Longitudinal adherence to antiretroviral drugs for preventing mother-to-child transmission of HIV in Zambia

Level of adherence to option B+ program and associated factors among HIV-positive women in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Despite policy initiatives and strategic measures highly focused on preventing mother-to-child transmission through the implementation of the Option B+ program, adherence to the treatment is still challenging. The level of adherence and determinants of Option B+ program utilization reported by different studies were highly inconsistent in Ethiopia. Hence, this systematic review and meta-analysis aimed to estimate the pooled prevalence of adherence to the Option B+ program and its predictors among HIV-positive women in Ethiopia.

METHODS

PubMed, Google Scholar, EMBASE, HINAR, Scopus, and Web of Sciences were searched for published articles from March 2010 to March 2022. The pooled prevalence of adherence was estimated using a weighted DerSimonian-Laird random effect model. The I2 statistics was used to identify the degree of heterogeneity. Publication bias was also assessed using the funnel plot and Egger's regression test.

RESULTS

A total of 15 studies were included. The pooled estimate of the option B+ program among HIV-positive women in Ethiopia was 81.58% (95% CI: 77.33-85.84). Getting social and financial support (AOR = 3.73, 95% CI: 2.12, 6.58), disclosure of HIV status to partners (AOR = 2.05, 95% CI: 1.75, 2.41), time to reach a health facility (AOR = 0.33, 95% CI: 0.16, 0.67), receiving counseling on drug side effects (AOR = 4.09, 95% CI: 2.74, 6.11), experience of drug side effects (AOR = 0.17, 95% CI: 0.08, 0.36), and knowledge (AOR = 4.73, 95% CI: 2.62, 8.51) were significantly associated with adherence to the Option B+ program.

CONCLUSION

This meta-analysis showed that the level of adherence to the Option B+ program in Ethiopia is lower than the 95% level of adherence planned to be achieved in 2020. Social and financial support, disclosure of HIV status, time to reach the health facility, counseling, drug side effects, and knowledge of PMTCT were significantly associated with option B+ adherence. The findings of this meta-analysis highlight that governmental, non-governmental, and other stakeholders need to design an effective strategy to scale up the level of disclosing one's own HIV status, access health facilities, improve knowledge of PMTCT, and counsel the potential side effects of Option B+ drugs, and advocate the program to reduce the multidimensional burden of HIV/AIDS.

TRIAL REGISTRATION

Prospero registration: CRD42022320947. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022320947.

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

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.

Interpersonal therapy versus antidepressant medication for treatment of postpartum depression and anxiety among women with HIV in Zambia: a randomized feasibility trial

Introduction

Postpartum depression (PPD) is a prevalent and debilitating disease that may affect medication adherence and thus maternal health and vertical transmission among women with HIV. We assessed the feasibility of a trial of interpersonal psychotherapy (IPT) versus antidepressant medication (ADM) to treat PPD and/or anxiety among postpartum women with HIV in Lusaka, Zambia.

Methods

Between 29 October 2019 and 8 September 2020, we pre‐screened women 6–8 weeks after delivery with the Edinburgh Postnatal Depression Scale (EPDS) and diagnosed PPD or anxiety with the Mini International Neuropsychiatric Interview. Consenting participants were randomized 1:1 to up to 11 sessions of IPT or daily self‐administered sertraline and followed for 24 weeks. We assessed EPDS score, Clinical Global Impression‐Severity of Illness (CGI‐S) and medication side effects at each visit and measured maternal HIV viral load at baseline and final study visit. Retention, visit adherence, change in EPDS, CGI‐S and log viral load were compared between groups with t‐tests and Wilcoxon signed rank tests; we report mean differences, relative risks and 95% confidence intervals. A participant satisfaction survey assessed trial acceptability.

Results

78/80 (98%) participants were retained at the final study visit. In the context of the COVID‐19 pandemic, visit adherence was greater among women allocated to ADM (9.9 visits, SD 2.2) versus IPT (8.9 visits, SD 2.4; p = 0.06). EPDS scores decreased from baseline to final visit overall, though mean change was greater in the IPT group (−13.8 points, SD 4.7) compared to the ADM group (−11.4 points, SD 5.5; p = 0.04). Both groups showed similar changes in mean log viral load from baseline to final study visit (mean difference −0.43, 95% CI −0.32, 1.18; p = 0.48). In the IPT group, viral load decreased significantly from baseline (0.9 log copies/ml, SD 1.7) to final visit (0.2 log copies/ml, SD 0.9; p = 0.01).

Conclusions

This pilot study demonstrates that a trial of two forms of PPD treatment is feasible and acceptable among women with HIV in Zambia. IPT and ADM both improved measures of depression severity; however, a full‐scale trial is required to determine whether treatment of PPD and anxiety improves maternal–infant HIV outcomes.

Tenofovir Diphosphate in Dried Blood Spots in Pregnant and Postpartum Women With HIV in Kenya: A Novel Approach to Measuring Peripartum Adherence

BACKGROUND

Adherence to antiretroviral therapy (ART) among pregnant and postpartum women with HIV (PWLWH) is critical to promote maternal health and prevent HIV transmission. Tenofovir diphosphate (TFV-DP) in dried blood spots (DBS) is an objective assessment of cumulative ART adherence that has not been fully assessed in PWLWH.

SETTING

Southwestern Kenya.

METHODS

PWLWH receiving tenofovir disoproxil fumarate-based ART from 24 health facilities provided DBS samples at 3 time points [pregnancy/early postpartum (PP), 6 months PP, and 9-12 months PP]. Thresholds for daily adherence were defined as TFV-DP in DBS ≥650 fmol/punch in pregnancy and ≥950 PP. Descriptive analysis is presented. Cluster adjusted χ2 and t-tests were used to test for association with clinical and demographic factors.

RESULTS

A total of 419 DBS samples were collected from 150 PWLWH. Median TFV-DP in DBS was lowest, 552 fmol/punch [interquartile range (IQR), 395-759] in pregnancy and declined over time [914 (IQR, 644-1176) fmol/punch; early PP; 838 (IQR, 613-1063) fmol/punch 6 months PP; and 785 (IQR, 510-1009) fmol/punch 9-12 months; P < 0.001]. Only 42% of samples in pregnancy and 38.5% of samples in PP met thresholds for daily adherence. Clinical or demographic factors were not associated with suboptimal adherence levels.

