Linking women who test HIV-positive in pregnancy-related services to long-term HIV care and treatment services: a systematic review

Understanding Fijian health system challenges in the prevention of mother-to-child transmission of HIV services in the three tertiary hospitals in Fiji

Mother-to-child transmission is the most common route of human immunodeficiency virus transmission in children, which could be prevented with proper treatment and access to care. Health system challenges can impede the effectiveness of prevention of mother-to-child transmission (PMTCT) programmes. We aim to understand the health system challenges to the provision of PMTCT services for pregnant women in three tertiary hospitals in Fiji. Data were collected using in-depth interviews in the three tertiary hospitals and associated health clinics in Fiji between April-May 2013 and February-March 2014. Ethical approvals were obtained. A total of 58 healthcare providers were interviewed including doctors (n = 12), midwives (n = 19), nurses (n = 14), laboratory technicians (n = 5) and counsellors (n = 8). The data were analysed using thematic analysis. We found that the healthcare workers faced a wide range of health system challenges including institutional and human resource challenges. Staff shortage, limited PMTCT training and shortage of supplies were barriers to the quality of PMTCT services. Our findings would be useful in developing strategies to overcome barriers as it would be imperative in improving the quality of PMTCT service provision in Fiji and other similar settings.

Stressors and Maladaptive Coping Mechanisms Associated with Elevated Perinatal Depressive Symptoms and Suicidality Among Women Living with HIV in Uganda

BACKGROUND

Perinatal depression is highly prevalent among women living with HIV and contributes to nonadherence to the PMTCT (prevention of mother-to-child transmission) care continuum. We examined correlates of elevated depressive symptoms and suicidality in this population.

METHOD

Baseline data from 391 Ugandan women enrolled in a cluster randomized controlled trial of a depression care intervention were analyzed. Adult women with confirmed sero-positive HIV status were eligible if their gestation period was ≤ 32 weeks, and they had a Patient Health Questionnaire (PHQ-9) score ≥ 5. Correlates of elevated depressive symptoms (PHQ-9 > 9) and moderate-to-severe suicidal ideation (more than half of the days in the prior 2 weeks) were assessed using bivariate and multivariate logistic regression models, controlling for clustering within study sites by using a random effects specification (with study site as the random effect), as well as age and education.

RESULTS

The mean PHQ-9 score was 12.7 (SD = 5.1); 267 (68.3%) participants had elevated depressive symptoms, and 51 (13.0%) reported moderate-to-severe suicidality. In multiple logistic regression analysis, perceived provider stigma of childbearing [OR (95% CI) = 1.81 (1.16, 2.84)], greater use of negative problem-solving [OR (95% CI) = 1.09 (1.04, 1.15)], and lower general social support [OR (95% CI) = 0.50 (0.30, 0.82)] were correlated with elevated depression symptoms, while moderate-to-severe suicidal ideation was correlated with greater experience of physical interpersonal violence (IPV) and greater use of negative problem-solving.

CONCLUSIONS

Programs aimed at improving provider support for the childbearing needs of persons living with HIV, supporting women who are experiencing IPV, and helping women to develop effective problem-solving skills and social supports may reduce symptoms of perinatal depression and help optimize PMTCT care outcomes.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03892915 (registered March 21, 2019).

Increasing Prevention of Mother to Child Transmission (PMTCT) Uptake through Facility-Based Health Promotion: Intervention Development

In Sudan, the HIV testing rates during pregnancy remain low. Limitations in scaling and uptake of PMTCT services are linked to several factors within the healthcare system, including the motivation of healthcare providers. This article describes how a health facility-based health promotion intervention plan was developed, implemented, and evaluated to increase the uptake of PMTCT services using the Intervention Mapping approach. Individual-level and environmental determinants were previously identified and included in the intervention plan. Some factors that impacted the intention of women to test for HIV during pregnancy include level of knowledge on MTCT, who offers the HIV test, the fear and tension experienced when thinking about HIV/AIDS, the non-confidentiality of the HIV test results, and self-efficacy. This provides insights into how to develop, implement, and evaluate a facility-based health promotion intervention. The pre-assessment was critical in shaping the intervention and making it relevant and evidence based. The Intervention Mapping approach that was applied facilitated the systematic design of the intervention and supported guiding the implementation.

Understanding the relationship between the public sector healthcare workers and NGO-based HIV counsellors while providing HIV counselling and testing services to pregnant women: A Qualitative Study in Suva, Fiji

Human immunodeficiency virus (HIV) counselling and testing plays a significant role in the prevention of mother-to-child transmission of HIV. HIV counselling and testing during pregnancy is an essential gateway for HIV prevention, timely treatment, and care services. Lack of proper counselling could jeopardise the quality of services. This paper aims to understand the relationship between the government employed hospital healthcare workers and the Non-Governmental Organisation based counsellors while providing HIV counselling and testing services to pregnant women attending antenatal clinic in one of the main hospitals in Suva, Fiji. Data were collected via individual, in-depth, interviews held in a single hospital and an associated reproductive health centre in Suva in April-May 2013. A total of 15 healthcare providers including doctors (n = 4), midwives (n = 5), nurses (n = 4), and counsellors (n = 2) were interviewed. The data were analysed using thematic analysis. Ethical approvals were obtained. We found that there was tension between the government employed hospital healthcare workers and the Non-Governmental Organisation based counsellors involved in the provision of HIV counselling and testing services to pregnant women. The predominant causes of tension were poor referral for HIV test counselling, long counselling time, lack of cooperation and conflict due to the differences in counselling approaches. Tension between the government employed hospital healthcare workers and the Non- Governmental Organisation based HIV counsellors appear to be the main challenge to effective provision of HIV test counselling services in the hospital. Ongoing tension between both groups could restrict healthcare workers abilities to provide quality HIV counselling services. Our findings would be useful in developing strategies to overcome tension amongst healthcare workers as it would be an imperative step in providing streamlined HIV counselling services to women attending antenatal clinic in Fiji.

Programmatic Retention in Prevention of Mother-to-Child Transmission (PMTCT) Programs: Estimated Rates and Cofactors Using Different Nonretention Measures

BACKGROUND

Prevention of mother-to-child transmission programs serve women continuing and initiating antiretroviral therapy (ART) in pregnancy, and follow-up schedules align to delivery rather than ART initiation, making conventional HIV retention measures (assessed from ART initiation) challenging to apply. We evaluated 3 measures of peripartum nonretention in Kenyan women living with HIV from pregnancy to 2 years postpartum.

METHODS

This longitudinal analysis used programmatic data from the Mobile WAChX trial (NCT02400671). Outcomes included loss to follow-up (LTFU) (no visit for ≥6 months), incomplete visit coverage (<80% of 3-month intervals with a visit), and late visits (>2 weeks after scheduled date). Predictors of nonretention were determined using Cox proportional hazards, log-binomial, and generalized estimating equation models.

RESULTS

Among 813 women enrolled at a median of 24 weeks gestation, incidence of LTFU was 13.6/100 person-years; cumulative incidence of LTFU by 6, 12, and 24 months postpartum was 16.7%, 20.9%, and 22.5%, respectively. Overall, 35.5% of women had incomplete visit coverage. Among 794 women with 12,437 scheduled visits, a median of 11.1% of visits per woman were late (interquartile range 4.3%-23.5%). Younger age, unsuppressed viral load, unemployment, ART initiation in pregnancy, and nondisclosure were associated with nonretention by all measures. Partner involvement was associated with better visit coverage and timely attendance. Women who became LTFU had higher frequency of previous late visits (16.7% vs. 7.7%, P < 0.0001).

CONCLUSIONS

Late visit attendance may be a sentinel indicator of LTFU. Identified cofactors of prevention of mother-to-child transmission programmatic retention may differ depending on retention measure assessed, highlighting the need for standardized measures.

Perinatal Depressive Symptoms and Viral Non-suppression Among a Prospective Cohort of Pregnant Women Living with HIV in Nigeria, Kenya, Uganda, and Tanzania

Depression is common during pregnancy and is associated with reduced adherence to HIV-related care, though little is known about perinatal trajectories of depression and viral suppression among women living with HIV (WLHV) in sub-Saharan Africa. We sought to assess any association between perinatal depressive symptoms and viral non-suppression among WLWH. Depressive symptomatology and viral load data were collected every 6 months from WLWH enrolled in the African Cohort Study (AFRICOS; January 2013-February 2020). Generalized estimating equations modeled associations between depressive symptoms [Center for Epidemiological Studies Depression (CES-D) ≥ 16] and viral non-suppression. Of 1722 WLWH, 248 (14.4%) had at least one pregnancy (291 total) and for 61 pregnancies (21.0%), women reported depressive symptoms (13.4% pre-conception, 7.6% pregnancy, 5.5% one-year postpartum). Depressive symptomatology was associated with increased odds of viral non-suppression (aOR 2.2; 95% CI 1.2-4.0, p = 0.011). Identification and treatment of depression among women with HIV may improve HIV outcomes for mothers.

Motivational interviewing retention counseling and adherence to early infant diagnostic HIV testing schedule in South Africa: The PAEDLINK randomized trial

INTRODUCTION

We report the PAEDLINK randomized trial results on the effect of motivational interviewing (MI) retention counseling on the adherence of postpartum women to the early infant diagnostic human immunodeficiency virus (HIV) testing schedule.

METHODS

HIV positive women and their babies were enrolled 3 to 6 days after delivery at 4 midwife obstetric units in the Gauteng province of South Africa and randomized into (A) MI retention counseling and telephonic tracing, (B) biannual telephonic tracing, and (C) standard care. Mother-baby pairs were followed up for 18 months via medical records. The uptake of child HIV tests and maternal retention in the 0 to 6 and 7 to 18 month periods were modeled using Log-binomial regression.

RESULTS

Overall, 501/711 enrolled mother-baby pairs received a second HIV polymerase chain reaction test by 6 months (70.0%, 70.5%, and 70.0% in groups A, B, and C, respectively). A higher proportion of intervention children (60.9%) were tested at 7 to 90 days than group B (48.1%, adjusted risk ratio [aRR] 0.8 for B vs A, 95% confidence interval [CI]: 0.7-0.9) and group C children (52.7%, aRR 0.9 for C vs A, 95% CI: 0.9-1.0). Child testing between 7 and 18-months was also higher in group A than C (10.7% A, vs 5.5% C, RR 2.0, 95% CI: 1.0-3.7). However, maternal retention was similar across groups, with 41.6% and 16.3% retained during the 0 to 6 and the 7 to 18-months periods, respectively.

