A mixed-methods approach to understanding barriers to postpartum retention in care among low-income, HIV-infected women

Primary Care Clinician Perspectives on Barriers to Postpartum Transition to Primary Care

Background: The transition from obstetric to primary care is often suboptimal, particularly for individuals with barriers to accessing care. We aimed to understand experiences of primary care clinicians regarding provision of care and their perceptions of barriers to the transition of care in this critical period. Methods: We conducted focus groups with primary care clinicians recruited from diverse, urban health care settings, including an academic medical center, private practice, and federally qualified health centers. Groups were conducted in person or virtually (December 2019 to February 2021) using a semi-structured approach. Data were analyzed using the constant comparative method to identify themes regarding barriers to providing primary care to postpartum individuals. Results: The study included 28 primary care clinicians (26 physicians and two advanced practice providers) who participated in eight focus groups. Clinicians identified multiple barriers to the successful transition from obstetric to primary care in the postpartum period. Clinician-based barriers included the lack of a clear hand-off from the obstetric care team and limited capacity to adequately address social determinants of health. Clinician perceptions of patient-based barriers included adverse social determinants of health such as lack of childcare and financial and transportation limitations, challenges addressing ongoing health needs (such as persistence of postpartum medical conditions), and limited health care engagement. Conclusions: Our results illustrate multiple complex and interrelated challenges to providing optimal primary care during and after the postpartum period that are related to a fragmented health care system, suboptimal support for complex social needs, and insufficient communication between obstetric and primary care clinicians.

Factors Associated With Retention in HIV Care Within 12 Months Postpartum: A Retrospective Cohort Study

BACKGROUND

Loss to follow-up to HIV care after delivery puts birthing parents with HIV at higher risk of loss of viral suppression, disease progression, and HIV partner transmission. This study assessed factors associated with retention in postpartum HIV care.

METHODS

This is a retrospective cohort study at a single academic medical center and included patients followed from January 2014 to December 2022. The primary outcome was retention in postpartum HIV care (any health care encounter discussing HIV medication adherence or viral load within 12 months postpartum). Data were analyzed using χ 2 and student t test for discrete and continuous variables. Univariate and multivariable log regressions were used to measure independent associations on care retention and health care utilization outcomes.

RESULTS

Of the 111 patients with planned follow-up at our facility, 93 (83.8%) participants had ≥1 HIV care encounter within 12 months of delivery. Participants had a mean age of 31.2 (±5.84) years, were predominantly Black (79.3%), non-Hispanic (91%), and non-U.S. born (57.5%) with substantial exposure of prior IPV (29.6%). Participants retained in care were more likely to use ART during pregnancy (92/99% vs 16/94.2%, P = 0.01) and have viral suppression at delivery (n = 83/90% vs 12/67%, P = 0.02). Retention in care was negatively associated with substance use during pregnancy (aOR 0.29, 95% CI: 0.09 to 0.95) after adjustment for social health covariates.

CONCLUSIONS

Although almost 84% of participants were retained in HIV care within 12 months of delivery, substance use during pregnancy was a significant risk factor for HIV care attrition postpartum.

Barriers to Retention in Care among Adults with HIV in Developed Countries: An Integrative Review

Focusing on factors hindering viral suppression is essential for improving the health outcomes of people with Human Immunodeficiency Virus (HIV) and working towards ending the HIV/AIDS epidemic. The aim of this integrative review is to create an overview of barriers to retention in care among adults with HIV living in developed countries. Based on a systematic literature search across EMBASE, PubMed, Scopus, CINAHL, and PsycInfo, 4,089 studies of various methodology were identified. A total of 52 studies met the inclusion criteria. Quality assessment was performed using the Mixed Method Appraisal Tool. Based on thematic analysis, the following five main themes were identified as most common barriers to retention in care: financial challenges, logistical challenges, stigma, mental health problems, and substance use. The integrative review highlights that various factors can hinder retention in care and underscores that strategies to promote retention in care should be person-centered and targeted the individual person's barriers to retention in care.

Association between mental health and substance use among reproductive-age women with HIV on cervical cancer screening and viral suppression outcomes

Women with HIV (WWH) face a heightened risk of cervical cancer and sub-optimal viral suppression. Although mental health conditions and substance use are known barriers to cervical cancer screening and viral suppression among WWH, little is known about the impact of specific mental health symptoms and substance use issues in reproductive-age WWH. This cross-sectional study examined the associations among depression and anxiety symptoms, substance use, cervical cancer screening, and viral suppression in a cohort of reproductive-age WWH enrolled in the Florida Cohort Study. Of WWH (n = 202) in the study, 42% reported anxiety, 35% reported depressive symptoms, 49% reported drug use, and 64% reported alcohol use within the past 12 months. In addition, 24% were not virally suppressed, 34% did not receive cervical cancer screening within the last year, and 13% did not receive cervical cancer screening within the last 3 years. Sub-optimal cervical cancer screening within the last year was associated with depression (p = 0.04) and anxiety (p = 0.007) symptoms. Mental health symptoms were significantly related to sub-optimal cervical cancer screening, which may be a target for clinical intervention. Future research should include social and structural barriers that may exist for achieving guideline-concordant cervical cancer screening and viral suppression.

Impacts of Substance Use and Mental Health Symptoms on Cervical Cancer Screening and Viral Suppression: A Mixed Methods Study With Reproductive-Age Women With HIV in Florida

ABSTRACT

Women with HIV (WWH) often receive suboptimal screening for cervical cancer despite being at an increased risk for cervical cancer and poor viral suppression. Mental health symptoms and substance use can adversely influence cervical cancer screening and viral suppression. The subjective experience of how these variables influence these outcomes in reproductive-age WWH is not well understood. Our study explored the perspectives of reproductive-age WWH living in Florida regarding the mechanisms by which mental health or substance abuse influences cervical cancer screening and viral suppression. An explanatory sequential mixed methods research design was used. A one-on-one semi-structured interview guided and informed by the Social Ecological Model (SEM) and results from previous quantitative analysis were used (N =16). Themes related to how substance use and mental health symptoms as barriers, and facilitators, including motherhood, community support, marijuana use, and medication adherence were reported. Study finding implications for research and clinicians are discussed.

"I Have to Stand Up on My Own and Do the Best I Can for My Kids"a: Work (Re-)entry Among New Mothers Living with HIV in Cape Town, South Africa

In recent years, significant progress has been made in treatment access for women living with HIV (WLHIV). For example, option B+, which requires that all pregnant persons who test positive for HIV start on antiretroviral treatment, has been instrumental in reducing the risk of vertical transmission. For birthing individuals who have a low HIV viral load, there is a minimized risk of vertical transmission during breastfeeding. However, an alarming rate of WLHIV in South Africa disengage from care during postpartum. Given that work is intricately linked to individuals' socioeconomic status, and thus health outcomes, and their health-seeking ability, it is important to explore the role of work in decisions that impact HIV-related care for the dyad postpartum. Semi-structured interviews were conducted with 26 women living with HIV at 6-8 weeks postpartum in Cape Town, South Africa. A secondary qualitative data analysis was conducted following thematic content analysis. Three themes were identified, spanning participants' financial considerations, navigating childcare needs, and considerations for exclusive breastfeeding. For many participants, there was often a conflict between returning to work, childcare, and the decision whether or not to breastfeed-in addition to their HIV care. This conflict between participants' commitments suggests an increased pressure that WLHIV may face postpartum, which could impact their ability to remain engaged in their healthcare and adherent to medication. Although exclusive breastfeeding is an important recommendation for the baby's health outcomes; there is a need for structural support for WLHIV as they navigate work re-entry during postpartum.

Mapping the Postpartum Experience Through Obstetric Patient Navigation for Low-Income Individuals

Background: Although the postpartum period is an opportunity to address long-term health, fragmented care systems, inadequate attention to social needs, and a lack of structured transition to primary care threaten patient wellbeing, particularly for low-income individuals. Postpartum patient navigation is an emerging innovation to address these disparities. Methods: This mixed-methods analysis uses data from the first year of an ongoing randomized controlled trial to understand the needs of low-income postpartum individuals through 1 year of patient navigation. We designed standardized logs for navigators to record their services, tracking mode, content, intensity, and target of interactions. Navigators also completed semistructured interviews every 3 months regarding relationships with patients and care teams, care system gaps, and navigation process. Log data were categorized, quantified, and mapped temporally through 1 year postpartum. Qualitative data were analyzed using the constant comparative method. Results: Log data from 50 participants who received navigation revealed the most frequent needs related to health care access (45.4%), health and wellness (18.2%), patient-navigator relationship building (14.8%), parenting (13.6%), and social determinants of health (8.0%). Navigation activities included supporting physical and mental recovery, accomplishing health goals, connecting patients to primary and specialty care, preparing for health system utilization beyond navigation, and referring individuals to community resources. Participant needs fluctuated, yielding a dynamic timeline of the first postpartum year. Conclusion: Postpartum needs evolved throughout the year, requiring support from various teams. Navigation beyond the typical postpartum care window may be useful in mitigating health system barriers, and tracking patient needs may be useful in optimizing postpartum care. Clinical Trial Registration: Registered April 19, 2019, enrollment beginning January 21, 2020, NCT03922334, https://clinicaltrials.gov/ct2/show/NCT03922334.