CONCLUSION

Cumulative ART exposure in PWLWH, quantified by TFV-DP in DBS, demonstrated a stepwise decrease (ie, adherence) PP. Most women demonstrated less than daily adherence throughout the peripartum period. Use of TFV-DP in DBS as a measure of cumulative ART adherence could help optimize health outcomes in PWLWH and their infants.

High willingness to use injectable antiretroviral therapy among women who have been lost to follow-up from HIV programmes: A nested cross-sectional study

OBJECTIVES

Efforts to achieve zero transmission of HIV to infants born to women living with HIV in sub-Saharan African are undermined by high rates of loss to follow-up in prevention of vertical transmission (PVT) programmes. The fear of HIV status disclosure through the discovery of pill bottles at home is a major contributor. Injectable antiretroviral therapy (ART) has proved to be efficacious in clinical trials and is discreet, offering a potential solution. We investigated the knowledge and willingness to use injectable ART among women who were lost to follow-up from the PVT programme in Uganda.

METHODS

Women were traced by nurse counsellors and knowledge and opinions relating to injectable ART, including willingness to use it when it becomes available, were collected. Generalized linear models were used to determine predictors of willingness to use injectable ART.

CONCLUSIONS

Among 1023 women registered between 2017 and 2019 under the PVT programmes in Kampala and Wakiso districts, Uganda, 385 (38%) were lost to follow-up from care and 22% of these (83/385) were successfully traced and interviewed. Only 25% (21/83) had heard of injectable ART. Over half (55%, 46/83) were very willing to use injectable ART, 40% (33/83) were somewhat willing and four (5%) were not willing. Those who associated ART tablets with disclosure risk were more willing to consider injectable ART (adjusted odds ratio = 4.21; 95% confidence interval: 1.45-12.19; p = 0.008). We report high willingness to use injectable ART associated with fears that ART tablets were a potential source of HIV status disclosure. Injectable ART could be a solution for women who have challenges with disclosure.

Insaka: mobile phone support groups for adolescent pregnant women living with HIV

BACKGROUND

Mobile phone-based interventions have been demonstrated in different settings to overcome barriers to accessing critical psychosocial support. In this study, we aimed to assess the acceptability and feasibility of a phone-based, peer-to-peer support group intervention for adolescent pregnant women aged 15-24 years living with HIV in Zambia.

METHODS

Sixty-one consenting participants were recruited from Antenatal Clinics of two large urban communities in Lusaka. They were invited to participate in the mobile phone-based intervention that allowed them to anonymously communicate in a small group led by a facilitator for 4 months. A mixed methods approach was used to assess acceptability and feasibility, including a focus group discussion, pre- and post-intervention interview and analysis of the content of the text message data generated.

RESULTS

Participants reported finding the platform "not hard to use" and enjoyed the anonymity of the groups. Seventy-one percent of participants (n = 43) participated in the groups, meaning they sent text messages to their groups. Approximately 12,000 text messages were sent by participants (an average of 169 messages/user and 6 mentors in 6 groups. Topics discussed were related to social support and relationships, stigma, HIV knowledge and medication adherence.

CONCLUSION

The study showed that the intervention was acceptable and feasible, and highlighted the potential of the model for overcoming existing barriers to provision of psychosocial support to this population.

Level of adherence to option B plus PMTCT and associated factors among HIV positive pregnant and lactating women in public health facilities of Hawassa city, Southern Ethiopia

BACKGROUND

Adherence to antiretroviral therapy is very essential to achieve a great outcome of drugs via suppressing viral load, preventing multidrug resistance, and reducing mother to a child transmission rate of the Human Immune Virus.

OBJECTIVE

This study aimed to assess the level of adherence to option B plus PMTCT and associated factors among HIV Positive pregnant and lactating women in public health facilities of Hawassa city, Southern Ethiopia, 2020 G.C.

METHODS

Institution-based cross-sectional study was done on 254 HIV-positive pregnant and lactating women attending the prevention of mother-to-child transmission (PMTCT) follow-up. Participants were selected by simple random sampling. Data collected through a structured interviewer-administered questionnaire were cleaned and entered into Epi-data 3.1 and exported to SPSS 20 for statistical analysis. Descriptive analysis was done. Bivariable and multivariable logistic regressions were done to measure the strength of association between independent and dependent variables using the odds ratio and 95% of confidence interval. A p-value <0.05 was taken as statistically significant.

RESULT

The overall adherence level to option B+ was 224 (88.2%). Respondents in age group of ≤ 25 [AOR = 0.12, 95% CI (0.03, 0.42)], with no formal education [AOR = 0.12, 95% CI (0.03, 0.51)], experienced drug side effects [AOR = 0.11, 95% CI (0.04, 0.32)], have good knowledge of PMTCT [AOR = 3.6, 95% CI (1.16, 11.3)], and get support from partner/family [AOR = 4.5, 95% CI (1.62, 12.4)] were identified associated factors with adherence level.

CONCLUSION

The level of adherence to option B plus PMTCT was 88.2% which is suboptimal. Ages, educational level, knowledge on PMTCT, getting support from partner/family, and drug side effect were significantly associated with adherence. Therefore, educating and counseling on the service of PMTCT to improve their knowledge and encouraging partner/family involvement in care are mandatory to achieve the standard adherence level.

Designing a couple-based relationship strengthening and health enhancing intervention for pregnant women living with HIV and their male partners in Zambia: Interview findings from the target community

INTRODUCTION

Interpersonal support can promote positive outcomes among people living with HIV. In order to develop an acceptable psychoeducational couples-based intervention aimed at strengthening the relationship context and improving HIV outcomes before and after pregnancy, we conducted qualitative interviews with pregnant women living with HIV and their male partners.

METHODS

We interviewed a convenience clinic-based sample of pregnant women living with HIV (n = 30) and male partners (n = 18) in Lusaka, Zambia. Interviews included pile sorting relationship topics in order of perceived priority. Interviews also focused on family health concerns. Interviews were audio-recorded, translated, transcribed, and thematically analyzed. Pile sorting data was analyzed using descriptive statistics.

RESULTS

All female participants were living with HIV; 61% of the male partners interviewed were additionally living with HIV. The most prioritized relationship topic among both genders was communication between couples. Honesty and respect were important relationship topics but prioritized differently based on gender. Female participants considered emotional and instrumental support from male partners critical for their physical and mental health; men did not prioritize support. Intimate partner violence was discussed often by both genders. Family health priorities included good nutrition during pregnancy, preventing infant HIV infection, safe infant feeding, sexual health, and men's alcohol use.

