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Noholoza S, Phillips TK, Madwayi S, Mrubata M, Camlin CS, Myer L, Clouse K. Smartphone Ownership and Usage Among Pregnant Women Living With HIV in South Africa: Secondary Analysis of CareConekta Trial Data. JMIR Form Res 2023; 7:e43855. [PMID: 37347521 DOI: 10.2196/43855] [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: 10/27/2022] [Revised: 04/06/2023] [Accepted: 04/23/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Mobile health (mHealth) initiatives are increasingly common in low-resource settings, but the appropriateness of smartphone interventions in health care settings is uncertain. More research is needed to establish the appropriateness and feasibility of integrating new mHealth modalities (novel apps and social media apps) in the South African context. OBJECTIVE In this study, to inform future mHealth interventions, we describe smartphone ownership, preferences, and usage patterns among pregnant women living with HIV in Gugulethu, South Africa. METHODS We screened pregnant women living with HIV from December 2019 to February 2021 for the CareConekta trial. To be enrolled in the trial, respondents were required to be 18 years of age or older, living with HIV, ≥28 weeks pregnant, and own a smartphone that met the technical requirements of the CareConekta app. In this secondary analysis, we describe mobile phone ownership and sociodemographic characteristics of all women screened for eligibility (n=639), and smartphone use patterns among those enrolled in the trial (n=193). RESULTS Overall, median age was 31 (IQR 27-35) years. Of the 582 women who owned smartphones, 580 responded to the question about whether or not it was a smartphone, 2 did not. Among those with smartphones, 92% (421/458) of them used the Android operating system of version 5.0 or above, 98% (497/506) of phones had a GPS, and 96% (485/506) of individuals charged their phones less than twice a day. Among women who were enrolled in the trial, nearly all (99%, 190/193) owned the smartphone themselves; however, 14% (26/193) shared their smartphone with someone. In this case, 96% (25/26) reported possessing the phone most of the day. Median duration of ownership of the smartphone was 12 (IQR 5-24) months, median duration with current phone number use was 25 (IQR 12-60) months, and median number of cell phone numbers owned 2 years prior to enrollment in the trial was 2 (IQR 1-2). Receiving (192/193, 99.5%) and making (190/193, 99%) phone calls were among the most common smartphone uses. The least used features were GPS (106/193, 55%) and email (91/193, 47%). WhatsApp was most frequently reported as a favorite app (181/193, 94%). CONCLUSIONS Smartphone ownership is very common among pregnant women living with HIV in this low-resource, periurban setting. Phone sharing was uncommon, nearly all used the Android system, and phones retained sufficient battery life. These results are encouraging to the development of mHealth interventions. Existing messaging platforms-particularly WhatsApp-are exceedingly popular and could be leveraged for interventions. Findings of moderate smartphone ownership turnover and phone number turnover are considerations for mHealth interventions in similar settings. TRIAL REGISTRATION ClinicalTrials.gov NCT03836625; https://clinicaltrials.gov/ct2/show/NCT03836625?term=NCT03836625.
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Affiliation(s)
- Sandisiwe Noholoza
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Tamsin K Phillips
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Sindiswa Madwayi
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Megan Mrubata
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Carol S Camlin
- Department of Obstetrics, Gynaecology & Reproductive Sciences, University of California, San Francisco, CA, United States
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Kate Clouse
- Vanderbilt University School of Nursing, Vanderbilt University, Nashville, TN, United States
- Vanderbilt Institute for Global Health, Nashville, TN, United States
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Clouse K, Noholoza S, Madwayi S, Mrubata M, Camlin CS, Myer L, Phillips TK. The Implementation of a GPS-Based Location-Tracking Smartphone App in South Africa to Improve Engagement in HIV Care: Randomized Controlled Trial. JMIR Mhealth Uhealth 2023; 11:e44945. [PMID: 37204838 PMCID: PMC10238954 DOI: 10.2196/44945] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/10/2023] [Accepted: 04/21/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND Mobile health interventions are common in public health settings in Africa, and our preliminary work showed that smartphones are increasing in South Africa. We developed a novel smartphone app-CareConekta-that used GPS location data to characterize personal mobility to improve engagement in HIV care among pregnant and postpartum women living with HIV in South Africa. The app also used the user's location to map nearby clinics. OBJECTIVE We aimed to describe the feasibility, acceptability, and initial efficacy of using the app in a real-world setting. METHODS We conducted a prospective randomized controlled trial at a public sector clinic near Cape Town, South Africa. We enrolled 200 pregnant (third trimester) women living with HIV who owned a smartphone that met the required specifications. All participants installed the app, designed to collect 2 GPS heartbeats per day to geolocate the participant within a random 1-km fuzzy radius (for privacy). We randomized (1:1) participants to a control arm to receive the app with no additional support or an intervention arm to receive supportive phone calls, WhatsApp (Meta Platforms, Inc) messages, or both from the study team when traveling >50 km from the study area for >7 days. In addition to mobility data collected daily through the phone, participants completed questionnaires at enrollment and follow-up (approximately 6 months post partum). RESULTS A total of 7 participants were withdrawn at enrollment or shortly after because of app installation failure (6/200, 3%) or changing to an unsuitable phone (1/200, 0.50%). During the study period, no participant's smartphone recorded at least 1 heartbeat per day, which was our primary feasibility measure. Of the 171 participants who completed follow-up, only half (91/171, 53.2%) reported using the same phone as that used at enrollment, with the CareConekta app still installed on the phone and GPS usually enabled. The top reasons reported for the lack of heartbeat data were not having mobile data, uninstalling the app, and no longer having a smartphone. Acceptability measures were positive, but participants at follow-up demonstrated a lack of understanding of the app's purpose and function. The clinic finder was a popular feature. Owing to the lack of consistent GPS heartbeats throughout the study, we were unable to assess the efficacy of the intervention. CONCLUSIONS Several key challenges impeded our study feasibility. Although the app was designed to reverse bill participants for any data use, the lack of mobile data was a substantial barrier to our study success. Participants reported purchasing WhatsApp data, which could not support the app. Problems with the web-based dashboard meant that we could not consistently monitor mobility. Our study provides important lessons about implementing an ambitious GPS-based study under real-world conditions in a limited-resource setting. TRIAL REGISTRATION ClinicalTrials.gov NCT03836625; https://clinicaltrials.gov/ct2/show/NCT03836625. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1186/s13063-020-4190-x.
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Affiliation(s)
- Kate Clouse
- Vanderbilt University School of Nursing, Nashville, TN, United States
- Vanderbilt Institute for Global Health, Nashville, TN, United States
| | - Sandisiwe Noholoza
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Sindiswa Madwayi
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Megan Mrubata
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Tamsin K Phillips
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
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Nevrekar N, Butler K, Shapiro DE, Atuhaire P, Taha TE, Makanani B, Chinula L, Owor M, Moodley D, Chipato T, McCarthy K, Flynn PM, Currier J, Fowler MG, Gupta A, Suryavanshi N. Self-reported Antiretroviral Adherence: Association With Maternal Viral Load Suppression in Postpartum Women Living With HIV-1 From Promoting Maternal and Infant Survival Everywhere, a Randomized Controlled Trial in Sub-Saharan Africa and India. J Acquir Immune Defic Syndr 2023; 92:76-83. [PMID: 36170749 PMCID: PMC9722360 DOI: 10.1097/qai.0000000000003102] [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: 06/09/2022] [Accepted: 09/06/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Optimal adherence to antiretroviral therapy (ART) is crucial to promoting maternal-infant health. SETTING Fourteen sites in 7 countries within sub-Saharan Africa and India. METHODS The multicomponent, open-label strategy PROMISE trial enrolled breastfeeding mother-infant pairs not meeting in-country criteria for maternal ART (mART) initiation in the postpartum component within 5 days of delivery. Randomization was to mART versus infant NVP (iNVP) prophylaxis. Infants in the mART arm also received 6 weeks of iNVP. Self-reported adherence was assessed in a secondary analysis. Time-to-event analyses were performed to explore the association between adherence and maternal viral load (mVL) in the mART arm. RESULTS Two thousand four hundred thirty-one mother-infant pairs were enrolled between 2011 and 2014; the baseline maternal median CD4 was 686 (IQR 553-869), and the median mVL was 322 copies/mL (IQR 40-1422). Self-reported adherence was lower in the mART arm compared with the iNVP arm (no missed doses within 4 weeks of all study visits: 66% vs 83%; within 2 weeks: 71% vs 85%; P < 0.0001). The iNVP adherence at week 6 was high in both arms: 97% in mART arm; 95% in iNVP arm. Time-to-event analyses showed that adherence to mART was associated with time to first mVL ≥400 copies/mL ( P < 0.0001). Missing 1 full day of doses over 3 days was associated with a 66% risk of mVL ≥1000 copies/mL (HR: 1.66; 95% CI: 1.37, 1.99). CONCLUSIONS Postpartum women were less adherent to their own ART than mothers providing their infant's nevirapine prophylaxis. The self-reported missed mART doses were associated with high mVL. Strategies to optimize postpartum mART adherence are urgently needed. CLINICAL TRIAL NUMBER ClinicalTrials.gov: NCT01061151; closed to follow-up.
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Affiliation(s)
- Neetal Nevrekar
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site, Pune, India
| | - Kevin Butler
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - David E. Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Patience Atuhaire
- Makerere University–John Hopkins University Research Collaboration (MUJHU CARE LTD) CRS, Kampala, Uganda
| | - Taha E. Taha
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Bonus Makanani
- College of Medicine-Johns Hopkins Project, Blantyre, Malawi
| | | | - Maxensia Owor
- Makerere University–John Hopkins University Research Collaboration (MUJHU CARE LTD) CRS, Kampala, Uganda
| | - Dhayendre Moodley
- Centre for the AIDS Programme of Research in South Africa and Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
- Nelson R. Mandela School of Medicine, Durban, South Africa
| | - Tsungai Chipato
- Department of Obstetrics and Gynaecology, University of Zimbabwe, Harare, Zimbabwe
| | | | - Patricia M. Flynn
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN
| | - Judith Currier
- UCLA Centre for Clinical AIDS Research and Education, Los Angeles, CA
| | - Mary Glenn Fowler
- Department of Pathology, Johns Hopkins University, School of Medicine, Baltimore, MD; and
| | - Amita Gupta
- Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Nishi Suryavanshi
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site, Pune, India
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Oluoch T, Cornet R, Muthusi J, Katana A, Kimanga D, Kwaro D, Okeyo N, Abu-Hanna A, de Keizer N. A clinical decision support system is associated with reduced loss to follow-up among patients receiving HIV treatment in Kenya: a cluster randomized trial. BMC Med Inform Decis Mak 2021; 21:357. [PMID: 34930228 PMCID: PMC8686234 DOI: 10.1186/s12911-021-01718-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background Loss to follow-up (LFTU) among HIV patients remains a major obstacle to achieving treatment goals with the risk of failure to achieve viral suppression and thereby increased HIV transmission. Although use of clinical decision support systems (CDSS) has been shown to improve adherence to HIV clinical guidance, to our knowledge, this is among the first studies conducted to show its effect on LTFU in low-resource settings. Methods We analyzed data from a cluster randomized controlled trial in adults and children (aged ≥ 18 months) who were receiving antiretroviral therapy at 20 HIV clinics in western Kenya between Sept 1, 2012 and Jan 31, 2014. Participating clinics were randomly assigned, via block randomization. Clinics in the control arm had electronic health records (EHR) only while the intervention arm had an EHR with CDSS. The study objectives were to assess the effects of a CDSS, implemented as alerts on an EHR system, on: (1) the proportion of patients that were LTFU, (2) LTFU patients traced and successfully linked back to treatment, and (3) time from enrollment on the study to documentation of LTFU. Results Among 5901 eligible patients receiving ART, 40.6% (n = 2396) were LTFU during the study period. CDSS was associated with lower LTFU among the patients (Adjusted Odds Ratio—aOR 0.70 (95% CI 0.65–0.77)). The proportions of patients linked back to treatment were 25.8% (95% CI 21.5–25.0) and 30.6% (95% CI 27.9–33.4)) in EHR only and EHR with CDSS sites respectively. CDSS was marginally associated with reduced time from enrollment on the study to first documentation of LTFU (adjusted Hazard Ratio—aHR 0.85 (95% CI 0.78–0.92)). Conclusion A CDSS can potentially improve quality of care through reduction and early detection of defaulting and LTFU among HIV patients and their re-engagement in care in a resource-limited country. Future research is needed on how CDSS can best be combined with other interventions to reduce LTFU. Trial registration NCT01634802. Registered at www.clinicaltrials.gov on 12-Jul-2012. Registered prospectively.
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Affiliation(s)
- Tom Oluoch
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, 1600 Clifton Road NE, GA, 30329, Atlanta, USA.
| | - Ronald Cornet
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jacques Muthusi
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Abraham Katana
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Davies Kimanga
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Daniel Kwaro
- Kenya Medical Research Institute - CDC Collaborative Program, Kisumu, Kenya
| | - Nicky Okeyo
- Kenya Medical Research Institute - CDC Collaborative Program, Kisumu, Kenya
| | - Ameen Abu-Hanna
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicolette de Keizer
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Naburi HE, Mujinja P, Kilewo C, Biberfeld G, Bärnighausen T, Manji K, Lyatuu G, Urrio R, Zethraeus N, Orsini N, Ekström AM. Health care costs associated with clinic visits for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania. Medicine (Baltimore) 2021; 100:e27828. [PMID: 34797311 PMCID: PMC8601283 DOI: 10.1097/md.0000000000027828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/28/2021] [Indexed: 01/05/2023] Open
Abstract
Early and appropriate antenatal care (ANC) is key for the effectiveness of prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV). We evaluated the importance of ANC visits and related service costs for women receiving option B+ to prevent mother-to-child transmission (MTCT) of HIV in Tanzania.A cost analysis from a health care sector perspective was conducted using routine data of 2224 pregnant women newly diagnosed with HIV who gave birth between August 2014 and May 2016 in Dar es Salaam, Tanzania. We evaluated risk of infant HIV infection at 12 weeks postnatally in relation to ANC visits (<4 vs ≥4 visits). Costs for service utilisation were estimated through empirical observations and the World Health Organisation Global Price Reporting Mechanism.Mean gestational age at first ANC visit was 22 (±7) weeks. The average number of ANC/prevention of MTCT visits among the 2224 pregnant women in our sample was 3.6 (95% confidence interval [CI] 3.6-3.7), and 57.3% made ≥4 visits. At 12 weeks postnatally, 2.7% (95% CI 2.2-3.6) of HIV exposed infants had been infected. The risk of MTCT decreased with the number of ANC visits: 4.8% (95% CI 3.6-6.4) if the mother had <4 visits, and 1.0% (95% CI 0.5-1.7) at ≥4. The adjusted MTCT rates decreased by 51% (odds ratio 0.49, 95% CI 0.31-0.77) for each additional ANC visit made. The potential cost-saving was 2.2 US$ per woman at ≥4 visits (84.8 US$) compared to <4 visits (87.0 US$), mainly due to less defaulter tracing.Most pregnant women living with HIV in Dar es Salaam initiated ANC late and >40% failed to adhere to the recommended minimum of 4 visits. Improved ANC attendance would likely lead to fewer HIV-infected infants and reduce both short and long-term health care costs due to less spending on defaulter tracing and future treatment costs for the children.