Factors associated with HIV viral load control in the early postpartum period - a Canadian prospective cohort study

Despite success in managing HIV during pregnancy, challenges remain around sustained adherence with antiretroviral therapy (ART), and the suboptimal viral load (VL) suppression during the postpartum period. The objective of this study was to compare VL levels at delivery and during the postpartum period and assess factors associated with lack of viral suppression during the postpartum period in Canada. We combined data from two Canadian prospective cohorts, which included 286 HIV-positive women (352 pregnancies) who delivered between 2012 and 2020. Delivery VL, postpartum VL, and potential factors associated with an undetectable VL (<50 copies/mL), 2-18 weeks after delivery were assessed. To account for the correlation between multiple pregnancies from the same woman, generalized estimating equations were used to assess bivariate associations. Ninety-nine per cent of pregnant women were on ART during pregnancy compared to 93% during the postpartum period. Of those with available VL results (n = 214 pregnancies), 94% of women achieved an undetectable VL at delivery compared to 87% during the postpartum period. The postpartum period is a challenging time for ART use and VL control. Qualitative studies are needed to better understand these challenges and guide us in designing adequate interventions.

A Systematic Review of the Impact of HIV-Related Stigma and Serostatus Disclosure on Retention in Care and Antiretroviral Therapy Adherence Among Women with HIV in the United States/Canada

This systematic review explores the roles of HIV stigma and disclosure of HIV serostatus in antiretroviral therapy (ART) adherence and retention in care (RIC) among women with HIV (WHIV) in the United States and Canada. We conducted a systematic search of electronic databases (PubMed, Embase, CINAHL, PsycINFO, and Google scholar) to identify peer-reviewed articles published between January 1996 and December 2022. The search yielded 1120 articles after duplicates were removed. Of these, 27 articles met the inclusion criteria. The majority (89%) of the studies were conducted in the United States. The studies included WHIV from diverse racial/ethnic groups, residing in both urban and rural areas. Most of the studies suggested that internalized stigma, perceived community stigma, and fear of disclosure were important barriers to ART adherence and RIC among WHIV. HIV-related stigma experienced within the health care setting was also reported as a factor impacting health care utilization. A few studies identified mental health distress as a potential mechanism accounting for the association and suggested that social support and resilience may buffer the negative effects of stigma and disclosure on ART adherence and RIC among WHIV. Our review indicates that stigma and concerns about disclosure continue to significantly affect HIV health outcomes for WHIV in high-income countries. It underscores the importance of integrated HIV care services and interventions targeting mental health, resilience building, and improved patient-provider relationships for WHIV to enhance ART adherence and RIC. Longitudinal studies and investigations into additional mechanisms are needed to advance understanding and inform women-centered interventions.

Attitudes on breast feeding among persons with HIV who have given birth and their perceptions of coercion during counseling on safe infant feeding practices

Persons with HIV can receive mixed messages about the safety of breastfeeding. We sought to assess if they felt coerced to formula feed when counseled about practices to reduce HIV transmission. Persons with HIV who had given birth were eligible to complete a survey to describe their experiences with infant feeding counseling and if they felt coerced to formula feed. An Iowa Infant Feeding Attitude Scale (IIFAS) assessed attitudes towards breastfeeding. Qualitative analyses were performed on narrative responses. One hundred surveys were collected from sites in Georgia, North Carolina, Pennsylvania, and South Carolina. The mean IIFAS score (n, 85) was 47 (SD 9.2), suggesting relatively favorable attitudes toward breastfeeding. Thirteen persons reported feeling coerced to formula feed. When controlling for choosing to give any breast milk, persons with any college education were more likely to report feeling coerced (aOR 9.8 [95% CI 1.8-52.5]). Qualitative analyses revealed three themes: perceiving breastfeeding as unsafe, engaging in shared decision-making, and resisting advice to formula feed. Persons with HIV desire to be counseled about safe infant feeding practices and have their questions answered without judgement. We highlight experiences of persons with HIV that reflect a need for a nuanced approach to infant feeding counseling.

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.

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.

A qualitative metasynthesis of stigma in women living with HIV in the United States

Our goal was to synthesize qualitative studies on HIV-related stigma as experienced by women living with HIV (WLWH) in the U.S. Qualitative metasynthesis techniques as developed by Sandelowski et al. (Res Nurs Health 30(1):99-111, 2007) were used to integrate and update findings on stigma in WLWH in the U.S. in 43 reports of qualitative studies conducted between 2004 and 2023 with 1118 participants. Developed themes explored a collective narrative of women first surviving the intersectionality of multiple sources of stigma, discovering non-linear pathways to transcend their stigma, and finally experiencing resilience through their transcendence of stigma. While this metasynthesis revealed similarities to an earlier metasynthesis in the ubiquity and persistence of stigma, they differ primarily in women's abilities to find agency in managing and opposing their stigma. This cognitive reframing of their stigma helped women to redefine stigma as ignorance and move towards a more positive assessment of the self. In doing so, they separated themselves from their stigma and the damaging effects of it. Findings from this metasynthesis may serve as a useful tool for the development of stigma reduction interventions specific to the needs and experiences of WLWH in the U.S.

Mental health, substance use, and risky sexual behaviors among women living with HIV

INTRODUCTION

Risky sexual behavior has been explored in women living with HIV (WLHIV) internationally but is not well studied in WLHIV in the United States (U.S.). This merits further investigation due to the negative reproductive and HIV health outcomes associated with risky sexual behavior, such as the increased risk for HIV transmission and infertility from sexually transmitted infections (STIs). The aims of this study are to (1) describe sexual behaviors in a cohort of WLHIV in Florida, (2) determine whether demographic characteristics, substance use, and mental health symptoms are associated with risky sexual behavior in a cohort of WLHIV in Florida, and (3) explore whether the relationship between substance use and mental health symptoms and risky sexual behavior differs in reproductive-age (age 18-49), compared to non-reproductive-age WLHIV (age 50+).

DESIGN

This was a cross-sectional analysis of data from a multisite cohort study done in Florida.

METHODS

Data were collected from a sample of 304 participants who were recruited into the Florida Cohort Study from 9 clinical and community sites in Florida between 2014 to 2017. The predictor variables of interest were mental health symptoms, substance use, and demographic variables. The outcome variable of interest was risky sexual behavior which was defined as reporting ≥1 of the following: (1) at least one STI diagnosis in the past 12 months, (2) two or more sexual partners in the past 12 months, or (3) any inconsistent condom use in the past 12 months. Descriptive statistics, bivariate analysis, and logistic regression (p < 0.1) were conducted on the variables of interest.

RESULTS

The mean age of the sample was 47.8 years, and approximately half (51.6%) of the sample was of reproductive-age. Reporting ≥1 risky sexual behavior was reported in over half (51.6%) of the reproductive-age WLHIV in the sample and 32% of the non-reproductive-age WLHIV in the sample. Binge drinking, alcohol-related problems, marijuana use, and age were all significantly associated with self-reporting ≥1 risky sexual behaviors in all WLHIV. Self-reporting binge drinking, marijuana use, and a high alcohol-related problems score respectively were associated with increased odds of self-reporting ≥1 risky sexual behavior in all WLHIV. Neither mental health symptoms nor race/ethnicity or education were significantly associated with self-reporting ≥1 risky sexual behavior in all WLHIV. Self-reporting severe anxiety symptoms and high alcohol-related problems scores respectively were associated with increased odds of self-reporting ≥1 risky sexual behavior only in reproductive-age WLHIV from the sample.

