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Astawesegn FH, Mannan H, Stulz V, Conroy E. Understanding the uptake and determinants of prevention of mother-to-child transmission of HIV services in East Africa: Mixed methods systematic review and meta-analysis. PLoS One 2024; 19:e0300606. [PMID: 38635647 PMCID: PMC11025786 DOI: 10.1371/journal.pone.0300606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 02/28/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Prevention of mother-to-child transmission (PMTCT) of HIV service is conceptualized as a series of cascades that begins with all pregnant women and ends with the detection of a final HIV status in HIV-exposed infants (HEIs). A low rate of cascade completion by mothers' results in an increased risk of HIV transmission to their infants. Therefore, this review aimed to understand the uptake and determinants of key PMTCT services cascades in East Africa. METHODS We searched CINAHL, EMBASE, MEDLINE, Scopus, and AIM databases using a predetermined search strategy to identify studies published from January 2012 through to March 2022 on the uptake and determinants of PMTCT of HIV services. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. A random-effects model was used to obtain pooled estimates of (i) maternal HIV testing (ii) maternal ART initiation, (iii) infant ARV prophylaxis and (iv) early infant diagnosis (EID). Factors from quantitative studies were reviewed using a coding template based on the domains of the Andersen model (i.e., environmental, predisposing, enabling and need factors) and qualitative studies were reviewed using a thematic synthesis approach. RESULTS The searches yielded 2231 articles and we systematically reduced to 52 included studies. Forty quantitative, eight qualitative, and four mixed methods papers were located containing evidence on the uptake and determinants of PMTCT services. The pooled proportions of maternal HIV test and ART uptake in East Africa were 82.6% (95% CI: 75.6-88.0%) and 88.3% (95% CI: 78.5-93.9%). Similarly, the pooled estimates of infant ARV prophylaxis and EID uptake were 84.9% (95% CI: 80.7-88.3%) and 68.7% (95% CI: 57.6-78.0) respectively. Key factors identified were the place of residence, stigma, the age of women, the educational status of both parents, marital status, socioeconomic status, Knowledge about HIV/PMTCT, access to healthcare facilities, attitudes/perceived benefits towards PMTCT services, prior use of maternal and child health (MCH) services, and healthcare-related factors like resource scarcity and insufficient follow-up supervision. CONCLUSION Most of the identified factors were modifiable and should be considered when formulating policies and planning interventions. Hence, promoting women's education and economic empowerment, strengthening staff supervision, improving access to and integration with MCH services, and actively involving the community to reduce stigma are suggested. Engaging community health workers and expert mothers can also help to share the workload of healthcare providers because of the human resource shortage.
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Affiliation(s)
- Feleke Hailemichael Astawesegn
- Translational Health Research Institute (THRI), Western Sydney University, Campbelltown Campus, Penrith, New South Wales, Australia
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
- Rural Health Research Institute, Charles Sturt University, Orange, New South Wales, Australia
| | - Haider Mannan
- Translational Health Research Institute (THRI), Western Sydney University, Campbelltown Campus, Penrith, New South Wales, Australia
| | - Virginia Stulz
- School of Nursing and Midwifery Centre for Nursing and Midwifery Research, Western Sydney University, Kingswood, New South Wales, Australia
| | - Elizabeth Conroy
- Translational Health Research Institute (THRI), Western Sydney University, Campbelltown Campus, Penrith, New South Wales, Australia
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Li J, Li A, Ye J, Shao Y, Zhang H, Liu A, Li Z, Zhang G, Sun L. Loss to follow-up among human immunodeficiency virus-positive postpartum women and its predictive factors: A retrospective study. HIV Med 2022; 23 Suppl 1:42-53. [PMID: 35293108 DOI: 10.1111/hiv.13248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 10/28/2021] [Accepted: 01/07/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Antiretroviral treatment (ART) is essential in preventing mother-to-child transmission of human immunodeficiency virus (HIV), and postpartum discontinuation of ART is associated with adverse outcomes. This study identified factors associated with postpartum follow-up of HIV-positive women. METHODS This was a retrospective cohort study of 170 HIV-infected pregnant women who received regular obstetric examination and delivered successfully in Beijing between 2003 and 2020.The women's sociodemographic, clinical, treatment, obstetric, and gestational characteristics were analyzed. Cox proportional hazards models were used to estimate adjusted hazard ratios (AHRs) of loss to follow-up between levels of confounders. RESULTS In the multivariable Cox proportional hazard models, women with a longer time from HIV diagnosis to delivery per year had a 1.4-timeshigher risk (AHR = 1.433, 95% CI: 0.897-2.229) and a higher rate of loss to follow-up than the other women. Perinatal health care (AHR = 0.003,95% CI: 0.000-0.105) and gestational age above 37 weeks at delivery (AHR = 0.294, 95% CI: 0.005-15.818) were associated with a longer follow-up of postpartum HIV-positive women, when compared to women who did not receive perinatal healthcare and who delivered before 37 weeks of gestation, respectively. CONCLUSIONS The longer time from HIV diagnosis to delivery, access to perinatal care, and full-term gestation at delivery improved postpartum ART adherence and follow-up among HIV-positive women. Early initiation of ART, integration of adult ART into prevention of mother-to-child transmission, combination ART with maternal healthcare, and enhanced pregnancy care will improve ART adherence among HIV-positive women after delivery.
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Affiliation(s)
- Jianwei Li
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Aixin Li
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Jiangzhu Ye
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Ying Shao
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Hongwei Zhang
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - An Liu
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Zaicun Li
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Guang Zhang
- National Center for AIDS/STD Control and Prevention, China CDC, Beijing, China
| | - Lijun Sun
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
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Kerschberger B, Boulle A, Kuwengwa R, Ciglenecki I, Schomaker M. The Impact of Same-Day Antiretroviral Therapy Initiation Under the World Health Organization Treat-All Policy. Am J Epidemiol 2021; 190:1519-1532. [PMID: 33576383 PMCID: PMC8327202 DOI: 10.1093/aje/kwab032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 01/27/2021] [Accepted: 02/09/2021] [Indexed: 12/18/2022] Open
Abstract
Rapid initiation of antiretroviral therapy (ART) is recommended for people living with human immunodeficiency virus (HIV), with the option to start treatment on the day of diagnosis (same-day ART). However, the effect of same-day ART remains unknown in realistic public sector settings. We established a cohort of ≥16-year-old patients who initiated first-line ART under a treat-all policy in Nhlangano (Eswatini) during 2014-2016, either on the day of HIV care enrollment (same-day ART) or 1-14 days thereafter (early ART). Directed acyclic graphs, flexible parametric survival analysis, and targeted maximum likelihood estimation (TMLE) were used to estimate the effect of same-day-ART initiation on a composite unfavorable treatment outcome (loss to follow-up, death, viral failure, treatment switch). Of 1,328 patients, 839 (63.2%) initiated same-day ART. The adjusted hazard ratio of the unfavorable outcome was higher, 1.48 (95% confidence interval: 1.16, 1.89), for same-day ART compared with early ART. TMLE suggested that after 1 year, 28.9% of patients would experience the unfavorable outcome under same-day ART compared with 21.2% under early ART (difference: 7.7%; 1.3%-14.1%). This estimate was driven by loss to follow-up and varied over time, with a higher hazard during the first year after HIV care enrollment and a similar hazard thereafter. We found an increased risk with same-day ART. A limitation was that possible silent transfers that were not captured.
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Affiliation(s)
- Bernhard Kerschberger
- Correspondence to Dr. Bernhard Kerschberger, Médecins Sans Frontières, Mantsholo Road 325, Mbabane, Eswatini (e-mail: )
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Goodwin T, Gregson S, Maswera R, Moorhouse L, Nyamukapa C. Understanding the determinants and consequences of HIV status disclosure in Manicaland, Zimbabwe: cross-sectional and prospective analyses. AIDS Care 2021; 33:1577-1594. [PMID: 33813969 DOI: 10.1080/09540121.2021.1883507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Few longitudinal studies have measured trends and effects of disclosure over ART scale-up in general-population samples. We investigated levels, determinants and outcomes of disclosure to relatives and partners in a large general-population cohort in Zimbabwe. Trends in disclosure levels from 2003 to 2013 were analysed, and multivariable logistic regression was used to identify determinants. Longitudinal analyses were conducted testing associations between disclosure and prevention/treatment-related outcomes. Disclosure to anyone increased from 79% to 100% in men and from 63% to 98% in women from 2003 to 2008; but declined to 89% in both sexes in 2012-2013. More women than men disclosed to relatives (67.8% versus 44.4%; p < 0.001) but fewer women disclosed to partners (85.3% versus 95.0%; p < 0.001). In 2012-2013,secondary/higher education, being single, and experience of stigma were associated with disclosure to relatives in both sexes. Partner characteristics and HIV-group attendance were associated with disclosure to partners for women. Reactions to disclosure were generally supportive but less so for females than males disclosing to partners (92.0% versus 97.4%). Partner disclosure was weakly associated (p < 0.08) with having had a CD4 count or taken ART at follow-up in females. To conclude, this study shows disclosure is vital to HIV prevention and treatment, and programmes to facilitate disclosure should be re-invigorated.
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Affiliation(s)
| | - Simon Gregson
- Imperial College London, London, UK.,Biomedical Research and Training Institute, Harare, Zimbabwe
| | | | | | - Constance Nyamukapa
- Imperial College London, London, UK.,Biomedical Research and Training Institute, Harare, Zimbabwe
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Hopkins KL, Hlongwane KE, Otwombe K, Dietrich J, Jaffer M, Cheyip M, Olivier J, van Rooyen H, Wade AN, Doherty T, Gray GE. Does peer-navigated linkage to care work? A cross-sectional study of active linkage to care within an integrated non-communicable disease-HIV testing centre for adults in Soweto, South Africa. PLoS One 2020; 15:e0241014. [PMID: 33091093 PMCID: PMC7580918 DOI: 10.1371/journal.pone.0241014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/07/2020] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION South Africa is the HIV epidemic epicentre; however, non-communicable diseases (NCDs) will be the most common cause of death by 2030. To improve identification and initiation of care for HIV and NCDs, we assessed proportion of clients referred and linked to care (LTC) for abnormal/positive screening results and time to LTC and treatment initiation from a HIV Testing Services (HTS) Centre before and after integrated testing for NCDs with optional peer-navigated linkage to care. MATERIALS AND METHODS This two-phase prospective study was conducted at an adult HTS Centre in Soweto, South Africa. Phase 1 (February-June 2018) utilised standard of care (SOC) HTS services (blood pressure [BP], HIV rapid diagnostic testing (RDT), sexually transmitted infections [STI]/Tuberculosis [TB] symptom screening) with passive referral for abnormal/positive results. Phase 2 (June 2018-March 2019) further integrated blood glucose/cholesterol/chlamydia RDT, with optional peer-navigated referral. Enrolled referred clients completed telephonic follow-up surveys confirming LTC/treatment initiation ≤3 months post-screening. Socio-demographics, screening results, time to LTC/treatment initiation, peer-navigated referral uptake were reported. Analysis included Fisher's exact, chi-squared, Kruskal Wallis, and Student's T-tests. Thematic analysis was conducted for open-ended survey responses. RESULTS Of all 320 referrals, 40.0% were HIV-infections, 11.9% STIs, 6.6% TB, and 28.8% high/low BP. Of Phase 2-only referrals, 29.4% were for glucose and 23.5% cholesterol. Integrated NCD-HTS had significantly more clients LTC for HIV (76.7%[n = 66/86] vs 52.4%[n = 22/42], p = 0.0052) and within a shorter average time (6-8 days [Interquartile range (IQR):1-18.5] vs 8-13 days [IQR:2-32]) as compared to SOC HTS. Integrated NCD-HTS clients initiated HIV/STIs/BP treatment on average more quickly as compared to SOC HTS (5 days for STIs [IQR:1-21], 8 days for HIV/BP [IQR:5-17 and 2-13, respectively] vs 10 days for STIs [IQR: 4-32], 19.5 days for HIV [IQR:6.5-26.5], 8 days for BP [IQR:2-29)]. Participants chose passive over active referral (89.1% vs 10.9%; p<0.0001). Participants rejecting peer-navigated referral preferred to go alone (55.7% [n = 39/70]). Non-LTC was due to being busy (41.1% [n = 39/95]) and not being ready/refusing treatment (31.6% [n = 30/95]). Normalised results assessed at referral clinic (49.7% [n = 98/196]), prescribed lifestyle modification/monitoring (30.9% [n = 61/196]), and poor clinic flow/congestion and/or further testing required (10.7% [n = 21/196]) were associated with non-treatment initiation. CONCLUSION Same-day treatment initiation is not achieved across diseases, despite peer-navigated referral. There are psychosocial and health systems barriers at entry to care/treatment initiation. Additional research may identify best strategies for rapid treatment initiation.