CONCLUSIONS

A major contribution of this study is a better understanding of the dyad-level factors pregnant women living with HIV and their male partners perceive to be the most important for a healthy, well-functioning relationship. This study additionally identified gaps in antenatal health education and the specific family health issues most prioritized by pregnant women living with HIV and their male partners. The findings of this study will inform the development of an acceptable couples-based intervention with greater likelihood of efficacy in strengthening the relationship context and promoting family health during and after pregnancies that are affected by HIV.

Adherence to Antiretroviral Therapy Among HIV-Positive Pregnant Women on followup at Mizan Tepi University Teaching and Tepi General Hospitals, Southwest Ethiopia

Background: The introduction of highly active antiretroviral therapy has not only improved longevity in human immunodeficiency virus (HIV)–infected individuals but in addition has had a significant impact on the rate of mother-to-child transmission of the infection. Objective: To assess antiretroviral therapy adherence among HIV-positive pregnant women on follow-up at antiretroviral therapy clinic of Mizan Tepi University Teaching and Tepi General Hospitals. Methods: A descriptive cross-sectional study was undertaken in antiretroviral therapy clinics of Mizan Tepi University Teaching and Tepi General Hospitals from April to May 2018. Data were collected through face to face interview using structured and pretested questionnaires and analyzed using Statistical Package for Social Sciences version 20. Results: Majority of the patients had good adherence to their antiretroviral therapy, 68 (66.00%). Medication side effects, 12 (34.00%) and forgetfulness and distance of the hospital from home, each accounting 11 (31.00%) were the main reasons for nonadherence among nonadherent patients. Frequency of counseling (P = .000), CD4 count (χ² = 37.529, P = .000), World Health Organization’s clinical stage (χ² = 17.515, P = .000), stigma (χ² = 70.426, P = .000), and family support (χ² = 46.383, P = .000) were found to be associated with patients’ medication adherence. Conclusion: The overall patient adherence to antiretroviral therapy in the study facilities was good. Collaborative work among patients, health care organizations, and the public are necessary to tackle the adherence obstacles and enhance patient adherence to the prescribed medication.

What influences uptake and early adherence to Option B+ (lifelong antiretroviral therapy among HIV positive pregnant and breastfeeding women) in Central Uganda? A mixed methods study

Background

High uptake and optimal adherence to Option B+ antiretroviral therapy (ART) increase effectiveness in averting mother-to-child transmission of HIV. Option B+ ART uptake, early adherence, and associated factors need to be evaluated in Central Uganda.

Methods

A mixed approaches study was carried out in six health facilities in Masaka, Mityana, and Luwero districts from October 2013 to February 2016. Questionnaires were administered to 507 HIV positive pregnant females seeking antenatal care services. Key informant interviews were conducted with 54 health providers, and in-depth interviews (IDIs) with 57 HIV positive women on Option B+ ART. Quantitative data were analyzed using log-binomial regression model to determine factors associated with optimal adherence (taking at least 95% of the prescribed ART), while thematic analysis was used on qualitative data.

Results

Ninety one percent of women (463/507) received a prescription of life long ART. Of these, 93.3% (432/463) started swallowing their medicines. Overall, 83% of women who received ART prescriptions (310/374) felt they were ready to initiate ART immediately. Main motivating factors to swallow ART among those who received a prescription were women’s personal desire to be healthy (92.3%) and desire to protect their babies (90.6%). Optimal adherence to ART was achieved by 76.8% (315/410). Adherence was higher among females who were ready to start ART (adj. PR = 3.20; 95% CI: 1.15–8.79) and those who had revealed their HIV positive result to someone (adj. PR = 1.23; 95% CI: 1.04–1.46). Facilitators of ART uptake from qualitative findings included adequate counseling, willingness to start, and knowing the benefits of ART. Reasons for refusal to start ART included being unready to start ART, fear to take ART for life, doubt of HIV positive results, and preference for local herbs. Reasons for non-adherence were travelling far away from health facilities, fear of side effects, non-disclosure of HIV results to anyone, and perception that the baby is safe from HIV infection post-delivery.

Conclusions

Uptake of Option B+ ART was very high. However, failure to start swallowing ART and sub-optimal adherence are a major public health concern. Enhancing women’s readiness to start ART and encouraging HIV result revelation could improve ART uptake and adherence.

Video-Based Intervention for Improving Maternal Retention and Adherence to HIV Treatment: Patient Perspectives and Experiences

VITAL Start is a video-based intervention aimed to improve maternal retention in HIV care and adherence to antiretroviral therapy (ART) in Malawi. We explored the experiences of pregnant women living with HIV (PWLHIV) not yet on ART who received VITAL Start before ART initiation to assess the intervention’s acceptability, feasibility, fidelity of delivery, and perceived impact. Between February and September 2019, we conducted semi-structured interviews with a convenience sample of 34 PWLHIV within one month of receiving VITAL Start. The participants reported that VITAL Start was acceptable and feasible and had good fidelity of delivery. They also reported that the video had a positive impact on their lives, encouraging them to disclose their HIV status to their sexual partners who, in turn, supported them to adhere to ART. The participants suggested using a similar intervention to provide health-related education/counseling to people with long term conditions. Our findings suggest that video-based interventions may be an acceptable, feasible approach to optimizing ART retention and adherence amongst PWLHIV, and they can be delivered with high fidelity. Further exploration of the utility of low cost, scalable, video-based interventions to address health counseling gaps in sub-Saharan Africa is warranted.

The magnitude of adherence to option B plus program and associated factors among women in eastern African countries: a systematic review and meta-analysis

Background

Despite coverage and benefits associated with the prevention of mothers to child transmission (PMTCT) services, mothers’ adherence to option B plus is still a challenge. Though few primary studies are available on the magnitude of adherence to option B plus and factors associated in Eastern African countries, they do not provide strong evidence in helping policymakers to address suboptimal adherence to option B plus. Therefore, this systematic review and meta-analysis was intended to estimate the pooled magnitude of adherence to option B plus program and associated factors among women in Eastern African countries.