CONCLUSION

MI retention counseling can reduce delays in the early infant diagnosis testing schedule for HIV-exposed infants. However, further support is necessary to maximize later HIV tests and maternal retention.

Investigating clinic transfers among HIV patients considered lost to follow-up to improve understanding of the HIV care cascade: Findings from a cohort study in rural north-eastern South Africa

Investigating clinical transfers of HIV patients is important for accurate estimates of retention and informing interventions to support patients. We investigate transfers for adults reported as lost to follow-up (LTFU) from eight HIV care facilities in the Agincourt health and demographic surveillance system (HDSS), South Africa. Using linked clinic and HDSS records, outcomes of adults more than 90 days late for their last scheduled clinic visit were determined through clinic and routine tracing record reviews, HDSS data, and supplementary tracing. Factors associated with transferring to another clinic were determined through Cox regression models. Transfers were graphically and geospatially visualised. Transfers were more common for women, patients living further from the clinic, and patients with higher baseline CD4 cell counts. Transfers to clinics within the HDSS were more likely to be undocumented and were significantly more likely for women pregnant at ART initiation. Transfers outside the HDSS clustered around economic hubs. Patients transferring to health facilities within the HDSS may be shopping for better care, whereas those who transfer out of the HDSS may be migrating for work. Treatment programmes should facilitate transfer processes for patients, ensure continuity of care among those migrating, and improve tracking of undocumented transfers.

Frameworks, measures, and interventions for HIV-related internalised stigma and stigma in healthcare and laws and policies: systematic review protocol

INTRODUCTION

There is strong global commitment to eliminate HIV-related stigma. Wide variation exists in frameworks and measures, and many strategies to prevent, reduce or mitigate stigma have been proposed but critical factors determining success or failure remain elusive.

METHODS AND ANALYSIS

Building on existing knowledge syntheses, we designed a systematic review to identify frameworks, measures and intervention evaluations aiming to address internalised stigma, stigma and discrimination in healthcare, and stigma and discrimination at the legal or policy level. The review addresses four key questions (KQ): KQ1: Which conceptual frameworks have been proposed to assess internal stigma, stigma and discrimination experienced in healthcare settings, and stigma and discrimination entrenched in national laws and policies? KQ2: Which measures of stigma have been proposed and what are their descriptive properties? KQ3: Which interventions have been evaluated that aimed to reduce these types of stigma and discrimination or mitigate their adverse effects and what are the effectiveness and unintended consequences? KQ4: What common 'critical factors for success or failure' can be identified across interventions that have been evaluated? We will search PubMed, PsycINFO, Web of Science, Universal Human Rights Index, HeinOnline, PAIS, HIV Legal Network, CDSR, Campbell Collaboration, PROSPERO and Open Science Framework. Critical appraisal will assess the source, processes and consensus finding for frameworks; COnsensus-based Standards for the selection of health Measurement Instruments criteria for measures; and risk of bias for interventions. Quality of evidence grading will apply . A gap analysis will provide targeted recommendations for future research. We will establish a compendium of frameworks, a comprehensive catalogue of available measures, and a synthesis of intervention characteristics to advance the science of HIV-related stigma.

PROSPERO REGISTRATION NUMBER

CRD42021249348.

A mega-aggregation framework synthesis of the barriers and facilitators to linkage, adherence to ART and retention in care among people living with HIV

BACKGROUND

People living with human immunodeficiency virus (PLHIV) struggle with the challenges of living with a chronic disease and integrating antiretroviral treatment (ART) and care into their daily lives. The aims of this study were as follows: (1) to undertake the first mega-aggregation of qualitative evidence syntheses using the methods of framework synthesis and (2) make sense of existing qualitative evidence syntheses that explore the barriers and facilitators of adherence to antiretroviral treatment, linkage to care and retention in care for PLHIV to identify research gaps.

METHODS

We conducted a comprehensive search and did all screening, data extraction and critical appraisal independently and in duplicate. We used the Kaufman HIV Behaviour Change model (Kaufman et al., 2014) as a framework to synthesise the findings using the mega-aggregative framework synthesis approach, which consists of 8 steps: (1) identify a clearly defined review question and objectives, (2) identify a theoretical framework or model, (3) decide on criteria for considering reviews for inclusion, (4) conduct searching and screening, (5) conduct quality appraisal of the included studies, (6) data extraction and categorisation, (7) present and synthesise the findings, and (8) transparent reporting. We evaluated systematic reviews up to July 2018 and assessed methodological quality, across reviews, using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews.

RESULTS

We included 33 systematic reviews from low, middle- and high-income countries, which reported on 1,111,964 PLHIV. The methodological quality of included reviews varied considerably. We identified 544 unique third-order concepts from the included systematic reviews, which were reclassified into 45 fourth-order themes within the individual, interpersonal, community, institutional and structural levels of the Kaufman HIV Behaviour Change model. We found that the main influencers of linkage, adherence and retention behaviours were psychosocial and personal characteristics-perceptions of ART, desires, fears, experiences of HIV and ART, coping strategies and mental health issues-interwoven with other factors on the interpersonal, community, institutional and structural level. Using this approach, we found interdependence between factors influencing ART linkage, retention and adherence and identified the need for qualitative evidence that explores, in greater depth, the complex relationships between structural factors and adherence, sociodemographic factors such as community violence and retention, and the experiences of growing up with HIV in low- and middle-income countries-specifically in children, youth, women and key populations.

CONCLUSIONS

This is the first mega-aggregation framework synthesis, or synthesis of qualitative evidence syntheses using the methods of framework synthesis at the overview level. We found the novel method to be a transparent and efficient method for assessing the quality and making sense of existing qualitative systematic reviews.

SYSTEMATIC REVIEW REGISTRATION

The protocol of this overview was registered on PROSPERO ( CRD42017078155 ) on 17 December 2017.

HIV Stigma and Viral Suppression Among People Living With HIV in the Context of Universal Test and Treat: Analysis of Data From the HPTN 071 (PopART) Trial in Zambia and South Africa

BACKGROUND

The impact of HIV stigma on viral suppression among people living with HIV (PLHIV) is not well characterized.

SETTING

Twenty-one communities in Zambia and South Africa, nested within the HPTN 071 (PopART) trial.

METHODS

We analyzed data on viral suppression (<400 copies HIV RNA/mL) among 5662 laboratory-confirmed PLHIV aged 18-44 years who were randomly sampled within the PopART trial population cohort 24 months after enrolment (PC24). We collected data on experiences and internalization of stigma from those PLHIV who self-reported their HIV status (n = 3963/5662) and data on perceptions of stigma from a 20% random sample of all PLHIV (n = 1154/5662). We also measured stigma at the community-level among PLHIV, community members, and health workers. We analyzed the association between individual- and community-level measures of HIV stigma and viral suppression among PLHIV, adjusting for confounding.

RESULTS

Of all 5662 PLHIV, 69.1% were virally suppressed at PC24. Viral suppression was highest among those 3963 cohort participants who self-reported living with HIV and were on ART (88.3%), and lower among those not on treatment (37.5%). Self-identifying PLHIV who reported internalized stigma were less likely to be virally suppressed (75.0%) than those who did not (80.7%; adjusted risk ratio, 0.94 95% CI: 0.89 to 0.98). Experiences, perceptions, and community-level measures of stigma were not associated with viral suppression.

CONCLUSION

Internalized stigma among PLHIV was associated with a lower level of viral suppression; other dimensions of stigma were not. Stigma reduction approaches that address internalized stigma should be an integral component of efforts to control the HIV epidemic.

Retired Nurses Can Improve Retention in Prevention of Mother-to-Child Transmission Programmes

Background:

The success of prevention of mother-to-child transmission (PMTCT) programmes depends on retention of mothers throughout the PMTCT cascade.

Methods:

In a clinical trial of short-course combination antiretroviral therapy (cART) for PMTCT in Tanzania, senior nurses were employed to reduce the substantial loss-to-follow up (LTFU) rate.

Results:

Following intervention, the relative risk (RR) of receiving a CD4 count result and antiretroviral therapy was 1.16 (95% confidence interval [CI], 1.05 to 1.27), the RR of delivery at clinic was 2.51 (95% CI, 2.06 to 3.06), the RR for reporting for follow-up at 6 to 8 weeks postpartum was 4.63 (95% CI, 3.41 to 6.27), and the RR for being retained until 9 months postpartum was 28.19 (95% CI, 11.81 to 67.28). No significant impact on transmission was found.

Conclusion:

Significantly higher retention was found after senior nurses were employed. No impact on transmission was found. Relatively low transmission was found in both study arms.

Patient-provider communication about pregnancy and HIV among female sex workers living with HIV in Santo Domingo, Dominican Republic

Background

Health providers can play an important role in communication about pregnancy, particularly for women at increased risk for pregnancy complications, including female sex workers (FSWs) living with HIV. This study explored factors related to patient-provider communication about pregnancy among 253 FSWs living with HIV of reproductive age in Santo Domingo, Dominican Republic.

Methods

A cross-sectional design was employed including structured socio-behavioral surveys. Data were analyzed utilizing bivariate and multivariate logistic regression.

Results

Of the 253 FSWs living with HIV in this study, 95.7% had been pregnant at least once (median: 4; IQR: 3,6), 28.0% wanted more children and 36% reported a pregnancy after HIV diagnosis. Over half of participants (58.0%) reported having ever spoken to a health provider about pregnancy while living with HIV. Multivariate logistic regression found significant associations between having spoken to a health provider about HIV in pregnancy and a more positive perception of their provider (AOR: 2.0; 95% CI: 1.0, 2.5) and years since HIV diagnosis (AOR: 1.1; 95% CI: 1.0, 1.1). Participants were less likely to speak with a provider if they had a history of drug use (AOR: 0.4; 95% CI: 0.2, 0.9) or current alcohol use (AOR: 0.5; 95% CI: 0.3, 0.9).

