1
|
Ayele AD, Kassa BG, Mihretie GN, Belay HG, Sewyew DA, Semahegn AM, Yehuala ED, Tiruneh GA, Tenaw LA, Sendekie AD, Teffera AG, Aychew EW, Belachew YY, Liyeh TM, Worke MD. Level of adherence to option B+ program and associated factors among HIV-positive women in Ethiopia: A systematic review and meta-analysis. PLoS One 2024; 19:e0298119. [PMID: 38662634 PMCID: PMC11045077 DOI: 10.1371/journal.pone.0298119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 01/16/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Despite policy initiatives and strategic measures highly focused on preventing mother-to-child transmission through the implementation of the Option B+ program, adherence to the treatment is still challenging. The level of adherence and determinants of Option B+ program utilization reported by different studies were highly inconsistent in Ethiopia. Hence, this systematic review and meta-analysis aimed to estimate the pooled prevalence of adherence to the Option B+ program and its predictors among HIV-positive women in Ethiopia. METHODS PubMed, Google Scholar, EMBASE, HINAR, Scopus, and Web of Sciences were searched for published articles from March 2010 to March 2022. The pooled prevalence of adherence was estimated using a weighted DerSimonian-Laird random effect model. The I2 statistics was used to identify the degree of heterogeneity. Publication bias was also assessed using the funnel plot and Egger's regression test. RESULTS A total of 15 studies were included. The pooled estimate of the option B+ program among HIV-positive women in Ethiopia was 81.58% (95% CI: 77.33-85.84). Getting social and financial support (AOR = 3.73, 95% CI: 2.12, 6.58), disclosure of HIV status to partners (AOR = 2.05, 95% CI: 1.75, 2.41), time to reach a health facility (AOR = 0.33, 95% CI: 0.16, 0.67), receiving counseling on drug side effects (AOR = 4.09, 95% CI: 2.74, 6.11), experience of drug side effects (AOR = 0.17, 95% CI: 0.08, 0.36), and knowledge (AOR = 4.73, 95% CI: 2.62, 8.51) were significantly associated with adherence to the Option B+ program. CONCLUSION This meta-analysis showed that the level of adherence to the Option B+ program in Ethiopia is lower than the 95% level of adherence planned to be achieved in 2020. Social and financial support, disclosure of HIV status, time to reach the health facility, counseling, drug side effects, and knowledge of PMTCT were significantly associated with option B+ adherence. The findings of this meta-analysis highlight that governmental, non-governmental, and other stakeholders need to design an effective strategy to scale up the level of disclosing one's own HIV status, access health facilities, improve knowledge of PMTCT, and counsel the potential side effects of Option B+ drugs, and advocate the program to reduce the multidimensional burden of HIV/AIDS. TRIAL REGISTRATION Prospero registration: CRD42022320947. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022320947.
Collapse
Affiliation(s)
- Alemu Degu Ayele
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Bekalu Getnet Kassa
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Gedefaye Nibret Mihretie
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Habtamu Gebrehana Belay
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Dagne Addisu Sewyew
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Abenezer Melkie Semahegn
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Enyew Dagnew Yehuala
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | | | - Lebeza Alemu Tenaw
- School of Public Health, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | | | - Adanech Getie Teffera
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Eden Workneh Aychew
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Yismaw Yimam Belachew
- School of Medicine, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Tewachew Muche Liyeh
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Mulugeta Dile Worke
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| |
Collapse
|
2
|
Anderson K, Kalk E, Heekes A, Phelanyane F, Jacob N, Boulle A, Mehta U, Kassanjee R, Sridhar G, Ragone L, Vannappagari V, Davies M. Factors associated with vertical transmission of HIV in the Western Cape, South Africa: a retrospective cohort analysis. J Int AIDS Soc 2024; 27:e26235. [PMID: 38528395 PMCID: PMC10963590 DOI: 10.1002/jia2.26235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 03/07/2024] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION Monitoring mother-infant pairs with HIV exposure is needed to assess the effectiveness of vertical transmission (VT) prevention programmes and progress towards VT elimination. METHODS We used routinely collected data on infants with HIV exposure, born May 2018-April 2021 in the Western Cape, South Africa, with follow-up through mid-2022. We assessed the proportion of infants diagnosed with HIV at birth (≤7 days), 10 weeks (>1 to 14 weeks) and >14 weeks as proxies for intrauterine, intrapartum/early breastfeeding and late breastfeeding transmission, respectively. We used mixed-effects Poisson regression to assess factors associated with VT in mothers known with HIV by delivery. RESULTS We included 50,461 infants born to mothers known with HIV by delivery. HIV was diagnosed in 894 (1.8%) infants. Among mothers, 51% started antiretroviral treatment (ART) before and 27% during pregnancy; 17% restarted during pregnancy after ≥6 months interruption; and 6% had no recorded ART during pregnancy. Most pregnancy ART regimens included non-nucleoside reverse transcriptase inhibitors (83%). Of mothers with available results (90% with viral load [VL]; 70% with CD4), VL nearest delivery was <100 copies/ml in 78% and CD4 count ≥350 cells/μl in 62%. HIV-PCR results were available for 86%, 67% and 48% of eligible infants at birth, 10 weeks and >14 weeks. Among these infants, 0.9%, 0.4% and 1.5% were diagnosed positive at birth, 10 weeks and >14 weeks, respectively. Among infants diagnosed with HIV, 43%, 16% and 41% were diagnosed at these respective time periods. Among mothers with VL<100, 100-999, 1000-99,000 and ≥100,000 copies/ml nearest delivery, infant HIV diagnosis incidence was 0.4%, 2.3%, 6.6% and 18.4%, respectively. Increased VT was strongly associated with recent elevated maternal VL with a seven-fold increased rate with even modestly elevated VL (100-999 vs. <100 copies/ml). VT was also associated with unknown/low maternal CD4, maternal age <20 years, no antenatal ART, later maternal ART start/restart in pregnancy and ART gaps. CONCLUSIONS Despite high maternal ART coverage and routine postnatal prophylaxis, ongoing VT remains a concern. Timing of infant HIV diagnoses suggests intrapartum and/or breastfeeding transmission in nearly 60%. Interventions to ensure retention on ART and sustained maternal viral suppression are needed to reduce VT.
Collapse
Affiliation(s)
- Kim Anderson
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Emma Kalk
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Alexa Heekes
- Health Intelligence, Western Cape Department of HealthCape TownSouth Africa
| | | | - Nisha Jacob
- Division of Public Health MedicineSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
- Health Intelligence, Western Cape Department of HealthCape TownSouth Africa
- Division of Public Health MedicineSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Ushma Mehta
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Reshma Kassanjee
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | | | | | - Vani Vannappagari
- ViiV HealthcareDurhamNorth CarolinaUSA
- Department of EpidemiologyGilling School of Public HealthUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Mary‐Ann Davies
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
- Health Intelligence, Western Cape Department of HealthCape TownSouth Africa
- Division of Public Health MedicineSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| |
Collapse
|
3
|
Nevrekar N, Butler K, Shapiro DE, Atuhaire P, Taha TE, Makanani B, Chinula L, Owor M, Moodley D, Chipato T, McCarthy K, Flynn PM, Currier J, Fowler MG, Gupta A, Suryavanshi N. Self-reported Antiretroviral Adherence: Association With Maternal Viral Load Suppression in Postpartum Women Living With HIV-1 From Promoting Maternal and Infant Survival Everywhere, a Randomized Controlled Trial in Sub-Saharan Africa and India. J Acquir Immune Defic Syndr 2023; 92:76-83. [PMID: 36170749 PMCID: PMC9722360 DOI: 10.1097/qai.0000000000003102] [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: 06/09/2022] [Accepted: 09/06/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Optimal adherence to antiretroviral therapy (ART) is crucial to promoting maternal-infant health. SETTING Fourteen sites in 7 countries within sub-Saharan Africa and India. METHODS The multicomponent, open-label strategy PROMISE trial enrolled breastfeeding mother-infant pairs not meeting in-country criteria for maternal ART (mART) initiation in the postpartum component within 5 days of delivery. Randomization was to mART versus infant NVP (iNVP) prophylaxis. Infants in the mART arm also received 6 weeks of iNVP. Self-reported adherence was assessed in a secondary analysis. Time-to-event analyses were performed to explore the association between adherence and maternal viral load (mVL) in the mART arm. RESULTS Two thousand four hundred thirty-one mother-infant pairs were enrolled between 2011 and 2014; the baseline maternal median CD4 was 686 (IQR 553-869), and the median mVL was 322 copies/mL (IQR 40-1422). Self-reported adherence was lower in the mART arm compared with the iNVP arm (no missed doses within 4 weeks of all study visits: 66% vs 83%; within 2 weeks: 71% vs 85%; P < 0.0001). The iNVP adherence at week 6 was high in both arms: 97% in mART arm; 95% in iNVP arm. Time-to-event analyses showed that adherence to mART was associated with time to first mVL ≥400 copies/mL ( P < 0.0001). Missing 1 full day of doses over 3 days was associated with a 66% risk of mVL ≥1000 copies/mL (HR: 1.66; 95% CI: 1.37, 1.99). CONCLUSIONS Postpartum women were less adherent to their own ART than mothers providing their infant's nevirapine prophylaxis. The self-reported missed mART doses were associated with high mVL. Strategies to optimize postpartum mART adherence are urgently needed. CLINICAL TRIAL NUMBER ClinicalTrials.gov: NCT01061151; closed to follow-up.
