018] [Indexed: 11/19/2022] Open
Abstract
Background As of September 2014, Kenya implemented the WHO recommended Option B+ guidelines in which all newly diagnosed HIV-infected pregnant women are immediately eligible for triple antiretroviral therapy (ART) for life regardless of CD4 count. In addition, Kenya previously established the Kenya Mentor Mother Program (KMMP) in 2012 to improve peer education and psychosocial support services within the national prevention of mother-to-child transmission (PMTCT) program. The primary objectives of the study described in the current protocol are: (1) to evaluate implementation of these new guidelines (Option B+ with Mentor Mothers) as part of routine service delivery; and (2) to evaluate potential benefits of a package of services within the KMMP (called EMMA) to improve PMTCT service delivery. Methods We will conduct a cluster randomized controlled trial in western Kenya. We will allocate 12 clinics providing PMTCT services including ART to two study arms using pair matching: the standard of care (SOC) arm, which includes the KMMP as implemented by the clinics; and the intervention arm, which is the SOC (including KMMP) with the EMMA package of services (a targeted exit interview, visit reminders, and targeted follow-up). At the intervention clinics, the EMMA package of services is implemented as part of routine service delivery. A total of 360 (180 in each arm) pregnant women will be enrolled in the study at or near their first visit for antenatal care for prospective records review through 72 weeks post-partum. The primary and secondary outcomes are uninterrupted supplies of ART medications throughout the PMTCT cascade of care as well as infants completing HIV testing on schedule. Discussion The EMMA package of services provides specific structure to the use of Mentor Mothers within PMTCT programs. This strategy was developed in collaboration with local health facility and PMTCT program staff based on their experience providing PMTCT services within the integrated ART-MCH facilities. If successful, this approach has the potential to improve dramatically PMTCT service delivery with minor additional costs beyond the basic mother–mentor program and support global goals to eliminate mother-to-child transmission. Trial registration ClinicalTrials.gov, NCT02848235. Registered on 19 July 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2975-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bruce A Larson
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.
| | - Margaret Bii
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya.,HJF Medical Research International, Inc., Nairobi, Kenya
| | - Isaac Tsikhutsu
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya.,HJF Medical Research International, Inc., Nairobi, Kenya
| | - Nafisa Halim
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Vanessa Wolfman
- US Military HIV Research Program (MHRP), Henry Jackson Foundation, Bethesda, MD, USA
| | - Peter Coakley
- US Military HIV Research Program (MHRP), Henry Jackson Foundation, Bethesda, MD, USA
| | - William Sugut
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya.,HJF Medical Research International, Inc., Nairobi, Kenya
| | - Fredrick Sawe
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya.,HJF Medical Research International, Inc., Nairobi, Kenya
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Tan N, Sharma M, Winer R, Galloway D, Rees H, Barnabas RV. Model-estimated effectiveness of single dose 9-valent HPV vaccination for HIV-positive and HIV-negative females in South Africa. Vaccine 2018; 36:4830-4836. [PMID: 29891348 PMCID: PMC6508597 DOI: 10.1016/j.vaccine.2018.02.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 01/23/2018] [Accepted: 02/01/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Women in sub-Saharan Africa have high dual burden of HPV and HIV infections, which can interact to increase cervical cancer (CC) risk. The 9-valent HPV (9vHPV) vaccine has high demonstrated effectiveness against HPV types causing 90% of CC. Additionally, one dose of the 9vHPV vaccine has the potential to achieve greater coverage at lower costs than a two-dose schedule. However, the potential impact of single-dose 9vHPV vaccine accounting for HPV-HIV interactions has not been estimated. METHODS We adapted a dynamic HIV transmission model to include HPV acquisition and CC pathogenesis and projected the impact of a single dose 9vHPV preadolescent vaccination in KwaZulu-Natal, South Africa. We report health impacts of HPV vaccination separately for HIV-positive women stratified by HIV treatment and CD4 count and HIV-negative women. RESULTS At 90% coverage of females age 9 years with 80% lifelong vaccine efficacy, single dose HPV vaccination was projected to reduce CC incidence by 74% and mortality by 71% in the general female population at 70 years after the start of the vaccination program. Age-standardized CC incidence and mortality reductions were comparable among HIV-negative women, HIV-positive women, and HIV-positive women on ART. Health benefits were reduced when assuming waning protection at 10, 15 and 20 years after vaccination. DISCUSSION Single dose 9vHPV vaccination is projected to avert substantial CC burden in South Africa and similar high HIV prevalence settings. Health benefits were comparable across all female subpopulations stratified by HIV status, CD4 count, and ART status.
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Affiliation(s)
- Nicholas Tan
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Rachel Winer
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Denise Galloway
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; School of Medicine, University of Washington, Seattle, WA, USA; Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Helen Rees
- Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa
| | - Ruanne V Barnabas
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; School of Medicine, University of Washington, Seattle, WA, USA; Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
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13
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Clouse K, Fox MP, Mongwenyana C, Motlhatlhedi M, Buthelezi S, Bokaba D, Norris SA, Bassett J, Lurie MN, Aronoff DM, Vermund SH. "I will leave the baby with my mother": Long-distance travel and follow-up care among HIV-positive pregnant and postpartum women in South Africa. J Int AIDS Soc 2018; 21 Suppl 4:e25121. [PMID: 30027665 PMCID: PMC6053484 DOI: 10.1002/jia2.25121] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 05/12/2018] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION It is common in urban African settings for postpartum women to temporarily return to family in distant settings. We sought to explore mobility among peripartum HIV-positive women to understand the timing and motivation of travel, particularly vis-à-vis delivery, and how it may affect healthcare access. METHODS Using the same mobility measurements within three different studies, we examined long-distance travel of mother and infant before and after delivery in three diverse clinics within greater Johannesburg, South Africa (n = 150). Participants were interviewed prior to delivery at two sites (n = 125) and after delivery at one (n = 25). Quantitative and qualitative results are reported. RESULTS Among 150 women, median age was 29 years (IQR: 26 to 34) and 36.3% were employed. Overall, 76.7% of the participants were born in South Africa: 32.7% in Gauteng Province (Johannesburg area) and 44.0% in other South African provinces, but birthplace varied greatly by site. Almost half (44.0%) planned to travel around delivery; nearly all after delivery. Median duration of stay was 30 days (IQR: 24 to 90) overall, but varied from 60 days at two sites to just 7 days at another. Participants discussed travel to eight of South Africa's nine provinces and four countries. Travel most frequently was to visit family, typically to receive help with the new baby. Nearly all the employed participants planned to return to work in Johannesburg after delivery, sometimes leaving the infant in the care of family outside of Johannesburg. All expressed their intent to continue HIV care for themselves and their infant, but few planned to seek care at the destination site, and care for the infant was emphasized over care for the mother. CONCLUSIONS We identified frequent travel in the peripartum period with substantial differences in travel patterns by site. Participants more frequently discussed seeking care for the infant than for themselves. HIV-exposed children often were left in the care of family members in distant areas. Our results show the frequent mobility of women and infants in the peripartum period. This underscores the challenge of ensuring a continuity of HIV care in a fragmented healthcare system that is not adapted for a mobile population.