Conclusion

Findings highlight the importance of non-judgmental and tailored provider-initiated conversations surrounding pregnancy. Future research is needed to better understand how and when pregnancy communication is initiated, as well as the content of clinical care conversations, to address the reproductive health of FSWs living with HIV.

Strengthening service integration for effective linkage of HIV-positive mothers to antiretroviral treatment: a cross-sectional study in two military health facilities in Kaduna, Nigeria, 2014

Introduction

strong PMTCT-ART service linkages ensure continuity of care for healthier mothers and children born HIV free. Program data showed weak PMTCT- ART linkages in military health facilities. We conducted a study to assess the PMTCT-adult ART service linkage in two Nigerian military health facilities in Kaduna State.

Methods

we conducted a cross-sectional study using mixed methods (interviews and FGDs) in 44 Nigeria Army Reference Hospital (NARH) and 1 Division Hospital, Kaduna. We studied 372 HIV-positive mothers after a delivery of their babies, referred for ART services from January 2009 to December 2013. We conducted FGDs among ANC, PMTCT and ART clinics staff. We analysed data using descriptive and inferential methods. A p-value of < 0.05 was considered significant with 95% confidence intervals (CI) for estimates.

Results

of the 372 respondents studied, 320 (86%) accessed PMTCT services from the 44 NARH. Most respondents (206,55.4%) respondents aged < 25 years. One in six (16.7%) respondents had no record of referral. Delivering baby in a separate facility from where PMTCT services were accessed, increased the likelihood of not accessing ART services (odd ratio [OR]: 6.7, 95% CI= 3.3 -13.6). The qualitative study identified poor service integration between PMTCT and ANC clinics.

Conclusion

the key factors hindering PMTCT-ART linkage in military health facilities included poor service integration, clients delivering of a baby in a facility separate from where PMTCT services were accessed. The Ministry of Defence HIV programme should strengthen ANC-PMTCT-ART service integration through a centrally coordinated client information management system.

Associations between health systems capacity and mother-to-child HIV prevention program outcomes in Zambia

Introduction

Zambia has made substantial investments in health systems capacity, yet it remains unclear whether improved service quality improves outcomes. We investigated the association between health system capacity and use of prevention of mother-to-child HIV transmission (PMTCT) services in Zambia.

Materials and methods

We analyzed data from two studies conducted in rural and semi-urban Lusaka Province in 2014–2015. Health system capacity, our primary exposure, was measured with a validated balanced scorecard approach. Based on WHO building blocks for health systems strengthening, we derived overall and domain-specific facility scores (range: 0–100), with higher scores indicating greater capacity. Our outcome, community-level maternal antiretroviral drug use at 12 months postpartum, was measured via self-report in a large cohort study evaluating PMTCT program impact. Associations between health systems capacity and our outcome were analyzed via linear regression.

Results

Among 29 facilities, median overall facility score was 72 (IQR:67–74). Median domain scores were: patient satisfaction 75 (IQR 71–78); human resources 85 (IQR:63–87); finance 50 (IQR:50–67); governance 82 (IQR:74–91); service capacity 77 (IQR:68–79); service provision 60 (IQR:52–76). Our programmatic outcome was measured from 804 HIV-infected mothers. Median community-level antiretroviral use at 12 months was 81% (IQR:69–89%). Patient satisfaction was the only domain score significantly associated with 12-month maternal antiretroviral use (β:0.22; p = 0.02). When we excluded the human resources and finance domains, we found a positive association between composite 4-domain facility score and 12-month maternal antiretroviral use in peri-urban but not rural facilities.

Conclusions

In these Zambian health facilities, patient satisfaction was positively associated with maternal antiretroviral 12 months postpartum. The association between overall health system capacity and maternal antiretroviral drug use was stronger in peri-urban versus rural facilities. Additional work is needed to guide strategic investments for improved outcomes in HIV and broader maternal-child health region-wide.

"I found that I was well and strong": Women's motivations for remaining on ART under Option B+ in Malawi

Most Malawian women who start ART under Option B+ are still in care three years later, a higher than average adherence rate for life-threatening chronic disease treatments, worldwide (50%). We asked 75 Malawian on ART their motivations for remaining in treatment, and what barriers they overcame. Focus groups and interviews included 75 women on ART for 6+ months, at 12 health facilities. Four main motivations for continuing ART emerged: 1) evidence that ART improved their own and their children's health; 2) strong desire to be healthy and keep their children healthy; 3) treatment was socially supported; 4) HIV/ART counselling effectively showed benefits of ART and told women what to expect. Women surmounted the following barriers: 1) stigma; 2) health care system; 3) economic; 4) side effects. Women stayed on ART because they believed it works. Future interventions should focus on emphasizing ART's effectiveness, along with other services they provide.

Understanding Predictors of Early Antenatal Care Initiation in Relationship to Timing of HIV Diagnosis in South Africa

Effective prevention of mother-to-child transmission benefits from early presentation to antenatal care (ANC). It is, however, unclear whether a previous HIV diagnosis results in earlier initiation of ANC. We estimated the probability of early ANC initiation among women with a previous HIV-positive diagnosis compared to those who first tested for HIV during ANC and explored determinants of early ANC among HIV-positive women. We conducted an analysis of a cross-sectional survey among 411 HIV-positive adult (>18 years) women who gave birth at midwife obstetrics units in Gauteng between October 2016 and May 2017. Predictors of early ANC (defined as initiating ANC before or at 14 weeks of gestation) were assessed by multivariate log-binomial regression model. Overall, 51% (210) were diagnosed during pregnancy with 89% (188) initiating antiretroviral therapy on the same day of diagnosis. There was no meaningful difference in the timing of ANC initiation between women with previous HIV diagnosis [adjusted risk ratio (aRR) = 1.2; 95% confidence interval (95% CI): 0.9-1.7] compared with those diagnosed during pregnancy. Early ANC was predicted by planned pregnancy [aRR = 1.3; 95% CI: 1.1-1.7], parity (>2 children) [aRR = 0.6; 95% CI: 0.2-0.9] compared to not having a child, and tuberculosis diagnosis [aRR = 2.9; 95% CI: 1.4-6.1]. Our results suggest the need for a targeted intervention among HIV-positive women by improving the quality, content and outreach of ANC services to enhance early ANC uptake, and minimize mother-to-child transmission risk.

"I just wish that everything is in one place": facilitators and barriers to continuity of care among HIV-positive, postpartum women with a non-communicable disease in South Africa

HIV and non-communicable diseases (NCD) are co-epidemics in South Africa. Comorbid individuals must engage in lifelong care. Postpartum HIV-positive women in South Africa are at high risk of dropping out of HIV care. We explored healthcare utilization among postpartum women requiring chronic management of HIV and NCD. From August - December 2016, we enrolled 25 women in Soweto, South Africa, and conducted one-time interviews. All participants were adult (≥18 years), HIV-positive, postpartum, and diagnosed with a NCD that required further evaluation after delivery. We developed a conceptual model that describes how maternal factors, interaction with environments, and social networks influence follow up engagement. Barriers to follow-up included separate visit days, increased time commitment, transportation and logistics, unfamiliar clinic environments, and disrespectful staff. Factors facilitating patient engagement included social support and partner disclosure. Women were more likely to turn to friends and family for advice regarding HIV or the NCD, rather than a clinic. Women prioritized infant care after delivery, suggesting that baby care may be an entry point for improving maternal care after delivery. Our results support advocating for better integration of services at the primary care level as a method to improve continuity of care for both women and children.

Interventions to significantly improve service uptake and retention of HIV-positive pregnant women and HIV-exposed infants along the prevention of mother-to-child transmission continuum of care: systematic review

OBJECTIVES

Despite the success of Prevention of Mother-to-Child Transmission of HIV (PMTCT) programmes, low uptake of services and poor retention pose a formidable challenge to achieving the elimination of vertical HIV transmission in low- and middle-income countries. This systematic review summarises interventions that demonstrate statistically significant improvements in service uptake and retention of HIV-positive pregnant and breastfeeding women and their infants along the PMTCT cascade.

METHODS

Databases were systematically searched for peer-reviewed studies. Outcomes of interest included uptake of services, such as antiretroviral therapy (ART) such as initiation, early infant diagnostic testing, and retention of HIV-positive pregnant and breastfeeding women and their infants. Interventions that led to statistically significant outcomes were included and mapped to the PMTCT cascade. An eight-item assessment tool assessed study rigour.

PROSPERO ID

CRD42017063816.

RESULTS

Of 686 citations reviewed, 11 articles met inclusion criteria. Ten studies detailed maternal outcomes and seven studies detailed infant outcomes in PMTCT programmes. Interventions to increase access to antenatal care (ANC) and ART services (n = 4) and those using lay cadres (n = 3) were most common. Other interventions included quality improvement (n = 2), mHealth (n = 1), and counselling (n = 1). One study described interventions in an Option B+ programme. Limitations included lack of HIV testing and counselling and viral load monitoring outcomes, small sample size, geographical location, and non-randomized assignment and selection of participants.

CONCLUSIONS

Interventions including ANC/ART integration, family-centred approaches, and the use of lay healthcare providers are demonstrably effective in increasing service uptake and retention of HIV-positive mothers and their infants in PMTCT programmes. Future studies should include control groups and assess whether interventions developed in the context of earlier 'Options' are effective in improving outcomes in Option B+ programmes.

The impact of programs for prevention of mother-to-child transmission of HIV on health care services and systems in sub-Saharan Africa - A review

BACKGROUND

The global scale-up of Prevention of mother-to-child transmission (PMTCT) services is credited for a 52% worldwide decline in new HIV infections among children between 2001 and 2012. However, the epidemic continues to challenge maternal and paediatric HIV control efforts in Sub Saharan Africa (SSA), with repercussions on other health services beyond those directly addressing HIV and AIDS. This systematised narrative review describes the effects of PMTCT programs on other health care services and the implications for improving health systems in SSA as reported in the existing articles and scientific literature. The following objectives framed our review:To describe the effects of PMTCT on health care services and systems in SSA and assess whether the PMTCT has strengthened or weakened health systems in SSATo describe the integration of PMTCT and its extent within broader programs and health systems.

