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

Acceptability and feasibility of using a blended quality improvement strategy among health workers to monitor women engagement in Option B+ program in Lilongwe Malawi

Option B + provides lifelong ART to pregnant and breastfeeding women with HIV to reduce mother-to-child transmission of HIV (eMTCT) and improve maternal health. The effectiveness of Option B + relies on continuous engagement, but suboptimal monitoring of HIV care hinders our measurements of engagement. Process mapping and quality improvement (PROMAQI) is a quality improvement strategy for healthcare workers (HCWs) to optimize complex processes such as monitoring HIV care. We assessed the acceptability and feasibility of the PROMAQI among HCWs and identified barriers and facilitators for PROMAQI implementation. A cross-sectional study using a mixed method approach was conducted from August 2021 to March 2022 across five urban health facilities participating in PROMAQI implementation n the Lilongwe district, Malawi. We assessed PROMAQI acceptability and feasibility at the end of the study. A 5-point Likert (1 = worst to 5 = best) scale tool was administered to 110 HCWs (n = 15-33 per facility) involved in PROMAQI implementationThese data were analysed using descriptive statistics Among the 110 HCWs, twenty-two (QI team (n = 11) and QI implementers (n = 11)) were purposively selected for in-depth interviews. Thematic analysis was conducted using deducted and inductive approaches. The theoretical framework for acceptability (TFA) was used to identify reasons for acceptability. The Consolidated Framework for Implementation Research (CFIR) was used to characterize the barriers and facilitators of PROMAQI implementation. HCWs recruited had a median age of 37 (32-43) years, 82.0% of whom were female. Most (42%) had completed secondary education, and 84% were nurses and community health workers. The median (IQR) acceptability and feasibility scores for the PROMAQI were 5 (IQR 4-5) and 4 (IQR 4-5), respectively. Reasons for high PROMAQI acceptability included addressing a relevant gap and improving performance. Perceived implementation barriers included poor work attitudes, time constraints, resource limitations, knowledge gaps, and workbook difficulties. The facilitators included communication, mentorship, training, and financial incentives. PROMAQI is a highly acceptable and feasible tool for monitoring engagement of women in Option B + . Addressing these barriers may optimize the implementation of PROMAQI. Scaling up PROMAQI may enhance retention in the Option B + program and facilitate eMTCT.

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.

Adherence to option B + antiretroviral therapy and associated factors in pregnant and breastfeeding women in Sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

To assess the adherence to option B + antiretroviral therapy (ART) and associated factors in pregnant and breastfeeding women in Sub-Saharan Africa (SSA).

METHODS

We conducted a comprehensive search from 01st January 2012 to 03rd October 2022, across four databases: PubMed, Scopus, Proquest Central, and Index Medicus Africain, to identify studies focused on pregnant and/or breastfeeding women living with HIV and receiving option B+ ART in SSA. Studies reporting adherence data were included in the meta-analysis. Were excluded studies published before 01st January 2012, grey literature, systematic reviews, and meta-analysis studies. Articles selection and data extraction were performed independently by two reviewers. We evaluated pooled adherence and pooled association between various factors and adherence using a random-effects model.

RESULTS

Overall, 42 studies involving 15,158 participants across 15 countries contributed to the meta-analysis. The overall pooled adherence was 72.3% (95% CI: 68.2-76.1%). Having high education level (pooled odds ratio (OR): 2.25; 95% CI: 1.57-3.21), living in urban area (pooled OR: 1.75; 95% CI: 1.10-2.81), disclosing status to a family/partner (pooled OR: 1.74; 95% CI: 1.27-2.40), having a support system (pooled OR: 3.19; 95% CI: 1.89-5.36), receiving counseling (pooled OR: 3.97; 95% CI: 2.96-5.34), initiating ART at early clinical HIV stage (pooled OR: 2.22; 95% CI: 1.08-4.56), and having good knowledge on PMTCT/HIV (pooled OR: 2.71; 95% CI: 1.40-5.25) were factors significantly associated with adherence to option B + ART.

