Increasing retention of HIV positive pregnant and breastfeeding mothers on option-b plus by upgrading and providing full time HIV services at a lower health facility in rural Uganda

Enhanced peer-group strategies to support the prevention of mother-to-child HIV transmission leads to increased retention in care in Uganda: A randomized controlled trial

INTRODUCTION

Despite the scale-up of Option B+, long-term retention of women in HIV care during pregnancy and the postpartum period remains an important challenge. We compared adherence to clinic appointments and antiretroviral therapy (ART) at 6 weeks, 6, and and 24 months postpartum among pregnant women living with HIV and initiating Option B+. Women were randomized to a peer group support, community-based drug distribution and income-generating intervention called "Friends for Life Circles" (FLCs) versus the standard of care (SOC). Our secondary outcome was infant HIV status and HIV-free survival at 6 weeks and 18 months postpartum.

METHODS

Between 16 May 2016 and 12 September 2017, 540 ART-naïve pregnant women living with HIV at urban and rural health facilities in Uganda were enrolled in the study at any gestational age. Participants were randomized 1:1 to the unblinded FLC intervention or SOC at enrolment and assessed for adherence to the prevention of mother-to-child HIV transmission (PMTCT) clinic appointments at 6 weeks, 12, and 24 months postpartum, self-reported adherence to ART at 6 weeks, 6 and 24 months postpartum and supported by plasma HIV-1 RNA viral load (VL) measured at the same time points, retention in care through the end of study, and HIV status and HIV-free survival of infants at 18 months postpartum. The FLC groups were formed during pregnancy within 4 months of enrollment and held monthly meetings in their communites, and were followed up until the last group participant reached 24 months post delivery. We used Log-rank and Chi-Square p-values to test the equality of Kaplan-Meier survival probabilities and hazard rates (HR) for failure to retain in care for any reason by study arm.

RESULTS

There was no significant difference in adherence to PMTCT clinic visits or to ART or in median viral loads between FLC and SOC arms at any follow-up time points. Retention in care through the end of study was high in both arms but significantly higher among participants randomized to FLC (86.7%) compared to SOC (79.3%), p = 0.022. The adjusted HR of visit dropout was 2.4 times greater among participants randomized to SOC compared to FLC (aHR = 2.363, 95% CI: 1.199-4.656, p = 0.013). Median VL remained < 400 copies/ml in both arms at 6 weeks, 6, and 24 months postpartum. Eight of the 431 infants tested at 18 months were HIV positive (1.9%), however, this was not statistically different among mothers enrolled in the FLC arm compared to those in the SOC arm. At 18 months, HIV-free survival of children born to mothers in the FLC arm was significantly higher than that of children born to mothers in the SOC arm.

CONCLUSIONS

Our findings suggest that programmatic interventions that provide group support, community-based ART distribution, and income-generation activities may contribute to retention in PMTCT care, HIV-free survival of children born to women living with HIV, and ultimately, to the elimination of mother-to-child HIV transmission (EMTCT).

TRIAL REGISTRATION

NCT02515370 (04/08/2015) on ClinicalTrials.gov.

"It Soothes Your Heart": A Multimethod Study Exploring Acceptability of Point-of-Care Viral Load Testing among Ugandan Pregnant and Postpartum Women Living with HIV

BACKGROUND

High adherence to antiretroviral therapy (ART) is critical for achieving viral suppression and preventing onward HIV transmission. ART continuation can be challenging for pregnant women living with HIV (PWLHIV), which has critical implications for risk of vertical HIV transmission. Point-of-care viral load (POC VL) testing has been associated with improved treatment and retention outcomes. We sought to explore acceptability of POC VL testing among Ugandan PWLHIV during pregnancy and postpartum.

METHODS

This multimethod analysis drew on quantitative and qualitative data collected between February and December 2021. Quantitatively, we used an intent-to-treat analysis to assess whether randomization to clinic-based POC VL testing during pregnancy and infant testing at delivery was associated with improved viral suppression (≤50 copies/mL) by 3 months postpartum compared to standard-of-care (SOC) VL testing through a central laboratory, adjusting for factorial randomization for the male partner testing strategy. Additionally, a subset of 22 PWLHIV in the POC VL arm participated in in-depth qualitative interviews. We inductively analyzed transcripts to develop categories representing concepts that characterized women's perceptions of POC VL testing during pregnancy and at delivery and ways that POC VL testing may have impacted their ART adherence and viral suppression. Key themes around women's perceptions of POC VL testing were then organized into main categories.