Collapse
Affiliation(s)
- Neetal Nevrekar
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site, Pune, India
| | - Kevin Butler
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - David E. Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Patience Atuhaire
- Makerere University–John Hopkins University Research Collaboration (MUJHU CARE LTD) CRS, Kampala, Uganda
| | - Taha E. Taha
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Bonus Makanani
- College of Medicine-Johns Hopkins Project, Blantyre, Malawi
| | | | - Maxensia Owor
- Makerere University–John Hopkins University Research Collaboration (MUJHU CARE LTD) CRS, Kampala, Uganda
| | - Dhayendre Moodley
- Centre for the AIDS Programme of Research in South Africa and Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
- Nelson R. Mandela School of Medicine, Durban, South Africa
| | - Tsungai Chipato
- Department of Obstetrics and Gynaecology, University of Zimbabwe, Harare, Zimbabwe
| | | | - Patricia M. Flynn
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN
| | - Judith Currier
- UCLA Centre for Clinical AIDS Research and Education, Los Angeles, CA
| | - Mary Glenn Fowler
- Department of Pathology, Johns Hopkins University, School of Medicine, Baltimore, MD; and
| | - Amita Gupta
- Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Nishi Suryavanshi
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site, Pune, India
| |
Collapse
|
4
|
Intimate partner violence and HIV treatment adherence in urban South Africa: Mediating role of perinatal common mental disorders. SSM - MENTAL HEALTH 2022; 2:100112. [PMID: 36688232 PMCID: PMC9792377 DOI: 10.1016/j.ssmmh.2022.100112] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/28/2022] [Accepted: 05/04/2022] [Indexed: 01/25/2023] Open
Abstract
Background Antiretroviral therapy (ART) has potential to eliminate perinatal HIV infections, but adherence to ART in late pregnancy and postpartum is often suboptimal. Intimate partner violence (IPV) may influence non-adherence among perinatal women living with HIV (WWH), but few quantitative studies have examined this over time or explored mechanisms for this association. Methods We used secondary data from a parent trial in Johannesburg comprising WWH from the control arm (n=63) and WWH ineligible for the trial (n=133). Trained nurse researchers administered questionnaires at first antenatal visit on past-year psychological, physical, and/or sexual IPV (WHO instrument), socio-demographics (age, food security, education), and perinatal common mental symptoms of depression (Hospital Anxiety and Depression Screener-d); anxiety (HADS-a); post-traumatic stress disorder (PTSD; Harvard Trauma Questionnaire). At endline visit 2-4 months postpartum, nurse researchers assessed self-reported ART adherence using a visual analog scale (with ≥95% considered "good"). We fitted structural equation models (SEM) in MPlus to explore direct and indirect effects of IPV on ART adherence. Results Of 196 perinatal WWH, 53.1% reported IPV exposure at baseline. The majority of participants (85.7%) had good perinatal ART adherence. In adjusted models, IPV at baseline was associated with halved odds of good adherence (aOR=0.51, 95%CI=0.20-0.96). IPV was associated with higher adjusted odds of probable depression (aOR=4.64), anxiety (aOR=2.85), and PTSD (aOR=3.42). In SEM, IPV had a direct (standardized coef=-0.22) and indirect effect (coef=-0.05) on ART via common mental disorders. The total effect of IPV on perinatal adherence was of moderate size (coef= -0.27) and the model had good fit (CFI=0.972; TLI=0.969; RMSEA=0.045; SRMR=0.076). Conclusion IPV was longitudinally associated with perinatal ART non-adherence in part due to its relationship with mental health symptomology. Addressing IPV within clinical care has potential to improve perinatal mental health, maternal HIV outcomes, and HIV-free infant survival.
Collapse
|
5
|
Adugna Wubneh C, Dessalegn Mekonnen B, Wesenyeleh Delelegn M, Asmare Atalell K. Adherence to option B+ and its association with disclosure status and counseling among HIV-positive pregnant and lactating women in Ethiopia: systematic review and meta-analysis. Public Health 2022; 211:105-113. [PMID: 36058198 DOI: 10.1016/j.puhe.2022.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 05/22/2022] [Accepted: 07/20/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVES This systematic review and meta-analysis aimed to assess the pooled estimate of option B+ level of adherence and its association with disclosure status and counseling among pregnant and lactation women in Ethiopia after option B+ implementation. STUDY DESIGN Systematic review and meta-analysis. METHODS We searched Web of Science, MEDLINE, PUBMED, Scopus, Embase, CINAHL, and Google Scholar databases for studies reporting adherence to option B+ and its association with disclosure status and counseling among pregnant and lactating women in Ethiopia. Heterogeneity was assessed by forest plot, Cochran's Q test, and I2 test. A random effects model was calculated to estimate the pooled prevalence of adherence toward option B+. RESULTS We included eight studies, which gives a total of 1852 pregnant and lactating women in this systematic review and meta-analysis. The overall pooled estimate of good adherence toward option B+ antiretroviral therapy (ART) drug among pregnant and lactating women in Ethiopia was 84.23% (95% confidence interval [CI]: 80.79-87.66). Women who have disclosed their HIV status to their partner (adjusted odds ratio = 4.48, 95% CI: 1.86-10.76) and got counseling during the antenatal period (adjusted odds ratio = 5.02, 95% CI: 2.43-10.34) had a positive association with good adherence to option B+ ART drugs. CONCLUSION Four of five pregnant and lactating women have good adherence to option B+ ART drugs in Ethiopia. Therefore, promoting HIV disclosure status to partners and enhancing counseling services should be strengthened to improve adherence toward option B+ among pregnant and lactating women.
Collapse
Affiliation(s)
- Chalachew Adugna Wubneh
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Science, University of Gondar, P.O.BOX: 196, Gondar, Ethiopia.
| | - Birye Dessalegn Mekonnen
- Department of Nursing, Teda Health Science College, Gondar, Ethiopia, P.O.BOX: 790, Gondar, Ethiopia.
| | - Mekdess Wesenyeleh Delelegn
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Science, University of Gondar, P.O.BOX: 196, Gondar, Ethiopia.
| | - Kendalem Asmare Atalell
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Science, University of Gondar, P.O.BOX: 196, Gondar, Ethiopia.
| |
Collapse
|
6
|
Eastment MC, Kinuthia J, Wang L, Wanje G, Wilson K, Kaggiah A, Simoni JM, Mandaliya K, Poole DN, Richardson BA, Jaoko W, John-Stewart G, McClelland RS. Late antiretroviral refills and condomless sex in a cohort of HIV-seropositive pregnant and postpartum Kenyan women. PLoS One 2021; 16:e0254767. [PMID: 34280229 PMCID: PMC8289061 DOI: 10.1371/journal.pone.0254767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 07/02/2021] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION The postpartum period can be challenging for women living with HIV. Understanding how the postpartum period impacts ART adherence and condomless sex could inform the development of comprehensive sexual and reproductive health and HIV services tailored to the needs of women living with HIV during this critical interval. METHODS In a longitudinal cohort study of HIV-seropositive Kenyan women, late ART refills and self-reported condomless sex were compared between the woman's pregnancy and the postpartum period. Analyses were conducted using generalized estimating equations and adjusted for alcohol use, depressive symptoms, intimate partner violence (IPV), and having a recent regular partner. Effect modification was explored for selected variables. RESULTS AND DISCUSSION 151 women contributed visits. Late ART refills occurred at 7% (32/439) of pregnancy visits compared to 18% (178/1016) during the postpartum period (adjusted relative risk [aRR] 2.44, 95% confidence interval [CI] 1.62-3.67). This association differed by women's education level. Women with ≥8 years of education had late ART refills more during the postpartum period than pregnancy (aRR 3.00, 95%CI 1.95-4.62). In contrast, in women with <8 years of education, late ART refills occurred similarly during pregnancy and the postpartum period (aRR 0.88, 95%CI 0.18-4.35). Women reported condomless sex at 10% (60/600) of pregnancy visits compared to 7% (72/1081) of postpartum visits (aRR 0.76, 95%CI 0.45-1.27). This association differed by whether women had experienced recent IPV. Women without recent IPV had a significant decline in condomless sex from pregnancy to postpartum (aRR 0.53, 95%CI 0.30-0.95) while women with recent IPV had no significant change in condomless sex from pregnancy to postpartum (aRR 1.76, 95%CI 0.87-3.55). CONCLUSION Improved support for ART adherence during the postpartum period and addressing IPV to limit condomless sex could improve HIV treatment and prevention outcomes for HIV-seropositive women as well as their infants and sexual partners.