CONCLUSION

Marijuana use, binge drinking, and alcohol-related problems appear to have a relationship with risky sexual behavior in WLHIV regardless of age. Reproductive-age also appears to influence risky sexual behavior in WLHIV, and specific reporting severe anxiety symptoms and high alcohol-related problems in reproductive-age WLHIV increases the odds of engaging in risky sexual behavior.

CLINICAL SIGNIFICANCE

This study holds clinical significance for nurses and other clinicians working in reproductive health settings and clinics with WLHIV. Results indicate that it could be beneficial to do more screening for mental health symptoms (particularly anxiety) and alcohol use in younger reproductive-age WLHIV.

Optimizing PMTCT Adherence by Treating Depression in Perinatal Women with HIV in South Africa: A Pilot Randomized Controlled Trial

BACKGROUND

South Africa (SA) has the greatest HIV prevalence in the world, with rates as high as 40% among pregnant women. Depression is a robust predictor of nonadherence to antiretroviral therapy (ART) and engagement in HIV care; perinatal depression may affect upwards of 47% of women in SA. Evidence-based, scalable approaches for depression treatment and ART adherence in this setting are lacking.

METHOD

Twenty-three pregnant women with HIV (WWH), ages 18-45 and receiving ART, were randomized to a psychosocial depression and adherence intervention or treatment as usual (TAU) to evaluate intervention feasibility, acceptability, and preliminary effect on depressive symptoms and ART adherence. Assessments were conducted pre-, immediately post-, and 3 months post-treatment, and included a qualitative exit interview.

RESULTS

Most (67.6%) eligible individuals enrolled; 71% completed at least 75% of sessions. Compared to TAU, intervention participants had significantly greater improvements in depressive symptoms at post-treatment, β =  - 11.1, t(24) =  - 3.1, p < 0.005, 95% CI [- 18.41, - 3.83], and 3 months, β =  - 13.8, t(24) =  - 3.3, p < 0.005, 95% CI [- 22.50, - 5.17]. No significant differences in ART adherence, social support, or stigma were found. Qualitatively, perceived improvements in social support, self-esteem, and problem-solving adherence barriers emerged as key benefits of the intervention; additional sessions were desired.

CONCLUSION

A combined depression and ART adherence intervention appears feasible and acceptable, and demonstrated preliminary evidence of efficacy in a high-need population. Additional research is needed to confirm efficacy and identify dissemination strategies to optimize the health of WWH and their children.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03069417. Protocol available at https://clinicaltrials.gov/ct2/show/NCT03069417.

The feasibility and acceptability of a task-shifted intervention for perinatal depression among women living with HIV in Malawi: a qualitative analysis

BACKGROUND

Perinatal depression (PND) is prevalent and negatively impacts HIV care among women living with HIV (WLHIV), yet PND remains under-identified in Malawian WLHIV. Accordingly, this formative study explored perceptions of the feasibility and acceptability of an integrated, task-shifted approach to PND screening and treatment in maternity clinics.

METHODS

We completed consecutive PND screenings of HIV+ women attending pre- or post-natal appointments at 5 clinics in Lilongwe district, Malawi. We conducted in-depth interviews with the first 4-5 women presenting with PND per site (n = 24 total) from July to August 2018. PND classification was based on a score ≥ 10 on the Edinburgh Postnatal Depression Scale (EPDS). We conducted 10 additional in-depth interviews with HIV and mental health providers at the 5 clinics.

RESULTS

Most participants endorsed the feasibility of integrated PND screening, as they believed that PND had potential for significant morbidity. Among providers, identified barriers to screening were negative staff attitudes toward additional work, inadequate staffing numbers and time constraints. Suggested solutions to barriers were health worker training, supervision, and a brief screening tool. Patient-centered counselling strategies were favored over medication by WLHIV as the acceptable treatment of choice, with providers supporting the role of medication to be restricted to severe depression. Providers identified nurses as the most suitable health workers to deliver task-shifted interventions and emphasized further training as a requirement to ensure successful task shifting.

CONCLUSION

Improving PND in a simple, task-shifted intervention is essential for supporting mental health among women with PND and HIV. Our results suggest that an effective PND intervention for this population should include a brief, streamlined PND screening questionnaire and individualized counselling for those who have PND, with supplemental support groups and depression medication readily available. These study results support the development of a PND intervention to address the gap in treatment of PND and HIV among WLHIV in Malawi.

Associations between female birth sex and risk of chronic kidney disease development among people with HIV in the USA: A longitudinal, multicentre, cohort study

Background

Women represent a meaningful proportion of new HIV diagnoses, with Black women comprising 58% of new diagnoses among women. As HIV infection also increases risk of chronic kidney disease (CKD), understanding CKD risk among women with HIV (WWH), particularly Black women, is critical.

Methods

In this longitudinal cohort study of people with HIV (PWH) enrolled in CFAR Network of Integrated Clinical Systems (CNICS), a multicentre study comprised of eight academic medical centres across the United States from Jan 01, 1996 and Nov 01, 2019, adult PWH were excluded if they had ≤2 serum creatinine measurements, developed CKD prior to enrollment, or identified as intersex or transgendered, leaving a final cohort of 33,998 PWH. The outcome was CKD development, defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1·73 m2 calculated using the CKD-EPI equation, for ≥90 days with no intervening higher values.

Findings

Adjusting for demographic and clinical characteristics, WWH were 61% more likely to develop CKD than men (adjusted hazard ratio [aHR]: 1·61, 95% CI: 1·46-1·78, p<0·001). This difference persisted after further adjustment for APOL1 risk variants (aHR female sex: 1·92, 95% CI: 1·63-2·26, p<0·001) and substance abuse (aHR female sex: 1·70, 95% CI: 1·54-1·87, p<0·001).

Interpretation

WWH experienced increased risk of CKD. Given disparities in care among patients with end-stage kidney disease, efforts to engage WWH in nephrology care to improve chronic disease management are critical.

Funding

US National Institutes of Health.

The Boundary of HIV Care: Barriers and Facilitators to Care Engagement Among People with HIV in the United States

Treating people with HIV (PWH) quickly and effectively to achieve viral suppression is a key strategy for Ending the HIV Epidemic. Understanding barriers and facilitators to HIV care engagement could improve outcomes among PWH and reduce HIV infections. We sampled PWH who participated in the Medical Monitoring Project from June 2018 to May 2019 and were not engaged in HIV care to participate in 60-min semistructured telephone interviews on barriers and facilitators to HIV care engagement. We used applied thematic analysis and placed codes into themes based on their frequency and salience. Participants reported various intrapersonal, health system, and structural barriers to care. We conceptualize the boundary of care as the space between the stages of the HIV care continuum, where PWH may find themselves when they lack intrapersonal, health system, and structural support. Research and interventions tackling these barriers are needed to improve outcomes among PWH and reduce HIV infections.

A systematic review of the qualitative literature on barriers to high-quality prenatal and postpartum care among low-income women

OBJECTIVE

To examine the qualitative literature on low-income women's perspectives on the barriers to high quality prenatal and postpartum care.

DATA SOURCES AND STUDY SETTING

We performed searches in PubMed, Web of Science, Embase, SocIndex, and CINAHL for peer-reviewed studies published between 1990 to 2021.

STUDY DESIGN

Systematic review of qualitative studies with participants who were currently pregnant or had delivered within the past two years and identified as low-income at delivery.

DATA COLLECTION / EXTRACTION METHODS

Two reviewers independently assessed studies for inclusion, evaluated study quality, and extracted information on study design and themes.

PRINCIPLE FINDINGS

We identified 34 studies that met inclusion criteria, including 23 focused on prenatal care, 6 on postpartum care, and 5 on both. The most frequently mentioned barriers to prenatal and postpartum care were structural. These included delays in gaining pregnancy-related Medicaid coverage, challenges finding providers who would accept Medicaid, lack of provider continuity, transportation and childcare hurdles, and legal system concerns. Individual-level factors, such as lack of awareness of pregnancy, denial of pregnancy, limited support, conflicting priorities, and indifference to pregnancy also interfered with timely use of prenatal and postpartum care. For those who accessed care, experiences of dismissal, discrimination, and disrespect related to race, insurance status, age, substance use, and language were common.

CONCLUSIONS

Over a period of 30 years, qualitative studies have identified consistent structural and individual barriers to high-quality prenatal and postpartum care. Medicaid policy changes including expanding presumptive eligibility, increased reimbursement rates for pregnancy services, payment for birth doula support, and extension of postpartum coverage may help overcome these challenges.