METHODS

Articles published in English and French over the period 1st January 2007 (the year of publication of WHO/UNICEF guidelines on global scale-up of the PMTCT) to 31 November 2016 on PMTCT programs in SSA were sought through searches of electronic databases (Medline and Google Scholar). Articles describing the impact (positive and negative effects) of PMTCT on other health care services and those describing its integration in health systems in SSA were eligible for inclusion. We assessed 6223 potential papers, reviewed 225, and included 57.

RESULTS

The majority of selected articles offered arguments for increased health services utilisation, notably of ante-natal care, and some evidence of beneficial synergies between PMTCT programs and other health services especially maternal health care, STI prevention and early childhood immunisation. Positive and negative impact of PMTCT on other health care services and health systems are suggested in thirty-two studies while twenty-five papers recommend more integration and synergies. However, the empirical evidence of impact of PMTCT integration on broader health systems is scarce. Underlying health system challenges such as weak physical and human resource infrastructure and poor working conditions, as well as social and economic barriers to accessing health services, affect both PMTCT and the health services with which PMTCT interacts.

CONCLUSIONS

PMTCT services increase to some extent the availability, accessibility and utilisation of antenatal care and services beyond HIV care. Vertical PMTCT programs work, when well-funded and well-managed, despite poorly functioning health systems. The beneficial synergies between PMTCT and other services are widely suggested, but there is a lack of large-scale evidence of this.

Promoting high standards of care for women living with HIV: position statement from the Women Against Viruses in Europe Working Group

OBJECTIVES

Gender-related factors can influence management decisions, treatment outcomes and the overall long-term wellbeing of people living with HIV (PLWH). The Women Against Viruses in Europe (WAVE) Working Group was established to promote the health and wellbeing of women living with HIV (WLWH). WAVE is part of the European AIDS Clinical Society (EACS) and organizes annual workshops to discuss different issues in the management of WLWH.

METHODS

In 2016, 34 WAVE members including community representatives, HIV clinicians and researchers met to discuss standards of care for WLWH and to review current guidelines. Participants focused on three different themes: (1) access to and engagement and retention in care; (2) monitoring of women on antiretroviral therapy and management of comorbidities; and (3) review of EACS treatment guidelines.

RESULTS

Five priority areas for optimizing the care of WLWH were identified: (1) psychosocial aspects of HIV diagnosis and care; (2) mental health and wellbeing; (3) pharmacokinetics, toxicity and tolerability of antiretroviral therapy; (4) coinfections and comorbidities; and (5) sexual and reproductive health. WAVE recommendations are provided for each of these areas, and gaps in knowledge and needs for changes in currently existing standards are discussed.

CONCLUSIONS

This position statement provides an overview of the key recommendations to optimize the care of WLWH that emerged during the 2016 WAVE workshop.

Non-disclosure to male partners and incomplete PMTCT regimens associated with higher risk of mother-to-child HIV transmission: a national survey in Kenya

Health worker experience and community support may be higher in high HIV prevalence regions than low prevalence regions, leading to improved prevention of mother-to-child HIV transmission (PMTCT) programs. We evaluated 6-week and 9-month infant HIV transmission risk (TR) in a high prevalence region and nationally. Population-proportionate-to-size sampling was used to select 141 clinics in Kenya, and mobile teams surveyed mother-infant pairs attending 6-week and 9-month immunizations. HIV DNA testing was performed on HIV-exposed infants. Among 2521 mother-infant pairs surveyed nationally, 2423 (94.7%) reported HIV testing in pregnancy or prior diagnosis, of whom 200 (7.4%) were HIV-infected and 188 infants underwent HIV testing. TR was 8.8% (4.0%-18.3%) in 6-week and 8.9% (3.2%-22.2%) in 9-month cohorts including mothers with HIV diagnosed postpartum, of which 53% of infant infections were due to previously undiagnosed mothers. Of 276 HIV-exposed infants in the Nyanza survey, TR was 1.4% (0.4%-5.3%) at 6-week and 5.1% (2.5%-9.9%) at 9-months. Overall TR was lower in Nyanza, high HIV region, than nationally (3.3% vs. 7.2%, P = 0.02). HIV non-disclosure to male partners and incomplete ARVs were associated with TR in both surveys [aOR = 12.8 (3.0-54.3); aOR = 5.6 (1.2-27.4); aOR = 4.5 (1.0-20.0), aOR = 2.5, (0.8-8.4), respectively]. TR was lower in a high HIV prevalence region which had better ARV completion and partner HIV disclosure, possibly due to programmatic efficiencies or community/peer/partner support. Most 9-month infections were among infants of mothers without prior HIV diagnosis. Strategies to detect incident or undiagnosed maternal infections will be important to achieve PMTCT.

Acceptability and feasibility of a financial incentive intervention to improve retention in HIV care among pregnant women in Johannesburg, South Africa

Women initiating antiretroviral therapy during pregnancy are at high risk of dropping out of HIV care after delivery. We assessed the acceptability and feasibility of a financial incentive - a one-time R50 (∼USD4) supermarket voucher for completing one postpartum visit ≤10 weeks of delivery - to improve postpartum retention. We enrolled 100 pregnant, HIV-positive women at a primary health clinic in Johannesburg, South Africa. Participants were interviewed at enrollment and we reviewed files to assess retention ≥14 weeks postpartum. Median (IQR) respondent age was 28 years (24-31) and 31% were employed. Most (86%) said the incentive would motivate them to return and 76% supported clinics offering incentives. Among the 23% who found the intervention unacceptable, the most frequent reason was perceived personal responsibility for health. Feasibility was demonstrated, as 79.7% (51/64) of eligible participants received a voucher. When asked to rank preferred hypothetical incentive interventions, assistance with social services ranked first (29%), followed by infant formula (22%) and cash (21%); assistance with social services was the top-ranked choice by both those who found the voucher incentive intervention acceptable and unacceptable. To encourage HIV-positive women to remain in care, respondents most frequently suggested health education (34%), counseling (29%), financial incentives (25%), home visits (13%), and better service (6%). Our results suggest financial incentives are acceptable, but women frequently expressed preference for integrated services and improved education and counseling to improve retention. Interventions exploring the feasibility and efficacy of education and counseling interventions to improve postpartum HIV care are warranted.

Programmes for the prevention of parent-to-child transmission of HIV in Papua New Guinea: Health system challenges and opportunities

BACKGROUND

Prevention of parent-to-child transmission (PPTCT) of HIV is a highly complex package of interventions, which spans services in both maternal and child health programmes. In Papua New Guinea (PNG), a commitment to ensure that all pregnant women and their partners have access to the full range of PPTCT interventions exists; however, efforts to increase access and utilisation of PPTCT remain far from optimal. The aim of this paper is to examine health care worker (HCW) perception of health system factors impacting on the performance of PPTCT programmes.

METHOD

Sixteen interviews were undertaken with HCWs involved in the PPTCT programme. Application of the WHO 6 building blocks of a health system was applied, and further thematic analysis was conducted on the data with assistance from the analysis software NVivo.

RESULTS

Broken equipment, problems with access to medication and supplies, and poorly supported workforce were reported as barriers for implementing a successful PPTCT programme. The absence of central coordination of this complex, multistaged programme was also recognised as a key issue.

CONCLUSION

The study findings highlight an important need for investment in appropriately trained and supported HCWs and integration of services at each stage of the PPTCT programme. Lessons from the PPTCT experience in PNG may inform policy discussions and considerations in other similar contexts.

Identifying gaps in HIV service delivery across the diagnosis-to-treatment cascade: findings from health facility surveys in six sub-Saharan countries

Introduction: Despite the rollout of antiretroviral therapy (ART), challenges remain in ensuring timely access to care and treatment for people living with HIV. As part of a multi-country study to investigate HIV mortality, we conducted health facility surveys within 10 health and demographic surveillance system sites across six countries in Eastern and Southern Africa to investigate clinic-level factors influencing (i) use of HIV testing services, (ii) use of HIV care and treatment and (iii) patient retention on ART.

Methods: Health facilities (n = 156) were sampled within 10 surveillance sites: Nairobi and Kisumu (Kenya), Karonga (Malawi), Agincourt and uMkhanyakude (South Africa), Ifakara and Kisesa (Tanzania), Kyamulibwa and Rakai (Uganda) and Manicaland (Zimbabwe). Structured questionnaires were administered to in-charge staff members of HIV testing, prevention of mother-to-child transmission (PMTCT) and ART units within the facilities. Forty-one indicators influencing uptake and patient retention along the continuum of HIV care were compared across sites using descriptive statistics.

Results: The number of facilities surveyed ranged from six in Malawi to 36 in Zimbabwe. Eighty percent were government-run; 73% were lower-level facilities and 17% were district/referral hospitals. Client load varied widely, from less than one up to 65 HIV testing clients per provider per week. Most facilities (>80%) delivered services or interventions that would support patient retention in care such as delivering free services, offering PMTCT within antenatal care, pre-ART monitoring and adherence counselling. Many facilities under-delivered in several areas, however, such as targeted testing for high-risk groups (21%) and mobile testing (36%). There were also intra-site and inter-site differences, including in the delivery of Option B+ (ranging from 6% in Kisumu to 93% in Kyamulibwa), and nurse-led ART initiation (ranging from 50% in Kisesa to 100% in Karonga and Agincourt). Only facilities in Malawi did not require additional lab tests for ART initiation. Stock-outs of HIV test kits and antiretroviral drugs were particularly common in Tanzania.

Conclusions: We identified a high standard of health facility performance in delivering strategies that may support progression through the continuum of HIV care. HIV testing policy and practice was particularly weak. Inter- and intra-country differences in quality and coverage represent opportunities to improve the delivery of comprehensive services to people living with HIV.

Mobility and Clinic Switching Among Postpartum Women Considered Lost to HIV Care in South Africa

OBJECTIVE

Retention in HIV care, particularly among postpartum women, is a challenge to national antiretroviral therapy programs. Retention estimates may be underestimated because of unreported transfers. We explored mobility and clinic switching among patients considered lost to follow-up (LTFU).

DESIGN

Observational cohort study.