Methods

PubMed, Medline, HINARI, Cochrane library, the Web of Science, and Google Scholar were searched for studies reported on the magnitude of adherence to option B plus among women in Eastern African countries. The search terms used were “option B plus”, “magnitude”, “prevalence”, “PMTCT”, “ART adherence”, “associated factors”, “all lists of Eastern African countries” and their combination by Boolean operators. The effect sizes of the meta-analysis were the magnitude of adherence to option B plus and the odds ratio of the associated factors. STATA/SE V14 was used for statistical analysis, and publication bias was assessed using funnel plots and Egger’s test.

Results

Fourteen studies having total participants of 4883 were included in the systematic review and meta-analysis. Using the random effect model, the pooled prevalence of adherence to option B plus was 71.88% (95% CI: 58.54–85.23%). The factors associated with good adherence to option B plus PMTCT program were partner support (Adjusted odds ratio (AOR) = 4.13; 95% CI: 2.78–6.15), received counseling services (AOR = 4.12, 95% CI: 2.81–6.02), disclosure of HIV status to partner (AOR = 4.38; 95% CI: 1.79–10.70), and clinical stage of HIV/AIDS I/II (AOR = 2.62; 95% CI: 1.53–4.46).

Conclusion

The level of adherence to option B plus program in Eastern African countries was generally sub-optimal. Thus, a coordinated effort is needed to raise the number of mothers to be tested, and early treatment initiation for HIV positive mothers before the disease advances. Furthermore, counseling services for couples on the importance of early treatment initiation and adherence to medications must be given due attention.

Adherence to Antiretroviral Treatment for Prevention of Mother-to-Child Transmission of HIV in Eastern Ethiopia: A Cross-Sectional Study

INTRODUCTION

Even though PMTCT (prevention of mother-to-child transmission) is the most effective option to prevent vertical transmission of HIV, achieving optimal adherence has been a universal challenge to PMTCT, including Ethiopia.

OBJECTIVE

To assess levels of adherence and associated factors among pregnant and lactating mothers on PMTCT at public health facilities in Harar town, Harari region, Eastern Ethiopia.

METHODS

A facility-based cross-sectional study was conducted from April 01 to April 30, 2019, at the selected public health facilities of Harar town, Harari regional state, Eastern Ethiopia. Adherence was measured using a multi-method tool that includes pill counting and self-reporting method. Binary logistic regression analysis was used to determine factors associated with PMTCT adherence. The results were adjusted for possible confounding variables and P-value <0.05 or CI not including 1 was considered statistically significant.

RESULTS

Of the 190 included patients, 83.2% of them had good adherence to PMTCT. Forgetfulness (79%) and being busy (71%) were among the main reasons for non-adherence to PMTCT. In multivariate logistic regression, participants who have received counseling on side effects were 3.4 times more likely to have good adherence [AOR=3.4, 95% CI: 2.1-9.2]; those with previously known HIV status were 2.1 times more likely to have good adherence to PMTCT [AOR=2.1, 95% CI: 1.6-7.1] and women who were knowledgeable on PMTCT were 5.2 times more likely to have good adherence [AOR=5.2, 95% CI: 1.6-6.28].

CONCLUSION

In this study, the overall level of adherence to PMTCT care and support was 83.2%. Counseling on side effects, knowledge about PMTCT, and pregnancy status during initiation of ART were the factors that determine adherence of pregnant and lactating women towards PMTCT service. Thus, it is recommended to raise awareness about PMTCT among all reproductive-age women by stressing the benefit of the early initiation of ART and by providing information on the possible side effect of the drugs.

Digitized HIV/AIDS Treatment Adherence Interventions: A Review of Recent SMS/Texting Mobile Health Applications and Implications for Theory and Practice

BACKGROUND

Mobile health technologies (mHealth) are efficacious along the continuum of HIV/AIDS-from prevention of HIV transmission to those at the highest risk of acquiring infection, to adherence to HIV medical care, for those living with the disease-decreasing the public health burden of the disease. HIV/AIDS is a complex condition, as certain population subgroups are disproportionately affected. Furthermore, barriers experienced at the individual level (e.g., HIV stigma) and at the systems level (i.e., access to care) contribute to these disparities. Low cost, high penetration rates and ease of use mean mHealth SMS/texting solutions hold the biggest promise for curbing the global HIV/AIDS epidemic; yet these technologies have their own challenges. Our primary objective was to assess interventions that promote adherence, which are delivered via SMS/texting, and important design and ethical considerations of these technologies. Specifically, we evaluated the underlying frameworks underpinning intervention design, strategies to safeguard privacy and confidentiality, and measures taken to ensure equity and equitable access across different subgroups of persons living with HIV (PLWH). We also synthesized study outcomes, barriers/facilitators to adherence, and barriers/facilitators of technology to support HIV adherence.

METHODS

A scoping review methodology was utilized, searching the Medline database for recently published articles (January 2017 to June 2019). Two reviewers independently screened titles and abstracts for relevancy using the following eligibility criteria: (a) original research or protocol; (b) inclusion of persons living with HIV; (c) intervention delivery via SMS/text messaging; and, (d) intervention included HIV care adherence.

RESULTS

Seven (7) of the 134 articles met full criteria. The great majority (n = 6) did not report whether the interventions were developed under established behavioral change models or frameworks. Strategies to address privacy, confidentiality and equity/equitable access were taken in four (n = 4) studies.

CONCLUSION

Our mixed methods review determined that privacy and confidentiality remain a concern for PLWH. Provisions to accommodate literacy, infrastructure, technology and other challenges (e.g., access to smartphones and Wifi) are important ethical considerations that guarantee equity and equitable access. Further investigation will determine the contexts within which theoretical models and frameworks remain relevant in the rapidly evolving field of digitized interventions that support adherence.

Support or control? Qualitative interviews with Zambian women on male partner involvement in HIV care during and after pregnancy

BACKGROUND

Efforts to promote male partner involvement in the prevention of mother-to-child transmission (PMTCT) may inadvertently exploit gender power differentials to achieve programme targets.

METHODS

We explored women's relative power and perceptions of male partner involvement through interviews with postpartum Zambian women living with HIV (n = 32) using a critical discourse analysis.

RESULTS

Women living with HIV reported far-reaching gender power imbalances, including low participation in household decision-making, economic reliance on husbands, and oppressive gendered sexual norms, which hindered their autonomy and prevented optimal mental and physical health during and after their pregnancy. When the husband was HIV-negative, sero-discordance exacerbated women's low power in these heterosexual couples. Male involvement in HIV care was both helpful and hurtful, and often walked a fine line between support for the woman and controlling behaviours over her. Inequities in the sexual divisions of power and labour and gender norms, combined with HIV stigma created challenging circumstances for women navigating the PMTCT cascade.

