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Phillips TK, Kassanjee R, Maxwell N, Anderson K, Johnson L, Moolla H, Myer L, Chi BH, Euvrard J, Boulle A, Davies M, Cornell M, de Waal R. ART history prior to conception: trends and association with postpartum disengagement from HIV care in Khayelitsha, South Africa (2013-2019): a retrospective cohort study. J Int AIDS Soc 2024; 27:e26236. [PMID: 38566482 PMCID: PMC10988117 DOI: 10.1002/jia2.26236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 03/12/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION In recent years, the expansion of HIV treatment eligibility has resulted in an increase in people with antiretroviral therapy (ART) experience prior to pregnancy but little is known about postpartum engagement in care in this population. We examined differences in disengagement from HIV care after delivery by maternal ART history before conception. METHODS We analysed data from people living with HIV (aged 15-49) in Khayelitsha, South Africa, with ≥1 live birth between April 2013 and March 2019. We described trends over time in ART history prior to estimated conception, classifying ART history groups as: (A) on ART with no disengagement (>270 days with no evidence of HIV care); (B) returned before pregnancy following disengagement; (C) restarted ART in pregnancy after disengagement; and (D) ART new start in pregnancy. We used Kaplan-Meier curves and proportional-hazards models (adjusted for maternal age, number of pregnancy records and year of delivery) to examine the time to disengagement from delivery to 2 years postpartum. RESULTS Among 7309 pregnancies (in 6680 individuals), the proportion on ART (A) increased from 19% in 2013 to 41% in 2019. The proportions of those who returned (B) and restarted (C) increased from 2% to 13% and from 2% to 10%, respectively. There was a corresponding decline in the proportion of new starts (D) from 77% in 2013 to 36% in 2019. In the first recorded pregnancy per person in the study period, 26% (95% CI 25-27%) had disengaged from care by 1 year and 34% (95% CI 33-36%) by 2 years postpartum. Individuals who returned (B: aHR 2.10, 95% CI 1.70-2.60), restarted (C: aHR 3.32, 95% CI 2.70-4.09) and newly started ART (D: aHR 2.41, 95% CI 2.12-2.74) had increased hazards of postpartum disengagement compared to those on ART (A). CONCLUSIONS There is a growing population of people with ART experience prior to conception and postpartum disengagement varies substantially by ART history. Antenatal care presents an important opportunity to understand prior ART experiences and an entry into interventions for strengthened engagement in HIV care.
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Affiliation(s)
- Tamsin Kate Phillips
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
- Division of Epidemiology & BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Reshma Kassanjee
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Nicola Maxwell
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Kim Anderson
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Leigh Johnson
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Haroon Moolla
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Landon Myer
- Division of Epidemiology & BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Benjamin H. Chi
- Department of Obstetrics and GynecologySchool of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
- Department of Health and WellnessProvincial Government of the Western CapeCape TownSouth Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
- Department of Health and WellnessProvincial Government of the Western CapeCape TownSouth Africa
| | - Mary‐Ann Davies
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
- Department of Health and WellnessProvincial Government of the Western CapeCape TownSouth Africa
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Renee de Waal
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
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Pellowski JA, Jensen D, Tsawe N, Colvin C, Cu-Uvin S, Operario D, Lurie M, Harrison A, Myer L, Knight L. Womandla Health: development and rationale of a behavioral intervention to support HIV treatment adherence among postpartum women in South Africa. BMC Womens Health 2023; 23:649. [PMID: 38057777 PMCID: PMC10701937 DOI: 10.1186/s12905-023-02817-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/28/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND While Option B + has made great strides in eliminating vertical transmission of HIV and improving access to lifelong antiretroviral therapy (ART) for women, the postpartum period remains a risk period for disengagement from HIV care and non-adherence. METHODS Longitudinal qualitative data was collected from 30 women living with HIV in Cape Town, South Africa from pregnancy through 1 year postpartum to examine key barriers and facilitators to HIV treatment adherence across this transition. Participants were also asked about their preferences for behavioral intervention content, format, and scope. The intervention development process was guided by Fernandez et al.'s Intervention Mapping process and was informed by the qualitative data, the wider literature on ART adherence, and Transition Theory. RESULTS The Womandla Health Intervention is a multicomponent intervention consisting of four individual sessions with a lay health worker and four peer group sessions, which span late pregnancy and early postpartum. These sessions are guided by Transition Theory and utilize motivational interviewing techniques to empower women to ascertain their own individual barriers to HIV care and identify solutions and strategies to overcome these barriers. CONCLUSIONS This intervention will be tested in a small scale RCT. If successful, findings will provide an innovative approach to HIV treatment by capitalizing on the transition into motherhood to bolster self-care behaviors, focusing on ART adherence and also women's overall postpartum health and psychosocial needs.
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Affiliation(s)
- Jennifer A Pellowski
- School of Public Health, Brown University, Providence, USA.
- School of Public Health, University of Cape Town, Cape Town, South Africa.
| | - Destry Jensen
- School of Public Health, Brown University, Providence, USA
| | - Nokwazi Tsawe
- School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Christopher Colvin
- School of Public Health, University of Cape Town, Cape Town, South Africa
- School of Medicine, University of Virginia, Charlottesville, USA
| | - Susan Cu-Uvin
- The Warren Alpert Medical School of Brown University, Providence,, USA
| | - Don Operario
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Mark Lurie
- School of Public Health, Brown University, Providence, USA
- School of Public Health, University of Cape Town, Cape Town, South Africa
| | | | - Landon Myer
- School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Lucia Knight
- School of Public Health, University of Cape Town, Cape Town, South Africa
- School of Public Health, University of the Western Cape, Cape Town, South Africa
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Brittain K, Brown K, Phillips T, Zerbe A, Pellowski J, Remien RH, Mellins CA, Abrams EJ, Myer L. Why do Integrated Maternal HIV and Infant Healthcare Services work? A Secondary Analysis of a Randomised Controlled Trial in South Africa. AIDS Behav 2023; 27:3831-3843. [PMID: 37306847 PMCID: PMC10598190 DOI: 10.1007/s10461-023-04097-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2023] [Indexed: 06/13/2023]
Abstract
In a randomised trial, we found that integrated maternal HIV and infant health services through the end of breastfeeding were significantly associated with the primary outcome of engagement in HIV care and viral suppression at 12 months postpartum, compared to the standard of care. Here, we quantitatively explore potential psychosocial modifiers and mediators of this association. Our findings suggest that the intervention was significantly more effective among women experiencing an unintended pregnancy but did not improve outcomes among women reporting risky alcohol use. Although not statistically significant, our results suggest that the intervention may also be more effective among women experiencing higher levels of poverty and HIV-related stigma. We observed no definitive mediator of the intervention effect, but women allocated to integrated services reported better relationships with their healthcare providers through 12 months postpartum. These findings point to high-risk groups that may benefit the most from integrated care, as well as groups for whom these benefits are hampered and that warrant further attention in intervention development and evaluation.
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Affiliation(s)
- Kirsty Brittain
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.
| | - Karryn Brown
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - Tamsin Phillips
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - Allison Zerbe
- Mailman School of Public Health, ICAP at Columbia University, Columbia University, New York, NY, USA
| | - Jennifer Pellowski
- Department of Behavioral & Social Sciences, Brown University School of Public Health, Providence, RI, USA
- International Health Institute, Brown University School of Public Health, Providence, RI, USA
| | - Robert H Remien
- New York State Psychiatric Institute, HIV Center for Clinical & Behavioral Studies, Columbia University, New York, NY, USA
| | - Claude A Mellins
- New York State Psychiatric Institute, HIV Center for Clinical & Behavioral Studies, Columbia University, New York, NY, USA
| | - Elaine J Abrams
- Mailman School of Public Health, ICAP at Columbia University, Columbia University, New York, NY, USA
- Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
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Geremew H, Geremew D, Abdisa S, Dessie AM, Kassa GM, Moges NA. Adherence to option B+ PMTCT program and its predictors among HIV-positive women in Ethiopia. A systematic review and meta-analysis. Health Sci Rep 2023; 6:e1404. [PMID: 37425229 PMCID: PMC10323164 DOI: 10.1002/hsr2.1404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/08/2023] [Accepted: 06/26/2023] [Indexed: 07/11/2023] Open
Abstract
Background Previously, few studies investigated level of adherence to option B+ lifelong antiretroviral therapy (ART) in Ethiopia. However, their findings were inconsistent. Therefore, this review aimed to determine the pooled magnitude of adherence to option B+ lifelong ART and its predictors among human immune virus (HIV)-positive women in Ethiopia. Methods A comprehensive web-based search was conducted using PubMed, Cochrane Library, Science Direct, Google scholar, and African Journals Online databases to retrieve relevant articles. STATA 14 statistical software was used to carry out the meta-analysis. We used the random effects model to account for the large heterogeneity across included studies. Egger's regression test in conjunction with funnel plot and I 2 statistics were utilized to assess publication bias and heterogeneity among included studies respectively. Result Twelve studies with a total of 2927 study participants were involved in this analysis. The pooled magnitude of adherence to option B+ lifelong ART was 80.72% (95% confidence interval [CI]: 77.05-84.39; I 2 = 85.4%). Disclosure of sero-status (OR 2.58 [95% CI: 1.55-4.3]), receiving counseling (OR 4.93 [95% CI: 3.21-7.57]), attending primary school and above (OR 2.45 [95% CI: 1.31-4.57]), partner support (OR 2.24 [95% CI: 1.11, 4.52]), good knowledge about prevention of mother-to-child transmission (PMTCT) (OR 4.22 [95% CI: 2.02-8.84]), taking less time to reach health facility (OR 1.64 [95% CI: 1.13-2.4]), and good relation with care provider (OR 3.24 [95% CI: 1.96-5.34]) were positively associated with adherence. Whereas, fear of stigma and discrimination (OR 0.12 [95% CI: 0.06-0.22]) and advanced disease stage (OR 0.59 [95% CI: 0.37-0.92]) were negatively associated. Conclusion The level of adherence to option B+ lifelong ART was suboptimal. Strengthened comprehensive counseling and client education on PMTCT, HIV status disclosure, and male partner involvement are important to eliminate mother to child transmission and control the pandemic.
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Affiliation(s)
- Habtamu Geremew
- College of Health SciencesOda Bultum UniversityChiroEthiopia
| | - Demeke Geremew
- Department of Medical Laboratory Sciences, Immunology and Molecular Biology Unit, College of Medicine and Health SciencesBahir Dar UniversityBahir DarEthiopia
| | - Samuel Abdisa
- College of Health SciencesOda Bultum UniversityChiroEthiopia
| | - Anteneh Mengist Dessie
- Department of Public Health, College of Health SciencesDebre Tabor UniversityDebre TaborEthiopia
| | - Getachew Mullu Kassa
- Department of Public Health, College of Health SciencesDebre Markos UniversityDebre MarkosEthiopia
| | - Nurilign Abebe Moges
- Department of Public Health, College of Health SciencesDebre Markos UniversityDebre MarkosEthiopia
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Chagomerana MB, Harrington BJ, DiPrete BL, Wallie S, Maliwichi M, Wesevich A, Phulusa JN, Kumwenda W, Jumbe A, Hosseinipour MC. Three-year outcomes for women newly initiated on lifelong antiretroviral therapy during pregnancy - Malawi option B. AIDS Res Ther 2023; 20:37. [PMID: 37308909 PMCID: PMC10258937 DOI: 10.1186/s12981-023-00523-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 05/02/2023] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION Antiretroviral therapy (ART) is very effective in preventing vertical transmission of HIV but some women on ART experience different virologic, immunologic, and safety profiles. While most pregnant women are closely monitored for short-term effects of ART during pregnancy, few women receive similar attention beyond pregnancy. We aimed to assess retention in care and clinical and laboratory-confirmed outcomes over 3 years after starting ART under Malawi's Option B + program. METHODS We conducted a prospective cohort study of pregnant women newly diagnosed with HIV who started tenofovir disoproxil fumarate/emtricitabine/efavirenz (TDF/3TC/EFV) for the first time at Bwaila Hospital in Lilongwe, Malawi between May 2015 and June 2016. Participants were followed for 3 years. We summarized demographic characteristics, pregnancy outcomes, and clinical and laboratory adverse events findings using proportions. Log-binomial regression models were used to estimate the overall risk ratios (RR) and the corresponding 95% confidence interval (CI) for the association between index pregnancy (i.e. index pregnancy vs. subsequent pregnancy) and preterm birth, and index pregnancy and low birthweight. RESULTS Of the 299 pregnant women who were enrolled in the study, 255 (85.3%) were retained in care. There were 340 total pregnancies with known outcomes during the 36-month study period, 280 index pregnancies, and 60 subsequent pregnancies. The risks of delivering preterm (9.5% for index pregnancy and13.5% for subsequent pregnancy: RR = 0.70; 95% CI: 0.32-1.54), or low birth weight infant (9.8% for index pregnancy and 4.2% for subsequent pregnancy: RR = 2.36; 95% CI: 0.58-9.66) were similar between index and subsequent pregnancies. Perinatally acquired HIV was diagnosed in 6 (2.3%) infants from index pregnancies and none from subsequent pregnancies. A total of 50 (16.7%) women had at least one new clinical adverse event and 109 (36.5%) women had at least one incident abnormal laboratory finding. Twenty-two (7.3%) women switched to second line ART: of these 64.7% (8/17) had suppressed viral load and 54.9% (6/17) had undetectable viral load at 36 months. CONCLUSION Most of the women who started TDF/3TC/EFV were retained in care and few infants were diagnosed with perinatally acquired HIV. Despite switching, women who switched to second line therapy continued to have higher viral loads suggesting that additional factors beyond TDF/3TC/EFV failure may have contributed to the switch. Ongoing support during the postpartum period is necessary to ensure retention in care and prevention of vertical transmission.
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Affiliation(s)
- Maganizo B Chagomerana
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi.
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Bryna J Harrington
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- Johns Hopkins Dept. of Gynecology & Obstetrics, Baltimore, MD, USA
| | - Bethany L DiPrete
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Austin Wesevich
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- Section of Hematology/Oncology, University of Chicago, Chicago, IL, USA
| | | | - Wiza Kumwenda
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Allan Jumbe
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Mina C Hosseinipour
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Musanhu CCC, Takarinda KC, Shea J, Chitsike I, Eley B. Viral load testing among pregnant women living with HIV in Mutare district of Manicaland province, Zimbabwe. AIDS Res Ther 2022; 19:52. [PMID: 36384677 PMCID: PMC9667426 DOI: 10.1186/s12981-022-00480-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 10/07/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Viral load (VL) monitoring of pregnant women living with HIV (PWLHIV) and antiretroviral therapy (ART) may contribute to lowering the risk of vertical transmission of HIV. The aims of this study were to assess the uptake of HIV VL testing among PWLHIV at entry to the prevention-of-mother-to-child transmission (PMTCT) services and identify facilitatory factors and barriers to HIV VL access. METHODS A retrospective, cross-sectional study was conducted at 15 health facilities in Mutare district, Manicaland Province, Zimbabwe from January to December 2018. This analysis was complemented by prospective interviews with PWLHIV and health care providers between October 2019 and March 2020. Quantitative data were analysed using descriptive and inferential statistical methods. Risk factors were evaluated using multivariate logistic regression. Open-ended questions were analysed and recurring and shared experiences and perceptions of PWLHIV and health care providers identified. RESULTS Among 383 PWLHIV, enrolled in antenatal care (ANC) and receiving ART, only 121 (31.6%) had a VL sample collected and 106 (88%) received their results. Among these 106 women, 93 (87.7%) had a VL < 1000 copies/mL and 77 (73%) a VL < 50 copies/mL. The overall median duration from ANC booking to VL sample collection was 87 (IQR, 7-215) days. The median time interval for the return of VL results from date of sample collection was 14 days (IQR, 7-30). There was no significant difference when this variable was stratified by time of ART initiation. VL samples were significantly less likely to be collected at local authority compared to government facilities (aOR = 0.28; 95% CI 0.16-0.48). Barriers to VL testing included staff shortages, non-availability of consumables and sub-optimal sample transportation. Turnaround time was prolonged by the manual results feedback system. CONCLUSIONS AND RECOMMENDATION The low rate of HIV VL testing among PWLHIV in Mutare district is a cause for concern. To reverse this situation, the Ministry of Health should consider interventions such as disseminating antiretroviral guidelines and policies electronically, conducting regular PMTCT mentorship for clinical staff members, and utilising point of care testing and telecommunication devices like mHealth to increase uptake of VL testing and improve results turnaround time.