CONCLUSIONS

Despite the implementation of option B+ ART, the level of adherence among pregnant and breastfeeding women in SSA falls short of meeting the critical thresholds for viral load suppression as outlined in the 95-95-95 objectives set for 2025. These objectives are integral for achieving HIV elimination, and in turn, preventing HIV mother-to-child transmission. To bridge this gap, urgent tailored interventions based on individual and structural factors are essential to enhance adherence within these subgroups of women. This targeted approach is crucial in striving towards the HIV elimination target in SSA.

HIV pre-exposure prophylaxis initiation, persistence, and adherence during pregnancy through the postpartum period

OBJECTIVE

We evaluated pre-exposure prophylaxis (PrEP) initiation, persistence, and adherence measured via tenofovir-diphosphate (TFV-DP) concentrations in dried blood spots (DBS) among women offered PrEP during pregnancy.

METHODS

We prospectively analyzed data from participants in the PrIMA Study (NCT03070600) who were offered PrEP during the second trimester and followed through 9 months postpartum. At follow-up visits (monthly in pregnancy; 6 weeks, 6 months, 9 months postpartum), self-reported PrEP use was assessed, and DBS were collected for quantifying TFV-DP concentrations.

RESULTS

In total, 2949 participants were included in the analysis. At enrollment, median age was 24 years [interquartile range IQR) 21-29], gestational age 24 weeks (IQR 20-28), and 4% had a known partner living with HIV. Overall, 405 (14%) participants initiated PrEP in pregnancy with higher frequency among those with risk factors for HIV acquisition, including >2 lifetime sexual partners, syphilis during pregnancy, forced sex, and intimate partner violence ( P  < 0.05). At 9 months postpartum, 58% of PrEP initiators persisted with PrEP use, of which 54% self-reported not missing any PrEP pills in the last 30 days. Among DBS randomly selected from visits where participants persisted with PrEP ( n  = 427), 50% had quantifiable TFV-DP. Quantifiable TFV-DP was twice as likely in pregnancy than postpartum [adjusted risk ratio (aRR) = 1.90, 95% confidence interval (CI) 1.40-2.57, P  < 0.001]. Having a partner known to be living with HIV was the strongest predictor of PrEP initiation, persistence, and quantifiable TFV-DP ( P  < 0.001).

CONCLUSIONS

PrEP persistence and adherence waned postpartum, though over half of PrEP initiators persisted through 9-months postpartum. Interventions should prioritize increasing knowledge of partner HIV status and sustaining adherence in the postpartum period.

Facilitators and barriers to infant post-natal HIV prophylaxis, a qualitative sub-study of the PROMISE-EPI trial in Lusaka, Zambia

Background

Infant post-natal prophylaxis (PNP) is used to prevent HIV transmission through breastfeeding. The WHO edited recommendations but so far there is no consensus on the duration of prophylaxis and the type of drug used depends on national guidelines. In Zambia, the national recommendations include a three-drug prophylaxis, composed of a dispersible combined tablet of zidovudine (AZT) and lamivudine (3TC) and an oral suspension of nevirapine (NVP) for 12 weeks or until the mother's viral load is <1,000 cp/mL. The PROMISE-EPI study, modified the PNP regimen to lamivudine only, initiated at 6 weeks and continued until 12 months to all HIV exposed uninfected infants of virally unsuppressed mothers. Our aim in this analysis was to identify barriers and facilitators to this extended PNP, the keystone toward an effective prevention.

Methods

Individual interviews and focus group discussion (FGD) were conducted with PROMISE-EPI participants who had received prophylaxis for their children from the national program up to 6 weeks and then lamivudine oral solution in PROMISE-EPI study. Health care providers and PROMISE-EPI staff were also interviewed. Sessions were recorded, transcribed verbatim and translated from local languages into English. An initial code-book was designed and then adapted on the basis of the emerging themes, to allow a descriptive thematic analysis.