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Affiliation(s)
- Kathryn L. Hopkins
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Khuthadzo E. Hlongwane
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Kennedy Otwombe
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Janan Dietrich
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Maya Jaffer
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Mireille Cheyip
- Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Jacobus Olivier
- Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Heidi van Rooyen
- Human and Social Development Programme, Human Sciences Research Council, Pretoria, South Africa
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alisha N. Wade
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tanya Doherty
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Glenda E. Gray
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Office of the President, South African Medical Research Council, Cape Town, South Africa
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Etoori D, Renju J, Reniers G, Ndhlovu V, Ndubane S, Makhubela P, Maritze M, Gomez-Olive FX, Wringe A. 'If the results are negative, they motivate us'. Experiences of early infant diagnosis of HIV and engagement in Option B. Glob Public Health 2020; 16:186-200. [PMID: 32673142 DOI: 10.1080/17441692.2020.1795220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Few studies have explored the relationship between early infant diagnosis (EID) of HIV and mothers' engagement in care under Option B+. We conducted in-depth interviews with 20 women who initiated antiretroviral therapy (ART) under Option B+ in rural South Africa to explore the interactions between EID and maternal care engagement. Drawing on practice theory, we identified themes relating to Option B+ care engagement and EID. Women's practice of engagement with HIV care shaped their decision-making around EID. Mothers who disengaged from care during pregnancy were less inclined to utilise EID as they lacked information about its availability and benefits. For some mothers, tensions between wanting to breastfeed and perceptions that it could facilitate transmission led to repeated utilisation of EID as reassurance that the child remained negative. Some mothers used their child's negative result as a proxy for their status, subsequently disengaging from care. For some participants, an HIV diagnosis of their infant and the subsequent double burden of treatment visits for themselves and their infant, contributed to their disengagement. Women's care-seeking practices for themselves and their infants work in a symbiotic ecosystem and should be viewed interdependently to tailor interventions to improve EID uptake and Option B+ care engagement.
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Affiliation(s)
- David Etoori
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jenny Renju
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Georges Reniers
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.,MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Violet Ndhlovu
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sherly Ndubane
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Princess Makhubela
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Meriam Maritze
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Francesc Xavier Gomez-Olive
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Viral suppression and factors associated with failure to achieve viral suppression among pregnant women in South Africa. AIDS 2020; 34:589-597. [PMID: 31821189 PMCID: PMC7050794 DOI: 10.1097/qad.0000000000002457] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Supplemental Digital Content is available in the text Objective: To describe viral load levels among pregnant women and factors associated with failure to achieve viral suppression (viral load ≤50 copies/ml) during pregnancy. Design: Between 1 October and 15 November 2017, a cross-sectional survey was conducted among 15–49-year-old pregnant women attending antenatal care (ANC) at 1595 nationally representative public facilities. Methods: Blood specimens were taken from each pregnant woman and tested for HIV. Viral load testing was done on all HIV-positive specimens. Demographic and clinical data were extracted from medical records or self-reported. Survey logistic regression examined factors associated with failure to achieve viral suppression. Result: Of 10 052 HIV-positive participants with viral load data, 56.2% were virally suppressed. Participants initiating antiretroviral therapy (ART) prior to pregnancy had higher viral suppression (71.0%) by their third trimester compared with participants initiating ART during pregnancy (59.3%). Booking for ANC during the third trimester vs. earlier: [adjusted odds ratio (AOR) 1.8, 95% confidence interval (CI):1.4–2.3], low frequency of ANC visits (AOR for 2 ANC visits vs. ≥4 ANC visits: 2.0, 95% CI:1.7–2.4), delayed initiation of ART (AOR for ART initiated at the second trimester vs. before pregnancy:2.2, 95% CI:1.8–2.7), and younger age (AOR for 15–24 vs. 35–49 years: 1.4, 95% CI:1.2–1.8) were associated with failure to achieve viral suppression during the third trimester. Conclusion: Failure to achieve viral suppression was primarily associated with late ANC booking and late initiation of ART. Efforts to improve early ANC booking and early ART initiation in the general population would help improve viral suppression rates among pregnant women. In addition, the study found, despite initiating ART prior to pregnancy, more than one quarter of participants did not achieve viral suppression in their third trimester. This highlights the need to closely monitor viral load and strengthen counselling and support services for ART adherence.
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Brittain K, Mellins CA, Remien RH, Phillips TK, Zerbe A, Abrams EJ, Myer L. Impact of HIV-Status Disclosure on HIV Viral Load in Pregnant and Postpartum Women on Antiretroviral Therapy. J Acquir Immune Defic Syndr 2020; 81:379-386. [PMID: 30939530 DOI: 10.1097/qai.0000000000002036] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND HIV-status disclosure is widely encouraged by counseling services, in part because it is thought to improve antiretroviral therapy (ART) adherence and thus HIV viral suppression. However, few longitudinal studies have examined the impact of disclosure on HIV viral load (VL) during pregnancy and postpartum. METHODS We explored these associations among 1187 women living with HIV, enrolled between March 2013 and June 2014 in Cape Town, South Africa. RESULTS Among women who tested HIV-positive before pregnancy, we observed no association between disclosure and VL at entry into antenatal care among those already on ART, nor at delivery and 12 months postpartum among those initiating ART. Among women who tested HIV-positive during pregnancy and initiated ART subsequently, disclosure to a male partner was associated with a reduced risk of VL ≥50 copies/mL at delivery (adjusted risk ratio: 0.56; 95% confidence interval: 0.31 to 1.01). After stratification by relationship status, this association was only observed among women who were married and/or cohabiting. In addition, disclosure to ≥1 family/community member was associated with a reduced risk of VL ≥50 copies/mL at 12 months postpartum (adjusted risk ratio: 0.69; 95% confidence interval: 0.48 to 0.97) among newly-diagnosed women. CONCLUSIONS These findings suggest that the impact of disclosure on VL is modified by 3 factors: (1) timing of HIV diagnosis (before vs. during the pregnancy); (2) relationship to the person(s) to whom women disclose; and (3) in the case of disclosure to a male partner, relationship status. Counseling about disclosure may be most effective if tailored to individual women's circumstances.
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Affiliation(s)
- Kirsty Brittain
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Claude A Mellins
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY
| | - Robert H Remien
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY
| | - Tamsin K Phillips
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Allison Zerbe
- Mailman School of Public Health, ICAP at Columbia University, New York, NY
| | - Elaine J Abrams
- Mailman School of Public Health, ICAP at Columbia University, New York, NY.,Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Maughan-Brown B, Beckett S, Kharsany ABM, Cawood C, Khanyile D, Lewis L, Venkataramani A, George G. Poor rates of linkage to HIV care and uptake of treatment after home-based HIV testing among newly diagnosed 15-to-49 year-old men and women in a high HIV prevalence setting in South Africa. AIDS Care 2020; 33:70-79. [DOI: 10.1080/09540121.2020.1719025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Brendan Maughan-Brown
- Southern Africa Labour and Development Research Unit (SALDRU), University of Cape Town, Rondebosch, South Africa
| | - Sean Beckett
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Ayesha B. M. Kharsany
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | | | | | - Lara Lewis
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Atheendar Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gavin George
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
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Phillips TK, Myer L. Shifting to the long view: engagement of pregnant and postpartum women living with HIV in lifelong antiretroviral therapy services. Expert Rev Anti Infect Ther 2019; 17:349-361. [PMID: 30978126 DOI: 10.1080/14787210.2019.1607296] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: The advent of policies promoting lifelong antiretroviral therapy (ART) for all pregnant and postpartum women living with HIV has shifted focus from short-term prevention of mother-to-child transmission (PMTCT) to lifelong engagement in ART services. However, disengagement from care threatens the long-term treatment and prevention benefits of lifelong ART. Areas covered: A framework for considering the unique aspects of ART for pregnant and postpartum women is presented along with a review of the literature on maternal engagement in care in sub-Saharan Africa and a discussion of potential interventions to sustain engagement in lifelong ART. Expert opinion: Engaging women and mothers in ART services for life is critical for maternal health, PMTCT, and prevention of sexual transmission. Evidence-based interventions exist to support engagement in care but most focus on periods of mother-to-child transmission risk. In the long term, life transitions and health-care transfers are inevitable. Thus, interventions that can reach beyond a single facility or provide a bridge between health services should be prioritized. Multicomponent interventions will also be essential to address the numerous intersecting barriers to sustained engagement in ART services.
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Affiliation(s)
- Tamsin K Phillips
- a Division of Epidemiology & Biostatistics and Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa
| | - Landon Myer
- a Division of Epidemiology & Biostatistics and Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa
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11
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Brittain K, Mellins CA, Remien RH, Phillips T, Zerbe A, Abrams EJ, Myer L. HIV-status disclosure and depression in the context of unintended pregnancy among South African women. Glob Public Health 2018; 14:1087-1097. [PMID: 30584810 DOI: 10.1080/17441692.2018.1560485] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Depressive symptoms are common among pregnant women living with HIV, and an unintended pregnancy may heighten vulnerability. HIV-status disclosure is thought to improve psychological well-being, but few quantitative studies have explored the relationships among disclosure, pregnancy intention and depression. Using multivariable linear regression models, we examined the impact of disclosure on depressive symptoms (Edinburgh Postnatal Depression Scale; EPDS) during pregnancy and postpartum among women who tested HIV-positive during the pregnancy in South Africa; and explored the role of pregnancy intention in this relationship. Among 350 women (median age: 27 years; 70% reporting that their current pregnancy was unintended), neither disclosure to a male partner nor disclosure to ≥1 family/community member had a consistent effect on depressive symptoms. However, pregnancy intention modified the association between disclosure to a male partner and depression during pregnancy: disclosure was associated with higher depression scores among women who reported that their current pregnancy was unintended but was associated with lower depression scores among women who reported that their pregnancy was intended. During the early postpartum period, disclosure to ≥1 family/community member was associated with higher depression scores. Counselling around disclosure in pregnancy should consider the heightened vulnerability that women face when experiencing an unintended pregnancy.