Postpartum Visit Attendance in the United States: A Systematic Review

INTRODUCTION

Adequate postpartum care, including the comprehensive postpartum visit, is critical for long-term maternal health and the reduction of maternal mortality, particularly for people who may lose insurance coverage postpartum. However, variation in previous estimates of postpartum visit attendance in the United States makes it difficult to assess rates of attendance and associated characteristics.

METHODS

We conducted a systematic review of estimates of postpartum visit attendance. We searched PubMed, CINAHL, PsycInfo, and Web of Science for articles published in English from 1995 to 2020 using search terms to capture postpartum visit attendance and use in the United States.

RESULTS

Eighty-eight studies were included in this analysis. Postpartum visit attendance rates varied substantially, from 24.9% to 96.5%, with a mean of 72.1%. Postpartum visit attendance rates were higher in studies using patient self-report than those using administrative data. The number of articles including an estimate of postpartum visit attendance increased considerably over the study period; the majority were published in 2015 or later.

CONCLUSIONS

Our findings suggest that increased systematic data collection efforts aligned with postpartum care guidelines and attention to postpartum visit attendance rates may help to target policies to improve maternal wellbeing. Most estimates indicate that a substantial proportion of women do not attend at least one postpartum visit, potentially contributing to maternal morbidity as well as preventing a smooth transition to future well-woman care. Estimates of current postpartum visit attendance are important for informing efforts that seek to increase postpartum visit attendance rates and to improve the quality of care.

Study of Treatment and Reproductive Outcomes Among Reproductive-Age Women With HIV Infection in the Southern United States: Protocol for a Longitudinal Cohort Study

BACKGROUND

Nearly a quarter of the 1.1 million individuals with HIV in the United States are women. Racial and ethnic minority women in the Southern United States are disproportionately impacted. Reproductive-age women with HIV are prone to poor HIV outcomes but remain underrepresented in HIV research. We will answer contemporary questions related to the health outcomes in this population by enrolling a prospective cohort of reproductive-age women with and without HIV in the Southern United States.

OBJECTIVE

The Study of Treatment and Reproductive Outcomes (STAR) will enroll and retain 2000 reproductive-age women with and without HIV. The STAR will leverage the infrastructure of the US-based Multicenter AIDS Cohort Study (MACS)/Women's Interagency HIV Study (WIHS) Combined Cohort Study, comprising the WIHS (a cohort of women with and at risk for HIV, which began in 1993), and the MACS (a cohort of gay and bisexual men with and at risk for HIV, which began in 1984). Although the advancing age of the participants enrolled in the MACS/WIHS Combined Cohort Study provides an opportunity to address the questions related to HIV and aging, the research questions pertinent to the reproductive years must also be addressed. The STAR will conduct high-priority scientific research in key areas with the overall aim of addressing the unique needs of reproductive-age women with HIV.

METHODS

The STAR is a prospective, observational cohort study that will be conducted at 6 sites in the United States-Atlanta, Georgia; Birmingham, Alabama; Jackson, Mississippi; Chapel Hill, North Carolina; Miami, Florida; and Washington, District of Columbia. Visits will occur semiannually for 2 years, with additional visits for up to 5 years. At each visit, the participating women will complete a structured interview for collecting key demographic, psychosocial, and clinical variables, and undergo biospecimen collection for laboratory testing and repositing (blood, urine, hair, vaginal, anal, and oral specimens). Pregnant women and infants will undergo additional study assessments. The initial scientific focus of the STAR is to understand the roles of key social determinants of health, depression, reproductive health, and oral health on HIV and pregnancy outcomes across the reproductive life span.

RESULTS

Enrollment in the STAR commenced in February 2021 and is ongoing.

CONCLUSIONS

Through in-depth, longitudinal data and biospecimen collection, the newly initiated STAR cohort will create a platform to answer scientific questions regarding reproductive-age women with and without HIV. STAR will be uniquely positioned to enable investigators to conduct high-impact research relevant to this population. Building on the legacy of the MACS and WIHS cohorts, the STAR is designed to foster multidisciplinary collaborations to galvanize scientific discoveries to improve the health of reproductive-age women with HIV and ameliorate the effects of the HIV epidemic in this population in the United States.

Association of pregnancy with engagement in HIV care among women with HIV in the UK: a cohort study

BACKGROUND

Women with HIV face challenges in engaging in HIV care post partum. We aimed to examine changes in engagement in HIV care through clinic attendance before, during, and after pregnancy, compared with matched women with HIV who had never had a recorded pregnancy.

METHODS

In this cohort study, we describe changes in engagement in HIV care before, during, and after pregnancy among women with HIV from the UK Collaborative HIV Cohort (CHIC) study from 25 HIV clinics in the UK with a livebirth reported to the National Surveillance of HIV in Pregnancy and Childhood between Jan 1, 2000, and Dec 31, 2017. To investigate whether changes were specific to HIV, we compared these changes to those over equivalent periods among non-pregnant women with HIV in the UK CHIC study matched for ethnicity, year of conception, age, CD4 cell count, viral suppression, and antiretroviral therapy use. Analyses were via logistic regression using generalised estimated equations with an interaction between case-control status (pregnant women vs non-pregnant women) and pregnancy or pseudo pregnancy (for non-pregnant women) stage.

FINDINGS

1116 matched pairs of pregnant and non-pregnant women were included (median age 34 years [IQR 30-38], 80·1% Black African, 12·5% white). 69 330 person-months of follow-up were recorded, 25 412 in the before stage, 18 897 during, and 25 021 after pregnancy or pseudo pregnancy stages. Among pregnant women, the proportion of time engaged in care increased during pregnancy (8477 [90·5%] of 9371 person-months) and after pregnancy (10 501 [84·6%] of 12 407), compared with before pregnancy (9979 [78·5%] of 12 707). Among non-pregnant women in the control group, engagement in HIV care remained stable across the three equivalent stages (9688 [76·3%] of 12 705 person-months before pseudo pregnancy; 7463 [78·3%] of 9526 during pseudo pregnancy; and 9892 [78·4%] of 12 614 after pseudo pregnancy). The association of engagement in HIV care with pregnancy or pseudo pregnancy stage differed significantly by case-control status (pinteraction<0·0001); the odds of engagement in HIV care were higher during pregnancy (odds ratio [OR] 3·32, 95% CI 2·68-4·12) and after pregnancy (OR 1·49, 1·24-1·79) only among pregnant women, and not among non-pregnant women, when compared with the before pseudo pregnancy stage.

INTERPRETATION

Women with HIV and a pregnancy resulting in a livebirth were more likely to engage in HIV care post partum when compared with before pregnancy. A detailed understanding of the reason for this finding could support interventions to maximise engagement in HIV care for all women with HIV.

FUNDING

Medical Research Council and National Institute for Health Research.

Provider Perceptions of Barriers to HIV Care Among Women with HIV in Miami-Dade County, Florida, and Possible Solutions: A Qualitative Study

In Miami-Dade County, women with HIV (WWH) enrolled in Ryan White Program (RWP) services belong to groups that have historically faced structural barriers to care. To examine provider perceptions of WWH's barriers to care and elicit possible solutions, we conducted semi-structured interviews (n = 20) with medical case managers and human immunodeficiency virus (HIV) healthcare providers from medical case management sites serving WWH enrolled in the Miami-Dade RWP. Verbatim transcripts were analyzed thematically by two coders through an iterative process; disagreements were resolved through consensus. Barriers included lack of disclosure and stigma, additional psychosocial barriers to care, structural and logistical barriers, and negative interactions with health care providers. Participant suggestions to address these barriers included strategies that support women and foster individualized services that are responsive to their lived experiences and needs. Other solutions, such as those related to transportation, housing, and general funding for the RWP, will require advocacy and policy change.

Enduring stigma and precarity: A review of qualitative research examining the experiences of women living with HIV in high income countries over two decades

The lived experience of HIV for women remains poorly understood. In particular, there has been little attention to the consequences for women living with HIV (WLHIV) of changing social, epidemiological, biomedical and policy contexts, or to the implications of long-term treatment and aging for the current generation of HIV-positive women. We reviewed qualitative research with WLHIV in selected high-income countries (Australia, Canada, New Zealand, the UK and the USA) to identify the most prevalent experiences of HIV for women and trends over time. Our synthesis highlights the relative consistency of experiences of a diverse sample of WLHIV, particularly the enduring prevalence of gendered HIV-related stigma, sociostructural barriers to healthcare and support, and negative encounters with health professionals. We also identified gaps in knowledge. Understanding women's experiences, particularly their changing needs and strategies for coping as they live long-term with HIV, is key to effective support and services for WLHIV.