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Affiliation(s)
- Christine Chiedza Chakanyuka Musanhu
- World Health Organization Country Office, Highlands, P.O.Box HG 430, Harare, Zimbabwe ,grid.415818.1AIDS & TB Department, Ministry of Health and Child Care, Harare, Zimbabwe ,grid.7836.a0000 0004 1937 1151Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | | | - Jawaya Shea
- grid.7836.a0000 0004 1937 1151Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Inam Chitsike
- grid.13001.330000 0004 0572 0760College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Brian Eley
- grid.7836.a0000 0004 1937 1151Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa ,grid.415742.10000 0001 2296 3850Paediatric Infectious Diseases Unit, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
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Caniglia EC, Zash R, Swanson SA, Smith E, Sudfeld C, Finkelstein JL, Diseko M, Mayondi G, Mmalane M, Makhema J, Fawzi W, Lockman S, Shapiro RL. Iron, folic acid, and multiple micronutrient supplementation strategies during pregnancy and adverse birth outcomes in Botswana. Lancet Glob Health 2022; 10:e850-e861. [PMID: 35561720 PMCID: PMC9309424 DOI: 10.1016/s2214-109x(22)00126-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 02/10/2022] [Accepted: 03/16/2022] [Indexed: 12/18/2022]
Abstract
Background Methods Findings Interpretation Funding
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Affiliation(s)
- Ellen C Caniglia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Rebecca Zash
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana; Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Emily Smith
- School of Public Health, George Washington University, Washington DC, USA
| | - Christopher Sudfeld
- Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Julia L Finkelstein
- Division of Nutritional Sciences, Cornell College of Human Ecology, Cornell University, Ithaca, NY, USA
| | - Modiegi Diseko
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Gloria Mayondi
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mompati Mmalane
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Joseph Makhema
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Wafaie Fawzi
- Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Shahin Lockman
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana; Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Roger L Shapiro
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana; Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
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Lyatuu GW, Naburi H, Mwashemele S, Lyaruu P, Urrio R, Simba B, Philipo E, Kibao A, Kajoka D, Sando D, Orsini N, Biberfeld G, Kilewo C, Ekström AM. Effect of peer-mother interactive programme on prevention of mother-to-child HIV transmission outcomes among pregnant women on anti-retroviral treatment in routine healthcare in Dar es Salaam, Tanzania. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000256. [PMID: 36962367 PMCID: PMC10021914 DOI: 10.1371/journal.pgph.0000256] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/13/2022] [Indexed: 11/18/2022]
Abstract
Peer support services are increasingly being integrated in programmes for the prevention of mother-to-child HIV transmission (PMTCT). We aimed to evaluate the effect of a peer-mother interactive programme on PMTCT outcomes among pregnant women on anti-retroviral treatment (ART) in routine healthcare in Dar es Salaam, Tanzania. Twenty-three health facilities were cluster-randomized to a peer-mother intervention and 24 to a control arm. We trained 92 ART experienced women with HIV to offer peer education, adherence and psychosocial support to women enrolling in PMTCT care at the intervention facilities. All pregnant women who enrolled in PMTCT care at the 47 facilities from 1st January 2018 to 31st December 2019 were identified and followed up to 31st July 2021. The primary outcome was time to ART attrition (no show >90 days since the scheduled appointment, excluding transfers) and any difference in one-year retention in PMTCT and ART care between intervention and control facilities. Secondary outcomes were maternal viral suppression (<400 viral copies/mL) and mother-to-child HIV transmission (MTCT) by ≥12 months post-partum. Analyses were done using Kaplan Meier and Cox regression (ART retention/attrition), generalized estimating equations (viral suppression) and random effects logistic regression (MTCT); reporting rates, proportions and 95% confidence intervals (CI). There were 1957 women in the peer-mother and 1384 in the control facilities who enrolled in routine PMTCT care during 2018-2019 and were followed for a median [interquartile range (IQR)] of 23 [10, 31] months. Women in both groups had similar median age of 30 [IQR 25, 35] years, but differed slightly with regard to proportions in the third pregnancy trimester (14% versus 19%); advanced HIV (22% versus 27%); and ART naïve (55% versus 47%). Peer-mother facilities had a significantly lower attrition rate per 1000 person months (95%CI) of 14 (13, 16) versus 18 (16, 19) and significantly higher one-year ART retention (95%CI) of 78% (76, 80) versus 74% (71, 76) in un-adjusted analyses, however in adjusted analyses the effect size was not statistically significant [adjusted hazard ratio of attrition (95%CI) = 0.85 (0.67, 1.08)]. Viral suppression (95%CI) was similar in both groups [92% (91, 93) versus 91% (90, 92)], but significantly higher among ART naïve women in peer-mother [91% (89, 92)] versus control [88% (86, 90)] facilities. MTCT (95%CI) was similar in both groups [2.2% (1.4, 3.4) versus 1.5% (0.7, 2.8)]. In conclusion, we learned that integration of peer-mother services in routine PMTCT care improved ART retention among all women and viral suppression among ART naïve women but had no significant influence on MTCT.
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Affiliation(s)
- Goodluck Willey Lyatuu
- Management and Development for Health, Dar es Salaam, Tanzania
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Helga Naburi
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Shally Mwashemele
- Health Section, United Nations Children's Fund, Dar es Salaam, Tanzania
| | - Peter Lyaruu
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Roseline Urrio
- Management and Development for Health, Dar es Salaam, Tanzania
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Brenda Simba
- Management and Development for Health, Dar es Salaam, Tanzania
| | | | - Ayoub Kibao
- Department of Health and Social Welfare, Regional Administrative Secretary, Dar es Salaam, Tanzania
| | - Deborah Kajoka
- Department of Preventive Services, Tanzania Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - David Sando
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Nicola Orsini
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Gunnel Biberfeld
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Charles Kilewo
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Redinger S, Udedi E, Richter LM, Dovel KL, Bruns L, Coates TJ, Rochat TJ. Double benefit? Integrating an early childhood development programme into HIV PMTCT Option B+ services in Malawi. AIDS Care 2021; 33:1595-1602. [PMID: 33615906 DOI: 10.1080/09540121.2021.1876834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Abstract
KEY MESSAGES Benefits for mothers and children can be achieved through the successful integration of an early childhood development programme into PMTCT Option B+ services in Malawi.Our study based on in-depth interviews with 62 mothers indicated that such an approach is feasible and acceptable.Participating mothers reported that the integration of the early childhood development component improved their confidence and they believed it improved their parenting;led to improved relationships with health care providers;increased the engagement of fathers and support from others in the family;helped mothers build a new social network and support system through the peer engagement components;reduced the risk of stigmatization in the health care setting.
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Affiliation(s)
- Stephanie Redinger
- SAMRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- DSI-NRF Centre of Excellence in Human Development, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Linda M Richter
- DSI-NRF Centre of Excellence in Human Development, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathryn L Dovel
- Partners in Hope, Lilongwe, Malawi
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Laurie Bruns
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Thomas J Coates
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Tamsen J Rochat
- SAMRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- DSI-NRF Centre of Excellence in Human Development, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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10
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Shah SK, London AJ, Mofenson L, Lavery JV, John-Stewart G, Flynn P, Theron G, Bangdiwala SI, Moodley D, Chinula L, Fairlie L, Sekoto T, Kakhu TJ, Violari A, Dadabhai S, McCarthy K, Fowler MG. Ethically designing research to inform multidimensional, rapidly evolving policy decisions: Lessons learned from the PROMISE HIV Perinatal Prevention Trial. Clin Trials 2021; 18:681-689. [PMID: 34524048 DOI: 10.1177/17407745211045734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Research in rapidly evolving policy contexts can lead to the following ethical challenges for sponsors and researchers: the study's standard of care can become different than what patients outside the study receive, there may be political or other pressure to move ahead with unproven interventions, and new findings or revised policies may decrease the relevance of ongoing studies. These ethical challenges are considerable, but not unprecedented. In this article, we review the case of a multinational, randomized, controlled perinatal HIV prevention trial, the "PROMISE" (Promoting Maternal Infant Survival Everywhere) study. PROMISE compared the relative efficacy and safety of interventions to prevent mother to child transmission of HIV. The sponsor engaged an independent international ethics panel to address controversy about the study's standard of care and relevance as national and international guidelines changed. This ethics panel concluded that continuing the PROMISE trial as designed was ethically permissible because: (1) participants in all arms received interventions that were effective, and there was insufficient evidence about whether one intervention was more effective or safer than the other, and (2) data from PROMISE could be useful for a diverse range of stakeholders. In general, trials designed to inform rapidly evolving policy issues should develop mechanisms to revisit social value while recognizing that the value of research varies for diverse stakeholders with legitimate reasons to weigh evidence differently. We conclude by providing four reasons that trials may depart from the standard of care after a change in policy, while remaining ethically justifiable, and by suggesting how to improve existing trial oversight mechanisms to address evolving social value.
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Affiliation(s)
- Seema K Shah
- Department of Pediatrics, Northwestern Feinberg School of Medicine, Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation (SCHORE) Center, Stanley Manne Children's Research Institute, Lurie Children's Hospital, Northwestern Pritzker School of Law, by courtesy, Chicago, IL, USA
| | - Alex John London
- Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Lynne Mofenson
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | - James V Lavery
- Global Health Ethics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Patricia Flynn
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Gerhard Theron
- Department of Obstetrics and Gynaecology, Stellenbosch University, Cape Town, South Africa
| | | | - Dhayendre Moodley
- Centre for AIDS Research in South Africa and Department of Obstetrics and Gynecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
| | | | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
| | - Tumalano Sekoto
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Tebogo J Kakhu
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Avy Violari
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
| | - Sufia Dadabhai
- Johns Hopkins Bloomberg School of Public Health, Blantyre, Malawi
| | | | - Mary Glenn Fowler
- Johns Hopkins University Research Collaboration, Makerere University, Kampala, Uganda
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11
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Caniglia EC, Abrams J, Diseko M, Mayondi G, Mabuta J, Makhema J, Mmalane M, Lockman S, Bernstein A, Zash R, Shapiro R. Seasonality of adverse birth outcomes in women with and without HIV in a representative birth outcomes surveillance study in Botswana. BMJ Open 2021; 11:e045882. [PMID: 34479931 PMCID: PMC8420660 DOI: 10.1136/bmjopen-2020-045882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 08/05/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Sub-Saharan Africa has the largest number of people with HIV, one of the most severe burdens of adverse birth outcomes globally and particular vulnerability to climate change. We examined associations between seasonality and adverse birth outcomes among women with and without HIV in a large geographically representative birth outcomes surveillance study in Botswana from 2015 to 2018. METHODS We evaluated stillbirth, preterm delivery, very preterm delivery, small for gestational age (SGA), very SGA, and combined endpoints of any adverse or severe birth outcome. We estimated the risk of each outcome by month and year of delivery, and adjusted risks ratios (ARRs) of outcomes during the early wet (1 November-15 January), late wet (16 January-31 March) and early dry (1 April-15 July) seasons, compared with the late dry (16 July-31 October) season. Analyses were conducted overall and separately by HIV status. RESULTS Among 73 178 women (24% with HIV), the risk of all adverse birth outcomes peaked in November-January and reached low points in September. Compared with the late dry season, the ARRs for any adverse birth outcome were 1.03 (95% CI 1.00 to 1.06) for the early dry season, 1.08 (95% CI 1.04 to 1.11) for the early wet season and 1.07 (95% CI 1.03 to 1.10) for the late wet season. Comparing the early wet season to the late dry season, we found that ARRs for stillbirth and very preterm delivery were higher in women with HIV (1.23, 95% CI 0.96 to 1.59, and 1.33, 95% CI 1.10 to 1.62, respectively) than in women without HIV (1.07, 95% CI 0.91 to 1.26, and 1.19, 95% CI 1.04 to 1.36, respectively). CONCLUSIONS We identified a modest association between seasonality and adverse birth outcomes in Botswana, which was greatest among women with HIV. Understanding seasonal patterns of adverse birth outcomes and the role of HIV status may allow for mitigation of their impact in the face of seasonal extremes related to climate change.
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Affiliation(s)
- Ellen C Caniglia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jasmyn Abrams
- Department of Population Health, NYU Langone Health, New York, New York, USA
| | - Modiegi Diseko
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Gloria Mayondi
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Judith Mabuta
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Joseph Makhema
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mompati Mmalane
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Shahin Lockman
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Infectious Disease, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Aaron Bernstein
- Immunology and Infectious Diseases, Center for Climate, Health, and the Global Environment, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Rebecca Zash
- Department of Infectious Diseases, BIDMC, Boston, Massachusetts, USA
| | - Roger Shapiro
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Immunology and Infectious Diseases, Center for Climate, Health, and the Global Environment, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, USA
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12
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Brittain K, Teasdale CA, Ngeno B, Odondi J, Ochanda B, Brown K, Langat A, Modi S, Abrams EJ. Improving retention in antenatal and postnatal care: a systematic review of evidence to inform strategies for adolescents and young women living with HIV. J Int AIDS Soc 2021; 24:e25770. [PMID: 34449121 PMCID: PMC8395389 DOI: 10.1002/jia2.25770] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/17/2021] [Accepted: 06/01/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Young pregnant and postpartum women living with HIV (WLHIV) are at high risk of poor outcomes in prevention of mother-to-child transmission services. The aim of this systematic review was to collate evidence on strategies to improve retention in antenatal and/or postpartum care in this population. We also conducted a secondary review of strategies to increase attendance at antenatal care (ANC) and/or facility delivery among pregnant adolescents, regardless of HIV status, to identify approaches that could be adapted for adolescents and young WLHIV. METHODS Selected databases were searched on 1 December 2020, for studies published between January 2006 and November 2020, with screening and data abstraction by two independent reviewers. We identified papers that reported age-disaggregated results for adolescents and young WLHIV aged <25 years at the full-text review stage. For the secondary search, we included studies among female adolescents aged 10 to 19 years. RESULTS AND DISCUSSION Of 37 papers examining approaches to increase retention among pregnant and postpartum WLHIV, only two reported age-disaggregated results: one showed that integrated care during the postpartum period increased retention in HIV care among women aged 18 to 24 years; and another showed that a lay counsellor-led combination intervention did not reduce attrition among women aged 16 to 24 years; one further study noted that age did not modify the effectiveness of a combination intervention. Mobile health technologies, enhanced support, active follow-up and tracing and integrated services were commonly examined as standalone interventions or as part of combination approaches, with mixed evidence for each strategy. Of 10 papers identified in the secondary search, adolescent-focused services and continuity of care with the same provider appeared to be effective in improving attendance at ANC and/or facility delivery, while home visits and group ANC had mixed results. CONCLUSIONS This review highlights the lack of evidence regarding effective strategies to improve retention in antenatal and/or postpartum care among adolescents and young WLHIV specifically, as well as a distinct lack of age-disaggregated results in studies examining retention interventions for pregnant WLHIV of all ages. Identifying and prioritizing approaches to improve retention of adolescents and young WLHIV are critical for improving maternal and child health.