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Affiliation(s)
- Kirsty Brittain
- a Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa.,b Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa
| | - Claude A Mellins
- c HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute , Columbia University , New York , NY , USA
| | - Robert H Remien
- c HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute , Columbia University , New York , NY , USA
| | - Tamsin Phillips
- a Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa.,b Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa
| | - Allison Zerbe
- d Mailman School of Public Health , ICAP at Columbia University , New York , NY , USA
| | - Elaine J Abrams
- d Mailman School of Public Health , ICAP at Columbia University , New York , NY , USA.,e Vagelos College of Physicians & Surgeons , Columbia University , New York , NY , USA
| | - Landon Myer
- a Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa.,b Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa
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HIV Disclosure Among Pregnant Women Initiating ART in Cape Town, South Africa: Qualitative Perspectives During the Pregnancy and Postpartum Periods. AIDS Behav 2018; 22:3945-3956. [PMID: 30196332 DOI: 10.1007/s10461-018-2272-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
For women enrolled in prevention of mother-to-child transmission (PMTCT) programs, non-disclosure of their HIV status can be a significant barrier to sustained HIV care engagement. To explore decision-making surrounding HIV disclosure among HIV-infected pregnant women, we conducted repeated in-depth interviews during pregnancy and postpartum with 20 women recruited from a PMTCT clinic in Cape Town, South Africa. Three domains were examined using thematic analysis: (1) disclosure experiences, (2) challenges associated with partner disclosure, and (3) implications of nondisclosure. All women had disclosed to someone by the time of the baby's birth, typically limiting their disclosure to trusted individuals. Only half of participants disclosed to the father of the child. Nondisclosure, particularly to partners, was a significant source of worry and stress. Women used pregnancy as an explanation for using medication and attending frequent clinic appointments, and recognized impending challenges in the postpartum period when this excuse would no longer apply. Results suggest that PMTCT programs have a key role to play in helping individuals to make decisions about HIV disclosure, and assisting patients to navigate the disclosure process, especially with partners.
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Kiwanuka G, Kiwanuka N, Muneza F, Nabirye J, Oporia F, Odikro MA, Castelnuovo B, Wanyenze RK. Retention of HIV infected pregnant and breastfeeding women on option B+ in Gomba District, Uganda: a retrospective cohort study. BMC Infect Dis 2018; 18:533. [PMID: 30355356 PMCID: PMC6201534 DOI: 10.1186/s12879-018-3450-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 10/16/2018] [Indexed: 12/12/2022] Open
Abstract
Background Lifelong antiretroviral therapy for HIV infected pregnant and lactating women (Option B+) has been rapidly scaled up but there are concerns about poor retention of women initiating treatment. However, facility-based data could underestimate retention in the absence of measures to account for self-transfers to other facilities. We assessed retention-in-care among women on Option B+ in Uganda, using facility data and follow-up to ascertain transfers to other facilities. Methods In a 25-month retrospective cohort analysis of routine program data, women who initiated Option B+ between March 2013 and March 2015 were tracked and interviewed quantitatively and qualitatively (in-depth interviews). Kaplan Meier survival analysis was used to estimate time to loss-to-follow-up (LTFU) while multivariable Cox proportional hazards regression was applied to estimate the adjusted predictors of LTFU, based on facility data. Thematic analysis was done for qualitative data, using MAXQDA 12. Quantitative data were analyzed with STATA® 13. Results A total of 518 records were reviewed. The mean (SD) age was 26.4 (5.5) years, 289 women (55.6%) attended primary school, and 53% (276/518) had not disclosed their HIV status to their partners. At 25 months post-ART initiation, 278 (53.7%) were LTFU based on routine facility data, with mean time to LTFU of 15.6 months. Retention was 60.2 per 1000 months of observation (pmo) (95% CI: 55.9–64.3) at 12, and 46.3/1000pmo (95% CI: 42.0–50.5) at 25 months. Overall, 237 (55%) women were successfully tracked and interviewed and 43/118 (36.4%) of those who were classified as LTFU at facility level had self-transferred to another facility. The true 25 months post-ART initiation retention after tracking was 71.3% (169/237). Women < 25 years, aHR = 1.71 (95% CI: 1.28–2.30); those with no education, aHR = 5.55 (95% CI: 3.11–9.92), and those who had not disclosed their status to their partners, aHR = 1.59 (95% CI: 1.16–2.19) were more likely to be LTFU. Facilitators for Option B+ retention based on qualitative findings were adequate counselling, disclosure, and the desire to stay alive and raise HIV-free children. Drug side effects, inadequate counselling, stigma, and unsupportive spouses, were barriers to retention in care. Conclusions Retention under Option B+ is suboptimal and is under-estimated at health facility level. There is need to institute mechanisms for tracking of women across facilities. Retention could be enhanced through strategies to enhance disclosure to partners, targeting the uneducated, and those < 25 years.
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Affiliation(s)
- George Kiwanuka
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O Box 7072, Kampala, Uganda.
| | - Noah Kiwanuka
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Fiston Muneza
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Juliet Nabirye
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O Box 7072, Kampala, Uganda
| | - Frederick Oporia
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | - Magdalene A Odikro
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Barbara Castelnuovo
- Department of Research, Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
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Major PB, Puthussery S, Pappas Y. Attitudes and perceptions of pregnant women towards the use of Anti-Retroviral Therapy in Nigeria. Women Birth 2018; 32:e189-e196. [PMID: 29954689 DOI: 10.1016/j.wombi.2018.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/28/2018] [Accepted: 06/05/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mother-to-child transmission of Human Immunodeficiency Virus continues to be a major problem in Nigeria. Despite several initiatives, the number of infected pregnant women receiving Anti-Retroviral Therapy to prevent mother-to-child transmission of the virus remains low in Nigeria. Evidence suggests that attitudes and perceptions of the pregnant women influence their use of Anti-Retroviral Therapy. AIM To understand the attitudes and perceptions of Human Immunodeficiency Virus infected pregnant women towards the use of Anti-Retroviral Therapy for prevention of mother-to-child transmission in Nigeria. METHOD Twenty four Human Immunodeficiency Virus infected pregnant women were purposively selected from antenatal clinics. Women's attitudes and perceptions towards the use of Anti-Retroviral Therapy were explored using semi-structured in-depth interviews conducted in May/June 2016. All interviews were recorded, transcribed and analysed using thematic approach. FINDINGS Overall, participants reflected a positive attitude about using Anti-Retroviral Therapy to prevent mother-to-child transmission and perceived the treatment as beneficial. The main themes identified included: perceived benefits of Anti-Retroviral Therapy; barriers to using Anti-Retroviral Therapy; threat from the susceptibility to the illness and the severity; perceived roles in treatment; and the negative behaviours of healthcare providers. CONCLUSION The findings provide useful insights to inform Nigeria's health policies on Anti-Retroviral Therapy. There is a need to educate the women on the benefits of the treatment as well as how they can cope with side effects and the daily regimen of the therapy during pregnancy. The findings also indicate the need for training healthcare providers on facilitative patient-provider relationship.
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Affiliation(s)
- Puremeluan B Major
- Institute for Health Research, University of Bedfordshire, United Kingdom
| | - Shuby Puthussery
- Institute for Health Research, University of Bedfordshire, United Kingdom.
| | - Yannis Pappas
- Institute for Health Research, University of Bedfordshire, United Kingdom
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Ross J, Edmonds A, Hoover DR, Shi Q, Anastos K, Lelo P, Behets F, Yotebieng M. Association between pregnancy at enrollment into HIV care and loss to care among women in the Democratic Republic of Congo, 2006-2013. PLoS One 2018; 13:e0195231. [PMID: 29608618 PMCID: PMC5880386 DOI: 10.1371/journal.pone.0195231] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 03/08/2018] [Indexed: 01/08/2023] Open
Abstract
Background Loss to care is high among asymptomatic HIV-infected women initiated on antiretroviral therapy (ART) during pregnancy or in the postpartum period. However, whether pregnancy itself plays a role in the high loss to care rate is uncertain. We compared loss to care over seven years between pregnant and non-pregnant women at enrollment into HIV care in the Democratic Republic of Congo (DRC). Methods We conducted a retrospective analysis of all ART-naive women aged 15–45 initiating HIV care at two large clinics in Kinshasa, DRC, from 2007–2013. Pregnancy status was recorded at care enrollment. Patients were classified as having no follow-up if they did not return to care after the initial enrollment visit. Among those with at least one follow-up visit after enrollment, we classified patients as lost to care if more than 365 days had passed since their last clinic visit. We used logistic regression to model the association between pregnancy status and no follow-up, and Cox proportional hazards regression to model the association between pregnancy status and time to loss to care. Results Of 2175 women included in the analysis, 1497 (68.8%) were pregnant at enrollment. Compared to non-pregnant women, pregnant women were less likely to be over 35 years of age (19.1% vs. 31.9%, p<0.0001) and less likely to be in WHO stage III or IV (9.0% vs. 26.3%, p<0.0001). Among pregnant women, 106 (7.1%) were not seen after enrollment, versus 25 (3.7%) non-pregnant women (adjusted odds ratio 2.01, 95% CI 1.24–3.24). Of the 2,044 women with at least one follow-up visit, 46.5% of pregnant women and 46.7% of non-pregnant women were lost to care by 5 years; hazards of loss to care were similar for pregnant and non-pregnant women (adjusted hazard ratio 1.08, 95% CI 0.93–1.26). Conclusions In this large cohort of HIV-infected women, patients pregnant at care enrollment were more likely to never return for follow-up. Among those who attended at least one follow-up visit, loss to care was not different between pregnant and non-pregnant women, suggesting that pregnancy itself may not be the main driver of the high attrition observed in this cohort.