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Affiliation(s)
- Kate Clouse
- Vanderbilt Institute for Global HealthVanderbilt UniversityNashvilleTNUSA
- Division of Infectious DiseasesDepartment of MedicineVanderbilt UniversityNashvilleTNUSA
- Department of Internal MedicineHealth Economics and Epidemiology Research Office (HERO)School of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Matthew P Fox
- Department of Internal MedicineHealth Economics and Epidemiology Research Office (HERO)School of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBoston UniversityBostonMAUSA
- Department of EpidemiologyBoston University School of Public HealthBoston UniversityBostonMAUSA
| | - Constance Mongwenyana
- Department of Internal MedicineHealth Economics and Epidemiology Research Office (HERO)School of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Molebogeng Motlhatlhedi
- MRC/Wits Developmental Pathways for Health Research UnitUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | - Dorah Bokaba
- Hikhensile ClinicCity of JohannesburgJohannesburgSouth Africa
| | - Shane A Norris
- MRC/Wits Developmental Pathways for Health Research UnitUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Jean Bassett
- Witkoppen Health and Welfare CentreJohannesburgSouth Africa
| | - Mark N Lurie
- Department of EpidemiologyBrown University School of Public HealthProvidenceRIUSA
| | - David M Aronoff
- Division of Infectious DiseasesDepartment of MedicineVanderbilt UniversityNashvilleTNUSA
| | - Sten H Vermund
- Department of Epidemiology of Microbial Diseases and Center for Interdisciplinary Research on AIDSYale University School of Public HealthNew HavenCTUSA
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Tariq S, Elford J, Chau C, French C, Cortina-Borja M, Brown A, Delpech V, Tookey PA. Loss to Follow-Up After Pregnancy Among Sub-Saharan Africa-Born Women Living With Human Immunodeficiency Virus in England, Wales and Northern Ireland: Results From a Large National Cohort. Sex Transm Dis 2017; 43:283-9. [PMID: 27100763 PMCID: PMC4841179 DOI: 10.1097/olq.0000000000000442] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Combining 2 national United Kingdom data sets, we found that 1 in 8 human immunodeficiency virus–positive women were lost to follow-up in the year after pregnancy. This was associated with being Sub-Saharan Africa-born and recent migration. Background Little is known about retention in human immunodeficiency virus (HIV) care in HIV-positive women after pregnancy in the United Kingdom. We explored the association between loss to follow-up (LTFU) in the year after pregnancy, maternal place of birth and duration of UK residence, in HIV-positive women in England, Wales, and Northern Ireland. Methods We analyzed combined data from 2 national data sets: the National Study of HIV in Pregnancy and Childhood; and the Survey of Prevalent HIV Infections Diagnosed, including pregnancies in 2000 to 2009 in women with diagnosed HIV. Logistic regression models were fitted with robust standard errors to estimate adjusted odds ratios (AOR). Results Overall, 902 of 7211 (12.5%) women did not access HIV care in the year after pregnancy. Factors associated with LTFU included younger age, last CD4 in pregnancy of 350 cells/μL or greater and detectable HIV viral load at the end of pregnancy (all P < 0.001). On multivariable analysis, LTFU was more likely in sub-Saharan Africa-born (SSA-born) women than white UK-born women (AOR, 2.17; 95% confidence interval, 1.50–3.14; P < 0.001). The SSA-born women who had migrated to the UK during pregnancy were 3 times more likely than white UK-born women to be lost to follow-up (AOR, 3.19; 95% confidence interval, 1.94–3.23; P < 0.001). Conclusions One in 8 HIV-positive women in England, Wales, and Northern Ireland did not return for HIV care in the year after pregnancy, with SSA-born women, especially those who migrated to the United Kingdom during pregnancy, at increased risk. Although emigration is a possible explanatory factor, disengagement from care may also play a role.
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Affiliation(s)
- Shema Tariq
- From the *School of Health Sciences, City University London; †Population and Practice Programme, UCL Institute of Child Health; and ‡Public Health England, London, United Kingdom
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15
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Clouse K, Mongwenyana C, Musina M, Bokaba D, Long L, Maskew M, Ahonkhai A, Fox MP. Acceptability and feasibility of a financial incentive intervention to improve retention in HIV care among pregnant women in Johannesburg, South Africa. AIDS Care 2017; 30:453-460. [PMID: 29067861 DOI: 10.1080/09540121.2017.1394436] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Women initiating antiretroviral therapy during pregnancy are at high risk of dropping out of HIV care after delivery. We assessed the acceptability and feasibility of a financial incentive - a one-time R50 (∼USD4) supermarket voucher for completing one postpartum visit ≤10 weeks of delivery - to improve postpartum retention. We enrolled 100 pregnant, HIV-positive women at a primary health clinic in Johannesburg, South Africa. Participants were interviewed at enrollment and we reviewed files to assess retention ≥14 weeks postpartum. Median (IQR) respondent age was 28 years (24-31) and 31% were employed. Most (86%) said the incentive would motivate them to return and 76% supported clinics offering incentives. Among the 23% who found the intervention unacceptable, the most frequent reason was perceived personal responsibility for health. Feasibility was demonstrated, as 79.7% (51/64) of eligible participants received a voucher. When asked to rank preferred hypothetical incentive interventions, assistance with social services ranked first (29%), followed by infant formula (22%) and cash (21%); assistance with social services was the top-ranked choice by both those who found the voucher incentive intervention acceptable and unacceptable. To encourage HIV-positive women to remain in care, respondents most frequently suggested health education (34%), counseling (29%), financial incentives (25%), home visits (13%), and better service (6%). Our results suggest financial incentives are acceptable, but women frequently expressed preference for integrated services and improved education and counseling to improve retention. Interventions exploring the feasibility and efficacy of education and counseling interventions to improve postpartum HIV care are warranted.
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Affiliation(s)
- Kate Clouse
- a Vanderbilt Institute for Global Health , Vanderbilt University , Nashville , TN , USA.,b Department of Medicine, Division of Infectious Diseases , Vanderbilt University , Nashville , TN , USA.,c Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Constance Mongwenyana
- c Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Melda Musina
- c Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Dorah Bokaba
- d Hikhensile Clinic , City of Johannesburg , Johannesburg , South Africa
| | - Lawrence Long
- c Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Mhairi Maskew
- c Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Aima Ahonkhai
- a Vanderbilt Institute for Global Health , Vanderbilt University , Nashville , TN , USA.,b Department of Medicine, Division of Infectious Diseases , Vanderbilt University , Nashville , TN , USA
| | - Matthew P Fox
- c Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa.,e Department of Global Health , Boston University School of Public Health, Boston University , Boston , MA , USA.,f Department of Epidemiology , Boston University School of Public Health, Boston University , Boston , MA , USA
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Stepped-Wedge Cluster Randomized Controlled Trial to Promote Option B+ Retention in Central Mozambique. J Acquir Immune Defic Syndr 2017; 76:273-280. [PMID: 28777263 DOI: 10.1097/qai.0000000000001515] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This randomized trial studied performance of Option B+ in Mozambique and evaluated an enhanced retention package in public clinics. SETTING The study was conducted at 6 clinics in Manica and Sofala Provinces in central Mozambique. METHODS Seven hundred sixty-one pregnant women tested HIV+, immediately initiated antiretroviral (ARV) therapy, and were followed to track retention at 6 clinics from May 2014 to May 2015. Clinics were randomly allocated within a stepped-wedge fashion to intervention and control periods. The intervention included (1) workflow modifications and (2) active patient tracking. Retention was defined as percentage of patients returning for 30-, 60-, and 90-day medication refills within 25-35 days of previous refills. RESULTS During control periods, 52.3% of women returned for 30-day refills vs. 70.8% in intervention periods [odds ratio (OR): 1.80; 95% confidence interval (CI): 1.05 to 3.08]. At 60 days, 46.1% control vs. 57.9% intervention were retained (OR: 1.82; CI: 1.06 to 3.11), and at 90 days, 38.3% control vs. 41.0% intervention (OR: 1.04; CI: 0.60 to 1.82). In prespecified subanalyses, birth before pickups was strongly associated with failure-women giving birth before ARV pickup were 33.3 times (CI: 4.4 to 250.3), 7.5 times (CI: 3.6 to 15.9), and 3.7 times (CI: 2.2 to 6.0) as likely to not return for ARV pickups at 30, 60, and 90 days, respectively. CONCLUSIONS The intervention was effective at 30 and 60 days, but not at 90 days. Combined 90-day retention (40%) and adherence (22.5%) were low. Efforts to improve retention are particularly important for women giving birth before ARV refills.