METHODS

Of 788 women initiating antiretroviral therapy during pregnancy at 6 public clinics in Johannesburg, South Africa, 300 (38.1%) were LTFU (no visit ≥3 months). We manually searched for these women in the South African National Health Laboratory Services database to assess continuity of HIV care. We used geographic information system tools to map mobility to new facilities.

RESULTS

Over one-third (37.6%) of women showed evidence of continued HIV care after LTFU. Of these, 67.0% continued care in the same province as the origin clinic. Compared with those who traveled outside of the province for care, these same-province "clinic shoppers" stayed out-of-care longer {median 373 days [interquartile range (IQR): 175-790] vs. 175.5 days (IQR: 74-371)} and had a lower CD4 cell count on re-entry [median 327 cells/μL (IQR: 196-576) vs. 493 cells/μL (IQR: 213-557). When considering all women with additional evidence of care as engaged in care, cohort LTFU dropped from 38.1% to 25.0%.

CONCLUSIONS

We found evidence of continued care after LTFU and identified local and national clinic mobility among postpartum women. Laboratory records do not show all clinic visits and manual matching may have been under- or overestimated. A national health database linked to a unique identifier is necessary to improve reporting and patient care among highly mobile populations.

Quality maternity care for every woman, everywhere: a call to action

To improve maternal health requires action to ensure quality maternal health care for all women and girls, and to guarantee access to care for those outside the system. In this paper, we highlight some of the most pressing issues in maternal health and ask: what steps can be taken in the next 5 years to catalyse action toward achieving the Sustainable Development Goal target of less than 70 maternal deaths per 100 000 livebirths by 2030, with no single country exceeding 140? What steps can be taken to ensure that high-quality maternal health care is prioritised for every woman and girl everywhere? We call on all stakeholders to work together in securing a healthy, prosperous future for all women. National and local governments must be supported by development partners, civil society, and the private sector in leading efforts to improve maternal-perinatal health. This effort means dedicating needed policies and resources, and sustaining implementation to address the many factors influencing maternal health-care provision and use. Five priority actions emerge for all partners: prioritise quality maternal health services that respond to the local specificities of need, and meet emerging challenges; promote equity through universal coverage of quality maternal health services, including for the most vulnerable women; increase the resilience and strength of health systems by optimising the health workforce, and improve facility capability; guarantee sustainable finances for maternal-perinatal health; and accelerate progress through evidence, advocacy, and accountability.

The impact of leadership hubs on the uptake of evidence-informed nursing practices and workplace policies for HIV care: a quasi-experimental study in Jamaica, Kenya, Uganda and South Africa

BACKGROUND

The enormous impact of HIV on communities and health services in Sub-Saharan Africa and the Caribbean has especially affected nurses, who comprise the largest proportion of the health workforce in low- and middle-income countries (LMICs). Strengthening action-based leadership for and by nurses is a means to improve the uptake of evidence-informed practices for HIV care.

METHODS

A prospective quasi-experimental study in Jamaica, Kenya, Uganda and South Africa examined the impact of establishing multi-stakeholder leadership hubs on evidence-informed HIV care practices. Hub members were engaged through a participatory action research (PAR) approach. Three intervention districts were purposefully selected in each country, and three control districts were chosen in Jamaica, Kenya and Uganda. WHO level 3, 4 and 5 health care institutions and their employed nurses were randomly sampled. Self-administered, validated instruments measured clinical practices (reports of self and peers), quality assurance, work place policies and stigma at baseline and follow-up. Standardised average scores ranging from 0 to 1 were computed for clinical practices, quality assurance and work place policies. Stigma scores were summarised as 0 (no reports) versus 1 (one or more reports). Pre-post differences in outcomes between intervention and control groups were compared using the Mantel Haenszel chi-square for dichotomised stigma scores, and independent t tests for other measures. For South Africa, which had no control group, pre-post differences were compared using a Pearson chi-square and independent t test. Multivariate analysis was completed for Jamaica and Kenya. Hub members in all countries self-assessed changes in their capacity at follow-up; these were examined using a paired t test.

RESULTS

Response rates among health care institutions were 90.2 and 80.4 % at baseline and follow-up, respectively. Results were mixed. There were small but statistically significant pre-post, intervention versus control district improvements in workplace policies and quality assurance in Jamaica, but these were primarily due to a decline in scores in the control group. There were modest improvements in clinical practices, workplace policies and quality assurance in South Africa (pre-post) (clinical practices of self-pre 0.67 (95 % CI, 0.62, 0.72) versus post 0.78 (95 % CI, 0.73-0.82), p = 0.002; workplace policies-pre 0.82 (95 % CI, 0.70, 0.85) versus post 0.87 (95 % CI, 0.84, 0.90), p = 0.001; quality assurance-pre 0.72 (95 % CI, 0.67, 0.77) versus post 0.84 (95 % CI, 0.80, 0.88)). There were statistically significant improvements in scores for nurses stigmatising patients (Jamaica reports of not stigmatising-pre-post intervention 33.9 versus 62.4 %, pre-post control 54.7 versus 64.4 %, p = 0.002-and Kenya pre-post intervention 35 versus 51.6 %, pre-post control 34.2 versus 47.8 %, p = 0.006) and for nurses being stigmatised (Kenya reports of no stigmatisation-pre-post intervention 23 versus 37.3 %, pre-post control 15.4 versus 27 %, p = 0.004). Multivariate results for Kenya and Jamaica were non-significant. Twelve hubs were established; 11 were active at follow-up. Hub members (n = 34) reported significant improvements in their capacity to address care gaps.

CONCLUSIONS

Leadership hubs, comprising nurses and other stakeholders committed to change and provided with capacity building can collectively identify issues and act on strategies that may improve practice and policy. Overall, hubs did not provide the necessary force to improve the uptake of evidence-informed HIV care in their districts. If hubs are to succeed, they must be integrated within district health authorities and become part of formal, legal organisations that can regularise and sustain them.

Mother and child both matter: reconceptualizing the prevention of mother-to-child transmission care continuum

PURPOSE OF REVIEW

To propose a prevention of mother-to-child transmission (PMTCT) care continuum that defines the programmatic steps necessary to provide HIV care to the HIV-infected pregnant woman and her infant during the risk period for HIV transmission.

RECENT FINDINGS

There are several complexities of PMTCT care that should be considered in the care continuum, including the evolution in the population of women entering PMTCT care, various models of PMTCT service delivery and patterns of PMTCT care, and the critical step of transfer of women's HIV care from PMTCT programs to adult HIV clinics.

SUMMARY

We propose a reconceptualized PMTCT care continuum that accounts for the complexities of PMTCT care. We also propose a combined outcome for pregnant women and their infants across an interlinked PMTCT continuum to measure both maternal and child health outcomes.

A systematic review of interventions to improve prevention of mother-to-child HIV transmission service delivery and promote retention

Introduction

The success of prevention of mother-to-child transmission of HIV (PMTCT) is dependent upon high retention of mother-infant pairs within these programmes. This is a systematic review to evaluate the effectiveness of interventions that aim to improve PMTCT service delivery and promote retention throughout the PMTCT steps.

Methods

Selected databases were searched for studies published in English (up to September 2015). Outcomes of interest included antiretroviral (ARV) drugs or antiretroviral therapy (ART) initiation among HIV-positive pregnant and/or breastfeeding women and their infants, retention into PMTCT programs, the uptake of early infant diagnosis (EID) of HIV and infant HIV status. Risk ratios and random-effect meta-analysis were used in the analysis.

Results

Interventions assessed in the 34 identified studies included male partner involvement in PMTCT, peer mentoring, the use of community health workers (CHWs), mobile phone-based reminders, conditional cash transfer, training of midwives, integration of PMTCT services and enhanced referral. Five studies (two randomized) that evaluated mobile phone-based interventions showed a statistically significant increase (pooled RR 1.18; 95% CI 1.05 to 1.32, I²=83%) in uptake of EID of HIV at around six weeks postpartum. Male partner involvement in PMTCT was associated with reductions in infant HIV transmission (pooled RR 0.61; 95% CI 0.39 to 0.94, I²=0%) in four studies (one randomized). Four studies (three randomized) that were grounded on psychological interventions reported non-significant results (pooled RR 1.01; 95% CI 0.93 to 1.09, I²=69%) in increasing ARV/ART uptake among HIV-positive pregnant and/or breastfeeding women and infant HIV testing (pooled RR 1.00; 95% CI 0.94 to 1.07, I²=45%). The effect of the other interventions on the effectiveness of improving PMTCT uptake was unclear. Heterogeneity of interventions limits these findings.

Conclusions

Our findings indicate that mobile phone-based reminders may increase the uptake of EID of HIV. Studies on male partner involvement in PMTCT reported reductions in infant HIV transmission. Stronger evidence is needed and future studies should determine the long-term effects of these interventions in improving retention throughout the PMTCT steps.

Antiretroviral therapy among pregnant and postpartum women in China: A systematic review and meta-analysis

BACKGROUND

The objectives of this study were to estimate the antiretroviral therapy (ART) rate and the proportion of women with adequate ART adherence (100%), and to identify the reasons for not initiating ART in HIV-infected pregnant women in China.

METHODS

We searched MEDLINE, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Wanfang (Chinese) to identify research studies published from 1990-2015. Only descriptive epidemiologic studies were eligible for this study.

RESULTS

A total of 58 eligible studies were included in this meta-analysis. The eligible articles were published from 2006-2015 and covered all Chinese provinces. The estimated ART rate in HIV-positive pregnant women was continually increased, and the mean estimated ART rate increased from 47.1% (95% confidence interval [CI], 22.4-71.8) in 2006 to 95.0% (95% CI, 93.2-96.0) in 2013. In the meta-regression model, study year, study region, and income level were statistically significantly associated with ART rate estimates. During the last 10 years, the pooled ART adherence proportions for all studies yielded an estimate of 76.7% (95% CI, 61.0-92.5) of patients with adequate ART adherence (100%). Emergency cesarean delivery (57.9%; 95% CI, 9.9-100) and not knowing their HIV-infection status before starting (45.7%; 95% CI, 24.4-67.0) account for the dominant reasons for not initiating ART.

