A risk score to identify HIV-infected women most likely to become lost to follow-up in the postpartum period

Predictors and social determinants of HIV treatment engagement among post-partum Black women living with HIV in southeastern United States

AIM

Guided by Mcleroy's socio-ecological model, this study explored the predictors and social determinants of HIV treatment engagement among Black post-partum women living with HIV.

METHOD

Quantitative, research methodology.

DESIGN

We conducted a retrospective, secondary data analysis of 143 Black post-partum women living with HIV who received peripartum care in South-Florida, United States, from 2009 to 2017. We examined odds of immediate post-partum engagement at 3 months post-partum, and ongoing primary care engagement at 12 months post-partum.

RESULTS

The independent group analyses showed low levels of immediate post-partum (32.9%) and ongoing primary care engagement (24.5%). At the intrapersonal level, maternal prenatal health significantly affected both immediate post-partum and ongoing primary care engagement; and at the interpersonal level, HIV disclosure and intimate partner violence/abuse significantly affected immediate post-partum engagement. Also, immediate post-partum disengagement was a significant predictor for ongoing primary care disengagement.

CONCLUSION

This study provides timely and critical information to address recent calls for awareness and interventions to address issues on health disparities and inequities among racialized communities.

IMPACT

The study provides significant evidence on the effects of social determinants of health on health outcomes for Black women living with HIV. Critical understanding and assessment of these factors, together with proper, proactive interventions may help to gauge such negative effects. Healthcare providers taking care of Black women living with HIV ought to be cognizant of these factors, assess at-risk women and intervene accordingly to ensure that their care is not marginalized.

PATIENT/PUBLIC CONTRIBUTION

This study includes direct patient data from Black post-partum women living with HIV who were seen at prenatal and post-partum clinics wherein data for this study were obtained. The study results were presented locally, nationally and internationally to communities, organizations of healthcare providers, stakeholders and service-users, who further corroborated our findings, and provided insights and future recommendations.

Factors Associated with Retention of HIV Patients on Antiretroviral Therapy in Care: Evidence from Outpatient Clinics in Two Provinces of the Democratic Republic of the Congo (DRC)

Interruptions in the continuum of care for HIV can inadvertently increase a patient’s risk of poor health outcomes such as uncontrolled viral load and a greater likelihood of developing drug resistance. Retention of people living with HIV (PLHIV) in care and determinants of attrition, such as adherence to treatment, are among the most critical links strengthening the continuum of care, reducing the risk of treatment failure, and assuring viral load suppression. Objective: To analyze the variation in, and factors associated with, retention of patients enrolled in HIV services at outpatient clinics in the provinces of Kinshasa and Haut-Katanga, Democratic Republic of the Congo (DRC). Methods: Data for the last visit of 51,286 patients enrolled in Centers for Disease Control (CDC)-supported outpatient HIV clinics in 18 health zones in Haut-Katanga and Kinshasa, DRC were extracted in June 2020. Chi-square tests and multivariable logistic regressions were performed. Results: The results showed a retention rate of 78.2%. Most patients were classified to be at WHO clinical stage 1 (42.1%), the asymptomatic stage, and only 3.2% were at stage 4, the severest stage of AIDS. Odds of retention were significantly higher for patients at WHO clinical stage 1 compared to stage 4 (adjusted odds ratio (AOR), 1.325; confidence interval (CI), 1.13−1.55), women as opposed to men (AOR, 2.00; CI, 1.63−2.44), and women who were not pregnant (vs. pregnant women) at the start of antiretroviral therapy (ART) (AOR, 2.80; CI, 2.04−3.85). Odds of retention were significantly lower for patients who received a one-month supply rather than multiple months (AOR, 0.22; CI, 0.20−0.23), and for patients in urban health zones (AOR, 0.75; CI, 0.59−0.94) rather than rural. Compared to patients 55 years of age or older, the odds of retention were significantly lower for patients younger than 15 (AOR, 0.35; CI, 0.30−0.42), and those aged 15 and <55 (AOR, 0.75; CI, 0.68−0.82). Conclusions: Significant variations exist in the retention of patients in HIV care by patient characteristics. There is evidence of strong associations of many patient characteristics with retention in care, including clinical, demographic, and other contextual variables that may be beneficial for improvements in HIV services in DRC.