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Affiliation(s)
- Kirsty Brittain
- Division of Epidemiology & BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Chloe A Teasdale
- Mailman School of Public HealthICAP‐Columbia UniversityNew YorkNYUSA
- Department of EpidemiologyMailman School of Public HealthNew YorkNYUSA
- Department of Epidemiology and BiostatisticsCUNY Graduate School of Public Health & Health PolicyNew YorkNYUSA
| | - Bernadette Ngeno
- Division of Global HIV and Tuberculosis (DGHT)US Centers for Disease Control and PreventionAtlantaGAUSA
| | - Judith Odondi
- Mailman School of Public HealthICAP‐Columbia UniversityNew YorkNYUSA
| | - Boniface Ochanda
- Division of Global HIV and Tuberculosis (DGHT)US Centers for Disease Control and PreventionNairobiKenya
| | - Karryn Brown
- Division of Epidemiology & BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Agnes Langat
- Division of Global HIV and Tuberculosis (DGHT)US Centers for Disease Control and PreventionNairobiKenya
| | - Surbhi Modi
- Division of Global HIV and Tuberculosis (DGHT)US Centers for Disease Control and PreventionAtlantaGAUSA
| | - Elaine J Abrams
- Mailman School of Public HealthICAP‐Columbia UniversityNew YorkNYUSA
- Department of EpidemiologyMailman School of Public HealthNew YorkNYUSA
- Department of PediatricsVagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
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13
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Zash R, Caniglia EC, Diseko M, Mayondi G, Mabuta J, Luckett R, Hofmeyr GJ, Morroni C, Ramogola‐Masire D, Williams PL, Zera C, Wylie BJ, Makhema J, Lockman S, Shapiro RL. Maternal weight and birth outcomes among women on antiretroviral treatment from conception in a birth surveillance study in Botswana. J Int AIDS Soc 2021; 24:e25763. [PMID: 34176240 PMCID: PMC8236225 DOI: 10.1002/jia2.25763] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 05/13/2021] [Accepted: 05/25/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Antiretrovirals such as dolutegravir (DTG) and tenofovir alafenamide (TAF) have been associated with excessive weight gain. The objective of this study was to understand the potential impact of ART-associated weight gain on pregnancy outcomes among women living with HIV. METHODS Using data from the Tsepamo birth outcomes surveillance study in Botswana, we evaluated the relationship between maternal weight (and weight gain) and severe birth outcomes (very preterm delivery <32 weeks, very small for gestational age (SGA) <3rd percentile, perinatal death), macrosomia (birthweight > 4000 g) and maternal hypertension. We estimated the relative risk of each outcome by baseline weight (first weight in pregnancy <24 weeks) and second trimester average weekly weight gain (kg/week from 12 ± 2 to 24 ± 2 weeks) using log binomial regression and evaluated effect modification by ART regimen (DTG vs. Efavirenz (EFV)). RESULTS Of 22,828 women on ART at conception with singleton deliveries between August 2014 and April 2020, 16,300 (71.4%) had a weight measured <24 weeks' gestation (baseline weight) and 4437 (19.2%) had weight measured both at 12 (±2) weeks and 24 (±2) weeks, allowing second trimester weight gain calculation. Compared to women with baseline weight 60 to 70 kg, low baseline weight (<50 kg) was associated with increased risk of very preterm delivery (aRR 1.30, 95% CI 1.03, 1.65) and very SGA (aRR1.96, 95% CI 1.69, 2.28). High baseline weight (>90 kg) was associated with increased risk of macrosomia (aRR 3.24, 95% CI 2.36, 4.44) and maternal hypertension (aRR 1.79, 95% CI 1.62, 1.97). Baseline weight was not associated with stillbirth or early neonatal death. For all outcomes, second trimester weight gain showed weaker associations than did baseline weight. Duration of pre-pregnancy ART (years) was associated with higher baseline weight for DTG but not for EFV, and the risk of maternal hypertension by baseline weight category was higher for DTG than EFV for all strata. CONCLUSIONS ART regimens associated with weight gain may reduce the number of women at risk for certain severe adverse pregnancy outcomes associated with low weight but increase the number at risk of macrosomia and maternal hypertension. Further research could determine whether weight-based ART treatment strategies improve maternal and child health.
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Affiliation(s)
- Rebecca Zash
- Beth Israel Deaconess Medical CenterBostonMAUSA
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Harvard T.H. Chan School of Public HealthBostonMAUSA
| | | | - Modiegi Diseko
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Gloria Mayondi
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Judith Mabuta
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Rebecca Luckett
- Beth Israel Deaconess Medical CenterBostonMAUSA
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- University of BotswanaGaboroneBotswana
| | | | - Chelsea Morroni
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Liverpool School of Tropical MedicineLiverpoolUK
| | | | | | - Chloe Zera
- Beth Israel Deaconess Medical CenterBostonMAUSA
| | | | - Joseph Makhema
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Shahin Lockman
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Harvard T.H. Chan School of Public HealthBostonMAUSA
- Brigham and Women’s HospitalBostonMAUSA
| | - Roger L Shapiro
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Liverpool School of Tropical MedicineLiverpoolUK
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14
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Mukose AD, Bastiaens H, Makumbi F, Buregyeya E, Naigino R, Musinguzi J, Van Geertruyden JP, Wanyenze RK. What influences uptake and early adherence to Option B+ (lifelong antiretroviral therapy among HIV positive pregnant and breastfeeding women) in Central Uganda? A mixed methods study. PLoS One 2021; 16:e0251181. [PMID: 33951109 PMCID: PMC8099116 DOI: 10.1371/journal.pone.0251181] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 04/21/2021] [Indexed: 11/25/2022] Open
Abstract
Background High uptake and optimal adherence to Option B+ antiretroviral therapy (ART) increase effectiveness in averting mother-to-child transmission of HIV. Option B+ ART uptake, early adherence, and associated factors need to be evaluated in Central Uganda. Methods A mixed approaches study was carried out in six health facilities in Masaka, Mityana, and Luwero districts from October 2013 to February 2016. Questionnaires were administered to 507 HIV positive pregnant females seeking antenatal care services. Key informant interviews were conducted with 54 health providers, and in-depth interviews (IDIs) with 57 HIV positive women on Option B+ ART. Quantitative data were analyzed using log-binomial regression model to determine factors associated with optimal adherence (taking at least 95% of the prescribed ART), while thematic analysis was used on qualitative data. Results Ninety one percent of women (463/507) received a prescription of life long ART. Of these, 93.3% (432/463) started swallowing their medicines. Overall, 83% of women who received ART prescriptions (310/374) felt they were ready to initiate ART immediately. Main motivating factors to swallow ART among those who received a prescription were women’s personal desire to be healthy (92.3%) and desire to protect their babies (90.6%). Optimal adherence to ART was achieved by 76.8% (315/410). Adherence was higher among females who were ready to start ART (adj. PR = 3.20; 95% CI: 1.15–8.79) and those who had revealed their HIV positive result to someone (adj. PR = 1.23; 95% CI: 1.04–1.46). Facilitators of ART uptake from qualitative findings included adequate counseling, willingness to start, and knowing the benefits of ART. Reasons for refusal to start ART included being unready to start ART, fear to take ART for life, doubt of HIV positive results, and preference for local herbs. Reasons for non-adherence were travelling far away from health facilities, fear of side effects, non-disclosure of HIV results to anyone, and perception that the baby is safe from HIV infection post-delivery. Conclusions Uptake of Option B+ ART was very high. However, failure to start swallowing ART and sub-optimal adherence are a major public health concern. Enhancing women’s readiness to start ART and encouraging HIV result revelation could improve ART uptake and adherence.
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Affiliation(s)
- Aggrey David Mukose
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Global Health Institute, Department of Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium
- * E-mail:
| | - Hilde Bastiaens
- Global Health Institute, Department of Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium
- Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Fredrick Makumbi
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Esther Buregyeya
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rose Naigino
- Makerere University School of Public Health, Kampala, Uganda
| | | | - Jean-Pierre Van Geertruyden
- Global Health Institute, Department of Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium
| | - Rhoda K. Wanyenze
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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15
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Chamanga R, Katumbi C, Gadama L, Kawalazira R, Dula D, Makanani B, Dadabhai S, Taha TE. Comparison of adverse birth outcomes among HIV-infected and HIV-uninfected women delivering in high and low risk settings in the era of universal ART in Malawi: a registry study. Paediatr Int Child Health 2021; 41:112-122. [PMID: 33881967 DOI: 10.1080/20469047.2021.1874200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Recent studies show that ART is associated with an adverse birth outcome in HIV-infected women.Aim: To compare rates of low birthweight (LBW) and preterm birth (PTB) between HIV-infected women receiving lifelong ART and HIV-uninfected women giving birth in low- and high-risk settings in Malawi.Methods: This observational, registry study was conducted from January 2016 to August 2017 in one large, tertiary referral hospital and four primary healthcare (PHC) facilities in Blantyre, Malawi. Women who delivered singleton live births or stillbirths of ≥20 weeks gestation were included in the analysis. Descriptive and stratified analyses were conducted using χ2 tests and multivariable logistic models to control for maternal age, gravidity and health facility.Results: A total of 14,233 births were included in the analysis (7715 from the tertiary hospital and 6518 from PHC facilities). In the univariable analysis, there were no differences in rates of LBW (6.7% vs 6.4%) and PTB (42.5% vs 42.0%) between HIV-infected and -uninfected women delivering in PHC facilities. However, differences in LBW were significantly higher in HIV-infected women in multivariable analysis (LBW aOR 1.40, 95% CI 1.01-1.95). Rates of LBW and PTB were significantly higher in HIV-infected women than in uninfected women delivering at the tertiary hospital (LBW 17.6% vs 13.2%, aOR 1.53, 95% CI 1.27-1.85; PTB 28.2% vs 24.9%, aOR 1.37, 95% CI 1.17-1.60)Conclusion: Rates of adverse birth outcomes are significantly higher in HIV-infected women than in HIV-uninfected women, and this is more apparent in high-risk hospital settings than in low-risk PHC settings.
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Affiliation(s)
- Rachel Chamanga
- College of Medicine, Johns Hopkins Research Project, Blantyre, Malawi
| | - Chaplain Katumbi
- College of Medicine, Johns Hopkins Research Project, Blantyre, Malawi
| | - Luis Gadama
- College of Medicine, Johns Hopkins Research Project, Blantyre, Malawi.,Department of Obstetrics and Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Rachel Kawalazira
- College of Medicine, Johns Hopkins Research Project, Blantyre, Malawi
| | - Dingase Dula
- College of Medicine, Johns Hopkins Research Project, Blantyre, Malawi
| | - Bonus Makanani
- College of Medicine, Johns Hopkins Research Project, Blantyre, Malawi.,Department of Obstetrics and Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Sufia Dadabhai
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Taha E Taha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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16
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Chagomerana MB, Edwards JK, Zalla LC, Carbone NB, Banda GT, Mofolo IA, Hosseinipour MC, Herce ME. Timing of HIV testing among pregnant and breastfeeding women and risk of mother-to-child HIV transmission in Malawi: a sampling-based cohort study. J Int AIDS Soc 2021; 24:e25687. [PMID: 33749155 PMCID: PMC7982503 DOI: 10.1002/jia2.25687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 02/02/2021] [Accepted: 02/17/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Pregnant women living with HIV can achieve viral suppression and prevent HIV mother-to-child transmission (MTCT) with timely HIV testing and early ART initiation and maintenance. Although it is recommended that pregnant women undergo HIV testing early in antenatal care in Malawi, many women test positive during breastfeeding because they did not have their HIV status ascertained during pregnancy, or they tested negative during pregnancy but seroconverted postpartum. We sought to estimate the association between the timing of last positive HIV test (during pregnancy vs. breastfeeding) and outcomes of maternal viral suppression and MTCT in Malawi's PMTCT programme. METHODS We conducted a two-stage cohort study among mother-infant pairs in 30 randomly selected high-volume health facilities across five nationally representative districts of Malawi between 1 July 2016 and 30 June 2017. Log-binomial regression was used to estimate prevalence ratios (PR) and risk ratios (RR) for associations between timing of last positive HIV test (i.e. breastfeeding vs. pregnancy) and maternal viral suppression and MTCT, controlling for confounding using inverse probability weighting. RESULTS Of 822 mother-infant pairs who had available information on the timing of the last positive HIV test, 102 mothers (12.4%) had their last positive test during breastfeeding. Women who lived one to two hours (PR = 2.15; 95% CI: 1.29 to 3.58) or >2 hours (PR = 2.36; 95% CI: 1.37 to 4.10) travel time to the nearest health facility were more likely to have had their last positive HIV test during breastfeeding compared to women living <1 hour travel time to the nearest health facility. The risk of unsuppressed VL did not differ between women who had their last positive HIV test during breastfeeding versus pregnancy (adjusted RR [aRR] = 0.87; 95% CI: 0.48 to 1.57). MTCT risk was higher among women who had their last positive HIV test during breastfeeding compared to women who had it during pregnancy (aRR = 6.57; 95% CI: 3.37 to 12.81). CONCLUSIONS MTCT in Malawi occurred disproportionately among women with a last positive HIV test during breastfeeding. Testing delayed until the postpartum period may lead to higher MTCT. To optimize maternal and child health outcomes, PMTCT programmes should focus on early ART initiation and providing targeted testing, prevention, treatment and support to breastfeeding women.
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Affiliation(s)
- Maganizo B Chagomerana
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jessie K Edwards
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lauren C Zalla
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Godfrey T Banda
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | - Innocent A Mofolo
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Mina C Hosseinipour
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Michael E Herce
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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17
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Mabaya L, Matarira HT, Tanyanyiwa DM, Musarurwa C, Mukwembi J. Growth Trajectories of HIV Exposed and HIV Unexposed Infants. A Prospective Study in Gweru, Zimbabwe. Glob Pediatr Health 2021; 8:2333794X21990338. [PMID: 33614842 PMCID: PMC7868486 DOI: 10.1177/2333794x21990338] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 12/14/2020] [Accepted: 01/04/2021] [Indexed: 11/15/2022] Open
Abstract
Background With the increasing HIV seroprevalence among women of childbearing age in sub-Saharan Africa, limited data on growth outcomes of HIV exposed infants under current policies of universal maternal antiretroviral therapy exist. Methods The longitudinal growth patterns of 114 HIV exposed and unexposed infants were assessed and compared. The prevalence and factors associated with malnutrition were established. Infants under prevention of mother to child transmission care were recruited at 6 weeks post-delivery as were their HIV unexposed counterparts. Weight and length measurements were recorded at birth, 6 and 16 weeks postpartum. Results HIV vertical transmission rate was 8.8%. HIV exposed infants had significantly lower mean birth weights compared to HIV unexposed infants (2.9 ± 0.3; 3.2 ± 0.5; P < .001) respectively. Mean weight/length-for-age z-scores for HIV exposed, uninfected (HEU) infants were significantly below those of the HIV unexposed infants during follow up. By 6 weeks of age, 28.5% of HEU infants were malnourished while no malnutrition was evident in HIV unexposed infants. A gestational age <37 weeks (OR: 3.83; 95% CI: 1.03-14.30; P = .045) and HIV exposure (OR: 1.62; 95% CI: 0.17-15.73; P = .017) substantially increased the risk of stunting. Conclusion Growth deficits were witnessed in HIV exposed infants compared to HIV unexposed infants. There is need for early nutritional monitoring and support among HIV exposed infants.
