Patterns and Predictors of HIV-Status Disclosure Among Pregnant Women in South Africa: Dimensions of Disclosure and Influence of Social and Economic Circumstances

Perceived and Enacted HIV-Related Stigma in Eastern and Southern Sierra Leone: A Psychometric Study of an HIV Stigma Scale

Background

HIV stigma continues to hinder the care of people with HIV (PWH), especially in low-resource settings. We aimed to adapt and validate a concise HIV stigma scale for perceived HIV stigma in Sierra Leone.

Methods

We enrolled participants in two HIV clinics in Eastern and Southern Sierra Leone in 2022. We assessed perceived stigma using a 12-item adaptation of Berger's HIV Stigma Scale and enacted stigma using select USAID indicators. We used ordinal logistic regression to identify predictors of perceived stigma and Pearson's correlation to examine associations between perceived and enacted stigma.

Results

624 PWH were enrolled. The final adapted 6-item HIV stigma scale demonstrated acceptable internal consistency (Cronbach's α = 0.72) and a four-factor solution accounting for 84.8% of variance: concern about public attitude (2 items), personalized stigma (2 items), negative self-image (1 item), and disclosure concerns (1 item). The prevalence of perceived HIV stigma was 68.6%, with disclosure concerns as the most prominent contributor. Enacted HIV stigma was reported by only 6.7% of participants, with partner/spousal abandonment and workplace stigma being the most common discriminatory experiences. Employment (β = 0.525, p <0.001), residence in Eastern Sierra Leone (β = 3.215, p < 0.001), and experiencing enacted stigma (β = 0.804, p < 0.001) were significantly associated with perceived stigma. Having a family member or friend with HIV (β = -0.499, p < 0.001), and HIV disclosure (β = -0.710, p < 0.001) were protective against perceived stigma. Enacted stigma strongly correlated with partner abandonment and family isolation (r = 0.223, p < 0.001).

Conclusion

We found high levels of perceived HIV stigma, underscoring the need for targeted interventions to combat stigma and promote inclusivity for PWH in Sierra Leone.

Determinants of social support among people living with HIV in Nigeria-a multicenter cross-sectional study

Background

More than 38.4 million people were living with HIV worldwide in 2021. Sub-Saharan Africa bears two-thirds of the burden, with Nigeria having nearly two million people living with HIV (PLWH). Social support from social networks such as family and friends improve the quality of life, and reduces enacted and perceived stigma, but social support for PLWH remains suboptimal in Nigeria. This study aimed to assess the prevalence of social support and associated factors among PLWH in Nigeria and to test whether stigma reduces types of social support.

Methods

This cross-sectional study was conducted in Lagos State, Nigeria, between the months of June and July 2021. A total of 400 PLWH were surveyed across six health facilities providing antiretroviral therapy. Social support (family, friends, and significant others) and stigma were measured with the Multidimensional Scale of Perceived Social Support and Berger's HIV Stigma Scale, respectively. Binary logistic regression was used to identify determinants of social support.

Results

More than half (50.3%) of the respondents had adequate social support overall. The prevalence of family, friends, and significant others support was 54.3, 50.5, and 54.8%, respectively. Stigma (Adjusted Odds Ratio [AOR]: 0.945; 95% Confidence Interval [CI]: 0.905-0.987) was negatively associated with adequate friend support. Female gender (AOR: 6.411; 95% CI: 1.089-37.742), higher income (AOR: 42.461; 95% CI: 1.452-1241.448), and seropositive disclosure (AOR: 0.028; 95% CI: 0.001-0.719) were associated with adequate significant others support. Stigma (AOR:0.932; 95% CI: 0.883-0.983) was negatively associated with adequate support overall. Our findings corroborate the social support theory, as stigma reduces the chance of receiving social support.

Conclusion

PLWH that enjoy support from families or friends were less likely to be affected by HIV-related stigma. More support is needed by PLWH from family, friends, and significant others to improve the quality of life and reduce stigma among PLWH in Lagos State.