Improving identification of symptomatic cancer at primary care clinics: A predictive modeling analysis in Botswana

In resource-limited settings, augmenting primary care provider (PCP)-based referrals with data-derived algorithms could direct scarce resources towards those patients most likely to have a cancer diagnosis and benefit from early treatment. Using data from Botswana, we compared accuracy of predictions of probable cancer using different approaches for identifying symptomatic cancer at primary clinics. We followed cancer suspects until they entered specialized care for cancer treatment (following pathologically confirmed diagnosis), exited from the study following noncancer diagnosis, or died. Routine symptom and demographic data included baseline cancer probability assessed by the primary care provider (low, intermediate, high), age, sex, performance status, baseline cancer probability by study physician, predominant symptom (lump, bleeding, pain or other) and HIV status. Logistic regression with 10-fold cross-validation was used to evaluate classification by different sets of predictors: (1) PCPs, (2) Algorithm-only, (3) External specialist physician review and (4) Primary clinician augmented by algorithm. Classification accuracy was assessed using c-statistics, sensitivity and specificity. Six hundred and twenty-three adult cancer suspects with complete data were retained, of whom 166 (27%) were diagnosed with cancer. Models using PCP augmented by algorithm (c-statistic: 77.2%, 95% CI: 73.4%, 81.0%) and external study physician assessment (77.6%, 95% CI: 73.6%, 81.7%) performed better than algorithm-only (74.9%, 95% CI: 71.0%, 78.9%) and PCP initial assessment (62.8%, 95% CI: 57.9%, 67.7%) in correctly classifying suspected cancer patients. Sensitivity and specificity statistics from models combining PCP classifications and routine data were comparable to physicians, suggesting that incorporating data-driven algorithms into referral systems could improve efficiency.

Models of service delivery for optimizing a patient's first six months on antiretroviral therapy for HIV: an applied research agenda

Differentiated models of service delivery (DSD models) for HIV treatment in sub-Saharan Africa were conceived as a way to manage rapidly expanding populations of experienced patients who are clinically "stable" on antiretroviral therapy (ART). Entry requirements for most models include at least six months on treatment and a suppressed viral load. These models thus systematically exclude newly-initiated patients, who instead experience the conventional model of care, which requires frequent, multiple clinic visits that impose costs on both providers and patients. In this open letter, we argue that the conventional model of care for the first six months on ART is no longer adequate. The highest rates of treatment discontinuation are in the first six-month period after treatment initiation. Newly initiating patients are generally healthier than in the past, with higher CD4 counts, and antiretroviral medications are better tolerated, with fewer side effects and substitutions, making extra clinic visits unnecessary. Improvements in the treatment initiation process, such as same-day initiation, have not been followed by innovations in the early treatment period. Finally, the advent of COVID-19 has made it riskier to require multiple clinic visits. Research to develop differentiated models of care for the first six-month period is needed. Priorities include estimating the minimum number and type of provider interactions and ART education needed, optimizing the timing of a patient's first viral load test, determining when lay providers can replace clinicians, ensuring that patients have sufficient but not burdensome access to support, and identifying ways to establish a habit of lifelong adherence.

Risk factors for loss to follow-up from antiretroviral therapy programmes in low-income and middle-income countries

INTRODUCTION

Loss to follow-up (LTFU) rates from antiretroviral treatment (ART) programmes in low- and middle-income countries (LMIC) are high, leading to poor treatment outcomes and onward transmission of HIV. Knowledge of risk factors is required to address LTFU. In this systematic review, risk factors for LTFU are identified and meta-analyses performed.

METHODS

PubMed, Embase, Psycinfo and Cochrane were searched for studies that report on potential risk factors for LTFU in adults who initiated ART in LMICs. Meta-analysis was performed for risk factors evaluated by at least five studies. Pooled effect estimates and their 95% confidence intervals (95% CI) were calculated using random effect models with inverse variance weights. Risk of bias was assessed and sensitivity analyses performed.