Collapse
Affiliation(s)
- McKenna C. Eastment
- Departments of Medicine, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| | - John Kinuthia
- Global Health, University of Washington, Seattle, Washington, United States of America
- Kenyatta National Hospital, Nairobi, Kenya
| | - Lei Wang
- Global Health, University of Washington, Seattle, Washington, United States of America
| | - George Wanje
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Katherine Wilson
- Global Health, University of Washington, Seattle, Washington, United States of America
| | | | - Jane M. Simoni
- Global Health, University of Washington, Seattle, Washington, United States of America
- Psychology, University of Washington, Seattle, Washington, United States of America
| | | | - Danielle N. Poole
- Department of Geography, Dartmouth College, Hanover, New Hampshire, United States of America
| | - Barbra A. Richardson
- Global Health, University of Washington, Seattle, Washington, United States of America
- Biostatistics, University of Washington, Seattle, Washington, United States of America
| | - Walter Jaoko
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Grace John-Stewart
- Departments of Medicine, University of Washington, Seattle, Washington, United States of America
- Global Health, University of Washington, Seattle, Washington, United States of America
- Epidemiology, University of Washington, Seattle, Washington, United States of America
- Pediatrics, University of Washington, Seattle, Washington, United States of America
| | - R. Scott McClelland
- Departments of Medicine, University of Washington, Seattle, Washington, United States of America
- Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
- Epidemiology, University of Washington, Seattle, Washington, United States of America
| |
Collapse
|
7
|
Mennecier A, Kankasa C, Fao P, Moles JP, Eymard-Duvernay S, Mwiya M, Kania D, Chunda-Liyoka C, Sakana L, Rutagwera D, Tassembedo S, Wilfred-Tonga MM, Mosqueira B, Tylleskär T, Nagot N, Van de Perre P. Design and challenges of a large HIV prevention clinical study on mother-to-child transmission: ANRS 12397 PROMISE-EPI study in Zambia and Burkina Faso. Contemp Clin Trials 2021; 105:106402. [PMID: 33872801 DOI: 10.1016/j.cct.2021.106402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 10/21/2022]
Abstract
Post-natal HIV infection through breastfeeding remains a challenge in many low and middle-income countries, particularly due to non-availability of alternative infant feeding options and the suboptimal Prevention of Mother to Child Transmission of HIV-1 (PMTCT) cascade implementation and monitoring. The PROMISE-EPI study aims to address the latter by identifying HIV infected mothers during an almost never-missed visit for their infant, the second extended program on immunization visit at 6-8 weeks of age (EPI-2). The study is divided into 3 components inclusive of an open-label randomized controlled trial aiming to assess the efficacy of a responsive preventive intervention compared to routine intervention based on the national PMTCT guidelines for HIV-1 uninfected exposed breastfeeding infants. The preventive intervention includes: a) Point of care testing for early infant HIV diagnosis and maternal viral load; b) infant, single-drug Pre-Exposure Prophylaxis (PrEP) (lamivudine) if mothers are virally unsuppressed. The primary outcome is HIV-transmission rate from EPI-2 to 12 months. The study targets to screen 37,000 mother/infant pairs in Zambia and Burkina Faso to identify 2000 mother/infant pairs for the clinical trial. The study design and challenges faced during study implementation are described, including the COVID-19 pandemic and the amended HIV guidelines in Zambia in 2020 (triple-drug PrEP in HIV exposed infants guided by quarterly maternal viral load). The changes in the Zambian guidelines raised several questions including the equipoise of PrEP options, the standard of care-triple-drug (control arm in Zambia) versus the study-single-drug (intervention arm). Trial registration number (www.clinicaltrials.gov): NCT03869944. Submission category: Study Design, Statistical Design, Study Protocols.
Collapse
Affiliation(s)
- Anaïs Mennecier
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France.
| | - Chipepo Kankasa
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Paulin Fao
- Centre MURAZ, Bobo-Dioulasso, Burkina Faso
| | - Jean-Pierre Moles
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France
| | - Sabrina Eymard-Duvernay
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France
| | - Mwiya Mwiya
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | | | | | | | - David Rutagwera
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | | | | | - Beatriz Mosqueira
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France
| | | | - Nicolas Nagot
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France
| | - Philippe Van de Perre
- Pathogenesis and Control of Chronic and Emerging Infections, INSERM, University of Montpellier, Etablissement Français du Sang, Antilles University, CHU Montpellier, Montpellier, France
| |
Collapse
|
8
|
Myer L, Redd AD, Mukonda E, Lynch BA, Phillips TK, Eisenberg A, Hsiao NY, Capoferri A, Zerbe A, Clarke W, Lesosky M, Breaud A, McIntyre J, Bruno D, Martens C, Abrams EJ, Reynolds SJ. Antiretroviral Adherence, Elevated Viral Load, and Drug Resistance Mutations in Human Immunodeficiency Virus-infected Women Initiating Treatment in Pregnancy: A Nested Case-control Study. Clin Infect Dis 2021; 70:501-508. [PMID: 30877752 DOI: 10.1093/cid/ciz209] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/15/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Elevated viral load (VL) early after antiretroviral therapy (ART) initiation appears frequently in pregnant and postpartum women living with human immunodeficiency virus; however the relative contributions of pre-ART drug resistance mutations (DRMs) vs nonadherence in the etiology of elevated VL are unknown. METHODS Within a cohort of women initiating ART during pregnancy in Cape Town, South Africa, we compared women with elevated VL after initial suppression (cases, n = 80) incidence-density matched to women who maintained suppression over time (controls, n = 87). Groups were compared on pre-ART DRMs and detection of antiretrovirals in stored plasma. RESULTS The prevalence of pre-ART DRMs was 10% in cases and 5% in controls (adjusted odds ratio [aOR], 1.53 [95% confidence interval {CI}, .4-5.9]); all mutations were to nonnucleoside reverse transcriptase inhibitors. At the time of elevated VL, 19% of cases had antiretrovirals detected in plasma, compared with 87% of controls who were suppressed at a matched time point (aOR, 131.43 [95% CI, 32.8-527.4]). Based on these findings, we estimate that <10% of all elevated VL in the cohort may be attributable to pre-ART DRMs vs >90% attributable to ART nonadherence. CONCLUSIONS DRMs account for a small proportion of all elevated VL among women occurring in the 12 months after ART initiation during pregnancy in this setting, with nonadherence appearing to drive most episodes of elevated VL. Alongside the drive for access to more robust antiretroviral agents in resource-limited settings, there is an ongoing need for effective strategies to support ART adherence in this patient population.
Collapse
Affiliation(s)
- Landon Myer
- Division of Epidemiology and Biostatistics, University of Cape Town, South Africa.,Centre for Infectious Diseases Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Andrew D Redd
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda.,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Elton Mukonda
- Division of Epidemiology and Biostatistics, University of Cape Town, South Africa
| | - Briana A Lynch
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda
| | - Tamsin K Phillips
- Division of Epidemiology and Biostatistics, University of Cape Town, South Africa.,Centre for Infectious Diseases Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Anna Eisenberg
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda
| | - Nei-Yuan Hsiao
- Division of Medical Virology, Department of Pathology, University of Cape Town, South Africa.,National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa
| | - Adam Capoferri
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alison Zerbe
- ICAP at Columbia University Mailman School of Public Health, New York, New York
| | - William Clarke
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Maia Lesosky
- Division of Epidemiology and Biostatistics, University of Cape Town, South Africa
| | - Autumn Breaud
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - James McIntyre
- Division of Epidemiology and Biostatistics, University of Cape Town, South Africa.,Anova Health Institute, Johannesburg, South Africa
| | - Daniel Bruno
- Genomics Unit, Research Technologies Branch, Rocky Mountain Laboratories, NIAID, NIH, Hamilton, Montana
| | - Craig Martens
- Genomics Unit, Research Technologies Branch, Rocky Mountain Laboratories, NIAID, NIH, Hamilton, Montana
| | - Elaine J Abrams
- ICAP at Columbia University Mailman School of Public Health, New York, New York.,Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Steven J Reynolds
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda.,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| |
Collapse
|
9
|
Medeiros FBD, Faria ERD, Piccinini CA. Maternidade e HIV: Continuidade do Tratamento e Adesão em Mulheres após Parto. PSICO-USF 2021. [DOI: 10.1590/1413-82712021260105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo O estudo examinou fatores sociodemográficos, clínicos e psicossociais que afetam a continuidade do tratamento e a adesão à medicação antirretroviral em mulheres nos primeiros três meses após o parto. Participaram 56 mulheres vivendo com HIV, com idades entre 18 e 43 anos, na sua grande maioria brancas e casadas. Foram utilizadas entrevistas sobre dados sociodemográficos e clínicos, exames laboratoriais e escalas psicológicas. Análises estatísticas revelaram que mais de um terço das participantes (37,5%) descontinuaram o próprio tratamento após o parto. A qualidade de vida e o apoio instrumental podem favorecer a continuidade do tratamento de HIV após o parto, e as condições de trabalho e a situação clínica dessas mulheres pode afetar a adesão após o parto. Tais resultados podem contribuir para o desenvolvimento de intervenções que favoreçam a continuidade do tratamento e adesão das mulheres no pós-parto.
Collapse
|
10
|
Momplaisir FM, Fortune K, Nkwihoreze H, Groves AK, Aaron E, Jemmott JB. Outcome expectancies toward adherence to antiretroviral therapy for pregnant and postpartum women with HIV. WOMEN'S HEALTH 2021; 17:17455065211061094. [PMID: 34812095 PMCID: PMC8640315 DOI: 10.1177/17455065211061094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objectives: Adherence to antiretroviral therapy and retention in care significantly drop for women with HIV during the postpartum period. We have a limited understanding of how outcome expectancies influence maternal adherence and retention in care. Methods: Women with HIV from an urban academic clinic completed in-depth interviews in the third trimester and at 3 to 9 months postpartum to evaluate outcome expectancies, facilitators, and barriers to antiretroviral therapy adherence and retention in care. Interviews were audio-recorded and analyzed for content. A codebook was created using deductive (based on the theory of reasoned action approach) and inductive (based on emergent themes) codes. Results: We conducted 21 interviews with 12 women during pregnancy and 9 women during postpartum period. Participants had a mean age of 31 (standard deviation = 5.7) and most were African American (75%). Outcome expectancies centered mostly around pediatric health to prevent perinatal transmission of HIV and to be healthy to raise their children. Other outcome expectancies included preventing transmission of HIV to their partners. Social support from partners served as a strong facilitator as they helped routinize pill-taking behaviors, provided reminders, and decreased social isolation. Barriers to antiretroviral therapy adherence included depression, the disruption of scheduling routines, and the physical demands associated with the postpartum period. These barriers were accentuated for women with multiple children. Conclusion: Women’s commitment to pediatric health was the primary motive for antiretroviral therapy adherence. Partners also served an important role. These findings suggest that interventions linking pediatric and maternal health, and partner support can improve maternal HIV treatment in the postpartum period.