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Affiliation(s)
- Helga Elineema Naburi
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Phares Mujinja
- Institute of Public health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Charles Kilewo
- Departments of Obstetrics and Gynaecology, MUHAS, Dar es Salaam, Tanzania
| | - Gunnel Biberfeld
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
- Africa Health Research Institute (AHRI), Mtubatuba, South Africa
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Karim Manji
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Goodluck Lyatuu
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Departments of Obstetrics and Gynaecology, MUHAS, Dar es Salaam, Tanzania
- Management and Development for Health (MDH), Dar es Salaam, Tanzania
| | - Roseline Urrio
- Departments of Obstetrics and Gynaecology, MUHAS, Dar es Salaam, Tanzania
- Management and Development for Health (MDH), Dar es Salaam, Tanzania
| | - Niklas Zethraeus
- Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | - Nicola Orsini
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Kiirya Y, Musoke P, Adobea Odei Obeng-Amoako G, Kalyango J. Loss to follow up after pregnancy among mothers enrolled on the option B+ program in Uganda. PUBLIC HEALTH IN PRACTICE 2021; 2:100085. [PMID: 36101573 PMCID: PMC9461603 DOI: 10.1016/j.puhip.2021.100085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 01/19/2021] [Indexed: 11/04/2022] Open
Abstract
Objective Option-B+ programs in Uganda have reported high levels of loss to follow up (LTFU) after cessation of breastfeeding, and this remains unknown beyond this period. In this study, we assessed the incidence and factors associated with LTFU two to four years after delivery among Option-B+ mothers. Study design Retrospective cohort. Methods We reviewed files of 452 mothers who enrolled on Option-B+ between January 1st, 2013 and December 31st, 2014 at Kisenyi Health Centre IV in Kampala district. We assessed factors associated with LTFU using Cox proportional hazards regression. We also explored the reasons for LTFU using three focus group discussions, five in-depth and three key informant interviews. Results Of the 452 mothers, 131(29%) were LTFU after delivery. The incidence of LTFU after delivery was 17/1000 person months (95% CI, 14–30/1000) with a median follow up of 32 months. The risk of LTFU was higher among mothers who started ART on the day they tested HIV positive (aHR = 1.66, 95% CI; 1.25–2.20, p-value< 0.001). Reasons for LFTU included transport costs, stigma, poor human resource policies and non-disclosure. Conclusion LTFU after delivery among Option-B+ mothers is higher than the global target of 15%. ART initiation on the day a mother tests positive increases the risk of LTFU. The major reasons for LTFU were stigma and non-disclosure. To reduce the risk of LTFU, we recommend approaches that encourage disclosure to sexual partners and ongoing specific support to mothers who are initiated on ART-the day of positive test. Loss to follow up (LTFU) among Option-B+ mothers after delivery is high. ART initiation on the day a mother tests positive increases the risk of LTFU. Non-disclosure is a major contributor to LTFU among Option-B+ mothers.
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Chepuka L, Kwanjo-Banda C, Kafulafula U, Sefasi A, Chorwe-Sungani G. Prevalence and associated factors of intimate partner violence amongst women attending prevention of mother to child transmission services in Blantyre, Malawi. S Afr Fam Pract (2004) 2021; 63:e1-e7. [PMID: 34636592 PMCID: PMC8603061 DOI: 10.4102/safp.v63i1.5271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/09/2021] [Accepted: 03/12/2021] [Indexed: 12/02/2022] Open
Abstract
Background Intimate partner violence (IPV) during the perinatal period and when one is HIV-positive is a great concern because of the physical and mental impacts it has on health and on adherence to prevention of mother to child transmission (PMTCT) services. However, factors associated with IPV amongst perinatal women on PMTCT services are not adequately explored in Malawi. The aim of this study was to estimate the various types of IPV and the associated factors amongst HIV-positive pregnant and postnatal women in selected health centres in Blantyre district. Methods In this cross-sectional study, we recruited 200 HIV-positive women from antenatal, postnatal and antiretroviral therapy (ART) clinics from four selected primary care facilities of Blantyre district. Data were collected between March and May 2018. Results A total of 50% of the participants reported to have experienced either physical, psychological or sexual violence from their partner in the last 12 months. The multivariate logistic regression model showed that feelings about safety of the relationship and depression were the only factors that were consistently associated with IPV in the last 12 months (p = 0.001, Pseudo R2 = 0.20). Conclusion The presence of depression and safety concerns amongst our study participants calls for serious prioritisation of psychological interventions and risk assessment in the management of HIV-positive perinatal mothers who report IPV cases.
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Affiliation(s)
- Lignet Chepuka
- Department of Adult Health, Faculty of Nursing Health Studies, Kamuzu College of Nursing, University of Malawi, Blantyre.
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Yang LH, Poku OB, Misra S, Mehta HT, Rampa S, Eisenberg MM, Yang LS, Dai Cao TX, Blank LI, Becker TD, Link BG, Entaile P, Opondo PR, Arscott-Mills T, Ho-Foster AR, Blank MB. Stigma, Structural Vulnerability, and "What Matters Most" Among Women Living With HIV in Botswana, 2017. Am J Public Health 2021; 111:1309-1317. [PMID: 34110916 PMCID: PMC8493151 DOI: 10.2105/ajph.2021.306274] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Objectives. To explore whether beneficial health care policies, when implemented in the context of gender inequality, yield unintended structural consequences that stigmatize and ostracize women with HIV from "what matters most" in local culture. Methods. We conducted 46 in-depth interviews and 5 focus groups (38 individuals) with men and women living with and without HIV in Gaborone, Botswana, in 2017. Results. Cultural imperatives to bear children bring pregnant women into contact with free antenatal services including routine HIV testing, where their HIV status is discovered before their male partners'. National HIV policies have therefore unintentionally reinforced disadvantage among women with HIV, whereby men delay or avoid testing by using their partner's status as a proxy for their own, thus facilitating blame toward women diagnosed with HIV. Gossip then defines these women as "promiscuous" and as violating the essence of womanhood. We identified cultural and structural ways to resist stigma for these women. Conclusions. Necessary HIV testing during antenatal care has inadvertently perpetuated a structural vulnerability that propagates stigma toward women. Individual- and structural-level interventions can address stigma unintentionally reinforced by health care policies.
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Affiliation(s)
- Lawrence H. Yang
- Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the
| | - Ohemaa B. Poku
- Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the
| | - Supriya Misra
- Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the
| | - Haitisha T. Mehta
- Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the
| | - Shathani Rampa
- Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the
| | - Marlene M. Eisenberg
- Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the
| | - Lyla S. Yang
- Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the
| | - Thi Xuan Dai Cao
- Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the
| | - Lilo I. Blank
- Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the
| | - Timothy D. Becker
- Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the
| | - Bruce G. Link
- Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the
| | - Patlo Entaile
- Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the
| | - Philip R. Opondo
- Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the
| | - Tonya Arscott-Mills
- Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the
| | - Ari R. Ho-Foster
- Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the
| | - Michael B. Blank
- Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the
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9
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Njah J, Chiasson MA, Reidy W. Known HIV status among adolescent women attending antenatal care services in Eswatini, Ethiopia and Mozambique. Reprod Health 2021; 18:90. [PMID: 33941205 PMCID: PMC8091526 DOI: 10.1186/s12978-021-01090-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 01/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Antenatal care (ANC) clinics remain important entry points to HIV care for pregnant women living with HIV—including adolescents. Prior knowledge of their HIV status at ANC enrollment is crucial to providing services for prevention of mother-to-child transmission (PMTCT) of HIV. We examined known HIV status of pregnant adolescents and women in other age groups at ANC enrollment. Methods A descriptive study of routinely reported PMTCT data from 419 facilities in Eswatini, Ethiopia, and Mozambique, from January through December 2018 was conducted. We assessed knowledge of HIV status by country for three age groups: adolescents aged 15–19 years, young women aged 20–24 years, and older women aged 25–49 years. We report HIV prevalence and proportions of known and newly diagnosed HIV infections in women, by age group and country. The data were summarized by frequencies and proportions, including their 95% confidence intervals. Results Among the facilities examined, 52 (12.4%) were in Eswatini, 63 (15.0%) in Ethiopia, and 304 (72.6%) in Mozambique. Across three countries, 488,121 women attended a first ANC visit and 23,917 (4.9%) were HIV-positive. Adolescents constituted 22% of all ANC attendees, whereas young and older women represented 33% and 45%, respectively. HIV prevalence was lowest among adolescents than in other age groups in Eswatini (adolescents 11.9%, young 24.2% and older 47.3%), but comparable to young women in Ethiopia (adolescents 1.6%, young 1.6% and older 2.2%) and Mozambique (adolescents 2.5%, young 2.5% and older 5.8%), However, in each of the three countries, lower proportions of adolescents knew their HIV-positive status before ANC enrollment compared to other age groups: in Eswatini (adolescents 51.3%, young 59.9% and older 79.2%), in Ethiopia (adolescents 42.9%, young 63.7% and older 75.2%), and in Mozambique (adolescents 16.4%, young 33.2% and older 45.6%). Conclusion Overall, adolescents made up nearly one-quarter of the women examined and had the least knowledge of their HIV status at ANC enrollment. Their HIV prevalence and known HIV-positive status varied widely across the countries examined. Adolescent-friendly sexual and reproductive health, and PMTCT services, before pregnancy, are needed to improve knowledge of HIV status and support pregnant adolescents and their infants. Plain English summary Antenatal care (ANC) clinics are important for HIV testing of pregnant adolescents, who may not know their HIV-positive status at the first ANC visit. We describe data on pregnant adolescents and women in other age groups in ANC services to examine their prior HIV status at ANC enrollment across three African countries. We examined data from 419 PMTCT sites in Eswatini, Ethiopia, and Mozambique from January-December 2018, to evaluate HIV testing results for adolescents, young and older women aged 15–19, 20–24 and 25–49 years, respectively. We report the number of women living with HIV and the proportions of known and newly identified women living with HIV, by age-group and country. Across three countries, 488,121 women attended ANC and 23,917 (4.9%) were living with HIV. Adolescents constituted 22% of all ANC attendees, whereas young and older women represented 33% and 45%, respectively. HIV prevalence in each country compared to other age groups was lowest and varied among adolescents from 11.9% in Eswatini, to 1.6% in Ethiopia and to 2.5% in Mozambique. Also, fewer adolescents knew their HIV-positive status before ANC enrollment compared to young and older women from 51.3% in Eswatini, 42.9% in Ethiopia to only 16.4% in Mozambique. Pregnant adolescents made up nearly one-quarter of all ANC attendees; a majority of them had no previously known HIV-positive status. Adolescent-friendly, sexual and reproductive health services, before pregnancy and in PMTCT services, are needed to support pregnant adolescents and their infants. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-021-01090-2.
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Affiliation(s)
- Joel Njah
- ICAP At Columbia University's Mailman School of Public Health, 722 W. 168th St., New York, NY, 10032, USA
| | - Mary Ann Chiasson
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.,Division of Infectious Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - William Reidy
- ICAP At Columbia University's Mailman School of Public Health, 722 W. 168th St., New York, NY, 10032, USA. .,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
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10
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HATCHER AM, BRITTAIN K, PHILLIPS TK, ZERBE A, ABRAMS EJ, MYER L. Longitudinal association between intimate partner violence and viral suppression during pregnancy and postpartum in South African women. AIDS 2021; 35:791-799. [PMID: 33587440 PMCID: PMC7969405 DOI: 10.1097/qad.0000000000002796] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We examined the longitudinal association between women's exposure to intimate partner violence (IPV) and HIV viral load during pregnancy and postpartum. DESIGN Secondary analysis of an HIV-positive cohort enrolled during pregnancy at a South African antenatal clinic. METHODS Viral load was assessed at 10 study visits and analyzed continuously as log10 copies/ml and suppression at less than 50 copies/ml. IPV was measured at three timepoints using behaviorally specific items. We used multivariate logistic regression to examine the association between IPV and viral suppression, and cross-lagged dynamic panel modeling (DPMs) to estimate the longitudinal association between IPV (lagged by 3-6 months) and log10 viral load. RESULTS Of 471 women, 84% were virally suppressed by 6 weeks postpartum and 67% at 12 months postpartum. One-third reported IPV exposure. IPV victimization was not associated with viral suppression at delivery, but was associated with a reduced odds of viral suppression at 12 months postpartum (aOR = 0.48, 95% CI = 0.27-0.85). Findings were robust to sensitivity analyses at different timepoints and clinical cut-points. In DPMs, lagged IPV exposure was associated with higher log10 viral load after controlling for past viral load, duration on ART, age, alcohol use, and gestation at study enrolment. Each standardized increase in IPV intensity was associated with higher log10 viral load (standardized coefficient = 0.12, 95% CI = 0.05-0.23). CONCLUSION Although viral suppression was widely achieved during pregnancy, suppression rates declined postpartum in this South African cohort. These data suggest IPV is longitudinally associated with elevated viral load postpartum. Interventions for reducing exposure to IPV are important for the health of women and may improve HIV care and treatment.
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Affiliation(s)
- Abigail M HATCHER
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Kirsty BRITTAIN
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Tamsin K PHILLIPS
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Allison ZERBE
- ICAP, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Elaine J ABRAMS
- ICAP, Mailman School of Public Health, Columbia University, New York, New York, USA
- Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Landon MYER
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
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11
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Clouse K, Phillips TK, Mogoba P, Ndlovu L, Bassett J, Myer L. Attitudes Toward a Proposed GPS-Based Location Tracking Smartphone App for Improving Engagement in HIV Care Among Pregnant and Postpartum Women in South Africa: Focus Group and Interview Study. JMIR Form Res 2021; 5:e19243. [PMID: 33555261 PMCID: PMC7899801 DOI: 10.2196/19243] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/27/2020] [Accepted: 01/07/2021] [Indexed: 01/13/2023] Open
Abstract
Background Peripartum women living with HIV in South Africa are at high risk of dropping out of care and are also a particularly mobile population, which may impact their engagement in HIV care. With the rise in mobile phone use worldwide, there is an opportunity to use smartphones and GPS location software to characterize mobility in real time. Objective The aim of this study was to propose a smartphone app that could collect individual GPS locations to improve engagement in HIV care and to assess potential users’ attitudes toward the proposed app. Methods We conducted 50 in-depth interviews (IDIs) with pregnant women living with HIV in Cape Town and Johannesburg, South Africa, and 6 focus group discussions (FGDs) with 27 postpartum women living with HIV in Cape Town. Through an open-ended question in the IDIs, we categorized “positive,” “neutral,” or “negative” reactions to the proposed app and identified key quotations. For the FGD data, we grouped the text into themes, then analyzed it for patterns, concepts, and associations and selected illustrative quotations. Results In the IDIs, the majority of participants (76%, 38/50) responded favorably to the proposed app. Favorable comments were related to the convenience of facilitated continued care, a sense of helpfulness on the part of the researchers and facilities, and the difficulties of trying to maintain care while traveling. Among the 4/50 participants (8%) who responded negatively, their comments were primarily related to the individual’s responsibility for their own health care. The FGDs revealed four themes: facilitating connection to care, informed choice, disclosure (intentional or unintentional), and trust in researchers. Conclusions Women living with HIV were overwhelmingly positive about the idea of a GPS-based smartphone app to improve engagement in HIV care. Participants reported that they would welcome a tool to facilitate connection to care when traveling and expressed trust in researchers and health care facilities. Within the context of the rapid increase of smartphone use in South Africa, these early results warrant further exploration and critical evaluation following real-world experience with the app.
