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Burke RM, Rickman HM, Pinto C, Ehrenkranz P, Choko A, Ford N. Reasons for disengagement from antiretroviral care in the era of "Treat All" in low- or middle-income countries: a systematic review. J Int AIDS Soc 2024; 27:e26230. [PMID: 38494657 PMCID: PMC10945039 DOI: 10.1002/jia2.26230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 02/23/2024] [Indexed: 03/19/2024] Open
Abstract
INTRODUCTION Disengagement from antiretroviral therapy (ART) care is an important reason why people living with HIV do not achieve viral load suppression become unwell. METHODS We searched two databases and conference abstracts from January 2015 to December 2022 for studies which reported reasons for disengagement from ART care. We included quantitative (mainly surveys) and qualitative (in-depth interviews or focus groups) studies conducted after "treat all" or "Option B+" policy adoption. We used an inductive approach to categorize reasons: we report how often reasons were reported in studies and developed a conceptual framework for reasons. RESULTS We identified 21 studies which reported reasons for disengaging from ART care in the "Treat All" era, mostly in African countries: six studies in the general population of persons living with HIV, nine in pregnant or postpartum women and six in selected populations (one each in people who use drugs, isolated indigenous communities, men, women, adolescents and men who have sex with men). Reasons reported were: side effects or other antiretroviral tablet issues (15 studies); lack of perceived benefit of ART (13 studies); psychological, mental health or drug use (13 studies); concerns about stigma or confidentiality (14 studies); lack of social or family support (12 studies); socio-economic reasons (16 studies); health facility-related reasons (11 studies); and acute proximal events such as unexpected mobility (12 studies). The most common reasons for disengagement were unexpected events, socio-economic reasons, ART side effects or lack of perceived benefit of ART. Conceptually, studies described underlying vulnerability factors (individual, interpersonal, structural and healthcare) but that often unexpected proximal events (e.g. unanticipated mobility) acted as the trigger for disengagement to occur. DISCUSSION People disengage from ART care for individual, interpersonal, structural and healthcare reasons, and these reasons overlap and interact with each other. While HIV programmes cannot predict and address all events that may lead to disengagement, an approach that recognizes that such shocks will happen could help. CONCLUSIONS Health services should focus on ways to encourage clients to engage with care by making ART services welcoming, person-centred and more flexible alongside offering adherence interventions, such as counselling and peer support.
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Affiliation(s)
- Rachael M. Burke
- Clinical Research DepartmentLondon School of Hygiene and Tropical MedicineLondonUK
- Malawi Liverpool Wellcome Clinical Research ProgrammeQueen Elizabeth Central HospitalBlantyreMalawi
| | - Hannah M. Rickman
- Clinical Research DepartmentLondon School of Hygiene and Tropical MedicineLondonUK
- Malawi Liverpool Wellcome Clinical Research ProgrammeQueen Elizabeth Central HospitalBlantyreMalawi
| | - Clarice Pinto
- Global HIV, Hepatitis and STIs ProgrammeWorld Health OrganisationGenevaSwitzerland
| | - Peter Ehrenkranz
- Global Health, Bill & Melinda Gates FoundationSeattleWashingtonUSA
| | - Augustine Choko
- Malawi Liverpool Wellcome Clinical Research ProgrammeQueen Elizabeth Central HospitalBlantyreMalawi
- International Public Health DepartmentLiverpool School of Tropical MedicineLiverpoolUK
| | - Nathan Ford
- Global HIV, Hepatitis and STIs ProgrammeWorld Health OrganisationGenevaSwitzerland
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
