"I Found Out I was Pregnant, and I Started Feeling Stressed": A Longitudinal Qualitative Perspective of Mental Health Experiences Among Perinatal Women Living with HIV

Major Factors Contributing to Positive and Negative Childbirth Experiences in Pregnant Women Living with HIV

OBJECTIVE

The aim of this study was to assess the opinions of pregnant women living with HIV (PWLWHIV) about their positive childbirth experiences and the most important factors contributing to positive or negative experiences.

METHODS

A cross-sectional study was conducted with 82 PWLWHIV; semi-structured interviews were conducted in a public hospital in Rio de Janeiro.

RESULTS

A total of 65 (79.3%) PWLWHIV experienced a positive childbirth experience. Conversely, 14 (17.1%) PWLWHIV had a negative experience. The main reasons given by the PWLWHIV for positive experiences were the good health of the baby, their partner's presence at the childbirth, and good healthcare professional support. The main reasons for negative childbirth experiences were poor healthcare professional support, excessive pain or medication, and the absence of a companion during childbirth.

CONCLUSIONS

Our findings indicate that the health of the baby at birth was the main factor in positive childbirth experiences. On the other hand, poor healthcare professional support was the main cause of negative childbirth experiences. Increasing the incidence of positive childbirth experiences could reduce maternal depression and anxiety, and significantly impact neonatal outcomes (mainly low birth weights and preterm birth). Future studies should target reducing depressive symptoms in perinatal HIV-positive women, increasing partner involvement, and decreasing HIV stigma.

The Mental Health Effects and Experiences of Breastfeeding Decision-Making Among Postpartum Women Living with HIV

Prior to January 2023, women living with HIV (WLWH) in the United States (US) were discouraged from breastfeeding due to the potential risk of mother-to-child HIV transmission through breastfeeding. Lack of breastfeeding decision-making and experience among WLWH may negatively affect maternal mental health. We implemented a quality improvement initiative to screen WLWH for postpartum depression (PPD), evaluate their attitudes toward breastfeeding, and assess their experience with breastfeeding decision-making. We collected quantitative data from WLWH using a voluntary, self-administered 6-item breastfeeding decision-making and experience survey (administered 1 month postpartum) and a 10-item Edinburgh Postnatal Depression Scale (EPDS, negative = 0-9; administered 1 and 4 months postpartum) tool. We conducted descriptive statistics and cross tabulation analysis. We analyzed 106 WLWH (93.4% non-Hispanic Black/African American; mean age 33.1 years; 82.1% HIV RNA < 200 copies/mL). One in five (19.1%) WLWH had a positive baseline EPDS screen, with the mean EPDS scores decreasing from 5.3 ± 5.4 (baseline) to 4.6 ± 4.8 (follow-up). Among 55 WLWH who provided baseline and follow-up EPDS scores, only 3/13 with a positive baseline EPDS screen had resolved depressive symptoms at follow-up. Over one-third (37.7%) of WLWH indicated feeling "sadness" when asked whether lack of breastfeeding negatively affected their feelings or emotions. Over half of WLWH (51.9%) were aware of the US breastfeeding recommendations, but the majority (60.4%) had never discussed breastfeeding options with a medical provider. Improved provider-patient discussions on infant feeding options among WLWH is needed to increase awareness of breastfeeding choices and promote informed, autonomous breastfeeding decision-making among WLWH.

Understanding mother-to-child transmission of HIV among mothers engaged in HIV care in Kenya: a case report

BACKGROUND

Mother-to-child transmission of HIV, which may occur in utero, during birth, or through breastmilk, is now largely preventable with the advancement of HIV testing and treatment for women and their infants. Globally, great progress has been recorded over the years, with a 58% decline in new infections in children from 2010 to 2022. Currently, Kenya is among the countries with the highest rates of mother-to-child transmission of HIV despite consistent efforts to promote prevention of mother to child transmission strategies.