RESULTS

Eighty studies were included describing a total of 1 605 320 patients of which 87.4% from sub-Saharan Africa. The following determinants were significantly associated with an increased risk of LTFU in meta-analysis: male sex, older age, being single, unemployment, lower educational status, advanced WHO stage, low weight, worse functional status, poor adherence, nondisclosure, not receiving cotrimoxazole prophylactic therapy when indicated, receiving care at secondary level and more recent year of initiation. No association was seen for CD4 cell count, tuberculosis at baseline, regimen, and geographical setting.

CONCLUSION

There are several sociodemographic, clinical, patient behaviour, treatment-related and system level risk factors for LTFU from ART programs. Knowledge of risk factors should be used to better target retention interventions and develop tools to identify high-risk patients.

Supporting choices about HIV disclosure in the workplace: A cross-Canada survey of strategies

BACKGROUND:

People living with human immunodeficiency virus (HIV) often make highly personal decisions about whether or not to disclose their HIV status in the workplace.

OBJECTIVE:

We aimed to determine current practices that support people living with HIV to make workplace disclosure decisions and to understand factors that affect disclosure decision-making.

METHODS:

Ninety-four people who provide health, social and peer-based services responded to an on-line survey about their experiences supporting workplace disclosure decisions of employees living with HIV.

RESULTS:

Respondents identified a range of strategies to support workplace disclosure decision-making. One-third of respondents were only a little or not confident in their abilities to support people in making disclosure decisions and 32% expressed little or no confidence in the resources available. Respondents working at HIV-specific organizations, as compared to respondents not working at those organizations, were more confident supporting people with disclosure decisions and in available resources, p < .05. Perceived barriers to disclosure decisions included stigma, lack of knowledge, and personal factors. Supports for decision-making resided within personal, workplace and societal contexts.

CONCLUSIONS:

The study provides important understanding about the complexity of disclosure decision-making and strategies that people living with HIV can use to address this complex issue.

Developing a triage tool for use in identifying people living with HIV who are at risk for non-retention in HIV care

Introduction:

Identifying PLHIV in HIV care who are at particular risk of non-retention in care is an important element in improving their HIV care outcomes. The purpose of this study was to develop a risk prediction tool to identify PLHIV at risk of non-retention in care over the course of the next year.

Method:

We used stepwise logistic regression to assess sociodemographic, clinical and behavioral predictors of non-retention in HIV care. Retention in care was defined as having evidence of at least two encounters with an HIV care provider (or CD4 or viral load lab tests as a proxy measure for the encounter), at least 3 months apart within a year. We validated the risk prediction tool internally using the bootstrap method.

Results:

The risk prediction tool included a total of six factors: age group, race, poverty level, homelessness, problematic alcohol/drug use and viral suppression status. The total risk score ranged from 0 to 17. Compared to those in the lowest quartile (0 risk score), those who were in the middle two quartiles (score 1–4) and those in the upper quartile (>4 risk score) were more likely not to be retained in care (odds ratio [OR] 1.63 [CI; 1.39–1.92] and OR 4.82 [CI; 4.04–5.78] respectively). The discrimination ability for the prediction model was 0.651.

Conclusion:

We found that increased risk for non-retention in care can be predicted with routinely available variables. Since the discrimination of the tool was low, future studies may need to include more prognostic factors in the risk prediction tool.

Trends in post-partum viral load among women living with perinatal HIV infection in the USA: a prospective cohort study

BACKGROUND

Small studies reported poor post-partum outcomes among young women living with perinatal HIV infection who are now ageing into adulthood and becoming pregnant. For targeted clinical intervention, we sought to identify women in this population at risk of poor post-partum virological control.

METHODS

We abstracted data on pregnancy history for women living with perinatal HIV infection in the Pediatric HIV/AIDS Cohort Study-AMP Up protocol, a prospective study of young adults living with perinatal HIV from 14 sites in the USA. Linear models with generalised estimating equations described trends in HIV viral load through 1 year post-pregnancy by pregnancy outcome. We used group-based trajectory modelling to identify viral load trajectory groups in the first post-partum year after livebirths. We then compared sociodemographic and clinical factors across identified groups. We defined viraemia as 400 copies per mL or more.