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Anderson K, Kalk E, Heekes A, Phelanyane F, Jacob N, Boulle A, Mehta U, Kassanjee R, Sridhar G, Ragone L, Vannappagari V, Davies M. Factors associated with vertical transmission of HIV in the Western Cape, South Africa: a retrospective cohort analysis. J Int AIDS Soc 2024; 27:e26235. [PMID: 38528395 PMCID: PMC10963590 DOI: 10.1002/jia2.26235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 03/07/2024] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION Monitoring mother-infant pairs with HIV exposure is needed to assess the effectiveness of vertical transmission (VT) prevention programmes and progress towards VT elimination. METHODS We used routinely collected data on infants with HIV exposure, born May 2018-April 2021 in the Western Cape, South Africa, with follow-up through mid-2022. We assessed the proportion of infants diagnosed with HIV at birth (≤7 days), 10 weeks (>1 to 14 weeks) and >14 weeks as proxies for intrauterine, intrapartum/early breastfeeding and late breastfeeding transmission, respectively. We used mixed-effects Poisson regression to assess factors associated with VT in mothers known with HIV by delivery. RESULTS We included 50,461 infants born to mothers known with HIV by delivery. HIV was diagnosed in 894 (1.8%) infants. Among mothers, 51% started antiretroviral treatment (ART) before and 27% during pregnancy; 17% restarted during pregnancy after ≥6 months interruption; and 6% had no recorded ART during pregnancy. Most pregnancy ART regimens included non-nucleoside reverse transcriptase inhibitors (83%). Of mothers with available results (90% with viral load [VL]; 70% with CD4), VL nearest delivery was <100 copies/ml in 78% and CD4 count ≥350 cells/μl in 62%. HIV-PCR results were available for 86%, 67% and 48% of eligible infants at birth, 10 weeks and >14 weeks. Among these infants, 0.9%, 0.4% and 1.5% were diagnosed positive at birth, 10 weeks and >14 weeks, respectively. Among infants diagnosed with HIV, 43%, 16% and 41% were diagnosed at these respective time periods. Among mothers with VL<100, 100-999, 1000-99,000 and ≥100,000 copies/ml nearest delivery, infant HIV diagnosis incidence was 0.4%, 2.3%, 6.6% and 18.4%, respectively. Increased VT was strongly associated with recent elevated maternal VL with a seven-fold increased rate with even modestly elevated VL (100-999 vs. <100 copies/ml). VT was also associated with unknown/low maternal CD4, maternal age <20 years, no antenatal ART, later maternal ART start/restart in pregnancy and ART gaps. CONCLUSIONS Despite high maternal ART coverage and routine postnatal prophylaxis, ongoing VT remains a concern. Timing of infant HIV diagnoses suggests intrapartum and/or breastfeeding transmission in nearly 60%. Interventions to ensure retention on ART and sustained maternal viral suppression are needed to reduce VT.
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Affiliation(s)
- Kim Anderson
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Emma Kalk
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Alexa Heekes
- Health Intelligence, Western Cape Department of HealthCape TownSouth Africa
| | | | - Nisha Jacob
- Division of Public Health MedicineSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
- Health Intelligence, Western Cape Department of HealthCape TownSouth Africa
- Division of Public Health MedicineSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Ushma Mehta
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Reshma Kassanjee
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | | | | | - Vani Vannappagari
- ViiV HealthcareDurhamNorth CarolinaUSA
- Department of EpidemiologyGilling School of Public HealthUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Mary‐Ann Davies
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
- Health Intelligence, Western Cape Department of HealthCape TownSouth Africa
- Division of Public Health MedicineSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
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Bengtson AM, Filipowicz TR, Mphonda S, Udedi M, Kulisewa K, Meltzer-Brody S, Gaynes BN, Go VF, Chibanda D, Verhey R, Hosseinipour MC, Pence BW. An Intervention to Improve Mental Health and HIV Care Engagement Among Perinatal Women in Malawi: A Pilot Randomized Controlled Trial. AIDS Behav 2023; 27:3559-3570. [PMID: 37084104 PMCID: PMC10119837 DOI: 10.1007/s10461-023-04070-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 04/22/2023]
Abstract
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.