A Systematic Review of Patient-, Provider-, and Health System-Level Predictors of Postpartum Health Care Use by People of Color and Low-Income and/or Uninsured Populations in the United States

Introduction: People of color and low-income and uninsured populations in the United States have elevated risks of adverse maternal health outcomes alongside low levels of postpartum visit attendance. The postpartum period is a critical window for delivering health care services to reduce health inequities and their transgenerational effects. Evidence is needed to identify predictors of postpartum visit attendance in marginalized populations. Methods: We conducted a systematic review of the peer-reviewed literature to identify studies that quantified patient-, provider-, and health system-level predictors of postpartum health care use by people of color and low-income and uninsured populations. We extracted study design, sample, measures, and outcome data from studies meeting our eligibility criteria, and used a modified Cochrane Risk of Bias tool to evaluate risk of bias. Results: Out of 2,757 studies, 36 met our criteria for inclusion in this review. Patient-level factors consistently associated with postpartum care included higher socioeconomic status, rural residence, fewer children, older age, medical complications, and previous health care use. Perceived discrimination during intrapartum care and trouble understanding the health care provider were associated with lower postpartum visit use, while satisfaction with the provider and having a provider familiar with one's health history were associated with higher use. Health system predictors included public facilities, group prenatal care, and services such as patient navigators and appointment reminders. Discussion: Postpartum health service research in marginalized populations has predominantly focused on patient-level factors; however, the multilevel predictors identified in this review reflect underlying inequities and should be used to inform the design of structural changes.

Late antiretroviral refills and condomless sex in a cohort of HIV-seropositive pregnant and postpartum Kenyan women

INTRODUCTION

The postpartum period can be challenging for women living with HIV. Understanding how the postpartum period impacts ART adherence and condomless sex could inform the development of comprehensive sexual and reproductive health and HIV services tailored to the needs of women living with HIV during this critical interval.

METHODS

In a longitudinal cohort study of HIV-seropositive Kenyan women, late ART refills and self-reported condomless sex were compared between the woman's pregnancy and the postpartum period. Analyses were conducted using generalized estimating equations and adjusted for alcohol use, depressive symptoms, intimate partner violence (IPV), and having a recent regular partner. Effect modification was explored for selected variables.

RESULTS AND DISCUSSION

151 women contributed visits. Late ART refills occurred at 7% (32/439) of pregnancy visits compared to 18% (178/1016) during the postpartum period (adjusted relative risk [aRR] 2.44, 95% confidence interval [CI] 1.62-3.67). This association differed by women's education level. Women with ≥8 years of education had late ART refills more during the postpartum period than pregnancy (aRR 3.00, 95%CI 1.95-4.62). In contrast, in women with <8 years of education, late ART refills occurred similarly during pregnancy and the postpartum period (aRR 0.88, 95%CI 0.18-4.35). Women reported condomless sex at 10% (60/600) of pregnancy visits compared to 7% (72/1081) of postpartum visits (aRR 0.76, 95%CI 0.45-1.27). This association differed by whether women had experienced recent IPV. Women without recent IPV had a significant decline in condomless sex from pregnancy to postpartum (aRR 0.53, 95%CI 0.30-0.95) while women with recent IPV had no significant change in condomless sex from pregnancy to postpartum (aRR 1.76, 95%CI 0.87-3.55).

CONCLUSION

Improved support for ART adherence during the postpartum period and addressing IPV to limit condomless sex could improve HIV treatment and prevention outcomes for HIV-seropositive women as well as their infants and sexual partners.

Provider Perspectives on Barriers and Facilitators to Postpartum Care for Low-Income Individuals

Background: Recent paradigm shifts in postpartum care have conceptualized the “fourth trimester” as a critical transitional period requiring tailored, ongoing health care. However, this concept presents challenges for providers, especially in low-resource settings. Our objective was to understand providers' perspectives on challenges in postpartum care to highlight strategies for optimizing care.

Methods: Focus groups were conducted using a semistructured interview guide to elicit perspectives on barriers and facilitators to postpartum care. Participants included physicians, nurses, and social workers who care for low-income postpartum individuals. Interviews explored the provider experience of postpartum care, with a focus on barriers experienced by patients and providers, and tools for maintaining engagement. Analysis was performed using the constant comparative method and framed by the Social Ecological Model.

Results: Participants (N = 26) all acknowledged the importance of the “fourth trimester” but identified multiple barriers to providing optimal postpartum care. Challenges providers perceived for patients and those they perceived for themselves often overlapped, including difficulty with appointment scheduling, insurance limitations, lack of provider continuity, and knowledge gaps. Providers identified ease of referrals to specialists, access to tangible services (e.g., contraception), and enhanced care coordination (e.g., patient navigation) as potential facilitators of improved postpartum care.

Conclusions: Obstetric providers recognize the importance of postpartum care yet highlighted significant systems- and patient-based barriers to achieving optimal care. The development and implementation of postpartum care delivery system redesign, such as the use of patient navigators to improve health care utilization and resource attainment, may enhance care during this critical time. Clinical Trial No.: NCT03922334.

Perinatal Depressive Symptoms, HIV Suppression, and the Underlying Role of ART Adherence: A Longitudinal Mediation Analysis in the IMPAACT P1025 Cohort

Background

Women with HIV have higher risk of depressive symptoms in the perinatal period. Evidence on how perinatal depressive symptoms affect viral suppression (VS) and adherence to antiretroviral therapy (ART) remains limited.

Methods

Perinatal depressive symptoms were assessed using 6 items from the AIDS Clinical Trials Group (ACTG) Quality of Life questionnaire. VS (viral load <400 copies/mL) was the outcome. Adherence was defined as no missed dose in the past 1–4 weeks using the ACTG Adherence Questionnaire. Generalized mixed-effects structural equation models estimated the association of depressive symptoms on VS and the mediating role of ART adherence among women enrolled in the IMPAACT P1025 Perinatal Core Protocol (2002–2013).

Results

Among 1869 participants, 47.6% were 21–29 years, 57.6% non-Hispanic Black. In the third trimester, the mean depressive symptoms score was 14.0 (±5.2), 68.0% had consistent adherence, and 77.3% achieved VS. At 6 months postpartum, depressive symptoms declined while adherence and VS fell to 59.8% and 53.0%, respectively. In the fully adjusted model, a 1-SD increase in depressive symptoms was associated with a 3.8-percentage-point (95% CI: −5.7, −1.9) decline in VS. This effect is the sum of the indirect effect of depressive symptoms on VS via ART adherence (−0.4; 95% CI: −.7, −.2) and the direct effect through other pathways (−3.4; −5.2, −1.5). The decline in adherence driven by depressive symptoms accounted for ≥11% of the total negative effect of depressive symptoms on VS.

Conclusions

Perinatal depressive symptoms were associated with decreased adherence and VS, highlighting the need to screen for, diagnose, and treat perinatal depression to optimize maternal outcomes.

Clinical Trials Registration

NCT00028145.

Social determinants of peripartum depressive symptoms among Black peripartum women living with HIV

HIV infection during pregnancy, may present risk of developing depression during pregnancy and postpartum. This psychiatric mood disorder, and many others such as anxiety and HIV-related post-traumatic stress disorder (PTSD) have been reported prevalent among pregnant and non-pregnant women living with HIV (WLWH). Multiple studies have found associations between social determinants of health and depressive symptoms in this population. However, despite deleterious effects on mother and child which may include suicidal ideations and infant death, only very few studies have examined this phenomenon for peripartum women, particularly Black women- a population prone to living in poor social and economic environments. Therefore, guided by the socio-ecologic model, this study examined predictors of peripartum depressive symptoms among Black peripartum WLWH. The study was a secondary data analysis of 143 Black women seen at special prenatal and women's health clinics in Miami, South Florida, USA. More than half of the women who experienced peripartum depressive symptoms (PDS) (n = 81, 57%) were of low socio-economic status. Low income was associated with increased odds of experiencing PDS. Women who endorsed intimate partner violence/abuse (IPV/A) were 6.5 times more likely to experience PDS; and compared to women with 1 or no childcare burden, women with 2 children-care burden were 4.6 times more likely to experience PDS. These findings demonstrate the negative impact of social factors on the psychological health of Black peripartum WLWH. Burdensome interpersonal relationships may have deleterious effects and trigger PDS among these women. Implications for nursing practice, education and research are also discussed.

