Evidence on the effectiveness of community-based primary health care in improving HIV/AIDS outcomes for mothers and children in low- and middle-income countries: Findings from a systematic review

Facilitators, barriers and service availability for delivering integrated care for the triple elimination of HIV, syphilis and hepatitis B vertical transmission in Uganda: a multi-site explanatory mixed methods study

BACKGROUND

Elimination of vertical transmission of HIV, syphilis and hepatitis B is part of the global aspiration to end the three infections as public health threats by 2030. Whereas global and national policy guidelines recommend integration of screening, prevention and treatment for the three infections in maternal and child health (MCH) service delivery points, progress has been slow. We aimed to explore the health system factors that facilitate and hinder optimal integration of triple elimination services within the MCH platforms.

METHODS

This was a cross-sectional, explanatory mixed methods multi-site study implemented in two regions of Uganda, conducted in July - August 2024. Firstly, we used an observation checklist to assess for the availability of services and commodities required for provision of triple elimination care at 20 health facilities (two regional referral hospitals, two general hospitals, two specialized outpatient TASO clinics, five HCIVs, eight HCIIIs and one HCII), and computed a percentage service and commodity availability score for each site, and average for the sites. We then used findings from this assessment to guide open-ended probing during key informant interviews and focus group discussions among ten key informants and 43 focus group discussion participants. Interviews and discussions were recorded, transcribed verbatim, and then analysed manually. We categorized responses as either facilitators or barriers and extracted quotes, by theme, based on the World Health Organization's health systems building blocks framework.

RESULTS

The average percentage score of service and commodity availability was 61.8% (range: 46.4-78.6%) in Acholi region and 66.1% (range: 53.6-78.6%) in Teso region. We found that presence of trained focal persons, district accountability fora, routine data collection and utilization, and availability of motivated community health workers facilitated triple elimination service integration. Key barriers included limited district health team engagement, frequent stock-outs of diagnostic and treatment commodities, health personnel shortages and high reporting burden.

CONCLUSIONS

Health facility service readiness and availability percentage scores differed across facilities and between the two regions. Several health system factors facilitate integrated service provision for elimination of HIV, syphilis and hepatitis B vertical transmission. This integration is, however, constrained by a number of health system barriers. Further implementation research could contribute to addressing the various health system constraints and adoption of strategies for service integration tailored to site contexts.

Opportunities to Optimize Outcomes of Diagnosis and Treatment of HIV and Syphilis in Pregnancy: the Quest to Eliminate Maternal and Vertical Transmission

BACKGROUND

There is an urgent need to improve interventions for HIV and syphilis in pregnancy to achieve elimination.

RESULTS

The tenets of vertical transmission strategies for HIV and syphilis overlap but have varying success due to differences in their transmission dynamics, diagnoses, and treatment. Key principles include prevention of maternal infection, screening and diagnosis early and throughout antenatal care, curative treatment (syphilis), viral load suppression (HIV), early infant diagnosis and treatment (HIV and congenital syphilis). We recommend improved guidelines, provider training and focused research and surveillance, including implementation studies to align HIV and syphilis screening and treatment during pregnancy. Opportunities to integrate syphilis screening and treatment into antenatal and HIV care enable providers to offer comprehensive maternal care.

CONCLUSION

Integrated HIV/syphilis services ensure a cohesive and person-centered approach, improving health outcomes through streamlined, efficient, and family-centered care pathways. We recommend key interventions to reduce HIV and syphilis in pregnancy and prevent vertical transmission.

Effectiveness of a multi-component facility-based intervention on HIV-related infant and maternal outcomes: results from the IMPROVE clustered randomized study

Introduction

Even in the context of widespread access to prevention of vertical HIV transmission (PVT) services, health system challenges compromise health outcomes for women living with HIV and their children. The "Integrated Management Team to Improve Maternal-Child Outcomes" (IMPROVE) study measured the effect of a package of facility-based interventions on PVT and maternal and child health (MCH) outcomes in Lesotho.

Methods

This cluster-randomized study included six facilities randomized to the standard-of-care and six to the IMPROVE intervention. The intervention included multidisciplinary teams of health care and community workers providing MCH support, training in patient-centered care, and additional home support. Pregnant women with and without HIV were enrolled at their first antenatal visit and followed through 12-24 months postpartum with their infants. Data were collected through participant interviews and routine medical record abstraction. Primary outcomes included viral suppression and adherence to antiretroviral therapy (ART) for women with HIV and repeat HIV testing for women without HIV. Analysis utilized generalized estimating equations (GEE) adjusted for intra-site correlation.