Awareness of HIV serostatus by sex partners of women living with HIV in North-Central Nigeria: correlates and predictive analyses

Non-communication of HIV status among sex partners is a notable hurdle in halting transmission, largely due to socio-cultural factors. This study aimed to predict the determinants of male partners' awareness of women's serostatus. A total of 8825 women of reproductive age living with HIV who were clients at five comprehensive HIV treatment centres in Benue State, North-Central Nigeria were surveyed between June and December 2017, and 6655 reported having a sexual partner at the time of the survey selected for analysis. A regression model was used to estimate the determinants of male partner awareness of serostatus from the perspective of women. Conditional marginal analyses were conducted to evaluate the marginal effects of identified predictors on the probability of outcomes. Partners of married women were found to have greater odds of being aware of their spouse's serostatus (adjusted OR (aOR): 3.20; 95%CI: 2.13-4.81) than non-married partners. Similarly, the odds of male partner awareness increased with the years women had been on antiretroviral therapy (aOR: 1.13; 95%CI: 1.07-1.20). The probability of partners of married respondents being aware of their spouse's HIV serostatus was 97%. The conditional marginal effects of being educated to primary or higher level were 1.2 (95% CI: -0.2 to 2.7) and 1.8 (95% CI: 0.09-3.4) percentage points higher respectively when compared with women with no formal education. Being unemployed or being a trader significantly decreased the probability of partners being aware of respondents' serostatus when compared with farmers; conditional marginal effects of -6.7 (95% CI: -12.0 to -1.4) and -3.9 (95% CI: -5.7 to -2.2) percentage points, respectively. The study found that relationship status and girl-child education are factors that can improve communication of HIV status to sex partners. Policies and interventions aimed at improving the social determinants of health, and social support for healthy communications in relationships, are recommended to reduce HIV transmission between sex partners.

Perceived Stigma as a Contextual Barrier to Early Uptake of HIV Testing, Treatment Initiation, and Disclosure; the Case of Patients Admitted with AIDS-Related Illness in a Rural Hospital in South Africa

We explored the extent to which perceived HIV-related stigma influences the disclosure and concealment of HIV status to family among adult patients hospitalised for AIDS-related illness, and described reports of negative responses and enacted stigma following disclosure. We conducted interviews with a purposeful sample of 28 adult patients in a rural South African hospital. Data analysis was deductive and inductive and followed the thematic approach. We found evidence of delayed HIV diagnosis and initiation of treatment. There was delayed and selective disclosure as well as concealment of the HIV-positive status. The disclosure was delayed for months or even years. During that time, there was active concealment of the HIV status to avoid stigma from family, friends, and community. When disclosure occurred, there was selective disclosure to close family members who would keep the secret and respond favorably. Although the participants disclosed mostly to close family, some of their post-disclosure experiences included incidents of enacted stigma and discrimination. The fear of perceived stigma and self-stigma influenced the active concealment of their HIV status from others. Continuous concealment of one's HIV status and delayed disclosure limit the opportunities for support and care. There is a need to take into consideration the interaction between HIV-related stigma and disclosure to develop disclosure-counselling strategies in primary health care settings.

HIV Stigma and Status Disclosure in Three Municipalities in Ghana

Background

HIV-related stigma and HIV status disclosure are important elements in the continuous fight against HIV as these impact the prevention efforts and antiretroviral treatment adherence among people living with HIV/AIDS (PLWHA) in many communities.

Objectives

The objectives of the study were to examine the prevalence and experience of various types of HIV-related stigma and HIV status disclosure among PLWHA in Volta region.

Methods

A cross-sectional design was used to collect quantitative data from 301 PLWHA. Descriptive statistics were used to analyze and present data on socio-demographic variables. Correlation analysis was done to determine factors associated with HIV stigma and status disclosure while a Mann-Whitney U test was used to determine differences in internalized HIV stigma.