CONCLUSIONS

Future programmes should consider the benefits and risks of male partner involvement within specific relationships and according to women's needs, rather than advocating for universal male involvement in PMTCT. This work highlights the persistent need for gender transformative approaches alongside PMTCT efforts.

A population pharmacokinetic model is beneficial in quantifying hair concentrations of ritonavir-boosted atazanavir: a study of HIV-infected Zimbabwean adolescents

BACKGROUND

Adolescents experience higher levels of non-adherence to HIV treatment. Drug concentration in hair promises to be reliable for assessing exposure to antiretroviral (ARV) drugs. Pharmacokinetic modelling can explore utility of drug in hair. We aimed at developing and validating a pharmacokinetic model based on atazanavir/ritonavir (ATV/r) in hair and identify factors associated with variabilities in hair accumulation.

METHODS

We based the study on secondary data analysis whereby data from a previous study on Zimbabwean adolescents which collected hair samples at enrolment and 3 months follow-up was used in model development. We performed model development in NONMEM (version 7.3) ADVAN 13.

RESULTS

There is 16% / 18% of the respective ATV/r in hair as a ratio of steady-state trough plasma concentrations. At follow-up, we estimated an increase of 30% /42% of respective ATV/r in hair. We associated a unit increase in adherence score with 2% increase in hair concentration both ATV/r. Thinner participants had 54% higher while overweight had 21% lower atazanavir in hair compared to normal weight participants. Adolescents receiving care from fellow siblings had atazanavir in hair at least 54% less compared to other forms of care.

CONCLUSION

The determinants of increased ATV/r concentrations in hair found in our analysis are monitoring at follow up event, body mass index, and caregiver status. Measuring drug concentration in hair is feasibly accomplished and could be more accurate for monitoring ARV drugs exposure.

Mother's Knowledge on HIV, Syphilis, Rubella, and Associated Factors in Northern Tanzania: Implications for MTCT Elimination Strategies

Background

Infections transmitted from mother to child (MTCT) during pregnancy, childbirth, and breastfeeding contribute significantly to the high infant and childhood morbidity and mortality in sub-Saharan African countries. The most significant and preventable of these include HIV, syphilis, and rubella. To achieve elimination, mothers need to be aware of and to understand effective preventive measures against these infections. Lack of comprehensive knowledge on transmission and prevention of MTCT infections is one of the factors hindering achievement of the elimination goals for these infections. The aim of this study was to assess the knowledge of HIV, syphilis, rubella, and associated factors among mothers in the Kilimanjaro region of Tanzania.

Methods

We conducted a community-based cross-sectional study in three districts of the Kilimanjaro region from September to October 2016. The study involved mothers with children up to five years of age. Data collection involved the use of a questionnaire, administered by face-to-face interviews. Logistic regression analysis was used to assess predictors of mothers' knowledge on MTCT infections.

Results

A total of 618 mothers were recruited, with a mean age of 29.6 (SD 7.6) years. The overall knowledge on MTCT infections was low. The highest level of knowledge on MTCT infections was regarding HIV (89.2%). Fewer mothers had knowledge of syphilis (27.8%). Rubella was the least known; only 12% of mothers were aware of rubella infection. District of residence and having knowledge of syphilis were predictors for rubella knowledge, while for syphilis knowledge, significant predictors were age group, occupation, and those having knowledge on HIV and rubella. Predictors for HIV knowledge were residential district, having a mobile phone, and those having knowledge of syphilis and rubella.

Conclusions

This study confirmed that mothers have low overall knowledge on MTCT infections. To achieve the MTCT elimination goals, targeted interventions to improve knowledge among women of childbearing age are recommended.

Reducing Mother-to-Child Transmission of HIV Using Quality Improvement Approaches

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.

Predictors of Viremia in Postpartum Women on Antiretroviral Therapy

Supplemental Digital Content is Available in the Text.

HIV-infected, postpartum women on antiretroviral therapy (ART) have high rates of viremia. We examined predictors of postpartum viremia in the PROMISE study.

Level and determinants of postpartum adherence to antiretroviral therapy in the Eastern Cape, South Africa

BACKGROUND

Adherence to antiretroviral therapy (ART), especially during the postpartum period, remains a major challenge in the efforts towards eliminating mother-to-child transmission of HIV. This study examined the levels and determinants of postpartum adherence to ART among mothers with HIV in the Eastern Cape, South Africa.

METHODS

In this cross-sectional analytical study, we interviewed 495 postpartum women with HIV between January and May 2018. We measured postpartum adherence using six questions probing participants' adherence behaviours since child birth. We categorised the adherence behaviours into complete adherence (mothers who reported no missed episode(s) of ART since child birth) and suboptimal adherence (mothers with any missed episode(s) of ART). Adjusted and unadjusted logistic regression models were used to examine the determinants of postpartum adherence to ART.

RESULTS

Overall, 63.9% reported complete adherence during the postpartum period but the rates varied by socio-demographic and behavioural characteristics. The adjusted logistic regression analysis showed that younger mothers were 70% less likely to report complete adherence to ART compared to mothers aged 40 and above. Likewise, mothers who currently use alcohol were 53% less likely to report complete postpartum adherence to ART compared to those who did not use alcohol. However, mothers who knew their partner's status were twice more likely to report complete postpartum adherence compared to those who did not. There was no statistically significant relationship between ART adherence and breastfeeding durations.

CONCLUSION

Postpartum adherence to ART is suboptimal in the study setting, and younger mothers and those who use alcohol have a lower odds of complete adherence. Knowing a partner's status improves adherence, but infant feeding practices did not influence postpartum adherence behaviours. It is critical to design and strengthen interventions which target young mothers and alcohol users. Also, HIV sero-status disclosure should be encouraged among mothers to facilitate partner support.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Decreases in Self-Reported ART Adherence Predict HIV Viremia Among Pregnant and Postpartum South African Women

INTRODUCTION

Routine HIV viral load (VL) monitoring is recommended for patients on antiretroviral therapy, but frequent VL testing, required in pregnant and postpartum women, is often not feasible. Self-reported adherence can be valuable, but little is known about its longitudinal characteristics.