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Affiliation(s)
- Jonathan Ross
- Department of Medicine, Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Bronx, NY, United States of America
- * E-mail:
| | - Andrew Edmonds
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Donald R. Hoover
- Department of Statistics and Biostatistics, Rutgers University, New Brunswick, NJ, United States of America
| | - Qiuhu Shi
- Department of Epidemiology and Community Health, New York Medical College, Valhalla, NY, United States of America
| | - Kathryn Anastos
- Department of Medicine, Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Bronx, NY, United States of America
| | - Patricia Lelo
- Kalembelembe Pediatric Hospital, Kinshasa, The Democratic Republic of Congo
| | - Frieda Behets
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Marcel Yotebieng
- College of Public Health, Division of Epidemiology, The Ohio State University, Columbus, OH, United States of America
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van Lettow M, Landes M, van Oosterhout JJ, Schouten E, Phiri H, Nkhoma E, Kalua T, Gupta S, Wadonda N, Jahn A, Tippett-Barr B. Prevention of mother-to-child transmission of HIV: a cross-sectional study in Malawi. Bull World Health Organ 2018; 96:256-265. [PMID: 29695882 PMCID: PMC5872011 DOI: 10.2471/blt.17.203265] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 01/09/2018] [Accepted: 02/06/2018] [Indexed: 12/03/2022] Open
Abstract
Objective To estimate the use and outcomes of the Malawian programme for the prevention of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV). Methods In a cross-sectional analysis of 33 744 mother–infant pairs, we estimated the weighted proportions of mothers who had received antenatal HIV testing and/or maternal antiretroviral therapy and infants who had received nevirapine prophylaxis and/or HIV testing. We calculated the ratios of MTCT at 4–26 weeks postpartum for subgroups that had missed none or at least one of these four steps. Findings The estimated uptake of antenatal testing was 97.8%; while maternal antiretroviral therapy was 96.3%; infant prophylaxis was 92.3%; and infant HIV testing was 53.2%. Estimated ratios of MTCT were 4.7% overall and 7.7% for the pairs that had missed maternal antiretroviral therapy, 10.7% for missing both maternal antiretroviral therapy and infant prophylaxis and 11.4% for missing maternal antiretroviral therapy, infant prophylaxis and infant testing. Women younger than 19 years were more likely to have missed HIV testing (adjusted odds ratio, aOR: 4.9; 95% confidence interval, CI: 2.3–10.6) and infant prophylaxis (aOR: 6.9; 95% CI: 1.2–38.9) than older women. Women who had never started maternal antiretroviral therapy were more likely to have missed infant prophylaxis (aOR: 15.4; 95% CI: 7.2–32.9) and infant testing (aOR: 13.7; 95% CI: 4.2–83.3) than women who had. Conclusion Most women used the Malawian programme for the prevention of MTCT. The risk of MTCT increased if any of the main steps in the programme were missed.
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Affiliation(s)
- M van Lettow
- Dignitas International, PO Box 1071, Zomba, Malawi
| | - M Landes
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | | | - E Schouten
- Management Sciences for Health, Lilongwe, Malawi
| | - H Phiri
- Management Sciences for Health, Lilongwe, Malawi
| | - E Nkhoma
- Management Sciences for Health, Lilongwe, Malawi
| | - T Kalua
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - S Gupta
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - N Wadonda
- United States Centers for Disease Control and Prevention - Lilongwe, Lilongwe, Malawi
| | - A Jahn
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - B Tippett-Barr
- United States Centers for Disease Control and Prevention - Zimbabwe, Harare, Zimbabwe
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Holmes CB, Yiannoutsos CT, Elul B, Bukusi E, Ssali J, Kambugu A, Musick BS, Cohen C, Williams C, Diero L, Padian N, Wools-Kaloustian KK. Increased prevalence of pregnancy and comparative risk of program attrition among individuals starting HIV treatment in East Africa. PLoS One 2018; 13:e0190828. [PMID: 29342180 PMCID: PMC5771608 DOI: 10.1371/journal.pone.0190828] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 12/20/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The World Health Organization now recommends initiating all pregnant women on life-long antiretroviral therapy (ART), yet there is limited information about the characteristics and program outcomes of pregnant women already on ART in Africa. Our hypothesis was that pregnant women comprised an increasing proportion of those starting ART, and that sub-groups of these women were at higher risk for program attrition. METHODS AND FINDINGS We used the International Epidemiology Databases to Evaluate AIDS- East Africa (IeDEA-EA) to conduct a retrospective cohort study including HIV care and treatment programs in Kenya, Uganda, and Tanzania. The cohort consecutively included HIV-infected individuals 13 years or older starting ART 2004-2014. We examined trends over time in the proportion pregnant, their characteristics and program attrition rates compared to others initiating and already receiving ART. 156,474 HIV-infected individuals (67.0% women) started ART. The proportion of individuals starting ART who were pregnant women rose from 5.3% in 2004 to 12.2% in 2014. Mean CD4 cell counts at ART initiation, weighted for annual program size, increased from 2004 to 2014, led by non-pregnant women (annual increase 20 cells/mm3) and men (17 cells/mm3 annually), with lower rates of change in pregnant women (10 cells/mm3 per year) (p<0.0001). There was no significant difference in the cumulative incidence of program attrition at 6 months among pregnant women starting ART and non-pregnant women. However, healthy pregnant women starting ART (WHO stage 1/2) had a higher rate of attrition rate (9.6%), compared with healthy non-pregnant women (6.5%); in contrast among women with WHO stage 3/4 disease, pregnant women had lower attrition (8.4%) than non-pregnant women (14.4%). Among women who initiated ART when healthy and remained in care for six months, subsequent six-month attrition was slightly higher among pregnant women at ART start (3.5%) compared to those who were not pregnant (2.4%), (absolute difference 1.1%, 95% CI 0.7%-1.5%). CONCLUSIONS Pregnant women comprise an increasing proportion of those initiating ART in Africa, and pregnant women starting ART while healthy are at higher risk for program attrition than non-pregnant women. As ART programs further expand access to healthier pregnant women, further studies are needed to better understand the drivers of loss among this high risk group of women to optimize retention.
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Affiliation(s)
- Charles B. Holmes
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Georgetown University School of Medicine, Washington, DC, United States of America
| | - Constantin T. Yiannoutsos
- Indiana University R.M. Fairbanks School of Public Health, Indianapolis, Indiana, United States of America
| | - Batya Elul
- Mailman School of Public Health, Columbia University, ICAP at Columbia University, New York, New York, United States of America
| | - Elizabeth Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - John Ssali
- Masaka Regional Hospital, Masaka, Uganda
| | | | - Beverly S. Musick
- Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Craig Cohen
- University of California San Francisco, San Francisco, California, United States of America
| | - Carolyn Williams
- National Institute of Allergies and Infectious Diseases, Bethesda, Maryland, United States of America
| | - Lameck Diero
- Academic Model Providing Access to Health Care (AMPATH), Eldoret, Kenya
| | - Nancy Padian
- University of California, Berkeley, California, United States of America
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Lytvyn L, Siemieniuk RA, Dilmitis S, Ion A, Chang Y, Bala MM, Manja V, Mirza R, Rodriguez-Gutierrez R, Mir H, El Dib R, Banfield L, Vandvik PO, Bewley S. Values and preferences of women living with HIV who are pregnant, postpartum or considering pregnancy on choice of antiretroviral therapy during pregnancy. BMJ Open 2017; 7:e019023. [PMID: 28893759 PMCID: PMC5988094 DOI: 10.1136/bmjopen-2017-019023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To investigate women's values and preferences regarding antiretroviral therapy (ART) during pregnancy to inform a BMJ Rapid Recommendation. SETTING Primary studies reporting patient-reported outcomes relevant to decision-making regarding ART in any clinical and geographical setting. PARTICIPANTS Women living with HIV who are pregnant, postpartum or considering pregnancy. OUTCOME MEASURES Quantitative measurements and qualitative descriptions of values and preferences in relation to ART during pregnancy. We also included studies on women's reported barriers and facilitators to adherence. We excluded studies correlating objective measures (eg, CD4 count) with adherence, or reporting only outcomes which are not expected to differ between ART alternatives (eg, access to services, knowledge about ART). RESULTS We included 15 qualitative studies reporting values and preferences about ART in the peripartum period; no study directly studied choice of ART therapy during pregnancy. Six themes emerged: a desire to reduce vertical transmission (nine studies), desire for child to be healthy (five studies), concern about side effects to the child (eight studies), desire for oneself to be healthy (five studies), distress about side effect to oneself (10 studies) and pill burden (two studies). None of the studies weighed the relative importance of these outcomes directly, but pill burden/medication complexity appears to be a lower priority for most women compared with other factors. Overall, the body of evidence was at low risk of bias, with minor limitations. CONCLUSIONS Women who are or may become pregnant and who are considering ART appear to place a high value on both their own and their children's health. Evidence on the relative importance between these values when choosing between ART regimens is uncertain. There is variability in individual values and preferences among women. This highlights the importance of an individualised women-centred approach, such as shared decision-making when choosing between ART alternatives. TRIAL REGISTRATION NUMBER International Prospective Register of Systematic Reviews:CRD42017057157.
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Affiliation(s)
- Lyubov Lytvyn
- Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Reed A Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | | | - Allyson Ion
- School of Social Work, McMaster University, Hamilton, Canada
| | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Malgorzata M Bala
- Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - Veena Manja
- Department of Medicine, Division of Cardiology, VA Western New York Health Care System, Buffalo, New York, USA
| | - Reza Mirza
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Rene Rodriguez-Gutierrez
- Internal Medicine, University Hospital 'Dr. José E. González', Monterrey, Mexico
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hassan Mir
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Regina El Dib
- Institute of Science and Technology, UNESP—Universidade Estadual Paulista, São José dos Campos, São Paulo, Brazil
| | - Laura Banfield
- Health Sciences Library, McMaster University, Hamilton, Canada
| | - Per Olav Vandvik
- Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
| | - Susan Bewley
- Women's Health Academic Centre, King's College London, London, UK
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Patterns of HIV Care Clinic Attendance and Adherence to Antiretroviral Therapy Among Pregnant and Breastfeeding Women Living With HIV in the Context of Option B+ in Zimbabwe. J Acquir Immune Defic Syndr 2017; 75 Suppl 2:S198-S206. [PMID: 28498190 DOI: 10.1097/qai.0000000000001347] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Consistent use of antiretroviral therapy (ART) during pregnancy and breastfeeding reduces the likelihood of mother-to-child HIV transmission. All pregnant and breastfeeding women living with HIV in Zimbabwe are offered ART with same-day initiation regardless of CD4 count (Option B+). We investigated patterns of clinic attendance and adherence to ART among HIV-infected pregnant women in Zimbabwe. METHODS The Evidence for Elimination cluster-randomized trial evaluating point-of-care CD4 testing included 1150 HIV-infected ART-naive women attending antenatal care between January 2014 and June 2015. Thirty-two primary care facilities were randomized between 2 arms. In this secondary analysis of Evidence for Elimination data collected from routine clinic records, we classified women by number of pills dispensed, and estimated adherence from the ratio of pills to days since ART initiation (Medication Possession Ratio, adherent if ≥95%) or the period when they stopped receiving medication. RESULTS Two-thirds (67.7%) were still receiving medication 1 year after initiation; less than half of the cohort (39.1%) were adherent. Younger women, newly diagnosed with HIV, and/or first presenting to antenatal care in their third trimester were more likely to drop from care or be nonadherent 360 days after ART initiation. CONCLUSION Adherence to ART is suboptimal particularly among young, newly diagnosed, and/or late presenting patients. Interventions that target these groups, as well as provide additional support to all women who are newly diagnosed, may improve Option B+ ART care. More information is needed about the barriers to ART care among late presenters and teenagers.