Collapse
Affiliation(s)
- Florence M Momplaisir
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Hervette Nkwihoreze
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Allison K Groves
- Department of Community and Prevention, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA
| | - Erika Aaron
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - John B Jemmott
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
11
|
Wessels J, Sherman G, Bamford L, Makua M, Ntloana M, Nuttall J, Pillay Y, Goga A, Feucht U. The updated South African National Guideline for the Prevention of Mother to Child Transmission of Communicable Infections (2019). South Afr J HIV Med 2020; 21:1079. [PMID: 32832113 PMCID: PMC7433286 DOI: 10.4102/sajhivmed.v21i1.1079] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/03/2020] [Indexed: 11/01/2022] Open
Affiliation(s)
- Jeannette Wessels
- Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Pretoria, South Africa
| | - Gayle Sherman
- Department of Paediatrics & Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Centre for HIV & STI, National Institute for Communicable Diseases, Division of the National Health Laboratory Services, Johannesburg, South Africa
| | - Lesley Bamford
- Child, Youth, and School Health Chief Directorate, National Department of Health, Pretoria, South Africa.,School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
| | - Manala Makua
- Communicable and Non-Communicable Diseases Branch, National Department of Health, Pretoria
| | - Mathilda Ntloana
- Communicable and Non-Communicable Diseases Branch, National Department of Health, Pretoria
| | - James Nuttall
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Yogan Pillay
- Communicable and Non-Communicable Diseases Branch, National Department of Health, Pretoria
| | - Ameena Goga
- Health Systems Research Unit, South African Research Council, Cape Town, South Africa.,Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa.,HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Ute Feucht
- Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Pretoria, South Africa.,Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa.,Tshwane District Health Services, Gauteng Department of Health, Tshwane, South Africa.,Maternal and Infant Health Care Strategies Research Unit, South African Medical Research Council, Pretoria, South Africa
| |
Collapse
|
12
|
Rucinski KB, Schwartz SR, Powers KA, Pence BW, Chi BH, Black V, Rees H, Pettifor AE. Fertility Intentions and Clinical Care Attendance Among Women Living with HIV in South Africa. AIDS Behav 2020; 24:1585-1591. [PMID: 31228024 DOI: 10.1007/s10461-019-02564-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Poor HIV care retention impedes optimal treatment outcomes in persons living with HIV. Women trying to become pregnant may be motivated by periconception horizontal and vertical transmission concerns and thus more likely to attend HIV care visits than women not trying to conceive. We estimated the effect of fertility intentions on HIV care attendance over 12 months among non-pregnant, HIV-positive women aged 18-35 years who were on or initiating antiretroviral therapy in Johannesburg, South Africa. The percentage of women attending an HIV care visit decreased from 93.4% in the first quarter to 82.8% in the fourth quarter. Fertility intentions were not strongly associated with care attendance in this cohort of reproductive-aged women; however, attendance declined over time irrespective of childbearing plans. These findings suggest a need for reinforced efforts to support care engagement and risk reduction, including safer conception practices for women wishing to conceive.
Collapse
Affiliation(s)
- Katherine B Rucinski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E7133A, Baltimore, MD, 21205, USA.
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa.
| | - Sheree R Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E7133A, Baltimore, MD, 21205, USA
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Kimberly A Powers
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Brian W Pence
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Vivian Black
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
- Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Helen Rees
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey E Pettifor
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| |
Collapse
|
13
|
Kaplan S, Nteso KS, Ford N, Boulle A, Meintjes G. Loss to follow-up from antiretroviral therapy clinics: A systematic review and meta-analysis of published studies in South Africa from 2011 to 2015. South Afr J HIV Med 2019; 20:984. [PMID: 31956435 PMCID: PMC6956684 DOI: 10.4102/sajhivmed.v20i1.984] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/20/2019] [Indexed: 11/05/2022] Open
Abstract
Background South Africa has the largest antiretroviral therapy (ART) programme in the world. To optimise programme outcomes, it is critical that patients are retained in care and that retention is accurately measured. Objectives To identify all studies published in South Africa from 2011 to 2015 that used loss to follow-up (LTFU) as an indicator or outcome to describe the variation in definitions and to estimate the proportion of patients lost to care across studies. Method All studies published between 01 January 2011 and October 2015 that included loss to follow-up or default from ART care in a South African cohort were included by use of a broad search strategy across multiple databases. To be included, the cohort had to include any patient ART data, including follow-up time, from 01 January 2010. Two authors, working independently, extracted data and assessed risk of bias from all manuscripts. Meta-analysis was performed for studies stratified by the same loss to follow-up definition. Results Forty-eight adult, 15 paediatric and 4 pregnant cohorts were included. Median cohort size was 3737; follow-up time ranged from 9 weeks to 5 years. Meta-analysis did not reveal an important difference in LTFU estimates in adult cohorts at 1 year between loss to follow-up defined as 3 months (11.0%, n = 4; 95% CI 10.7% – 11.2%) compared with 6 months (12.0%, n = 4; 95% CI 11.8% – 12.2%). Only two cohorts reported reliable LTFU estimates at 5 years: this was 25.1% (95% CI 24.8% – 25.4%). Conclusion South Africa should standardise a LTFU definition. This would aid in monitoring and evaluation of ART programmes, with the broader goal of improving patient outcomes.
Collapse
Affiliation(s)
- Samantha Kaplan
- Department of Internal Medicine, University of Washington, Seattle, United States
| | - Katleho S Nteso
- Medical Care Development International, Maseru, Lesotho, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
14
|
Atuhaire P, Hanley S, Yende-Zuma N, Aizire J, Stranix-Chibanda L, Makanani B, Milala B, Cassim H, Taha T, Fowler MG. Factors associated with unsuppressed viremia in women living with HIV on lifelong ART in the multi-country US-PEPFAR PROMOTE study: A cross-sectional analysis. PLoS One 2019; 14:e0219415. [PMID: 31647806 PMCID: PMC6812809 DOI: 10.1371/journal.pone.0219415] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/10/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite recent efforts to scale-up lifelong combination antiretroviral therapy (cART) in sub-Saharan Africa, high rates of unsuppressed viremia persist among cART users, and many countries in the region fall short of the UNAIDS 2020 target to have 90% virally suppressed. We sought to determine the factors associated with unsuppressed viremia (defined for the purpose of this study as >200 copies/ml) among sub-Saharan African women on lifelong cART. METHODS This cross-sectional analysis was based on baseline data of the PROMOTE longitudinal cohort study at 8 sites in Uganda, Malawi, Zimbabwe and South Africa. The study enrolled 1987 women living with HIV who initiated lifelong cART at least 1-5 years ago. Socio-demographic, clinical, and cART adherence data were collected. We used multivariable Poisson regression with robust variance to identify factors associated with unsuppressed viremia. RESULTS At enrolment, 1947/1987 (98%) women reported taking cART. Of these, HIV-1 remained detectable in 293/1934 (15%), while 216/1934 (11.2%) were considered unsuppressed (>200 copies/ml). The following factors were associated with an increased risk of unsuppressed viremia: not having household electricity (adjusted prevalence risk ratio (aPRR) 1.74, 95% confidence interval (CI) 1.28-2.36, p<0.001); not being married (aPRR 1.32, 95% CI 0.99-1.78, p = 0.061), self-reported missed cART doses (aPRR 1.63, 95% CI 1.24-2.13, p<0.001); recent hospitalization (aPRR 2.48, 95% CI 1.28-4.80, p = 0.007) and experiencing abnormal vaginal discharge in the last three months (aPRR 1.88; 95% CI 1.16-3.04, p = 0.010). Longer time on cART (aPRR 0.75, 95% CI 0.64-0.88, p<0.001) and being older (aPRR 0.77, 95% CI 0.76-0.88, p<0.001) were associated with reduced risk of unsuppressed viremia. CONCLUSION Socioeconomic barriers such as poverty, and individual barriers like not being married, young age, and self-reported missed doses are key predictors of unsuppressed viremia. Targeted interventions are needed to improve cART adherence among women living with HIV with this risk factor profile.
Collapse
Affiliation(s)
- Patience Atuhaire
- Makerere University-Johns Hopkins University (MU-JHU) Kampala, Uganda
| | - Sherika Hanley
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Umlazi Clinical Research Site, Nelson R. Mandela School of Medicine, Durban, South Africa
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Jim Aizire
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, United States of America
| | - Lynda Stranix-Chibanda
- University of Zimbabwe College of Health Sciences Department of Paediatrics and Child Health, Harare, Zimbabwe
| | - Bonus Makanani
- Malawi College of Medicine-John's Hopkins Research Project, Blantyre, Malawi
| | - Beteniko Milala
- University of North Carolina (UNC) Project, Lilongwe, Malawi
| | - Haseena Cassim
- Perinatal HIV Research Unit (PHRU), Chris Hani Baragwanath Hospital, University of Witwatersrand, Johannesburg, South Africa
| | - Taha Taha
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, United States of America
| | - Mary Glenn Fowler
- Johns Hopkins University, Departments of Pathology and Epidemiology, Baltimore, MD, United States of America
| |
Collapse
|
15
|
Nachman S, Townsend CL, Abrams EJ, Archary M, Capparelli E, Clayden P, Lockman S, Jean-Philippe P, Mayer K, Mirochnick M, McKenzie-White J, Struble K, Watts H, Flexner C. Long-acting or extended-release antiretroviral products for HIV treatment and prevention in infants, children, adolescents, and pregnant and breastfeeding women: knowledge gaps and research priorities. Lancet HIV 2019; 6:e552-e558. [PMID: 31307946 PMCID: PMC7152795 DOI: 10.1016/s2352-3018(19)30147-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 03/14/2019] [Accepted: 04/04/2019] [Indexed: 12/31/2022]
Abstract
Antiretroviral agents with long-acting properties have potential to improve treatment outcomes substantially for people living with HIV. In November 2017, the Long acting/Extended Release Antiretroviral Resource Program (LEAP) convened a workshop with the aim of shaping the research agenda and promoting early development of long-acting or extended release products for key populations: pregnant and lactating women, children aged up to 10 years, and adolescents aged 10-19 years. Goals included strategies and principles to ensure that the needs of children, adolescents, and pregnant and lactating women are considered when developing long-acting formulations. Research should focus not only on how best to transition long-acting products to these populations, but also on early engagement across sectors and among stakeholders. A parallel rather than sequential approach is needed when establishing adult, adolescent, and paediatric clinical trials and seeking regulatory approval. Pregnant and lactating women should be included in adult clinical trials. Adolescent-friendly trial design is needed to improve recruitment and retention of young people.