FINDINGS

Between April 15, 2014, and Oct 1, 2017, we enrolled 323 women, of whom 234 had perinatal HIV infection, and reported age at sexual debut and history of heterosexual vaginal intercourse. Of the 172 pregnancies recorded in these women, 147 (85%, 104 livebirths and 43 spontaneous or elective abortions) were eligible for post-pregnancy viral load trajectory analyses (ie, had at least two viral loads in the year after end of pregnancy). Viral load increased by 0·7 log₁₀ copies per mL (95% CI 0·5 to 1·0) in the first 12 weeks post partum after 104 livebirths, and subsequently stabilised from 13 weeks to 1 year post partum (slope -0·01 log₁₀ copies per mL, 95% CI -0·3 to 0·3). By comparison, the average viral load trajectory after 43 spontaneous or elective abortions remained at less than 400 copies per mL. We identified three distinct groups of viral load trajectories after 104 livebirths, classified as reflecting sustained suppression (31 [30%]), rebound viraemia (55 [53%]), and persistent viraemia (18 [17%]). Women with sustained post-partum suppression were older at conception (22·9 years, IQR 19·4-25·9) than those with rebound viraemia (20·4 years, 18·8-22·2), or persistent post-partum viraemia (19·0 years, 17·7-20·5). Pre-conception viraemia and immune suppression were also strong risk factors for post-partum viraemia.

INTERPRETATION

Despite success achieving viral load suppression during pregnancy, women living with perinatal HIV infection have a high risk of post-partum viraemia. Younger age at conception, pre-conception viraemia, and pre-conception immune suppression could identify women in this population most likely to benefit from post-partum adherence interventions.

FUNDING

National Institutes of Health.

Breastfeeding with HIV: An Evidence-Based Case for New Policy

To help eliminate perinatal HIV transmission, the US Department of Health and Human Services recommends against breastfeeding for women living with HIV, regardless of viral load or combined antiretroviral therapy (cART) status. However, cART radically improves HIV prognosis and virtually eliminates perinatal transmission, and breastfeeding's health benefits are well-established. In this setting, pregnancy is increasing among American women with HIV, and a harm reduction approach to those who breastfeed despite extensive counseling is suggested. We assess the evidence and ethical justification for current policy, with attention to pertinent racial and health disparities. We first review perinatal transmission and breastfeeding data relevant to US infants. We compare hypothetical risk of HIV transmission from breastmilk to increased mortality from sudden infant death syndrome, necrotizing enterocolitis and sepsis from avoiding breastfeeding, finding that benefits may outweigh risks if mothers maintain undetectable viral load on cART. We then review maternal health considerations. We conclude that avoidance of breastfeeding by women living with HIV may not maximize health outcomes and discuss our recommendation for revising national guidelines in light of autonomy, harm reduction and health inequities.

Factors affecting linkage to HIV care and ART initiation following referral for ART by a mobile health clinic in South Africa: evidence from a multimethod study

Linkage to care from mobile clinics is often poor and inadequately understood. This multimethod study assessed linkage to care and antiretroviral therapy (ART) uptake following ART-referral by a mobile clinic in Cape Town (2015/2016). Clinic record data (N = 86) indicated that 67% linked to care (i.e., attended a clinic) and 42% initiated ART within 3 months. Linkage to care was positively associated with HIV-status disclosure intentions (aOR: 2.99, 95% CI 1.13-7.91), and treatment readiness (aOR: 2.97, 95% CI 1.05-8.34); and negatively with good health (aOR: 0.35, 95% CI 0.13-0.99), weekly alcohol consumption (aOR: 0.35, 95% CI 0.12-0.98), and internalised stigma (aOR: 0.32, 95% CI 0.11-0.91). Following linkage, perceived stigma negatively affected ART-initiation. In-depth interviews (N = 41) elucidated fears about ART side-effects, HIV-status denial, and food insecurity as barriers to ART initiation; while awareness of positive ART-effects, follow-up telephone counselling, familial responsibilities, and maintaining health to avoid involuntary disclosure were motivating factors. Results indicate that an array of interventions are required to encourage rapid ART-initiation following mobile clinic HIV-testing services.