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Affiliation(s)
- Kate Clouse
- Vanderbilt University School of Nursing, Nashville, TN, United States.,Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Tamsin K Phillips
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Phepo Mogoba
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Linda Ndlovu
- Division of Epidemiology and Biostatistics, 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
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12
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Abbamonte JM, Parrish MS, Lee TK, Ramlagan S, Sifunda S, Peltzer K, Weiss SM, Jones DL. Influence of Male Partners on HIV Disclosure Among South African Women in a Cluster Randomized PMTCT Intervention. AIDS Behav 2021; 25:604-614. [PMID: 32892297 PMCID: PMC10174224 DOI: 10.1007/s10461-020-03021-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Disclosure of HIV serostatus is beneficial for women, their partners, and their infants as it enables women to actively participate in preventative care (Hodgson et al. in PLoS ONE 9(11):e111421, 2014; Odiachi et al. in Reprod Health 15(1):36, 2018). Therefore, it is important that interventions addressing HIV prevention include elements that foster disclosure of HIV to partners. This study conducted in South Africa utilizes the "Protect Your Family" (PYF) behavioral intervention and compares Prevention of Mother to Child Transmission (PMTCT) among women participating in the program versus those in a control program. Within both groups, male partners were either present or not present for the intervention. The purpose of this study was to examine differential disclosure over time for individuals in the different conditions and partner involvement. A firth logistic regression revealed an interaction in the experimental condition with male partners participating (b = - 2.84, SE = 1.56, p = .012), in which female participants were less likely to disclose their HIV status over time. Findings from this study illustrate that additional efforts are needed to empower women to disclose their HIV status.
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Affiliation(s)
- John M Abbamonte
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Dominion Towers Suite 404, 1400 NW 10th Avenue, Miami, FL, 33136, USA
| | | | - Tae K Lee
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, USA
| | - Shandir Ramlagan
- HIV/AIDS/STIs and TB Research Programme, Human Sciences Research Council, Pretoria, South Africa
| | - Sibusiso Sifunda
- HIV/AIDS/STIs and TB Research Programme, Human Sciences Research Council, Pretoria, South Africa
| | - Karl Peltzer
- HIV/AIDS/STIs and TB Research Programme, Human Sciences Research Council, Pretoria, South Africa
- Department of Research Administration and Development, University of Limpopo, Polokwane, South Africa
- Department of Psychology, University of the Free State, Bloemfontain, South Africa
| | - Stephen M Weiss
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Dominion Towers Suite 404, 1400 NW 10th Avenue, Miami, FL, 33136, USA
| | - Deborah L Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Dominion Towers Suite 404, 1400 NW 10th Avenue, Miami, FL, 33136, USA.
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13
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Mogoba P, Phillips TK, le Roux S, Mukonda EE, Brittain K, Gomba Y, Zerbe A, Abrams EJ, Myer L. Mother-child separation among women living with HIV and their children in the first four years postpartum in South Africa. Trop Med Int Health 2020; 26:173-183. [PMID: 33159710 DOI: 10.1111/tmi.13518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Mother-child pairs may separate during early life, yet the health impacts thereof are unclear. We explored the patterns and impact of separation among women living with HIV (WLHIV) and their children in South Africa. METHODS WLHIV who had initiated antiretroviral therapy (ART) during pregnancy received HIV viral load (VL) testing and completed a timeline questionnaire of mother-child separation since delivery at 3-5 years post-partum. Health care usage was abstracted from routine medical records. We examined associations between separation and (a) maternal health outcomes (engagement in HIV care and HIV viral suppression, [VS]) and (b) child health outcomes (post-breastfeeding HIV testing and immunisation completion), using logistic regression. RESULTS Of 346 mother-child pairs (median maternal age at antenatal ART initiation, 28 years), 24% were ever separated (median time to first separation 20 months, interquartile range [IQR] 9, 31). Most separated children were living with their grandmothers (65/83, 78%). Mothers who ever separated were younger, and more likely to be employed, and to reside in informal housing than those who never separated. Any separation reduced the odds of VS ≤ 50 copies/mL at four years post-partum (odds ratio 0.57; 95% CI 0.34-0.93); associations were similar for VL ≤ 1000 copies/mL and maternal engagement in care. No association was found between separation and child confirmatory HIV testing or immunisation completion. CONCLUSIONS In this setting, mother-child separation is common in the first four years of life and appears associated with suboptimal maternal outcomes. Further research is required to understand the drivers and implications of mother-child separation.
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Affiliation(s)
- Phepo Mogoba
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Tamsin K Phillips
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Stanzi le Roux
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elton E Mukonda
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kirsty Brittain
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Yolanda Gomba
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Allison Zerbe
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Elaine J Abrams
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA.,College of Physicians and Surgeons, Columbia University, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,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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14
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Clouse K, Malope-Kgokong B, Bor J, Nattey C, Mudau M, Maskew M. The South African National HIV Pregnancy Cohort: evaluating continuity of care among women living with HIV. BMC Public Health 2020; 20:1662. [PMID: 33153468 PMCID: PMC7643452 DOI: 10.1186/s12889-020-09679-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND South Africa is home to more people living with HIV than any other country, including nearly one in three pregnant women attending antenatal care. Access to antiretroviral therapy (ART) has increased substantially since the start of the national ART program in 2004, with > 95% ART coverage during pregnancy and delivery, and vertical transmission of HIV greatly reduced. However, women who initiate ART during pregnancy are at heightened risk of dropping out of care, particularly after delivery, leading to the potential for viral transmission, morbidity and mortality. It is difficult to evaluate the success of policies of expanded access to ART care, and assess continuity of care, due to the lack of a national longitudinal HIV care database. Also, patient movement between unlinked facilities. For the first time on a national level, we propose to utilize routinely-collected laboratory data to develop and validate a cohort of pregnant women living with HIV in South Africa in a way that is uniquely robust to facility transfer. METHODS Using laboratory test data matched to facility type, we will identify entry to antenatal care to build the cohort, then describe key treatment milestones, including 1) engagement in antenatal care, 2) initiation of ART, 3) HIV viremia, and 4) continuity of HIV care in the postpartum period. Second, we will measure the effect of system-wide factors impacting continuity of care among pregnant women. We will assess policies of expanded treatment access on continuity of care using regression-discontinuity analyses. We then will assess mobility and its effect on continuity of care during and after pregnancy. Third, we will identify individual-level risk factors for loss from HIV care in order to develop targeted interventions to improve engagement in HIV care. DISCUSSION This work will create the world's largest national cohort of pregnant women living with HIV. This novel cohort will be a powerful tool available to policymakers, clinicians and researchers for improving our understanding of engagement in care among pregnant women in South Africa and assessing the performance of the South African national ART program in caring for pregnant women living with HIV. TRIAL REGISTRATION N/A (not a clinical trial).
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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
- 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
| | - Babatyi Malope-Kgokong
- Academic Affairs and Research, National Health Laboratory Service, Johannesburg, South Africa
| | - Jacob Bor
- 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
- Department of Global Health, Boston University School of Public Health, Boston, MA USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA USA
| | - Cornelius Nattey
- 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
| | - Maanda Mudau
- Academic Affairs and Research, National Health Laboratory Service, Johannesburg, South Africa
| | - Mhairi Maskew
- 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
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15
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Poku OB, Ho-Foster AR, Entaile P, Misra S, Mehta H, Rampa S, Goodman M, Arscott-Mills T, Eschliman E, Jackson V, Melese T, Becker TD, Eisenberg M, Link B, Go V, Opondo PR, Blank MB, Yang LH. 'Mothers moving towards empowerment' intervention to reduce stigma and improve treatment adherence in pregnant women living with HIV in Botswana: study protocol for a pragmatic clinical trial. Trials 2020; 21:832. [PMID: 33028387 PMCID: PMC7542742 DOI: 10.1186/s13063-020-04676-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/12/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND With high rates of HIV and multiple vulnerable subgroups across diverse settings, there is a need for culturally based, HIV stigma reduction interventions. Pregnant women who are living with HIV are especially in need of services to protect not only their own but also their children's lives. Uptake of HIV services worldwide is hindered by stigma towards persons living with HIV/AIDS. While cultural context plays a key role in shaping HIV stigma, these insights have not yet been fully integrated into stigma reduction strategies. By utilizing the "What Matters Most" stigma framework, we propose that an intervention to counter culturally salient aspects of HIV stigma will improve treatment adherence and other relevant outcomes. A pragmatic clinical trial in Botswana will evaluate the "Mothers Moving towards Empowerment" (MME) intervention, which seeks to address HIV stigma in Botswana and to specifically engage pregnant mothers so as to promote antiretroviral therapy (ART) adherence in the postpartum period. METHODS This study will test MME against treatment as usual (TAU) among pregnant mothers diagnosed with HIV and their infants. Outcomes will be assessed during pregnancy and 16 weeks postpartum. Women who meet eligibility criteria are assigned to MME or TAU. Women assigned to MME are grouped with others with similar estimated delivery dates, completing up to eight intervention group sessions scheduled before week 36 of their pregnancies. Primary outcomes among mothers include (i) reducing self-stigma, which is hypothesized to mediate improvements in (ii) psychological outcomes (quality of life, depression and social functioning), and (iii) adherence to antenatal care and ART. We will also examine a set of follow-up infant birth outcomes (APGAR score, preterm delivery, mortality (at < 16 weeks), birth weight, vaccination record, and HIV status). DISCUSSION Our trial will evaluate MME, a culturally based HIV stigma reduction intervention using the "What Matters Most" framework, to reduce stigma and improve treatment adherence among pregnant women and their infants. This study will help inform further refinement of MME and preparation for a future large-scale, multisite, randomized controlled trial (RCT) in Botswana. TRIAL REGISTRATION ClinicalTrials.gov NCT03698981 . Registered on October 8, 2018.
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Affiliation(s)
- Ohemaa B Poku
- Johns Hopkins University, Baltimore, MD, United States.
| | - Ari R Ho-Foster
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- University of Botswana, Gaborone, Botswana
| | | | | | | | | | | | - Tonya Arscott-Mills
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- University of Botswana, Gaborone, Botswana
| | | | - Valerie Jackson
- University of California San Francisco, San Francisco, CA, United States
| | | | - Timothy D Becker
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Bruce Link
- University of California Riverside, Riverside, CA, USA
| | - Vivian Go
- University of North Carolina at Chapel Hill, Chapel Hil, NC, USA
| | | | | | - Lawrence H Yang
- New York University, New York, NY, United States
- Columbia University Mailman School of Public Health, New York, NY, USA
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16
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Characterizing Viral Load Burden Among HIV-Infected Women Around the Time of Delivery: Findings From Four Tertiary Obstetric Units in Gauteng, South Africa. J Acquir Immune Defic Syndr 2020; 83:390-396. [PMID: 31914002 DOI: 10.1097/qai.0000000000002267] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Elimination of mother-to-child transmission of HIV requires sustained viral load suppression during pregnancy and breastfeeding among women living with HIV (WLHIV). Antenatal antiretroviral therapy coverage is reported at >95% in South Africa, but viral load suppression rates are unknown. We describe maternal VL burden around time of delivery at 4 tertiary obstetric units (TOUs) in Gauteng Province. METHODS Between June 2018 and March 2019, routine point-of-care (PoC) maternal HIV VL and early infant diagnosis (EID) testing were implemented at 3 TOUs in Johannesburg and 1 in Tshwane district. WLHIV and HIV-exposed neonates were eligible for HIV VL (Xpert HIV-1 VL) and EID (Xpert HIV-1 EID or m-PIMA HIV1/2 detection) testing around time of delivery, respectively. Proportions of viremic women and intrauterine (IU)-infected neonates were calculated among valid PoC results. RESULTS Among 8147 live births to WLHIV, 2769 (34.0%) women and 4333 (53.2%) neonates had valid PoC results. Median VL at delivery was <40 copies/mL (interquartile range: 0-398). The proportion of women with a VL < 50, 50 to <1000, and ≥1000 copies/mL was 63.6%, 13.9% and 22.4%, respectively. There were 65/4333 (1.5%) IU-infected neonates. Among 1449 mother-neonate pairs with both VL and EID results, IU transmission by VL threshold was 3/946 (0.3%), 6/187 (3.2%), and 25/316 (7.9%) for VL < 50, 50 to <1000, and ≥1000 copies/mL, respectively (P < 0.001). CONCLUSIONS Despite high antiretroviral therapy coverage, >1/3 of WLHIV had a VL ≥50 copies/mL at delivery. Among mother-neonate pairs, maternal VL ≥50 copies/mL accounted for 31/34 (91%) IU infections. Improvement in the quality of HIV care among WLHIV is essential if South Africa is to achieve elimination of mother-to-child transmission.
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17
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Sakyi KS, Lartey MY, Kennedy CE, Dension JA, Mullany LC, Owusu PG, Sacks E, Hurley EA, Surkan PJ. Barriers to maternal retention in HIV care in Ghana: key differences during pregnancy and the postpartum period. BMC Pregnancy Childbirth 2020; 20:398. [PMID: 32677910 PMCID: PMC7366890 DOI: 10.1186/s12884-020-03067-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 06/18/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maternal retention in HIV care is lower for women in the postpartum period than during pregnancy, but the reasons are poorly understood. We examined key differences in barriers to retention in HIV care during and after pregnancy. METHODS We conducted semi-structured, in-depth interviews with 30 postpartum women living with HIV. Participants were recruited from two tertiary facilities implementing Option B+ for prevention of mother-to-child HIV transmission in Accra, Ghana. We collected data from mothers who had disengaged from HIV care and those who were still engaged in care. The interviews were analyzed using principles adapted from grounded theory. RESULTS Participants' experiences and narratives showed that retention in HIV care was more challenging during the postpartum period than during pregnancy. Poor maternal physical health (from birth complications and cesarean section), socio-cultural factors (norms about newborn health and pregnancy), and economic difficulties linked to childbirth (such as unemployment, under-employment, and debt) made the costs of retention in HIV care more economically and socially expensive in the postpartum period than during pregnancy. Some participants also shared that transportation costs and resulting dependence on a partner to pay increased during the postpartum period because of a strong shift in maternal preference for private modes of transportation due to HIV stigma and the desire to protect the newborn. These factors played a larger role in the postpartum period than during pregnancy and created a significant barrier to retention. A conceptual model of how these factors interrelate, the synergy between them, and how they affect retention in the postpartum period is presented. CONCLUSIONS In Ghana, lower retention in HIV care in the postpartum period compared to in pregnancy may be primarily driven by social, economic, and newborn health factors. Multifaceted economic-based and stigma-reduction interventions are needed to increase retention in maternal HIV care after childbirth.
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Affiliation(s)
- Kwame S Sakyi
- Department of Public and Environmental Wellness, Oakland University, School of Health Sciences, 3101 Human Health Building, 433 Meadow Brook Rd, Rochester, MI, 48309-4452, USA.
- Center for Learning and Childhood Development-Ghana, AF, 3190, Adenta Flats, Accra, Ghana.