Collapse
Affiliation(s)
- Sharon Nachman
- Health Sciences Center, SUNY Stony Brook, Pediatrics, New York, NY, USA.
| | | | - Elaine J Abrams
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, NY, USA; Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | | | - Edmund Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA, USA
| | | | - Shahin Lockman
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Department of Immunology and Infectious Diseases, Harvard TH Chan School of Public Health, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Kenneth Mayer
- School of Medicine, Harvard University, Cambridge, MA, USA
| | | | | | | | - Heather Watts
- Office of the Global AIDS Coordinator and Health Diplomacy, Washington, DC, USA
| | | |
Collapse
|
16
|
Ntlantsana V, Hift RJ, Mphatswe WP. HIV viraemia during pregnancy in women receiving preconception antiretroviral therapy in KwaDukuza, KwaZulu-Natal. South Afr J HIV Med 2019; 20:847. [PMID: 31061722 PMCID: PMC6494933 DOI: 10.4102/sajhivmed.v20i1.847] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 02/05/2019] [Indexed: 01/01/2023] Open
Abstract
Background Preconception antiretroviral therapy (PCART) followed by sustained viral suppression is effective in preventing mother-to-child transmission of HIV. The rates of persistent and transient viraemia in such patients have not been prospectively assessed in South Africa. Objectives We determined the prevalence of transient and persistent viraemia in HIV-positive women entering antenatal care on PCART and studied variables associated with viraemia. Methods We performed a prospective cross-sectional observational study of HIV-positive pregnant women presenting to a primary healthcare facility in KwaZulu-Natal. All had received at least 6 months of first-line PCART. Viral load (VL) was measured, patients were interviewed, adherence estimated using a visual analogue scale and adherence counselling provided. Viral load was repeated after 4 weeks where baseline VL exceeded 50 copies/mL. Results We enrolled 82 participants. Of them, 59 (72%) pregnancies were unplanned. Fifteen participants (18.3%) were viraemic at presentation with VL > 50 copies/mL. Of these, seven (8.5%) had viral suppression (VL < 50 copies/mL), and eight remained viraemic at the second visit. Adherence correlated significantly with viraemia at baseline. Level of knowledge correlated with adherence but not with lack of viral suppression at baseline. Socio-economic indicators did not correlate with viraemia. No instances of vertical transmission were observed at birth. Conclusions Approximately 20% of women receiving PCART may demonstrate viraemia. Half of these may be transient. Poor adherence is associated with viraemia, and efforts to encourage and monitor adherence are essential. The rate of unplanned pregnancies is high, and antiretroviral therapy programmes should focus on family planning needs of women in the reproductive age group to prevent viral non-suppression prior to pregnancy. Keywords Preconception Antiretroviral Therapy; HIV; Viraemia; Antenatal Care; Adherence.
Collapse
Affiliation(s)
- Vuyokazi Ntlantsana
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Richard J Hift
- School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Wendy P Mphatswe
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| |
Collapse
|
17
|
Adhikari EH, Yule CS, Roberts SW, Rogers VL, Sheffield JS, Kelly MA, McIntire DD, Barnes A. Factors Associated with Postpartum Loss to Follow-Up and Detectable Viremia After Delivery Among Pregnant Women Living with HIV. AIDS Patient Care STDS 2019; 33:14-20. [PMID: 30601060 DOI: 10.1089/apc.2018.0117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Pregnant women living with HIV are at risk for loss to follow-up and viral rebound after delivery. We conducted a retrospective cohort study of women with HIV who delivered at Parkland Hospital, Dallas, to identify factors associated with postpartum loss to HIV care 1 year after delivery. Logistic regression was used to identify factors predicting loss to follow-up. For a subset of women, we compared odds of viremia detectable at delivery and postpartum among women with higher versus lower pill burden regimens. We included 604 women with HIV who delivered between 2005 and 2015. Three hundred ninety-one (65%) women completed at least one visit with an HIV provider within 1 year of delivery. The follow-up rate among black, non-Hispanic women was 65%; 57% for white, non-Hispanic women; and 78% for Hispanic women. Women without follow-up presented for prenatal care later (17 vs. 11 weeks, p < 0.001), and were less likely to be on antiretroviral therapy at initial prenatal visit (29% vs. 49%, p < 0.001). Factors predicting loss to follow-up in multivariate analysis included low-level viremia at delivery [adjusted odds ratio (aOR) = 2.85, 95% confidence interval (CI) = 1.73-4.71] and failure to return for a postpartum visit (aOR = 3.19, 95% CI = 2.07-4.94). High antiretroviral pill burden (≥6 pills daily) was associated with viremia (>1000 copies/mL) at the first prenatal visit (OR = 8.7, 95% CI = 4.6-16.6) through 1 year postpartum (OR = 2.3, 95% CI = 1.2-4.4). Viremia at delivery, failure to return for a postpartum visit, and high pill burden during pregnancy are predictors of postpartum loss to HIV care.
Collapse
Affiliation(s)
- Emily H. Adhikari
- Department of Obstetrics and Gynecology and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Casey S. Yule
- Department of Obstetrics and Gynecology and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Scott W. Roberts
- Department of Obstetrics and Gynecology and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Vanessa L. Rogers
- Department of Obstetrics and Gynecology and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jeanne S. Sheffield
- Department of Obstetrics and Gynecology and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mary Ann Kelly
- Department of Obstetrics and Gynecology and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Donald D. McIntire
- Department of Obstetrics and Gynecology and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Arti Barnes
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
18
|
Abuogi LL, Humphrey JM, Mpody C, Yotebieng M, Murnane PM, Clouse K, Otieno L, Cohen CR, Wools-Kaloustian K. Achieving UNAIDS 90-90-90 targets for pregnant and postpartum women in sub-Saharan Africa: progress, gaps and research needs. J Virus Erad 2018; 4:33-39. [PMID: 30515312 PMCID: PMC6248851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The implementation of the 2013 World Health Organization Option B+ recommendations for HIV treatment during pregnancy has helped drive significant progress in achieving universal treatment for pregnant and postpartum women in sub-Saharan Africa (SSA). Yet, critical research and implementation gaps exist in achieving the UNAIDS 90-90-90 targets. To help guide researchers, programmers and policymakers in prioritising these areas, we undertook a comprehensive review of the progress, gaps and research needs to achieve the 90-90-90 targets for this population in the Option B+ era, including early infant HIV diagnosis (EID) for HIV-exposed infants. Salient areas where progress has been achieved or where gaps remain include: (1) knowledge of HIV status is higher among people with HIV in southern and eastern Africa compared to western and central Africa (81% versus 48%, UNAIDS); (2) access to antiretroviral therapy (ART) for pregnant women has doubled in 22 of 42 SSA countries, but only six have achieved the second 90, and nearly a quarter of pregnant women initiating ART become lost to follow-up; (3) viral suppression data for this population are sparse (estimates range from 30% to 98% peripartum), with only half of women maintaining suppression through 12 months postpartum; and (4) EID rates range from 15% to 62%, with only three of 21 high-burden SSA countries testing >50% HIV-exposed infants within the first 2 months of life. We have identified and outlined promising innovations and research designed to address these gaps and improve the health of pregnant and postpartum women living with HIV and their infants.
Collapse
Affiliation(s)
- Lisa L Abuogi
- Department of Pediatrics, University of Colorado,
Denver, Aurora, CO,
USA,Corresponding author:
Lisa Abuogi, Department of Pediatrics, University of Colorado,
Denver, Aurora,
CO,
USA
| | - John M Humphrey
- Department of Medicine, Indiana University School of Medicine,
Indianapolis, IN,
USA
| | - Christian Mpody
- Division of Epidemiology, Ohio State University,
Columbus, OH,
USA
| | - Marcel Yotebieng
- Division of Epidemiology, Ohio State University,
Columbus, OH,
USA
| | - Pamela M Murnane
- Center for AIDS Prevention Studies, University of California San Francisco,
San Francisco, CA,
USA
| | - Kate Clouse
- Vanderbilt Institute for Global Health, Vanderbilt University,
Nashville, TN,
USA
| | - Lindah Otieno
- Center for Microbial Research, Research Care and Training Program, Kenya Medical Research Institute,
Nairobi,
Kenya
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences,
University of California San Francisco, CA,
USA
| | - Kara Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine,
Indianapolis, IN,
USA
| |
Collapse
|
19
|
Achieving UNAIDS 90-90-90 targets for pregnant and postpartum women in sub-Saharan Africa: progress, gaps and research needs. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30343-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
20
|
Perceived Barriers to Antepartum HIV Medication Adherence in HIV Infected Pregnant Women. Infect Dis Obstet Gynecol 2018; 2018:4049212. [PMID: 30410301 PMCID: PMC6206578 DOI: 10.1155/2018/4049212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 09/19/2018] [Accepted: 09/24/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Although rare, perinatal HIV transmission still occurs in the United States and most transmissions are preventable. We aim to identify patient barriers to antiretroviral therapy (ART) adherence during pregnancy and assess patient understanding of perinatal transmission. Methods This cross-sectional survey recruited HIV positive postpartum women at a large safety net hospital in Atlanta, Georgia, between January 2016 and February 2018. Survey questions included demographic characteristics, HIV history, knowledge of perinatal transmission, and ART adherence. Perinatal and HIV outcomes were assessed using chart abstraction. Results Of the 70 HIV infected postpartum women delivered at a large safety net hospital in Atlanta, GA, 45 women were eligible and consented to participate. Participating women were aged 18 to 40 years with an average age of 29 years old, 93% of participants were African-American, and 68% had ≥3 pregnancies. The majority of participants (75%) reported daily ART adherence. "Forgetting" was the most frequent reason for missing pills (57%). Thirteen women had a detectable viral load at the time of delivery and nine of those women had a viral load greater than 1000 copies/mL. Approximately 85% of women who correctly stated ART medications decrease perinatal transmission risk reported daily adherence compared with 50% of women without that knowledge (OR 5.6, 95% CI 1.17, 26.7). Almost half of women (40%) either did not know or believed a vaginal delivery, regardless of viral load, would increase their risk of perinatal transmission. Conclusion Overall, women who were diagnosed with HIV during the current pregnancy, those with planned pregnancies, and those who were on medications prior to pregnancy were more likely to report daily ART adherence. Detectable viral load at delivery is the greatest risk factor for perinatal transmission; therefore strategies to increase ART adherence are needed.