HIV-Adapted Group Prenatal Care: Assessing Viral Suppression and Postpartum Retention in Care

Viral suppression and postpartum retention in care have far-reaching health implications for pregnant women living with HIV and their children, yet remain public health challenges. Prenatal care presents a unique opportunity to engage pregnant women in care. The purpose of this study is to evaluate whether group prenatal care is effective in impacting these outcomes for pregnant women living with HIV. A retrospective cohort study was performed of all women living with HIV who obtained prenatal care from a community-based health center between 2013 and 2019. Women who spoke English or Spanish, remained within the system, and had not participated in group prenatal care previously were included. Women self-selected a prenatal care model: 85 selected group care and 109 elected individual care. Group prenatal care followed a standard Centering Pregnancy^® curriculum with the addition of HIV-related topics. The primary outcomes of the study were viral suppression (viral load <20 copies/mL) and postpartum retention in care (attending at least one or two visits with HIV primary care within 12 months postpartum). After adjusting for potential confounding factors, women who participated in group prenatal care were significantly more likely to have at least one HIV primary care visit postpartum {adjusted odds ratio (aOR) = 2.71 [95% confidence interval (CI 1.14-6.46)]; p = 0.024}, and had a trend for achieving viral suppression by the time of delivery [aOR = 2.29 (95% CI 0.94-5.55); p = 0.068]. We have demonstrated that group prenatal care for pregnant women living with HIV is feasible and effective, with positive impacts on retention in care and viral suppression, factors that affect long-term outcomes from patients living with HIV.

Maternidade e HIV: Continuidade do Tratamento e Adesão em Mulheres após Parto

Resumo O estudo examinou fatores sociodemográficos, clínicos e psicossociais que afetam a continuidade do tratamento e a adesão à medicação antirretroviral em mulheres nos primeiros três meses após o parto. Participaram 56 mulheres vivendo com HIV, com idades entre 18 e 43 anos, na sua grande maioria brancas e casadas. Foram utilizadas entrevistas sobre dados sociodemográficos e clínicos, exames laboratoriais e escalas psicológicas. Análises estatísticas revelaram que mais de um terço das participantes (37,5%) descontinuaram o próprio tratamento após o parto. A qualidade de vida e o apoio instrumental podem favorecer a continuidade do tratamento de HIV após o parto, e as condições de trabalho e a situação clínica dessas mulheres pode afetar a adesão após o parto. Tais resultados podem contribuir para o desenvolvimento de intervenções que favoreçam a continuidade do tratamento e adesão das mulheres no pós-parto.

Repeat Pregnancies Among US Women Living With HIV in the SMARTT Study: Temporal Changes in HIV Disease Status and Predictors of Preterm Birth

BACKGROUND

Birth rates among women living with HIV (WLHIV) have increased recently, with many experiencing multiple pregnancies. Yet, viral suppression is often not sustained between pregnancies. In addition, protease inhibitors (PIs) have been associated with preterm birth, but associations between integrase strand transfer inhibitors (INSTIs) and preterm birth are less well characterized.

METHODS

We studied WLHIV with ≥2 live-born infants enrolled into the Pediatric HIV/AIDS Cohort Study Surveillance Monitoring for Antiretroviral Treatment Toxicities (SMARTT) study between 2007 and 2018, comparing CD4 counts and viral loads (VLs) between 2 consecutive SMARTT pregnancies. We evaluated associations of covariates with CD4 and viral suppression and the association of PI/INSTI use during pregnancy with odds of preterm birth.

RESULTS

There were 736 women who had ≥2 live-born children enrolled in SMARTT (1695 pregnancies). Median CD4 counts remained stable over repeat pregnancies. Although >80% of women achieved VL suppression during pregnancy, more than half had a detectable VL early in their subsequent pregnancy. In adjusted models including all singleton pregnancies, an increased odds of preterm birth was observed for women with first trimester PI initiation (adjusted odds ratio: 1.97; 95% confidence interval: 1.27 to 3.07) compared with those not receiving PIs during pregnancy and for first trimester INSTI initiation (adjusted odds ratio: 2.39; 95% confidence interval: 1.04 to 5.46) compared with those never using INSTIs during pregnancy.

CONCLUSIONS

Most WLHIV achieved VL suppression by late pregnancy but many were viremic early in subsequent pregnancies. First trimester initiation of PIs or INSTIs was associated with a higher risk of preterm birth.

Experiences of HIV-infected adults and healthcare providers with healthcare delivery practices that influence engagement in US primary healthcare settings: a qualitative systematic review

INTRODUCTION

The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is a major public health problem that has claimed the lives of more than 34 million people worldwide. The health of people living with HIV (PLWH) is optimized by ongoing engagement in HIV care, yet many people living with HIV either do not enter or fall out of care. Access to care and ongoing engagement in care for antiretroviral (ARV) medication adherence and psychoeducational support are critical to achieving the desired outcomes of reducing the risk of further HIV transmission and HIV related morbidity and mortality, and managing other commonly co-occurring health, social and behavioral conditions, thereby maximizing wellness.

OBJECTIVE

The objective of the review was to identify, evaluate and synthesize existing qualitative evidence on the experiences of HIV-infected adults with healthcare systems/practices/processes, and the experiences of healthcare providers with healthcare systems/practices/processes that impact engagement in primary healthcare settings in the United States (US).

INCLUSION CRITERIA

The review included studies reporting on the qualitative experiences of HIV-infected adults, aged 18-65 years, with healthcare systems, practices and processes and their healthcare providers (physicians, nurses and others providing care to these patients in the primary care healthcare setting). Qualitative studies including but not limited to designs such as phenomenology, ethnography, grounded theory, action research and qualitative descriptive were included. Studies published in languages other than English and conducted outside of the US were excluded.

METHODS

Using a three-step search strategy, databases of published and unpublished articles were searched from 1997 to 2017. All included studies were assessed by two independent reviewers for methodological quality, and data was extracted and pooled using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Findings were rated according to their level of credibility, categorized based on similarity in meaning and subjected to a meta-synthesis.

RESULTS

A total of 1038 qualitative articles were identified of which 41 were included after critical appraisal. Meta-synthesis generated four synthesized findings: i) What I want from my provider: to be a respectful, empathetic and holistic partner in my care; ii) I cannot do it alone: the critical importance of actively guiding and assisting patients during transitions and securing the needed resources; iii) Help me to understand my illness and care needs; iv) One-stop care that is de-stigmatizing and welcoming to diverse cultures keeps clients in care. These synthesized findings were derived from 243 study findings that were subsequently aggregated into 19 categories. Of the 243 study findings, 240 were rated unequivocal and three were rated credible. The overall ConQual for each of the four synthesized findings was moderate due to common dependability issues across the included studies. A total of 1597 participants were included. Only two studies were included from 1997 to 2000. The majority of included studies were published from 2005 to 2017.

CONCLUSIONS

The synthesized findings illustrate clear quality indicators for primary care practice, emphasizing the patient-provider-care team partnership and shared decision making that is holistic, takes into account a patient's whole life, responsibilities and stressors, and reframes HIV associated misperceptions/myths. The review also highlights the importance of helping patients navigate and interact with the healthcare system by offering one-stop services that assist with multiple medical care needs and "wraparound" services that provide the needed care coordination to assist with critical quality of life needs such as food, housing, transportation, and assistance with applying for health insurance and medication.

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.

eHealth Interventions for Early Infant Diagnosis: Mothers' Satisfaction with the HIV Infant Tracking System in Kenya

The HIV Infant Tracking System (HITSystem) is an eHealth intervention to improve early infant diagnosis (EID) through alerts to providers and text messages to mothers. This study explored mothers' experiences receiving standard and HITSystem-enhanced EID services to assess perceived intervention benefits, acceptability, and opportunities for improvement. This qualitative study was embedded within a cluster-randomized control trial to evaluate the HITSystem at six Kenyan government hospitals (3 intervention, 3 control). We conducted semi-structured interviews with 137 mothers attending EID follow-up visits. Compared to control sites, participants at HITSystem sites described enhanced EID quality; HITSystem-generated texts informed them of result availability and retesting needs, provided cues-to-action for clinic attendance, and engendered opportunities for patient support. They described improved EID efficiency through shorter waiting periods for results and fewer hospital visits. Participants reported high satisfaction with EID and acceptability of text messages; however, modifications to ensure text delivery, increase repeat testing reminders, include low literacy content options, and provide encouraging messages were suggested. These user experience data suggest improvements in EID at HITSystem sites when compared with control sites.