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Margaret Y Lartey
- Department of Medicine & Therapeutics, University of Ghana School of Medicine & Dentistry, CHS, P.O. Box GP 4236, Accra, Ghana
| | - Caitlin E Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Julie A Dension
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Luke C Mullany
- Department of Public and Environmental Wellness, Oakland University, School of Health Sciences, 3101 Human Health Building, 433 Meadow Brook Rd, Rochester, MI, 48309-4452, USA
- Center for Learning and Childhood Development-Ghana, AF, 3190, Adenta Flats, Accra, Ghana
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Prince G Owusu
- Center for Learning and Childhood Development-Ghana, AF, 3190, Adenta Flats, Accra, Ghana
| | - Emma Sacks
- Department of Public and Environmental Wellness, Oakland University, School of Health Sciences, 3101 Human Health Building, 433 Meadow Brook Rd, Rochester, MI, 48309-4452, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Emily A Hurley
- Health Services and Outcomes Research, Children's Mercy, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Pamela J Surkan
- Center for Learning and Childhood Development-Ghana, AF, 3190, Adenta Flats, Accra, Ghana
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
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18
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Livesley N, Coly A, Karamagi E, Nsubuga-Nyombi T, Mwita SK, Ngonyani MM, Mvungi J, Kinyua K, Muange P, Ismail A, Quick T, Stern A. Reducing Mother-to-Child Transmission of HIV Using Quality Improvement Approaches. J Int Assoc Provid AIDS Care 2020; 18:2325958219855631. [PMID: 31213119 PMCID: PMC6748455 DOI: 10.1177/2325958219855631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Over half of mother-to-child HIV transmission (MTCT) occurs postdelivery. Keeping mother-infant pairs in care remains challenging. Health workers in 3 countries used quality improvement (QI) approaches to improve data systems, mother-infant retention, and facility-based care delivery. The number and proportion of infants with known HIV status at time of discharge from early infant diagnosis programs increased in Tanzania and Uganda. We analyzed data using statistical process control charts. Mother-to-child HIV transmission did not decrease in 15 Kenyan sites, decreased from 12.7% to 3.8% in 28 Tanzanian sites, and decreased from 17.2% to 1.5% in 10 Ugandan sites with baseline data. This improvement is likely due to the combination of option B+, service delivery improvements, and retention through QI approaches. Reaching the global MTCT elimination target and maximizing infant survival will require health systems to support mother-infant pairs to remain in care and support health workers to deliver care. Quality improvement approaches can support these changes.
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Affiliation(s)
- Nigel Livesley
- 1 United States Agency for International Development (USAID) Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co, LLC (URC), Chevy Chase, MD, USA
| | - Astou Coly
- 1 United States Agency for International Development (USAID) Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co, LLC (URC), Chevy Chase, MD, USA
| | - Esther Karamagi
- 2 United States Agency for International Development (USAID) Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co, LLC (URC), Kampala, Uganda
| | - Tamara Nsubuga-Nyombi
- 2 United States Agency for International Development (USAID) Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co, LLC (URC), Kampala, Uganda
| | - Stella Kasindi Mwita
- 3 United States Agency for International Development (USAID) Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co, LLC (URC), Dar es Salaam, Tanzania
| | - Monica M Ngonyani
- 3 United States Agency for International Development (USAID) Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co, LLC (URC), Dar es Salaam, Tanzania
| | - Jane Mvungi
- 3 United States Agency for International Development (USAID) Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co, LLC (URC), Dar es Salaam, Tanzania
| | - Kevin Kinyua
- 4 United States Agency for International Development (USAID) Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co, LLC (URC), Nairobi, Kenya
| | - Prisca Muange
- 4 United States Agency for International Development (USAID) Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co, LLC (URC), Nairobi, Kenya
| | - Anisa Ismail
- 1 United States Agency for International Development (USAID) Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co, LLC (URC), Chevy Chase, MD, USA
| | - Timothy Quick
- 5 US Agency for International Development Office of HIV/AIDS, Bureau for Global Health, Washington, DC, USA
| | - Amy Stern
- 1 United States Agency for International Development (USAID) Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co, LLC (URC), Chevy Chase, MD, USA
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19
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Toska E, Laurenzi CA, Roberts KJ, Cluver L, Sherr L. Adolescent mothers affected by HIV and their children: A scoping review of evidence and experiences from sub-Saharan Africa. Glob Public Health 2020; 15:1655-1673. [PMID: 32507031 DOI: 10.1080/17441692.2020.1775867] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
While adolescents have received increasing attention in the global HIV response and international strategies and commitments, adolescent mothers and their children remain largely overlooked in research, funding and, programming for health-related outcomes. We conducted an extensive scoping review of current evidence on the experiences of adolescent mothers affected by HIV and their children in this region. We included published literature and conference abstracts, complemented by consultations with key stakeholders, and a review of documents through grey literature searching. First, we summarise the experiences of adolescent mothers and their children related to HIV and key health and development indicators. The syndemic of early motherhood and HIV in sub-Saharan Africa increases the vulnerability of adolescent mothers and their children. We then highlight lessons from a series of promising programmes focused on supporting adolescent mothers through novel approaches. In sub-Saharan Africa, supporting adolescent mothers living in high HIV-risk communities is critical not only to eliminate HIV/AIDS, but also to attain the Sustainable Development Goals. While research on and programming for adolescent mothers and their children is growing, the complex needs for this vulnerable group remain unmet. We conclude with evidence gaps and programming priorities for adolescent mothers affected by HIV and their children.
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Affiliation(s)
- Elona Toska
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa.,Department of Social Policy and Intervention, University of Oxford, Oxford, UK.,Department of Sociology, University of Cape Town, Cape Town, South Africa
| | - Christina A Laurenzi
- Institute for Life Course Health Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | | | - Lucie Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK.,Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Lorraine Sherr
- Institute for Global Health, University College London, London, UK
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20
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Rucinski KB, Schwartz SR, Powers KA, Pence BW, Chi BH, Black V, Rees H, Pettifor AE. Fertility Intentions and Clinical Care Attendance Among Women Living with HIV in South Africa. AIDS Behav 2020; 24:1585-1591. [PMID: 31228024 PMCID: PMC6925340 DOI: 10.1007/s10461-019-02564-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Poor HIV care retention impedes optimal treatment outcomes in persons living with HIV. Women trying to become pregnant may be motivated by periconception horizontal and vertical transmission concerns and thus more likely to attend HIV care visits than women not trying to conceive. We estimated the effect of fertility intentions on HIV care attendance over 12 months among non-pregnant, HIV-positive women aged 18-35 years who were on or initiating antiretroviral therapy in Johannesburg, South Africa. The percentage of women attending an HIV care visit decreased from 93.4% in the first quarter to 82.8% in the fourth quarter. Fertility intentions were not strongly associated with care attendance in this cohort of reproductive-aged women; however, attendance declined over time irrespective of childbearing plans. These findings suggest a need for reinforced efforts to support care engagement and risk reduction, including safer conception practices for women wishing to conceive.
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Affiliation(s)
- Katherine B Rucinski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E7133A, Baltimore, MD, 21205, USA.
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa.
| | - Sheree R Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E7133A, Baltimore, MD, 21205, USA
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Kimberly A Powers
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Brian W Pence
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Vivian Black
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
- Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Helen Rees
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey E Pettifor
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
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21
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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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22
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Kim HY, Dobra A, Tanser F. Migration and first-year maternal mortality among HIV-positive postpartum women: A population-based longitudinal study in rural South Africa. PLoS Med 2020; 17:e1003085. [PMID: 32231390 PMCID: PMC7108693 DOI: 10.1371/journal.pmed.1003085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 02/26/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND In South Africa, within-country migration is common. Mobility affects many of the factors in the pathway for entry to or retention in care among people living with HIV. We characterized the patterns of migration (i.e., change in residency) among peripartum women from rural South Africa and their association with first-year postpartum mortality. METHODS AND FINDINGS All pregnant women aged ≥15 years were followed-up during pregnancy and the first year postpartum in a population-based longitudinal demographic and HIV surveillance program in KwaZulu-Natal, South Africa, from 2000 to 2016. During the household surveys (every 4-6 months), each household head was interviewed to record demographic components of the household, including composition, migration, and mortality. External migration was defined as moving (i.e., change in residency) into or out of the study area. For women of reproductive age, detailed information on new pregnancy and birth was recorded. Maternal death was ascertained via verbal autopsy and HIV status at delivery via annual HIV surveys. We fitted mixed-effects Cox regression models adjusting for multiple pregnancies per individual. Overall, 19,334 women had 30,291 pregnancies: 3,339 were HIV-positive, 10,958 were HIV-negative, and 15,994 had unknown HIV status at delivery. The median age was 24 (interquartile range: 20-30) years. During pregnancy and the first year postpartum, 64% (n = 19,344) and 13% (n = 3,994) did not migrate and resided within and outside the surveillance area, respectively. Of the 23% who had externally migrated at least once, 39% delivered outside the surveillance area. Overall, the mortality rate was 5.8 per 1,000 person-years (or 831 deaths per 100,000 live births) in the first year postpartum. The major causes of deaths were AIDS- or tuberculosis-related conditions both within 42 days of delivery (53%) and during the first year postpartum (62%). In this study, we observed that HIV-positive peripartum women who externally migrated and delivered outside the surveillance area had a hazard of mortality more than two times greater (hazard ratio = 2.74; 95% confidence interval 1.01-7.40, p-value = 0.047)-after adjusting for age, time period (before or after 2010), and sociodemographic status-compared to that of HIV-positive women who continuously resided within the surveillance area. Study limitations include lack of data on access to antiretroviral therapy (ART) care and social or clinical context at the destinations among mobile participants, which could lead to unmeasured confounding. Further information on how mobile postpartum women access and remain in care would be instructive. CONCLUSIONS In this study, we found that a substantial portion of peripartum women moved within the country around the time of delivery and experienced a significantly higher risk of mortality. Despite the scale-up of universal ART and declining trends in maternal mortality, there is an urgent need to derive a greater understanding of the mechanisms underlying this finding and to develop targeted interventions for mobile HIV-positive peripartum women.
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Affiliation(s)
- Hae-Young Kim
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), KwaZulu-Natal, South Africa
- Department of Population Health, New York University School of Medicine, New York, New York, United States of America
| | - Adrian Dobra
- Department of Statistics, University of Washington, Seattle, Washington, United States of America
| | - Frank Tanser
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Lincoln Institute for Health, University of Lincoln, Lincoln, United Kingdom
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, KwaZulu-Natal, South Africa
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23
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Acceptability of Interventions to Improve Engagement in HIV Care Among Pregnant and Postpartum Women at Two Urban Clinics in South Africa. Matern Child Health J 2020; 23:1260-1270. [PMID: 31218606 DOI: 10.1007/s10995-019-02766-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Pregnant women initiating antiretroviral therapy (ART) in sub-Saharan Africa have been shown to have sub-optimal engagement in care, particularly after delivery, and interventions to improve engagement in care for this unique population are urgently needed. METHODS We enrolled 25 pregnant women living with HIV at each of two large antenatal clinics in Johannesburg and Cape Town, South Africa (n = 50), and conducted in-depth interviews. We assessed participants' reported acceptability of the following proposed interventions to improve engagement in care and retention monitoring data systems: financial incentives, educational toys, health education, combined maternal/infant visits, cell phone text reminders, mobility tracking, fingerprint/biometric devices, and smartcards. RESULTS Acceptability overall for interventions was high, with mixed responses for some interventions. Overall themes identified included (i) the intersection of individual and facility responsibility for a patient's health, (ii) a call for more health education, (iii) issues of disclosure and concerns about privacy, and (iv) openness to interventions that could improve health systems. DISCUSSION These findings provide insight into the preferences and concerns of potential users of interventions to improve engagement in HIV care for pregnant women, and support the development of tools that specifically target this high-risk group.
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24
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Kaplan S, Nteso KS, Ford N, Boulle A, Meintjes G. Loss to follow-up from antiretroviral therapy clinics: A systematic review and meta-analysis of published studies in South Africa from 2011 to 2015. South Afr J HIV Med 2019; 20:984. [PMID: 31956435 PMCID: PMC6956684 DOI: 10.4102/sajhivmed.v20i1.984] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/20/2019] [Indexed: 11/05/2022] Open
Abstract
Background South Africa has the largest antiretroviral therapy (ART) programme in the world. To optimise programme outcomes, it is critical that patients are retained in care and that retention is accurately measured. Objectives To identify all studies published in South Africa from 2011 to 2015 that used loss to follow-up (LTFU) as an indicator or outcome to describe the variation in definitions and to estimate the proportion of patients lost to care across studies. Method All studies published between 01 January 2011 and October 2015 that included loss to follow-up or default from ART care in a South African cohort were included by use of a broad search strategy across multiple databases. To be included, the cohort had to include any patient ART data, including follow-up time, from 01 January 2010. Two authors, working independently, extracted data and assessed risk of bias from all manuscripts. Meta-analysis was performed for studies stratified by the same loss to follow-up definition. Results Forty-eight adult, 15 paediatric and 4 pregnant cohorts were included. Median cohort size was 3737; follow-up time ranged from 9 weeks to 5 years. Meta-analysis did not reveal an important difference in LTFU estimates in adult cohorts at 1 year between loss to follow-up defined as 3 months (11.0%, n = 4; 95% CI 10.7% – 11.2%) compared with 6 months (12.0%, n = 4; 95% CI 11.8% – 12.2%). Only two cohorts reported reliable LTFU estimates at 5 years: this was 25.1% (95% CI 24.8% – 25.4%). Conclusion South Africa should standardise a LTFU definition. This would aid in monitoring and evaluation of ART programmes, with the broader goal of improving patient outcomes.
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Affiliation(s)
- Samantha Kaplan
- Department of Internal Medicine, University of Washington, Seattle, United States
| | - Katleho S Nteso
- Medical Care Development International, Maseru, Lesotho, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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25
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Rotheram-Borus MJ, Weichle TW, Wynn A, Almirol E, Davis E, Stewart J, Gordon S, Tubert J, Tomlinson M. Alcohol, But Not Depression or IPV, Reduces HIV Adherence Among South African Mothers Living with HIV Over 5 Years. AIDS Behav 2019; 23:3247-3256. [PMID: 31401739 DOI: 10.1007/s10461-019-02617-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Alcohol, depression, and intimate partner violence (IPV) are endemic in sub-Saharan Africa. This article examines whether and how these conditions affect mothers living with HIV (MLH), compared to mothers without HIV (MWOH). In particular, we assess the influence of these comorbidities on engagement in HIV care and adherence to antiretroviral therapies (ARV) among MLH. Data on maternal HIV care are typically based on clinic samples, with substantial loss to follow-up. This study fills that gap by including all mothers in specified areas. A cohort study examines MLH in Cape Town, South Africa recruited in pregnancy and followed repeatedly for 5 years, compared to MWOH. Almost all (98%) pregnant women in 12 neighborhoods (N = 594) were recruited in pregnancy. Mothers and children were reassessed five times over 5 years with high retention rates at each of the six assessments, from 98.7% at 2 weeks to 82.8% at 5 years post-birth. MLH's uptake and adherence to HIV care was evaluated over time associated with maternal comorbidities of alcohol use, depressed mood, and IPV using mixed effects logistic regression. MLH have fewer resources (income, food, education) and are more likely to face challenges from alcohol, depression, and having seropositive partners over time than MWOH. Only 22.6% of MLH were consistently engaged in HIV care from 6 months to 5 years post-birth. At 5 years, 86.7% self-reported engaged in HIV care, 76.9% were receiving ARVs and 87% of those on ARV reported consistent ARV adherence. However, data on viral suppression are unavailable. Alcohol use, but not depressed mood or IPV, was significantly related to reduced uptake of HIV care and adherence to ARV over time. Adherence to lifelong ARV by MLH requires a combination of structural and behaviorally-focused interventions. Alcohol abuse is not typically addressed in low and middle-income countries, but is critical to support MLH.