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Affiliation(s)
- Lucy Mabaya
- Midlands State University Medical School, Gweru, Midlands, Zimbabwe.,University of Zimbabwe Medical School Harare, Harare, Zimbabwe
| | | | - Donald Moshen Tanyanyiwa
- University of Witwatersrand/National Health Laboratory Services, Chris Hani Baragwanath Academic Hospital, Johannesburg, Gauteng, South Africa
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18
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Lyatuu GW, Mwashemele SZ, Urrio R, Naburi H, Kashmir N, Machumi L, Kibao A, Sellah Z, Ulenga N, Orsini N, Biberfeld G, Kilewo C, Ekström AM. Long-term virological outcomes in women who started option B+ care during pregnancy for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania: a cohort study. Lancet HIV 2021; 8:e256-e265. [PMID: 33581776 DOI: 10.1016/s2352-3018(20)30308-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 10/20/2020] [Accepted: 11/09/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Option B+ marked a milestone in prevention of mother-to-child transmission (PMTCT) of HIV by recommending lifelong antiretroviral therapy (ART) for all pregnant women with HIV. Nevertheless, concerns remain regarding long-term outcomes in settings with a high HIV burden. We analysed long-term virological outcomes in women enrolled on option B+ in Tanzania. METHODS In this prospective cohort study, we extracted data for pregnant women with HIV starting PMTCT care between Oct 1, 2014, and Sept 30, 2016, in routine health-care settings in Dar es Salaam, Tanzania, from national HIV and district health information system databases. We then excluded women who exited study sites before 6 months of ART follow-up and women who did not have a viral load test. Women were followed up until March 8, 2019. We used Poisson generalised estimating equations to examine trends in HIV viral suppression (<400 copies per mL) and virological failure (≥400 copies per mL), reporting relative risks (RRs) and 95% CIs adjusted for maternal age, gestational age, and several clinical characteristics. FINDINGS We identified 15 586 pregnant women with HIV, of whom 10 161 were eligible for follow-up. Women were followed up for a median of 37 months (IQR 31-45) and a maximum of 53 months. The median age at PMTCT initiation was 31 years (IQR 27-35). At PMTCT enrolment, 1245 (17·0%) of 7318 women with available data were in their third trimester, 4901 (48·2%) of 10 161 women started ART at least 1 month before PMTCT enrolment, and 3380 (33·4%) of 10 131 women with available data had advanced HIV. Overall, a viral suppression rate of 88·2% (95% CI 87·8-88·7) was observed over the entire follow-up period, ranging from 85·1% (84·3-85·9) in viral load tests done at 0-11 months to 90·6% (89·7-91·4) at 36 months or longer since PMTCT enrolment. In a complete-case analysis (ie, including patients with <30% missing data; n=7306), the risk of virological failure among women who remained in HIV care decreased over time (adjusted RR 0·87 [95% CI 0·80-0·95] at 12-23 months since PMTCT enrolment; 0·65 [0·59-0·72] at 24-35 months; and 0·63 [0·55-0·71] at ≥36 months vs at 0-11 months). Younger women (aged <20 years: 1·76 [1·40-2·23] vs aged 30-39 years) and those starting PMTCT late in pregnancy (third trimester: 1·28 [1·10-1·50] vs first trimester) or with advanced HIV (1·33 [1·16-1·51] vs without advanced HIV) had increased risk of virological failure. Women who attended an antenatal care facility where more than 50% of attendees received couples HIV testing had a decreased risk of virological failure (adjusted RR 0·81 [0·65-0·99] vs <50% having couples testing). INTERPRETATION High rates of viral suppression among women starting option B+ who remain in HIV care are sustainable, and might increase, at least up to 53 months. This rate might be further improved by addressing challenges of adolescent mothers, late presenters, and couples HIV testing at antenatal care. FUNDING Swedish International Development Agency.
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Affiliation(s)
- Goodluck W Lyatuu
- Management and Development for Health, Dar es Salaam, Tanzania; Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | | | - Roseline Urrio
- Management and Development for Health, Dar es Salaam, Tanzania; Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Helga Naburi
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Nassir Kashmir
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Lameck Machumi
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Ayoub Kibao
- Dar es Salaam Regional Administrative Secretary, Dar es Salaam, Tanzania
| | - Ziada Sellah
- Dar es Salaam Regional Administrative Secretary, Dar es Salaam, Tanzania
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Nicola Orsini
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Gunnel Biberfeld
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Charles Kilewo
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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19
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Long-Term Outcomes of HIV-Infected Women Receiving Antiretroviral Therapy After Transferring Out of an Integrated Maternal and Child Health Service in South Africa. J Acquir Immune Defic Syndr 2020; 83:202-209. [PMID: 31725060 DOI: 10.1097/qai.0000000000002236] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Integrated maternal and child health (MCH) services improve women's postpartum antiretroviral therapy (ART) outcomes during breastfeeding; however, long-term outcomes after transfer to general ART services remain unknown. METHODS The MCH-ART trial demonstrated that maternal retention and viral suppression at 12-months postpartum were improved significantly among women randomized to integrated MCH services continued in the antenatal clinic through cessation of breastfeeding (MCH-ART arm) compared with immediate transfer to general ART services postpartum (standard of care). We reviewed electronic health records for all women who participated in the MCH-ART trial to ascertain retention and gaps in care and invited all women for a study visit 36- to 60-months postpartum including viral load testing. RESULTS Of 471 women in MCH-ART, 450 (96%) contributed electronic health record data and 353 (75%) completed the study visit (median 44-month postpartum). At this time, outcomes were identical in both trial arms: 67% retained in care (P = 0.994) and 56% with viral loads <50 copies/mL (P = 0.751). Experiencing a gap in care after delivery was delayed in the MCH-ART arm with 17%, 36%, and 45% of women experienced a gap in care by 12-, 24-, and 36-months postpartum compared with 35%, 48%, and 57% in the standard of care arm, respectively. CONCLUSIONS The benefits of integrated maternal HIV and child health care did not persist after transfer to general ART services. The transfer of women postpartum to routine adult care is a critical period requiring interventions to support continuity of HIV care.
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20
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Brittain K, Mellins CA, Remien RH, Phillips TK, Zerbe A, Abrams EJ, Myer L. Impact of HIV-Status Disclosure on HIV Viral Load in Pregnant and Postpartum Women on Antiretroviral Therapy. J Acquir Immune Defic Syndr 2020; 81:379-386. [PMID: 30939530 DOI: 10.1097/qai.0000000000002036] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND HIV-status disclosure is widely encouraged by counseling services, in part because it is thought to improve antiretroviral therapy (ART) adherence and thus HIV viral suppression. However, few longitudinal studies have examined the impact of disclosure on HIV viral load (VL) during pregnancy and postpartum. METHODS We explored these associations among 1187 women living with HIV, enrolled between March 2013 and June 2014 in Cape Town, South Africa. RESULTS Among women who tested HIV-positive before pregnancy, we observed no association between disclosure and VL at entry into antenatal care among those already on ART, nor at delivery and 12 months postpartum among those initiating ART. Among women who tested HIV-positive during pregnancy and initiated ART subsequently, disclosure to a male partner was associated with a reduced risk of VL ≥50 copies/mL at delivery (adjusted risk ratio: 0.56; 95% confidence interval: 0.31 to 1.01). After stratification by relationship status, this association was only observed among women who were married and/or cohabiting. In addition, disclosure to ≥1 family/community member was associated with a reduced risk of VL ≥50 copies/mL at 12 months postpartum (adjusted risk ratio: 0.69; 95% confidence interval: 0.48 to 0.97) among newly-diagnosed women. CONCLUSIONS These findings suggest that the impact of disclosure on VL is modified by 3 factors: (1) timing of HIV diagnosis (before vs. during the pregnancy); (2) relationship to the person(s) to whom women disclose; and (3) in the case of disclosure to a male partner, relationship status. Counseling about disclosure may be most effective if tailored to individual women's circumstances.
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Affiliation(s)
- Kirsty Brittain
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Claude A Mellins
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY
| | - Robert H Remien
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY
| | - Tamsin K Phillips
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Allison Zerbe
- Mailman School of Public Health, ICAP at Columbia University, New York, NY
| | - Elaine J Abrams
- Mailman School of Public Health, ICAP at Columbia University, New York, NY.,Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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21
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Kim MH, Tembo TA, Mazenga A, Yu X, Myer L, Sabelli R, Flick R, Hartig M, Wetzel E, Simon K, Ahmed S, Nyirenda R, Kazembe PN, Mphande M, Mkandawire A, Chitani MJ, Markham C, Ciaranello A, Abrams EJ. The Video intervention to Inspire Treatment Adherence for Life (VITAL Start): protocol for a multisite randomized controlled trial of a brief video-based intervention to improve antiretroviral adherence and retention among HIV-infected pregnant women in Malawi. Trials 2020; 21:207. [PMID: 32075677 PMCID: PMC7031891 DOI: 10.1186/s13063-020-4131-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/01/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Improving maternal antiretroviral therapy (ART) retention and adherence is a critical challenge facing prevention of mother-to-child transmission (PMTCT) of HIV programs. There is an urgent need for evidence-based, cost-effective, and scalable interventions to improve maternal adherence and retention that can be feasibly implemented in overburdened health systems. Brief video-based interventions are a promising but underutilized approach to this crisis. We describe a trial protocol to evaluate the effectiveness and implementation of a standardized educational video-based intervention targeting HIV-infected pregnant women that seeks to optimize their ART retention and adherence by providing a VITAL Start (Video intervention to Inspire Treatment Adherence for Life) before committing to lifelong ART. METHODS This study is a multisite parallel group, randomized controlled trial assessing the effectiveness of a brief facility-based video intervention to optimize retention and adherence to ART among pregnant women living with HIV in Malawi. A total of 892 pregnant women living with HIV and not yet on ART will be randomized to standard-of-care pre-ART counseling or VITAL Start. The primary outcome is a composite of retention and adherence (viral load < 1000 copies/ml) 12 months after starting ART. Secondary outcomes include assessments of behavioral adherence (self-reported adherence, pharmacy refill, and tenofovir diphosphate concentration), psychosocial impact, and resource utilization. We will also examine the implementation of VITAL Start via surveys and qualitative interviews with patients, partners, and health care workers and conduct cost-effectiveness analyses. DISCUSSION This is a robust evaluation of an innovative facility-based video intervention for pregnant women living with HIV, with the potential to improve maternal and infant outcomes. TRIAL REGISTRATION ClinicalTrials.gov, NCT03654898. Registered on 31 August 2018.
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Affiliation(s)
- Maria H Kim
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA. .,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.
| | - Tapiwa A Tembo
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Alick Mazenga
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Xiaoying Yu
- University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Rachael Sabelli
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Robert Flick
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Miriam Hartig
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Elizabeth Wetzel
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Katie Simon
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Saeed Ahmed
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Rose Nyirenda
- HIV Unit, Malawi Ministry of Health, Lilongwe, Malawi
| | - Peter N Kazembe
- Baylor College of Medicine International Pediatric AIDS Initiative, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Mtisunge Mphande
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Angella Mkandawire
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Mike J Chitani
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Christine Markham
- Health Promotion & Behavioral Sciences, The University of Texas School of Public Health, Houston, TX, USA
| | - Andrea Ciaranello
- Division of Infectious Diseases, Department of Medicine; Medical Practice Evaluation Center; both at Massachusetts General Hospital, Boston, MA, USA
| | - Elaine J Abrams
- ICAP at Columbia, Mailman School of Public Health and Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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22
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Muyunda B, Musonda P, Mee P, Todd J, Michelo C. Effectiveness of Lifelong ART (Option B+) in the Prevention of Mother-to-Child Transmission of HIV Programme in Zambia: Observations Based on Routinely Collected Health Data. Front Public Health 2020; 7:401. [PMID: 32010656 PMCID: PMC6978742 DOI: 10.3389/fpubh.2019.00401] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 12/16/2019] [Indexed: 11/29/2022] Open
Abstract
Background: Mother to child transmission of HIV (MTCT) is a global challenge affecting many countries especially in sub-Saharan Africa. In 2009 about 370,000 infants were infected with HIV mainly through MTCT and most of them in sub-Saharan Africa. We aimed to determine the effectiveness of Option B+ compared to other options in reducing rates of early MTCT of HIV infections in Zambia. Methods: This was a retrospective cohort study based on routinely collected data using SmartCare in Zambia. Survival analysis with Cox Proportional Hazard regression was used to determine association between MTCT and regimen type of mothers. Kaplan-Meier (K-M) curves were used to compare MTCT for infants born to mothers option B+ to those on other options, and Wilcoxon (Breslow) test was used to establish statistical significance. Results: Overall (n = 1,444), mother-baby pairs with complete data were included in the analysis, with the median age of mothers being 33 (28–38) years; and 57% of these women were on Option B+. MTCT rate was estimated at 5% (73/1,444) [P = 0.025]. A Kaplan-Meier estimate showed that HIV Exposed Infants (HEI) of mothers on Option B+ had lower MTCT rate than those who were on other MTCT prevention interventions [Wilcoxon test; chi2 = 4.97; P = 0.025]. Furthermore, The Nelson Aalen cumulative hazard estimates indicated similar evidence of option B+ being more effective than other options with some statistical significance [HR = 0.63, P = 0.068]. HEI of option B+ mothers had 50% reduced risk of having HIV infection compared to option A/B [adjusted HR = 0.4; 95% CI = 0.28–0.84; P = 0.010]. HEI to women who were married had an increased risk 50% of getting infected compared to those not married [adjusted HR = 1.5; 95% CI = 3.43–6.30; P < 0.001]. Exposed infants whose mothers had assisted delivery had 3 times increased risk of getting infected compared to those born through normal vaginal delivery [Adjusted HR = 3.2; 95% CI = 0.98–10.21; P = 0.050]. Conclusions: The use of Option B+ as PMTCT intervention was found to be more effective in reducing MTCT of HIV compared to other options. Scaling up access to life-long ART and improving retention for women on treatment can potentially reduce further vertical transmission.
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Affiliation(s)
- Brian Muyunda
- Department of Epidemiology and Biostatistics, The University of Zambia School of Public Health, Lusaka, Zambia.,Ministry of Health, University Teaching Hospital, Lusaka, Zambia
| | - Patrick Musonda
- Department of Epidemiology and Biostatistics, The University of Zambia School of Public Health, Lusaka, Zambia
| | - Paul Mee
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jim Todd
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Charles Michelo
- Department of Epidemiology and Biostatistics, The University of Zambia School of Public Health, Lusaka, Zambia
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23
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Kim MH, Ahmed S, Tembo T, Sabelli R, Flick R, Yu X, Mazenga A, Le Blond H, Simon K, Hartig M, Wetzel E, Nyirenda R, Kazembe PN, Mphande M, Mkandawire A, Chitani MJ, Abrams EJ. VITAL Start: Video-Based Intervention to Inspire Treatment Adherence for Life-Pilot of a Novel Video-Based Approach to HIV Counseling for Pregnant Women Living with HIV. AIDS Behav 2019; 23:3140-3151. [PMID: 31410618 PMCID: PMC6803103 DOI: 10.1007/s10461-019-02634-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We developed and piloted a video-based intervention targeting HIV-positive pregnant women to optimize antiretroviral therapy (ART) retention and adherence by providing a VITAL Start (Video-intervention to Inspire Treatment Adherence for Life) before ART. VITAL Start (VS) was grounded in behavior-determinant models and developed through an iterative multi-stakeholder process. Of 306 pregnant women eligible for ART, 160 were randomized to standard of care (SOC), 146 to VS and followed for one-month. Of those assigned to VS, 100% completed video-viewing; 96.5% reported they would recommend VS. Of 11 health workers interviewed, 82% preferred VS over SOC; 91% found VS more time-efficient. Compared to SOC, VS group had greater change in HIV/ART knowledge (p < 0.01), trend towards being more likely to start ART (p = 0.07), and better self-reported adherence (p = 0.02). There were no significant group differences in 1-month retention and pharmacy pill count. VITAL Start was highly acceptable, feasible, with promising benefits to ART adherence.
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Affiliation(s)
- Maria H Kim
- Baylor College of Medicine International Paediatric AIDS Initiative, Texas Children's Hospital, Houston, USA.