Predicting death and lost to follow-up among adults initiating antiretroviral therapy in resource-limited settings: Derivation and external validation of a risk score in Haiti

Background

Over 18 million adults have initiated life-saving antiretroviral therapy (ART) in resource-poor settings; however, mortality and lost-to-follow-up rates continue to be high among patients in their first year after treatment start. Clinical decision tools are needed to identify patients at high risk for poor outcomes in order to provide individualized risk assessment and intervention. This study aimed to develop and externally validate risk prediction tools that estimate the probability of dying or of being lost to follow-up (LTF) during the year after starting ART.

Methods

We used a derivation cohort of 7,031 adults age 15–70 years initiating ART from 2007 to 2013 at 6 clinics in Haiti; 242 (3.5%) had documented death and 1,521 (21.6%) were LTF at 1 year after starting ART. The following routinely collected data were used as predictors in two logistic regression models (one to predict death and another to predict LTF): age, gender, weight, CD4 count, WHO Stage, and diagnosis of tuberculosis (TB). The validation cohort consisted of 1,835 adults initiating ART at a different HIV clinic in Haiti during 2012. We assessed model discrimination by measuring the C-statistic, and measured model calibration by how closely the predicted probabilities approximated actual probabilities of the two outcomes. We derived a nomogram and a point-based risk score from the predictive models.

Findings

The model predicting death within the year after starting ART had a C-statistic of 0.75 (95% CI 0.74 to 0.81). There was no evidence for significant overfitting and the predictions were well calibrated. The strongest predictors of 1-year mortality were male gender, low weight, low CD4 count, advanced WHO stage, and the absence of TB. In the validation cohort, the C-statistic was 0.69 (95% CI 0.59 to 0.77). A point-based risk score for death had a C-statistic 0.73 (95% CI 0.69 to 0.76) and categorizes patients as low risk (<2% risk of death), average risk (3–4%), and high-risk (8–10%) and very high-risk (14–19%) with likelihood ratios to be used in settings where the baseline risk is different from our study population. The model predicting LTF did not discriminate well (C-statistic 0.59).

Conclusions

A simple risk-score using routinely collected data can predict 1-year mortality after ART initiation for HIV-positive adults in Haiti. However, predicting lost to follow-up using routinely collected data was not as successful. The next step is to assess whether use of this risk score can identify patients who need tailored services to reduce mortality in resource-poor settings such as Haiti.

Linkage to care, mobility and retention of HIV-positive postpartum women in antiretroviral therapy services in South Africa

INTRODUCTION

Linkage to care and mobility postpartum present challenges to long-term retention after initiating antiretroviral therapy (ART) in pregnancy, but there are few insights from sub-Saharan Africa. We aimed to describe postpartum linkage to care, mobility, retention and viral suppression after ART initiation in pregnancy.

METHODS

Using routine electronic data we assessed HIV-specific health contacts and clinic movements among women initiating ART in an integrated antenatal care (ANC) and ART clinic in Cape Town, South Africa. The local care model includes mandatory transfer to general ART clinics postpartum. We investigated linkage to care after leaving the integrated clinic and mobility to new clinics until 30 months on ART. We used Poisson regression to explore predictors of linkage, retention (accessing care at least once at both 12 [6 to <18] and 24 [18 to <30] months on ART), and viral suppression (HIV viral load [VL] ≤50 and ≤1000 copies/mL after 12 months on ART).