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Affiliation(s)
- Mary Jane Rotheram-Borus
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute, University of California at Los Angeles, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA, 90024, USA.
| | - Thomas W Weichle
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute, University of California at Los Angeles, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA, 90024, USA
| | - Adriane Wynn
- Division of Infectious Diseases & Global Public Health, School of Medicine, UCSD, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Ellen Almirol
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute, University of California at Los Angeles, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA, 90024, USA
| | - Emily Davis
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute, University of California at Los Angeles, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA, 90024, USA
| | - Jacqueline Stewart
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Francie van Zijl Drive, Cape Town, 7505, South Africa
| | - Sarah Gordon
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Francie van Zijl Drive, Cape Town, 7505, South Africa
| | - Julia Tubert
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute, University of California at Los Angeles, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA, 90024, USA
| | - Mark Tomlinson
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Francie van Zijl Drive, Cape Town, 7505, South Africa
- School of Nursing and Midwifery, Queens University, Belfast, UK
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Kim HY, Hanrahan CF, Martinson N, Golub JE, Dowdy DW. Cost-effectiveness of universal isoniazid preventive therapy among HIV-infected pregnant women in South Africa. Int J Tuberc Lung Dis 2019; 22:1435-1442. [PMID: 30606315 DOI: 10.5588/ijtld.18.0370] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To estimate the incremental cost-effectiveness of universal vs. test-directed treatment of latent tuberculous infection (LTBI) among human immunodeficiency virus (HIV) positive pregnant women in South Africa. METHODS We compared tuberculin skin test (TST) directed isoniazid preventive therapy (IPT) (TST placement with delivery of IPT to women with positive results) against QuantiFERON®-TB Gold In-Tube (QGIT) directed IPT and universal IPT using decision analysis. Costs were measured empirically in six primary care public health clinics in Matlosana, South Africa. The primary outcome was the incremental cost-effectiveness ratio, expressed in 2016 US$ per disability-adjusted life-year (DALY) averted. RESULTS We estimated that 29.2 of every 1000 pregnant women would develop TB over the course of 1 year in the absence of IPT. TST-directed IPT reduced this number to 24.5 vs. 22.6 with QGIT-directed IPT and 21.0 with universal IPT. Universal IPT was estimated to cost $640/DALY averted (95% uncertainty range $44-$3146) relative to TST-directed IPT and was less costly and more effective (i.e., dominant) than QGIT-directed IPT. Cost-effectiveness was most sensitive to the probability of developing TB and LTBI prevalence. CONCLUSION Providing IPT to all eligible women can be a cost-effective strategy to prevent TB among HIV-positive pregnant women in South Africa.
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Affiliation(s)
- H-Y Kim
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, Africa Health Research Institute, Durban, School of Nursing & Public Health, University of KwaZulu-Natal, Durban
| | - C F Hanrahan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - N Martinson
- Perinatal HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa, Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland
| | - J E Golub
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - D W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Impact of Shifts to Birth Testing on Early Infant Diagnosis Program Outcomes in KwaZulu-Natal, South Africa. Pediatr Infect Dis J 2019; 38:e138-e142. [PMID: 31192977 PMCID: PMC6598715 DOI: 10.1097/inf.0000000000002341] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND South African early infant diagnosis guidelines shifted to recommending an initial HIV nucleic acid-based test (NAT) test at birth in 2015. Prior to this, initial NAT was recommended at 6 weeks of age. Here we examine parameters of early infant diagnosis performance in KwaZulu-Natal before and after this change. METHODS Data on all HIV diagnostic NAT conducted for the province between January 2013 and April 2016 were assembled and analyzed. Laboratory barcodes allowed identification of repeat tests on the same child. We evaluated coverage, positivity rates, age at testing and frequency of repeat tests across birth cohorts. RESULTS In birth cohorts 2013 and 2014, 62.1% and 61.8%, respectively, of tests <16 weeks were done in children who were 6-8 weeks of age. In birth cohort 2015, 41.3% of tests <16 weeks were done earlier at <2 weeks of age. The percentage of children with a positive result who had at least 1 follow-up test increased from 11.5% and 13.1% in birth cohorts 2013 and 2014, respectively, to 24.8% in 2015. The percentage of infants with an initial nonpositive result who received at least 1 follow-up test did not appreciably change from 15.0% and 14.4% in 2013 and 2014, respectively, to 14.7% in 2015. CONCLUSIONS Birth testing allows for earlier identification of HIV-infected infants who need urgent antiretroviral treatment initiation. Although follow-up testing rates may be underestimated in this data source, repeat testing rates remained low. More effort is needed to ensure infants tested at birth continue to be engaged in care and undergo follow-up testing.
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Kim HY, Dowdy DW, Martinson NA, Kerrigan D, Tudor C, Golub J, Bridges JFP, Hanrahan CF. Maternal Motivation to Take Preventive Therapy in Antepartum and Postpartum Among HIV-Positive Pregnant Women in South Africa: A Choice Experiment. AIDS Behav 2019; 23:1689-1697. [PMID: 30415430 PMCID: PMC6810563 DOI: 10.1007/s10461-018-2324-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
HIV-positive pregnant women who are initiated on lifelong antiretroviral therapy (ART) and isoniazid preventive therapy (IPT) have lower adherence rates after delivery. We quantified maternal motivation to take preventive therapy before and after delivery among pregnant women newly diagnosed with HIV. We enrolled pregnant women (≥ 18 years) with a recent HIV diagnosis (< 6 months) at 14 public primary health clinics in Matlosana, South Africa and followed them in the postpartum period. Participants received eight choice tasks comparing two mutually exclusive sub-sets of seven possible benefits related to preventive therapy identified through literature reviews and key informant interviews. Data was analyzed using conditional logit regression in the antepartum versus postpartum periods. Coefficients are reported with 95% confidence intervals (CI). Sixty-five women completed surveys both at enrollment and in the postpartum period. All women were already on ART, while 21 (32%) were receiving IPT at enrollment. The mean CD4 count was 436 (± 246) cells/mm3. In the antepartum period, preventing HIV transmission to partners was the most important benefit (coefficients (ß) = 0.87, 95% CI 0.64, 1.11), followed by keeping healthy for family (ß = 0.75, 95% CI 0.52, 0.97). Such prioritization significantly decreased in the postpartum period (p < 0.001). Compared to other motivators, keeping a high CD4 count was least prioritized in the antepartum period (ß = 0.19, 95% CI - 0.04, 0.43) but was most prioritized in the postpartum period (ß = 0.39, 95% CI 0.21, 0.57). These results highlight that messages on family might be particularly salient in the antepartum period, and keeping CD4 count high in the postpartum period. Understanding maternal motivation may help to design targeted health promotion messages to HIV-positive women around the time of delivery.
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Affiliation(s)
- Hae-Young Kim
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA
- Africa Health Research Institute, Kwazulu-Natal, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Kwazulu-Natal, South Africa
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Neil A Martinson
- Perinatal HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa
- Center for Tuberculosis Research, Johns Hopkins University, Baltimore, MD, USA
| | - Deanna Kerrigan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Carrie Tudor
- International Council of Nurses, Geneva, Switzerland
| | - Jonathan Golub
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Tuberculosis Research, Johns Hopkins University, Baltimore, MD, USA
| | - John F P Bridges
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Colleen F Hanrahan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA.
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Spooner E, Govender K, Reddy T, Ramjee G, Mbadi N, Singh S, Coutsoudis A. Point-of-care HIV testing best practice for early infant diagnosis: an implementation study. BMC Public Health 2019; 19:731. [PMID: 31185962 PMCID: PMC6560857 DOI: 10.1186/s12889-019-6990-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 05/15/2019] [Indexed: 01/05/2023] Open
Abstract
Background With Universal Health Coverage and Integrated People-centred Health Care, streamlined health-systems and respectful care are necessary. South Africa has made great strides in prevention of mother-to-child transmission (PMTCT) but with the great burden of HIV, a minimum of birth and 10-week HIV-PCR testing are required for the estimated 360,000 HIV-exposed infants born annually which presents many challenges including delayed results and loss to follow-up. Point-of-care (POC) HIV testing of infants addresses these challenges well and facilitates initiation of HIV-infected infants rapidly after diagnosis for best clinical outcomes. Methods Objectives were to determine accuracy, feasibility and acceptability of POC testing compared to standard-of-care (SOC) central-laboratory testing. HIV-exposed infants for birth PCR testing in hospital (n = 323) and follow-up at a primary health care clinic (n = 117) in Durban, South Africa were included. A baseline situational-analysis reviewed registers and phoned mothers of HIV-exposed infants prior to the intervention. An effectiveness-implementation study of the Alere™q HIV-1/2 Detect POC test (heel-prick specimen processed in 50 min) was compared with SOC with questionnaires to mothers and staff. Stata 14 was used for analysis. Results At baseline 2% of birth HIV tests were missed; only 40% of mothers could be contacted; 17% did not receive birth test result; 19% did not have a 10-week test; 39% had not received the 10-week results. There were 5(1.5%) HIV-infected and 318(98.5%) HIV-negative infants detected in hospital with all clinic babies negative. All positive infants commenced ART before discharge. Ultimately POC and SOC had perfect concordance but for 10 SOC tests researchers actively tracked-down results or repeated tests. Turn around times for SOC tests were on average 8-days (IQR 6-10 days) and for POC testing was 0-days. The POC error-rate was 9,6% with all giving a result when repeated. The majority of mothers (92%) preferred POC testing with 7% having no preference. No staff preferred SOC testing with 79% preferring POC and 21% having no preference. Conclusions Point-of-care HIV testing for EID is accurate, feasible and acceptable, with benefits of early ART for all positive infants at birth facilities. We recommend that it be considered best practice for EID. Trial registration ISRCTN38911104 registered 9 January 2018 – retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s12889-019-6990-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elizabeth Spooner
- Department of Paediatrics and Child Health, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - Kerusha Govender
- Department of Virology, Inkosi Albert Luthuli Central Hospital, National Health Laboratory Service, Durban, KwaZulu-Natal, South Africa
| | - Tarylee Reddy
- South African Medical Research Council, Biostatistics Unit, Durban, South Africa
| | - Gita Ramjee
- South African Medical Research Council, HIV Prevention Research Unit, Durban, South Africa
| | - Noxolo Mbadi
- Department of Paediatrics, Addington Hospital, Durban, South Africa
| | - Swaran Singh
- Department of Paediatrics, Addington Hospital, Durban, South Africa
| | - Anna Coutsoudis
- Department of Paediatrics and Child Health, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
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Sakyi KS, Lartey MY, Dension JA, Kennedy CE, Mullany LC, Owusu PG, Kwara A, Surkan PJ. Low Birthweight, Retention in HIV Care, and Adherence to ART Among Postpartum Women Living with HIV in Ghana. AIDS Behav 2019; 23:433-444. [PMID: 29968140 PMCID: PMC6710623 DOI: 10.1007/s10461-018-2194-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Care for low birthweight (LBW) infants can contribute to psychological difficulties and stigma among mothers living with HIV, creating challenges for antiretroviral therapy (ART) adherence and retention in HIV care. We explored how caring for LBW infants affects maternal ART adherence and retention in care. We conducted 30 in-depth interviews with postpartum women living with HIV in Accra, Ghana: 15 with LBW infants and 15 with normal birthweight (NBW) infants. Compared to mothers with NBW infants, mothers with LBW infants described how caring for their newborns led to increased caregiver burden, prolonged hospital stays, and stigma-contributing to incomplete ART adherence and missed clinical appointments. For a few women, care for LBW infants created opportunities for re-engagement in HIV care and motivation to adhere to ART. Results suggest women living with HIV and LBW babies in Ghana face increased challenges that impact their adherence to care and ART.
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Affiliation(s)
- Kwame S Sakyi
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
- Center for Learning and Childhood Development Ghana, AF 3190 Adenta Flats, Accra, Ghana.
- Department of Public and Environmental Wellness, School of Health Sciences, Oakland University, 3101 Human Health Building, 433 Meadow Brook Rd, Rochester, MI, 48309-4452, USA.
| | - Margaret Y Lartey
- Department of Medicine & Therapeutics, University of Ghana School of Medicine & Dentistry, CHS, P.O. Box GP 4236, Accra, Ghana
| | - Julie A Dension
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Caitlin E Kennedy
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Luke C Mullany
- Center for Learning and Childhood Development Ghana, AF 3190 Adenta Flats, Accra, Ghana
- Department of International Health, Global Epidemiology and Disease Control, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Prince G Owusu
- Center for Learning and Childhood Development Ghana, AF 3190 Adenta Flats, Accra, Ghana
| | - Awewura Kwara
- Division of Infectious Disease and Global Medicine, Department of Medicine, University of Florida, 2055 Mowry Road, Ste 250, PO Box 103600, Gainesville, FL, USA
| | - Pamela J Surkan
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
- Center for Learning and Childhood Development Ghana, AF 3190 Adenta Flats, Accra, Ghana
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31
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Fayorsey RN, Wang C, Chege D, Reidy W, Syengo M, Owino SO, Koech E, Sirengo M, Hawken MP, Abrams EJ. Effectiveness of a Lay Counselor-Led Combination Intervention for Retention of Mothers and Infants in HIV Care: A Randomized Trial in Kenya. J Acquir Immune Defic Syndr 2019; 80:56-63. [PMID: 30399035 PMCID: PMC6319592 DOI: 10.1097/qai.0000000000001882] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 09/27/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Retention of mothers and infants across the prevention of mother-to-child HIV transmission (PMTCT) continuum remains challenging. We assessed the effectiveness of a lay worker administered combination intervention compared with the standard of care (SOC) on mother-infant attrition. METHODS HIV-positive pregnant women starting antenatal care at 10 facilities in western Kenya were randomized using simple randomization to receive individualized health education, retention/adherence support, appointment reminders, and missed visit tracking vs. routine care per guidelines. The primary endpoint was attrition of mother-infant pairs at 6 months postpartum. Attrition was defined as the proportion of mother-infant pairs not retained in the clinic at 6 months postpartum because of mother or infant death or lost to follow-up. Intent-to-treat analysis was used to assess the difference in attrition. This trial is registered with ClinicalTrials.gov; NCT01962220. RESULTS From September 2013 to June 2014, 361 HIV-positive pregnant women were screened, and 340 were randomized to the intervention (n = 170) or SOC (n = 170). Median age at enrollment was 26 years (interquartile range 22-30); median gestational age was 24 weeks (interquartile range 17-28). Overall attrition of mother-infant pairs was 23.5% at 6 months postpartum. Attrition was significantly lower in the intervention arm compared with SOC (18.8% vs. 28.2%, relative risk (RR) = 0.67, 95% confidence interval: 0.45 to 0.99, P = 0.04). Overall, the proportion of mothers who were retained and virally suppressed (<1000 copies/mL) at 6 months postpartum was 54.4%, with no difference between study arms. CONCLUSIONS Provision of a combination intervention by lay counselors can decrease attrition along the PMTCT cascade in low-resource settings.