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Gugsa S, Potter K, Tweya H, Phiri S, Sande O, Sikwese P, Chikonda J, O’Malley G. Exploring factors associated with ART adherence and retention in care under Option B+ strategy in Malawi: A qualitative study. PLoS One 2017. [PMID: 28636669 PMCID: PMC5479573 DOI: 10.1371/journal.pone.0179838] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Although several studies have documented challenges related to inadequate adherence to antiretroviral therapy (ART) and high loss to follow-up (LTFU) among Option B+ women, there is limited understanding of why these challenges occur and how to address them. This qualitative study examines women's experiences with ART adherence and retention in care. Between July and October 2015, in-depth interviews were conducted with 39 pregnant and lactating women who initiated ART at Bwaila Hospital in Lilongwe, Malawi. Study participants included 14 in care and 25 out of care women, according to facility records. Data were analyzed using an inductive, open-coding approach to thematic analysis. Ten of the respondents (7 out of care, 3 in-care) had stopped and re-started treatment before the interview date. One of the most important factors influencing adherence and retention was the strength of women's support systems. In contrast to women in-care, most out-of-care women lacked emotional and financial support from male partners, received minimal counseling from providers at initiation, lacked designated guardians to assist with medication refills or clinic appointments, and were highly mobile. Mobility led to difficulties in accessing treatment in new settings. The most common reasons women re-started treatment following interruptions were due to providers' counseling and encouragement and the mother's desire to be healthy. Improved counseling at initiation, active follow-up counseling, women's economic empowerment interventions, promotion of peer counseling schemes and meaningful engagement of male partners can help in addressing the identified barriers and promoting sustained retention of Option B+ women.
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Affiliation(s)
- Salem Gugsa
- Lighthouse Trust, Lilongwe, Malawi
- International Training and Education Center for Health (I-TECH), University of Washington Department of Global Health, Seattle, Washington, United States of America
- * E-mail:
| | - Katy Potter
- International Training and Education Center for Health (I-TECH), University of Washington Department of Global Health, Seattle, Washington, United States of America
| | - Hannock Tweya
- Lighthouse Trust, Lilongwe, Malawi
- The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Sam Phiri
- Lighthouse Trust, Lilongwe, Malawi
- University of North Carolina, School of Medicine, Department of Medicine, Chapel Hill, North Carolina, United States of America
- University of Malawi, College of Medicine, School of Public Health and Family Medicine, Department of Public Health, Lilongwe, Malawi
| | | | | | - Janet Chikonda
- Ministry of Health, District Health Office, Lilongwe, Malawi
| | - Gabrielle O’Malley
- International Training and Education Center for Health (I-TECH), University of Washington Department of Global Health, Seattle, Washington, United States of America
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21
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Ashaba S, Kaida A, Coleman JN, Burns BF, Dunkley E, O'Neil K, Kastner J, Sanyu N, Akatukwasa C, Bangsberg DR, Matthews LT, Psaros C. Psychosocial challenges facing women living with HIV during the perinatal period in rural Uganda. PLoS One 2017; 12:e0176256. [PMID: 28459866 PMCID: PMC5411062 DOI: 10.1371/journal.pone.0176256] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 04/07/2017] [Indexed: 01/08/2023] Open
Abstract
The complexities of navigating pregnancy while living with HIV predispose women to additional stress. Finding ways to minimize psychosocial challenges during the perinatal period may maximize the well-being of mothers living with HIV and their children. The goal of this study was to explore psychosocial challenges experienced by women living with HIV (WLWH) during pregnancy and the postpartum. We conducted individual in-depth interviews with 20 WLWH recruited from an HIV treatment cohort study in Mbarara, Uganda as part of a larger study exploring perinatal depression. We conducted content analyses to identify themes related to challenges of WLWH during pregnancy and the postpartum. Participants had a median age of 33 years [IQR: 28-35], a median of 3 living children [IQR: 2-5], and 95% had achieved HIV-RNA suppression. Challenges were organized around the following themes: HIV -related stigma from health professionals, HIV status disclosure dilemma, unintended pregnancy and intimate partner violence, HIV and environmental structural barriers and distress and fear related to maternal and child health. Stigma centered on discrimination by health care professionals and personal shame associated with being pregnant as a WLWH. This led to difficulty engaging in HIV care, particularly when coupled with structural barriers, such as lack of transportation to clinic. Participants experienced intimate partner violence and lacked support from their partners and family members. Distress and fear about the health and uncertainty about the future of the unborn baby due to maternal deteriorating physical health was common. The perinatal period is a time of stress for WLWH. Challenges experienced by WLWH may compromise successful engagement in HIV care and may reduce quality of life for women and their children. Strategies aimed at alleviating the challenges of WLWH should involve the larger structural environment including partners, family and community member as well as policy makers, funders and program implementers to work together for the common cause. These consolidated efforts may not only lower the risk of psychological distress but has potential to create long lasting solutions to benefit the wider community.
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Affiliation(s)
- Scholastic Ashaba
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
| | - Jessica N Coleman
- Behavioral Medicine Program, Department of Psychiatry, Massachusetts General Hospital (MGH), Boston, United States of America
| | - Bridget F Burns
- Division of Global Health, Massachusetts General Hospital (MGH), Boston, United States of America
| | - Emma Dunkley
- Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
| | - Kasey O'Neil
- Division of Global Health, Massachusetts General Hospital (MGH), Boston, United States of America
| | - Jasmine Kastner
- Research Institute, McGill University Health Centre, Montreal, Canada
| | - Naomi Sanyu
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Cecilia Akatukwasa
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda
| | - David R Bangsberg
- Oregon Health Sciences University-Portland State University School of Public Health, Portland, OR, United States of America
| | - Lynn T Matthews
- Division of Global Health, Massachusetts General Hospital (MGH), Boston, United States of America
- Division of Infectious Disease, Massachusetts General Hospital (MGH), Boston, United States of America
| | - Christina Psaros
- Behavioral Medicine Program, Department of Psychiatry, Massachusetts General Hospital (MGH), Boston, United States of America
- Harvard Medical School, Boston, MA
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Horter S, Thabede Z, Dlamini V, Bernays S, Stringer B, Mazibuko S, Dube L, Rusch B, Jobanputra K. "Life is so easy on ART, once you accept it": Acceptance, denial and linkage to HIV care in Shiselweni, Swaziland. Soc Sci Med 2017; 176:52-59. [PMID: 28129547 DOI: 10.1016/j.socscimed.2017.01.006] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 12/15/2016] [Accepted: 01/04/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Timely uptake of antiretroviral therapy, adherence and retention in care for people living with HIV (PLHIV) can improve health outcomes and reduce transmission. Médecins Sans Frontières and the Swaziland Ministry of Health provide community-based HIV testing services (HTS) in Shiselweni, Swaziland, with high HTS coverage but sub-optimal linkage to HIV care. This qualitative study examined factors influencing linkage to HIV care for PLHIV diagnosed by community-based HTS. METHODS Participants were sampled purposively, exploring linkage experiences among both genders and different age groups. Interviews were conducted with 28 PLHIV (linked and not linked) and 11 health practitioners. Data were thematically analysed to identify emergent patterns and categories using NVivo 10. Principles of grounded theory were applied, including constant comparison of findings, raising codes to a conceptual level, and inductively generating theory from participant accounts. RESULTS The process of HIV status acceptance or denial influenced the accounts of patients' health seeking and linkage to care. This process was non-linear and varied temporally, with some experiencing non-acceptance for an extended period of time. Non-acceptance was linked to perceptions of HIV risk, with those not identifying as at risk less likely to expect and therefore be prepared for a positive result. Status disclosure was seen to support linkage, reportedly occurring after the acceptance of HIV status. HIV status acceptance motivated health seeking and tended to be accompanied by a perceived need for, and positive value placed on, HIV health care. CONCLUSIONS The manner in which PLHIV process a positive result can influence their engagement with HIV treatment and care. Thus, there is a need for individually tailored approaches to HTS, including the potential for counselling over multiple sessions if required, supporting status acceptance, and disclosure. This is particularly relevant considering 90-90-90 targets and the need to better support PLHIV to engage with HIV treatment and care following diagnosis.
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Affiliation(s)
- Shona Horter
- Médecins Sans Frontières (MSF), London, UK; London School of Hygiene and Tropical Medicine, London, UK.
| | | | | | - Sarah Bernays
- London School of Hygiene and Tropical Medicine, London, UK.
| | | | - Sikhathele Mazibuko
- Swaziland National AIDS Programme, Ministry of Health of Swaziland, Mbabane, Swaziland.
| | - Lenhle Dube
- Swaziland National AIDS Programme, Ministry of Health of Swaziland, Mbabane, Swaziland.
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23
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Katirayi L, Chouraya C, Kudiabor K, Mahdi MA, Kieffer MP, Moland KM, Tylleskar T. Lessons learned from the PMTCT program in Swaziland: challenges with accepting lifelong ART for pregnant and lactating women - a qualitative study. BMC Public Health 2016; 16:1119. [PMID: 27776495 PMCID: PMC5078916 DOI: 10.1186/s12889-016-3767-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 10/13/2016] [Indexed: 11/25/2022] Open
Abstract
Background Swaziland has one of the highest HIV prevalence rates in sub-Saharan Africa, 26 % of the adult population is infected with HIV. The prevalence is highest among pregnant women, at 41.1 %. According to Swaziland’s prevention of mother-to-child transmission (PMTCT) guidelines, approximately 50 % of pregnant women are eligible for antiretroviral therapy (ART) by CD4 criteria (<350 cells/ml). Studies have shown that most mother-to-child transmission and postnatal deaths occur among women who are eligible for ART. Therefore, ensuring that ART eligible women are initiated on ART is critical for PMTCT and for mother and baby survival. This study provides insight into the challenges of lifelong ART initiation among pregnant women under Option A in Swaziland. We believe that these challenges and lessons learned from initiating women on lifelong ART under Option A are relevant and important to consider during implementation of Option B+. Methods HIV-positive, treatment-eligible, postpartum women and nurses were recruited within maternal and child health (MCH) units using convenience and purposive sampling. Participants came from both urban and rural areas. Focus group discussions (FGDs) and structured interviews using a short answer questionnaire were conducted to gain an understanding of the challenges experienced when initiating lifelong ART. Seven FGDs (of 5–11 participants) were conducted, four FGDs with nurses, two FGDs with women who initiated ART, and one FGD with women who did not initiate ART. A total of 83 interviews were conducted; 50 with women who initiated ART and 33 with women who did not initiate. Data collection with the women was conducted in the local language of SiSwati and data collection with the nurses was done in English. FGDs were audio-recorded and simultaneously transcribed and translated into English. Analysis was conducted using thematic analysis. Transcripts were coded by two researchers in the qualitative software program MAXqda v.10. Thematic findings were illustrated using verbatim quotes which were selected on the basis of being representative of a specific theme. The short-answer interview questionnaire included specific questions about the different steps in the woman’s experience initiating ART; therefore the responses for each question were analyzed separately. Results Findings from the study highlight women feeling overwhelmed by the lifetime commitment of ART, feeling “healthy” when asked to initiate ART, preference for short-course prophylaxis and fear of side effects (body changes). Also, the preference for nurses to determine on an individual basis the number of counseling appointments a woman needs before initiating ART, more information about HIV and ART needed at the community level, and the need to educate men about HIV and ART. Conclusion Women face a myriad of challenges initiating lifelong ART. Understanding women’s concerns will aid in developing effective counseling messages, designing appropriate counseling structures, understanding where additional support is needed in the process of initiating ART, and knowing who to target for community level messages.