Assessing the Acceptability of a Peer Mentor Mother Intervention to Improve Retention in Care of Postpartum Women Living with HIV

Background: Many women living with HIV (WLWH) experience poor postpartum retention in HIV care. There are limited evidence-based interventions in the United States aimed at increasing retention of WLWH postpartum; however, evidence from low-resource settings suggest that women who receive peer mentoring experience higher retention and viral suppression postpartum.

Methods: We conducted 15 semistructured interviews with pregnant or postpartum women from an urban U.S. clinic to assess factors influencing maternal adherence to antiretroviral therapy (ART) and retention in HIV care. We then assessed the acceptability of a peer intervention in mitigating barriers to sustain adherence and retention in care postpartum. Interviews were audio taped, transcribed, and analyzed. Codes were developed and applied to all transcripts, and matrices were used to facilitate comparisons across different types of participants.

Results: Participants included low-income black and Hispanic women with a mean age of 31 years (range 22–42). Social support and concern for infants' well-being were strong facilitators for engaging in care. Psychosocial challenges, such as stigma and isolation, fear of disclosure, and depression, negatively influenced adherence to ART and engagement in care. Regardless of their level of adherence to ART, women felt that peer mentoring would be an acceptable intervention to reinforce skill-related ART adherence and sustain engagement in care after delivery.

Conclusion: A peer mentor mother program is a promising intervention that can improve the care continuum of pregnant and postpartum women in the United States. Messaging that maximizes maternal support and women's motivation to keep their infant healthy may leverage retention in care postpartum.

"A way of escaping": a qualitative study exploring reasons for clinic transferring and its impact on engagement in care among women in Option B

Clinic transfers among women in Option B+ are frequent, often undocumented, and may lead to suboptimal engagement in care and HIV outcomes. The reasons women move between HIV clinics are not well understood. We conducted four focus group discussions (FGD) among HIV-infected pregnant women in Option B+ and four FGDs and five in-depth interviews among healthcare workers (HCWs) at two large ART clinics in Lilongwe, Malawi. Mobility and fear of inadvertent HIV disclosure, particularly due to seeing neighbors or acquaintances at a clinic, were key drivers of transferring between HIV clinics. Women were aware of the need to obtain a formal transfer, but in practice this was often not feasible and led women to self-transfer clinics. Self-transferring to a new clinic frequently resulted to re-testing and re-initiating ART and concerns about disruptions in ART. Strategies to monitor women's engagement in HIV care without requiring a formal transfer are urgently needed.

Improved Perinatal and Postpartum Human Immunodeficiency Virus Outcomes After Use of a Perinatal Care Coordination Team

In a high-volume clinic in the Southeastern United States, pregnant women living with human immunodeficiency virus (HIV) had improved HIV outcomes up to 6 months after delivery following the introduction of a multidisciplinary perinatal care coordination team.

Postpartum HIV care continuum outcomes in the southeastern USA

OBJECTIVE

The aim of this study was to evaluate postpartum HIV care outcomes.

DESIGN

A prospective clinical cohort of women with HIV and a live birth at the University of North Carolina, 1996-2014.

METHODS

We estimated two stages of the HIV care continuum in the first 24 months postpartum: care retention (at least two visits per year, ≥90 days apart) and viral suppression (HIV RNA < 400 copies/ml). Multivariable models were fit using logistic regression.

RESULTS

Among 1416 women, 141 experienced a live birth at a median age of 28 years, with 74% virally suppressed at delivery. Among all women, 48% were retained in care and 25% maintained viral suppression for the first 24 months postpartum. Among women with available HIV RNA measures, 42% were suppressed at 24 months. HIV care retention estimates were stable across calendar years, but viral suppression rates at 24 months postpartum, among women with available HIV RNA measures, increased from 33 to 67% from 1996-2001 to 2009-2014 (P = 0.04). Being at least 30 years old was positively, and receiving less than 12 weeks of antenatal antiretroviral therapy was negatively, associated with HIV care retention at 24 months postpartum [adjusted odds ratio (AOR): 2.41, 95% confidence interval (95% CI): 1.09-5.29 and AOR: 0.27, 95% CI: 0.08-0.86]. Older maternal age and viral suppression at delivery were both positively associated with virologic suppression at 24 months postpartum (AOR: 2.52, CI: 1.02-6.22, and AOR: 6.42 CI: 1.29-31.97, respectively).

CONCLUSION

HIV care continuum outcomes decrease substantially postpartum, with younger women and those with less antenatal HIV care less likely to successfully remain engaged in HIV care following childbirth.

HIV Care Continuum among Postpartum Women Living with HIV in Atlanta

Introduction

While increased healthcare engagement and antiretroviral therapy (ART) adherence occurs during pregnancy, women living with HIV (WLWH) are often lost to follow-up after delivery. We sought to evaluate postpartum retention in care and viral suppression and to identify associated factors among WLWH in a large public hospital in Atlanta, Georgia.

Methods

Data from the time of entry into prenatal care until 24 months postpartum were collected by chart review from WLWH who delivered with ≥20 weeks gestational age from 2011 to 2016. Primary outcomes were retention in HIV care (two HIV care visits or viral load measurements >90 days apart) and viral suppression (<200 copies/mL) at 12 and 24 months postpartum. Obstetric and contraception data were also collected.

Results

Among 207 women, 80% attended an HIV primary care visit in a mean 124 days after delivery. At 12 and 24 months, respectively, 47% and 34% of women were retained in care and 41% and 30% of women were virally suppressed. Attending an HIV care visit within 90 days postpartum was associated with retention in care at 12 months (aOR 3.66, 95%CI 1.72-7.77) and 24 months (aOR 4.71, 95%CI 2.00-11.10) postpartum. Receiving ART at pregnancy diagnosis (aOR 2.29, 95%CI 1.11-4.74), viral suppression at delivery (aOR 3.44, 95%CI 1.39-8.50), and attending an HIV care visit within 90 days postpartum (aOR 2.40, 95%CI 1.12-5.16) were associated with 12-month viral suppression, and older age (aOR 1.09, 95% CI 1.01-1.18) was associated with 24-month viral suppression.

Conclusions

Long-term retention in HIV care and viral suppression are low in this population of postpartum WLWH. Prompt transition to HIV care in the postpartum period was the strongest predictor of optimal HIV outcomes. Efforts supporting women during the postpartum transition from obstetric to HIV primary care may improve long-term HIV outcomes in women.

Substance Use, Demographic and Socioeconomic Factors Are Independently Associated With Postpartum HIV Care Engagement in the Southern United States, 1999-2016

Background

Retention in care (RIC) and viral suppression (VS) are associated with reduced HIV transmission and mortality. Studies addressing postpartum engagement in HIV care have been limited by small sample size, short follow-up, and a lack of data from the Southeast United States.

Methods

HIV-positive adult women with ≥1 prenatal visit at the Vanderbilt Obstetrics Comprehensive Care Clinic from 1999 to 2015 were included. Poor RIC was defined as not having ≥2 encounters per year, ≥90 days apart; poor VS was a viral load >200 copies/mL. Modified Poisson regression was used to estimate adjusted relative risks (aRRs) of poor postpartum RIC and VS.

Results

Among 248 women over 2070 person-years of follow-up, 37.6% person-years had poor RIC and 50.4% lacked VS. Prenatal substance use was independently associated with poor RIC (aRR, 1.40; 95% confidence interval [CI], 1.08–1.80) and poor VS (aRR, 1.20; 95% CI, 1.04–1.38), and lack of VS at enrollment was associated with poor RIC (aRR, 1.64; 95% CI, 1.15–2.35) and poor VS (aRR, 1.59; 95% CI, 1.30–1.94). Hispanic women were less likely and women with lower educational attainment were more likely to have poor RIC. Women >30 years of age and married women were less likely to have poor VS.

Conclusions

In this population of women in prenatal care at an HIV primary medical home in Tennessee, women with prenatal substance use and a lack of VS at enrollment into prenatal care were at greater risk of poor RIC and lack of VS postpartum. Interventions aimed at improving postpartum engagement in HIV care among these high-risk groups are needed.