Results

More barriers to PNP adherence were identified with triple drug prophylaxis than with lamivudine. These barriers were related to the formulation and bitter taste of AZT/3TC tablets. The ready to use formulation and sweet taste of lamivudine syrup were appreciated by mothers. Extended PNP proposed in the PROMISE-EPI study was globally well accepted and strategies were found to increase adherence. Adherence to lamivudine appeared to be better than the mothers' adherence to their own antiretroviral therapy.

Conclusion

Accompanying mothers living with HIV and giving them the choice of the PNP to prevent transmission via breastfeeding (type of PNP regimen and extended PNP in non-adherent mothers), may be one of the keys to reducing the burden of pediatric HIV acquisition in low and middle income countries.

Adherence to option B+ PMTCT program and its predictors among HIV-positive women in Ethiopia. A systematic review and meta-analysis

Background

Previously, few studies investigated level of adherence to option B+ lifelong antiretroviral therapy (ART) in Ethiopia. However, their findings were inconsistent. Therefore, this review aimed to determine the pooled magnitude of adherence to option B+ lifelong ART and its predictors among human immune virus (HIV)-positive women in Ethiopia.

Methods

A comprehensive web-based search was conducted using PubMed, Cochrane Library, Science Direct, Google scholar, and African Journals Online databases to retrieve relevant articles. STATA 14 statistical software was used to carry out the meta-analysis. We used the random effects model to account for the large heterogeneity across included studies. Egger's regression test in conjunction with funnel plot and I 2 statistics were utilized to assess publication bias and heterogeneity among included studies respectively.

Result

Twelve studies with a total of 2927 study participants were involved in this analysis. The pooled magnitude of adherence to option B+ lifelong ART was 80.72% (95% confidence interval [CI]: 77.05-84.39; I 2 = 85.4%). Disclosure of sero-status (OR 2.58 [95% CI: 1.55-4.3]), receiving counseling (OR 4.93 [95% CI: 3.21-7.57]), attending primary school and above (OR 2.45 [95% CI: 1.31-4.57]), partner support (OR 2.24 [95% CI: 1.11, 4.52]), good knowledge about prevention of mother-to-child transmission (PMTCT) (OR 4.22 [95% CI: 2.02-8.84]), taking less time to reach health facility (OR 1.64 [95% CI: 1.13-2.4]), and good relation with care provider (OR 3.24 [95% CI: 1.96-5.34]) were positively associated with adherence. Whereas, fear of stigma and discrimination (OR 0.12 [95% CI: 0.06-0.22]) and advanced disease stage (OR 0.59 [95% CI: 0.37-0.92]) were negatively associated.

Conclusion

The level of adherence to option B+ lifelong ART was suboptimal. Strengthened comprehensive counseling and client education on PMTCT, HIV status disclosure, and male partner involvement are important to eliminate mother to child transmission and control the pandemic.

The effect of an interactive weekly text-messaging intervention on retention in prevention of mother-to-child transmission of HIV care: a randomised controlled trial (WelTel PMTCT)

Retention in prevention of mother-to-child transmission (PMTCT) care is critical to prevent vertical HIV transmission and reduce morbidity and mortality of mother-infant pairs. We investigated whether weekly, interactive text-messaging improved 18-month postpartum retention in PMTCT care. This randomised, two-armed, parallel trial was conducted at six PMTCT clinics in western Kenya. Pregnant women with HIV at least 18 years of age with access to a mobile phone, able to text-message, or had somebody who could text on their behalf, were eligible. Participants were randomly assigned at a 1:1 ratio in block sizes of four to the intervention or control group. The intervention group received weekly text messages asking "How are you?" ("Mambo?" in Swahili) and were requested to respond within 48 h. Healthcare workers called women who indicated a problem or did not respond. The intervention was administered up to 24 months after delivery. Both groups received standard care. The primary outcome was retention in care at 18 months postpartum (i.e., clinic attendance 16-24 months after delivery based on data from patient files, patient registers and Kenya's National AIDS and STI Control Programme database), which was analysed by intention-to-treat. Researchers and data collectors were masked to group assignment, while healthcare workers were not. Between June 25th, 2015, and July 5th, 2016, we randomly assigned 299 women to the intervention and 301 to standard care only. Follow-up concluded on July 26th, 2019. The proportion of women retained in PMTCT care at 18 months postpartum was not significantly different between the intervention (n = 210/299) and control groups (n = 207/301) (risk ratio 1.02, 95% confidence interval 0.92-1.14, p = 0.697). No adverse events related to the mobile phone intervention were reported. Weekly, interactive text-messaging was not associated with improved retention in PMTCT care at 18 months postpartum or linkage to care up to 30 months postpartum in this setting. (ISRCTN No. 98818734).