RESULTS

Overall, 151 PWLHIV were enrolled into the study, 77 (51%) of whom were randomized to receive POC VL testing during pregnancy and at delivery. Women reported in qualitative interviews that POC VL testing had (1) motivated their ART adherence during pregnancy and postpartum and that they felt this testing method had (2) helped them protect their infants from acquiring HIV and (3) improved their emotional wellbeing.

CONCLUSIONS

POC VL testing was highly acceptable among Ugandan PWLHIV and was viewed as an important tool that women believed improved their ART adherence, gave them information necessary to protect their infants from vertical HIV acquisition, and improved their emotional wellbeing. These findings support the global scale-up of POC VL testing in settings with high HIV burden, especially for PWLHIV who may be at risk of treatment disruptions or loss to follow-up.

Experiences of Mothers Living With HIV in a South African Prevention of Mother-to-Child Transmission of HIV Programme: A Qualitative Descriptive Study

ABSTRACT

More than 90% of all HIV infections in children result from mother to child transmission. Elimination of mother-child transmission is a global priority and vital for the improvement of child survival in high-burden, limited resource settings. Retention in HIV care is vital to reduce transmission risk. This qualitative study explored the experiences and adherence challenges of mothers living with HIV of the Prevention of Mother-to-Child Transmission of HIV (PMTCT) programme in Khayelitsha, Cape Town, South Africa. Interviews were conducted with purposively selected participants enrolled in a PMTCT programme at a primary care facility. Thematic analysis generated six themes. Findings demonstrate the complexity of living as a woman with HIV in a socioeconomically disadvantaged and marginalized periurban community. For each woman, there is a set of concerns relating to person, home, community, and clinic which may affect her understanding, acceptance of, and adherence to the PMTCT programme.

Prevalence of undetectable and suppressed viral load in HIV-infected pregnant women initiating Option B+ in Uganda: an observational study nested within a randomized controlled trial

BACKGROUND

Viral load (VL) testing is key in monitoring adherence to antiretroviral therapy (ART) and documenting HIV treatment response. As per HIV treatment guidelines in Uganda, the first VL test is recommended 6 months after initiation of ART. Undetectable VL (uVL) at ART initiation may be helpful in detecting elite controllers in the absence of previous ART use. We investigated viral suppression at ART initiation among a cohort of HIV-positive pregnant women enrolled in the Friends for Life Circles (FLC) for Option B+ randomized controlled trial (RCT).

METHODS

Pregnant women ≥ 18 years of age testing positive for HIV at their first antenatal care visit and starting on ART Option B+ as per the National PMTCT Program guidelines were enrolled into the FLC for Option B+ RCT in urban Kampala and rural Mityana districts of Uganda. Each participant had whole blood samples collected at enrolment to assess baseline VL. Plasma HIV-1 RNA was quantified using COBAS Ampliprep /COBAS Taqman. Baseline VL below 400 RNA copies/ml was considered as viral suppression while baseline VL below 20 RNA copies/ml was considered uVL.

RESULTS

The mean duration from the date of ART initiation to time of sample collection for baseline VL assessment was 4.4 days (SD 3.6). Of the 532 HIV-positive pregnant women enrolled in the FLC for Option B+ study and newly starting Option B+ without a self-reported history of prior ART use, 29 (5.5%) had uVL and 113 (21.4%) had suppressed VL at baseline. There was no association between participants' age, gravidity, marital status, mean monthly income, educational level, disclosure of HIV status to partner, and uVL or viral suppression at baseline. However, non-disclosure of HIV status to any other person was associated with decreased odds of viral suppression at baseline (OR 0.640; 0.416-0.982).

CONCLUSION

Twenty-one percent of HIV-positive Ugandan pregnant women initiating ART (Option B+) showed virological suppression at baseline and were presumed to be "elite controllers" or to have misreported being ART-naive. Further studies are needed to better understand the biologic mechanisms of elite controllers among pregnant women as well as to differentiate elite controllers from concealed ART use. Trial Registration The trial was registered as NCT02515370 (04/08/2015) on Clinicaltrials.gov.

Growth Faltering and Developmental Delay in HIV-Exposed Uninfected Ugandan Infants: A Prospective Cohort Study

BACKGROUND

HIV-exposed but uninfected (HEU) infants are at increased risk of impaired early linear growth and cognitive development. We examined associations between prenatal and postnatal growth and subsequent neurodevelopment in Ugandan HEU infants, hypothesizing that early insults may explain alterations in both somatic growth and brain development.

METHODS

We prospectively followed a cohort of HEU infants from birth to 18 months of age, and measured length/height, weight, head, and arm circumference longitudinally. The Malawi Development Assessment Tool (MDAT, 12 and 18 months) and the Color Object Association Test (18 months) were used for developmental assessments.