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Affiliation(s)
- Leila Katirayi
- Elizabeth Glaser Pediatric AIDS Foundation, 1140 Connecticut Ave NW, Suite 200, Washington DC, 20036, USA. .,Center for International Health, University of Bergen, Bergen, Norway.
| | | | | | - Mohammed Ali Mahdi
- Elizabeth Glaser Pediatric AIDS Foundation, 1140 Connecticut Ave NW, Suite 200, Washington DC, 20036, USA
| | - Mary Pat Kieffer
- Elizabeth Glaser Pediatric AIDS Foundation, 1140 Connecticut Ave NW, Suite 200, Washington DC, 20036, USA
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24
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Landes M, Sodhi S, Matengeni A, Meaney C, van Lettow M, Chan AK, van Oosterhout JJ. Characteristics and outcomes of women initiating ART during pregnancy versus breastfeeding in Option B+ in Malawi. BMC Public Health 2016; 15:713. [PMID: 27487775 PMCID: PMC4973045 DOI: 10.1186/s12889-016-3380-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 07/27/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malawi adopted the PMTCT strategy 'Option B+' in 2011, providing life-long ART for all HIV-infected pregnant and breastfeeding women. We explored differences in characteristics and outcomes of women initiating ART during pregnancy versus breastfeeding. METHODS We conducted a retrospective cohort analysis of women in Zomba District, southern Malawi, from January 2012- September 2013. Data were extracted from the Zomba District Observational Cohort Study, a surveillance project collecting data from standardized Ministry of Health ART monitoring tools. RESULTS 1986 (67.2 %) women initiated ART during pregnancy and 969 (32.8 %) during breastfeeding. Women initiating ART in breastfeeding were more likely to be > 30 years (aOR = 1.33, 95 % CI1.11-1.59, p = 0.003) and have WHO Stage 3/4 (aOR = 2.74, 95 % CI1.94-3.87, p < 0.001). Eighteen (0.6 %) deaths occurred and 942 (31.9 %) women defaulted ART. 'Early' death (< 30 days) occurred in 3 (0.1 %) women and 449 (16.4 %) women defaulted early. Death/default < 30 days was more likely among women initiating ART during pregnancy (aOR 1.62, 95 % CI1.28-2.05, p < 0.001) or < 30 years old (aOR 1.27, 95 % CI 1.02-1.57, p = 0.03) and was less likely among those with WHO Stage 3/4 (aOR 0.30, 95 % CI 0.15-0.60, p < 0.001). Using Kaplan-Meier estimators to investigate time to death/default, we showed a sharp drop in death/default-free survival probability at time zero, yet survival probability decreased in a nearly linear manner after this initial period of high default. Women under 30 years had increased rates of death/default over time (log rank test: p < 0.001), however no significant differences were observed in death/default over time associated with timing of ART initiation, documented clinical stage at initiation, health clinic size or adherence rates. CONCLUSIONS Many women in Malawi started ART during breastfeeding within Option B+ and were older and had more advanced WHO Clinical Staging. This represents a missed PMTCT opportunity to initiate treatment early in pregnancy. Early defaulting is identified as a challenge within Option B+, and was more likely among younger women and those initiating ART in pregnancy. Targeted research to understand factors associated with uptake of ART during pregnancy and retention in care could improve the efficacy of Option B+ in Malawi.
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Affiliation(s)
- M Landes
- Dignitas International, Zomba, Malawi. .,Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
| | - S Sodhi
- Dignitas International, Zomba, Malawi.,Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | | | - C Meaney
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - M van Lettow
- Dignitas International, Zomba, Malawi.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - A K Chan
- Dignitas International, Zomba, Malawi.,Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - J J van Oosterhout
- Dignitas International, Zomba, Malawi.,Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi
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25
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Fatti G, Shaikh N, Eley B, Grimwood A. Effectiveness of community-based support for pregnant women living with HIV: a cohort study in South Africa. AIDS Care 2016; 28 Suppl 1:114-8. [PMID: 26922939 PMCID: PMC4828595 DOI: 10.1080/09540121.2016.1148112] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Antiretroviral treatment (ART) initiation in HIV-infected pregnant women in sub-Saharan Africa (SSA) remains inadequate, and there is a severe shortage of professional healthcare workers in the region. The effectiveness of community support programmes for HIV-infected pregnant women and their infants in SSA is unclear. This study compared initiation of maternal antiretrovirals and infant outcomes amongst HIV-infected pregnant women and their infants who received and did not receive community-based support (CBS) in a high HIV-prevalence setting in South Africa. A cohort study, including HIV-infected pregnant women and their infants, was conducted at three sentinel surveillance facilities between January 2009 and June 2012, utilising enhanced routine clinical data. Through home visits, CBS workers encouraged uptake of interventions in the ART cascade, provided HIV-related education, ART initiation counselling and psychosocial support. Outcomes were compared using Kaplan–Meier analyses and multivariable Cox and log-binomial regression. Amongst 1105 mother–infant pairs included, 264 (23.9%) received CBS. Amongst women eligible to start ART antenatally, women who received CBS had a reduced risk of not initiating antenatal ART, 5.4% vs. 30.3%; adjusted risk ratio (aRR) = 0.18 (95% CI: 0.08–0.44; P < .0001). Women who received CBS initiated antenatal ART with less delay after the first antenatal visit, median 26 days vs. 39 days; adjusted hazard ratio (aHR) = 1.57 (95% CI: 1.15–2.14; P = .004). Amongst women who initiated antenatal zidovudine (ZDV) to prevent vertical transmission, women who received CBS initiated ZDV with less delay, aHR = 1.52 (95% CI: 1.18–2.01; P = .001). Women who received CBS had a lower risk of stillbirth, 1.5% vs. 5.4%; aRR = 0.24 (95% CI: 0.07–1.00; P = .050). Pregnant women living with HIV who received CBS had improved antenatal triple ART initiation in eligible women, women initiated ART and ZDV with shorter delays, and had a lower risk of stillbirth. CBS is an intervention that shows promise in improving maternal and infant health in high HIV-prevalence settings.
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Affiliation(s)
| | | | - Brian Eley
- b Department of Paediatrics and Child Health , Red Cross War Memorial Children's Hospital, University of Cape Town , Cape Town , South Africa
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26
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Schuster RC, McMahon DE, Young SL. A comprehensive review of the barriers and promoters health workers experience in delivering prevention of vertical transmission of HIV services in sub-Saharan Africa. AIDS Care 2016; 28:778-94. [PMID: 26883903 DOI: 10.1080/09540121.2016.1139041] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Despite significant biomedical and policy advances, 199,000 infants and young children in sub-Saharan Africa (SSA) became infected with HIV in 2013, indicating challenges to implementation of these advances. To understand the nature of these challenges, we sought to (1) characterize the barriers and facilitators that health workers encountered delivering prevention of vertical transmission of HIV (PVT) services in SSA and (2) evaluate the use of theory to guide PVT service delivery. The PubMed and CINAHL databases were searched using keywords barriers, facilitators, HIV, prevention of vertical transmission of HIV, health workers, and their synonyms to identify relevant studies. Barriers and facilitators were coded at ecological levels according to the Determinants of Performance framework. Factors in this framework were then classified as affecting motivation, opportunity, or ability, per the Motivation-Opportunity-Ability (MOA) framework in order to evaluate domains of health worker performance within each ecological level. We found that the most frequently reported challenges occurred within the health facility level and spanned all three MOA domains. Barriers reported in 30% or more of studies from most proximal to distal included those affecting health worker motivation (stress, burnout, depression), patient opportunity (stigma), work opportunity (poor referral systems), health facility opportunity (overburdened workload, lack of supplies), and health facility ability (inadequate PVT training, inconsistent breastfeeding messages). Facilitators were reported in lower frequencies than barriers and tended to be resolutions to challenges (e.g., quality supervision, consistent supplies) or responses to an intervention (e.g., record systems and infrastructure improvements). The majority of studies did not use theory to guide study design or implementation. Interventions addressing health workers' multiple ecological levels of interactions, particularly the health facility, hold promise for far-reaching impact as distal factors influence more proximal factors. Incorporating theory that considers factors beyond the health worker will strengthen endeavors to mitigate barriers to PVT service delivery.
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Affiliation(s)
- Roseanne C Schuster
- a Program in International Nutrition, Division of Nutritional Sciences , Cornell University , Ithaca , NY , USA
| | - Devon E McMahon
- b Division of Nutritional Sciences , Cornell University , Ithaca , NY , USA
| | - Sera L Young
- a Program in International Nutrition, Division of Nutritional Sciences , Cornell University , Ithaca , NY , USA
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27
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Implementation and Operational Research: Postpartum Transfer of Care Among HIV-Infected Women Initiating Antiretroviral Therapy During Pregnancy. J Acquir Immune Defic Syndr 2016; 70:e102-9. [PMID: 26470033 DOI: 10.1097/qai.0000000000000771] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The integration of antiretroviral therapy (ART) services into antenatal care for prevention of mother-to-child transmission has resulted in the need to transfer HIV-infected women to general ART clinics after delivery. Transfer of patients on ART between services may present a challenge to adherence and retention, but there are few data describing this step in the HIV care cascade for women starting ART in pregnancy. METHODS We described postpartum transfer of care in a cohort of women initiating ART during pregnancy and referred from integrated antenatal ART services to general ART clinics. Engagement in ART care at general ART clinics was assessed through routine laboratory records and telephonic interviews. RESULTS Overall, 279 postpartum women were transferred to ART clinics. By 5 months postreferral, between 74% and 91% of women had evidence of engagement at an ART clinic depending on the outcome definition. In a log-binomial model adjusted for age, CD4 cell count and being diagnosed with HIV in the current pregnancy, additional months on ART before delivery improved the likelihood of engagement in an ART clinic (relative risk: 1.05, 95% confidence interval: 1.00 to 1.09, P = 0.036). CONCLUSIONS Postpartum transfer of ART care is an important and previously neglected step in the HIV care cascade for pregnant women. Even in this cohort of highly adherent women up to 25% did not remain in care after transfer. Retention is required across all steps of the cascade, including transfer of ART care after delivery, to maximize the benefits of ART for both maternal and child health.
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28
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Spindola T, Dantas KTDB, Cadavez NFV, Fonte VRFD, Oliveira DCD. Maternity perception by pregnant women living with HIV. INVESTIGACION Y EDUCACION EN ENFERMERIA 2015; 33:440-448. [PMID: 28569951 DOI: 10.17533/udea.iee.v33n3a07] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 04/15/2015] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Identify the perceptions of pregnant women living with HIV about motherhood and understand the expectations and feelings experienced by these women. METHODOLOGY Study with descriptive design and qualitative approach, carried out with 10 pregnant women living with HIV who attend the prenatal service of a university hospital in Rio de Janeiro, Brazil. The participants answered a semi-structured interview. Data were analyzed using the content analysis technique. RESULTS Pregnant women in their descriptions revealed that motherhood gives them different perspectives on the present and future. They see it as a good thing, a responsibility to care for the child, and consider bearing a child to be a gift. CONCLUSION For pregnant women living with HIV, motherhood is a positive experience in their lives. Nurses must be sensitive to the needs of this group and aware of their role in health care and preventing any possible complications that may affect the mother and her baby.