METHODS

We followed women living with HIV from antiretroviral therapy initiation in pregnancy through 18-month postpartum in Cape Town, South Africa, with repeated measurement of VL and self-reported adherence using a 3-item scale. We used generalized estimating equations [with results presented as odds ratios (ORs) with 95% confidence intervals (CIs)] to investigate the association between viremia and change in adherence over pairs of consecutive visits.

RESULTS

Among 2085 visit pairs from 433 women, a decrease in self-reported adherence relative to the previous visit on any of the 3 self-report items, or the combined scale, was associated with VL >50 and >1000 copies per milliliter. The best-performing thresholds to predict VL >50 copies per milliliter were a single-level decrease on the Likert response item "how good a job did you do at taking your HIV medicines in the way that you were supposed to?" (OR 2.08, 95% CI: 1.48 to 2.91), and a decrease equivalent to ≥5 missed doses or a one-level decrease in score on either of 2 Likert items (OR 1.34, 95% CI: 1.06 to 1.69).

CONCLUSIONS

Longitudinal changes in self-reported adherence can help identify patients with viremia. This approach warrants consideration in settings where frequent VL monitoring or other objective adherence measures are not possible.

VITAL Start: Video-Based Intervention to Inspire Treatment Adherence for Life-Pilot of a Novel Video-Based Approach to HIV Counseling for Pregnant Women Living with HIV

We developed and piloted a video-based intervention targeting HIV-positive pregnant women to optimize antiretroviral therapy (ART) retention and adherence by providing a VITAL Start (Video-intervention to Inspire Treatment Adherence for Life) before ART. VITAL Start (VS) was grounded in behavior-determinant models and developed through an iterative multi-stakeholder process. Of 306 pregnant women eligible for ART, 160 were randomized to standard of care (SOC), 146 to VS and followed for one-month. Of those assigned to VS, 100% completed video-viewing; 96.5% reported they would recommend VS. Of 11 health workers interviewed, 82% preferred VS over SOC; 91% found VS more time-efficient. Compared to SOC, VS group had greater change in HIV/ART knowledge (p < 0.01), trend towards being more likely to start ART (p = 0.07), and better self-reported adherence (p = 0.02). There were no significant group differences in 1-month retention and pharmacy pill count. VITAL Start was highly acceptable, feasible, with promising benefits to ART adherence.

Longitudinal adherence to maternal antiretroviral therapy and infant Nevirapine prophylaxis from 6 weeks to 18 months postpartum amongst a cohort of mothers and infants in South Africa

BACKGROUND

Despite improved policies to prevent mother-to-child HIV transmission (MTCT), adherence to maternal antiretroviral therapy (ART) and infant Nevirapine prophylaxis (NVP) is low in South Africa. We describe ART adherence amongst a cohort of HIV-positive mothers and HIV-exposed but uninfected infants from 6 weeks until 18 months post-delivery and identify risk factors for nonadherence.

METHODS

Data were collected in 2012-2014 through a nationally representative survey of PMTCT effectiveness. Mother-infant pairs were enrolled during the infant's first immunization visit at 6 weeks. Mothers and HIV-exposed infants (2811 pairs) were followed to 18 months at 3-month intervals. Mothers who self-reported being on ART at 6 weeks postpartum (N = 1572 (55.9%)) and infants on NVP at 6 weeks (N = 2370 (84.3%)) were eligible for this analysis and information about their adherence was captured at each interview they attended thereafter. We defined nonadherence within each 3-month interval as self-report of missing > 5% of daily ART/NVP doses, estimated adherence using a Cox survival curve with Andersen & Gill setup for recurring events, and identified risk factors for nonadherence with an extended Cox regression model (separately for mothers and infants) in Stata 13. Results are not nationally representative as this is a subgroup analysis of the follow-up cohort.

RESULTS

Amongst mothers on ART at 6 weeks postpartum, cumulative adherence to maternal ART until 18 months was 63.4%. Among infants on NPV at 6 weeks postpartum, adherence to NVP was 74.5%.. Risk factors for nonadherence to maternal ART, controlling for other factors, included mother's age (16-24 years vs. ≥34 years, adjusted Hazard Ratio (aHR): 1.9, 95% CI: 1.4-2.5), nondisclosure of HIV status to anyone (nondisclosure vs. disclosure: aHR: 1.7, 95% CI: 1.3-2.1), and timing of ART initiation (initiated ART after delivery vs. initiated ART before delivery: aHR: 1.6, 95% CI: 1.3-2.0). Provincial variation was seen in nonadherence to infant NVP, controlling for other factors.

CONCLUSION

Maintaining ART adherence until 18 months postpartum remains a crucial challenge, with maternal ART adherence among the six week maternal ART cohort below 65% and infant NVP adherence among breastfeeding infants in this cohort below 75%.This is gravely concerning, given the global policy shift to lifelong ART amongst pregnant and lactating women, and the need for extended infant prophylaxis amongst mothers who are not virally suppressed. Our findings suggest that young mothers and mothers who do not disclose their status should be targeted with messages to improve adherence, and that late maternal ART initiation (after delivery) increases the risk of maternal nonadherence.

Option B plus antiretroviral therapy adherence and associated factors among HIV positive pregnant women in Southern Ethiopia

Background

Adherence to Option B plus Antiretroviral Therapy plays a vital role in preventing mother to child transmission of Human Immunodeficiency Virus and development of drug resistance. This study was aimed to assess adherence to option B plus ART and associated factors among HIV positive pregnant women at public Hospitals in Southern Ethiopia.

Methods

Facility based cross sectional study was conducted on HIV positive pregnant mothers attending public health facilities’ antenatal care unit. Systematic random sampling technique was employed to select 290 HIV positive pregnant women enrolled in the Option B plus program. Data were collected by using structured questionnaire. Bivariate and multivariable logistic regression analysis were used to identify factors associated with option B plus ART adherence. P-value less than 0.05 was considered as cut of point to declare statistical significance.

Results

The overall adherence to option B plus ART among HIV positive pregnant women was 236 (81.4%). Three in twenty, (14.8%) participants were none adherent to Option B plus ART due to difficulty in adopting time schedule and forgetting to take medication. During first trimester of pregnancy, 16 (5.5%) were stopped taking ART medication due to side effects. Pregnant women who started ART at the time of HIV diagnosis [AOR = 1.99, 95% CI: (1.02, 3.95)], and who had five or more antenatal care visits [AOR = 4.10, 95% CI (1.65, 10.02)] were more likely to adhere to option B plus ART. Women who should travel 30–60 min on foot to access ART from service delivering facilities were less likely to adhere to option B plus [AOR = 0.39, 95% C I: (0.17, 0.88)].