CONCLUSIONS

The geographic variation in ART rate of HIV-infected pregnant women was significant in China, and >25% of pregnant women did not achieved optimal ART adherence. It is crucial to investigate specific barriers for lower ART rates in the high-income regions and to develop interventions to maintain the adequate ART adherence.

Implementation and Operational Research: Postpartum Transfer of Care Among HIV-Infected Women Initiating Antiretroviral Therapy During Pregnancy

BACKGROUND

The integration of antiretroviral therapy (ART) services into antenatal care for prevention of mother-to-child transmission has resulted in the need to transfer HIV-infected women to general ART clinics after delivery. Transfer of patients on ART between services may present a challenge to adherence and retention, but there are few data describing this step in the HIV care cascade for women starting ART in pregnancy.

METHODS

We described postpartum transfer of care in a cohort of women initiating ART during pregnancy and referred from integrated antenatal ART services to general ART clinics. Engagement in ART care at general ART clinics was assessed through routine laboratory records and telephonic interviews.

RESULTS

Overall, 279 postpartum women were transferred to ART clinics. By 5 months postreferral, between 74% and 91% of women had evidence of engagement at an ART clinic depending on the outcome definition. In a log-binomial model adjusted for age, CD4 cell count and being diagnosed with HIV in the current pregnancy, additional months on ART before delivery improved the likelihood of engagement in an ART clinic (relative risk: 1.05, 95% confidence interval: 1.00 to 1.09, P = 0.036).

CONCLUSIONS

Postpartum transfer of ART care is an important and previously neglected step in the HIV care cascade for pregnant women. Even in this cohort of highly adherent women up to 25% did not remain in care after transfer. Retention is required across all steps of the cascade, including transfer of ART care after delivery, to maximize the benefits of ART for both maternal and child health.

Uptake of services for prevention of mother-to-child transmission of HIV in a community cohort in rural Tanzania from 2005 to 2012

Background

Estimates of population-level coverage with prevention of mother-to-child transmission (PMTCT) services are vital for monitoring programmes but are rarely undertaken. This study describes uptake of PMTCT services among HIV-positive pregnant women in a community cohort in rural Tanzania.

Methods

Kisesa cohort incorporates demographic and HIV sero-surveillance rounds since 1994. Cohort data were linked retrospectively to records from four Kisesa clinics with PMTCT services from 2009 (HIV care and treatment clinic (CTC) available in one facility from 2008; referrals to city hospitals for PMTCT and antiretroviral treatment (ART) from 2005). The proportion of HIV-positive pregnant women residing in Kisesa in 2005–2012 who accessed PMTCT service components (based on linkage to facility records) was calculated per HIV-positive pregnancy and by year, with adjustments made to account for the sensitivity of the linkage algorithm.

Results

Out of 1497 HIV-positive pregnancies overall (to 849 women), 26 % (n = 387/1497) were not linked to any facility records, 35 % (n = 519/1497) registered for ANC but not HIV services (29 % (n = 434/1497) were not tested at ANC or diagnosed previously), 8 % (n = 119/1497) enrolled in PMTCT but not CTC services (6 % (n = 95/1497) received antiretroviral prophylaxis), and 32 % (n = 472/1497) registered for CTC (14 % (n = 204/1497) received ART or prophylaxis) (raw estimates). Adjusted estimates for coverage with ANC were 92 %, 57 % with HIV care, and 29 % with antiretroviral drugs in 2005–2012, trending upwards over time.

Conclusions

Population-level coverage with PMTCT services was low overall, with weaknesses throughout the service continuum, but increased over time. Option B+ should improve coverage with antiretrovirals for PMTCT through simplified decisions for initiating ART, but will rely on strengthening access to CTC services.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1249-6) contains supplementary material, which is available to authorized users.

The physical and psychological effects of HIV infection and its treatment on perinatally HIV-infected children

INTRODUCTION

As highly active antiretroviral therapy (HAART) transforms human immunodeficiency virus (HIV) into a manageable chronic disease, new challenges are emerging in treating children born with HIV, including a number of risks to their physical and psychological health due to HIV infection and its lifelong treatment.

METHODS

We conducted a literature review to evaluate the evidence on the physical and psychological effects of perinatal HIV (PHIV+) infection and its treatment in the era of HAART, including major chronic comorbidities.

RESULTS AND DISCUSSION

Perinatally infected children face concerning levels of treatment failure and drug resistance, which may hamper their long-term treatment and result in more significant comorbidities. Physical complications from PHIV+ infection and treatment potentially affect all major organ systems. Although treatment with antiretroviral (ARV) therapy has reduced incidence of severe neurocognitive diseases like HIV encephalopathy, perinatally infected children may experience less severe neurocognitive complications related to HIV disease and ARV neurotoxicity. Major metabolic complications include dyslipidaemia and insulin resistance, complications that are associated with both HIV infection and several ARV agents and may significantly affect cardiovascular disease risk with age. Bone abnormalities, particularly amongst children treated with tenofovir, are a concern for perinatally infected children who may be at higher risk for bone fractures and osteoporosis. In many studies, rates of anaemia are significantly higher for HIV-infected children. Renal failure is a significant complication and cause of death amongst perinatally infected children, while new data on sexual and reproductive health suggest that sexually transmitted infections and birth complications may be additional concerns for perinatally infected children in adolescence. Finally, perinatally infected children may face psychological challenges, including higher rates of mental health and behavioural disorders. Existing studies have significant methodological limitations, including small sample sizes, inappropriate control groups and heterogeneous definitions, to name a few.

CONCLUSIONS

Success in treating perinatally HIV-infected children and better understanding of the physical and psychological implications of lifelong HIV infection require that we address a new set of challenges for children. A better understanding of these challenges will guide care providers, researchers and policymakers towards more effective HIV care management for perinatally infected children and their transition to adulthood.

Brief Report: Impact of Option B+ on the Infant PMTCT Cascade in Lilongwe, Malawi

This observational study compared uptake of infant prevention of mother-to-child transmission of HIV services pre/post implementation of Option B+ in Lilongwe, Malawi. There were 845 (pre) and 998 (post) births. Post-B+, infants had longer median predelivery maternal antiretroviral therapy {62 days [interquartile range (IQR): 38-94] pre-B+ vs. 95 days [IQR: 61-131] post-B+; P < 0.0001} and improved polymerase chain reaction testing (82.0% vs. 86.5%; P = 0.01) at younger median age [7.6 weeks (IQR: 6.6-10.9) vs. 6.9 (IQR: 6.4-8.1); P < 0.0001]. Proportion testing polymerase chain reaction positive decreased (4.6% vs. 2.6%; P = 0.03). Proportion of HIV-infected infants starting antiretroviral therapy (75% vs. 77.3%) and age at initiation [19.7 weeks (IQR: 15.4-31.1) vs. 16 (IQR: 13.3-17.9)] remained unchanged. These findings suggest modest improvements in infant care with Option B+.

Effectiveness of peer support on care engagement and preventive care intervention utilization among pre-antiretroviral therapy, HIV-infected adults in Rakai, Uganda: a randomized trial

442 pre-ART, HIV-infected adults were randomized to peer support consisting of structured home visits to promote clinic attendance and preventive care intervention use or standard of care. At baseline, 62 % reported previously visiting an HIV clinic, 45 % reported taking cotrimoxazole prophylaxis, and 31 % were "care-naïve" (no previous clinic visit and not on cotrimoxazole). After 1 year, intervention participants were more likely to report being in care (92 vs 84 %; PRR 1.09, p = 0.039), on cotrimoxazole (89 vs 81 %; PRR 1.10, p = 0.047), and safe water vessel adherence (23 vs 14 %; PRR 1.64, p = 0.024). The effect was observed only among care-naïve participants (n = 139) with 83 % intervention versus 56 % controls reporting being in HIV care (PRR 1.47, p = 0.006), 78 versus 58 % on cotrimoxazole (PRR 1.35, p = 0.04), and 20 versus 4 % safe water vessel adherence (PRR 5.78, p = 0.017). Peer support may be an effective intervention to facilitate pre-ART care compliance in this important population.

Implementation and Operational Research: Effects of Antenatal Care and HIV Treatment Integration on Elements of the PMTCT Cascade: Results From the SHAIP Cluster-Randomized Controlled Trial in Kenya

BACKGROUND

Integrating antenatal care (ANC) and HIV care may improve uptake and retention in services along the prevention of mother-to-child transmission (PMTCT) cascade. This study aimed to determine whether integration of HIV services into ANC settings improves PMTCT service utilization outcomes.

METHODS

ANC clinics in rural Kenya were randomized to integrated (6 clinics, 569 women) or nonintegrated (6 clinics, 603 women) services. Intervention clinics provided all HIV services, including highly active antiretroviral therapy (HAART), whereas control clinics provided PMTCT services but referred women to HIV care clinics within the same facility. PMTCT utilization outcomes among HIV-infected women (maternal HIV care enrollment, HAART initiation, and 3-month infant HIV testing uptake) were compared using generalized estimating equations and Cox regression.

RESULTS

HIV care enrollment was higher in intervention compared with control clinics [69% versus 36%; odds ratio = 3.94, 95% confidence interval (CI): 1.14 to 13.63]. Median time to enrollment was significantly shorter among intervention arm women (0 versus 8 days, hazard ratio = 2.20, 95% CI: 1.62 to 3.01). Eligible women in the intervention arm were more likely to initiate HAART (40% versus 17%; odds ratio = 3.22, 95% CI: 1.81 to 5.72). Infant testing was more common in the intervention arm (25% versus 18%), however, not statistically different. No significant differences were detected in postnatal service uptake or maternal retention.

CONCLUSIONS

Service integration increased maternal HIV care enrollment and HAART uptake. However, PMTCT utilization outcomes were still suboptimal, and postnatal service utilization remained poor in both study arms. Further improvements in the PMTCT cascade will require additional research and interventions.

The Uptake of Prevention of Mother-to-Child HIV Transmission Programs in China: A Systematic Review and Meta-Analysis

BACKGROUND

No systematic review of prevention of mother to child transmission (PMTCT) in China has been performed. We aimed to estimate the uptake of PMTCT programs services in China.

METHODS

We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Wanfang (Chinese) to identify research studies. Only descriptive epidemiological studies were eligible for this study.