METHODS

This case report presents the experiences of a woman, engaged in HIV care in Kenya, whose baby contracted HIV. The data used to describe this case come from surveys, provider notes, health records, observational notes, notes from phone call consultations, and one in-depth interview. All data sources were carefully reviewed, compared and complied to describe the timeline of events and context of the participant's experience.

RESULTS

We found multiple factors which may have contributed to this case of mother-to-child transmission of HIV. Antenatal care was initiated late in pregnancy (during the third trimester), and as a result, HIV diagnosis and treatment also occurred late in pregnancy. In addition, a lack of coordination between the clinic providing antenatal care and HIV treatment, and the hospital providing labor and delivery services led to breastfeeding initiation prior to the administration of infant HIV prophylaxis medications. Finally, poor maternal adherence to HIV medications went undetected and unaddressed until it was revealed by routine viral load monitoring three months after initiating HIV treatment (more than two months postpartum).

CONCLUSIONS

Our case report shows the continued need for more intensive and integrated care for mothers living with HIV and their infants including support for pregnant women newly diagnosed with HIV, coordination of perinatal and HIV care, provisions for routine monitoring of HIV medication adherence, intensive follow-up care including point of care testing for HIV exposed infants and in person breastfeeding support. Our case report contributes an important perspective especially in light of the current UNAIDS Global AIDS Strategy which recently inspired the Global Alliance to end AIDS in Children.

Nurse-patient relationship and its implications for retention in the PMTCT of HIV programme in Ghana: an appreciative inquiry

BACKGROUND

Relationships established between nurses and midwives, and their patients have far-reaching implications; the most significant being their impact on the health-related outcomes of patients. These relationships are especially relevant in the Prevention of Mother-to-Child Transmission (PMTCT) of Human Immunodeficiency Virus (HIV) programme as women, diagnosed with HIV navigate the emotional and psychological effects of their diagnosis while carrying pregnancies. This study aimed to explore the relationships between nurses, midwives and mothers diagnosed with HIV and its impact on retention in the PMTCT Programme.

METHODS

An Appreciative Inquiry approach that employed qualitative research methods was conducted among twenty-four participants made up of 12 HIV positive mothers, and eight midwives and four community health nurses engaged in the PMTCT programme. Individual generative interviews were conducted among the mothers while paired interviews were conducted among the health professionals. Thematic analysis guided by Colaizzi's approach was conducted.

RESULTS

Three main themes emerged each with its subthemes. Under Establishing Rapport, two sub-themes emerged; making the connection and building trusting relationships. The second theme, Journeying Together, describes how the nurse-patient relationship evolved as the participant engaged in the programme; sub-themes include developing mutual goals, impactful communication, and showing commitment and building self-worth. The third theme; Ending the professional relationship details two sub-themes; continuity of care across the cascade, and termination of care which proved unsuccessful in some relationships due to blurring professional boundaries.

CONCLUSIONS

The nurse-patient relationship in the PMTCT programme evolved as the relationship progressed along the PMTCT cascade. Strengthening of the nurse-patient relationships was underscored by building trust through the maintenance of confidentiality, setting mutual goals, shared emotional experiences and personal stories, and building clients' self-worth. Therefore, there is a need to ensure that professional boundaries are set and maintained to reduce the occurrence of over-dependence of the clients and burnout of the nurses.

"It has changed my life": unconditional cash transfers and personalized infant feeding support- a feasibility intervention trial among women living with HIV in western Kenya

BACKGROUND

The syndemic effects of poverty, food insecurity and living with HIV are recognized as global health priorities, including through the United Nations Sustainability Goals 1, 2 and 3. Today, women and girls account for 63% of all new HIV infections in eastern and southern Africa, including Kenya. Pregnant and postpartum women living with HIV in this setting face unique challenges including increased financial insecurity as women leave the work force to care for their newborn infants. This contributes to poverty, food scarcity and stress.