Findings

The mean age of the participants was 44.82 (SD: 12.22), 224 (74.4%) were female, and 90% attained at least primary education. A Pearson r analysis revealed that ethnicity (r[299] = 0.170, p = 0.003), religious affiliation (r[299] = -0.205, p = 0.001) and social support (r[299] = 0.142, p = 0.014) significantly predicted disclosure of HIV status. Fear of family rejection (62%) and shame (56%) were reasons for non-disclosure of HIV status. A Mann-Whitney's U-test revealed that females are more likely than males to internalize HIV stigma. Community-related HIV stigma in the form of gossip (56.1%), verbal harassment (30.9%), and physical harassment (8.6%) was reported.

Conclusion

A high rate of HIV status disclosure was found with social support, ethnicity, and religious affiliation being the associated factors. Internalized HIV stigma is prevalent among PLWHA while community-related stigma impacts HIV status disclosure. Strengthening social support systems and implementing culturally appropriate educational interventions may help in reducing community-related HIV stigma.

"This is My Life We are Talking About": Adaptive Strategies for HIV Care Retention and Treatment Adherence Among Postpartum Women Living with HIV in Cape Town, South Africa

INTRODUCTION

Retaining postpartum women living with HIV in ongoing care is critical for the health of the mother-child dyad but low adherence to antiretroviral therapy (ART) and retention in HIV care are a global concern. This issue is particularly salient in South Africa, where approximately 50% of women fall out of the care cascade by 6 months postpartum. The purpose of this secondary analysis is to understand the strategies that women use to navigate HIV care during the postpartum period.

METHODS

This study was conducted in Gugulethu, in Cape Town, South Africa. In-depth interviews were conducted with 21 study participants at 18-months postpartum. Participants were interviewed about their perceptions and experiences of their postpartum HIV care, and barriers and facilitators to their adherence and retention.

RESULTS

All participants reported using care navigation strategies across a spectrum of individual, interpersonal and structural levels to remain retained in care and adherent to ART. Participants expressed the importance of individual empowerment and knowledge of treatment benefits for their HIV care. Interpersonal relationships were discussed as a pathway to access both psychosocial and tangible support. Participants described overcoming structural barriers to care through creative problem solving and identified opportunities for care delivery improvement.

DISCUSSION

Participants described a wide range of overlapping and interconnected care navigation strategies. Consistent with the assets model, participants discussed their own capacity and that of their communities to engage in lifelong HIV care. Better understanding of potentially successful individual care navigation strategies should guide future intervention work.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01933477.

From "Secret" to "Sensitive Issue": Shifting Ideas About HIV Disclosure Among Middle-Aged and Older Rural South Africans in the Era of Antiretroviral Treatment

OBJECTIVE

As HIV shifts from "death sentence" to "chronic condition," disclosure of HIV status to intimate partners and family is a significant component of both prevention and treatment adherence. While disclosure is closely considered in many studies, few examine middle-aged and older persons' (age 40+) perspectives or practices. We trace older rural South Africans' views on HIV disclosure to their partners and family members in a high prevalence community over a period of extensive antiretroviral treatment (ART) rollout.

METHODS

Community focus group discussions (FGD) conducted in 2013 and 2018 show shifts in older persons' thinking about HIV disclosure.

FINDINGS

Our FGD participants saw fewer negative consequences of disclosure in 2018 than in 2013, and highlighted positive outcomes including building trust (partners) as well as greater support for medication collection and adherence (family).

DISCUSSION

Particularly as the epidemic ages in South Africa and globally, tracing changes in older persons' views on disclosure is an important step in developing messaging that could enhance treatment as prevention and ART adherence.

Barriers to and facilitators of HIV serostatus disclosure to sexual partners among postpartum women living with HIV in South Africa

Background

Disclosure of HIV serostatus to a sexual partner can facilitate partner’s support and testing and better treatment outcomes. Studies examining changes in disclosure rates of serostatus from delivery and postpartum periods are scarce. Our study fills this gap by using a follow-up survey of postpartum women with HIV to examine if disclosure prevalence has improved compared to the proportion recorded at childbirth. We further assessed the reasons for non-disclosure and correlates of serostatus disclosure to sexual partners.

Methods

We conducted a cross-sectional analytical study (exit interview) with a final sample of 485 postpartum women with HIV drawn from the East London Prospective Cohort study database between January and May 2018. Disclosure of HIV status to partner was based on self-reporting. We fitted adjusted and unadjusted logistic regression models and also conducted descriptive statistical analyses. Sampling weights were used to correct for sampling errors.