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Affiliation(s)
- Angela M Bengtson
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA.
| | - Teresa R Filipowicz
- Department of Epidemiology, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | | | - Michael Udedi
- Mental Health Unit, Malawi Ministry of Health, Lilongwe, Malawi
| | - Kazione Kulisewa
- Department of Psychiatry and Mental Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Samantha Meltzer-Brody
- Department of Psychiatry, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Bradley N Gaynes
- Department of Epidemiology, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
- Department of Psychiatry, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Vivian F Go
- Department of Health Behavior, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Dixon Chibanda
- Department of Psychiatry & Research Support Centre, University of Zimbabwe, Harare, Zimbabwe
| | | | - Mina C Hosseinipour
- UNC Project Malawi, Lilongwe, Malawi
- Division of Infectious Diseases, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Brian Wells Pence
- Department of Epidemiology, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
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Yang L, Cambou MC, Nielsen-Saines K. The End Is in Sight: Current Strategies for the Elimination of HIV Vertical Transmission. Curr HIV/AIDS Rep 2023; 20:121-130. [PMID: 36971951 DOI: 10.1007/s11904-023-00655-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE OF REVIEW The goal of this review is to highlight and interpret recent trends and developments in the diagnosis, treatment, and prevention of HIV vertical transmission from a clinical perspective. RECENT FINDINGS Universal third-trimester retesting and partner testing may better identify incident HIV among pregnant patients and result in early initiation of antiretroviral therapy to prevent vertical transmission. The proven safety and efficacy of integrase inhibitors such as dolutegravir may be particularly useful in suppressing viremia in pregnant persons who present late for ART treatment. Pre-exposure prophylaxis (PrEP) during pregnancy may play a role in preventing HIV acquisition; however, its role in preventing vertical transmission is difficult to elucidate. Substantial progress has been made in recent years to eliminate HIV perinatal transmission. Future research hinges upon a multipronged approach to improving HIV detection, risk-stratified treatment strategies, and prevention of primary HIV infection among pregnant persons.
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Affiliation(s)
- Lanbo Yang
- Warren Alpert Medical School, Brown University, 222 Richmond Street, Providence, RI, 02903, USA.
| | - Mary Catherine Cambou
- Division of Infectious Diseases, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Karin Nielsen-Saines
- Division of Pediatric Infectious Diseases, Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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Vertical HIV transmission within 18 months post partum among women on lifelong antiretroviral therapy for HIV in Dar es Salaam, Tanzania: a prospective cohort study. Lancet HIV 2023; 10:e33-e41. [PMID: 36495896 DOI: 10.1016/s2352-3018(22)00289-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The UNAIDS estimate of vertical HIV transmission in Tanzania is high (11%), despite 84% uptake of antiretroviral therapy (ART) among pregnant women with HIV. We aimed to evaluate vertical transmission and its determinants by 18 months post partum among women on lifelong ART in routine health-care settings in Tanzania. METHODS We conducted a prospective cohort study in 226 health facitilies across Dar-es-Salaam, Tanzania. Eligible participants were pregnant women of any age with HIV, and later their infants, who enrolled in routine health-care services for the prevention of vertical transmission. We prospectively followed up mother-infant pairs at routine monthly visits until 18 months post partum and extracted data from the care and treatment clinic (CTC2) database, a national electronic database that stores patient-level HIV care and treatment clinic data. The primary outcome was time