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Mobility and Clinic Switching Among Postpartum Women Considered Lost to HIV Care in South Africa. J Acquir Immune Defic Syndr 2017; 74:383-389. [PMID: 28225717 DOI: 10.1097/qai.0000000000001284] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Retention in HIV care, particularly among postpartum women, is a challenge to national antiretroviral therapy programs. Retention estimates may be underestimated because of unreported transfers. We explored mobility and clinic switching among patients considered lost to follow-up (LTFU). DESIGN Observational cohort study. METHODS Of 788 women initiating antiretroviral therapy during pregnancy at 6 public clinics in Johannesburg, South Africa, 300 (38.1%) were LTFU (no visit ≥3 months). We manually searched for these women in the South African National Health Laboratory Services database to assess continuity of HIV care. We used geographic information system tools to map mobility to new facilities. RESULTS Over one-third (37.6%) of women showed evidence of continued HIV care after LTFU. Of these, 67.0% continued care in the same province as the origin clinic. Compared with those who traveled outside of the province for care, these same-province "clinic shoppers" stayed out-of-care longer {median 373 days [interquartile range (IQR): 175-790] vs. 175.5 days (IQR: 74-371)} and had a lower CD4 cell count on re-entry [median 327 cells/μL (IQR: 196-576) vs. 493 cells/μL (IQR: 213-557). When considering all women with additional evidence of care as engaged in care, cohort LTFU dropped from 38.1% to 25.0%. CONCLUSIONS We found evidence of continued care after LTFU and identified local and national clinic mobility among postpartum women. Laboratory records do not show all clinic visits and manual matching may have been under- or overestimated. A national health database linked to a unique identifier is necessary to improve reporting and patient care among highly mobile populations.
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Option B+ in Mozambique: Formative Research Findings for the Design of a Facility-Level Clustered Randomized Controlled Trial to Improve ART Retention in Antenatal Care. J Acquir Immune Defic Syndr 2017; 72 Suppl 2:S181-8. [PMID: 27355507 PMCID: PMC5113244 DOI: 10.1097/qai.0000000000001061] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION With the rollout of "Option B+" in Mozambique in 2013, initial data indicated major challenges to early retention in antiretroviral therapy (ART) among HIV-positive pregnant women. We sought to develop and test a pilot intervention in 6 large public clinics in central Mozambique to improve retention of mothers starting ART in antenatal care. The results from the formative research from this study described here were used to design the intervention. METHODS The research was initiated in early 2013 and completed in early 2014 in each of the 6 study clinics and consisted of (1) patient flow mapping and measurement of retention through collection of health systems data from antenatal care registries, pharmacy registries, ART clinic databases, (2) workforce assessment and measurement of patient waiting times, and (3) patient and worker individual interviews and focus groups. RESULTS Coverage of HIV testing and ART initiation were over 90% at all sites, but retention at 30-, 60-, and 90-day pharmacy refill visits was very low ranging from only 5% at 1 site to 30% returning at 90 days. These data revealed major systemic bottlenecks that contributed to poor adherence and retention in the first month after ART initiation. Long wait times, short consultations, and poor counseling were identified as barriers. CONCLUSIONS Based on these findings, we designed an intervention with these components: (1) workflow modification to redefine nurse tasks, shift tasks to community health workers, and enhance patient tracking and (2) an adherence and retention package to systematize active patient follow-up, ensure home visits by community health workers, use text messaging, and intensify counseling by health staff. This intervention is currently under evaluation using a stepped wedge design.
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Bautista-Arredondo S, Sosa-Rubí SG, Opuni M, Contreras-Loya D, Kwan A, Chaumont C, Chompolola A, Condo J, Galárraga O, Martinson N, Masiye F, Nsanzimana S, Ochoa-Moreno I, Wamai R, Wang’ombe J. Costs along the service cascades for HIV testing and counselling and prevention of mother-to-child transmission. AIDS 2016; 30:2495-2504. [PMID: 27753679 PMCID: PMC5051528 DOI: 10.1097/qad.0000000000001208] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
We estimate facility-level average annual costs per client along the HIV testing and counselling (HTC) and prevention of mother-to-child transmission (PMTCT) service cascades.
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Altan AMD, Taafo F, Fopa F, Buonomo E, Marazzi MC, Nielsen-Saines K, Orlando S, Scarcella P, Ciccacci F, Mancinelli S, Lio MMS, Palombi L. An assessment of option B implementation for the prevention of mother to child transmission in Dschang, Cameroon: results from the DREAM (Drug Resource Enhancement against AIDS and Malnutrition) cohort. Pan Afr Med J 2016; 23:72. [PMID: 27217896 PMCID: PMC4862786 DOI: 10.11604/pamj.2016.23.72.7958] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 02/27/2016] [Indexed: 11/12/2022] Open
Abstract
Introduction Scaling up of antiretroviral therapy (ART) to HIV+ pregnant women is crucial for the elimination of HIV infection in children. The aim of this study was to evaluate the feasibility and effectiveness of triple ART for Prevention of Mother-to Child Transmission (PMTCT) in Cameroon. Methods HIV-positive pregnant women attending the DREAM Centre of Dschang, Cameroon for prenatal care were enrolled in a prospective cohort study, and received ART until the end of breastfeeding or indefinitely if their CD4 count was <350mm3. Infants were evaluated for HIV infection at 1, 6 and 12 months of age. Results A total of 298 women were enrolled. Among them, 152 were already on established ART. Women were followed until 6 months after delivery with a retention rate of 92.6%. Eight women died. Those with a CD4 count <350 cells/mm3 during pregnancy had the highest mortality risk (RR 2.53; 95% CL= 1.86-3.44). The HIV transmission rate was 1.2% at 12 months with an HIV free survival of 91%. In the proportional Cox regression analysis, the following factors were positively associated with infant mortality: maternal CD4< 350 cells/mm3, no breastfeeding in the first 6 months of life, weight-for-age z score<-2. Conclusion Results confirm the feasibility and effectiveness of the implementation of Option B, with very low rates of HIV MTC transmission, and potential benefits to the health of mothers and infants with earlier initiation of ART. Breastfeeding again demonstrates to be highly beneficial for the growth and survival of HIV exposed children.