Results

Overall, 81.8% of women in the study cohort had disclosed their status to their partners, representing a 7.4 percentage point increase since child delivery. After adjusting for important covariates, women were more likely to disclose their status if they were married [adjusted odds ratio (AOR): 3.10; 95% confidence interval (CI):1.39–6.91] but were less likely to disclose if they used alcohol [AOR: 0.61; 95% CI:0.37–0.99] or had reported adherence to ART [AOR: 0.59; 95% CI:0.36–0.96]. Fear of rejection, stigma or being judged, new or casual relationships, and having a violent partner were the main reasons for not disclosing HIV status to sexual partners.

Conclusion

We found a relatively higher rate of HIV status disclosure in the cohort compared to the rate recorded at childbirth, suggesting an improvement over time. Also, complicated relationship dynamics and fear of social exclusion still constitute barriers to HIV status disclosure to sexual partners despite patients’ counselling.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10955-x.

Understanding the determinants and consequences of HIV status disclosure in Manicaland, Zimbabwe: cross-sectional and prospective analyses

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.

Correlates of HIV Status Nondisclosure by Pregnant Women Living With HIV to Their Male Partners in Uganda: A Cross-Sectional Study

BACKGROUND

HIV status disclosure by pregnant women living with HIV (PWLHIV) to their male partners is associated with improved maternal and infant outcomes. Understanding relationship factors associated with nondisclosure of HIV status by PWLHIV to their partners can inform the design of interventions to facilitate disclosure.

METHODS

We conducted a cross-sectional study using enrollment data from 500 PWLHIV unaware of their male partners' HIV status and participating in a randomized clinical trial assessing secondary distribution of HIV self-testing kits in Kampala, Uganda. The primary outcome was women's HIV status nondisclosure to their partners. We conducted univariate and multivariate binomial regressions to assess the association between baseline sociodemographic, HIV history, and relationship characteristics with HIV status nondisclosure.

RESULTS

68.2% of the 500 PWLHIV had not disclosed their HIV status to their partner(s). Factors associated with higher likelihood of nondisclosure included relationship duration <1 year [adjusted prevalence ratio (aPR = 1.25); 95% confidence interval (CI): 1.02 to 1.54], being in a polygamous relationship (aPR = 1.21; 95% CI: 1.07 to 1.36), unmarried (aPR = 1.20; 95% CI: 1.07 to 1.35), uncertainty about whether their partner had ever tested for HIV (aPR = 1.55; 95% CI: 1.28 to 1.88), and a lack of social support from people aware of their status (aPR = 1.32; 95% CI: 1.18 to 1.49).

CONCLUSION

Relationship factors, including shorter-term, unmarried, and polygamous relationships and uncertainty about partner's HIV testing history, were associated with higher likelihood of pregnant women's nondisclosure of HIV status to their partner. Interventions that facilitate couples' HIV testing and disclosure, provide counseling to reduce relationship dissolution in serodiscordant couples, and offer peer support for women may increase disclosure.

CLINICALTRIALSREGISTRATION

Clinicaltrials.gov ID number: NCT03484533.

HIV serostatus disclosure and associated factors among HIV positive pregnant and lactating women at Nekemte public health facilities, western Ethiopia

BACKGROUND

Disclosure of Human Immune Virus (HIV) serostatus by pregnant and lactating women is crucial for the successful prevention of mother to child transmission of HIV/AIDS. However, little has been studied regarding the prevalence and factors associated with HIV status disclosure among HIV positive pregnant and lactating women in Ethiopia.

METHODS

An institution-based cross-sectional study was conducted in the Nekemte Public Health facilities among 380 pregnant and lactating women enrolled in universal antiretroviral therapy (ART) treatment from January 2015-December, 2019. The data were collected by using a checklist, developed from Prevention of Mother to Child Transmission (PMTCT) logbook, ART intake forms, and medical cards of the patients. Epidata version 3.2 was used for data entry, and then the data were exported to STATA version 14 for further analysis. The binary logistic regression model was employed to determine factors associated with the disclosure status among HIV positive pregnant and lactating women. Adjusted Odds Ratio (AOR) with 95% confidence intervals was computed and statistical significance was declared when it is significant at a 5% level (p-value < 0.05).