RESULTS

A total of 57 eligible cross-section studies were finally included. We estimated that the mean HIV-positive rate of exposed infants was 4.4% (95% CI = 3.2-5.5), and more than 33% of exposed infants had not undergone HIV diagnostic testing. The percentage of initiating antiretroviral therapy (ART) in HIV-positive women was 71.0% (95% CI = 66.3-75.8), and that for initiating antiretroviral prophylaxis (ARP) in exposed infants was 78.3% (95% CI = 74.9-81.8); also, 31.3% (95% CI = 15.5-47.0) of women with HIV and < 1% of exposed infants received the combination of three antiretroviral drugs. There were bigger gap of uptake of PMTCT programs between income levels, and cities with a low income level had a higher percentage of initiating ART in HIV-positive women (80%) and ARP in exposed infants (85%) compared to cities with high-middle income (57% and 65%, respectively) (P<0.05).

CONCLUSIONS

This paper highlights the need to further scale up PMTCT services in China, especially in regions with the lowest coverage, so that more women can access and utilize them. However, some estimated outcome should be interpreted with caution due to the high level of heterogeneity and the small number of studies.

Postnatal retention in HIV care: insight from the Swiss HIV Cohort Study over a 15-year observational period

OBJECTIVES

The aim of this study was to quantify loss to follow-up (LTFU) in HIV care after delivery and to identify risk factors for LTFU, and implications for HIV disease progression and subsequent pregnancies.

METHODS

We used data on pregnancies within the Swiss HIV Cohort Study from 1996 to 2011. A delayed clinical visit was defined as > 180 days and LTFU as no visit for > 365 days after delivery. Logistic regression analysis was used to identify risk factors for LTFU.

RESULTS

A total of 695 pregnancies in 580 women were included in the study, of which 115 (17%) were subsequent pregnancies. Median maternal age was 32 years (IQR 28-36 years) and 104 (15%) women reported any history of injecting drug use (IDU). Overall, 233 of 695 (34%) women had a delayed visit in the year after delivery and 84 (12%) women were lost to follow-up. Being lost to follow-up was significantly associated with a history of IDU [adjusted odds ratio (aOR) 2.79; 95% confidence interval (CI) 1.32-5.88; P = 0.007] and not achieving an undetectable HIV viral load (VL) at delivery (aOR 2.42; 95% CI 1.21-4.85; P = 0.017) after adjusting for maternal age, ethnicity and being on antiretroviral therapy (ART) at conception. Forty-three of 84 (55%) women returned to care after LTFU. Half of them (20 of 41) with available CD4 had a CD4 count < 350 cells/μL and 15% (six of 41) a CD4 count < 200 cells/μL at their return.

CONCLUSIONS

A history of IDU and detectable HIV VL at delivery were associated with LTFU. Effective strategies are warranted to retain women in care beyond pregnancy and to avoid CD4 cell count decline. ART continuation should be advised especially if a subsequent pregnancy is planned.

Perceptions of Sudanese women of reproductive age toward HIV/AIDS and services for Prevention of Mother-to-Child Transmission of HIV

BACKGROUND

Access to antenatal HIV testing during pregnancy and the level of uptake of services for Prevention of Mother-to-Child Transmission (PMTCT) in Sudan are very low. This study aimed to obtain insights into the perceptions of Sudanese pregnant women toward HIV/AIDS and the use of PMTCT services.

METHODS

Ten focus group discussions (FGDs) with women of reproductive age were conducted at community settings in Khartoum (N = 121). Recruitment eligibility included living near or around a PMTCT site and being in the age range of 18-40 years. Out of 121 women who participated, 72 (61 %) were pregnant. Predefined themes were addressed in the theory-based interview scheme, which was derived from multiple socio-cognitive theories-i.e., the Extended Parallel Process Model, the Reasoned Action Approach and the socio-psychological view on stigma. Emerging themes were incorporated during data analysis.

RESULTS

Few women knew about the Mother to child transmission (MTCT) of HIV. No one indicated that MTCT might occur during labor. Most women believed that HIV/AIDS is a serious and fatal condition for them and also for their children. They believed they were susceptible to HIV/AIDS as a result of cesarean section, contaminated items (blood and sharp items) and husband infidelity. The usefulness and advantages of HIV testing were questioned; for some women it was perceived as an additional burden of anxiety and worry. Doctors were the most influential with regard to acceptance of HIV testing. The speed of the testing process and confidentiality were mentioned by some women as key factors affecting willingness to undergo HIV testing at a health facility during pregnancy.

CONCLUSION

The study reveals that most of the women felt susceptible to HIV infection with perceived high severity; however, this perception has not translated into positive attitudes toward the importance of HIV testing during pregnancy. Because of anticipated stigma, women are not likely to disclose their HIV status. Further research should focus on gaining a more in-depth understanding of the psycho-social determinants and processes underlying the factors identified above. In addition, the adequate implementation of Provider Initiated Testing and Counseling (PITC) should be critically assessed in future research about PMTCT in Sudan.

Implementation and operational research: the impact of option B+ on the antenatal PMTCT cascade in Lilongwe, Malawi

OBJECTIVE

In 2011, Malawi implemented Option B+ (B+), lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women. We aimed to describe changes in service uptake and outcomes along the antenatal prevention of mother-to-child transmission (PMTCT) cascade post-B+ implementation.

DESIGN

Pre/post study using routinely collected program data from 2 large Lilongwe-based health centers.

METHODS

We compared the testing of HIV-infected pregnant women at antenatal care, enrollment into PMTCT services, receipt of ART, and 6-month ART outcomes pre-B+ (October 2009-March 2011) and post-B+ (October 2011-March 2013).

RESULTS

A total of 13,926 (pre) and 14,532 (post) women presented to antenatal care. Post-B+, a smaller proportion were HIV-tested (99.3% vs. 87.7% post-B+; P < 0.0001). There were 1654 (pre) and 1535 (post) HIV-infected women identified, with a larger proportion already known to be HIV-infected (18.1% vs. 41.2% post-B+; P < 0.0001) and on ART post-B+ (18.7% vs. 30.2% post-B+; P < 0.0001). A significantly greater proportion enrolled into the PMTCT program (68.3% vs. 92.6% post-B+; P < 0.0001) and was retained through delivery post-B+ (51.1% vs. 65% post-B+; P < 0.0001). Among those not on ART at enrollment, there was no change in the proportion newly initiating ART/antiretrovirals (79% vs. 81.9% post-B+; P = 0.11), although median days to initiation of ART decreased [48 days (19, 130) vs. 0 days (0, 15.5) post-B+; P < 0.0001]. Among those newly initiating ART, a smaller proportion was alive on ART 6 months after initiation (89.3% vs. 78.8% post-B+; P = 0.0004).

CONCLUSIONS

Although several improvements in PMTCT program performance were noted with implementation of B+, challenges remain at several critical steps along the cascade requiring innovative solutions to ensure an AIDS-free generation.

Virologic and immunologic failure, drug resistance and mortality during the first 24 months postpartum among HIV-infected women initiated on antiretroviral therapy for life in the Mitra plus Study, Dar es Salaam, Tanzania

Background

In the Mitra plus study of prevention of mother-to-child transmission of HIV-1, which included 501 women in Dar es Salaam, Tanzania, triple antiretroviral therapy (ART) was given from late pregnancy throughout breastfeeding up to 6 months postnatally. Here we report findings in a sub-cohort of women with ≤200 CD4cells/μL at enrolment who were continued on ART for life and followed up during 24 months after delivery to determine virologic and immunologic responses, drug resistance and mortality.

Methods

Blood samples for viral load and CD4 counts testing were collected at enrolment and at 3, 6, 12 and 24 months postpartum. HIV drug resistance testing was performed at 12 months. Data analysis included descriptive statistics and multivariate analysis using Generalized Estimated Equations of 73 women with at least two postpartum assessments. The mortality analysis included 84 women who had delivered.

Results

The proportion of women with a viral load ≥400 copies/mL was 97% (71/73) at enrolment, 16% (11/67), 22% (15/69), 61% (36/59) and 86% (48/56) at 3, 6, 12 and 24 months postpartum, respectively. The proportion of women with immunologic failure was 12% (8/69), 25% (15/60) and 41% (24/58) at 6, 12 and 24 months, respectively. At 12 months, drug resistance was demonstrated in 34% (20/59), including 12 with dual-class resistance. Self-report on drug adherence was 95% (64/68), 85% (56/66), 74% (39/53) and 65% (30/46) at 3, 6, 12 and 24 months, respectively. The mortality rate was 5.9% (95% CI 2.5-13.7%) at 24 months. The probability of virologic and immunologic failure was significantly higher among women who reported non-perfect adherence to ART at month 24 postpartum.

Conclusions

Following an initial decline of viral load, virologic failure was common at 12 and 24 months postpartum among women initiated on ART for life during pregnancy because of low CD4 cell counts. A high proportion of viremic mothers also had resistance mutations. However, at 24 months follow-up, the mortality rate was still fairly low. Continuous adherence counseling and affordable means of monitoring of the virologic response are crucial for successful implementation of the WHO Option B+ guidelines to start all HIV-infected pregnant women on ART for life.

Barriers to antiretroviral treatment initiation in rural KwaZulu-Natal, South Africa

OBJECTIVES

Although antiretroviral therapy (ART) has been freely available since 2004 in South Africa, not all those who are eligible initiate ART. We aimed to investigate individual and household characteristics as barriers to ART initiation in men and women in rural KwaZulu-Natal.

METHODS

Adults ≥ 16 years old living within a sociodemographic surveillance area (DSA) who accessed the local HIV programme between 2007 and 2011 were included in the study. Individual and household factors associated with ART initiation within 3 months of becoming eligible for ART were investigated using multivariable logistic regression stratified by sex and after exclusion of individuals who died before initiating ART.

RESULTS

Of the 797 men and 1598 women initially included, 8% and 5.5%, respectively, died before ART initiation and were excluded from further analysis. Of the remaining 733 men and 1510 women, 68.2% and 60.2%, respectively, initiated ART ≤ 3 months after becoming eligible (P = 0.34 after adjustment for CD4 cell count). In men, factors associated with a higher ART initiation rate were being a member of a household located < 2 km from the nearest HIV clinic and being resident in the DSA at the time of ART eligibility. In women, ART initiation was more likely in those who were not pregnant, in members of a household where at least one person was on ART and in those with a high wealth index.