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Affiliation(s)
- Thelma Spindola
- University of the State of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
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29
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Ishola AG, Chipps J. The use of mobile phones to deliver acceptance and commitment therapy in the prevention of mother-child HIV transmission in Nigeria. J Telemed Telecare 2015; 21:423-6. [PMID: 26391511 DOI: 10.1177/1357633x15605408] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 08/20/2015] [Indexed: 11/15/2022]
Abstract
The objective of this study was to determine if introducing acceptance and commitment therapy in the prevention of mother to child HIV transmission (PMTCT) programme using weekly mobile phone messages would result in improved mental health status of HIV-positive, pregnant women in Nigeria. We used a Solomon four-group (two intervention and two control groups) randomised design. The study population was 144 randomly selected, HIV-positive pregnant women attending four randomly selected PMTCT centres in Nigeria. The intervention groups were exposed to one session of acceptance and commitment therapy with weekly value-based health messages sent by mobile phone for three months during pregnancy. The control groups received only post-HIV test counselling. A total of 132 participants (33 per site) were enrolled in the study from the two intervention and two control sites. In the pre-tests, the intervention and control groups did not differ significantly with regard to demographics. Evaluation of the pre- and post-tests of the intervention group indicated significantly higher Action and Acceptance Questionnaire (AAQ-II) scores. The introduction of a mobile phone acceptance and commitment therapy programme may result in greater psychological flexibility in women diagnosed with HIV.
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Affiliation(s)
- A G Ishola
- School of Nursing, University of the Western Cape, Cape Town, South Africa Department of Nursing, University of Ibadan, Nigeria
| | - J Chipps
- School of Nursing, University of the Western Cape, Cape Town, South Africa Sydney Nursing School, University of Sydney, Australia
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30
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Katz IT, Dietrich J, Tshabalala G, Essien T, Rough K, Wright AA, Bangsberg DR, Gray GE, Ware NC. Understanding treatment refusal among adults presenting for HIV-testing in Soweto, South Africa: a qualitative study. AIDS Behav 2015; 19:704-14. [PMID: 25304330 DOI: 10.1007/s10461-014-0920-y] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
HIV treatment initiatives have focused on increasing access to antiretroviral therapy (ART). There is growing evidence, however, that treatment availability alone is insufficient to stop the epidemic. In South Africa, only one third of individuals living with HIV are actually on treatment. Treatment refusal has been identified as a phenomenon among people who are asymptomatic, however, factors driving refusal remain poorly understood. We interviewed 50 purposively sampled participants who presented for voluntary counseling and testing in Soweto to elicit a broad range of detailed perspectives on ART refusal. We then integrated our core findings into an explanatory framework. Participants described feeling "too healthy" to start treatment, despite often having a diagnosis of AIDS. This subjective view of wellness was framed within the context of treatment being reserved for the sick. Taking ART could also lead to unintended disclosure and social isolation. These data provide a novel explanatory model of treatment refusal, recognizing perceived risks and social costs incurred when disclosing one's status through treatment initiation. Our findings suggest that improving engagement in care for people living with HIV in South Africa will require optimizing social integration and connectivity for those who test positive.
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31
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Ciaranello AL, Myer L, Kelly K, Christensen S, Daskilewicz K, Doherty K, Bekker LG, Hou T, Wood R, Francke JA, Wools-Kaloustian K, Freedberg KA, Walensky RP. Point-of-care CD4 testing to inform selection of antiretroviral medications in south african antenatal clinics: a cost-effectiveness analysis. PLoS One 2015; 10:e0117751. [PMID: 25756498 PMCID: PMC4355621 DOI: 10.1371/journal.pone.0117751] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 12/29/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Many prevention of mother-to-child HIV transmission (PMTCT) programs currently prioritize antiretroviral therapy (ART) for women with advanced HIV. Point-of-care (POC) CD4 assays may expedite the selection of three-drug ART instead of zidovudine, but are costlier than traditional laboratory assays. METHODS We used validated models of HIV infection to simulate pregnant, HIV-infected women (mean age 26 years, gestational age 26 weeks) in a general antenatal clinic in South Africa, and their infants. We examined two strategies for CD4 testing after HIV diagnosis: laboratory (test rate: 96%, result-return rate: 87%, cost: $14) and POC (test rate: 99%, result-return rate: 95%, cost: $26). We modeled South African PMTCT guidelines during the study period (WHO "Option A"): antenatal zidovudine (CD4 ≤350/μL) or ART (CD4>350/μL). Outcomes included MTCT risk at weaning (age 6 months), maternal and pediatric life expectancy (LE), maternal and pediatric lifetime healthcare costs (2013 USD), and cost-effectiveness ($/life-year saved). RESULTS In the base case, laboratory led to projected MTCT risks of 5.7%, undiscounted pediatric LE of 53.2 years, and undiscounted PMTCT plus pediatric lifetime costs of $1,070/infant. POC led to lower modeled MTCT risk (5.3%), greater pediatric LE (53.4 years) and lower PMTCT plus pediatric lifetime costs ($1,040/infant). Maternal outcomes following laboratory were similar to POC (LE: 21.2 years; lifetime costs: $23,860/person). Compared to laboratory, POC improved clinical outcomes and reduced healthcare costs. CONCLUSIONS In antenatal clinics implementing Option A, the higher initial cost of a one-time POC CD4 assay will be offset by cost-savings from prevention of pediatric HIV infection.
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Affiliation(s)
- Andrea L. Ciaranello
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- * E-mail: (ALC); (RPW)
| | - Landon Myer
- School of Public Health and Family Medicine, Division of Epidemiology and Biostatistics, University of Cape Town, Cape Town, South Africa
| | - Kathleen Kelly
- General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Sarah Christensen
- General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Kristen Daskilewicz
- School of Public Health and Family Medicine, Division of Epidemiology and Biostatistics, University of Cape Town, Cape Town, South Africa
| | - Katie Doherty
- General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Taige Hou
- General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Robin Wood
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Jordan A. Francke
- General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Kara Wools-Kaloustian
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Illinois, United States of America
| | - Kenneth A. Freedberg
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Rochelle P. Walensky
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America
- * E-mail: (ALC); (RPW)
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Tam M, Amzel A, Phelps BR. Disclosure of HIV serostatus among pregnant and postpartum women in sub-Saharan Africa: a systematic review. AIDS Care 2015; 27:436-50. [DOI: 10.1080/09540121.2014.997662] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Hodgson I, Plummer ML, Konopka SN, Colvin CJ, Jonas E, Albertini J, Amzel A, Fogg KP. A systematic review of individual and contextual factors affecting ART initiation, adherence, and retention for HIV-infected pregnant and postpartum women. PLoS One 2014; 9:e111421. [PMID: 25372479 PMCID: PMC4221025 DOI: 10.1371/journal.pone.0111421] [Citation(s) in RCA: 212] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 09/15/2014] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Despite progress reducing maternal mortality, HIV-related maternal deaths remain high, accounting, for example, for up to 24 percent of all pregnancy-related deaths in sub-Saharan Africa. Antiretroviral therapy (ART) is effective in improving outcomes among HIV-infected pregnant and postpartum women, yet rates of initiation, adherence, and retention remain low. This systematic literature review synthesized evidence about individual and contextual factors affecting ART use among HIV-infected pregnant and postpartum women. METHODS Searches were conducted for studies addressing the population (HIV-infected pregnant and postpartum women), intervention (ART), and outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. Individual and contextual enablers and barriers to ART use were extracted and organized thematically within a framework of individual, interpersonal, community, and structural categories. RESULTS Thirty-four studies were included in the review. Individual-level factors included both those within and outside a woman's awareness and control (e.g., commitment to child's health or age). Individual-level barriers included poor understanding of HIV, ART, and prevention of mother-to-child transmission, and difficulty managing practical demands of ART. At an interpersonal level, disclosure to a spouse and spousal involvement in treatment were associated with improved initiation, adherence, and retention. Fear of negative consequences was a barrier to disclosure. At a community level, stigma was a major barrier. Key structural barriers and enablers were related to health system use and engagement, including access to services and health worker attitudes. CONCLUSIONS To be successful, programs seeking to expand access to and continued use of ART by integrating maternal health and HIV services must identify and address the relevant barriers and enablers in their own context that are described in this review. Further research on this population, including those who drop out of or never access health services, is needed to inform effective implementation.
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Affiliation(s)
- Ian Hodgson
- Independent Consultant, Bingley, United Kingdom
| | | | - Sarah N. Konopka
- Center for Health Services, Management Sciences for Health, Arlington, Virginia, USA
| | - Christopher J. Colvin
- Centre for Infectious Disease Epidemiology and Research (CIDER), Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Edna Jonas
- Center for Health Services, Management Sciences for Health, Arlington, Virginia, USA
| | - Jennifer Albertini
- United States Agency for International Development (USAID)/Africa Bureau, Washington, D.C., USA
| | - Anouk Amzel
- USAID/Bureau for Global Health (BGH)/Office of HIV/AIDS, Washington, D.C., USA
| | - Karen P. Fogg
- USAID/BGH/Office of Health, Infectious Diseases, and Nutrition, Washington, D.C., USA
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Disengagement of HIV-positive pregnant and postpartum women from antiretroviral therapy services: a cohort study. J Int AIDS Soc 2014; 17:19242. [PMID: 25301494 PMCID: PMC4192834 DOI: 10.7448/ias.17.1.19242] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 08/25/2014] [Accepted: 09/02/2014] [Indexed: 12/05/2022] Open
Abstract
Introduction Recent international guidelines call for expanded access to triple-drug antiretroviral therapy (ART) in HIV-positive women during pregnancy and postpartum. However, high levels of non-adherence and/or disengagement from care may attenuate the benefits of ART for HIV transmission and maternal health. We examined the frequency and predictors of disengagement from care among women initiating ART during pregnancy in Cape Town, South Africa. Methods We used routine medical records to follow-up pregnant women initiating ART within prevention of mother-to-child transmission of HIV services in Cape Town, South Africa. Outcomes assessed through six months postpartum were (1) disengagement (no attendance within 56 days of a scheduled visit) and (2) missed visits (returning to care 14–56 days late for a scheduled visit). Results A total of 358 women (median age, 28 years; median gestational age, 26 weeks) initiated ART during pregnancy. By six months postpartum, 24% of women (n=86) had missed at least one visit and an additional 32% (n=115) had disengaged from care; together, 49% of women had either missed a visit or had disengaged by six months postpartum. Disengagement was more than twice as frequent postpartum compared to in the antenatal period (6.2 vs. 2.4 per 100 woman-months, respectively; p<0.0001). In a proportional hazards model, later gestational age at initiation (HR: 1.04; 95% CI: 1.00–1.07; p=0.030) and being newly diagnosed with HIV (HR: 1.57; 95% CI: 1.07–2.33; p=0.022) were significant predictors of disengagement after adjusting for patient age, starting CD4 cell count and site of ART initiation. Conclusions These results demonstrate that missed visits and disengagement from care occur frequently, particularly post-delivery, among HIV-positive women initiating ART during pregnancy. Women who are newly diagnosed with HIV may be particularly vulnerable and there is an urgent need for interventions both to promote retention overall, as well as targeting women newly diagnosed with HIV during pregnancy.
