A group randomized trial using an appointment system to improve adherence to ART at reproductive and child health clinics implementing Option B+ in Tanzania

Improving retention in antenatal and postnatal care: a systematic review of evidence to inform strategies for adolescents and young women living with HIV

INTRODUCTION

Young pregnant and postpartum women living with HIV (WLHIV) are at high risk of poor outcomes in prevention of mother-to-child transmission services. The aim of this systematic review was to collate evidence on strategies to improve retention in antenatal and/or postpartum care in this population. We also conducted a secondary review of strategies to increase attendance at antenatal care (ANC) and/or facility delivery among pregnant adolescents, regardless of HIV status, to identify approaches that could be adapted for adolescents and young WLHIV.

METHODS

Selected databases were searched on 1 December 2020, for studies published between January 2006 and November 2020, with screening and data abstraction by two independent reviewers. We identified papers that reported age-disaggregated results for adolescents and young WLHIV aged <25 years at the full-text review stage. For the secondary search, we included studies among female adolescents aged 10 to 19 years.

RESULTS AND DISCUSSION

Of 37 papers examining approaches to increase retention among pregnant and postpartum WLHIV, only two reported age-disaggregated results: one showed that integrated care during the postpartum period increased retention in HIV care among women aged 18 to 24 years; and another showed that a lay counsellor-led combination intervention did not reduce attrition among women aged 16 to 24 years; one further study noted that age did not modify the effectiveness of a combination intervention. Mobile health technologies, enhanced support, active follow-up and tracing and integrated services were commonly examined as standalone interventions or as part of combination approaches, with mixed evidence for each strategy. Of 10 papers identified in the secondary search, adolescent-focused services and continuity of care with the same provider appeared to be effective in improving attendance at ANC and/or facility delivery, while home visits and group ANC had mixed results.

CONCLUSIONS

This review highlights the lack of evidence regarding effective strategies to improve retention in antenatal and/or postpartum care among adolescents and young WLHIV specifically, as well as a distinct lack of age-disaggregated results in studies examining retention interventions for pregnant WLHIV of all ages. Identifying and prioritizing approaches to improve retention of adolescents and young WLHIV are critical for improving maternal and child health.

Longitudinal analysis of client appointment adherence under Universal Test and Treat strategy: A stepped-wedge trial

OBJECTIVES

Universal Test and Treat (UTT) strategies are being adopted across sub-Saharan Africa based on clinical benefits to morbidity and mortality and to attain targets of the Joint United Nations Programme on HIV/AIDS (UNAIDS). Universal Test and Treat is expected to change the client population at clinics, due to more asymptomatic HIV clients initiating antiretroviral therapy (ART). We assessed the impact of UTT on client appointment adherence at 14 government-managed health facilities in Eswatini's public sector health system.

METHODS

We assessed the impact of UTT on client adherence to appointment schedules from 2014 to 2017 in a stepped-wedge trial. Repeated measures analysis was used to assess adherence to each scheduled appointment (primary definition: presenting for care within 7 days after the scheduled appointment), adjusting for time, age, sex, stage, marital status, ART status and facility.

RESULTS

Among 3354 clients (62.1% female; 57.4% < 35 years), a median (interquartile range) of 10 (6-15) appointments were scheduled during follow-up. In a multivariable-adjusted model, appointment adherence was significantly greater in clients who were female [odds ratio (OR) = 1.38, 95% confidence interval (CI): 1.25-1.52], older (e.g. 40 to < 50 years vs. < 20 years; OR = 1.45, 95% CI: 1.00-2.09), married (OR = 1.31, 95% CI: 1.19-1.44), had lower WHO stage at study enrolment (1-2 vs. 3-4: OR = 1.26, 95% CI: 1.13-1.41), and were currently on ART (OR = 3.55, 95% CI: 2.62-4.82). However, UTT strategy was not significantly associated with client adherence to scheduled appointments (OR = 1.02, 95% CI: 0.72-1.45).

CONCLUSIONS

Despite transitioning to UTT, there was no change in visit adherence, a reassuring finding given the large volume of clients currently being initiated at earlier stages of HIV.

Shifting to the long view: engagement of pregnant and postpartum women living with HIV in lifelong antiretroviral therapy services

Introduction: The advent of policies promoting lifelong antiretroviral therapy (ART) for all pregnant and postpartum women living with HIV has shifted focus from short-term prevention of mother-to-child transmission (PMTCT) to lifelong engagement in ART services. However, disengagement from care threatens the long-term treatment and prevention benefits of lifelong ART. Areas covered: A framework for considering the unique aspects of ART for pregnant and postpartum women is presented along with a review of the literature on maternal engagement in care in sub-Saharan Africa and a discussion of potential interventions to sustain engagement in lifelong ART. Expert opinion: Engaging women and mothers in ART services for life is critical for maternal health, PMTCT, and prevention of sexual transmission. Evidence-based interventions exist to support engagement in care but most focus on periods of mother-to-child transmission risk. In the long term, life transitions and health-care transfers are inevitable. Thus, interventions that can reach beyond a single facility or provide a bridge between health services should be prioritized. Multicomponent interventions will also be essential to address the numerous intersecting barriers to sustained engagement in ART services.