CONCLUSIONS

In this rural South African setting, barriers to ART initiation differed for men and women. Supportive individual- and household-level interventions should be developed to guarantee rapid ART initiation taking account gender specificities.

Invitation cards during pregnancy enhance male partner involvement in prevention of mother to child transmission (PMTCT) of human immunodeficiency virus (HIV) in Blantyre, Malawi: a randomized controlled open label trial

Introduction

Male involvement (MI) is vital for the uptake of Prevention of Mother to Child Transmission (PMTCT) of Human Immunodeficiency Virus (HIV) interventions. Partner notification (PN) is among the strategies identified for MI in PMTCT services. The purpose of this randomized controlled trial was to evaluate the efficacy of an invitation card to the male partners as a strategy for MI in PMTCT services by comparing the proportion of pregnant women that were accompanied by their partners between the intervention and the non-intervention study groups.

Methods

Pregnant women attending antenatal care without a male partner at South Lunzu and Mpemba health centres in Blantyre, Malawi, were enrolled in the study from June to December 2013. In an intention-to-treat analysis, we compared all participants that were randomized in the invitation card group with the standard of care (SoC) group. Risk ratios (RR) with 95% confidence intervals (CI) were computed to assess the efficacy of the invitation card.

Results

Of the 462 randomized women, 65/230 (28.26%) of the women in the invitation card group reported to the antenatal care clinic with their partners compared to 44/232 (18.97%) women in the SoC group. In an unadjusted intention-to-treat analysis women in the invitation card group were 50% more likely to be accompanied by their male partners than those in the SoC group RR: 1.49 (95% CI: 1.06-2.09); p = 0.02. Our random effects analysis showed that there was no clustering by site of recruitment with an inter cluster correlation coefficient (ICC) of 1.98x 10^-3, (95% CI: 1.78 x10^-7 - 0.96 x 10^-1); p =0.403.

Conclusion

An invitation card significantly increased the proportion of women who were accompanied by their male partners for the PMTCT services. An invitation card is a feasible strategy for MI in PMTCT.

Patient and provider perspectives on improving the linkage of HIV-positive pregnant women to long-term HIV care and treatment in eastern Uganda

Despite strong evidence that antiretroviral therapy (ART) reduces the risk of mother-to-child transmission of HIV and improves the health of HIV-positive mothers, many HIV-positive pregnant women do not enrol into long-term HIV care and treatment. This study examined barriers and facilitators to the linkage of HIV-positive pregnant women from antenatal care (ANC) to long-term HIV care from patient and provider perspectives, following the implementation of a collaborative quality improvement project in Eastern Uganda. It also solicited recommendations for improving linkages to HIV care. Structured interviews were conducted with 11 health providers and 48 HIV-positive mothers enrolled in HIV care. Facilitators to linking HIV-positive pregnant women to long-term HIV care identified included support from expert clients, escorted referrals, same-day HIV care registration, and coordination between ANC and HIV services. Barriers reported included shortages in HIV testing kits and fear of social, physical and medical consequences. Participants recommended integration of ANC and HIV services, reduction in waiting times, HIV counselling by expert clients, and community-based approaches for improving linkages to HIV care. Linking HIV-positive pregnant women to HIV care can be improved through deliberate implementation of quality improvement interventions in facilities to address barriers to access and provide stronger support and community mobilisation.

Evolution of antiretroviral therapy services for HIV-infected pregnant women in Cape Town, South Africa

BACKGROUND

Approaches to antiretroviral therapy (ART) in HIV-infected pregnant women have changed considerably in recent years, but there are few comparative data on the implementation of different models of service delivery.

METHODS

Using routine clinic records we examined ART initiation in pregnant women attending a large antenatal care (ANC) facility between January 2010 and December 2013 in Cape Town, South Africa. Over this time six different service delivery models were implemented sequentially to provide ART in pregnancy, including the integration of ART into ANC, use of point-of-care CD4 cell count testing, and universal ART initiation for all HIV-infected pregnant women.

RESULTS

During the study period 19,432 women sought ANC, levels of HIV testing were high (98%) and 30% of pregnant women tested HIV-positive. Integration of ART into ANC was associated with significant increases in the proportion of eligible women initiating treatment before delivery compared to referral to a separate ART clinic (p<0.001). When CD4 cell counts were used to determine ART eligibility, point-of-care testing was associated with decreased delays to ART initiation compared to laboratory-based testing (p<0.001). The strategy of universal ART led to the highest levels of ART initiation (with 92% of women starting before delivery) and the shortest delays, with 82% of women starting ART on the day of the first ANC visit.

CONCLUSION

Developments in service delivery models, most notably service integration and universal ART for pregnant women, have improved antenatal ART initiation dramatically in this setting. Further research is needed into how strategies for antenatal ART initiation impact maternal and child health over the long-term.

Eliminating preventable HIV-related maternal mortality in sub-Saharan Africa: what do we need to know?

INTRODUCTION

HIV makes a significant contribution to maternal mortality, and women living in sub-Saharan Africa are most affected. International commitments to eliminate preventable maternal mortality and reduce HIV-related deaths among pregnant and postpartum women by 50% will not be achieved without a better understanding of the links between HIV and poor maternal health outcomes and improved health services for the care of women living with HIV (WLWH) during pregnancy, childbirth, and postpartum.

METHODS

This article summarizes priorities for research and evaluation identified through consultation with 30 international researchers and policymakers with experience in maternal health and HIV in sub-Saharan Africa and a review of the published literature.

RESULTS

Priorities for improving the evidence about effective interventions to reduce maternal mortality and improve maternal health among WLWH include better quality data about causes of maternal death among WLWH, enhanced and harmonized program monitoring, and research and evaluation that contributes to improving: (1) clinical management of pregnant and postpartum WLWH, including assessment of the impact of expanded antiretroviral therapy on maternal mortality and morbidity, (2) integrated service delivery models, and (3) interventions to create an enabling social environment for women to begin and remain in care.

CONCLUSIONS

As the global community evaluates progress and prepares for new maternal mortality and HIV targets, addressing the needs of WLWH must be a priority now and after 2015. Research and evaluation on maternal health and HIV can increase collaboration on these 2 global priorities, strengthen political constituencies and communities of practice, and accelerate progress toward achievement of goals in both areas.

Program synergies and social relations: implications of integrating HIV testing and counselling into maternal health care on care seeking

Background

Women and children in sub-Saharan Africa bear a disproportionate burden of HIV/AIDS. Integration of HIV with maternal and child services aims to reduce the impact of HIV/AIDS. To assess the potential gains and risks of such integration, this paper considers pregnant women’s and providers’ perceptions about the effects of integrated HIV testing and counselling on care seeking by pregnant women during antenatal care in Tanzania.

Methods

From a larger evaluation of an integrated maternal and newborn health care program in Morogoro, Tanzania, this analysis included a subset of information from 203 observations of antenatal care and interviews with 57 providers and 190 pregnant women from 18 public health centers in rural and peri-urban settings. Qualitative data were analyzed manually and with Atlas.ti using a framework approach, and quantitative data of respondents’ demographic information were analyzed with Stata 12.0.

Results

Perceptions of integrating HIV testing with routine antenatal care from women and health providers were generally positive. Respondents felt that integration increased coverage of HIV testing, particularly among difficult-to-reach populations, and improved convenience, efficiency, and confidentiality for women while reducing stigma. Pregnant women believed that early detection of HIV protected their own health and that of their children. Despite these positive views, challenges remained. Providers and women perceived opt out HIV testing and counselling during antenatal services to be compulsory. A sense of powerlessness and anxiety pervaded some women’s responses, reflecting the unequal relations, lack of supportive communications and breaches in confidentiality between women and providers. Lastly, stigma surrounding HIV was reported to lead some women to discontinue services or seek care through other access points in the health system.

Conclusion

While providers and pregnant women view program synergies from integrating HIV services into antenatal care positively, lack of supportive provider-patient relationships, lack of trust resulting from harsh treatment or breaches in confidentiality, and stigma still inhibit women’s care seeking. As countries continue rollout of Option B+, social relations between patients and providers must be understood and addressed to ensure that integrated delivery of HIV counselling and services encourages women’s care seeking in order to improve maternal and child health.

"What they wanted was to give birth; nothing else": barriers to retention in option B+ HIV care among postpartum women in South Africa

BACKGROUND

Women initiating antiretroviral therapy during pregnancy have high rates of dropout, particularly after delivery. We aimed to identify challenges to postpartum retention in care under Option B+, which expands antiretroviral therapy access to all HIV-positive pregnant women regardless of CD4 count.

METHODOLOGY

We performed 2 semi-structured interviews (SSI, n = 50) and 1 focus group discussion (n = 8) with HIV-positive women at Witkoppen Health and Welfare Centre, a primary care facility in Johannesburg, South Africa, that is one of the only clinics offering Option B+ in South Africa.

RESULTS

Fifty women completed the SSI before delivery, and 48 (96%) completed the second SSI within 3 months of delivery. Median age was 28 years (interquartile range: 26-34); most women worked (62%) or had worked in the previous year (18%). Postpartum women attending HIV care perceived that barriers to HIV care after delivery among other women included the belief that mothers care more about the baby's health than their own (29.2%, 14/48), women were "ignorant" or "irresponsible" (16.7%, 8/48), negative clinic staff treatment (12.5%, 6/48), and denial or lack of disclosure of HIV status (10.4% each, 5/48). Experienced barriers included lack of money (18.0%, 9/50), work conflict (6.0%, 3/50), and negative staff treatment (6.0%, 3/50). During the focus group discussion, 3 main themes emerged: conflict with work commitment, negative treatment from health-care workers, and lack of disclosure related to stigma.

CONCLUSIONS

We identified a complex set of interconnected barriers to retaining postpartum women in HIV care under Option B+, including structural, personal, and societal barriers. The importance of postpartum HIV care for the mother's own health must be embraced by health-care workers and public health programs.