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Affiliation(s)
- Ruby N. Fayorsey
- Department of Epidemiology, ICAP at Columbia University, Mailman School of Public Health, New York, NY
| | - Chunhui Wang
- Department of Epidemiology, ICAP at Columbia University, Mailman School of Public Health, New York, NY
| | - Duncan Chege
- ICAP Kenya, Columbia University, Mailman School of Public Health, New York, NY
| | - William Reidy
- Department of Epidemiology, ICAP at Columbia University, Mailman School of Public Health, New York, NY
| | - Masila Syengo
- ICAP Kenya, Columbia University, Mailman School of Public Health, New York, NY
| | | | - Emily Koech
- ICAP Kenya, Columbia University, Mailman School of Public Health, New York, NY
- Currently, PACT Endeleza, University of Maryland, Maryland, Baltimore
- Kenya Program, Nairobi, Kenya
| | - Martin Sirengo
- National AIDS and STI Control Program, Nairobi, Kenya; and
| | - Mark P. Hawken
- ICAP Kenya, Columbia University, Mailman School of Public Health, New York, NY
| | - Elaine J. Abrams
- Department of Epidemiology, ICAP at Columbia University, Mailman School of Public Health, New York, NY
- College of Physicians and Surgeons, Columbia University, New York, NY
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Mazuguni F, Mwaikugile B, Cichowitz C, Watt MH, Mwanamsangu A, Mmbaga BT, Njau P, Mahande MJ, Todd J, Renju J. Unpacking Loss to Follow-Up Among HIV-Infected Women Initiated on Option B+ In Northern Tanzania: A Retrospective Chart Review. East Afr Health Res J 2019; 3:6-15. [PMID: 34308190 PMCID: PMC8279164 DOI: 10.24248/eahrj-d-18-00025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 05/24/2019] [Indexed: 11/20/2022] Open
Abstract
Background: In 2014, Tanzania adopted the Option B+ policy for the prevention of mother-to-child transmission of HIV (PMTCT), which stipulates lifelong antiretroviral therapy (ART) for HIV-infected pregnant, postpartum and breastfeeding women, irrespective of CD4 count or WHO clinical staging. Loss to follow-up (LTFU) during pregnancy and the postpartum period may undermine the effectiveness of Option B+. Factors associated with no follow-up (NFU) care, may differ from those associated with LTFU at later time points. This study aimed to identify factors associated with NFU and LTFU among women who initiate ART under Option B+ in Moshi, Tanzania. Methods: We conducted a retrospective chart review of patients initiating ART on Option B+ between February 2014 and December 2015 in Moshi Municipality, Tanzania. Multivariable log-binomial regression was used to analyse factors associated with NFU. Kaplan-Meier survival functions were used to estimate time to LTFU. Multivariable Cox proportion hazards regression models were used to evaluate variables associated with time to LTFU. Results: Among 468 women initiating ART under the option B+ programme, 109 (23.3%) had NFU after the initial appointment. Factors associated with increased risk of NFU were: age < 25 years (adjusted hazard ratio [aRR] 1.7; 95% CI, 1.2 to 2.3), initiating ART at a hospital compared to a lower level health facilities (aRR 2.9; 95% CI, 2.1 to 3.9), and having no treatment supporter (aRR 1.5; 95% CI, 1.1 to 2.1). LTFU was higher in women aged < 25 years (aHR 1.4; 95% CI, 1.1 to 1.9), and in women with no treatment supporter (aHR 1.8; 95% CI, 1.4 to 2.3). In women who returned to the clinic after ART initiation, no factor was significantly associated with LTFU. Conclusion: The factors associated with NFU (being young, not having a treatment supporter, and being diagnosed at hospitals) reflect a vulnerable and potentially highly mobile population. Additional interventions are needed to support and retain this group at ART initiation on Option B+.
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Affiliation(s)
- Festo Mazuguni
- Department of Epidemiology & Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical College, Moshi, Tanzania.,Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Boaz Mwaikugile
- Department of Health, Rombo District Council, Kilimanjaro, Tanzania
| | - Cody Cichowitz
- Duke Global Health Institute, Duke University, Durham, NC, USA.,School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Melissa H Watt
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Amasha Mwanamsangu
- Department of Epidemiology & Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Blandina T Mmbaga
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Paediatric and Child Health Department, Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Prosper Njau
- Prevention of Mother-to-Child HIV Transmission Programme, Ministry of Health, Community Development, Gender, Elderly, and Children, Dar es Salaam, Tanzania
| | - Michael J Mahande
- Department of Epidemiology & Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Jim Todd
- Department of Epidemiology & Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical College, Moshi, Tanzania.,Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Jenny Renju
- Department of Epidemiology & Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical College, Moshi, Tanzania.,Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Carlucci JG, Liu Y, Friedman H, Pelayo BE, Robelin K, Sheldon EK, Clouse K, Vermund SH. Attrition of HIV-exposed infants from early infant diagnosis services in low- and middle-income countries: a systematic review and meta-analysis. J Int AIDS Soc 2018; 21:e25209. [PMID: 30649834 PMCID: PMC6287094 DOI: 10.1002/jia2.25209] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 10/22/2018] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Identification and retention of HIV-exposed infants in early infant diagnosis (EID) services helps to ensure optimal health outcomes. This systematic review and meta-analysis examines the magnitude of attrition from EID services in low- and middle-income countries (LMICs). METHODS We performed a comprehensive database search through April 2016. We included original studies reporting retention/attrition data for HIV-exposed infants in LMICs. Outcomes included loss to follow-up (LTFU), death and overall attrition (LTFU + death) at time points along the continuum of EID services. At least two authors determined study eligibility, performed data extraction and made quality assessments. We used random-effects meta-analytic methods to aggregate effect sizes and perform meta-regression analyses. This study adhered to PRISMA reporting guidelines. RESULTS We identified 3040 unique studies, of which 92 met eligibility criteria and were included in the quantitative synthesis. The included studies represent data from 110,805 HIV-exposed infants, the majority of whom were from Africa (77%). LTFU definitions varied widely, and there was significant variability in outcomes across studies. The bulk of attrition occurred in the first six months of follow-up, with additional losses over time. Overall, 39% of HIV-exposed infants were no longer in care at 18 months. When restricted to non-intervention studies, 43% were not retained at 18 months. CONCLUSIONS These findings underscore the high attrition of HIV-exposed infants from EID services in LMICs and the urgent need for implementation research and resources to improve retention among this vulnerable population.
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Affiliation(s)
- James G Carlucci
- Vanderbilt Institute for Global HealthVanderbilt University Medical CenterNashvilleTNUSA
- Division of Pediatric Infectious DiseasesDepartment of PediatricsVanderbilt University Medical CenterNashvilleTNUSA
| | - Yu Liu
- Department of Public Health SciencesSchool of Medicine and DentistryUniversity of RochesterRochesterNYUSA
| | | | | | | | - Emily K Sheldon
- Vanderbilt Institute for Global HealthVanderbilt University Medical CenterNashvilleTNUSA
| | - Kate Clouse
- Vanderbilt Institute for Global HealthVanderbilt University Medical CenterNashvilleTNUSA
| | - Sten H Vermund
- Yale School of Public HealthYale UniversityNew HavenCTUSA
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Akama E, Mburu M, Mutegi E, Nyanaro G, Otieno JP, Ndolo S, Ochanda B, Ojwang’ L, Lewis-Kulzer J, Abuogi L, Oyaro P, Cohen CR, Bukusi EA, Onono M. Impact of a Rapid Results Initiative Approach on Improving Male Partner Involvement in Prevention of Mother to Child Transmission of HIV in Western Kenya. AIDS Behav 2018; 22:2956-2965. [PMID: 29948337 DOI: 10.1007/s10461-018-2140-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
A rapid results initiative (RRI) aimed at increasing male involvement in prevention of mother-to-child transmission (PMTCT) and service uptake among pregnant women at 116 antenatal clinics in Western Kenya was compared at baseline, during the RRI, and 3-months post-RRI. Male involvement increased from 7.4 to 54.2% during RRI (risk difference [RD] 0.47, CI 0.45-0.48) then 43.4% post-RRI (RD 0.36, CI 0.35-0.37). Among HIV-infected women, facility delivery increased from 40.0 to 49.9% (RD 0.10, 95% CI 0.06-0.13) and 65.0% post-RRI (RD 0.25, 95% CI 0.22-0.28). HIV-infected pregnant women linkage to HIV care increased from 58.6 to 85.9% (RD 0.27, CI 0.24-0.30) and 97.3% post-RRI (RD 0.39, CI 0.36-0.41). Time to ART initiation reduced from 29 days (interquartile range [IQR] 6-56) to 14 days (IQR 0-28) to 7 days (IQR 0-20). A male-centered RRI can significantly increase men's engagement in antenatal care leading to improved partner utilization of PMTCT and antenatal services.
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Omonaiye O, Nicholson P, Kusljic S, Manias E. A meta-analysis of effectiveness of interventions to improve adherence in pregnant women receiving antiretroviral therapy in sub-Saharan Africa. Int J Infect Dis 2018; 74:71-82. [PMID: 30003952 DOI: 10.1016/j.ijid.2018.07.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 07/03/2018] [Accepted: 07/03/2018] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE We evaluated the effectiveness of interventions aimed at improving antiretroviral therapy (ART) adherence during pregnancy in sub-Saharan Africa. METHODS For this meta-analysis, the following databases were searched: MEDLINE Complete, Embase, Global Health, CINAHL Complete, and Google Scholar. Randomized and nonrandomized studies were considered for inclusion if they involved an intervention with the intent of improving medication adherence among pregnant women taking ART in sub-Saharan Africa. Databases were searched from inception to the end of August 2017. The primary outcome assessed was adherence to ART, defined as the proportion of women adherent to treatment in the control and intervention groups. Risk ratios and random effect meta-analysis were undertaken, and heterogeneity was examined with the I2 statistic. RESULTS The systematic search of databases yielded a total of 402 articles, of which 19 studies were selected for meta-analysis with a total of 27,974 participants. Nine types of interventions were identified in the 19 studies to improve ART adherence. The test for the subgroup differences showed that there was a statistically significant difference among the 9 subgroups of interventions, χ2 (8)=102.38; p=0.00001. Collectively, in the meta-analysis, the various intervention types made a significant impact on improving medication adherence. The overall effect estimate with 95% CI was as follows: 1.25 (95% CI=1.03, 1.52, p=0.03). The following risk ratio results for meta-analysis were obtained for the three interventions that showed significant impact on adherence; namely social support and structural support, 1.58 (95% CI=1.36, 1.84, p<0.00001); education, social support and structural support=2.60 (95% CI=1.95, 3.45, p<0.00001); and device reminder=1.13 (95% CI=1.05, 1.20, p=0.0004). The proportion of women who were adherent to ART as a result of the interventions was 59.3% compared with 22.5% in the control groups. CONCLUSION The use of device reminder, a combination of social support and structural support, and education, social support and structural support has the potential to improve ART adherence during pregnancy. Good quality prospective observational studies and randomized control trials are needed in sub-Saharan Africa to determine the most effective interventions.
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Affiliation(s)
- Olumuyiwa Omonaiye
- Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, Melbourne Burwood, Victoria, Australia.
| | - Pat Nicholson
- Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, Melbourne Burwood, Victoria, Australia
| | - Snezana Kusljic
- Department of Nursing, The University of Melbourne, Melbourne, Australia
| | - Elizabeth Manias
- Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, Melbourne Burwood, Victoria, Australia
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Cook RR, Peltzer K, Weiss SM, Rodriguez VJ, Jones DL. A Bayesian Analysis of Prenatal Maternal Factors Predicting Nonadherence to Infant HIV Medication in South Africa. AIDS Behav 2018; 22:2947-2955. [PMID: 29302843 DOI: 10.1007/s10461-017-2010-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
While efforts to prevent mother-to-child transmission of HIV been successful in some districts in South Africa, rates remain unacceptably high in others. This study utilized Bayesian logistic regression to examine maternal-level predictors of adherence to infant nevirapine prophylaxis, including intimate partner violence, maternal adherence, HIV serostatus disclosure reaction, recency of HIV diagnosis, and depression. Women (N = 303) were assessed during pregnancy and 6 weeks postpartum. Maternal adherence to antiretroviral therapy during pregnancy predicted an 80% reduction in the odds of infant nonadherence [OR 0.20, 95% posterior credible interval (.11, .38)], and maternal prenatal depression predicted an increase [OR 1.04, 95% PCI (1.01, 1.08)]. Results suggest that in rural South Africa, failure to provide medication to infants may arise from shared risk factors with maternal nonadherence. Intervening to increase maternal adherence and reduce depression may improve adherence to infant prophylaxis and ultimately reduce vertical transmission rates.
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Affiliation(s)
- R R Cook
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, 1400 NW 10th Ave. Suite 404A, Miami, FL, 33136, USA.
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA.
| | - K Peltzer
- HIV/AIDS/STIs and TB (HAST) Research Programme, Human Sciences Research Council, Pretoria, South Africa
- ASEAN Institute for Health Development, Mahidol University, Salaya, Thailand
- Department of Research & Innovation, University of Limpopo, Sovenga, South Africa
| | - S M Weiss
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, 1400 NW 10th Ave. Suite 404A, Miami, FL, 33136, USA
| | - V J Rodriguez
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, 1400 NW 10th Ave. Suite 404A, Miami, FL, 33136, USA
| | - D L Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, 1400 NW 10th Ave. Suite 404A, Miami, FL, 33136, USA
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Maskew M, Jamieson L, Mohomi G, Long L, Mongwenyana C, Nyoni C, Mokaba D, Fox MP, Sanne I, Rosen S. Implementation of Option B and a fixed-dose combination antiretroviral regimen for prevention of mother-to-child transmission of HIV in South Africa: A model of uptake and adherence to care. PLoS One 2018; 13:e0201955. [PMID: 30161147 PMCID: PMC6116946 DOI: 10.1371/journal.pone.0201955] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 07/23/2018] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Initiating and retaining pregnant women on antiretroviral therapy (ART) to prevent mother-to-child HIV transmission (PMTCT) remains a major challenge facing African HIV programs, particularly during the critical final months prior to delivery. In 2013, South Africa implemented its "Option B" PMTCT regimen (three-drug ART throughout pregnancy and breastfeeding, regardless of maternal CD4 count) and introduced once-daily fixed-dose combinations and lifelong ART. Currently, the uptake of Option B and its possible impact on adherence to PMTCT during the critical final months of pregnancy is unclear. MATERIALS AND METHODS We prospectively collected visit data from a cohort of adult, HIV-infected, pregnant women between July 2013-August 2014 to estimate three models of adherence to PMTCT during the final 16 weeks immediately preceding delivery. Adherence was defined according to possession of antiretroviral drugs, which was inferred from clinic visit records under varying assumptions in each model. We describe uptake of the PMTCT regimen, gestational age at initiation, and model possible scenarios of adherence through delivery after the implementation of Option B. RESULTS Among 138 women enrolled (median (IQR) age 28 years (24-32), median CD4 count 378 cells/mm3), median (IQR) gestational age at initiation was 22 weeks (16-26). Estimates of adherence during the final 16 weeks of pregnancy prior to delivery ranged from 75% (52-89%) under the best case scenario assumptions to 52% (30-75%) under the worst case scenario assumptions. Estimates of the proportion of women who would achieve 80% adherence to PMTCT were <50% across all models. CONCLUSIONS Despite the switch to Option B and once-daily dosing, South African women continue to initiate PMTCT late in pregnancy, and estimations of regimen adherence, as modelled using PMTCT visit attendance data, is poor, with <50% of women reaching 80% adherence during final months of pregnancy across all models. Further guideline changes and interventions are needed to achieve vertical transmission goals. TRIAL REGISTRATION ClinicalTrials.gov NCT01710397 South African National Clinical Trials Register DOH-27-0213-4177.