Conclusions

The overall adherence to option B plus ART was suboptimal. Measures that improve recalling ability of individuals to take ART on time, and minimize ART side effects during first trimester of pregnancy need to be given emphasis. The study finding indicates the need for reconsidering the ad-hoc focused antenatal care visit at policy and program level by increasing the number of follow up visit with proper counseling on ART adherence benefits, and improving service accessibility.

Post Option B+ implementation programme in Nigeria: Determinants of adherence of antiretroviral therapy among pregnant women with HIV

OBJECTIVE

Nigeria has the highest rate of mother to child transmission of HIV (MTCT) in the world. By 2015, all Global Plan priority countries, except Nigeria, had adopted the Option B+ programme. Nigeria finally adopted Option B+ in 2016 with full implementation reported in 2017. We examined adherence to antiretroviral therapy (ART) among pregnant women since the rollout of Option B+ in Nigeria.

METHODS

A cross sectional approach was adopted that involved dissemination of a survey (Adult AIDS Clinical Trial Groups [AACTG] standardised survey) to HIV positive pregnant women, to assess adherence to ART. This study was conducted from February to June, 2018 in four health care sites in Akwa Ibom State, in the South-South region of Nigeria. Bootstrapping was used to estimate the 95% confidence interval of the prevalence of adherence. Bivariate associations between patient demographic characteristics and medication taking behaviours, and the outcome variable of ART adherence were examined using Chi-square tests. Multivariable logistic regression was used to identify factors independently associated with adherence.

RESULTS

Of the 275 women (response rate=92.6%), 32.7% (95% CI: 26.9-38.5) self-reported taking all ART doses in the past 96 hours. In the multivariable logistic regression analyses, there were positive associations between an increased education level (OR=1.7, p=0.006) and disclosure of HIV status (OR=2.3, p=0.024), and medication adherence. For women who had previous prevention of MTCT exposure, the odds of medication adherence were 2.5 times higher compared with those with no previous MTCT exposure (OR=2.5, p=0.005).

CONCLUSION

Adherence to ART among pregnant women in Nigeria is low. There is a need to improve adherence during pregnancy under the Option B+ programme in Nigeria.

A Bayesian Analysis of Prenatal Maternal Factors Predicting Nonadherence to Infant HIV Medication in South Africa

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.

Medication adherence in pregnant women with human immunodeficiency virus receiving antiretroviral therapy in sub-Saharan Africa: a systematic review

BACKGROUND

The use of antiretroviral therapy (ART) is a core strategy proposed by the World Health Organization in preventing mother to child transmission (MTCT) of HIV. This systematic review aimed to examine the enablers and barriers of medication adherence among HIV positive pregnant women in sub-Saharan Africa.

METHODS

We used the following keywords: HIV AND (Pregnancy OR Pregnant*) AND (PMTCT OR "PMTCT Cascade" OR "Vertical Transmission" OR "Mother-to-Child") AND (Prevent OR Prevention) AND (HAART OR "Antiretroviral Therapy" OR "Triple Therapy") AND (Retention OR Concordance OR Adherence OR Compliance) to conduct electronic searches in the following databases: MEDLINE Complete (1916-Dec 2017), Embase (1947-Dec 2017), Global Health (1910-Dec 2017) and CINAHL Complete (1937-Dec 2017). Of the four databases searched, 401 studies were identified with 44 meeting the inclusion criteria. Seven studies were added after searching reference lists of included articles, resulting in 51 articles in total.

RESULTS

The review demonstrated that stigma, cost of transportation, food deprivation and a woman's disclosure or non-disclosure of her HIV status to a partner, family and the community, could limit or define the extent of her adherence to prescribed antiretroviral drugs during pregnancy. Furthermore, the review indicated that knowledge of HIV status, either before or during pregnancy, was significantly associated with medication adherence. Women who knew their HIV status before pregnancy demonstrated good adherence while women who found out their HIV infection status during pregnancy were linked with non-adherence to ART.

CONCLUSION

This review revealed several barriers and enablers of adherence among pregnant women taking ART in sub-Saharan Africa. Major barriers included the fear of HIV infection status disclosure to partners and family members, stigma and discrimination. A major enabler of adherence in women taking ART was women's knowledge of their HIV status prior to becoming pregnant. Enhanced effort is needed to facilitate women's knowledge of their HIV status before pregnancy to enable disease acceptance and management, and to support pregnant women and her partner and family in dealing with fear, stigma and discrimination about HIV.

Association of maternal KIR gene content polymorphisms with reduction in perinatal transmission of HIV-1

The role of killer cell immunoglobulin-like receptors (KIRs) in the transmission of HIV-1 has not been extensively studied. Here, we investigated the association of KIR gene content polymorphisms with perinatal HIV-1 transmission. The KIR gene family comprising 16 genes was genotyped in 313 HIV-1 positive Kenyan mothers paired with their infants. Gene content polymorphisms were presented as presence of individual KIR genes, haplotypes, genotypes and KIR gene concordance. The genetic data were analyzed for associations with perinatal transmission of HIV. There was no association of infant KIR genes with perinatal HIV-1 transmission. After adjustment for gravidity, viral load, and CD4 cell count, there was evidence of an association between reduction in perinatal HIV-1 transmission and the maternal individual KIR genes KIR2DL2 (adjusted OR = 0.50; 95% CI: 0.24–1.02, P = 0.06), KIR2DL5 (adjusted OR = 0.47; 95% CI: 0.23–0.95, P = 0.04) and KIR2DS5 (adjusted OR = 0.39; 95% CI: 0.18–0.80, P = 0.01). Furthermore, these maternal KIR genes were only significantly associated with reduction in perinatal HIV transmission in women with CD4 cell count ≥ 350 cells/ μl and viral load <10000 copies/ml. Concordance analysis showed that when both mother and child had KIR2DS2, there was less likelihood of perinatal HIV-1 transmission (adjusted OR = 0.44; 95% CI: 0.20–0.96, P = 0.039). In conclusion, the maternal KIR genes KIR2DL2, KIR2DL5, KIR2DS5, and KIR2DS2 were associated with reduction of HIV-1 transmission from mother to child. Furthermore, maternal immune status is an important factor in the association of KIR with perinatal HIV transmission.