Collapse
|
21
|
Trafford Z, Gomba Y, Colvin CJ, Iyun VO, Phillips TK, Brittain K, Myer L, Abrams EJ, Zerbe A. Experiences of HIV-positive postpartum women and health workers involved with community-based antiretroviral therapy adherence clubs in Cape Town, South Africa. BMC Public Health 2018; 18:935. [PMID: 30064405 PMCID: PMC6069812 DOI: 10.1186/s12889-018-5836-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 07/11/2018] [Indexed: 11/10/2022] Open
Abstract
Background The rollout of universal, lifelong treatment for all HIV-positive pregnant and breastfeeding women (“Option B+”) has rapidly increased the number of women initiating antiretroviral treatment (ART) and requiring ART care postpartum. In a pilot project in South Africa, eligible postpartum women were offered the choice of referral to the standard of care, a local primary health care clinic, or a community-based model of differentiated ART services, the adherence club (AC). ACs have typically enrolled only non-pregnant and non-postpartum adults; postpartum women had not previously been referred directly from antenatal care. There is little evidence regarding postpartum women’s preferences for and experiences of differentiated models of care, or the capacity of this particular model to cater to their specific needs. This qualitative paper reports on feedback from both postpartum women and health workers who care for them on their respective experiences of the AC. Methods One-on-one in-depth qualitative interviews were conducted with 19 (23%) of the 84 postpartum women who selected the AC and were retained at approximately 12 months postpartum, and 9 health workers who staff the AC. Data were transcribed and thematically analysed using NVivo 11. Results Postpartum women’s inclusion in the AC was acceptable for both participants and health workers. Health workers were welcoming of postpartum women but expressed concerns about prospects for longer term adherence and retention, and raised logistical issues they felt might compromise trust with AC members in general. Conclusions Enrolling postpartum women in mixed groups with the general adult population is feasible and acceptable. Preliminary recommendations are offered and may assist in supporting the specific needs of postpartum women transitioning from antenatal ART care. Trial registration Number NCT02417675 clinicaltrials.gov/ct2/show/record/NCT02417675 (retrospective reg.)
Collapse
Affiliation(s)
- Zara Trafford
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Yolanda Gomba
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Christopher J Colvin
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Victoria O Iyun
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Tamsin K Phillips
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kirsty Brittain
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elaine J Abrams
- Mailman School of Public Health, ICAP, Columbia University, New York, USA.,College of Physicians and Surgeons, Columbia University, New York, USA
| | - Allison Zerbe
- Mailman School of Public Health, ICAP, Columbia University, New York, USA
| |
Collapse
|
22
|
Brittain K, Remien RH, Mellins CA, Phillips TK, Zerbe A, Abrams EJ, Myer L. Determinants of suboptimal adherence and elevated HIV viral load in pregnant women already on antiretroviral therapy when entering antenatal care in Cape Town, South Africa. AIDS Care 2018; 30:1517-1523. [PMID: 30047287 DOI: 10.1080/09540121.2018.1503637] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Across sub-Saharan Africa, prevention of mother-to-child transmission services are encountering increasing numbers of women already established on antiretroviral therapy (ART) when entering antenatal care. However, there are few data examining ART adherence and HIV viral load in this group. We used multivariable logistic regression models to examine self-reported suboptimal adherence (defined as missed ART doses on ≥2 days during the preceding 30 days), elevated viral load (≥1000 copies/mL), and factors associated with each among women entering antenatal care on ART. Participants were recruited from one primary care clinic in Gugulethu, Cape Town, as part of a larger study of HIV-positive pregnant and postpartum women. Among 482 pregnant women established on ART and enrolled between May 2013 and June 2014 (median age: 31 years; median duration of ART use: 3 years), 15% reported suboptimal adherence and 12% had elevated viral load. After adjustment for age, suboptimal adherence was significantly more common among women who were not married/cohabiting and women who reported a higher level of concern about taking ART; a higher level of adherence self-efficacy was associated with a reduced odds of suboptimal adherence. In a multivariable model, elevated viral load was significantly associated with previous discontinuation of ART, a higher level of concern about taking ART, and report of an unintended pregnancy. Suboptimal adherence and elevated viral load are common among women entering antenatal care already on ART. Our findings highlight specific beliefs and concerns about ART use during pregnancy that should be addressed in counselling messaging, and suggest that family planning should be more effectively integrated into HIV care. Including adherence and viral load monitoring as part of pregnancy planning for women on ART may be important to achieve safer conception and promote healthy pregnancies.
Collapse
Affiliation(s)
- Kirsty Brittain
- a Division of Epidemiology & Biostatistics , School of Public Health & Family Medicine, University of Cape Town , Cape Town , South Africa.,b Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town , Cape Town , South Africa
| | - Robert H Remien
- c HIV Center for Clinical and Behavioral Studies , New York State Psychiatric Institute, Columbia University , New York , NY , USA
| | - Claude A Mellins
- c HIV Center for Clinical and Behavioral Studies , New York State Psychiatric Institute, Columbia University , New York , NY , USA
| | - Tamsin K Phillips
- a Division of Epidemiology & Biostatistics , School of Public Health & Family Medicine, University of Cape Town , Cape Town , South Africa.,b Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town , Cape Town , South Africa
| | - Allison Zerbe
- d ICAP , Columbia University, Mailman School of Public Health , New York , NY , USA
| | - Elaine J Abrams
- d ICAP , Columbia University, Mailman School of Public Health , New York , NY , USA.,e College of Physicians & Surgeons , Columbia University , New York , NY , USA
| | - Landon Myer
- a Division of Epidemiology & Biostatistics , School of Public Health & Family Medicine, University of Cape Town , Cape Town , South Africa.,b Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town , Cape Town , South Africa
| |
Collapse
|
23
|
Myer L, Phillips TK, Zerbe A, Brittain K, Lesosky M, Hsiao NY, Remien RH, Mellins CA, McIntyre JA, Abrams EJ. Integration of postpartum healthcare services for HIV-infected women and their infants in South Africa: A randomised controlled trial. PLoS Med 2018; 15:e1002547. [PMID: 29601570 PMCID: PMC5877834 DOI: 10.1371/journal.pmed.1002547] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 02/28/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND As the number of HIV-infected women initiating lifelong antiretroviral therapy (ART) during pregnancy increases globally, concerns have emerged regarding low levels of retention in HIV services and suboptimal adherence to ART during the postpartum period. We examined the impact of integrating postpartum ART for HIV+ mothers alongside infant follow-up within maternal and child health (MCH) services in Cape Town, South Africa. METHODS AND FINDINGS We conducted a randomised trial among HIV+ postpartum women aged ≥18 years who initiated ART during pregnancy in the local antenatal care clinic and were breastfeeding when screened before 6 weeks postpartum. We compared an integrated postnatal service among mothers and their infants (the MCH-ART intervention) to the local standard of care (control)-immediate postnatal referral of HIV+ women on ART to general adult ART services and their infants to separate routine infant follow-up. Evaluation data were collected through medical records and trial measurement visits scheduled and located separately from healthcare services involved in either arm. The primary trial outcome was a composite endpoint of women's retention in ART care and viral suppression (VS) (viral load < 50 copies/ml) at 12 months postpartum; secondary outcomes included duration of any and exclusive breastfeeding, mother-to-child HIV transmission, and infant mortality. Between 5 June 2013 and 10 December 2014, a total of 471 mother-infant pairs were enrolled and randomised (mean age, 28.6 years; 18% nulliparous; 57% newly diagnosed with HIV in pregnancy; median duration of ART use at randomisation, 18 weeks). Among 411 women (87%) with primary endpoint data available, 77% of women (n = 155) randomised to the MCH-ART intervention achieved the primary composite outcome of retention in ART services with VS at 12 months postpartum, compared to 56% of women (n = 117) randomised to the control arm (absolute risk difference, 0.21; 95% CI: 0.12-0.30; p < 0.001). The findings for improved retention in care and VS among women in the MCH-ART intervention arm were consistent across subgroups of participants according to demographic and clinical characteristics. The median durations of any breastfeeding and exclusive breastfeeding were longer in women randomised to the intervention versus control arm (6.9 versus 3.0 months, p = 0.006, and 3.0 versus 1.4 months, p < 0.001, respectively). For the infants, overall HIV-free survival through 12 months of age was 97%: mother-to-child HIV transmission was 1.2% overall (n = 4 and n = 1 transmissions in the intervention and control arms, respectively), and infant mortality was 1.9% (n = 6 and n = 3 deaths in the intervention and control arms, respectively), and these outcomes were similar by trial arm. Interpretation of these findings should be qualified by the location of this study in a single urban area as well as the self-reported nature of breastfeeding outcomes. CONCLUSIONS In this study, we found that integrating ART services into the MCH platform during the postnatal period was a simple and effective intervention, and this should be considered for improving maternal and child outcomes in the context of HIV. TRIAL REGISTRATION ClinicalTrials.gov NCT01933477.