from birth to HIV diagnosis, defined as a positive infant HIV DNA PCR or antibody test from age 18 months. We used the Kaplan-Meier method to estimate cumulative risk of vertical transmission by 18 months post partum and Cox proportional hazards regression with shared frailties to account for potential clustering in health facilities to evaluate predictors of transmission. FINDINGS Between Jan 1, 2015, and Dec 31, 2017, 22 930 pregnant women with HIV (median age 30 years, IQR 25-34) enrolled on a care programme. After excluding 9140 (39·9%) women and 539 (2·4%) infants with missing outcome data, 13 251 (59·0%) mother-infant pairs were analysed, of whom 6072 (45·8%) women were already on ART before pregnancy. By 18 months post partum, 159 (1·2%) of 13 251 infants were diagnosed with HIV, equivalent to a risk of vertical transmission of 1·4% (95% CI 1·2-1·6). In the complete case analysis, the rates of vertical transmission were higher among women who enrolled in the third trimester of pregnancy than among those who enrolled in the first trimester (adjusted hazard ratio 3·01, 95% CI 1·59-5·70; p=0·0003), among women with advanced HIV disease than among those with early-stage disease (1·89, 1·22-2·93; p=0·0046), and among women who were on a second-line ART regimen than among those on a first-line regimen (3·58, 1·08-11·82; p=0·037). By contrast, the rate of vertical transmission was lower among women who were already on ART at enrolment than among those starting ART at enrolment (0·39, 0·25-0·60; p<0·0001) as well as among women in high-volume clinics than among those in low-volume clinics (0·46 (0·24-0·90; p<0·0097). INTERPRETATION Provision of ART for life (WHO's option B+ recommendation) has reduced the risk of vertical transmission to less than 2% among pregnant women with HIV in routine care settings in urban Tanzania. There is still a need to improve timely HIV diagnosis and ART uptake, and to optimise follow-up for the prevention of vertical transmission and the uptake of infant HIV testing. FUNDING Swedish International Development Cooperation Agency.
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Edwards JK, Donastorg Y, Zadrozny S, Hileman S, Gómez H, Seamans MJ, Herce ME, Ramírez E, Barrington C, Weir S. A Two-stage Approach for Rapid Assessment of the Proportion Achieving Viral Suppression Using Routine Clinical Data. Epidemiology 2022; 33:642-649. [PMID: 35648416 PMCID: PMC9378579 DOI: 10.1097/ede.0000000000001513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Improving viral suppression among people with HIV reduces morbidity, mortality, and transmission. Accordingly, monitoring the proportion of patients with a suppressed viral load is important to optimizing HIV care and treatment programs. But viral load data are often incomplete in clinical records. We illustrate a two-stage approach to estimate the proportion of treated people with HIV who have a suppressed viral load in the Dominican Republic. METHODS Routinely collected data on viral load and patient characteristics were recorded in a national database, but 74% of patients on treatment at the time of the study did not have a recent viral load measurement. We recruited a subset of these patients for a rapid assessment that obtained additional viral load measurements. We combined results from the rapid assessment and main database using a two-stage weighting approach and compared results to estimates obtained using standard approaches to account for missing data. RESULTS Of patients with recent routinely collected viral load data, 60% had a suppressed viral load. Results were similar after applying standard approaches to account for missing data. Using the two-stage approach, we estimated that 77% (95% confidence interval [CI] = 74, 80) of those on treatment had a suppressed viral load. CONCLUSIONS When assessing the proportion of people on treatment with a suppressed viral load using routinely collected data, applying standard approaches to handle missing data may be inadequate. In these settings, augmenting routinely collected data with data collected through sampling-based approaches could allow more accurate and efficient monitoring of HIV treatment program effectiveness.