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Affiliation(s)
- Mhairi Maskew
- 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
- * E-mail:
| | - Lise Jamieson
- 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
| | - Given Mohomi
- 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
| | - Lawrence Long
- 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
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Constance Mongwenyana
- 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
| | - Cynthia Nyoni
- 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
| | - Dorah Mokaba
- City of Johannesburg, Johannesburg, South Africa
| | - Matthew P. Fox
- 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
- Department of Epidemiology, Boston University School of Public Health, Boston, Boston University School of Public Health, Boston, Massachusetts
| | - Ian Sanne
- 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
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Sydney Rosen
- 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
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
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Chetty T, Yapa HMN, Herbst C, Geldsetzer P, Naidu KK, De Neve JW, Herbst K, Matthews P, Pillay D, Wyke S, Bärnighausen T. The MONARCH intervention to enhance the quality of antenatal and postnatal primary health services in rural South Africa: protocol for a stepped-wedge cluster-randomised controlled trial. BMC Health Serv Res 2018; 18:625. [PMID: 30089485 PMCID: PMC6083494 DOI: 10.1186/s12913-018-3404-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 07/19/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Gaps in maternal and child health services can slow progress towards achieving the Sustainable Development Goals. The Management and Optimization of Nutrition, Antenatal, Reproductive, Child Health & HIV Care (MONARCH) study will evaluate a Continuous Quality Improvement (CQI) intervention targeted at improving antenatal and postnatal health service outcomes in rural South Africa where HIV prevalence among pregnant women is extremely high. Specifically, it will establish the effectiveness of CQI on viral load (VL) testing in pregnant women who are HIV-positive and repeat HIV testing in pregnant women who are HIV-negative. METHODS This is a stepped-wedge cluster-randomised controlled trial (RCT) of 7 nurse-led primary healthcare clinics to establish the effect of CQI on selected routine antenatal and postnatal services. Each clinic was a cluster, with the exception of the two smallest clinics, which jointly formed one cluster. The intervention was applied at the cluster level, where staff received training on CQI methodology and additional mentoring as required. In the control exposure state, the clusters received the South African Department of Health standard of care. After a baseline data collection period of 2 months, the first cluster crossed over from control to intervention exposure state; subsequently, one additional cluster crossed over every 2 months. The six clusters were divided into 3 groups by patient volume (low, medium and high). We randomised the six clusters to the sequences of crossing over, such that both the first three and the last three sequences included one cluster with low, one with medium, and one with high patient volume. The primary outcome measures were (i) viral load testing among pregnant women who were HIV-positive, and (ii) repeat HIV testing among pregnant women who were HIV-negative. Consenting women ≥18 years attending antenatal and postnatal care during the data collection period completed outcome measures at delivery, and postpartum at three to 6 days, and 6 weeks. Data collection started on 15 July 2015. The total study duration, including pre- and post-exposure phases, was 19 months. Data will be analyzed by intention-to-treat based on first booked clinic of study participants. DISCUSSION The results of the MONARCH trial will establish the effectiveness of CQI in improving antenatal and postnatal clinic processes in primary care in sub-Saharan Africa. More generally, the results will contribute to our knowledge on quality improvement interventions in resource-poor settings. TRIAL REGISTRATION This trial was registered on 10 December 2015: www.clinicaltrials.gov, identifier NCT02626351 .
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Affiliation(s)
- Terusha Chetty
- Africa Health Research Institute, Somkhele, P.O. Box 198, Mtubatuba, KwaZulu-Natal 3935 South Africa
| | - H. Manisha N. Yapa
- Africa Health Research Institute, Somkhele, P.O. Box 198, Mtubatuba, KwaZulu-Natal 3935 South Africa
| | - Carina Herbst
- Africa Health Research Institute, Somkhele, P.O. Box 198, Mtubatuba, KwaZulu-Natal 3935 South Africa
| | - Pascal Geldsetzer
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115 USA
| | - Kevindra K. Naidu
- Africa Health Research Institute, Somkhele, P.O. Box 198, Mtubatuba, KwaZulu-Natal 3935 South Africa
- Maternal Adolescent and Child Health Systems (MatCH), School of Public Health, University of Witswatersrand, Braamfontein, South Africa
| | - Jan-Walter De Neve
- Institute of Public Health, Heidelberg University, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
| | - Kobus Herbst
- Africa Health Research Institute, Somkhele, P.O. Box 198, Mtubatuba, KwaZulu-Natal 3935 South Africa
| | - Philippa Matthews
- Africa Health Research Institute, Somkhele, P.O. Box 198, Mtubatuba, KwaZulu-Natal 3935 South Africa
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele, P.O. Box 198, Mtubatuba, KwaZulu-Natal 3935 South Africa
- Division of Infection & Immunity, University College London, Gower Street, Bloomsbury, London, WC1E 6BT UK
| | - Sally Wyke
- Africa Health Research Institute, Somkhele, P.O. Box 198, Mtubatuba, KwaZulu-Natal 3935 South Africa
- Institute for Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ Scotland, UK
| | - Till Bärnighausen
- Africa Health Research Institute, Somkhele, P.O. Box 198, Mtubatuba, KwaZulu-Natal 3935 South Africa
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115 USA
- Institute of Public Health, Heidelberg University, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
- Department of Global Health, University College London, Gower Street, Bloomsbury, London, WC1E 6BT UK
| | - for the MONARCH study team
- Africa Health Research Institute, Somkhele, P.O. Box 198, Mtubatuba, KwaZulu-Natal 3935 South Africa
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115 USA
- Maternal Adolescent and Child Health Systems (MatCH), School of Public Health, University of Witswatersrand, Braamfontein, South Africa
- Institute of Public Health, Heidelberg University, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
- Division of Infection & Immunity, University College London, Gower Street, Bloomsbury, London, WC1E 6BT UK
- Institute for Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ Scotland, UK
- Department of Global Health, University College London, Gower Street, Bloomsbury, London, WC1E 6BT UK
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Trafford Z, Gomba Y, Colvin CJ, Iyun VO, Phillips TK, Brittain K, Myer L, Abrams EJ, Zerbe A. Experiences of HIV-positive postpartum women and health workers involved with community-based antiretroviral therapy adherence clubs in Cape Town, South Africa. BMC Public Health 2018; 18:935. [PMID: 30064405 PMCID: PMC6069812 DOI: 10.1186/s12889-018-5836-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 07/11/2018] [Indexed: 11/10/2022] Open
Abstract
Background The rollout of universal, lifelong treatment for all HIV-positive pregnant and breastfeeding women (“Option B+”) has rapidly increased the number of women initiating antiretroviral treatment (ART) and requiring ART care postpartum. In a pilot project in South Africa, eligible postpartum women were offered the choice of referral to the standard of care, a local primary health care clinic, or a community-based model of differentiated ART services, the adherence club (AC). ACs have typically enrolled only non-pregnant and non-postpartum adults; postpartum women had not previously been referred directly from antenatal care. There is little evidence regarding postpartum women’s preferences for and experiences of differentiated models of care, or the capacity of this particular model to cater to their specific needs. This qualitative paper reports on feedback from both postpartum women and health workers who care for them on their respective experiences of the AC. Methods One-on-one in-depth qualitative interviews were conducted with 19 (23%) of the 84 postpartum women who selected the AC and were retained at approximately 12 months postpartum, and 9 health workers who staff the AC. Data were transcribed and thematically analysed using NVivo 11. Results Postpartum women’s inclusion in the AC was acceptable for both participants and health workers. Health workers were welcoming of postpartum women but expressed concerns about prospects for longer term adherence and retention, and raised logistical issues they felt might compromise trust with AC members in general. Conclusions Enrolling postpartum women in mixed groups with the general adult population is feasible and acceptable. Preliminary recommendations are offered and may assist in supporting the specific needs of postpartum women transitioning from antenatal ART care. Trial registration Number NCT02417675 clinicaltrials.gov/ct2/show/record/NCT02417675 (retrospective reg.)
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Affiliation(s)
- Zara Trafford
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Yolanda Gomba
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Christopher J Colvin
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Victoria O Iyun
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Tamsin K Phillips
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kirsty Brittain
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elaine J Abrams
- Mailman School of Public Health, ICAP, Columbia University, New York, USA.,College of Physicians and Surgeons, Columbia University, New York, USA
| | - Allison Zerbe
- Mailman School of Public Health, ICAP, Columbia University, New York, USA
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40
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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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41
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Kim H, Dowdy DW, Martinson NA, E Golub J, Bridges JFP, Hanrahan CF. Maternal priorities for preventive therapy among HIV-positive pregnant women before and after delivery in South Africa: a best-worst scaling survey. J Int AIDS Soc 2018; 21:e25143. [PMID: 29972628 PMCID: PMC6031072 DOI: 10.1002/jia2.25143] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 05/15/2018] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Pregnant women newly diagnosed with HIV during pregnancy are often lost to follow up and their adherence rates drop after delivery. We quantified changes in priorities related to isoniazid preventive therapy (IPT) and antiretroviral therapy (ART) among pregnant women living with HIV. METHODS We enrolled pregnant women recently diagnosed with HIV from 14 primary health clinics during pregnancy and followed them after delivery in Matlosana, South Africa. Best-worst scaling (BWS) was used to determine the women's priorities out of 11 attributes related to preventive therapy in the ante- versus postpartum periods. Aggregate BWS scores were calculated based on the frequency with which participants selected each attribute as the best or worst among five options (across multiple choice sets). Individual BWS scores were also calculated and rescaled from 0 (always selected as worst) to 10 (always selected as best), and changes in BWS scores in the ante- versus postpartum periods were compared, using a paired t-test. Factors associated with the changes in BWS scores were examined in multiple linear regressions. Spearman's rho was used to compare the ranking of attributes. RESULTS Out of a total of 204 participants, 154 (75.5%) completed the survey in the postpartum at the median 15 (IQR: 11 to 27) weeks after delivery. Trust in healthcare providers was most highly prioritized both in the ante- (individual BWS Score = 7.34, SE = 0.13) and postpartum periods (BWS = 7.21 ± 0.11), followed by living a long life (BWS = 6.77 ± 0.09 in the ante- vs. BWS = 6.86 ± 0.10 in the postpartum). Prevention for infants' health was more prioritized in the post- (BWS = 6.54 ± 0.09) versus antepartum periods (BWS = 6.11 ± 0.10) (p = 0.05). This change was associated with IPT initiation at enrolment (regression coefficient = 0.78 ± 0.33, p = 0.001). Difficulty in daily pill-uptake was significantly more prioritized in the postpartum (BWS = 5.03 ± 0.11) than in the antepartum (BWS = 4.43 ± 0.10) (p < 0.01). Transportation cost and worry about side effects of pills were least prioritized. Overall ranking of attributes was similar in both time periods (spearman's rho = 0.90). CONCLUSIONS Comprehensive interventions to build trust in healthcare providers and support adherence may increase uptake of preventive therapy. Counselling needs to emphasize medication benefits for both maternal and infant health among HIV-positive pregnant women.
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Affiliation(s)
- Hae‐Young Kim
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
- Africa Health Research InstituteDurbanKwaZulu‐NatalSouth Africa
- School of Nursing & Public HealthUniversity of KwaZulu‐NatalDurbanKwaZulu‐NatalSouth Africa
| | - David W Dowdy
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Neil A Martinson
- Perinatal HIV Research UnitUniversity of WitwatersrandJohannesburgSouth Africa
- Center for Tuberculosis ResearchJohns Hopkins UniversityBaltimoreMDUSA
| | - Jonathan E Golub
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
- Center for Tuberculosis ResearchJohns Hopkins UniversityBaltimoreMDUSA
| | - John F P Bridges
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
- Department of Health Behavior and SocietyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Colleen F Hanrahan
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
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Mody A, Sikazwe I, Czaicki NL, Wa Mwanza M, Savory T, Sikombe K, Beres LK, Somwe P, Roy M, Pry JM, Padian N, Bolton-Moore C, Holmes CB, Geng EH. Estimating the real-world effects of expanding antiretroviral treatment eligibility: Evidence from a regression discontinuity analysis in Zambia. PLoS Med 2018; 15:e1002574. [PMID: 29870531 PMCID: PMC5988277 DOI: 10.1371/journal.pmed.1002574] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/27/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although randomized trials have established the clinical efficacy of treating all persons living with HIV (PLWHs), expanding treatment eligibility in the real world may have additional behavioral effects (e.g., changes in retention) or lead to unintended consequences (e.g., crowding out sicker patients owing to increased patient volume). Using a regression discontinuity design, we sought to assess the effects of a previous change to Zambia's HIV treatment guidelines increasing the threshold for treatment eligibility from 350 to 500 cells/μL to anticipate effects of current global efforts to treat all PLWHs. METHODS AND FINDINGS We analyzed antiretroviral therapy (ART)-naïve adults who newly enrolled in HIV care in a network of 64 clinics operated by the Zambian Ministry of Health and supported by the Centre for Infectious Disease Research in Zambia (CIDRZ). Patients were restricted to those enrolling in a narrow window around the April 1, 2014 change to Zambian HIV treatment guidelines that raised the CD4 threshold for treatment from 350 to 500 cells/μL (i.e., August 1, 2013, to November 1, 2014). Clinical and sociodemographic data were obtained from an electronic medical record system used in routine care. We used a regression discontinuity design to estimate the effects of this change in treatment eligibility on ART initiation within 3 months of enrollment, retention in care at 6 months (defined as clinic attendance between 3 and 9 months after enrollment), and a composite of both ART initiation by 3 months and retention in care at 6 months in all new enrollees. We also performed an instrumental variable (IV) analysis to quantify the effect of actually initiating ART because of this guideline change on retention. Overall, 34,857 ART-naïve patients (39.1% male, median age 34 years [IQR 28-41], median CD4 268 cells/μL [IQR 134-430]) newly enrolled in HIV care during this period; 23,036 were analyzed after excluding patients around the threshold to allow for clinic-to-clinic variations in actual guideline uptake. In all newly enrolling patients, expanding the CD4 threshold for treatment from 350 to 500 cells/μL was associated with a 13.6% absolute increase in ART initiation within 3 months of enrollment (95% CI, 11.1%-16.2%), a 4.1% absolute increase in retention at 6 months (95% CI, 1.6%-6.7%), and a 10.8% absolute increase in the percentage of patients who initiated ART by 3 months and were retained at six months (95% CI, 8.1%-13.5%). These effects were greatest in patients who would have become newly eligible for ART with the change in guidelines: a 43.7% increase in ART initiation by 3 months (95% CI, 37.5%-49.9%), 13.6% increase in retention at six months (95% CI, 7.3%-20.0%), and a 35.5% increase in the percentage of patients on ART at 3 months and still in care at 6 months [95% CI, 29.2%-41.9%). We did not observe decreases in ART initiation or retention in patients not directly targeted by the guideline change. An IV analysis found that initiating ART in response to the guideline change led to a 37.9% (95% CI, 28.8%-46.9%) absolute increase in retention in care. Limitations of this study include uncertain generalizability under newer models of care, lack of laboratory data (e.g., viral load), inability to account for earlier stages in the HIV care cascade (e.g., HIV testing and linkage), and potential for misclassification of eligibility status or outcome. CONCLUSIONS In this study, guidelines raising the CD4 threshold for treatment from 350 to 500 cells/μL were associated with a rapid rise in ART initiation as well as enhanced retention among newly treatment-eligible patients, without negatively impacting patients with lower CD4 levels. These data suggest that health systems in Zambia and other high-prevalence settings could substantially enhance engagement even among those with high CD4 levels (i.e., above 500 cells/μL) by expanding treatment without undermining existing care standards.