Collapse
Affiliation(s)
- 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 Diseases Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - 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 Diseases Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Allison Zerbe
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - 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 Diseases Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Maia Lesosky
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nei-Yuan Hsiao
- National Health Laboratory Service, Cape Town, South Africa
- Division of Medical Virology, University of Cape Town, Cape Town, South Africa
| | - Robert H. Remien
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, New York, New York, United States of America
| | - Claude A. Mellins
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, New York, New York, United States of America
| | - James A. McIntyre
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Anova Health Institute, Johannesburg, South Africa
| | - Elaine J. Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| |
Collapse
|
24
|
Mujugira A, Baeten J, Kidoguchi L, Haberer J, Celum C, Donnell D, Ngure K, Bukusi E, Mugo N, Asiimwe S, Odoyo J, Tindimwebwa E, Bulya N, Katabira E, Heffron R. High levels of viral suppression among East African HIV-infected women and men in serodiscordant partnerships initiating antiretroviral therapy with high CD4 counts and during pregnancy. AIDS Res Hum Retroviruses 2018; 34:140-147. [PMID: 28899162 PMCID: PMC5806074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2024] Open
Abstract
BACKGROUND People who are asymptomatic and feel healthy, including pregnant women, may be less motivated to initiate ART or achieve high adherence. We assessed whether ART initiation, and viral suppression 6, 12 and 24-months after ART initiation, were lower in HIV-infected members of serodiscordant couples who initiated during pregnancy or with higher CD4 counts. METHODS We used data from the Partners Demonstration Project, an open-label study of the delivery of integrated PrEP and ART (at any CD4 count) for HIV prevention among high-risk HIV serodiscordant couples in Kenya and Uganda. Differences in viral suppression (HIV RNA <400 copies/ml) among people initiating ART at different CD4 count levels (≤350, 351-500, and >500 cells/mm3) and during pregnancy were estimated using Poisson regression. RESULTS Of 865 HIV-infected participants retained after becoming eligible for ART during study follow-up, 95% initiated ART. Viral suppression 24-months after ART initiation was high overall (97%), and comparable among those initiating ART at CD4 counts >500, 351-500 and ≤350 cells/mm3 (96% vs 97% vs 97%; relative risk [RR] 0.98; 95% CI: 0.93-1.03 for CD4 >500 vs <350 and RR 0.99; 95% CI: (0.93-1.06) for CD4 351-500 vs ≤350). Viral suppression was as likely among women initiating ART primarily to prevent perinatal transmission as ART initiation for other reasons (p=0.9 at 6 months and p=0.5 at 12 months). CONCLUSIONS Nearly all HIV-infected partners initiating ART were virally suppressed by 24 months, irrespective of CD4 count or pregnancy status. These findings suggest that people initiating ART at high CD4 counts or due to pregnancy can adhere to ART as well as those starting treatment with symptomatic HIV disease or low CD4 counts.
Collapse
Affiliation(s)
- Andrew Mujugira
- University of Washington, Department of Global Health , 901 Boren Ave , Suite 1300 , Seattle, Washington, United States , 98104 ;
| | | | | | | | | | - Deborah Donnell
- Fred Hutchinson Cancer Research Center, SCHARP/VIDI/PHS , 1100 Fairview Ave N , Seattle, Washington, United States , 98109 ;
| | | | | | - Nelly Mugo
- Kenya Medical Research Institute, Nairobi, Kenya ;
| | | | | | | | | | - Elly Katabira
- Makerere University, Infectious Disease Institute, Kampala, Uganda ;
| | - Renee Heffron
- University of Washington, Department of Epidemiology, Seattle, United States ;
| |
Collapse
|
25
|
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: 43] [Impact Index Per Article: 6.1] [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.
Collapse
|
26
|
Mujugira A, Baeten JM, Kidoguchi L, Haberer J, Celum C, Donnell D, Ngure K, Bukusi EA, Mugo N, Asiimwe S, Odoyo J, Tindimwebwa E, Bulya N, Katabira E, Heffron R, for the Partners Demonstration Proj. High levels of viral suppression among East African HIV-infected women and men in serodiscordant partnerships initiating antiretroviral therapy with high CD4 counts and during pregnancy. AIDS Res Hum Retroviruses 2017. [PMID: 28899162 DOI: 10.1089/aid.2017.0020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND People who are asymptomatic and feel healthy, including pregnant women, may be less motivated to initiate ART or achieve high adherence. We assessed whether ART initiation, and viral suppression 6, 12 and 24-months after ART initiation, were lower in HIV-infected members of serodiscordant couples who initiated during pregnancy or with higher CD4 counts. METHODS We used data from the Partners Demonstration Project, an open-label study of the delivery of integrated PrEP and ART (at any CD4 count) for HIV prevention among high-risk HIV serodiscordant couples in Kenya and Uganda. Differences in viral suppression (HIV RNA <400 copies/ml) among people initiating ART at different CD4 count levels (≤350, 351-500, and >500 cells/mm3) and during pregnancy were estimated using Poisson regression. RESULTS Of 865 HIV-infected participants retained after becoming eligible for ART during study follow-up, 95% initiated ART. Viral suppression 24-months after ART initiation was high overall (97%), and comparable among those initiating ART at CD4 counts >500, 351-500 and ≤350 cells/mm3 (96% vs 97% vs 97%; relative risk [RR] 0.98; 95% CI: 0.93-1.03 for CD4 >500 vs <350 and RR 0.99; 95% CI: (0.93-1.06) for CD4 351-500 vs ≤350). Viral suppression was as likely among women initiating ART primarily to prevent perinatal transmission as ART initiation for other reasons (p=0.9 at 6 months and p=0.5 at 12 months). CONCLUSIONS Nearly all HIV-infected partners initiating ART were virally suppressed by 24 months, irrespective of CD4 count or pregnancy status. These findings suggest that people initiating ART at high CD4 counts or due to pregnancy can adhere to ART as well as those starting treatment with symptomatic HIV disease or low CD4 counts.
Collapse
Affiliation(s)
- Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, Washington
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Lara Kidoguchi
- Department of Global Health, University of Washington, Seattle, Washington
| | | | - Connie Celum
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Deborah Donnell
- Department of Global Health, University of Washington, Seattle, Washington
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, Washington
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | - Elizabeth A. Bukusi
- Department of Global Health, University of Washington, Seattle, Washington
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, Washington
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Josephine Odoyo
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Nulu Bulya
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Elly Katabira
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
| | | |
Collapse
|
27
|
Beyond "Option B+": Understanding Antiretroviral Therapy (ART) Adherence, Retention in Care and Engagement in ART Services Among Pregnant and Postpartum Women Initiating Therapy in Sub-Saharan Africa. J Acquir Immune Defic Syndr 2017; 75 Suppl 2:S115-S122. [PMID: 28498180 DOI: 10.1097/qai.0000000000001343] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several studies from sub-Saharan Africa have highlighted significant challenges in providing antiretroviral therapy (ART) to pregnant and postpartum women, with specific concerns around maintaining optimal levels of adherence to ART and/or retaining women in long-term services. However, there are few conceptual frameworks to help understand nonadherence and nonretention, as well as the drivers of these, among HIV-infected women, particularly in the postpartum period. METHODS This review provides an overview of the key issues involved in thinking about ART adherence, retention in care and engagement in ART services among pregnant and postpartum women. RESULTS The related behaviors of adherence and retention may be understood as components of effective engagement of patients in ART services, which share the goal of achieving and maintaining suppressed maternal viral load on ART. Under this framework, the existing literature indicates that disengagement from care is widespread among postpartum women, with strikingly similar data emerging from ART services around the globe and indications that similar challenges may be encountered by postpartum care services outside the context of HIV. However, the drivers of disengagement require further research, and evidence-based intervention strategies are limited. CONCLUSIONS The challenges of engaging women in ART services during pregnancy and the postpartum period seem pervasive, although the determinants of these are poorly understood. Looking forward, a host of innovative intervention approaches are needed to help improve women's engagement, and in turn, promote maternal and child health in the context of HIV.
Collapse
|
28
|
Onoya D, Sineke T, Brennan AT, Long L, Fox MP. Timing of pregnancy, postpartum risk of virologic failure and loss to follow-up among HIV-positive women. AIDS 2017; 31:1593-1602. [PMID: 28463877 PMCID: PMC5491237 DOI: 10.1097/qad.0000000000001517] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/20/2017] [Accepted: 04/20/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We assessed the association between the timing of pregnancy with the risk of postpartum virologic failure and loss from HIV care in South Africa. DESIGN This is a retrospective cohort study of 6306 HIV-positive women aged 15-49 at antiretroviral therapy (ART) initiation, initiated on ART between January 2004 and December 2013 in Johannesburg, South Africa. METHODS The incidence of virologic failure (two consecutive viral load measurements of >1000 copies/ml) and loss to follow-up (>3 months late for a visit) during 24 months postpartum were assessed using Cox proportional hazards modelling. RESULTS The rate of postpartum virologic failure was higher following an incident pregnancy on ART [adjusted hazard ratio 1.8, 95% confidence interval (CI): 1.1-2.7] than among women who initiated ART during pregnancy. This difference was sustained among women with CD4 cell count less than 350 cells/μl at delivery (adjusted hazard ratio 1.8, 95% CI: 1.1-3.0). Predictors of postpartum virologic failure were being viremic, longer time on ART, being 25 or less years old and low CD4 cell count and anaemia at delivery, as well as initiating ART on stavudine-containing or abacavir-containing regimen. There was no difference postpartum loss to follow-up rates between the incident pregnancies group (hazard ratio 0.9, 95% CI: 0.7-1.1) and those who initiated ART in pregnancy. CONCLUSION The risk of virologic failure remains high among postpartum women, particularly those who conceive on ART. The results highlight the need to provide adequate support for HIV-positive women with fertility intention after ART initiation and to strengthen monitoring and retention efforts for postpartum women to sustain the benefits of ART.