RESULTS

Among 617 women, 23% never linked to care; 71% and 65% were retained at 12 and 24 months on ART respectively, with 59% retained in care at both times. Those who linked (n = 485) accessed HIV care at 98 different clinics and 21% attended ≥2 clinics. Women >25 years, married/cohabiting or presenting early for ANC were more likely to link. Younger and unemployed women were more likely to attend ≥2 clinics (adjusted risk ratio [aRR] 1.10 95% confidence interval [CI] 1.02 to 1.18 and aRR 1.06 95% CI 0.99 to 1.12 respectively). Age >25 years (aRR 1.17 95% CI 1.02 to 1.33) and planned pregnancy (aRR 1.20 95% CI 1.09 to 1.33) were associated with being retained. Among 338 retained women with VL available, attending ≥2 clinics reduced the likelihood of viral suppression when defined as ≤50 copies/mL (aRR 0.81 95% CI 0.69 to 0.95). Distance moved was not associated with VL.

CONCLUSIONS

These data show that a substantial proportion of women do not link to postpartum ART care in this setting and, among those that do, long-term retention remains a challenge. Women move to a variety of clinics and young women appear particularly vulnerable to attrition. Interventions promoting linkage and continued retention for women initiating ART during pregnancy warrant urgent consideration.

Addressing Early Retention in Antenatal Care Among HIV-Positive Women Through a Simple Intervention in Kinshasa, DRC: The Elombe "Champion" Standard Operating Procedure

This cluster-randomized study aimed to assess the Elombe ("Champion") standard operating procedure (SOP), implemented by providers and Mentor Mothers, on HIV-positive pregnant women's retention between first and second antenatal visits. Sixteen facilities in Kinshasa were randomly assigned to intervention (SOP) or comparison (no SOP). Effect of the SOP was estimated using relative risk. Women in comparison facilities were more likely to miss second visits (RR 2.5, 95% CI 1.05-5.98) than women in intervention facilities (30.0%, n = 27 vs. 12.0%, n = 9, p < 0.002). Findings demonstrate that a simple intervention can reduce critical early loss to care in PMTCT programs providing universal, lifelong treatment.

Readiness for Antiretroviral Therapy: Implications for Linking HIV-Infected Individuals to Care and Treatment

Using survey data collected immediately after referral for ART (N = 87), this study examined ART-readiness among individuals (18 years and older) attending a mobile health clinic in South Africa. Most participants reported being very ready (84%) and motivated (85%) to start ART, but only 72% were assessed as ready for ART on all measures. Treatment readiness was lower among individuals who did not think they would test HIV-positive (aOR 0.26, p < 0.05) and among individuals who reported being in good health (aOR 0.44, p < 0.1). In contrast, higher readiness was associated with better ART knowledge (aOR 4.31, p < 0.05) and knowing someone who had experienced positive health effects from ART (aOR 2.65, p < 0.05). Results indicate that post-test counselling will need to be designed to deal with surprise at HIV diagnosis, and that health messaging needs to be carefully crafted to support uptake of ART among HIV-positive but healthy individuals. Further research is needed on effective post-test counselling approaches and effective framing of health messaging to increase awareness of the multiple positive benefits of early ART initiation and corresponding readiness to engage in treatment.

Improving postpartum retention in care for women living with HIV in the United States

: Research findings have consistently demonstrated that women living with HIV in the United States and globally experience declines in medication adherence and retention in care after giving birth. A number of studies have identified factors associated with postpartum retention in care, but the evidence base for interventions to address the problem and close this gap in the HIV care continuum is limited. Furthermore, the majority of studies have been conducted in low-resource or moderate-resource countries and may be less applicable or require adaptation for use in high resource countries. In the United States, up to two-thirds of women drop out of care after delivery and are unable to maintain or achieve viral suppression postpartum, at a time when maternal and pediatric health are closely linked. We conducted a critical review of the literature to identify existing gaps regarding maternal retention in the United States and conceptualize the problem through the lens of the integrated and ecological models of health behavior. This review describes existing barriers and facilitators to retention in HIV care postpartum from published studies and suggests steps that can be taken, using a multilevel approach, to improve maternal retention. We propose five core action steps related to increasing awareness of the problem of poor postpartum retention, addressing needs for improved care coordination and case management, and using novel approaches to adapt and implement peer support and technology-based interventions to improve postpartum retention and clinical outcomes of women living with HIV.