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Affiliation(s)
| | | | | | - Ersilia Buonomo
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy
| | | | - Karin Nielsen-Saines
- Department of Pediatrics, David Geffen UCLA School of Medicine, Los Angeles, California
| | | | - Paola Scarcella
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy
| | | | - Sandro Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy
| | | | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Italy
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Njuguna IN, Wagner AD, Cranmer LM, Otieno VO, Onyango JA, Chebet DJ, Okinyi HM, Benki-Nugent S, Maleche-Obimbo E, Slyker JA, John-Stewart GC, Wamalwa DC. Hospitalized Children Reveal Health Systems Gaps in the Mother-Child HIV Care Cascade in Kenya. AIDS Patient Care STDS 2016; 30:119-24. [PMID: 27308805 DOI: 10.1089/apc.2015.0239] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
To identify missed opportunities in HIV prevention, diagnosis, and linkage to care, we enrolled 183 hospitalized, HIV-infected, ART-naïve Kenyan children 0-12 years from four hospitals in Nairobi and Kisumu, and reviewed prevention of mother-to-child transmission of HIV (PMTCT), hospitalization, and HIV testing history. Median age was 1.8 years (IQR = 0.8, 4.5). Most mothers received HIV testing during pregnancy (77%). Among mothers tested, 60% and 40% reported HIV-negative and positive results, respectively; 33% of HIV-diagnosed mothers did not receive PMTCT antiretrovirals. First missed opportunities for pediatric diagnosis and linkage were due to failure to test mothers (23.1%), maternal HIV acquisition following initial negative test (45.7%), no early infant diagnosis (EID) or provider-initiated testing (PITC) (12.7%), late breastfeeding transmission (8.7%), failure to collect child HIV test results (1.2%), and no linkage to care following HIV diagnosis (8.7%). Among previously hospitalized children, 38% never received an HIV test. Strengthening initial and repeat maternal HIV testing and PITC are key interventions to prevent, detect, and treat pediatric HIV infections.
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Affiliation(s)
- Irene N. Njuguna
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, Washington
| | - Lisa M. Cranmer
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Vincent O. Otieno
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Judith A. Onyango
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Daisy J. Chebet
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Helen M. Okinyi
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | | | - Jennifer A. Slyker
- Department of Global Health, University of Washington, Seattle, Washington
| | - Grace C. John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology and Pediatrics, University of Washington, Seattle, Washington
| | - Dalton C. Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Lost to follow-up among pregnant women in a multi-site community based maternal and newborn health registry: a prospective study. Reprod Health 2015; 12 Suppl 2:S4. [PMID: 26062899 PMCID: PMC4464022 DOI: 10.1186/1742-4755-12-s2-s4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background It is important when conducting epidemiologic studies to closely monitor lost to follow up (LTFU) rates. A high LTFU rate may lead to incomplete study results which in turn can introduce bias to the trial or study, threatening the validity of the findings. There is scarce information on LTFU in prospective community-based perinatal epidemiological studies. This paper reports the rates of LTFU, describes socio-demographic characteristics, and pregnancy/delivery outcomes of mothers LTFU in a large community-based pregnancy registry study. Methods Data were from a prospective, population-based observational study of the Global Network for Women's and Children's Health Research Maternal Newborn Health Registry (MNHR). This is a multi-centre, international study in which pregnant women were enrolled in mid-pregnancy, followed through parturition and 42 days post-delivery. Risk for LTFU was calculated within a 95%CI. Results A total of 282,626 subjects were enrolled in this study, of which 4,893 were lost to follow-up. Overall, there was a 1.7% LTFU to follow up rate. Factors associated with a higher LTFU included mothers who did not know their last menstrual period (RR 2.2, 95% CI 1.1, 4.4), maternal age of < 20 years (RR 1.2, 95% CI 1.1, 1.3), women with no formal education (RR 1.2, 95% CI 1.1, 1.4), and attending a government clinic for antenatal care (RR 2.0, 95% CI 1.4, 2.8). Post-natal factors associated with a higher LTFU rate included a newborn with feeding problems (RR 1.6, 94% CI 1.2, 2.2). Conclusions The LTFU rate in this community-based registry was low (1.7%). Maternal age, maternal level of education, pregnancy status at enrollment and using a government facility for ANC are factors associated with being LTFU. Strategies to ensure representation and high retention in community studies are important to informing progress toward public health goals. Trial registration Registration at the Clinicaltrials.gov (ID# NCT01073475).
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Ngarina M, Kilewo C, Karlsson K, Aboud S, Karlsson A, Marrone G, Leyna G, Ekström AM, Biberfeld G. Virologic and immunologic failure, drug resistance and mortality during the first 24 months postpartum among HIV-infected women initiated on antiretroviral therapy for life in the Mitra plus Study, Dar es Salaam, Tanzania. BMC Infect Dis 2015; 15:175. [PMID: 25886277 PMCID: PMC4392730 DOI: 10.1186/s12879-015-0914-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 03/25/2015] [Indexed: 11/26/2022] Open
Abstract
Background In the Mitra plus study of prevention of mother-to-child transmission of HIV-1, which included 501 women in Dar es Salaam, Tanzania, triple antiretroviral therapy (ART) was given from late pregnancy throughout breastfeeding up to 6 months postnatally. Here we report findings in a sub-cohort of women with ≤200 CD4cells/μL at enrolment who were continued on ART for life and followed up during 24 months after delivery to determine virologic and immunologic responses, drug resistance and mortality. Methods Blood samples for viral load and CD4 counts testing were collected at enrolment and at 3, 6, 12 and 24 months postpartum. HIV drug resistance testing was performed at 12 months. Data analysis included descriptive statistics and multivariate analysis using Generalized Estimated Equations of 73 women with at least two postpartum assessments. The mortality analysis included 84 women who had delivered. Results The proportion of women with a viral load ≥400 copies/mL was 97% (71/73) at enrolment, 16% (11/67), 22% (15/69), 61% (36/59) and 86% (48/56) at 3, 6, 12 and 24 months postpartum, respectively. The proportion of women with immunologic failure was 12% (8/69), 25% (15/60) and 41% (24/58) at 6, 12 and 24 months, respectively. At 12 months, drug resistance was demonstrated in 34% (20/59), including 12 with dual-class resistance. Self-report on drug adherence was 95% (64/68), 85% (56/66), 74% (39/53) and 65% (30/46) at 3, 6, 12 and 24 months, respectively. The mortality rate was 5.9% (95% CI 2.5-13.7%) at 24 months. The probability of virologic and immunologic failure was significantly higher among women who reported non-perfect adherence to ART at month 24 postpartum. Conclusions Following an initial decline of viral load, virologic failure was common at 12 and 24 months postpartum among women initiated on ART for life during pregnancy because of low CD4 cell counts. A high proportion of viremic mothers also had resistance mutations. However, at 24 months follow-up, the mortality rate was still fairly low. Continuous adherence counseling and affordable means of monitoring of the virologic response are crucial for successful implementation of the WHO Option B+ guidelines to start all HIV-infected pregnant women on ART for life.