Antiretroviral Therapy Adherence During and Postbreastfeeding Cessation Measured by Tenofovir Levels in Hair

BACKGROUND

We examined change in antiretroviral treatment (ART) adherence after breastfeeding (BF) cessation using hair tenofovir (TFV) concentrations as an objective metric of medication consumption.

METHODS

A subset of postpartum women in Zimbabwe randomized in IMPAACT PROMISE to take ART while BF and post-BF cessation had hair TFV measured longitudinally. Using linear mixed-effect models, we estimated differences in hair TFV levels after BF cessation, accounting for trends in levels over time regardless of BF status and change in slope after breastfeeding cessation. We also estimated the relative risk of viremia (>50 copies/mL) per doubling of hair TFV concentration.

RESULTS

Among 55 women (median age 26, interquartile range 24-29 years), hair TFV levels (n = 305) were available for a median of 9 visits per woman between 3 and 29 months postpartum. Hair TFV levels ranged from undetected to 0.25 ng/mg (median 0.04 ng/mg). Controlling for trends since delivery [decline of 2.2% per month, 95% confidence interval (CI): -5.3 to 1.0], TFV levels averaged 24.4% higher (95% CI: -5.1 to 63.1) post-BF cessation than during BF, with no change in slope (0.0% per month, 95% CI: -3.8 to 3.9). Postpartum, 42% of women were ever viremic. Higher TFV levels were strongly protective; relative risk of viremia per doubling of TFV was 0.52 (95% CI: 0.43 to 0.63; P < 0.0001).

CONCLUSIONS

Leveraging an objective metric of ART use, we observed modestly declining adherence across the postpartum period, but no additional decline associated with breastfeeding cessation. High viremia frequency and varying postpartum TFV levels observed highlight the importance of enhanced adherence support with viral load monitoring among postpartum women.

Adherence to option B+ and its association with disclosure status and counseling among HIV-positive pregnant and lactating women in Ethiopia: systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to assess the pooled estimate of option B+ level of adherence and its association with disclosure status and counseling among pregnant and lactation women in Ethiopia after option B+ implementation.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

We searched Web of Science, MEDLINE, PUBMED, Scopus, Embase, CINAHL, and Google Scholar databases for studies reporting adherence to option B+ and its association with disclosure status and counseling among pregnant and lactating women in Ethiopia. Heterogeneity was assessed by forest plot, Cochran's Q test, and I² test. A random effects model was calculated to estimate the pooled prevalence of adherence toward option B+.

RESULTS

We included eight studies, which gives a total of 1852 pregnant and lactating women in this systematic review and meta-analysis. The overall pooled estimate of good adherence toward option B+ antiretroviral therapy (ART) drug among pregnant and lactating women in Ethiopia was 84.23% (95% confidence interval [CI]: 80.79-87.66). Women who have disclosed their HIV status to their partner (adjusted odds ratio = 4.48, 95% CI: 1.86-10.76) and got counseling during the antenatal period (adjusted odds ratio = 5.02, 95% CI: 2.43-10.34) had a positive association with good adherence to option B+ ART drugs.

CONCLUSION

Four of five pregnant and lactating women have good adherence to option B+ ART drugs in Ethiopia. Therefore, promoting HIV disclosure status to partners and enhancing counseling services should be strengthened to improve adherence toward option B+ among pregnant and lactating women.