Results

Between July 2016 and February 2017, 614 pregnant women with HIV and 390 without HIV were enrolled. At 12 months postpartum, over 90% of women with HIV with viral load (VL) testing had a VL < 1,000 copies/mL; the intervention arm had a trend toward higher proportion with undetectable VL (< 50 copies/mL) compared to the control arm [83% versus 72%, OR 1.9 (95% CI 0.86-4.14)]. Women with HIV in the intervention arm had significantly higher odds of consistent adherence to ART [OR 1.81 (95% CI 1.03-3.18)], and women without HIV in the intervention arm had significantly higher odds of being re-tested for HIV prior to delivery [OR 1.95 (95% CI 1.23-3.08)].

Conclusion

Sites that implemented the IMPROVE intervention documented better PVT and MCH outcomes than sites implementing standard-of-care. This package of facility-based interventions is a promising and easily scalable model for improving coordination, quality, and uptake of services within the existing health system.

The effectiveness of rural community health workers in improving health outcomes during the COVID-19 pandemic: a systematic review

BACKGROUND

Rural community health workers [CHWs] play a critical role in improving health outcomes during non-pandemic times, but evidence on their effectiveness during the COVID-19 pandemic is limited. There is a need to focus on rural CHWs and rural health systems as they have limited material and human resources rendering them more vulnerable than urban health systems to severe disruptions during pandemics.

OBJECTIVES

This systematic review aims to describe and appraise the current evidence on the effectiveness of rural CHWs in improving access to health services and health outcomes during the COVID-19 pandemic in low-and middle-income countries [LMICs].

METHODS

We searched electronic databases for articles published from 2020 to 2023 describing rural CHW interventions during the COVID-19 pandemic in LMICs. We extracted data on study characteristics, interventions, outcome measures, and main results. We conducted a narrative synthesis of key results.

RESULTS

Fifteen studies from 10 countries met our inclusion criteria. Most of the studies were from Asia [10 of 15 studies]. Study designs varied and included descriptive and analytical studies. The evidence suggested that rural CHW interventions led to increased household access to health services and may be effective in improving COVID-19 and non-COVID-19 health outcomes. Overall, however, the quality of evidence was poor due to methodological limitations; 14 of 15 studies had a high risk of bias.

CONCLUSION

Rural CHWs may have improved access to health services and health outcomes during the COVID-19 pandemic in LMICs but more rigorous studies are needed during future pandemics to evaluate their effectiveness in improving health outcomes in different settings and to assess appropriate support required to ensure their impact at scale.

Enablers and barriers of community health programs for improved equity and universal coverage of primary health care services: A scoping review

BACKGROUND

Community health programs (CHPs) are integral components of primary health care (PHC) systems and support the delivery of primary care and allied health and nursing care services. CHPs are necessary platforms for delivering health services toward universal health coverage (UHC). There are limited prior studies on comprehensive evidence synthesis on how CHPs strengthen community health systems for the demand and supply of PHC services. Therefore, this scoping review synthesized existing evidence on the interlinkage between CHPs and the community health system and beyond for delivering and utilising PHC services toward UHC.

METHODS

We conducted a scoping review of research articles on CHPs. We identified research articles in six databases (PubMed/Medline, CINAHL, Scopus, Cochrane, Web of Science, and Embase) and Google Scholar using search terms under three concepts: CHPs, PHC, and UHC. Of the 3836 records identified, 1407 duplicates were removed, and 2346 were removed based on titles and abstracts. A total of 83 articles were eligible for the full-text review; of them, 18 articles were removed with reasons, and the other 16 were included through hand search. Themes were identified and explained using Sacks and colleagues' "Beyond the Building Block" framework.

RESULTS

A total of 81 studies were included in the final review. Studies described CHPs as foundations for community health system readiness for PHC services, including decentralization in the health sector, community-controlled governance, resource mobilization, ensuring health commodities (e.g., through community pharmacies), and information evidence. These foundational inputs mediate the actions of CHPs by partnership with community organizations and health workforces (e.g., community health workers). CHPs contributed to improved access to health services by providing health services in public health emergencies, affordable and comprehensive care, and modifying social determinants of health.

CONCLUSIONS

CHPs are platforms for implementing and delivering PHC services close to communities. They help to modify social determinants of health, promote health and wellbeing, reduce care costs, prevent disease progression, and reduce hospitalisation rates. CHPs are integral parts of community health systems and require investment to improve access to PHC services. Gaps and challenges of CHPs include inadequate funding, limited engagement of the private sector, poor quality of health services, and limited focus on non-communicable diseases (NCDs). Further implementation research is needed to mitigate the burden of NCDs. Health systems efforts focus on increasing resources (e.g., financial and human) required in CHPs to ensure the quality of PHC services provided through CHPs toward better service access, and reaching the unreached and achieve equity and universality of PHC services.