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Affiliation(s)
- Matilda Ngarina
- Department of Obstetrics and Gynecology, Muhimbili National Hospital, 65000, Dar es Salaam, Tanzania. .,Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden. .,Public Health Agency of Sweden, Stockholm, Sweden.
| | - Charles Kilewo
- Departments of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, 65001, Dar es Salaam, Tanzania.
| | | | - Said Aboud
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, 65001, Dar es Salaam, Tanzania.
| | - Annika Karlsson
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Gaetano Marrone
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
| | - Germana Leyna
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Anna Mia Ekström
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. .,Department of Infectious Diseases, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
| | - Gunnel Biberfeld
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden. .,Public Health Agency of Sweden, Stockholm, Sweden.
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Sellers CJ, Lee H, Chasela C, Kayira D, Soko A, Mofolo I, Ellington S, Hudgens MG, Kourtis AP, King CC, Jamieson DJ, van der Horst C. Reducing lost to follow-up in a large clinical trial of prevention of mother-to-child transmission of HIV: the Breastfeeding, Antiretrovirals and Nutrition study experience. Clin Trials 2015; 12:156-65. [PMID: 25518956 PMCID: PMC4355163 DOI: 10.1177/1740774514562031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/AIMS Retaining patients in prevention of mother-to-child transmission of HIV studies can be challenging in resource-limited settings, where high lost to follow-up rates have been reported. In this article, we describe the effectiveness of methods used to encourage retention in the Breastfeeding, Antiretrovirals, and Nutrition study and analyze factors associated with lost to follow-up in the study. METHODS The Breastfeeding, Antiretrovirals, and Nutrition clinical trial was designed to evaluate the efficacy of three different mother-to-child HIV transmission prevention strategies. Lower than expected participant retention prompted enhanced efforts to reduce lost to follow-up during the conduct of the trial. Following study completion, we employed regression modeling to determine predictors of perfect attendance and variables associated with being lost to follow-up. RESULTS During the study, intensive tracing efforts were initiated after the first 1686 mother-infant pairs had been enrolled, and 327 pairs were missing. Of these pairs, 60 were located and had complete data obtained. Among the 683 participants enrolling after initiation of intensive tracing efforts, the lost to follow-up rate was 3.4%. At study's end, 290 (12.2%) of the 2369 mother-infant pairs were lost to follow-up. Among successfully traced missing pairs, relocation was common and three were deceased. Log-binomial regression modeling revealed higher maternal hemoglobin and older maternal age to be significant predictors of perfect attendance. These factors and the presence of food insecurity were also significantly associated with lower rates of lost to follow-up. CONCLUSION In this large HIV prevention trial, intensive tracing efforts centered on reaching study participants at their homes succeeded in finding a substantial proportion of lost to follow-up participants and were very effective in preventing further lost to follow-up during the remainder of the trial. The association between food insecurity and lower rates of lost to follow-up is likely related to the study's provision of nutritional support, including a family maize supplement, which may have contributed to patient retention.
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Affiliation(s)
- Christopher J Sellers
- Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Hana Lee
- Department of Biostatistics, School of Public Health, Brown University, Providence, RI, USA
| | - Charles Chasela
- UNC Project, Lilongwe, Malawi Division of Epidemiology and Biostatistics, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Sascha Ellington
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Michael G Hudgens
- Department of Biostatistics, School of Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Athena P Kourtis
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Caroline C King
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Denise J Jamieson
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Charles van der Horst
- Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
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Clouse K, Schwartz S, Van Rie A, Bassett J, Yende N, Pettifor A. "What they wanted was to give birth; nothing else": barriers to retention in option B+ HIV care among postpartum women in South Africa. J Acquir Immune Defic Syndr 2015; 67:e12-8. [PMID: 24977376 DOI: 10.1097/qai.0000000000000263] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Women initiating antiretroviral therapy during pregnancy have high rates of dropout, particularly after delivery. We aimed to identify challenges to postpartum retention in care under Option B+, which expands antiretroviral therapy access to all HIV-positive pregnant women regardless of CD4 count. METHODOLOGY We performed 2 semi-structured interviews (SSI, n = 50) and 1 focus group discussion (n = 8) with HIV-positive women at Witkoppen Health and Welfare Centre, a primary care facility in Johannesburg, South Africa, that is one of the only clinics offering Option B+ in South Africa. RESULTS Fifty women completed the SSI before delivery, and 48 (96%) completed the second SSI within 3 months of delivery. Median age was 28 years (interquartile range: 26-34); most women worked (62%) or had worked in the previous year (18%). Postpartum women attending HIV care perceived that barriers to HIV care after delivery among other women included the belief that mothers care more about the baby's health than their own (29.2%, 14/48), women were "ignorant" or "irresponsible" (16.7%, 8/48), negative clinic staff treatment (12.5%, 6/48), and denial or lack of disclosure of HIV status (10.4% each, 5/48). Experienced barriers included lack of money (18.0%, 9/50), work conflict (6.0%, 3/50), and negative staff treatment (6.0%, 3/50). During the focus group discussion, 3 main themes emerged: conflict with work commitment, negative treatment from health-care workers, and lack of disclosure related to stigma. CONCLUSIONS We identified a complex set of interconnected barriers to retaining postpartum women in HIV care under Option B+, including structural, personal, and societal barriers. The importance of postpartum HIV care for the mother's own health must be embraced by health-care workers and public health programs.
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Affiliation(s)
- Kate Clouse
- *Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC; †Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC; and ‡Witkoppen Health and Welfare Centre, Johannesburg, South Africa
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Hodgson I, Plummer ML, Konopka SN, Colvin CJ, Jonas E, Albertini J, Amzel A, Fogg KP. A systematic review of individual and contextual factors affecting ART initiation, adherence, and retention for HIV-infected pregnant and postpartum women. PLoS One 2014; 9:e111421. [PMID: 25372479 PMCID: PMC4221025 DOI: 10.1371/journal.pone.0111421] [Citation(s) in RCA: 212] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 09/15/2014] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Despite progress reducing maternal mortality, HIV-related maternal deaths remain high, accounting, for example, for up to 24 percent of all pregnancy-related deaths in sub-Saharan Africa. Antiretroviral therapy (ART) is effective in improving outcomes among HIV-infected pregnant and postpartum women, yet rates of initiation, adherence, and retention remain low. This systematic literature review synthesized evidence about individual and contextual factors affecting ART use among HIV-infected pregnant and postpartum women. METHODS Searches were conducted for studies addressing the population (HIV-infected pregnant and postpartum women), intervention (ART), and outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. Individual and contextual enablers and barriers to ART use were extracted and organized thematically within a framework of individual, interpersonal, community, and structural categories. RESULTS Thirty-four studies were included in the review. Individual-level factors included both those within and outside a woman's awareness and control (e.g., commitment to child's health or age). Individual-level barriers included poor understanding of HIV, ART, and prevention of mother-to-child transmission, and difficulty managing practical demands of ART. At an interpersonal level, disclosure to a spouse and spousal involvement in treatment were associated with improved initiation, adherence, and retention. Fear of negative consequences was a barrier to disclosure. At a community level, stigma was a major barrier. Key structural barriers and enablers were related to health system use and engagement, including access to services and health worker attitudes. CONCLUSIONS To be successful, programs seeking to expand access to and continued use of ART by integrating maternal health and HIV services must identify and address the relevant barriers and enablers in their own context that are described in this review. Further research on this population, including those who drop out of or never access health services, is needed to inform effective implementation.