RESULTS

A total of 380 women have participated in the study. Two hundred seventy-six (73.4%) of women had disclosed their HIV status to at least one individual. The study found living in urban (OR = 1.83, 95% CI: 1.04, 3.20), married women (OR = 4.16, 95% CI: 1.87, 9.24), higher educational status (OR = 2.35, 95% CI: 1.31, 5.51), positive HIV status of partner (OR = 2.35, 95%CI: 1.17, 4.70), and being multipara (OR = 4.94, 95% CI: 2.29, 10.66) were independent determinants of HIV status disclosure.

CONCLUSIONS

HIV status disclosure among pregnant and lactating women in the study area was sub-optimal. Empowering women through education, encouraging partners for HIV testing, and enhancing active male involvement in HIV treatment and control programs should get due attention.

Approaches to transitioning women into and out of prevention of mother-to-child transmission of HIV services for continued ART: a systematic review

INTRODUCTION

Women living with HIV are required to transition into the prevention of mother-to-child transmission of HIV (PMTCT) services when they become pregnant and back to ART services after delivery. Transition can be a vulnerable time when many women are lost from HIV care yet there is little guidance on the optimal transition approaches to ensure continuity of care. We reviewed the available evidence on existing approaches to transitioning women into and out of PMTCT, outcomes following transition and factors influencing successful transition.

METHODS

We searched PubMed and SCOPUS, as well as abstracts from international HIV-focused meetings, from January 2006 to July 2020. Studies were included that examined three points of transition: pregnant women already on ART into PMTCT (transition 1), pregnant women living with HIV not yet on ART into treatment services (transition 2) and postpartum women from PMTCT into general ART services after delivery (transition 3). Results were grouped and reported as descriptions of transition approach, comparison of outcomes following transition and factors influencing successful transition.

RESULTS & DISCUSSION

Out of 1809 abstracts located, 36 studies (39 papers) were included in this review. Three studies included transition 1, 26 transition 2 and 17 transition 3. Approaches to transition were described in 26 studies and could be grouped into the provision of information at the point of transition (n = 8), strengthened communication or linkage of data between services (n = 4), use of transition navigators (n = 12), and combination approaches (n = 4). Few studies were designed to directly assess transition and only nine compared outcomes between transition approaches, with substantial heterogeneity in study design, setting and outcomes. Four themes were identified in 25 studies reporting on factors influencing successful transition: fear, knowledge and preparedness, clinic characteristics and the transition requirements and process.

CONCLUSIONS

This review highlights that, despite the need for women to transition into and out of PMTCT services for continued ART in many settings, there is very limited evidence on optimal transition approaches. Ongoing operational research is required to identify sustainable and acceptable transition approaches and service delivery models that support continuity of HIV care during and after pregnancy.

HIV Status Disclosure and Sexual Transmission Risks Among People Who Are Living With HIV and Receiving Treatment for Non-HIV Sexually Transmitted Infections, Cape Town, South Africa

BACKGROUND

HIV status disclosure to sex partners potentially reduces the risk of sexually transmitting HIV. However, there is limited information on the associations between HIV status disclosure in types of sexual partnerships and ensuing sexual practices.

METHODS

We examined HIV status disclosure to sex partners among 205 men and women living with HIV and receiving diagnostic and treatment services for a co-occurring sexually transmitted infection (STI) in Cape Town, South Africa. Participants completed partner-by-partner sexual behavior interviews and provided permission to extract recurrent STI clinic visits over the subsequent 12 months.