- Baylor College of Medicine - Abbott Fund Children's Clinical Centre of Excellence, Private bag B-397, Lilongwe 3, Malawi.
| | - Saeed Ahmed
- Baylor College of Medicine International Paediatric AIDS Initiative, Texas Children's Hospital, Houston, USA
- Baylor College of Medicine - Abbott Fund Children's Clinical Centre of Excellence, Private bag B-397, Lilongwe 3, Malawi
| | - Tapiwa Tembo
- Baylor College of Medicine - Abbott Fund Children's Clinical Centre of Excellence, Private bag B-397, Lilongwe 3, Malawi
| | - Rachael Sabelli
- Baylor College of Medicine - Abbott Fund Children's Clinical Centre of Excellence, Private bag B-397, Lilongwe 3, Malawi
| | - Robert Flick
- Baylor College of Medicine International Paediatric AIDS Initiative, Texas Children's Hospital, Houston, USA
- Baylor College of Medicine - Abbott Fund Children's Clinical Centre of Excellence, Private bag B-397, Lilongwe 3, Malawi
| | - Xiaoying Yu
- University of Texas Medical Branch at Galveston, Galveston, USA
| | - Alick Mazenga
- Baylor College of Medicine - Abbott Fund Children's Clinical Centre of Excellence, Private bag B-397, Lilongwe 3, Malawi
| | | | - Katie Simon
- Baylor College of Medicine International Paediatric AIDS Initiative, Texas Children's Hospital, Houston, USA
- Baylor College of Medicine - Abbott Fund Children's Clinical Centre of Excellence, Private bag B-397, Lilongwe 3, Malawi
| | - Miriam Hartig
- Baylor College of Medicine International Paediatric AIDS Initiative, Texas Children's Hospital, Houston, USA
- Baylor College of Medicine - Abbott Fund Children's Clinical Centre of Excellence, Private bag B-397, Lilongwe 3, Malawi
| | - Elizabeth Wetzel
- Baylor College of Medicine International Paediatric AIDS Initiative, Texas Children's Hospital, Houston, USA
- Baylor College of Medicine - Abbott Fund Children's Clinical Centre of Excellence, Private bag B-397, Lilongwe 3, Malawi
| | - Rose Nyirenda
- HIV Unit, Malawi Ministry of Health, Lilongwe, Malawi
| | - Peter N Kazembe
- Baylor College of Medicine International Paediatric AIDS Initiative, Texas Children's Hospital, Houston, USA
- Baylor College of Medicine - Abbott Fund Children's Clinical Centre of Excellence, Private bag B-397, Lilongwe 3, Malawi
| | - Mtisunge Mphande
- Baylor College of Medicine - Abbott Fund Children's Clinical Centre of Excellence, Private bag B-397, Lilongwe 3, Malawi
| | - Angella Mkandawire
- Baylor College of Medicine - Abbott Fund Children's Clinical Centre of Excellence, Private bag B-397, Lilongwe 3, Malawi
| | - Mike J Chitani
- Baylor College of Medicine - Abbott Fund Children's Clinical Centre of Excellence, Private bag B-397, Lilongwe 3, Malawi
| | - Elaine J Abrams
- ICAP at Columbia, Mailman School of Public Health and Vagelos College of Physicians & Surgeons, Columbia University, New York, USA
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24
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Reidy W, Nuwagaba-Biribonwoha H, Shongwe S, Sahabo R, Hartsough K, Wu Y, Gachuhi A, Mthethwa-Hleta S, Abrams EJ. Engagement in care among women and their infants lost to follow-up under Option B+ in eSwatini. PLoS One 2019; 14:e0222959. [PMID: 31665137 PMCID: PMC6821080 DOI: 10.1371/journal.pone.0222959] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 09/10/2019] [Indexed: 11/18/2022] Open
Abstract
Background Universal antiretroviral treatment (ART) for pregnant women with HIV, Option B+, has been adopted widely for prevention of mother-to-child HIV transmission (PMTCT). Some evidence shows high loss to follow-up (LTF) under this model. However, gaps in data systems limit this evidence. We collected additional information for women and infants LTF from Option B+ in Eswatini to assess more accurate outcomes. Methods LTF at 6-months postpartum was assessed using facility data. Additional data was gathered from: 1) the national ART database and paper records; 2) patient tracing; and 3) interviews and abstraction from patient-held records. Engagement in care was defined as any clinic visit within 91 days before or after 6-months postpartum or completion of a documented transfer; or, for those traced but not completing study interviews, visits at 6-months postpartum or later (for infants), or visits within 3-months of tracing (for women). Multivariable loglinear models were used to identify correlates of engagement. Results One-hundred-ninety-four (44.7%) of 434 LTF women had outcomes ascertained, including 122 (62.9%) women engaged in care. Among 510 LTF infants, 265 (52.0%) had ascertained outcomes, including 143 (54.0%) engaged in care, 47 (17.7%) pregnancy losses, and 18 (6.8%) deaths. Seventy-two of 189 live infants (38.1%) with ascertained outcomes had a 6-week early infant diagnostic (EID) test. Among women with ascertained outcomes, gestational age of 20+ weeks (vs. fewer than 20 weeks, aRR 0.80; 95% CI 0.68–0.94) and age 25–29 years (vs. 15–24 years, aRR 0.81; 95% CI 0.67–0.97), were associated with lower engagement; initiating ART after first ANC visit was associated with higher engagement (vs. at first ANC visit, aRR 1.12; 95% CI 1.04–1.21). Among infants with ascertained outcomes, mother not initiating ART was associated with lower engagement (vs. ART at first ANC visit, aRR 0.71; 95% CI 0.54–0.91). Conclusion Substantial numbers of women and infants classified as LTF under Option B+ were engaged in care, though a suboptimal level of 6-week EID testing was observed. These findings highlight a need to improve coverage of routine EID testing, and improve data systems to better capture PMTCT patient outcomes.
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Affiliation(s)
- William Reidy
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, New York, United States of America
- * E-mail:
| | - Harriet Nuwagaba-Biribonwoha
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, New York, United States of America
| | - Siphesihle Shongwe
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Ruben Sahabo
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Kieran Hartsough
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Yingfeng Wu
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Averie Gachuhi
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | | | - Elaine J. Abrams
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, New York, United States of America
- Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, United States of America
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Brief Report: No HIV Transmission From Virally Suppressed Mothers During Breastfeeding in Rural Tanzania. J Acquir Immune Defic Syndr 2019; 79:e17-e20. [PMID: 29781882 DOI: 10.1097/qai.0000000000001758] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To what extent antiretroviral therapy (ART) reduces mother-to-child HIV transmission (MTCT) during breastfeeding remains unclear. We assessed the MTCT risk from mothers on ART to their infants during breastfeeding. SETTING Ifakara, rural Tanzania. METHODS We included infants born between January 2013 and May 2016 to mothers who initiated ART before delivery, had a negative HIV DNA polymerase chain reaction at 4-12 weeks and exclusively breastfed for ≥6 months. Mothers' plasma HIV-RNA viral loads (VLs) were measured up to 11 months postdelivery. Infants were tested for HIV following national guidelines. RESULTS Among 214 women with 218 pregnancies and 228 infants (10 twins), the median age at delivery was 33 years (interquartile range 28-36 years), and the mean time on ART was 23 months (interquartile range, 4-52 months). VL was measured twice in 53% (113/218) of pregnancies. During breastfeeding, 91% of mothers (199/218) had VL of <1000 copies per milliliter, and 75% (164/218) had <100 copies per milliliter. To November 2017, 8% (19/228) of infants were lost to follow-up (LTFU), 2% (5/228) transferred, and 8% (18/228) died before the determination of final HIV serostatus. Among the remaining 186 infants, 2 (1%; 95% confidence interval: 0.3% to 4%) were HIV positive: 1 born from a mother with high VL 1-month postdelivery and 1 from a mother who interrupted ART. Assuming a 15% MTCT risk through breastfeeding among the 42 infants LTFU, transferred, or dead, the overall MTCT risk would be 4%. CONCLUSIONS We found no MTCT from mothers who were retained in care and had suppressed VL. Breastfeeding signifies a very low risk when mothers adhere to ART. Adherence counseling, VL monitoring, and strategies to trace back those LTFU should be a priority.
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Why did I stop? And why did I restart? Perspectives of women lost to follow-up in option B+ HIV care in Dar es Salaam, Tanzania. BMC Public Health 2019; 19:1172. [PMID: 31455306 PMCID: PMC6712622 DOI: 10.1186/s12889-019-7518-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 08/19/2019] [Indexed: 11/13/2022] Open
Abstract
Background Despite an increased uptake of option B+ treatment among HIV- positive pregnant and breastfeeding women, retaining these women in care is still a major challenge. Previous studies have identified factors associated with loss to follow-up (LTFU) in HIV care, however, the perspectives from HIV-positive pregnant and breastfeeding women regarding their LTFU in option B+ needs further exploration. We explored reasons for LTFU and motivation to resume treatment among HIV-positive women initiated in option B+ in an Urban setting. Methods A descriptive qualitative study was conducted at three public care and treatment clinics (CTC) (Buguruni health center, Sinza hospital, and Mbagala Rangitatu health center) in Dar es Salaam, Tanzania between February and May 2017. In-depth interviews were conducted with 30 HIV-positive pregnant and breastfeeding women who were lost to follow up in the option B+ regimen. Analysis of data followed content analysis that was performed using NVivo 10 computer-assisted qualitative data analysis software. Results Eleven women were lost to follow-up and did not resume Option B+, while 19 had resumed treatment. The study indicated a struggle with long term disease amongst HIV-positive pregnant and breastfeeding women initiated in option B+ treatment. The reported reasons contributing to LTFU among these women appeared in three categories. The contribution of LTFU in the first category namely health-related factors included medication side effects and lack of disease symptoms. The second category highlighted the contribution of psychological factors such as loss of hope, fear of medication side effects and HIV-related stigma. The third category underscored the influence of socio-economic statuses such as financial constraints, lack of partner support, family conflicts, non-disclosure of HIV-positive status, and religious beliefs. Motivators to resume treatment after LTFU included support from health care providers and family members, a desire to protect the unborn child from HIV-infection and a need to maintain a healthy status. Conclusion The study has highlighted the reasons for LTFU and motivation to resume treatment among women initiated in Option B+. Our results provide further evidence on the need for future interventions to focus on these factors in order to improve retention in life-long treatment.
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Sikazwe I, Eshun-Wilson I, Sikombe K, Czaicki N, Somwe P, Mody A, Simbeza S, Glidden DV, Chizema E, Mulenga LB, Padian N, Duncombe CJ, Bolton-Moore C, Beres LK, Holmes CB, Geng E. Retention and viral suppression in a cohort of HIV patients on antiretroviral therapy in Zambia: Regionally representative estimates using a multistage-sampling-based approach. PLoS Med 2019; 16:e1002811. [PMID: 31150380 PMCID: PMC6544202 DOI: 10.1371/journal.pmed.1002811] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/23/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although the success of HIV treatment programs depends on retention and viral suppression, routine program monitoring of these outcomes may be incomplete. We used data from the national electronic medical record (EMR) system in Zambia to enumerate a large and regionally representative cohort of patients on treatment. We traced a random sample with unknown outcomes (lost to follow-up) to document true care status and HIV RNA levels. METHODS AND FINDINGS On 31 July 2015, we selected facilities from 4 provinces in 12 joint strata defined by facility type and province with probability proportional to size. In each facility, we enumerated adults with at least 1 clinical encounter after treatment initiation in the previous 24 months. From this cohort, we identified lost-to-follow-up patients (defined as 90 or more days late for their last appointment), selected a random sample, and intensively reviewed their records and traced them via phone calls and in-person visits in the community. In 1 of 4 provinces, we also collected dried blood spots (DBSs) for plasma HIV RNA testing. We used inverse probability weights to incorporate sampling outcomes into Aalen-Johansen and Cox proportional hazards regression to estimate retention and viremia. We used a bias analysis approach to correct for the known inaccuracy of plasma HIV RNA levels obtained from DBSs. From a total of 64 facilities with 165,464 adults on ART, we selected 32 facilities with 104,966 patients, of whom 17,602 (17%) were lost to follow-up: Those lost to follow-up had median age 36 years, 60% were female (N = 11,241), they had median enrollment CD4 count of 220 cells/μl, and 38% had WHO stage 1 clinical disease (N = 10,690). We traced 2,892 (16%) and found updated outcomes for 2,163 (75%): 412 (19%) had died, 836 (39%) were alive and in care at their original clinic, 457 (21%) had transferred to a new clinic, 255 (12%) were alive and out of care, and 203 (9%) were alive but we were unable to determine care status. Estimates using data from the EMR only suggested that 42.7% (95% CI 38.0%-47.1%) of new ART starters and 72.3% (95% CI 71.8%-73.0%) of all ART users were retained at 2 years. After incorporating updated data through tracing, we found that 77.3% (95% CI 70.5%-84.0%) of new initiates and 91.2% (95% CI 90.5%-91.8%) of all ART users were retained (at original clinic or transferred), indicating that routine program data underestimated retention in care markedly. In Lusaka Province, HIV RNA levels greater than or equal to 1,000 copies/ml were present in 18.1% (95% CI 14.0%-22.3%) of patients in care, 71.3% (95% CI 58.2%-84.4%) of lost patients, and 24.7% (95% CI 21.0%-29.3%). The main study limitations were imperfect response rates and the use of self-reported care status. CONCLUSIONS In this region of Zambia, routine program data underestimated retention, and the point prevalence of unsuppressed HIV RNA was high when lost patients were accounted for. Viremia was prevalent among patients who unofficially transferred: Sustained engagement remains a challenge among HIV patients in Zambia, and targeted sampling is an effective strategy to identify such gaps in the care cascade and monitor programmatic progress.
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Affiliation(s)
- Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- * E-mail:
| | - Ingrid Eshun-Wilson
- University of California, San Francisco, San Francisco, California, United States of America
| | | | - Nancy Czaicki
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of California, San Francisco, San Francisco, California, United States of America
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Aaloke Mody
- University of California, San Francisco, San Francisco, California, United States of America
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - David V. Glidden
- University of California, San Francisco, San Francisco, California, United States of America
| | | | | | - Nancy Padian
- University of California, Berkeley, Berkeley, California, United States of America
| | - Chris J. Duncombe
- International Association of Providers of AIDS Care, Washington, District of Columbia, United States of America
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Laura K. Beres
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Charles B. Holmes
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Johns Hopkins University, Baltimore, Maryland, United States of America
- Georgetown University, Washington, District of Columbia, United States of America
| | - Elvin Geng
- University of California, San Francisco, San Francisco, California, United States of America
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Njom Nlend AE, Nguedou Marcelle K, Koki Ndombo P, Brunelle Sandié A. [12-months efficacy of option B+ for prevention of mother-to-child transmission of HIV in Yaoundé, Cameroon]. Rev Epidemiol Sante Publique 2019; 67:163-167. [PMID: 30992178 DOI: 10.1016/j.respe.2019.03.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 09/04/2018] [Accepted: 03/14/2019] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Cameroon has adopted the option B+ for the prevention of mother-to-child transmission (MTCT) program of HIV in August 2014 in order to eradicate MTCT of HIV. OBJECTIVE To analyze in routine life settings, efficacy of option B+ for PMTCT and associate factors. METHODS We conducted a cross-sectional study over a 6-month period in the ESSOS hospital center. Study population comprised HIV-positive mothers and their infants aged 0-24 months. Variables included were : moment of HIV maternal testing, timing of commencement of maternal antiretroviral therapy (ART) and self-reported adherence to ART. Efficacy was measured through early and late MTCT rate and associated factors. RESULTS We included 200 mothers and 124 infants. Under option B+, the rate of transmission was at 4.20% at 6 weeks and 5.83% at 12 months. The rate of HIV transmission in breastfed infants stood at 3.7%. In unadjusted analysis, bottle-feeding, term at birth, early screening and management during pregnancy were associated with lower risk of HIV transmission. After adjustment, term at delivery after 37 weeks adjusted odds ratio (AOR) [0.059; (0.0061; 0.56)] was protective; while lack of prophylaxis was among HIV-exposed infants emerged as the main factor associated with residual transmission of HIV [AOR 117.23 ; (3.55 ; 3874.9)]. CONCLUSION In this setting of Yaoundé, routine option B+ posted laudable results at 12 months even amongst breastfed children and should therefore be made sustainable.