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Affiliation(s)
- Ian Hodgson
- Independent Consultant, Bingley, United Kingdom
| | | | - Sarah N. Konopka
- Center for Health Services, Management Sciences for Health, Arlington, Virginia, USA
| | - Christopher J. Colvin
- Centre for Infectious Disease Epidemiology and Research (CIDER), Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Edna Jonas
- Center for Health Services, Management Sciences for Health, Arlington, Virginia, USA
| | - Jennifer Albertini
- United States Agency for International Development (USAID)/Africa Bureau, Washington, D.C., USA
| | - Anouk Amzel
- USAID/Bureau for Global Health (BGH)/Office of HIV/AIDS, Washington, D.C., USA
| | - Karen P. Fogg
- USAID/BGH/Office of Health, Infectious Diseases, and Nutrition, Washington, D.C., USA
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Colvin CJ, Konopka S, Chalker JC, Jonas E, Albertini J, Amzel A, Fogg K. A systematic review of health system barriers and enablers for antiretroviral therapy (ART) for HIV-infected pregnant and postpartum women. PLoS One 2014; 9:e108150. [PMID: 25303241 PMCID: PMC4193745 DOI: 10.1371/journal.pone.0108150] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 08/25/2014] [Indexed: 11/29/2022] Open
Abstract
Background Despite global progress in the fight to reduce maternal mortality, HIV-related maternal deaths remain persistently high, particularly in much of Africa. Lifelong antiretroviral therapy (ART) appears to be the most effective way to prevent these deaths, but the rates of three key outcomes—ART initiation, retention in care, and long-term ART adherence—remain low. This systematic review synthesized evidence on health systems factors affecting these outcomes in pregnant and postpartum women living with HIV. Methods Searches were conducted for studies addressing the population of interest (HIV-infected pregnant and postpartum women), the intervention of interest (ART), and the outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. A four-stage narrative synthesis design was used to analyze findings. Review findings from 42 included studies were categorized according to five themes: 1) models of care, 2) service delivery, 3) resource constraints and governance challenges, 4) patient-health system engagement, and 5) maternal ART interventions. Results Low prioritization of maternal ART and persistent dropout along the maternal ART cascade were key findings. Service delivery barriers included poor communication and coordination among health system actors, poor clinical practices, and gaps in provider training. The few studies that assessed maternal ART interventions demonstrated the importance of multi-pronged, multi-leveled interventions. Conclusions There has been a lack of emphasis on the experiences, needs and vulnerabilities particular to HIV-infected pregnant and postpartum women. Supporting these women to successfully traverse the maternal ART cascade requires carefully designed and targeted interventions throughout the steps. Careful design of integrated service delivery models is of critical importance in this effort. Key knowledge gaps and research priorities were also identified, including definitions and indicators of adherence rates, and the importance of cumulative measures of dropout along the maternal ART cascade.
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Affiliation(s)
- Christopher J. Colvin
- Centre for Infectious Disease Epidemiology and Research (CIDER), Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Medical School Campus, Cape Town, South Africa
- * E-mail:
| | - Sarah Konopka
- Center for Health Services, Management Sciences for Health, Arlington, Virginia, United States of America
| | - John C. Chalker
- Center for Pharmaceutical Management, Management Sciences for Health, Arlington, Virginia, United States of America
| | - Edna Jonas
- Center for Health Services, Management Sciences for Health, Arlington, Virginia, United States of America
| | - Jennifer Albertini
- United States Agency for International Development (USAID)/Africa Bureau, Washington, District of Columbia, United States of America
| | - Anouk Amzel
- USAID/Bureau for Global Health (BGH)/Office of HIV/AIDS, Washington, District of Columbia, United States of America
| | - Karen Fogg
- USAID/BGH/Office of Health, Infectious Diseases and Nutrition, Washington, District of Columbia, United States of America
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Interventions to improve or facilitate linkage to or retention in pre-ART (HIV) care and initiation of ART in low- and middle-income settings--a systematic review. J Int AIDS Soc 2014; 17:19032. [PMID: 25095831 PMCID: PMC4122816 DOI: 10.7448/ias.17.1.19032] [Citation(s) in RCA: 199] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 05/26/2014] [Accepted: 06/11/2014] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Several approaches have been taken to reduce pre-antiretroviral therapy (ART) losses between HIV testing and ART initiation in low- and middle-income countries, but a systematic assessment of the evidence has not yet been undertaken. The aim of this systematic review is to assess the potential for interventions to improve or facilitate linkage to or retention in pre-ART care and initiation of ART in low- and middle-income settings. METHODS An electronic search was conducted on Medline, Embase, Global Health, Web of Science and conference databases to identify studies describing interventions aimed at improving linkage to or retention in pre-ART care or initiation of ART. Additional searches were conducted to identify on-going trials on this topic, and experts in the field were contacted. An assessment of the risk of bias was conducted. Interventions were categorized according to key domains in the existing literature. RESULTS A total of 11,129 potentially relevant citations were identified, of which 24 were eligible for inclusion, with the majority (n=21) from sub-Saharan Africa. In addition, 15 on-going trials were identified. The most common interventions described under key domains included: health system interventions (i.e. integration in the setting of antenatal care); patient convenience and accessibility (i.e. point-of-care CD4 count (POC) testing with immediate results, home-based ART initiation); behaviour interventions and peer support (i.e. improved communication, patient referral and education) and incentives (i.e. food support). Several interventions showed favourable outcomes: integration of care and peer supporters increased enrolment into HIV care, medical incentives increased pre-ART retention, POC CD4 testing and food incentives increased completion of ART eligibility screening and ART initiation. Most studies focused on the general adult patient population or pregnant women. The majority of published studies were observational cohort studies, subject to an unclear risk of bias. CONCLUSIONS Findings suggest that streamlining services to minimize patient visits, providing adequate medical and peer support, and providing incentives may decrease attrition, but the quality of the current evidence base is low. Few studies have investigated combined interventions, or assessed the impact of interventions across the HIV cascade. RESULTS from on-going trials investigating POC CD4 count testing, patient navigation, rapid ART initiation and mobile phone technology may fill the quality of evidence gap. Further high-quality studies on key population groups are required, with interventions informed by previously reported barriers to care.