RESULTS

Three groups were formed on the basis of HIV status disclosure to sex partners: (1) 22% reported only HIV same-status partners, (2) 26% had HIV-negative or unknown HIV status (HIV different status) sex partners to whom they had disclosed their HIV status, and (3) 52% had at least one HIV different-status partner to whom they had not disclosed. There were no associations between HIV status disclosure and demographic characteristics, sexual practices, or recurrent STI clinic visits. Undisclosed HIV status to at least one HIV different-status sex partner was associated with greater alcohol use and less likelihood of receiving antiretroviral therapy; participants who were least likely to disclose their HIV status to partners drank more alcohol and were less likely to be taking antiretroviral therapy.

CONCLUSIONS

High prevalence of partner nondisclosure and lack of significant correlates to HIV status disclosure indicate a need for further research with an eye toward identifying disclosure processes and mechanisms that may ultimately lead to effective interventions.

Individual Social Capital and the HIV Continuum of Care in a Rural Setting of the Southeast United States

Social capital is associated with the health of people living with HIV, and yet few studies have examined social capital in relation to the HIV continuum of care in the United States. The current study assessed individual social capital within social networks of 251 people living with HIV and residing in a rural area of the southeastern United States. Participants completed computerized self-administered measures that included markers of social capital and disclosure of HIV status to network members. We estimated individual social capital for each relationship identified in the social network interviews and tested regression models at three points along the HIV continuum of care: receiving ART, ART adherence, and HIV viral suppression. Results indicated that one in four participants had not disclosed their HIV status to at least one member of their social network and disclosure was not associated with social capital. Regression models showed that participants with larger social networks and less social capital were more likely to be receiving ART and more likely to have HIV suppressed viral loads. Alcohol use, not social capital, was related to ART non-adherence. Participant's depressive symptomatology was unrelated to any HIV care continuum metrics assessed in this study. We conclude that social capital is drawn upon at critical points along the HIV continuum of care. Interventions should focus on building social capital within social networks and provide support to key network members when patients are transitioning into care, initiating ART and experiencing HIV unsuppressed viral loads.

Impact of HIV-Status Disclosure on HIV Viral Load in Pregnant and Postpartum Women on Antiretroviral Therapy

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.

HIV viral suppression among pregnant and breastfeeding women in routine care in the Kinshasa province: a baseline evaluation of participants in CQI-PMTCT study

INTRODUCTION

Published data on viral suppression among pregnant and breastfeeding women in routine care settings are scarce. Here, we report provincial estimates of undetectable and suppressed viral load among pregnant or breastfeeding women in HIV care in Kinshasa, Democratic Republic of Congo (DRC) and associated risk factors.

METHODS

This cross-sectional study was conducted as part of a baseline assessment for the CQI-PMTCT study: an ongoing cluster randomized trial to evaluate the effect of continuous quality interventions (CQI) on long-term ART outcomes among pregnant and breastfeeding women (NCT03048669). From November 2016 to June 2018, in each of the 35 Kinshasa provincial health zones (HZ), study teams visited the three busiest maternal and child health clinics, enrolled all HIV-positive pregnant or breastfeeding women (≤1 year post-delivery) receiving ART, and performed viral load testing. Log binomial models with generalized estimating equations to account for clustering at the HZ level, were used to estimate prevalence ratios comparing participants with undetected (<40 copies/mL) or suppressed (<1000 copies/mL) viral load across levels of individual and site characteristics.

RESULTS

Of the 1752 eligible women, 1623 had viral load results available, including 38% who had been on ART for <6 months and 74% were on tenofovir-lamivudine-efavirenz. Viral load was undetectable in 53% of women and suppressed in 62%. Among women who were on ART for ≥12 months, only 60% and 67% respectively, had undetectable or suppressed viral load. Viral load was undetectable in 53%, 48% and 58% of women testing during pregnancy, at delivery, and in postpartum respectively. In multivariable log binomial models, duration of ART >12 months, older age, being married, disclosure of HIV status, receiving care in an urban health zone or one supported by PEPFAR were all positively associated with viral suppression.

CONCLUSIONS

The observed high level of detectable viral load suggests that high ART coverage alone without substantial efforts to improve the quality of care for pregnant and breastfeeding women, will not be enough to achieve the goal of virtual elimination of vertical HIV transmission in high-burden and limited resources settings like DRC.

HIV-status disclosure and depression in the context of unintended pregnancy among South African women

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.