METHODS

To address financial insecurity, improve infant feeding and reduce stress among mothers living with HIV in this setting, we developed a multilevel intervention, Supporting Healthy Mothers, consisting of 10 monthly unconditional cash transfers (10,000 KES, ~$75 USD/month) and personalized infant feeding support from pregnancy to 7 months postpartum. We conducted a non-randomized feasibility trial of this intervention among women engaged in HIV care in Kisumu, Kenya. From February 23, 2022 to March 23, 2022, we enrolled a total of 40 women who were 20-35 weeks pregnant-20 women to the intervention group at a public clinic, and 20 women to the control group at a similar clinic. Our aim was to assess feasibility, acceptability, and the potential impact of the intervention on food security, infant feeding and maternal mental health.

RESULTS

Analyzing data from all 40 participants, we found a significant reduction in food insecurity scores from baseline for the intervention group when compared to the control group at 6 weeks and 6 months postpartum (p = 0.0008 and p < 0.0001, respectively). Qualitative exit interviews with intervention group participants confirmed women felt more financially secure and had newly acquired practical knowledge and skills related to infant feeding. Women found the two intervention components highly acceptable and described an overall positive impact on wellbeing.

CONCLUSIONS

The Supporting Healthy Mothers intervention has potential to positively impact women across the perinatal period and beyond by increasing financial security and supporting women to overcome infant feeding challenges and should be assessed in larger trials.

TRIAL REGISTRATION

Supporting Healthy Mothers was registered with ClinicalTrials.gov Protocol Registration and Results System, initially published on February 1, 2022.

CLINICALTRIALS

gov ID: NCT05219552 Protocol ID: K23MH116807.

An Intervention to Improve Mental Health and HIV Care Engagement Among Perinatal Women in Malawi: A Pilot Randomized Controlled Trial

Perinatal depression (PND) is common and an important barrier to engagement in HIV care for women living with HIV (WLHIV). Accordingly, we adapted and enhanced The Friendship Bench, an evidence-based counseling intervention, for perinatal WLHIV. In a pilot randomized trial (NCT04143009), we evaluated the feasibility, acceptability, fidelity, and preliminary efficacy of the Enhanced Friendship Bench (EFB) intervention to improve PND and engagement in HIV care outcomes. Eighty pregnant WLHIV who screened positive for PND symptoms on the Self-Report Questionnaire (≥ 8) were enrolled, randomized 1:1 to EFB or usual care, and followed through 6 months postpartum. Overall, 100% of intervention participants were satisfied with the intervention and 93% found it beneficial to their overall health. Of 82 counseling sessions assessed for fidelity, 83% met or exceeded the fidelity threshold. At 6 months postpartum, intervention participants had improved depression remission (59% versus 36%, RD 23%, 95% CI 2%, 45%), retention in HIV care (82% versus 69%, RD 13%, -6%, 32%), and viral suppression (96% versus 90%, RD 7%, -7%, 20%) compared to usual care. Adverse events did not differ by arm. These results suggest that EFB intervention should be evaluated in a fully powered randomized trial to evaluate its efficacy to improve PND and engagement in HIV care outcomes for WLHIV.

Feasibility, acceptability and lessons learned from an infant feeding intervention trial among women living with HIV in western Kenya

BACKGROUND

The World Health Organization recommends mothers breastfeed exclusively for the first six months of their infant's life. However, women living with HIV in low resource settings face many barriers to recommended infant feeding practices such as fear of HIV transmission and perceived milk insufficiency. Moreover, current support for breastfeeding in this context is often insufficient to overcome these barriers. To support women's infant feeding experience, we tested a personalized infant feeding support program among perinatal women living with HIV in Kenya.

METHODS

Supporting Healthy Mothers is a theory and evidence-based multilevel intervention designed to address the mental health burden associated with financial and food insecurity and provide personalized support for optimal infant feeding postpartum. As part of the Supporting Healthy Mothers intervention feasibility trial, between February 23, 2022 and November 9, 2022, twenty mothers received five personalized infant feeding support sessions delivered by a local professional lactation specialist from pregnancy until three months postpartum. Through detailed observations of these sessions, clinical notes and repeated team discussions, we aimed to describe and provide a limited evaluation of these sessions. We identified the strengths and limitations of the lactation support sessions as well as areas for future development.