Collapse
Affiliation(s)
- Dorina Onoya
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tembeka Sineke
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alana T. Brennan
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P. Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
29
|
Retention in Care among HIV-Infected Pregnant Women in Haiti with PMTCT Option B. AIDS Res Treat 2016; 2016:6284290. [PMID: 27651953 PMCID: PMC5019862 DOI: 10.1155/2016/6284290] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 07/28/2016] [Accepted: 08/03/2016] [Indexed: 01/08/2023] Open
Abstract
Background. Preventing mother-to-child transmission of HIV relies on engagement in care during the prenatal, peripartum, and postpartum periods. Under PMTCT Option B, pregnant women with elevated CD4 counts are provided with antiretroviral prophylaxis until cessation of breastfeeding. Methods. Retrospective analysis of retention in care among HIV-infected pregnant women in Haiti was performed. Logistic regression was used to identify risk factors associated with loss to follow-up (LFU) defined as no medical visit for at least 6 months and Kaplan-Meier curves were created to show LFU timing. Results. Women in the cohort had 463 pregnancies between 2009 and 2012 with retention rates of 80% at delivery, 67% at one year, and 59% at 2 years. Among those who were LFU, the highest risk period was during pregnancy (60%) or shortly afterwards (24.4% by 12 months). Never starting on antiretroviral therapy (aRR 2.29, 95% CI 1.4–3.8) was associated with loss to follow-up. Conclusions. Loss to follow-up during and after pregnancy was common in HIV-infected women in Haiti under PMTCT Option B. Since sociodemographic factors and distance from home to facility did not predict LFU, future work should elicit and address barriers to retention at the initial prenatal care visit in all women. Better tracking systems to capture engagement in care in the wider network are needed.
Collapse
|
30
|
Kyle RP, Moodie EEM, Klein MB, Abrahamowicz M. Correcting for Measurement Error in Time-Varying Covariates in Marginal Structural Models. Am J Epidemiol 2016; 184:249-58. [PMID: 27416840 DOI: 10.1093/aje/kww068] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 02/16/2016] [Indexed: 01/03/2023] Open
Abstract
Unbiased estimation of causal parameters from marginal structural models (MSMs) requires a fundamental assumption of no unmeasured confounding. Unfortunately, the time-varying covariates used to obtain inverse probability weights are often error-prone. Although substantial measurement error in important confounders is known to undermine control of confounders in conventional unweighted regression models, this issue has received comparatively limited attention in the MSM literature. Here we propose a novel application of the simulation-extrapolation (SIMEX) procedure to address measurement error in time-varying covariates, and we compare 2 approaches. The direct approach to SIMEX-based correction targets outcome model parameters, while the indirect approach corrects the weights estimated using the exposure model. We assess the performance of the proposed methods in simulations under different clinically plausible assumptions. The simulations demonstrate that measurement errors in time-dependent covariates may induce substantial bias in MSM estimators of causal effects of time-varying exposures, and that both proposed SIMEX approaches yield practically unbiased estimates in scenarios featuring low-to-moderate degrees of error. We illustrate the proposed approach in a simple analysis of the relationship between sustained virological response and liver fibrosis progression among persons infected with hepatitis C virus, while accounting for measurement error in γ-glutamyltransferase, using data collected in the Canadian Co-infection Cohort Study from 2003 to 2014.
Collapse
|
31
|
Haas AD, Msukwa MT, Egger M, Tenthani L, Tweya H, Jahn A, Gadabu OJ, Tal K, Salazar-Vizcaya L, Estill J, Spoerri A, Phiri N, Chimbwandira F, van Oosterhout JJ, Keiser O. Adherence to Antiretroviral Therapy During and After Pregnancy: Cohort Study on Women Receiving Care in Malawi's Option B+ Program. Clin Infect Dis 2016; 63:1227-1235. [PMID: 27461920 PMCID: PMC5064160 DOI: 10.1093/cid/ciw500] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 07/17/2016] [Indexed: 12/28/2022] Open
Abstract
One-third of women enrolled in Malawi's program to prevent human immunodeficiency virus mother-to-child-transmission (Option B+) adhered inadequately to antiretroviral therapy during pregnancy and breastfeeding. Long-term virological outcomes must be closely monitored, and effective interventions to improve adherence should be deployed. Background. Adherence to antiretroviral therapy (ART) is crucial to preventing mother-to-child transmission of human immunodeficiency virus (HIV) and ensuring the long-term effectiveness of ART, yet data are sparse from African routine care programs on maternal adherence to triple ART. Methods. We analyzed data from women who started ART at 13 large health facilities in Malawi between September 2011 and October 2013. We defined adherence as the percentage of days “covered” by pharmacy claims. Adherence of ≥90% was deemed adequate. We calculated inverse probability of censoring weights to adjust adherence estimates for informative censoring. We used descriptive statistics, survival analysis, and pooled logistic regression to compare adherence between pregnant and breastfeeding women eligible for ART under Option B+, and nonpregnant and nonbreastfeeding women who started ART with low CD4 cell counts or World Health Organization clinical stage 3/4 disease. Results. Adherence was adequate for 73% of the women during pregnancy, for 66% in the first 3 months post partum, and for about 75% during months 4–21 post partum. About 70% of women who started ART during pregnancy and breastfeeding adhered adequately during the first 2 years of ART, but only about 30% of them had maintained adequate adherence at every visit. Risk factors for inadequate adherence included starting ART with an Option B+ indication, at a younger age, or at a district hospital or health center. Conclusions. One-third of women retained in the Option B+ program adhered inadequately during pregnancy and breastfeeding, especially soon after delivery. Effective interventions to improve adherence among women in this program should be implemented.
Collapse
Affiliation(s)
| | - Malango T Msukwa
- Institute of Social & Preventive Medicine The Baobab Health Trust
| | - Matthias Egger
- Institute of Social & Preventive Medicine Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Lyson Tenthani
- Institute of Social & Preventive Medicine International Training & Education Center for Health
| | - Hannock Tweya
- Institute of Social & Preventive Medicine Lighthouse Trust The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Andreas Jahn
- International Training & Education Center for Health Department of HIV and AIDS, Ministry of Health, Lilongwe
| | | | - Kali Tal
- Institute of Social & Preventive Medicine
| | - Luisa Salazar-Vizcaya
- Institute of Social & Preventive Medicine Department of Infectious Diseases, Bern University Hospital, University of Bern, Switzerland
| | | | | | | | | | - Joep J van Oosterhout
- Dignitas International, Zomba Department of Medicine, College of Medicine, University of Malawi, Blantyre
| | | |
Collapse
|
32
|
Matthews LT, Ribaudo HB, Kaida A, Bennett K, Musinguzi N, Siedner MJ, Kabakyenga J, Hunt PW, Martin JN, Boum Y, Haberer JE, Bangsberg DR. HIV-Infected Ugandan Women on Antiretroviral Therapy Maintain HIV-1 RNA Suppression Across Periconception, Pregnancy, and Postpartum Periods. J Acquir Immune Defic Syndr 2016; 71:399-406. [PMID: 26495883 PMCID: PMC4943862 DOI: 10.1097/qai.0000000000000874] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND HIV-infected women risk sexual and perinatal HIV transmission during conception, pregnancy, childbirth, and breastfeeding. We compared HIV-1 RNA suppression and medication adherence across periconception, pregnancy, and postpartum periods, among women on antiretroviral therapy (ART) in Uganda. METHODS We analyzed data from women in a prospective cohort study, aged 18-49 years, enrolled at ART initiation and with ≥1 pregnancy between 2005 and 2011. Participants were seen quarterly. The primary exposure of interest was pregnancy period, including periconception (3 quarters before pregnancy), pregnancy, postpartum (6 months after pregnancy outcome), or nonpregnancy related. Regression models using generalized estimating equations compared the likelihood of HIV-1 RNA ≤400 copies per milliliter, <80% average adherence based on electronic pill caps (medication event monitoring system), and likelihood of 72-hour medication gaps across each period. RESULTS One hundred eleven women contributed 486 person-years of follow-up. Viral suppression was present at 89% of nonpregnancy, 97% of periconception, 93% of pregnancy, and 89% of postpartum visits, and was more likely during periconception (adjusted odds ratio, 2.15) compared with nonpregnant periods. Average ART adherence was 90% [interquartile range (IQR), 70%-98%], 93% (IQR, 82%-98%), 92% (IQR, 72%-98%), and 88% (IQR, 63%-97%) during nonpregnant, periconception, pregnant, and postpartum periods, respectively. Average adherence <80% was less likely during periconception (adjusted odds ratio, 0.68), and 72-hour gaps per 90 days were less frequent during periconception (adjusted relative risk, 0.72) and more frequent during postpartum (adjusted relative risk, 1.40). CONCLUSIONS Women with pregnancy were virologically suppressed at most visits, with an increased likelihood of suppression and high adherence during periconception follow-up. Increased frequency of 72-hour gaps suggests a need for increased adherence support during postpartum periods.
Collapse
Affiliation(s)
- Lynn T Matthews
- *Division of Infectious Disease, Center for Global Health, Massachusetts General Hospital, Boston, MA; †Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA; ‡Faculty of Health Sciences, Simon Fraser University, Burnaby BC, Canada; §Bennett Statistical Consulting, Ballston Lake, NY; ‖Mbarara University of Science and Technology, Mbarara, Uganda; Departments of ¶Medicine, and #Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA; **Epicentre Mbarara, Mbarara, Uganda; ††Department of General Medicine, Center for Global Health, Massachusetts General Hospital, Boston, MA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Pinnetti C, Tintoni M, Ammassari A, Tamburrini E, Bernardi S, Liuzzi G, Scambia G, Perno CF, Floridia M, Antinori A, Cavaliere AF. Successful prevention of HIV mother-to-child transmission with dolutegravir-based combination antiretroviral therapy in a vertically infected pregnant woman with multiclass highly drug-resistant HIV-1. AIDS 2015; 29:2534-7. [PMID: 26372490 DOI: 10.1097/qad.0000000000000888] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|