RESULTS

Among 170 HEU infants, the prevalence of low-birth weight and failure to thrive was 7.6% and 37%, respectively. HEU infants had MDAT scores that were similar to the reference population. The mean (SD) score on the Color Object Association Test was 5.5 (3.1) compared with 6.9 (5.3) in developmentally normal children. Developmental ability at age 18 months showed strong cross-sectional correlation with weight-for-age (ρ = 0.36, P < 0.0001), length/height-for-age (ρ = 0.41, P < 0.0001), head circumference-for-age (ρ = 0.26, P = 0.0011), and mid-upper arm circumference-for-age (ρ = 0.34, P = 0.0014). There was a statistically significant correlation between birth weight and MDAT z-score at 18 months (ρ = 0.20, P = 0.010). Failure to thrive was associated with lower MDAT z-score [median -0.13 (IQR -0.75 to +0.14) versus +0.14 (IQR -0.44 to +0.63), P = 0.042].

CONCLUSION

Growth faltering in HEU infants was associated with lower attainment of developmental milestones at age 18 months. Our findings point to a simple screening method for identifying HEU infants at risk for developmental intervention.

Understanding the influence of health systems on women's experiences of Option B+: A meta-ethnography of qualitative research from sub-Saharan Africa

We explored women's experiences of Option B+ in sub-Saharan African health facility settings through a meta-ethnography of 32 qualitative studies published between 2010 and 2019. First and second-order constructs were identified from the data and authors' interpretations respectively. Using a health systems lens, third-order constructs explored how the health systems shaped women's experiences of Option B+ and their subsequent engagement in care. Women's experiences of Option B+ services were influenced by their interactions with health workers, which were often reported to be inadequate and rushed, reflecting insufficient staffing or training to address pregnant women's needs. Women's experiences were also undermined by various manifestations of stigma which persisted in the absence of resources for social or mental health support, and were exacerbated by space constraints in health facilities that infringed on patient confidentiality. Sub-optimal service accessibility, drug stock-outs and inadequate tracing systems also shaped women's experiences of care. Strengthening health systems by improving health worker capacity to provide respectful and high-quality clinical and support services, improving supply chains and improving the privacy of consultation spaces would improve women's experiences of Option B+ services, thereby contributing to improved care retention. These lessons should be considered as universal test and treat programmes expand.

Evaluation of human immunodeficiency virus-adapted group prenatal care

BACKGROUND

Efforts to further decrease perinatal transmission of HIV include efforts to improve engagement and retention in prenatal care. Group prenatal care has been reported to have benefits in certain other high-risk groups of pregnant women but has not been previously evaluated in pregnant women living with HIV.

OBJECTIVE

This study aimed to evaluate changes in HIV knowledge, stigma, social support, depression, self-efficacy, and medication adherence after HIV-adapted group prenatal care.

STUDY DESIGN

All women living with HIV who presented for prenatal care at ≤30 weeks' gestation in Harris Health System (Houston, TX) between September 2013 and December 2017 were offered either group or individual HIV-focused prenatal care. Patients were recruited for the study at their initial prenatal visit. HIV topics, such as HIV facts, disclosure, medication adherence, safe sex and conception, retention in care, and postdelivery baby testing, were added to the standard CenteringPregnancy curriculum (ten 2-hour sessions per pregnancy). Knowledge and attitudes toward factors associated with adherence to HIV treatment regimens (stigma, loneliness, perceived social support, and depressive symptoms) were compared on written pre- and postsurveys. Surveys included 58 items derived from validated scales, with Likert and dichotomous responses. McNemar's test, Wilcoxon signed-rank test, and paired t-tests compared pre- and postsurvey responses.

RESULTS

A total of 190 women living with HIV received prenatal care in the clinic during the study period, 93 (49%) of whom participated in CenteringHIV. A total of 66 Centering participants enrolled in the study and 42 of those completed the pre- and postsurveys. Among women in the Centering program who completed pre- and postsurveys, significant differences were noted with improved perceived social support from family (P=.011) and friends (P=.005), decreased depression (Edinburg Postnatal Depression Scale, ≥10; 43% vs 18%; P<.001; Edinburg Postnatal Depression Scale score mean (standard deviation), 9.3 (5.8) pre vs 5.2 (4.9) post; P<.001), and decreased missed medication doses related to depressed mood (P=.014). No statistically significant differences were noted in HIV knowledge, HIV stigma, attitude, or self-efficacy.

CONCLUSION

HIV-focused group prenatal care may positively affect perceived social support and depression scores, factors that are closely associated with antiretroviral adherence and retention in the care for pregnant women living with HIV.