RESULTS

Participation in the sessions was high and at three months postpartum all participants reported exclusive breastfeeding as recommended despite experiencing a myriad of challenges. Having face-to-face and frequent early postpartum sessions, being available to field participant concerns between sessions and measuring infant weights at each session were key strengths. Continuing sessions beyond three months postpartum and incorporating family planning and general maternal health counseling topics would enhance these supportive sessions.

CONCLUSIONS

The personalized professional infant feeding support sessions were highly acceptable and feasible to implement. In-person sessions, in a clinic setting provided opportunities to evaluate and adjust breastfeeding technique and led to successful exclusive breastfeeding practice. Future interventions should consider integrating with other perinatal care services and offering support on demand and immediately postpartum.

TRIAL REGISTRATION

Supporting Healthy Mothers was registered with ClinicalTrials.gov Protocol Registration and Results System, posted on February 2, 2022. Identifiers: NCT05219552 Unique Protocol ID: K23MH116807.

Women want male partner engagement in antenatal care services: A qualitative study of pregnant women from rural South Africa

INTRODUCTION

Evidence strongly shows that a supportive, involved male partner facilitates maternal HIV testing during pregnancy, increases maternal antiretroviral (ART) adherence and increases HIV-free infant survival. Partner engagement in antenatal care (ANC) is influential; however, the most effective strategy to engage male partners is currently unknown. Engaging pregnant women to understand whether male partner involvement is welcome in ANC, what this involvement entails and how best to invite their partner is an important first step in determining how best to engage male partners.

METHODS

We interviewed 36 pregnant women receiving ANC services at a district hospital in rural Mpumalanga, South Africa to assess the strengths and weaknesses of their current relationship, the type of partner support they receive, whether they would like their male partner to be involved in their ANC, and how best to invite their male partner to their appointments. We conducted a thematic analysis of the qualitative interviews using MAXQDA software.

RESULTS

Financial, emotional, and physical support were noted as important aspects of support currently provided by male partners, with most pregnant women wanting their partners to engage in ANC services during pregnancy. Preferred engagement strategies included participation in couple-based HIV testing and counseling, regular ANC appointment attendance, and delivery room presence. Women who reported a positive relationship with her partner were more likely to prefer inviting their partner without health facility assistance, while those who reported challenges in their relationship preferred assistance through a letter or community health worker. Pregnant women perceived regular business hours (due to their partner being employed and unable to take off work) and having a partner involved in multiple relationships as barriers in getting their partner to attend ANC services.

DISCUSSION

Rural South African women, even those in unsatisfactory relationships want their male partners to attend their ANC visits and birth. To make this possible, health facilities will have to tailor male partner engagement outreach strategies to the preferences and needs of the pregnant woman.

Interventions to improve antiretroviral adherence in HIV-infected pregnant women: A systematic review and meta-analysis

Background

Medication adherence in HIV-infected pregnant women remains suboptimal. This systematic review and meta-analysis aimed to evaluate the effectiveness of interventions on improving antiretroviral adherence targeting among HIV-infected pregnant women.

Methods

Five databases were screened to identify quasi-experimental studies and randomized controlled trials. The risk ratios (RR) and confidential intervals (CI) were extracted to estimate the improvement in antiretroviral adherence after interventions compared with control conditions. This study was registered with PROSPERO, number CRD42021256317.

Results

Nine studies were included in the review, totaling 2,900 participants. Three interventions had significance: enhanced standard of care (eSOC, RR 1.14, 95%CI 1.07-1.22, Z = 3.79, P < 0.01), eSOC with supporter (RR 1.12, 95%CI 1.04-1.20, Z = 2.97, P < 0.01) and device reminder (RR 1.33, 95%CI 1.04-1.72, Z = 2.23, P = 0.03).

Discussion

The study supported the eSOC and the device reminder as effective intervention strategies for improving HIV medication adherence. Based on the current findings, the study called for more efforts to improve antiretroviral care for pregnant women through involving multicenter, large-sample, and high-quality research and combining the device reminder with other intervention methods.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021256317, identifier CRD42021256317.