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Affiliation(s)
- A E Njom Nlend
- Centre hospitalier d'ESSOS, caisse nationale de prévoyance sociale, Yaoundé, Cameroun; Institut de technologies médicales Nkolondom, université de Douala, Yaoundé, Cameroun.
| | - K Nguedou Marcelle
- Institut de technologies médicales Nkolondom, université de Douala, Yaoundé, Cameroun
| | - P Koki Ndombo
- Faculté de médecine et de sciences biomédicales, université de Yaoundé, Cameroun; Centre mère-enfant fondation Chantal-Biya, Yaoundé, Cameroun
| | - A Brunelle Sandié
- Département de statistiques, université panafricaine de Nairobi, Nairobi, Kenya
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Long-term effects of unintended pregnancy on antiretroviral therapy outcomes among South African women living with HIV. AIDS 2019; 33:885-893. [PMID: 30649049 DOI: 10.1097/qad.0000000000002139] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Unintended pregnancies are common among women living with HIV, but there are no data on their long-term impact on treatment outcomes. In a cohort of women initiating antiretroviral therapy (ART) during pregnancy, we examined the association between the intendedness of the current pregnancy, measured antenatally, and elevated viral load up to 5 years postpartum. DESIGN Prospective study with enrolment at entry into antenatal care and follow-up at study visits separate from routine care. METHODS At enrolment women completed the London Measure of Unplanned Pregnancy. Mixed effects models examined the impact of the intendedness of the pregnancy (planned versus each of unplanned or ambivalent, respectively) on viral load 50 or more copies/ml across postpartum study visits. RESULTS Overall, 459 women were followed for a median of 43 months postpartum, contributing 2535 viral load measures (median per woman: 6). Ambivalent and unplanned pregnancy were commonly reported (20 and 60%, respectively), and the proportion of women with elevated viral load increased over time (16% at 6 weeks to 43% by 36-60 months postpartum). Compared with those reporting a planned pregnancy, elevated viral load was more common among women reporting an unplanned pregnancy (odds ratio: 2.87; 95% confidence interval: 1.46-5.64), with a trend towards a higher odds among those reporting ambivalence (odds ratio: 2.19; 95% confidence interval: 0.97-4.82); associations persisted after adjustment for a wide range of demographic, clinical and psychosocial factors. CONCLUSION These novel data suggest that unplanned pregnancy may be a prevalent and persistent predictor of poor ART outcomes among women initiating ART during pregnancy.
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Retention in HIV Care During Pregnancy and the Postpartum Period in the Option B+ Era: Systematic Review and Meta-Analysis of Studies in Africa. J Acquir Immune Defic Syndr 2019; 77:427-438. [PMID: 29287029 DOI: 10.1097/qai.0000000000001616] [Citation(s) in RCA: 172] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Under Option B+ guidelines for prevention of mother-to-child transmission of HIV, pregnant and breastfeeding women initiate antiretroviral therapy for lifelong use. The objectives of this study were: (1) to synthesize data on retention in care over time in option B+ programs in Africa, and (2) to identify factors associated with retention in care. METHODS PubMed, EMBASE, and African Index Medicus were systematically searched from January 2012 to June 2017. Pooled estimates of the proportion of women retained were generated and factors associated with retention were analyzed thematically. RESULTS Thirty-five articles were included in the final review; 22 reported retention rates (n = 60,890) and 25 reported factors associated with retention. Pooled estimates of retention were 72.9% (95% confidence interval: 66.4% to 78.9%) at 6 months for studies reporting <12 months of follow-up and 76.4% (95% confidence interval: 69.0% to 83.1%) at 12 months for studies reporting ≥12 months of follow-up. Data on undocumented clinic transfers were largely absent. Risk factors for poor retention included younger age, initiating antiretroviral therapy on the same day as diagnosis, initiating during pregnancy versus breastfeeding, and initiating late in the pregnancy. Retention was compromised by stigma, fear of disclosure, and lack of social support. CONCLUSIONS Retention rates in prevention of mother-to-child transmission under option B+ were below those of the general adult population, necessitating interventions targeting the complex circumstances of women initiating care under option B+. Improved and standardized procedures to track and report retention are needed to accurately represent care engagement and capture undocumented transfers within the health system.
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Impact of universal antiretroviral therapy for pregnant and postpartum women on antiretroviral therapy uptake and retention. AIDS 2019; 33:45-54. [PMID: 30289804 DOI: 10.1097/qad.0000000000002027] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Universal eligibility for lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women ('Option B+') has been widely adopted, but concerns remain. We tested the hypothesis that the change from CD4+-guided ART eligibility ('Option A'), to Option B+, would improve maternal ART uptake and retention. DESIGN A stepped-wedge evaluation at 12 health facilities in eSwatini. METHODS Primary outcome was maternal retention: proportion of women attending clinic within 56 days of delivery (antenatal retention) and clinic attendance within 84 days of 6-months postpartum (postnatal retention). Generalized estimating equations examined impact of Option B+ vs. Option A. RESULTS Between 19 August 2013 and 29 August 2014, 2347 HIV-positive women, 55% (n = 1296) Option A, 45%, (n = 1051) Option B+ were included. ART initiation was observed in 36% (n = 469) of Option A women vs. 94% (n = 983) under Option B+ (P < 0.001). Overall 39% (n = 912) were retained from first ANC visit through 6-months postpartum. Retention was higher under Option B+ (53%, n = 559) vs. Option A (24%, n = 353) with variation by site and study month. Adjusting for age, gestational age, previous HIV diagnosis, and CD4+, Option B+ women were significantly more likely to be retained antenatally (aRR 1.32; 95% CI 1.18-1.49; P < 0.001) and postnatally (aRR 2.11; 95% CI 1.79-2.49) compared with Option A. Restricted to women initiating ART, retention was lower under Option B+ (57%, n = 558) vs. Option A (66%, n = 309; aRR, 0.82; 95% CI 0.70-0.95; P < 0.0001). CONCLUSION Compared with CD4+-guided ART eligibility, universal ART resulted in substantial increases in pregnant women initiating ART and retained in care through 6 months postpartum.
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Koyuncu A, Dufour MSK, McCoy SI, Bautista-Arredondo S, Buzdugan R, Watadzaushe C, Dirawo J, Mushavi A, Mahomva A, Cowan F, Padian N. Protocol for the evaluation of the population-level impact of Zimbabwe's prevention of mother-to-child HIV transmission program option B+: a community based serial cross-sectional study. BMC Pregnancy Childbirth 2019; 19:15. [PMID: 30621615 PMCID: PMC6325877 DOI: 10.1186/s12884-018-2146-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 12/12/2018] [Indexed: 11/13/2022] Open
Abstract
Background WHO recommends that HIV infected women receive antiretroviral therapy (ART) minimally during pregnancy and breastfeeding (“Option B”), or ideally throughout their lives regardless of clinical stage (“Option B+”) (Coovadia et al., Lancet 379:221–228, 2012). Although these recommendations were based on clinical trials demonstrating the efficacy of ART during pregnancy and breastfeeding, the population-level effectiveness of Option B+ is unknown, as are retention on ART beyond the immediate post-partum period, and the relative impact and cost-effectiveness of Option B+ compared to Option A (Centers for Disease Control and Prevention, Morb Mortal Wkly Rep 62:148–151, 2013; Ahmed et al., Curr Opin HIV AIDS 8:473–488, 2013). To address these issues, we conducted an impact evaluation of Zimbabwe’s prevention of mother to child transmission programme conducted between 2011 and 2018 using serial, community-based cross-sectional serosurveys, which spanned changes in WHO recommendations. Here we describe the rationale for the design and analysis. Methods/design Our method is to survey mother-infant pairs residing in the catchment areas of 157 health facilities randomly selected from 5 of 10 provinces in Zimbabwe. We collect questionnaires, blood samples from mothers and babies for HIV antibody and viral load testing, and verbal autopsies for deceased mothers/babies. Using this approach, we collected data from two previous time points: 2012 (pre-Option A standard of care), 2014 (post-Option A / pre-Option B+) and will collect a third round of data in 2017–18 (post Option B+ implementation) to monitor population-level trends in mother-to-child transmission of HIV (MTCT) and HIV-free infant survival. In addition, we will collect detailed information on facility level factors that may influence service delivery and costs. Discussion Although the efficacy of antiretroviral therapy (ART) during pregnancy and breastfeeding for prevention of mother-to-child transmission of HIV (PMTCT) has been well-documented in randomized trials, little evidence exists on the population-level impact and cost-effectiveness of Option B+ or the influence of the facility on implementation (Siegfried et al., Cochrane Libr 7:CD003510, 2017). This study will provide essential data on these gaps and will provide estimates on retention in care among Option B+ clients after the breastfeeding period. Trial registration NCT03388398 Retrospectively registered January 3, 2018.
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Affiliation(s)
| | - Mi-Suk Kang Dufour
- Division of Prevention Science, University of California San Francisco, San Francisco, USA
| | | | | | | | | | - Jeffrey Dirawo
- Centre for Sexual Health and HIV Research Zimbabwe, Harare, Zimbabwe
| | | | - Agnes Mahomva
- Elizabeth Glaser Pediatric AIDS Foundation, Harare, Zimbabwe
| | - Frances Cowan
- Centre for Sexual Health and HIV Research Zimbabwe, Harare, Zimbabwe.,Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nancy Padian
- University of California Berkeley, Berkeley, USA
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Nsubuga-Nyombi T, Karamagi E, Nabitaka L, Namukose S, Calnan J, Nyakwezi S, Bachou H, Oucul L, Amoah AO. Increasing HIV-Free Survival of Infants: Reorganizing Care Using Quality Improvement for the Optimal Health and Nutrition of HIV-Positive Women and Their Exposed Infants in Uganda. J Int Assoc Provid AIDS Care 2019; 18:2325958219857724. [PMID: 31258023 PMCID: PMC6748534 DOI: 10.1177/2325958219857724] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 05/24/2019] [Accepted: 05/24/2019] [Indexed: 11/30/2022] Open
Abstract
Reorganizing service delivery to integrate nutrition and infant and young child feeding (IYCF) with prevention of mother-to-child transmission (PMTCT) is important for improving outcomes of HIV-positive mothers and HIV-exposed infants (HEIs). Quality improvement (QI) strategies were implemented at 22 health facilities. The percentage of HIV-positive pregnant women and lactating mothers who received IYCF counseling at each visit improved (45%-100%; mean = 93.1%, standard deviation [SD] = 15.5). Adherence to IYCF practices improved (70%-96%; mean = 92.4%, SD = 8.5). Mother-baby pairs receiving the standard care package improved (0%-100%; mean = 98.6%, SD = 22.6). The HEIs alive at 18 months and infected decreased (mean = 6.2%, SD = 4.8). Statistical significance of change was estimated using Fisher exact test and magnitude of change over time by calculating the odds ratio. For all indicators, improvement was rapid and significant (P < .001), especially in the first 6 months of QI implementation. Using QI to integrate nutrition and ensure consistent and comprehensive PMTCT service delivery improved IYCF adherence and decreased transmission.
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Affiliation(s)
- Tamara Nsubuga-Nyombi
- United States Agency for International Development (USAID) Applying Science
to Strengthen and Improve Systems (ASSIST) Project, University Research Co, LLC (URC),
Kampala, Uganda
| | - Esther Karamagi
- United States Agency for International Development (USAID) Applying Science
to Strengthen and Improve Systems (ASSIST) Project, University Research Co, LLC (URC),
Kampala, Uganda
| | - Linda Nabitaka
- AIDS Control Program, Ministry of Health, Kampala, Uganda
| | | | | | - Sheila Nyakwezi
- United States Agency for International Development, Kampala, Uganda
| | | | | | - Aurora Ose Amoah
- United States Agency for International Development (USAID) Applying Science
to Strengthen and Improve Systems (ASSIST) Project, Kampala, Uganda
- Data Analytics Research and Evaluation Group, Kampala, Uganda
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Phillips TK, Clouse K, Zerbe A, Orrell C, Abrams EJ, Myer L. Linkage to care, mobility and retention of HIV-positive postpartum women in antiretroviral therapy services in South Africa. J Int AIDS Soc 2018; 21 Suppl 4:e25114. [PMID: 30027583 PMCID: PMC6053482 DOI: 10.1002/jia2.25114] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/08/2018] [Indexed: 11/08/2022] Open
Abstract
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.
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Affiliation(s)
- Tamsin K Phillips
- Division of Epidemiology & BiostatisticsCentre for Infectious Disease Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
- The South African Department of Science and Technology/National Research Foundation (DST‐NRF)Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA)Stellenbosch UniversityStellenboschSouth Africa
| | - Kate Clouse
- Vanderbilt Institute for Global HealthVanderbilt UniversityNashvilleTNUSA
- Department of MedicineDivision of Infectious DiseasesVanderbilt UniversityNashvilleTNUSA
| | - Allison Zerbe
- ICAPColumbia UniversityMailman School of Public HealthNew YorkNYUSA
| | - Catherine Orrell
- Desmond Tutu HIV CentreInstitute of Infectious Disease and Molecular Medicine and Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Elaine J Abrams
- ICAPColumbia UniversityMailman School of Public HealthNew YorkNYUSA
- College of Physicians & SurgeonsColumbia UniversityNew YorkNYUSA
| | - Landon Myer
- Division of Epidemiology & BiostatisticsCentre for Infectious Disease Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
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Chersich MF, Newbatt E, Ng’oma K, de Zoysa I. UNICEF's contribution to the adoption and implementation of option B+ for preventing mother-to-child transmission of HIV: a policy analysis. Global Health 2018; 14:55. [PMID: 29859098 PMCID: PMC5984744 DOI: 10.1186/s12992-018-0369-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/06/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Between 2011 and 2013, global and national guidelines for preventing mother-to-child transmission (PMTCT) of HIV shifted to recommend Option B+, the provision of lifelong antiretroviral treatment for all HIV-infected pregnant women. METHODS We aimed to analyse how Option B+ reached the policy agenda, and unpack the processes, actors and politics that explain its adoption, with a focus on examining UNICEF's contribution to these events. Analysis drew on published articles and other documentation, 30 key informants interviews with staff at UNICEF, partner organisations and government officials, and country case studies. Cameroon, India, South Africa and Zimbabwe were each visited for 5-8 days. Interview transcripts were analysed using Dedoose software, reviewed several times and then coded thematically. RESULTS A national policy initiative in Malawi in 2011, in which the country adopted Option B+, rather than existing WHO recommended regimens, irrevocably placed the policy on the global agenda. UNICEF and other organisations recognised the policy's potential impact and strategically crafted arguments to support it, framing these around operational considerations, cost-effectiveness and values. As 'policy entrepreneurs', these organisations vigorously promoted the policy through a variety of channels and means, overcoming concerted opposition. WHO, on the basis of scanty evidence, released a series of documents towards the policy's endorsement, paving the way for its widespread adoption. National-level policy transformation was rapid and definitive, distinct from previous incremental policy processes. Many organisations, including UNICEF, facilitated these changes in country, acting individually, or in concert. CONCLUSIONS The adoption of the Option B+ policy marked a departure from established processes for PMTCT policy formulation which had been led by WHO with the support of technical experts, and in which recommendations were developed following shifts in evidence. Rather, changes were spurred by a country-level initiative, and a set of strategically framed arguments that resonated with funders and country-level actors. This bottom-up approach, supported by normative agencies, was transformative. For UNICEF, alignment between the organisation's country focus and the policy's underpinning values, enabled it to work with partners and accelerate widespread policy change.
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Affiliation(s)
- M. F. Chersich
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - K. Ng’oma
- United Nations Children’s Fund, Pretoria, South Africa
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Langwenya N, Phillips TK, Brittain K, Zerbe A, Abrams EJ, Myer L. Same-day antiretroviral therapy (ART) initiation in pregnancy is not associated with viral suppression or engagement in care: A cohort study. J Int AIDS Soc 2018; 21:e25133. [PMID: 29939483 PMCID: PMC6016637 DOI: 10.1002/jia2.25133] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 05/04/2018] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Many prevention of mother-to-child HIV transmission programmes across Africa initiate HIV-infected (HIV positive) pregnant women on lifelong antiretroviral therapy (ART) on the first day of antenatal care ("same-day" initiation). However, there are concerns that same-day initiation may limit patient preparation before starting ART and contribute to subsequent non-adherence, disengagement from care and raised viral load. We examined if same-day initiation was associated with viral suppression and engagement in care during pregnancy. METHODS Consecutive ART-eligible pregnant women making their first antenatal care (ANC) visit at a primary care facility in Cape Town, South Africa were enrolled into a prospective cohort between March 2013 and June 2014. Before July 2013, ART eligibility was based on CD4 cell count ≤350 cells/μL ("Option A"), with a 1 to 2 week delay from the first ANC visit to ART initiation for patient preparation; thereafter all women were eligible regardless of CD4 cell count ("Option B+") and offered ART on the same day as first ANC visit. Women were followed with viral load testing conducted separately from routine ART services, and engagement in ART services was measured using routinely collected clinic, pharmacy and laboratory records through 12 months postpartum. RESULTS Among 628 HIV-positive women (median age, 28 years; median gestation at ART start, 21 weeks; 55% newly diagnosed with HIV), 73% initiated ART same-day; this proportion was higher under Option B+ versus Option A (85% vs. 20%). Levels of viral suppression (viral load <50 copies/mL) at delivery (74% vs. 82%) and 12 months postpartum (74% vs. 71%) were similar under same-day versus delayed initiation respectively. Findings were consistent when viral suppression was defined at <1000 copies/mL, after adjustment for demographic/clinical measures and across subgroups of age, CD4 and timing of HIV diagnosis. Time to first viral rebound following initial suppression did not differ by timing of ART initiation nor did engagement in care through 12 months postpartum (same-day = 73%, delayed = 73%, p = 0.910). CONCLUSIONS These data suggest that same-day ART initiation during pregnancy is not associated with lower levels of engagement in care or viral suppression through 12 months post-delivery in this setting, providing reassurance to ART programmes implementing Option B+.