Enhanced peer-group strategies to support the prevention of mother-to-child HIV transmission leads to increased retention in care in Uganda: A randomized controlled trial

INTRODUCTION

Despite the scale-up of Option B+, long-term retention of women in HIV care during pregnancy and the postpartum period remains an important challenge. We compared adherence to clinic appointments and antiretroviral therapy (ART) at 6 weeks, 6, and and 24 months postpartum among pregnant women living with HIV and initiating Option B+. Women were randomized to a peer group support, community-based drug distribution and income-generating intervention called "Friends for Life Circles" (FLCs) versus the standard of care (SOC). Our secondary outcome was infant HIV status and HIV-free survival at 6 weeks and 18 months postpartum.

METHODS

Between 16 May 2016 and 12 September 2017, 540 ART-naïve pregnant women living with HIV at urban and rural health facilities in Uganda were enrolled in the study at any gestational age. Participants were randomized 1:1 to the unblinded FLC intervention or SOC at enrolment and assessed for adherence to the prevention of mother-to-child HIV transmission (PMTCT) clinic appointments at 6 weeks, 12, and 24 months postpartum, self-reported adherence to ART at 6 weeks, 6 and 24 months postpartum and supported by plasma HIV-1 RNA viral load (VL) measured at the same time points, retention in care through the end of study, and HIV status and HIV-free survival of infants at 18 months postpartum. The FLC groups were formed during pregnancy within 4 months of enrollment and held monthly meetings in their communites, and were followed up until the last group participant reached 24 months post delivery. We used Log-rank and Chi-Square p-values to test the equality of Kaplan-Meier survival probabilities and hazard rates (HR) for failure to retain in care for any reason by study arm.

RESULTS

There was no significant difference in adherence to PMTCT clinic visits or to ART or in median viral loads between FLC and SOC arms at any follow-up time points. Retention in care through the end of study was high in both arms but significantly higher among participants randomized to FLC (86.7%) compared to SOC (79.3%), p = 0.022. The adjusted HR of visit dropout was 2.4 times greater among participants randomized to SOC compared to FLC (aHR = 2.363, 95% CI: 1.199-4.656, p = 0.013). Median VL remained < 400 copies/ml in both arms at 6 weeks, 6, and 24 months postpartum. Eight of the 431 infants tested at 18 months were HIV positive (1.9%), however, this was not statistically different among mothers enrolled in the FLC arm compared to those in the SOC arm. At 18 months, HIV-free survival of children born to mothers in the FLC arm was significantly higher than that of children born to mothers in the SOC arm.

CONCLUSIONS

Our findings suggest that programmatic interventions that provide group support, community-based ART distribution, and income-generation activities may contribute to retention in PMTCT care, HIV-free survival of children born to women living with HIV, and ultimately, to the elimination of mother-to-child HIV transmission (EMTCT).

TRIAL REGISTRATION

NCT02515370 (04/08/2015) on ClinicalTrials.gov.

Protocol to develop a framework addressing barriers to utilization of elimination of mother- to -child transmission of HIV services among pregnant women and lactating mothers in Gauteng province

Mother-to-child transmission of HIV remains the primary contributor to HIV infections in children, globally. Despite the progress made to reduce new HIV infections in children, barriers to utilization of the Elimination of Mother-to-Child Transmission service remain the bottleneck that affects the program's effectiveness. This study aims to develop a framework to address barriers to the utilization of the Elimination of Mother-to-Child Transmission of HIV services among pregnant women and lactating mothers in Gauteng province. A convergent parallel mixed methods design will be employed in phases. Phase 1(a) quantitative will be collected from pregnant women and lactating mothers to describe barriers associated with poor utilization of elimination of mother-to-child transmission services and a potential strategy to facilitate EMTCT utilization; phase 1(b) qualitative data will be collected to explore reasons for poor utilization of EMTCT services and perceived strategy to enhance women's utilization of elimination of mother-to-child transmission services. Quantitative data will be analyzed using Stata software version 14.0 and qualitative data will be analyzed thematically and then results will be integrated. Phase 2: will focus on the development of a framework; Phase 3: will validate the developed framework. The conclusion and recommendations will be based on the findings of the study.

The Primary Healthcare Physician's Awareness and Engagement in Community-Based Medical Education: A Mixed Qualitative and Quantitative Study

BACKGROUND

Community-based medical education (CBME) is an essential component of medical education, where primary healthcare physicians (PCPs) play a crucial role. This study explores PCPs' awareness and engagement in CBME and investigates the factors influencing their participation.

METHODS

This mixed study was conducted in two phases. In the first phase, a qualitative study was conducted using semi-structured interviews with PCPs as well as thematic analysis related to their awareness and engagement in CBME. In the second phase, a quantitative survey was conducted on 72 PCPs' pre- and post-training programs.