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Affiliation(s)
- Jessie K. Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Yeycy Donastorg
- Instituto Dermatológico y Cirugia de Piel, Santo Domingo, Dominican Republic
| | - Sabrina Zadrozny
- Frank Porter Graham Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Hoisex Gómez
- Instituto Dermatológico y Cirugia de Piel, Santo Domingo, Dominican Republic
| | | | - Michael E. Herce
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Edwin Ramírez
- Servicio Nacional de Salud, Santo Domingo, Dominican Republic
| | - Clare Barrington
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sharon Weir
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Taha TE, Yende-Zuma N, Brummel SS, Stranix-Chibanda L, Wambuzi Ogwang L, Dadabhai S, Chinula L, Nyati MM, Hanley S, Makanani B, Chipato T, Atuhaire P, Aizire J, Fowler MG. Effects of long-term antiretroviral therapy in reproductive-age women in sub-Saharan Africa (the PEPFAR PROMOTE study): a multi-country observational cohort study. Lancet HIV 2022; 9:e394-e403. [PMID: 35489365 PMCID: PMC9639003 DOI: 10.1016/s2352-3018(22)00037-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 02/05/2022] [Accepted: 02/09/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND We report the long-term impact of ART in women of reproductive age (15-49 years) in Africa who have been using ART for up to 10 years. We assess outcomes of retention, adherence, maternal health, fertility intentions, and safety. METHODS This longitudinal, multicountry study (PROMOTE) enrolled women who initiated ART in an earlier perinatal clinical trial, PROMISE. PROMISE occurred from 2011 to 2016 and PROMOTE follow-up started in 2016 and is ongoing. The PROMOTE study was done at eight sites in four countries: Malawi (Blantyre and Lilongwe), South Africa (Durban and Soweto), Uganda (Kampala), and Zimbabwe (Harare, Seke North, and St Mary's). After baseline enrolment, women and their children are followed up every 6 months to collect information on medical history, antiretroviral therapy (ART) use, adherence, and health information, and to do physical examinations and laboratory tests. Obesity was defined as a body-mass index of 30 kg/m2 or more. Data analyses were restricted to summaries of the main long-term outcomes (retention, adherence, maternal health, fertility intentions, and safety). We used descriptive and stratified analyses, and estimated rates using person-years of follow-up and computed probabilities based on Kaplan-Meier methods. FINDINGS PROMOTE enrolled 1987 mothers and 2522 children. The median follow-up time for mothers was 41·8 (IQR 35·8-42·0) months and for children was 35·7 (23·8-42·0) months. Overall retention rates were 96·5% for mothers and 94·3% for children at 12 months, and, at 42 months, were 88·9% for mothers and 85·4% for children. 1115 (89·1%) of 1252 women had an undetectable viral load at 42 months, which varied by site (81·7-93·8%). Reported maternal health improved over time, with the proportion of women with excellent to very good health increasing from 67·5% at baseline to 87·5% at 42 months, the proportion of unwell participants who visited a health centre declining from 14·7% to 2·8%, and the proportion of those admitted to hospital declining from 1·5% to 1·0%. The desire to have more children was consistently high at some sites. The proportion of women with obesity was high in South Africa and increased over time from 40·2% at baseline to 52·8% at 42 months. The overall pregnancy rate was 17·6 (95% CI 16·5-18·7) per 100 women-years, and mortality rates were 2·4 (1·4-3·9) per 1000 person-years for mothers and 3·4 (2·2-5·10) per 1000 person-years for children (0-9 years). INTERPRETATION The findings from this multicountry study are reassuring. These findings show that African women can consistently use ART for a long period after initiation, and long-term benefits can be maintained. Services to support maternal HIV care, treatment, and reproductive health should be strengthened. FUNDING US President's Emergency Plan for AIDS Relief.