"You Come Back to the Same Ole Shit:" A Qualitative Study of Smoking Cessation Barriers among Women Living with HIV: Implications for Intervention Development

Although tobacco use among women living with HIV (WLWH) is decreasing, the prevalence is more than double that of women in the general population and remains an important health behavior to target among WLWH. Few smoking cessation interventions specifically focus on the unique social and medical needs of WLWH. Thus, the investigative team engaged WLWH (N=18) in qualitative focus groups to: 1) understand barriers and facilitators to smoking cessation; and 2) inform intervention structure and content priorities. Participants identified salient reasons for smoking and barriers to smoking cessation, which included coping with multiple life stressors, HIV-related stress, HIV-related stigma and social isolation. Further, WLWH highlighted the importance of long-term smoking cessation support, peer support, mental health content, religion/spirituality, and targeted risk messaging in smoking cessation intervention development. Study findings provide concrete, operational strategies for future use in a theory-based smoking cessation intervention, and underscore the importance of formative research to inform smoking cessation interventions for WLWH.

Factors Associated with Postpartum Loss to Follow-Up and Detectable Viremia After Delivery Among Pregnant Women Living with HIV

Pregnant women living with HIV are at risk for loss to follow-up and viral rebound after delivery. We conducted a retrospective cohort study of women with HIV who delivered at Parkland Hospital, Dallas, to identify factors associated with postpartum loss to HIV care 1 year after delivery. Logistic regression was used to identify factors predicting loss to follow-up. For a subset of women, we compared odds of viremia detectable at delivery and postpartum among women with higher versus lower pill burden regimens. We included 604 women with HIV who delivered between 2005 and 2015. Three hundred ninety-one (65%) women completed at least one visit with an HIV provider within 1 year of delivery. The follow-up rate among black, non-Hispanic women was 65%; 57% for white, non-Hispanic women; and 78% for Hispanic women. Women without follow-up presented for prenatal care later (17 vs. 11 weeks, p < 0.001), and were less likely to be on antiretroviral therapy at initial prenatal visit (29% vs. 49%, p < 0.001). Factors predicting loss to follow-up in multivariate analysis included low-level viremia at delivery [adjusted odds ratio (aOR) = 2.85, 95% confidence interval (CI) = 1.73-4.71] and failure to return for a postpartum visit (aOR = 3.19, 95% CI = 2.07-4.94). High antiretroviral pill burden (≥6 pills daily) was associated with viremia (>1000 copies/mL) at the first prenatal visit (OR = 8.7, 95% CI = 4.6-16.6) through 1 year postpartum (OR = 2.3, 95% CI = 1.2-4.4). Viremia at delivery, failure to return for a postpartum visit, and high pill burden during pregnancy are predictors of postpartum loss to HIV care.

Perceived Barriers to Antepartum HIV Medication Adherence in HIV Infected Pregnant Women

Introduction

Although rare, perinatal HIV transmission still occurs in the United States and most transmissions are preventable. We aim to identify patient barriers to antiretroviral therapy (ART) adherence during pregnancy and assess patient understanding of perinatal transmission.

Methods

This cross-sectional survey recruited HIV positive postpartum women at a large safety net hospital in Atlanta, Georgia, between January 2016 and February 2018. Survey questions included demographic characteristics, HIV history, knowledge of perinatal transmission, and ART adherence. Perinatal and HIV outcomes were assessed using chart abstraction.

Results

Of the 70 HIV infected postpartum women delivered at a large safety net hospital in Atlanta, GA, 45 women were eligible and consented to participate. Participating women were aged 18 to 40 years with an average age of 29 years old, 93% of participants were African-American, and 68% had ≥3 pregnancies. The majority of participants (75%) reported daily ART adherence. "Forgetting" was the most frequent reason for missing pills (57%). Thirteen women had a detectable viral load at the time of delivery and nine of those women had a viral load greater than 1000 copies/mL. Approximately 85% of women who correctly stated ART medications decrease perinatal transmission risk reported daily adherence compared with 50% of women without that knowledge (OR 5.6, 95% CI 1.17, 26.7). Almost half of women (40%) either did not know or believed a vaginal delivery, regardless of viral load, would increase their risk of perinatal transmission.

Conclusion

Overall, women who were diagnosed with HIV during the current pregnancy, those with planned pregnancies, and those who were on medications prior to pregnancy were more likely to report daily ART adherence. Detectable viral load at delivery is the greatest risk factor for perinatal transmission; therefore strategies to increase ART adherence are needed.

Mental health and retention in HIV care: A systematic review and meta-analysis

OBJECTIVE

Mental health (MH) diagnoses, which are prevalent among persons living with HIV infection, might be linked to failed retention in HIV care. This review synthesized the quantitative evidence regarding associations between MH diagnoses or symptoms and retention in HIV care, as well as determined if MH service utilization (MHSU) is associated with improved retention in HIV care.

METHOD

A comprehensive search of the Centers for Disease Control and Prevention's HIV/AIDS Prevention Research Synthesis database of electronic (e.g., MEDLINE, EMBASE, PsycINFO) and manual searches was conducted to identify relevant studies published during January 2002-August 2017. Effect estimates from individual studies were pooled by using random-effects meta-analysis, and a moderator analysis was conducted.

RESULTS

Forty-five studies, involving approximately 57,334 participants in total, met the inclusion criteria: 39 examined MH diagnoses or symptoms, and 14 examined MHSU. Overall, a significant association existed between MH diagnoses or symptoms, and lower odds of being retained in HIV care (odds ratio, OR = 0.94; 95% confidence interval [CI] [0.90, 0.99]). Health insurance status (β = 0.004; Z = 3.47; p = .001) significantly modified the association between MH diagnoses or symptoms and retention in HIV care. In addition, MHSU was associated with an increased odds of being retained in HIV care (OR = 1.84; 95% CI [1.45, 2.33]).

CONCLUSIONS

Results indicate that MH diagnoses or symptoms are a barrier to retention in HIV care and emphasize the importance of providing MH treatment to HIV patients in need. (PsycINFO Database Record

Health System Features That Enhance Access to Comprehensive Primary Care for Women Living with HIV in High-Income Settings: A Systematic Mixed Studies Review

Women living with HIV in high-income settings continue to experience modifiable barriers to care. We sought to determine the features of care that facilitate access to comprehensive primary care, inclusive of HIV, comorbidity, and sexual and reproductive healthcare. Using a systematic mixed studies review design, we reviewed qualitative, mixed methods, and quantitative studies identified in Ovid MEDLINE, EMBASE, and CINAHL databases (January 2000 to August 2017). Eligibility criteria included women living with HIV; high-income countries; primary care; and healthcare accessibility. We performed a thematic synthesis using NVivo. After screening 3466 records, we retained 44 articles and identified 13 themes. Drawing on a social-ecological framework on engagement in HIV care, we situated the themes across three levels of the healthcare system: care providers, clinical care environments, and social and institutional factors. At the care provider level, features enhancing access to comprehensive primary care included positive patient-provider relationships and availability of peer support, case managers, and/or nurse navigators. Within clinical care environments, facilitators to care were appointment reminder systems, nonidentifying clinic signs, women and family spaces, transportation services, and coordination of care to meet women's HIV, comorbidity, and sexual and reproductive healthcare needs. Finally, social and institutional factors included healthcare insurance, patient and physician education, and dispelling HIV-related stigma. This review highlights several features of care that are particularly relevant to the care-seeking experience of women living with HIV. Improving their health through comprehensive care requires a variety of strategies at the provider, clinic, and greater social and institutional levels.

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.

Long term engagement in HIV care among postpartum women with perinatal HIV infection in the United States

Despite growing literature on pregnancy in women with perinatally-acquired HIV infection (PHIV), little is known regarding HIV and reproductive health outcomes postpartum. We describe pregnancy, reproductive, and HIV care outcomes for 2 years postpartum among pregnant women with PHIV who delivered in a large urban health system in Atlanta, Georgia, USA from 2011-2016. We reviewed medical records of women with PHIV to estimate retention in HIV care (two HIV care visits or viral load measurements >90 days apart) and viral suppression (<200 copies/mL) at 12 and 24 months postpartum. Among 22 pregnant women with PHIV, 13 (59%) had a CD4 count of less than 300 cells/mm³ at the time of antenatal care entry; most (n = 13, 59%) women achieved viral suppression at time of delivery. Three quarters of women attended a postpartum HIV primary care visit, within an average of 193 (range 17-727) days. Only 4 (20%) women were retained and 3 (15%) virally suppressed at 12 postpartum, and 2 (12%) were retained and none virally suppressed at 24 months. Despite the unique challenges they face, multidisciplinary efforts are needed to engage women with PHIV during pregnancy and facilitate the transition to sustained HIV primary care in the postpartum period.