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Affiliation(s)
- Nontokozo Langwenya
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Centre for Infectious Diseases Epidemiology & ResearchUniversity of Cape TownCape TownSouth Africa
| | - Tamsin K Phillips
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Centre for Infectious Diseases Epidemiology & ResearchUniversity of Cape TownCape TownSouth Africa
| | - Kirsty Brittain
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Centre for Infectious Diseases Epidemiology & ResearchUniversity of Cape TownCape TownSouth Africa
| | - Allison Zerbe
- ICAP at Columbia UniversityMailman School of Public HealthNew YorkNew York
| | - Elaine J Abrams
- ICAP at Columbia UniversityMailman School of Public HealthNew YorkNew York
- Columbia UniversityCollege of Physicians & SurgeonsNew YorkNew York
| | - Landon Myer
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Centre for Infectious Diseases Epidemiology & ResearchUniversity of Cape TownCape TownSouth Africa
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HIV-1 transmission and survival according to feeding options in infants born to HIV-infected women in Yaoundé, Cameroon. BMC Pediatr 2018; 18:69. [PMID: 29458337 PMCID: PMC5817808 DOI: 10.1186/s12887-018-1049-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 02/06/2018] [Indexed: 11/17/2022] Open
Abstract
Background Evidence of 24-months survival in the frame of prevention of mother-to-child transmission (PMTCT) cascade-care is scare from routine programs in sub-Saharan African (SSA) settings. Specifically, data on infant outcomes according to feeding options remain largely unknown by month-24, thus limiting its breath for public-health recommendations toward eliminating new pediatric HIV-1 infections and improving care. We sought to evaluate HIV-1 vertical transmission and infant survival rates according to feeding options. Methods A retrospective cohort-study conducted in Yaounde from April 2008 through December 2013 among 1086 infants born to HIV-infected women and followed-up throughout the PMTCT cascade-care until 24-months. Infants with documented feeding option during their first 3 months of life (408 on Exclusive Breastfeeding [EBF], 663 Exclusive Replacement feeding [ERF], 15 mixed feeding [MF]) and known HIV-status were enrolled. HIV-1 vertical transmission, survival and feeding options were analyzed using Kaplan Meier Survival Estimate, Cox model and Schoenfeld residuals tests, at 5% statistical significance. Results Overall HIV-1 vertical transmission was 3.59% (39), and varied by feeding options: EBF (2.70%), ERF (3.77%), MF (20%), p = 0.002; without significance between EBF and ERF (p = 0.34). As expected, HIV-1 transmission also varied with PMTCT-interventions: 1.7% (10/566) from ART-group, 1.9% (8/411) from AZT-group, and 19.2% (21/109) from ARV-naïve group, p < 0.0001. Overall mortality was 2.58% (28), higher in HIV-infected (10.25%) vs. uninfected (2.29%) infants (p = 0.016); with a survival cumulative probability of 89.3% [79.9%–99.8%] vs. 96.4% [94.8%–97.9% respectively], p = 0.024. Mortality also varied by feeding option: ERF (2.41%), EBF (2.45%), MF (13.33%), p = 0.03; with a survival cumulative probability of 96% [94%–98%] in ERF, 96.4% [94.1%–98.8%] in EBF, and 86.67% [71.06%–100%] in MF, p = 0.04. Using Schoenfeld residuals test, only HIV status was a predictor of survival at 24 months (hazard ratio 0.23 [0.072–0.72], p = 0.01). Conclusion Besides using ART for PMTCT-interventions, practice of MF also drives HIV-1 vertical transmission and mortality among HIV-infected children. Thus, throughout PMTCT option B+ cascade-care, continuous counseling on safer feeding options would to further eliminating new MTCT, optimizing response to care, and improving the life expectancy of these children in high-priority countries.
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Thomson KA, Telfer B, Opondo Awiti P, Munge J, Ngunga M, Reid A. Navigating the risks of prevention of mother to child transmission (PMTCT) of HIV services in Kibera, Kenya: Barriers to engaging and remaining in care. PLoS One 2018; 13:e0191463. [PMID: 29364979 PMCID: PMC5783372 DOI: 10.1371/journal.pone.0191463] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 01/05/2018] [Indexed: 11/18/2022] Open
Abstract
Within the first year of implementation, 43% of women who tested HIV positive at their first antenatal care visit were no longer retained and being followed in the free prevention of mother to child transmission (PMTCT) of HIV program offered by the Kenyan Ministry of Health and Médecins Sans Frontières in the informal settlement of Kibera, Nairobi. This study aimed to explore barriers to enrolling and remaining engaged in PMTCT services throughout the pregnancy and postpartum periods. Qualitative data from 31 focus group discussions and 35 in-depth interviews across six stakeholder groups that included women, men, and PMTCT service providers were analyzed. Using an inductive exploratory approach, four researchers coded the data and identified key themes. Five themes emerged from the data that may influence attrition from PMTCT service in this setting: 1) HIV in the context of Kibera, 2) knowledge of HIV status, 3) knowledge of PMTCT, 4) disclosure of HIV status, and 5) male partner support for PMTCT services. A new HIV diagnosis during pregnancy immediately triggered an ongoing risk assessment of perceived hazards in the home, community, and clinic environments that could occur as a result of female participation in PMTCT services. Male partners were a major influence in this risk assessment, but were generally unaware of PMTCT services. To preserve relationships with male partners, meet community expectations of womanhood, and maintain confidentiality while following recommendations of healthcare providers, women had to continuously weigh the risks and benefits of PMTCT services and interventions. Community-based HIV testing and PMTCT education, male involvement in antenatal care, and counseling customized to assist each woman in her own unique risk assessment, may improve uptake of and retention in care and optimize the HIV prevention benefit of PMTCT interventions.
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Affiliation(s)
- Kerry A Thomson
- Médecins Sans Frontières (MSF) Operational Centre Brussels, Nairobi, Kenya
| | - Barbara Telfer
- Médecins Sans Frontières (MSF) Operational Centre Brussels, Nairobi, Kenya
| | | | - Jane Munge
- Médecins Sans Frontières (MSF) Operational Centre Brussels, Nairobi, Kenya
| | | | - Anthony Reid
- Médecins Sans Frontières (MSF) Operational Centre Brussels, Luxembourg City, Luxembourg
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Differentiated models of care for postpartum women on antiretroviral therapy in Cape Town, South Africa: a cohort study. J Int AIDS Soc 2017; 20:21636. [PMID: 28770593 PMCID: PMC5577773 DOI: 10.7448/ias.20.5.21636] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: The numbers of women initiating lifelong antiretroviral therapy (ART) during pregnancy and postpartum is increasing rapidly, presenting a burden on health systems and an urgent need for scalable models of care for this population. In a pilot project, we referred postpartum women who initiated ART during pregnancy to a community-based model of differentiated ART services. Methods: Eligible women (on ART for at least 3 months with viral load (VL)<1000 copies/mL) were offered a choice of two ART models of care: (i) referral to an existing system of community-based ‘adherence clubs’, operated by lay counsellors with medication collection every 2–4 months; or (ii) referral to local primary healthcare clinics (PHC) with services provided by clinicians and medication collection every 1–2 months (local standard of care for postpartum ART). For evaluation, women were followed through 6-months postpartum with VL testing separate from either ART service. Results: Through September 2015, n = 129 women were enrolled (median age, 28 years; median time postpartum, 10 days). Overall, 65% (n = 84) chose adherence clubs and 35% (n = 45) chose PHCs; there were no demographic or clinical predictors of this choice. Location of service delivery was commonly cited as a reason for choice by women selecting either model of care; shorter waiting times, ability to receive ART from lay counsellors and less frequent appointments were motivations for choosing adherence clubs. Among women choosing adherence clubs, 15% never attended the service and another 11% attended the service but were not retained through six months postpartum. Overall, 86% of women (n = 111) remained in the evaluation through 6 months postpartum; in this group, there were no differences in VL<1000 copies/mL at six months postpartum between women choosing PHCs (88%) vs. adherence clubs (92%; p = 0.483), but women who were not retained in adherence clubs were more likely to have VL≥1000 copies/mL compared to those who remained (p = 0.002). Discussion: Adherence clubs may be a valuable model for postpartum women initiating ART in pregnancy, with good short-term outcomes observed during this critical period. To support optimal implementation, further research is needed into patient preferences for models of care, with consideration of integration of maternal and child health services, while ART adherence and retention require ongoing consideration in this population.
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Stepped-Wedge Cluster Randomized Controlled Trial to Promote Option B+ Retention in Central Mozambique. J Acquir Immune Defic Syndr 2017; 76:273-280. [PMID: 28777263 DOI: 10.1097/qai.0000000000001515] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This randomized trial studied performance of Option B+ in Mozambique and evaluated an enhanced retention package in public clinics. SETTING The study was conducted at 6 clinics in Manica and Sofala Provinces in central Mozambique. METHODS Seven hundred sixty-one pregnant women tested HIV+, immediately initiated antiretroviral (ARV) therapy, and were followed to track retention at 6 clinics from May 2014 to May 2015. Clinics were randomly allocated within a stepped-wedge fashion to intervention and control periods. The intervention included (1) workflow modifications and (2) active patient tracking. Retention was defined as percentage of patients returning for 30-, 60-, and 90-day medication refills within 25-35 days of previous refills. RESULTS During control periods, 52.3% of women returned for 30-day refills vs. 70.8% in intervention periods [odds ratio (OR): 1.80; 95% confidence interval (CI): 1.05 to 3.08]. At 60 days, 46.1% control vs. 57.9% intervention were retained (OR: 1.82; CI: 1.06 to 3.11), and at 90 days, 38.3% control vs. 41.0% intervention (OR: 1.04; CI: 0.60 to 1.82). In prespecified subanalyses, birth before pickups was strongly associated with failure-women giving birth before ARV pickup were 33.3 times (CI: 4.4 to 250.3), 7.5 times (CI: 3.6 to 15.9), and 3.7 times (CI: 2.2 to 6.0) as likely to not return for ARV pickups at 30, 60, and 90 days, respectively. CONCLUSIONS The intervention was effective at 30 and 60 days, but not at 90 days. Combined 90-day retention (40%) and adherence (22.5%) were low. Efforts to improve retention are particularly important for women giving birth before ARV refills.
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Non-adoption of Option B+ for prevention of mother-to-child transmission of HIV in Nigeria: A look at the policymaking process. J Public Health Policy 2017; 38:105-120. [PMID: 28275257 DOI: 10.1057/s41271-016-0048-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In 2012, the World Health Organization recommended 'Option B+' (lifelong antiretroviral treatment for HIV-infected pregnant women regardless of their CD4 count or WHO clinical stage) for prevention of mother-to-child transmission of HIV-based on its operational and clinical advantages. By 2015, 21 out of the 22 Global Plan priority countries had adopted the Option B+ approach. Despite its huge HIV burden, Nigeria is the only country yet to adopt Option B+. We analyse the policymaking process on Option B+ in Nigeria from 2012-2015, highlighting how factors related to the content (uncertainty about Option B+, lack of local evidence), actors (interest and power) and context (low domestic funding and poor retention in care) affected the policymaking process and present the implications of this decision for improving HIV response in Nigeria.
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Miller K, Muyindike W, Matthews LT, Kanyesigye M, Siedner MJ. Program Implementation of Option B+ at a President's Emergency Plan for AIDS Relief-Supported HIV Clinic Improves Clinical Indicators But Not Retention in Care in Mbarara, Uganda. AIDS Patient Care STDS 2017; 31:335-341. [PMID: 28650703 PMCID: PMC5564010 DOI: 10.1089/apc.2017.0034] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
2013 WHO guidelines for prevention of mother to child transmission recommend combination antiretroviral therapy (ART) for all pregnant women, regardless of CD4 count (Option B/B+). We conducted a retrospective analysis of data from a government-operated HIV clinic in Mbarara, Uganda before and after implementation of Option B+ to assess the impact on retention in care. We limited our analysis to women not on ART at the time of their first reported pregnancy with CD4 count >350. We fit regression models to estimate relationships between calendar period (Option A vs. Option B+) and the primary outcome of interest, retention in care. One thousand and sixty-two women were included in the analysis. Women were more likely to start ART within 6 months of pregnancy in the Option B+ period (68% vs. 7%, p < 0.0001) and had significantly greater increases in CD4 count 1 year after pregnancy (+172 vs. -5 cells, p < 0.001). However, there was no difference in the proportion of women retained in care 1 year after pregnancy (73% vs. 70%, p = 0.34). In models adjusted for age, distance to clinic, marital status, and CD4 count, Option B+ was associated with a nonsignificant 30% increased odds of retention in care at 1 year [adjusted odds ratio (AOR) = 1.30, 95% CI 0.98-1.73, p = 0.06]. After transition to an Option B+ program, pregnant women with CD4 count >350 were more likely to initiate combination therapy; however, interventions to mitigate losses from HIV care during pregnancy are needed to improve the health of women, children, and families.
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Affiliation(s)
- Kathleen Miller
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Winnie Muyindike
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lynn T. Matthews
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Kanyesigye
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mark J. Siedner
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Hauser BM, Miller WC, Tweya H, Speight C, Mtande T, Phiri S, Ball LM, Hosseinipour MC, Hoffman IF, Rosenberg NE. Assessing Option B+ retention and infant follow-up in Lilongwe, Malawi. Int J STD AIDS 2017; 29:185-194. [PMID: 28750577 DOI: 10.1177/0956462417721658] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Malawi launched Option B+, a program for all pregnant or breastfeeding HIV-positive women to begin lifelong combination antiretroviral therapy (cART), in July 2011. This study characterises a portion of the continuum of care within an antenatal setting in Lilongwe. Women testing HIV-positive and having a cART initiation record at Bwaila Antenatal Clinic from July 2013 to January 2014 were included. Using logistic regression models, we analysed relationships between maternal characteristics and return for infant testing. Among 490 HIV-positive women with a cART initiation record, 360 (73%) were retained at three months. Of these, 203 (56%) were adherent. Records of infant testing were located for 204 women (42%). Women who were not retained were less likely to have an early infant diagnosis record (aOR = 0.20; 95% CI: 0.10, 0.41). Among the women retained, there was a non-significant association between maternal adherence and infant testing (OR = 1.35; 95% CI: 0.89, 2.06). Women lost at earlier continuum stages, who are at higher risk for mother-to-child-transmission, were less likely to bring infants for testing. Even with a test-and-treat program, many women did not remain in care or bring their infant for testing. Facilitating strategies to improve these measures remains an important unmet need.