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Affiliation(s)
- Taha E Taha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; SAMRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Sean S Brummel
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Lynda Stranix-Chibanda
- Clinical Trials Research Centre, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | | | - Sufia Dadabhai
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Lameck Chinula
- University of North Carolina Project, Lilongwe, Malawi; Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - Mandisa M Nyati
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Sherika Hanley
- Centre for the AIDS Programme of Research in South Africa, Umlazi Clinical Research Site, University of KwaZulu-Natal, Durban, South Africa
| | - Bonus Makanani
- Department of Obstetrics and Gynecology, University of Malawi College of Medicine, Blantyre, Malawi
| | - Tsungai Chipato
- Clinical Trials Research Centre, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Patience Atuhaire
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Jim Aizire
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Mary Glenn Fowler
- Department of Pathology, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Lyatuu GW, Naburi H, Mwashemele S, Lyaruu P, Urrio R, Simba B, Philipo E, Kibao A, Kajoka D, Sando D, Orsini N, Biberfeld G, Kilewo C, Ekström AM. Effect of peer-mother interactive programme on prevention of mother-to-child HIV transmission outcomes among pregnant women on anti-retroviral treatment in routine healthcare in Dar es Salaam, Tanzania. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000256. [PMID: 36962367 PMCID: PMC10021914 DOI: 10.1371/journal.pgph.0000256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/13/2022] [Indexed: 11/18/2022]
Abstract
Peer support services are increasingly being integrated in programmes for the prevention of mother-to-child HIV transmission (PMTCT). We aimed to evaluate the effect of a peer-mother interactive programme on PMTCT outcomes among pregnant women on anti-retroviral treatment (ART) in routine healthcare in Dar es Salaam, Tanzania. Twenty-three health facilities were cluster-randomized to a peer-mother intervention and 24 to a control arm. We trained 92 ART experienced women with HIV to offer peer education, adherence and psychosocial support to women enrolling in PMTCT care at the intervention facilities. All pregnant women who enrolled in PMTCT care at the 47 facilities from 1st January 2018 to 31st December 2019 were identified and followed up to 31st July 2021. The primary outcome was time to ART attrition (no show >90 days since the scheduled appointment, excluding transfers) and any difference in one-year retention in PMTCT and ART care between intervention and control facilities. Secondary outcomes were maternal viral suppression (<400 viral copies/mL) and mother-to-child HIV transmission (MTCT) by ≥12 months post-partum. Analyses were done using Kaplan Meier and Cox regression (ART retention/attrition), generalized estimating equations (viral suppression) and random effects logistic regression (MTCT); reporting rates, proportions and 95% confidence intervals (CI). There were 1957 women in the peer-mother and 1384 in the control facilities who enrolled in routine PMTCT care during 2018-2019 and were followed for a median [interquartile range (IQR)] of 23 [10, 31] months. Women in both groups had similar median age of 30 [IQR 25, 35] years, but differed slightly with regard to proportions in the third pregnancy trimester (14% versus 19%); advanced HIV (22% versus 27%); and ART naïve (55% versus 47%). Peer-mother facilities had a significantly lower attrition rate per 1000 person months (95%CI) of 14 (13, 16) versus 18 (16, 19) and significantly higher one-year ART retention (95%CI) of 78% (76, 80) versus 74% (71, 76) in un-adjusted analyses, however in adjusted analyses the effect size was not statistically significant [adjusted hazard ratio of attrition (95%CI) = 0.85 (0.67, 1.08)]. Viral suppression (95%CI) was similar in both groups [92% (91, 93) versus 91% (90, 92)], but significantly higher among ART naïve women in peer-mother [91% (89, 92)] versus control [88% (86, 90)] facilities. MTCT (95%CI) was similar in both groups [2.2% (1.4, 3.4) versus 1.5% (0.7, 2.8)]. In conclusion, we learned that integration of peer-mother services in routine PMTCT care improved ART retention among all women and viral suppression among ART naïve women but had no significant influence on MTCT.
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Affiliation(s)
- Goodluck Willey Lyatuu
- Management and Development for Health, Dar es Salaam, Tanzania
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Helga Naburi
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Shally Mwashemele
- Health Section, United Nations Children's Fund, Dar es Salaam, Tanzania
| | - Peter Lyaruu
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Roseline Urrio
- Management and Development for Health, Dar es Salaam, Tanzania
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Brenda Simba
- Management and Development for Health, Dar es Salaam, Tanzania
| | | | - Ayoub Kibao
- Department of Health and Social Welfare, Regional Administrative Secretary, Dar es Salaam, Tanzania
| | - Deborah Kajoka
- Department of Preventive Services, Tanzania Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - David Sando
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Nicola Orsini
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Gunnel Biberfeld
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Charles Kilewo
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Phillips TK, Myer L, Chi BH. All the viral loads we cannot see. Lancet HIV 2021; 8:e246-e247. [PMID: 33581777 DOI: 10.1016/s2352-3018(20)30336-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Tamsin K Phillips
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, 7925, South Africa.
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, 7925, South Africa
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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