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Ferguson L, Grant AD, Lewis J, Kielmann K, Watson-Jones D, Vusha S, Ong’ech JO, Ross DA. Linking women who test HIV-positive in pregnancy-related services to HIV care and treatment services in Kenya: a mixed methods prospective cohort study. PLoS One 2014; 9:e89764. [PMID: 24646492 PMCID: PMC3960101 DOI: 10.1371/journal.pone.0089764] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Accepted: 01/25/2014] [Indexed: 12/03/2022] Open
Abstract
Introduction There has been insufficient attention to long-term care and treatment for pregnant women diagnosed with HIV. Objective and Methods This prospective cohort study of 100 HIV-positive women recruited within pregnancy-related services in a district hospital in Kenya employed quantitative methods to assess attrition between women testing HIV-positive in pregnancy-related services and accessing long-term HIV care and treatment services. Qualitative methods were used to explore barriers and facilitators to navigating these services. Structured questionnaires were administered to cohort participants at enrolment and 90+ days later. Participants’ medical records were monitored prospectively. Semi-structured qualitative interviews were carried out with a sub-set of 19 participants. Findings Only 53/100 (53%) women registered at an HIV clinic within 90 days of HIV diagnosis, of whom 27/53 (51%) had a CD4 count result in their file. 11/27 (41%) women were eligible for immediate antiretroviral therapy (ART); only 6/11 (55%) started ART during study follow-up. In multivariable logistic regression analysis, factors associated with registration at the HIV clinic within 90 days of HIV diagnosis were: having cared for someone with HIV (aOR:3.67(95%CI:1.22, 11.09)), not having to pay for transport to the hospital (aOR:2.73(95%CI:1.09, 6.84)), and having received enough information to decide to have an HIV test (aOR:3.61(95%CI:0.83, 15.71)). Qualitative data revealed multiple factors underlying high patient drop-out related to women’s social support networks (e.g. partner’s attitude to HIV status), interactions with health workers (e.g. being given unclear/incorrect HIV-related information) and health services characteristics (e.g. restricted opening hours, long waiting times). Conclusion HIV testing within pregnancy-related services is an important entry point to HIV care and treatment services, but few women successfully completed the steps needed for assessment of their treatment needs within three months of diagnosis. Programmatic recommendations include simplified pathways to care, better-tailored counselling, integration of ART into antenatal services, and facilitation of social support.
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Affiliation(s)
- Laura Ferguson
- Institute for Global Health, University of Southern California, Los Angeles, California, United States of America
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- University of Nairobi Institute for Tropical and Infectious Diseases, Nairobi, Kenya
- * E-mail:
| | - Alison D. Grant
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - James Lewis
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Karina Kielmann
- Institute for International Health & Development, Queen Margaret University, Edinburgh, United Kingdom
| | - Deborah Watson-Jones
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Sophie Vusha
- University of Nairobi Institute for Tropical and Infectious Diseases, Nairobi, Kenya
| | - John O. Ong’ech
- University of Nairobi Institute for Tropical and Infectious Diseases, Nairobi, Kenya
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - David A. Ross
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Theuring S, Sewangi J, Nchimbi P, Harms G, Mbezi P. The challenge of referring HIV-positive pregnant women with treatment indication from PMTCT to ART services: a retrospective follow-up study in Mbeya, Tanzania. AIDS Care 2013; 26:850-6. [DOI: 10.1080/09540121.2013.869535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Comparison of point-of-care versus laboratory-based CD4 cell enumeration in HIV-positive pregnant women. J Int AIDS Soc 2013; 16:18649. [PMID: 24044627 PMCID: PMC3776301 DOI: 10.7448/ias.16.1.18649] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 08/05/2013] [Accepted: 08/19/2013] [Indexed: 12/05/2022] Open
Abstract
Introduction
Early initiation of antiretroviral therapy (ART) in eligible pregnant women is a key intervention for prevention of mother-to-child transmission (PMTCT) of HIV. However, in many settings in sub-Saharan Africa where ART-eligibility is determined by CD4 cell counts, limited access to laboratories presents a significant barrier to rapid ART initiation. Point-of-care (POC) CD4 cell count testing has been suggested as one approach to overcome this challenge, but there are few data on the agreement between POC CD4 cell enumeration and standard laboratory-based testing. Methods
Working in a large antenatal clinic in Cape Town, South Africa, we compared POC CD4 cell enumeration (using the Alere PimaTM Analyzer) to laboratory-based flow cytometry in consecutive HIV-positive pregnant women. Bland–Altman methods were used to compare the two methods, including analyses by subgroups of participant gestational age. Results
Among the 521 women participating, the median gestational age was 23 weeks, and the median CD4 cell count according to POC and laboratory-based methods was 388 and 402 cells/µL, respectively. On average, the Pima POC test underestimated CD4 cell count relative to flow cytometry: the mean difference (laboratory test minus Pima POC) was 22.7 cells/µL (95% CI, 16.1 to 29.2), and the limits of agreement were −129.2 to 174.6 cells/µL. When analysed by gestational age categories, there was a trend towards increasing differences between laboratory and POC testing with increasing gestational age; in women more than 36 weeks’ gestation, the mean difference was 45.0 cells/µL (p=0.04). Discussion
These data suggest reasonable overall agreement between Pima POC CD4 testing and laboratory-based flow cytometry among HIV-positive pregnant women. The finding for decreasing agreement with increasing gestational age requires further investigation, as does the operational role of POC CD4 testing to increase access to ART within PMTCT programmes.
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MacCarthy S, Bangsberg DR, Fink G, Reich M, Gruskin S. Late presentation to HIV/AIDS testing, treatment or continued care: clarifying the use of CD4 evaluation in the consensus definition. HIV Med 2013; 15:130-4. [PMID: 24024559 DOI: 10.1111/hiv.12088] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Late presentation to HIV/AIDS services compromises treatment outcomes and misses opportunities for biomedical and behavioural prevention. There has been significant heterogeneity in how the term 'late presentation' (LP) has been used in the literature. In 2011, a consensus definition was reached using CD4 counts to define and measure late presenters and, while it is useful for clinical care, the consensus definition has several important limitations that we discuss in this article. METHODS Using the spectrum of engagement in HIV care presented by Gardner and colleagues, this article highlights issues and opportunities associated with use of the consensus definition. RESULTS The consensus definition is limited by three principal factors: (1) the CD4 count threshold of 350 cells/μL is being increasingly questioned as the biomedical justification grows for earlier initiation of treatment; (2) CD4 evaluations are conducted at multiple services providing HIV care; thus it remains unclear to which service the patient is presenting late; and (3) the limited availability of CD4 evaluation restricts its use in determining the prevalence of LP in many settings. CONCLUSIONS The consensus definition is useful because it describes the level of disease progression and allows for consistent evaluation of the prevalence and determinants of LP. Suggestions are provided for improving the application of the consensus definition in future research.
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Affiliation(s)
- S MacCarthy
- Alpert Medical School of Brown University and The Miriam Hospital, Providence, RI, USA
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Stinson K, Jennings K, Myer L. Integration of antiretroviral therapy services into antenatal care increases treatment initiation during pregnancy: a cohort study. PLoS One 2013; 8:e63328. [PMID: 23696814 PMCID: PMC3656005 DOI: 10.1371/journal.pone.0063328] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 04/01/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Initiation of antiretroviral therapy (ART) during pregnancy is critical to promote maternal health and prevent mother-to-child HIV transmission (PMTCT). The separation of services for antenatal care (ANC) and ART may hinder antenatal ART initiation. We evaluated ART initiation during pregnancy under different service delivery models in Cape Town, South Africa. METHODS A retrospective cohort study was conducted using routinely collected clinic data. Three models for ART initiation in pregnancy were evaluated ART 'integrated' into ANC, ART located 'proximal' to ANC, and ART located some distance away from ANC ('distal'). Kaplan-Meier methods and Poisson regression were used to examine the association between service delivery model and antenatal ART initiation. RESULTS Among 14 617 women seeking antenatal care in the three services, 30% were HIV-infected and 17% were eligible for ART based on CD4 cell count <200 cells/µL. A higher proportion of women started ART antenatally in the integrated model compared to the proximal or distal models (55% vs 38% vs 45%, respectively, global p = 0.003). After adjusting for age and gestation at first ANC visit, women who at the integrated service were significantly more likely to initiate ART antenatally (rate ratio 1.33; 95% confidence interval: 1.09-1.64) compared to women attending the distal model; there was no difference between the proximal and distal models in antenatal ART initiation however (p = 0.704). CONCLUSIONS Integration of ART initiation into ANC is associated with higher levels of ART initiation in pregnancy. This and other forms of service integration may represent a valuable intervention to enhance PMTCT and maternal health.