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Affiliation(s)
- Aaloke Mody
- Division of HIV, ID and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Nancy L. Czaicki
- Division of HIV, ID and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, United States of America
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Mwanza Wa Mwanza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Theodora Savory
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Laura K. Beres
- Department of International Health, Johns Hopkins University School of Public Health, Baltimore, Maryland, United States of America
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Monika Roy
- Division of HIV, ID and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, United States of America
| | - Jake M. Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Public Health, University of California, Davis, Davis, California, United States of America
| | - Nancy Padian
- Division of Epidemiology, University of California, Berkeley, Berkeley, California, United States of America
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, University of Alabama, Birmingham, Alabama, United States of America
| | - Charles B. Holmes
- Department of International Health, Johns Hopkins University School of Public Health, Baltimore, Maryland, United States of America
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Elvin H. Geng
- Division of HIV, ID and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, United States of America
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Ross J, Edmonds A, Hoover DR, Shi Q, Anastos K, Lelo P, Behets F, Yotebieng M. Association between pregnancy at enrollment into HIV care and loss to care among women in the Democratic Republic of Congo, 2006-2013. PLoS One 2018; 13:e0195231. [PMID: 29608618 PMCID: PMC5880386 DOI: 10.1371/journal.pone.0195231] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 03/08/2018] [Indexed: 01/08/2023] Open
Abstract
Background Loss to care is high among asymptomatic HIV-infected women initiated on antiretroviral therapy (ART) during pregnancy or in the postpartum period. However, whether pregnancy itself plays a role in the high loss to care rate is uncertain. We compared loss to care over seven years between pregnant and non-pregnant women at enrollment into HIV care in the Democratic Republic of Congo (DRC). Methods We conducted a retrospective analysis of all ART-naive women aged 15–45 initiating HIV care at two large clinics in Kinshasa, DRC, from 2007–2013. Pregnancy status was recorded at care enrollment. Patients were classified as having no follow-up if they did not return to care after the initial enrollment visit. Among those with at least one follow-up visit after enrollment, we classified patients as lost to care if more than 365 days had passed since their last clinic visit. We used logistic regression to model the association between pregnancy status and no follow-up, and Cox proportional hazards regression to model the association between pregnancy status and time to loss to care. Results Of 2175 women included in the analysis, 1497 (68.8%) were pregnant at enrollment. Compared to non-pregnant women, pregnant women were less likely to be over 35 years of age (19.1% vs. 31.9%, p<0.0001) and less likely to be in WHO stage III or IV (9.0% vs. 26.3%, p<0.0001). Among pregnant women, 106 (7.1%) were not seen after enrollment, versus 25 (3.7%) non-pregnant women (adjusted odds ratio 2.01, 95% CI 1.24–3.24). Of the 2,044 women with at least one follow-up visit, 46.5% of pregnant women and 46.7% of non-pregnant women were lost to care by 5 years; hazards of loss to care were similar for pregnant and non-pregnant women (adjusted hazard ratio 1.08, 95% CI 0.93–1.26). Conclusions In this large cohort of HIV-infected women, patients pregnant at care enrollment were more likely to never return for follow-up. Among those who attended at least one follow-up visit, loss to care was not different between pregnant and non-pregnant women, suggesting that pregnancy itself may not be the main driver of the high attrition observed in this cohort.
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Affiliation(s)
- Jonathan Ross
- Department of Medicine, Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Bronx, NY, United States of America
- * E-mail:
| | - Andrew Edmonds
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Donald R. Hoover
- Department of Statistics and Biostatistics, Rutgers University, New Brunswick, NJ, United States of America
| | - Qiuhu Shi
- Department of Epidemiology and Community Health, New York Medical College, Valhalla, NY, United States of America
| | - Kathryn Anastos
- Department of Medicine, Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Bronx, NY, United States of America
| | - Patricia Lelo
- Kalembelembe Pediatric Hospital, Kinshasa, The Democratic Republic of Congo
| | - Frieda Behets
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Marcel Yotebieng
- College of Public Health, Division of Epidemiology, The Ohio State University, Columbus, OH, United States of America
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DiCarlo A, Fayorsey R, Syengo M, Chege D, Sirengo M, Reidy W, Otieno J, Omoto J, Hawken MP, Abrams EJ. Lay health worker experiences administering a multi-level combination intervention to improve PMTCT retention. BMC Health Serv Res 2018; 18:17. [PMID: 29321026 PMCID: PMC5763814 DOI: 10.1186/s12913-017-2825-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 12/29/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The recent scale-up of prevention of mother-to-child transmission of HIV (PMTCT) services has rapidly accelerated antiretroviral therapy (ART) uptake among pregnant and postpartum women in sub-Saharan Africa. The Mother and Infant Retention for Health (MIR4Health) study evaluates the impact of a combination intervention administered by trained lay health workers to decrease attrition among HIV-positive women initiating PMTCT services and their infants through 6 months postpartum. METHODS This was a qualitative study nested within the MIR4Health trial. MIR4Health was conducted at 10 health facilities in Nyanza, Kenya from September 2013 to September 2015. The trial intervention addressed behavioral, social, and structural barriers to PMTCT retention and included: appointment reminders via text and phone calls, follow-up and tracking for missed clinic visits, PMTCT health education at home visits and during clinic visits, and retention and adherence support and counseling. All interventions were administered by lay health workers. We describe results of a nested small qualitative inquiry which conducted two focus groups to assess the experiences and perceptions of lay health workers administering the interventions. Discussions were recorded and simultaneously transcribed and translated into English. Data were analyzed using framework analysis approach. RESULTS Study findings show lay health workers played a critical role supporting mothers in PMTCT services across a range of behavioral, social, and structural domains, including improved communication and contact, health education, peer support, and patient advocacy and assistance. Findings also identified barriers to the uptake and implementation of the interventions, such as concerns about privacy and stigma, and the limitations of the healthcare system including healthcare worker attitudes. Overall, study findings indicate that lay health workers found the interventions to be feasible, acceptable, and well received by clients. CONCLUSIONS Lay health workers played a fundamental role in supporting mothers engaged in PMTCT services and provided valuable feedback on the implementation of PMTCT interventions. Future interventions must include strategies to ensure client privacy, decrease stigma within communities, and address the practical limitations of health systems. This study adds important insight to the growing body of research on lay health worker experiences in HIV and PMTCT care. TRIAL REGISTRATION Clinicaltrials.gov NCT01962220 .
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Affiliation(s)
- Abby DiCarlo
- ICAP at Columbia University, Mailman School of Public Health, 722 W. 168th Street, New York, NY 10032 USA
| | - Ruby Fayorsey
- ICAP at Columbia University, Mailman School of Public Health, 722 W. 168th Street, New York, NY 10032 USA
| | - Masila Syengo
- ICAP Kenya, Mailman School of Public Health, Columbia University, New York, NY USA
| | - Duncan Chege
- ICAP Kenya, Mailman School of Public Health, Columbia University, New York, NY USA
| | | | - William Reidy
- ICAP at Columbia University, Mailman School of Public Health, 722 W. 168th Street, New York, NY 10032 USA
| | - Juliana Otieno
- Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu, Kenya
| | - Jackton Omoto
- School of Medicine, Maseno University, Kisumu, Kenya
| | - Mark P. Hawken
- ICAP Kenya, Mailman School of Public Health, Columbia University, New York, NY USA
| | - Elaine J. Abrams
- ICAP at Columbia University, Mailman School of Public Health, 722 W. 168th Street, New York, NY 10032 USA
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Differentiated models of care for postpartum women on antiretroviral therapy in Cape Town, South Africa: a cohort study. J Int AIDS Soc 2017; 20:21636. [PMID: 28770593 PMCID: PMC5577773 DOI: 10.7448/ias.20.5.21636] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: The numbers of women initiating lifelong antiretroviral therapy (ART) during pregnancy and postpartum is increasing rapidly, presenting a burden on health systems and an urgent need for scalable models of care for this population. In a pilot project, we referred postpartum women who initiated ART during pregnancy to a community-based model of differentiated ART services. Methods: Eligible women (on ART for at least 3 months with viral load (VL)<1000 copies/mL) were offered a choice of two ART models of care: (i) referral to an existing system of community-based ‘adherence clubs’, operated by lay counsellors with medication collection every 2–4 months; or (ii) referral to local primary healthcare clinics (PHC) with services provided by clinicians and medication collection every 1–2 months (local standard of care for postpartum ART). For evaluation, women were followed through 6-months postpartum with VL testing separate from either ART service. Results: Through September 2015, n = 129 women were enrolled (median age, 28 years; median time postpartum, 10 days). Overall, 65% (n = 84) chose adherence clubs and 35% (n = 45) chose PHCs; there were no demographic or clinical predictors of this choice. Location of service delivery was commonly cited as a reason for choice by women selecting either model of care; shorter waiting times, ability to receive ART from lay counsellors and less frequent appointments were motivations for choosing adherence clubs. Among women choosing adherence clubs, 15% never attended the service and another 11% attended the service but were not retained through six months postpartum. Overall, 86% of women (n = 111) remained in the evaluation through 6 months postpartum; in this group, there were no differences in VL<1000 copies/mL at six months postpartum between women choosing PHCs (88%) vs. adherence clubs (92%; p = 0.483), but women who were not retained in adherence clubs were more likely to have VL≥1000 copies/mL compared to those who remained (p = 0.002). Discussion: Adherence clubs may be a valuable model for postpartum women initiating ART in pregnancy, with good short-term outcomes observed during this critical period. To support optimal implementation, further research is needed into patient preferences for models of care, with consideration of integration of maternal and child health services, while ART adherence and retention require ongoing consideration in this population.
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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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Beyond "Option B+": Understanding Antiretroviral Therapy (ART) Adherence, Retention in Care and Engagement in ART Services Among Pregnant and Postpartum Women Initiating Therapy in Sub-Saharan Africa. J Acquir Immune Defic Syndr 2017; 75 Suppl 2:S115-S122. [PMID: 28498180 DOI: 10.1097/qai.0000000000001343] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several studies from sub-Saharan Africa have highlighted significant challenges in providing antiretroviral therapy (ART) to pregnant and postpartum women, with specific concerns around maintaining optimal levels of adherence to ART and/or retaining women in long-term services. However, there are few conceptual frameworks to help understand nonadherence and nonretention, as well as the drivers of these, among HIV-infected women, particularly in the postpartum period. METHODS This review provides an overview of the key issues involved in thinking about ART adherence, retention in care and engagement in ART services among pregnant and postpartum women. RESULTS The related behaviors of adherence and retention may be understood as components of effective engagement of patients in ART services, which share the goal of achieving and maintaining suppressed maternal viral load on ART. Under this framework, the existing literature indicates that disengagement from care is widespread among postpartum women, with strikingly similar data emerging from ART services around the globe and indications that similar challenges may be encountered by postpartum care services outside the context of HIV. However, the drivers of disengagement require further research, and evidence-based intervention strategies are limited. CONCLUSIONS The challenges of engaging women in ART services during pregnancy and the postpartum period seem pervasive, although the determinants of these are poorly understood. Looking forward, a host of innovative intervention approaches are needed to help improve women's engagement, and in turn, promote maternal and child health in the context of HIV.
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Mudau M, Peters RP, De Vos L, Olivier DH, J Davey D, Mkwanazi ES, McIntyre JA, Klausner JD, Medina-Marino A. High prevalence of asymptomatic sexually transmitted infections among human immunodeficiency virus-infected pregnant women in a low-income South African community. Int J STD AIDS 2017; 29:324-333. [PMID: 28799824 DOI: 10.1177/0956462417724908] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There is a lack of evidence on the burden of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) among HIV-infected pregnant women in South Africa. We conducted a cross-sectional analysis of HIV-infected pregnant women in two healthcare facilities in a South African township to determine the prevalence of CT, NG and TV. HIV-infected pregnant women were recruited during the first antenatal care visit for their current pregnancy and requested to self-collect vulvovaginal swab specimens. Specimens were tested for CT, NG and TV using the Xpert® assay (Cepheid, Sunnyvale, CA). Of 247 tested for CT, NG and TV, 47.8% tested positive for at least one organism; CT = 36.8%, TV = 23.9%, NG = 6.9%. Forty three (17.4%) had multiple infections, of which 42 included CT as one of the infecting organisms. Of the 118 participants who tested positive for at least one sexually transmitted infection (STI), 23.7% reported STI-like symptoms. Among women who tested positive for CT, 29.7% reported symptoms while 47.1 and 27.1% of those who tested positive for NG and TV, respectively, reported symptoms. The high STI prevalence coupled with the low symptom prevalence among infected individuals justifies the use of diagnostic screening approaches rather than syndromic management of STIs in this setting.
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Affiliation(s)
- Maanda Mudau
- 1 Research Unit, Foundation for Professional Development, Pretoria, South Africa
| | - Remco P Peters
- 2 Anova Health Institute, Johannesburg, South Africa.,3 Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Lindsey De Vos
- 1 Research Unit, Foundation for Professional Development, Pretoria, South Africa
| | - Dawie H Olivier
- 1 Research Unit, Foundation for Professional Development, Pretoria, South Africa
| | - Dvora J Davey
- 4 Department of Epidemiology and Biostatics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,5 David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.,6 Department of Epidemiology, University of California Los Angeles, Los Angeles, CA, USA
| | - Edwin S Mkwanazi
- 1 Research Unit, Foundation for Professional Development, Pretoria, South Africa
| | - James A McIntyre
- 2 Anova Health Institute, Johannesburg, South Africa.,7 School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Jeffrey D Klausner
- 5 David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.,6 Department of Epidemiology, University of California Los Angeles, Los Angeles, CA, USA
| | - Andrew Medina-Marino
- 1 Research Unit, Foundation for Professional Development, Pretoria, South Africa
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Miller K, Muyindike W, Matthews LT, Kanyesigye M, Siedner MJ. Program Implementation of Option B+ at a President's Emergency Plan for AIDS Relief-Supported HIV Clinic Improves Clinical Indicators But Not Retention in Care in Mbarara, Uganda. AIDS Patient Care STDS 2017; 31:335-341. [PMID: 28650703 PMCID: PMC5564010 DOI: 10.1089/apc.2017.0034] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
2013 WHO guidelines for prevention of mother to child transmission recommend combination antiretroviral therapy (ART) for all pregnant women, regardless of CD4 count (Option B/B+). We conducted a retrospective analysis of data from a government-operated HIV clinic in Mbarara, Uganda before and after implementation of Option B+ to assess the impact on retention in care. We limited our analysis to women not on ART at the time of their first reported pregnancy with CD4 count >350. We fit regression models to estimate relationships between calendar period (Option A vs. Option B+) and the primary outcome of interest, retention in care. One thousand and sixty-two women were included in the analysis. Women were more likely to start ART within 6 months of pregnancy in the Option B+ period (68% vs. 7%, p < 0.0001) and had significantly greater increases in CD4 count 1 year after pregnancy (+172 vs. -5 cells, p < 0.001). However, there was no difference in the proportion of women retained in care 1 year after pregnancy (73% vs. 70%, p = 0.34). In models adjusted for age, distance to clinic, marital status, and CD4 count, Option B+ was associated with a nonsignificant 30% increased odds of retention in care at 1 year [adjusted odds ratio (AOR) = 1.30, 95% CI 0.98-1.73, p = 0.06]. After transition to an Option B+ program, pregnant women with CD4 count >350 were more likely to initiate combination therapy; however, interventions to mitigate losses from HIV care during pregnancy are needed to improve the health of women, children, and families.
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Affiliation(s)
- Kathleen Miller
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Winnie Muyindike
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lynn T. Matthews
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Kanyesigye
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mark J. Siedner
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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