Implementation effectiveness of revised (post-2010) World Health Organization guidelines on prevention of mother-to-child transmission of HIV using routinely collected data in sub-Saharan Africa: A systematic literature review

BACKGROUND

To synthesize and evaluate the impact of implementing post-2010 World Health Organization (WHO) prevention of mother-to-child transmission (PMTCT) guidelines on attainment of PMTCT targets.

METHODS

Retrospective and prospective cohort study designs that utilized routinely collected data with a focus on provision and utilization of the cascade of PMTCT services were included. The outcomes included the proportion of pregnant women who were tested during their antenatal clinic (ANC) visits; mother-to-child transmission (MTCT) rate; adherence; retention rate; and loss to follow-up (LTFU).

RESULTS

Of the 1210 references screened, 45 met the inclusion criteria. The studies originated from 14 countries in sub-Saharan Africa. The highest number of studies originated from Malawi (10) followed by Nigeria and South Africa with 7 studies each. More than half of the studies were on option A while the majority of option B+ studies were conducted in Malawi. These studies indicated a high uptake of human immunodeficiency virus (HIV) testing ranging from 75% in Nigeria to over 96% in Zimbabwe and South Africa. High proportions of CD4 count testing were reported in studies only from South Africa despite that in most of the countries CD4 testing was a prerequisite to access treatment. MTCT rate ranged from 1.1% to 15.1% and it was higher in studies where data were collected in the early days of the WHO 2010 PMTCT guidelines. During the postpartum period, adherence and retention rate decreased, and LTFU increased for both HIV-positive mothers and exposed infants.

CONCLUSION

Irrespective of which option was followed, uptake of antenatal HIV testing was high but there was a large drop off along later points in the PMTCT cascade. More research is needed on how to improve later components of the PMTCT cascade, especially of option B+ which is now the norm throughout sub-Saharan Africa.

Prevention of mother-to-child transmission of HIV: Postpartum adherence to Option B+ until 18 months in Western Uganda

Since 2012, the WHO recommends Option B+ for the prevention of mother-to-child transmission of HIV. This approach entails the initiation of lifelong antiretroviral therapy in all HIV-positive pregnant women, also implying protection during breastfeeding for 12 months or longer. Research on long-term adherence to Option B+ throughout breastfeeding is scarce to date. Therefore, we conducted a prospective observational cohort study in Fort Portal, Western Uganda, to assess adherence to Option B+ until 18 months postpartum. In 2013, we recruited 67 HIV-positive, Option B+ enrolled women six weeks after giving birth and scheduled them for follow-up study visits after six, twelve and 18 months. Two adherence measures, self-reported drug intake and amount of drug refill visits, were combined to define adherence, and were assessed together with feeding information at all study visits. At six months postpartum, 51% of the enrolled women were considered to be adherent. Until twelve and 18 months postpartum, adherence for the respective follow-up interval decreased to 19% and 20.5% respectively. No woman was completely adherent until 18 months. At the same time, 76.5% of the women breastfed for ≥12 months. Drug adherence was associated with younger age (p<0.01), lower travel costs (p = 0.02), and lower number of previous deliveries (p = 0.04). Long-term adherence to Option B+ seems to be challenging. Considering that in our cohort, prolonged breastfeeding until ≥12 months was widely applied while postpartum adherence until the end of breastfeeding was poor, a potential risk of postpartum vertical transmission needs to be taken seriously into account for Option B+ implementation.

Barriers and facilitators of antiretroviral therapy adherence in rural Eastern province, Zambia: the role of household economic status

In Zambia, more people living with HIV now have access to lifesaving antiretroviral therapy than ever before. However, progress in HIV treatment and care has not always resulted in lower mortality. Adherence remains a critical barrier to treatment success. The objective of this study was to examine the barriers and facilitators of antiretroviral therapy adherence, particularly the role of household economic status. The study included a cross-sectional sample of 101 people living with HIV (PLHIV) in two rural communities in eastern Zambia. Adherence was measured using patient self-assessment and pharmacy information. Household economic status included components such as occupation, income, assets, food security, and debt. Multivariable logistic regression was conducted to examine the associations between household economic factors and adherence. Our findings suggest that the role of economic status on adherence appears to be a function of the economic component. Debt and non-farming-related occupation were consistently associated with non-adherence. The association between assets and adherence depends on the type of asset. Owning more transportation-related assets was consistently associated with non-adherence, whereas owning more livestock was associated with self-reported adherence. Additionally, living in a community with fewer economic opportunities was associated with non-adherence. The associations between place of residence and pharmacy refill adherence and between transportation assets and self-reported adherence were statistically significant. Improving adherence requires a multifaceted strategy that addresses the role of economic status as a potential barrier and facilitator. Programmes that provide economic opportunities and life-skills training may help PLHIV to overcome economic, social, and psychological barriers.

Levels of adherence and factors associated with adherence to option B+ prevention of mother-to-child transmission among pregnant and lactating mothers in selected government health facilities of South Wollo Zone, Amhara Region, northeast Ethiopia, 2016

OBJECTIVES

The aim of this study was to measure the levels of adherence and to identify factors associated with adherence to option B+ prevention of mother-to-child transmission (PMTCT) among pregnant and lactating mothers in selected government health facilities of South Wollo Zone, Amhara Region, northeast Ethiopia.

METHODS

An institution-based cross-sectional quantitative study design was employed from March 1, 2016 to April 14, 2016, using a standard structured data collection instrument. A sample of 191 human immunodeficiency virus (HIV)-positive pregnant and lactating mothers who were receiving PMTCT follow-up in the selected health facilities participated in the study. The data were entered using EpiData 3.1 and analyzed using SPSS version 21. Bivariate and multivariate logistic regression analyses were employed to identify factors associated with adherence. The p-values <0.05 and 95% confidence intervals (CIs) were used to identify associations between independent predictors and the outcome variable.

RESULTS

The level of adherence to option B+ PMTCT drugs was 87.9%. Women who received in-hospital treatment, who lived in rural areas, and faced challenges in initiating lifelong option B+ treatment on the same-day that they were diagnosed with HIV were less likely to adhere to the treatment (adjusted odds ratios [95% CI] of 0.3 [0.11 to 0.82], 0.26 [0.1 to 0.73], and 0.08 [0.02 to 0.37], respectively).

CONCLUSIONS

Collaborative efforts of zonal health departments with health facility administrators and counselors are recommended for effective and efficient interventions focusing on hospitals, rural areas, and patients who face challenges on the day of their diagnosis.