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Tweya H, Gugsa S, Hosseinipour M, Speight C, Ng'ambi W, Bokosi M, Chikonda J, Chauma A, Khomani P, Phoso M, Mtande T, Phiri S. Understanding factors, outcomes and reasons for loss to follow-up among women in Option B+ PMTCT programme in Lilongwe, Malawi. Trop Med Int Health 2014; 19:1360-6. [PMID: 25087778 DOI: 10.1111/tmi.12369] [Citation(s) in RCA: 142] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess factors, outcomes and reasons for loss to follow-up (LTFU) among pregnant and breastfeeding women initiated on a lifelong antiretroviral therapy (ART) for PMTCT in a large antenatal clinic in Malawi. METHODS We identified all pregnant and breastfeeding women who were initiated on ART between September 2011 and September 2013 and had missed their clinic appointment by at least 3 weeks at Bwaila Hospital, the largest antenatal clinic in Malawi. These women were traced by phone or home visits. Their true status and reasons for ART discontinuation were documented during tracing. RESULTS A total of 2930 women started ART for PMTCT; 2458 (84%) pregnant and 472 (16%) breastfeeding, of which, 577 (20%) missed a scheduled clinic appointment. LTFU was associated with younger age, being pregnant, and earlier year of ART initiation. We successfully traced 229 (40%), of whom, 10 (4%) had died. Of the 219 women found alive, 118 (54%) had stopped taking ARV drugs, 67 (30%) had self-transferred to another ART clinic, 13 (6%) had collected drugs from other sources, 9 (4%) had treatment interruptions and 12 (5%) had other outcomes. Reasons cited for stopping ART were travel (38%), lack of transport money (16%), not understanding the initial ARV education session (10%), being too weak/sick (10%), ARV side effects (10%) and other reasons. CONCLUSION Approximately half of the women who were traced were taking ARVs. The study emphasises the need for enhanced post-test counselling strategies, ongoing psychosocial support, provision of incentives and further decentralisation efforts of PMTCT services.
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Affiliation(s)
- Hannock Tweya
- The International Union Against Tuberculosis and Lung Disease, Paris, France; Lighthouse Trust, Lilongwe, Malawi; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Black S, Zulliger R, Marcus R, Mark D, Myer L, Bekker LG. Acceptability and challenges of rapid ART initiation among pregnant women in a pilot programme, Cape Town, South Africa. AIDS Care 2013; 26:736-41. [PMID: 24200029 DOI: 10.1080/09540121.2013.855300] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Maternal antiretroviral therapy (ART) is a critical intervention in the prevention-of-mother-to child transmission (PMTCT) of HIV. In South Africa, many HIV-infected pregnant women commence ART late in pregnancy, and as a result, the duration of ART prior to delivery is often insufficient to prevent vertical transmission. To address this, we designed an intervention for the rapid initiation of ART in pregnancy (RAP), where patient's ART preparation occurred during rather than before treatment commencement. Here we report on the acceptability and the challenges of the RAP programme. We conducted 7 key informant and 27 semi-structured interviews with RAP participants. Participants were purposefully selected based on ART-eligibility and stage in the pregnancy to post-partum continuum. Interviews were conducted in participants' home language by trained fieldworkers, with key informant interviews conducted by the study investigators. The data were analysed using a framework analysis approach. Rapid initiation in pregnancy was acceptable to the majority of programme participants and protection of the woman's unborn child was the primary motivation for starting treatment. The key barrier was the limited time to accept the dual challenges of being diagnosed HIV-positive and eligible for life-long ART. Truncated time also limited the opportunity for disclosure to others. Despite these and other barriers, most women found the benefits of rapid ART commencement outweighed the challenges, with 91% of women initiated onto ART starting the same day treatment eligibility was determined. Many participants and key informants identified the importance of counseling and the need to make an informed, independent choice on the timing of ART initiation, based on individual circumstances. Acceptance of ART-eligibility improved with time on the programme, however, as women's principal reason for initiating ART was protection of the unborn child, monitoring and supporting adherence during the post-partum period will be critical.
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Affiliation(s)
- Samantha Black
- a Desmond Tutu HIV Centre, Institute of Infectious Diseases & Molecular Medicine , University of Cape Town , Cape Town , South Africa
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Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review. J Int AIDS Soc 2013; 16:18588. [PMID: 23870277 PMCID: PMC3717402 DOI: 10.7448/ias.16.1.18588] [Citation(s) in RCA: 283] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 05/10/2013] [Accepted: 06/19/2013] [Indexed: 11/19/2022] Open
Abstract
Objectives To investigate and synthesize reasons for low access, initiation and adherence to antiretroviral drugs by mothers and exposed babies for prevention of mother-to-child transmission (PMTCT) of HIV in sub-Saharan Africa. Methods A systematic literature review was conducted. Four databases were searched (Medline, Embase, Global Health and Web of Science) for studies conducted in sub-Saharan Africa from January 2000 to September 2012. Quantitative and qualitative studies were included that met pre-defined criteria. Antiretroviral (ARV) prophylaxis (maternal/infant) and combination antiretroviral therapy (ART) usage/registration at HIV care and treatment during pregnancy were included as outcomes. Results Of 574 references identified, 40 met the inclusion criteria. Four references were added after searching reference lists of included articles. Twenty studies were quantitative, 16 were qualitative and eight were mixed methods. Forty-one studies were conducted in Southern and East Africa, two in West Africa, none in Central Africa and one was multi-regional. The majority (n=25) were conducted before combination ART for PMTCT was emphasized in 2006. At the individual-level, poor knowledge of HIV/ART/vertical transmission, lower maternal educational level and psychological issues following HIV diagnosis were the key barriers identified. Stigma and fear of status disclosure to partners, family or community members (community-level factors) were the most frequently cited barriers overall and across time. The extent of partner/community support was another major factor impeding or facilitating the uptake of PMTCT ARVs, while cultural traditions including preferences for traditional healers and birth attendants were also common. Key health-systems issues included poor staff-client interactions, staff shortages, service accessibility and non-facility deliveries. Conclusions Long-standing health-systems issues (such as staffing and service accessibility) and community-level factors (particularly stigma, fear of disclosure and lack of partner support) have not changed over time and continue to plague PMTCT programmes more than 10 years after their introduction. The potential of PMTCT programmes to virtually eliminate vertical transmission of HIV will remain elusive unless these barriers are tackled. The prominence of community-level factors in this review points to the importance of community-driven approaches to improve uptake of PMTCT interventions, although packages of solutions addressing barriers at different levels will be important.
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Stinson K, Jennings K, Myer L. Integration of antiretroviral therapy services into antenatal care increases treatment initiation during pregnancy: a cohort study. PLoS One 2013; 8:e63328. [PMID: 23696814 PMCID: PMC3656005 DOI: 10.1371/journal.pone.0063328] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 04/01/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Initiation of antiretroviral therapy (ART) during pregnancy is critical to promote maternal health and prevent mother-to-child HIV transmission (PMTCT). The separation of services for antenatal care (ANC) and ART may hinder antenatal ART initiation. We evaluated ART initiation during pregnancy under different service delivery models in Cape Town, South Africa. METHODS A retrospective cohort study was conducted using routinely collected clinic data. Three models for ART initiation in pregnancy were evaluated ART 'integrated' into ANC, ART located 'proximal' to ANC, and ART located some distance away from ANC ('distal'). Kaplan-Meier methods and Poisson regression were used to examine the association between service delivery model and antenatal ART initiation. RESULTS Among 14 617 women seeking antenatal care in the three services, 30% were HIV-infected and 17% were eligible for ART based on CD4 cell count <200 cells/µL. A higher proportion of women started ART antenatally in the integrated model compared to the proximal or distal models (55% vs 38% vs 45%, respectively, global p = 0.003). After adjusting for age and gestation at first ANC visit, women who at the integrated service were significantly more likely to initiate ART antenatally (rate ratio 1.33; 95% confidence interval: 1.09-1.64) compared to women attending the distal model; there was no difference between the proximal and distal models in antenatal ART initiation however (p = 0.704). CONCLUSIONS Integration of ART initiation into ANC is associated with higher levels of ART initiation in pregnancy. This and other forms of service integration may represent a valuable intervention to enhance PMTCT and maternal health.
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Affiliation(s)
- Kathryn Stinson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
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Myer L, Zulliger R, Bekker LG, Abrams E. Systemic delays in the initiation of antiretroviral therapy during pregnancy do not improve outcomes of HIV-positive mothers: a cohort study. BMC Pregnancy Childbirth 2012; 12:94. [PMID: 22963318 PMCID: PMC3490939 DOI: 10.1186/1471-2393-12-94] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 09/06/2012] [Indexed: 12/05/2022] Open
Abstract
Background Antiretroviral therapy (ART) initiation in eligible HIV-infected pregnant women is an important intervention to promote maternal and child health. Increasing the duration of ART received before delivery plays a major role in preventing vertical HIV transmission, but pregnant women across Africa experience significant delays in starting ART, partly due the perceived need to deliver ART counseling and patient education before ART initiation. We examined whether delaying ART to provide pre-ART counseling was associated with improved outcomes among HIV-infected women in Cape Town, South Africa. Methods We undertook a retrospective cohort study of 490 HIV-infected pregnant women referred to initiate treatment at an urban ART clinic. At this clinic all patients including pregnant women are screened by a clinician and then undergo three sessions of counseling and patient education prior to starting treatment, commonly introducing delays of 2–4 weeks before ART initiation. Data on viral suppression and retention in care after ART initiation were taken from routine clinic records. Results A total of 382 women initiated ART before delivery (78%); ART initiation before delivery was associated with earlier gestational age at presentation to the ART service (p < 0.001). The median delay between screening and ART initiation was 21 days (IQR, 14–29 days). Overall, 84.7%, 79.6% and 75.0% of women who were pregnant at the time of ART initiation were retained in care at 4, 8 and 12 months after ART initiation, respectively. Among those retained, 91% were virally suppressed at each follow-up visit. However the delay from screening to ART initiation was not associated with retention in care and/or viral suppression throughout the first year on ART in unadjusted or adjusted analyses. Conclusions A substantial proportion of eligible pregnant women referred for ART do not begin treatment before delivery in this setting. Among women who do initiate ART, delaying initiation for patient preparation is not associated with improved maternal outcomes. Given the need to maximize the duration of ART before delivery for prevention of mother-to-child HIV transmission, there is an urgent need for new strategies to help expedite ART initiation in eligible pregnant women.
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Affiliation(s)
- Landon Myer
- Centre for Infectious Diseases Epidemiologic Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa.
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