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Affiliation(s)
- Kathryn Stinson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
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Provider-initiated testing and counselling programmes in sub-Saharan Africa: a systematic review of their operational implementation. AIDS 2013; 27:617-26. [PMID: 23364442 DOI: 10.1097/qad.0b013e32835b7048] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The routine offer of an HIV test during patient-provider encounters is gaining momentum within HIV treatment and prevention programmes. This review examined the operational implementation of provider-initiated testing and counselling (PITC) programmes in sub-Saharan Africa. DESIGN AND METHODS PUBMED, EMBASE, Global Health, COCHRANE Library and JSTOR databases were searched systematically for articles published in English between January 2000 and November 2010. Grey literature was explored through the websites of international and nongovernmental organizations. Eligibility of studies was based on predetermined criteria applied during independent screening by two researchers. RESULTS We retained 44 studies out of 5088 references screened. PITC polices have been effective at identifying large numbers of previously undiagnosed individuals. However, the translation of policy guidance into practice has had mixed results, and in several studies of routine programmes the proportion of patients offered an HIV test was disappointingly low. There were wide variations in the rates of acceptance of the test and poor linkage of those testing positive to follow-up assessments and antiretroviral treatment. The challenges encountered encompass a range of areas from logistics, to data systems, human resources and management, reflecting some of the weaknesses of health systems in the region. CONCLUSIONS The widespread adoption of PITC provides an unprecedented opportunity for identifying HIV-positive individuals who are already in contact with health services and should be accompanied by measures aimed at strengthening health systems and fostering the normalization of HIV at community level. The resources and effort needed to do this successfully should not be underestimated.
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Clouse K, Pettifor A, Shearer K, Maskew M, Bassett J, Larson B, Van Rie A, Sanne I, Fox MP. Loss to follow-up before and after delivery among women testing HIV positive during pregnancy in Johannesburg, South Africa. Trop Med Int Health 2013; 18:451-60. [PMID: 23374278 DOI: 10.1111/tmi.12072] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE HIV-positive pregnant women are at heightened risk of becoming lost to follow-up (LTFU) from HIV care. We examined LTFU before and after delivery among pregnant women newly diagnosed with HIV. METHODS Observational cohort study of all pregnant women ≥18 years (N = 300) testing HIV positive for the first time at their first ANC visit between January and June 2010, at a primary healthcare clinic in Johannesburg, South Africa. Women (n = 27) whose delivery date could not be determined were excluded. RESULTS Median (IQR) gestation at HIV testing was 26 weeks (21-30). Ninety-eight per cent received AZT prophylaxis, usually started at the first ANC visit. Of 139 (51.3%) patients who were ART eligible, 66.9% (95% CI 58.8-74.3%) initiated ART prior to delivery; median (IQR) ART duration pre-delivery was 9.5 weeks (5.1-14.2). Among ART-eligible patients, 40.5% (32.3-49.0%) were cumulatively retained through 6 months on ART. Of those ART-ineligible patients at HIV testing, only 22.6% (95% CI 15.9-30.6%) completed CD4 staging and returned for a repeat CD4 test after delivery. LTFU (≥1 month late for last scheduled visit) before delivery was 20.5% (95% CI 16.0-25.6%) and, among those still in care, 47.9% (95% CI 41.2-54.6%) within 6 months after delivery. Overall, 57.5% (95% CI 51.6-63.3%) were lost between HIV testing and 6 months post-delivery. CONCLUSIONS Our findings highlight the challenge of continuity of care among HIV-positive pregnant women attending antenatal services, particularly those ineligible for ART.
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Affiliation(s)
- Kate Clouse
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Abstract
This article summarizes the conclusions and recommendations from the articles in this supplement. It presents a call for greater clarity of thinking related to projections of future need for HIV treatment and care. The demands placed on HIV treatment and care services will increase for the foreseeable future while the resources available for this are likely to remain constant or to decline. This highlights the need for realistic budgeting by national governments. The key strategies that should be employed to sustain HIV treatment and care programmes in high HIV-prevalence low and middle-income countries over the coming decade include further decentralization, task shifting, and integration of HIV services with other chronic disease treatment services. At the same time, greater attention will need to be given to the provision of mental healthcare for those living with HIV; to the specific treatment needs of children, adolescents, pregnant women and older people; and to the standard collection of validated indicators of treatment outcomes within national programmes. For the considerable gains that have been achieved to be sustained, funders--both internal and external to the country concerned--need to prioritize investment in operations research to maximise the efficiency of their other investments in HIV treatment and care services.
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Suthar AB, Hoos D, Beqiri A, Lorenz-Dehne K, McClure C, Duncombe C. Integrating antiretroviral therapy into antenatal care and maternal and child health settings: a systematic review and meta-analysis. Bull World Health Organ 2012; 91:46-56. [PMID: 23397350 DOI: 10.2471/blt.12.107003] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 10/27/2012] [Accepted: 10/30/2012] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine whether integrating antiretroviral therapy (ART) into antenatal care (ANC) and maternal and child health (MCH) clinics could improve programmatic and patient outcomes. METHODS The authors systematically searched PubMed, Embase, African Index Medicus and LiLACS for randomized controlled trials, prospective cohort studies, or retrospective cohort studies comparing outcomes in ANC or MCH clinics that had and had not integrated ART. The outcomes of interest were ART coverage, ART enrolment, ART retention, mortality and transmission of human immunodeficiency virus (HIV). FINDINGS Four studies met the inclusion criteria. All were conducted in ANC clinics. Increased enrolment of pregnant women in ART was observed in ANC clinics that had integrated ART (relative risk, RR: 2.09; 95% confidence interval, CI; 1.78-2.46; I(2): 15%). Increased ART coverage was also noted in such clinics (RR: 1.37; 95% CI: 1.05-1.79; I(2): 83%). Sensitivity analyses revealed a trend for the national prevalence of HIV infection to explain the heterogeneity in the size of the effect of ART integration on ART coverage (P = 0.13). Retention in ART was similar in ANC clinics with and without ART integration. CONCLUSION Although few data were available, ART integration in ANC clinics appears to lead to higher rates of ART enrolment and ART coverage. Rates of retention in ART remain similar to those observed in referral-based models.
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Affiliation(s)
- Amitabh B Suthar
- Department of HIV/AIDS, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland.
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