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Affiliation(s)
- Blake M Hauser
- 1 Department of Environmental Sciences and Engineering, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA
| | - William C Miller
- 2 Department of Medicine, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA.,3 Department of Epidemiology, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA
| | - Hannock Tweya
- 4 Lighthouse Trust, Lilongwe, Malawi.,5 The International Union against Tuberculosis and Lung Disease, Paris, France
| | | | - Tiwonge Mtande
- 6 156288 University of North Carolina Project , Lilongwe, Malawi
| | - Sam Phiri
- 2 Department of Medicine, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA.,4 Lighthouse Trust, Lilongwe, Malawi.,7 Department of Public Health, College of Medicine, School of Public Health and Family Medicine, University of Malawi, Lilongwe, Malawi
| | - L M Ball
- 1 Department of Environmental Sciences and Engineering, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA
| | - Mina C Hosseinipour
- 2 Department of Medicine, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA.,6 156288 University of North Carolina Project , Lilongwe, Malawi
| | - Irving F Hoffman
- 2 Department of Medicine, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA.,6 156288 University of North Carolina Project , Lilongwe, Malawi
| | - Nora E Rosenberg
- 2 Department of Medicine, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA.,6 156288 University of North Carolina Project , Lilongwe, Malawi
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PMTCT Option B+ Does Not Increase Preterm Birth Risk and May Prevent Extreme Prematurity: A Retrospective Cohort Study in Malawi. J Acquir Immune Defic Syndr 2017; 74:367-374. [PMID: 27875363 DOI: 10.1097/qai.0000000000001253] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate preterm birth risk among infants of HIV-infected women in Lilongwe, Malawi, according to maternal antiretroviral therapy (ART) status and initiation time under Option B+. DESIGN A retrospective cohort study of HIV-infected women delivering at ≥27 weeks of gestation, April 2012 to November 2015. Among women on ART at delivery, we restricted our analysis to those who initiated ART before 27 weeks of gestation. METHODS We defined preterm birth as a singleton live birth at ≥27 and <37 weeks of gestation, with births at <32 weeks classified as extremely to very preterm. We used log-binomial models to estimate risk ratios and 95% confidence intervals for the association between ART and preterm birth. RESULTS Among 3074 women included in our analyses, 731 preterm deliveries were observed (24%). Overall preterm birth risk was similar in women who had initiated ART at any point before 27 weeks and those who never initiated ART (risk ratio = 1.14; 95% confidence interval: 0.84 to 1.55), but risk of extremely to very preterm birth was 2.33 (1.39 to 3.92) times as great in those who never initiated ART compared with those who did at any point before 27 weeks. Among women on ART before delivery, ART initiation before conception was associated with the lowest preterm birth risk. CONCLUSIONS ART during pregnancy was not associated with preterm birth, and it may in fact be protective against severe adverse outcomes accompanying extremely to very preterm birth. As preconception ART initiation appears especially protective, long-term retention on ART should be a priority to minimize preterm birth in subsequent pregnancies.
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Option B+ in Mozambique: Formative Research Findings for the Design of a Facility-Level Clustered Randomized Controlled Trial to Improve ART Retention in Antenatal Care. J Acquir Immune Defic Syndr 2017; 72 Suppl 2:S181-8. [PMID: 27355507 PMCID: PMC5113244 DOI: 10.1097/qai.0000000000001061] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION With the rollout of "Option B+" in Mozambique in 2013, initial data indicated major challenges to early retention in antiretroviral therapy (ART) among HIV-positive pregnant women. We sought to develop and test a pilot intervention in 6 large public clinics in central Mozambique to improve retention of mothers starting ART in antenatal care. The results from the formative research from this study described here were used to design the intervention. METHODS The research was initiated in early 2013 and completed in early 2014 in each of the 6 study clinics and consisted of (1) patient flow mapping and measurement of retention through collection of health systems data from antenatal care registries, pharmacy registries, ART clinic databases, (2) workforce assessment and measurement of patient waiting times, and (3) patient and worker individual interviews and focus groups. RESULTS Coverage of HIV testing and ART initiation were over 90% at all sites, but retention at 30-, 60-, and 90-day pharmacy refill visits was very low ranging from only 5% at 1 site to 30% returning at 90 days. These data revealed major systemic bottlenecks that contributed to poor adherence and retention in the first month after ART initiation. Long wait times, short consultations, and poor counseling were identified as barriers. CONCLUSIONS Based on these findings, we designed an intervention with these components: (1) workflow modification to redefine nurse tasks, shift tasks to community health workers, and enhance patient tracking and (2) an adherence and retention package to systematize active patient follow-up, ensure home visits by community health workers, use text messaging, and intensify counseling by health staff. This intervention is currently under evaluation using a stepped wedge design.
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Optimizing Antiretroviral Therapy (ART) for Maternal and Child Health (MCH): Rationale and Design of the MCH-ART Study. J Acquir Immune Defic Syndr 2017; 72 Suppl 2:S189-96. [PMID: 27355508 PMCID: PMC5113242 DOI: 10.1097/qai.0000000000001056] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background: Prevention of mother-to-child transmission of HIV implementation faces significant challenges globally, particularly in the context of universal lifelong antiretroviral therapy (ART) for all HIV-infected pregnant women. Methods: We describe the rationale and methods of the Maternal and Child Health-Antiretroviral Therapy (MCH-ART) study, an implementation science project examining strategies for providing HIV care and treatment to HIV-infected women who initiate ART during pregnancy and their HIV-exposed infants. Results: MCH-ART is composed of 3 interrelated study designs across the antenatal and postnatal periods. Phase 1 is a cross-sectional evaluation of consecutive HIV-infected pregnant women seeking antenatal care; phase 2 is an observational cohort of all women from phase 1 who are eligible for initiation of ART following local guidelines; and phase 3 is a randomized trial of strategies for delivering ART to breastfeeding women from phase 2 during the postpartum period. During each phase, a set of study measurement visits is carried out separately from antenatal care and ART services; a maximum of 9 visits takes place from the beginning of antenatal care through 12 months postpartum. In parallel, in-depth interviews are used to examine issues of ART adherence and retention qualitatively, and costs and cost-effectiveness of models of care are examined. Separate substudies examine health outcomes in HIV-uninfected women and their HIV-unexposed infants, and the role of the adherence club model for long-term adherence and retention. Discussion: Combining observational and experimental components, the MCH-ART study presents a novel approach to understand and optimize ART delivery for MCH.
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Phiri S, Tweya H, van Lettow M, Rosenberg NE, Trapence C, Kapito-Tembo A, Kaunda-Khangamwa B, Kasende F, Kayoyo V, Cataldo F, Stanley C, Gugsa S, Sampathkumar V, Schouten E, Chiwaula L, Eliya M, Chimbwandira F, Hosseinipour MC. Impact of Facility- and Community-Based Peer Support Models on Maternal Uptake and Retention in Malawi's Option B+ HIV Prevention of Mother-to-Child Transmission Program: A 3-Arm Cluster Randomized Controlled Trial (PURE Malawi). J Acquir Immune Defic Syndr 2017; 75 Suppl 2:S140-S148. [PMID: 28498183 DOI: 10.1097/qai.0000000000001357] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many sub-Saharan African countries have adopted Option B+, a prevention of mother-to-child transmission approach providing HIV-infected pregnant and lactating women with immediate lifelong antiretroviral therapy. High maternal attrition has been observed in Option B+. Peer-based support may improve retention. METHODS A 3-arm stratified cluster randomized controlled trial was conducted in Malawi to assess whether facility- and community-based peer support would improve Option B+ uptake and retention compared with standard of care (SOC). In SOC, no enhancements were made (control). In facility-based and community-based models, peers provided patient education, support groups, and patient tracing. Uptake was defined as attending a second scheduled follow-up visit. Retention was defined as being alive and in-care at 2 years without defaulting. Attrition was defined as death, default, or stopping antiretroviral therapy. Generalized estimating equations were used to estimate risk differences (RDs) in uptake. Cox proportional hazards regression with shared frailties was used to estimate hazard of attrition. RESULTS Twenty-one facilities were randomized and enrolled 1269 women: 447, 428, and 394 in facilities that implemented SOC, facility-based, and community-based peer support models, respectively. Mean age was 27 years. Uptake was higher in facility-based (86%; RD: 6%, confidence interval [CI]: -3% to 15%) and community-based (90%; RD: 9%, CI: 1% to 18%) models compared with SOC (81%). At 24 months, retention was higher in facility-based (80%; RD: 13%, CI: 1% to 26%) and community-based (83%; RD: 16%, CI: 3% to 30%) models compared with SOC (66%). CONCLUSIONS Facility- and community-based peer support interventions can benefit maternal uptake and retention in Option B+.
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Affiliation(s)
- Sam Phiri
- *Lighthouse Trust, Lilongwe, Malawi; †Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC; ‡Department of Public Health, College of Medicine, School of Public Health and Family Medicine, University of Malawi, Malawi; §The International Union against Tuberculosis and Lung Disease, Center for Operational Research, Paris, France; ‖Research Department, Dignitas International, Zomba, Malawi; ¶Dalla Lana School of Public Health, University of Toronto, Tornoto, Canada; #University of North Carolina Project, Lilongwe, Malawi; **Malaria Alert Centre, College of Medicine, University of Malawi, Blantyre, Malawi; ††International Training and Education Center for Health (I-TECH), University of Washington, Lilongwe, Malawi; ‡‡mothers2mothers, Lilongwe, Malawi; §§Management Sciences for Health, Lilongwe, Malawi; ‖‖Department of Economics, University of Malawi, Chancellor College, Zomba, Malawi; and ¶¶Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
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48
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Ashaba S, Kaida A, Burns BF, O'Neil K, Dunkley E, Psaros C, Kastner J, Tsai AC, Bangsberg DR, Matthews LT. Understanding coping strategies during pregnancy and the postpartum period: a qualitative study of women living with HIV in rural Uganda. BMC Pregnancy Childbirth 2017; 17:138. [PMID: 28482821 PMCID: PMC5423027 DOI: 10.1186/s12884-017-1321-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/03/2017] [Indexed: 01/03/2023] Open
Abstract
Background In sub-Saharan Africa, 58% of adults living with HIV are women. In Uganda, HIV prevalence is 8.3% for women compared to 6.1% for men. Access to antiretroviral therapy (ART) and prevention of mother to child transmission (PMTCT) programs have enabled women living with HIV (WLWH) to have children with minimal risk of perinatal transmission. Nevertheless, pregnant WLWH face many challenges. We explored women’s perceptions of how they cope with the challenges of pregnancy and the postpartum period as HIV-infected women. Methods We conducted semi-structured interviews with postpartum WLWH accessing ART who had a pregnancy within 2 years prior to recruitment between February–August, 2014. Childbearing associated stressors and coping strategies were discussed. We used content analysis to identify major themes and NVivo 10 software facilitated data analysis. Results Twenty women were interviewed with median age 33 (IQR: 28–35) years, CD4 cell count 677 cells/mm3 (IQR: 440–767), number of live births 4 (IQR: 2–6), and number of living children 3 (IQR: 2–4.3). We summarize five identified coping strategies within a socio-ecological framework according to Bronfenbrenner’s Ecological Model. Coping strategies on the individual level included acceptance of self and HIV status, and self-reliance. On the interpersonal level, participants reported coping through support from partners, family, and friends. On the organizational level, participants reported coping through HIV-related healthcare delivery and system supports. At the community level, women reported coping through support from church and spirituality. Conclusions The results highlight coping strategies used by WLWH to manage the myriad challenges faced during pregnancy and the postpartum period. Intervention programs for WLWH must emphasize psychosocial care and incorporate strategies that address psychosocial challenges in the HIV care package in order to optimize well-being. Additionally policies that support networks of WLWH should be put in place and funding support should be provided through existing funding mechanisms in order to respond to the needs and challenges of WLWH. Programmes that support WLWH for economic empowerment and improved livelihoods should be strengthened across all regions in the country. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1321-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Scholastic Ashaba
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | | | - Kasey O'Neil
- MGH Global Health, Massachusetts General Hospital, Boston, MA, USA
| | - Emma Dunkley
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Christina Psaros
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Jasmine Kastner
- Research Institute McGill University Health Centre Montreal, Montreal, Canada
| | - Alexander C Tsai
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - David R Bangsberg
- MGH Global Health, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Lynn T Matthews
- MGH Global Health, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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49
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Moretton MA, Bertera F, Lagomarsino E, Riedel J, Chiappetta DA, Höcht C. Advances in therapy for the prevention of HIV transmission from mother to child. Expert Opin Pharmacother 2017; 18:657-666. [PMID: 28398096 DOI: 10.1080/14656566.2017.1316369] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Actually, ~17.8 million women and 1.8 million children (<15 years) are currently infected with the Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS). Particularly, the majority of pediatric infections (>90%) resulted from 'HIV mother-to-child transmission' (MTCT), both in pregnancy, labour, delivery and later by breastfeeding. Due to its high pediatric incidence, MTCT represents a public health concern. Areas covered: In this review, we focus on available treatments and antiretroviral drugs recommended by the World Health Organization, and the main clinical investigations in antiretroviral pharmacotherapy to prevent the MTCT. Expert opinion: The MTCT has been improved dramatically in the last few years mainly due to prophylactic perinatal antiretroviral therapy for pregnant women living with HIV. However, there is still a milestone to reach since HIV MTCT remains as a public health challenge associated with MTCT though breastfeeding (post-natal transmission). In this context, different strategies could be employed as an attempt to reduce pediatric HIV infections. One of them involves the improvement of patient adherence to the HIV therapy. One possible solution is the development of novel long-acting formulations for prophylaxis of mothers and children, and a second possible solution is increase the inclusion of mothers and infants in care programs to more effectively prevent the vertical transmission.
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Affiliation(s)
- Marcela A Moretton
- a Departamento de Tecnología Farmacéutica, Facultad de Farmacia y Bioquímica, Cátedra de Tecnología Farmacéutica I ., Universidad de Buenos Aires , Buenos Aires , Argentina.,b Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET) , Buenos Aires , Argentina
| | - Facundo Bertera
- c Departamento de Farmacología , Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Cátedra de Farmacología , Buenos Aires , Argentina
| | - Eduardo Lagomarsino
- d Departamento de Farmacología, Universidad de Buenos Aires , Facultad de Farmacia y Bioquímica, Cátedra de Farmacia Clínica , Buenos Aires , Argentina
| | - Jennifer Riedel
- a Departamento de Tecnología Farmacéutica, Facultad de Farmacia y Bioquímica, Cátedra de Tecnología Farmacéutica I ., Universidad de Buenos Aires , Buenos Aires , Argentina
| | - Diego A Chiappetta
- a Departamento de Tecnología Farmacéutica, Facultad de Farmacia y Bioquímica, Cátedra de Tecnología Farmacéutica I ., Universidad de Buenos Aires , Buenos Aires , Argentina.,b Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET) , Buenos Aires , Argentina
| | - Christian Höcht
- c Departamento de Farmacología , Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Cátedra de Farmacología , Buenos Aires , Argentina
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50
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Phillips T, Brittain K, Mellins CA, Zerbe A, Remien RH, Abrams EJ, Myer L, Wilson IB. A Self-Reported Adherence Measure to Screen for Elevated HIV Viral Load in Pregnant and Postpartum Women on Antiretroviral Therapy. AIDS Behav 2017; 21:450-461. [PMID: 27278548 PMCID: PMC5145763 DOI: 10.1007/s10461-016-1448-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Maternal adherence to antiretroviral therapy (ART) is a concern and monitoring adherence presents a significant challenge in low-resource settings. We investigated the association between self-reported adherence, measured using a simple three-item scale, and elevated viral load (VL) among HIV-infected pregnant and postpartum women on ART in Cape Town, South Africa. This is the first reported use of this scale in a non-English speaking setting and it achieved good psychometric characteristics (Cronbach α = 0.79). Among 452 women included in the analysis, only 12 % reported perfect adherence on the self-report scale, while 92 % had a VL <1000 copies/mL. Having a raised VL was consistently associated with lower median adherence scores and the area under the curve for the scale was 0.599, 0.656 and 0.642 using a VL cut-off of ≥50, ≥1000 and ≥10000 copies/mL, respectively. This simple self-report adherence scale shows potential as a first-stage adherence screener in this setting. Maternal adherence monitoring in low resource settings requires attention in the era of universal ART, and the value of this simple adherence scale in routine ART care settings warrants further investigation.
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Affiliation(s)
- Tamsin Phillips
- Division of Epidemiology & Biostatistics, Faculty of Health Sciences, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Kirsty Brittain
- Division of Epidemiology & Biostatistics, Faculty of Health Sciences, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Claude A Mellins
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - Allison Zerbe
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Robert H Remien
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - Elaine J Abrams
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA
- College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics, Faculty of Health Sciences, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Ira B Wilson
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
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