RESULTS

Primary healthcare physicians had a positive attitude toward community-based medical education. The participants had an acceptable level of awareness and engagement, which increased substantially by (p-value = 0.03) and (p-value = 0.003), respectively. Logistical analysis indicated that non-Saudi physicians were more likely to participate in the CBME (p-value = 0.001). Professions and academic experiences influenced their willingness to engage and participate in CBME (OR = 7.5, p-value = 0.001) and (OR = 0.21, p-value = 0.001), respectively.

CONCLUSION

The study findings highlighted the importance of increased awareness and the factors that enhance PCPs' engagement in CBME. This positive perspective of the PCPs will help build effective partnerships and facilitate the extension of the curriculum to apply CBME.

Enhanced Peer-Group strategies to support prevention of Mother-to-Child HIV transmission leads to increased retention in care in Uganda: A Randomized controlled trial

Introduction

Despite scale up of Option B+, long-term retention of women in HIV care during pregnancy and the postpartum period remains an important challenge. We compared adherence to clinic appointments and antiretroviral therapy (ART) at different follow-up time points between enrolment and 24 months postpartum among pregnant women living with HIV and initiating Option B+ randomized to a peer group support, community-based drug distribution and income-generating intervention called "Friends for Life Circles" (FLCs) versus the standard of care (SOC).

Methods

Between 16 May 2016 and 12 September 2017, 540 ART-naïve pregnant women living with HIV at urban and rural health facilities in Uganda were enrolled in the study. Participants were randomized 1:1 to the FLC intervention or SOC and assessed for adherence to prevention of mother to child HIV transmission (PMTCT) clinic appointments at 6 weeks, 12 and 24 months postpartum, self-reported adherence to ART at 6 weeks, 6 and 24 months postpartum validated by plasma HIV-1 RNA viral load (VL) measured at the same time points, and HIV status and HIV-free survival of infants at 18 months postpartum. We used Log-rank and Chi-Square p-values to test the equality of Kaplan-Meier survival probabilities and hazard rates (HR) for failure to retain in care for any reason by study arm.

Results

There was no significant difference in adherence to PMTCT clinic visits or to ART or in median viral loads between FLC and SOC arms at any follow-up time points. Retention in care through the end of study was high in both arms but significantly higher among participants randomized to FLC (86.7%) compared to SOC (79.3%), p=0.022. The adjusted HR of visit dropout was 2.5 times greater among participants randomized to SOC compared to FLC (aHR=2.498, 95% CI: 1.417 - 4.406, p=0.002). Median VL remained < 400 copies/ml in both arms at 6 weeks, 6 and 24 months postpartum.

Conclusions

Our findings suggest that programmatic interventions that provide group support, community based ART distribution and income-generation activities may contribute to retention in PMTCT care, HIV-free survival of children born to women living with HIV, and to the elimination of mother to child HIV transmission (MTCT).

Determinants of viral load suppression among orphaned and vulnerable children living with HIV on ART in Tanzania

Introduction

In Tanzania, only 66% children 0–14 years living with HIV know their HIV status, 66% are on treatment while 47% of children on ART are virally suppressed. Although retention on ART and poor adherence remain a challenge for children living with HIV, orphans and vulnerable children (OVC) face a greater limitation of access to and utilization of comprehensive HIV care and treatment. In response to this, the current study assessed the determinants of viral load suppression (VLS) among OVC aged 0–14 years living with HIV enrolled in HIV interventions.

Methods

This was a cross-sectional study that used secondary data collected by the USAID Kizazi Kipya project in 81 district councils of Tanzania. Included in this study are 1,980 orphans and vulnerable children living with HIV (OVCLHIV) (0–14 years) enrolled and served by the project for 24 months. Data analysis involved multivariable logistic regression, with viral load suppression as the outcome of interest and HIV interventions as the main independent variables.

Results

The overall VLS rate among the OVCLHIV was 85.3%. This rate increased from 85.3, 89.9, 97.6 to 98.8% after 6, 12, 18, and 24 months of retention on ART, respectively. Similar rates were observed as the duration of adherence to ART increased. In the multivariable analysis, OVCLHIV attending people living with HIV (PLHIV) support groups were 411 times more likely to be virally suppressed than those not attending (aOR = 411.25, 95% CI 168.2–1,005.4). OVCLHIV with health insurance were 6 times more likely to achieve viral suppression than those without (aOR = 6.05, 95% CI 3.28–11.15). OVCLHIV with &gt;95% adherence to ART were 149 times more likely to be virally suppressed than those not adherent to ART (aOR = 148.96, 95% CI 42.6–520.6, p &lt; 0.001). Other significant factors included food security and family size. OVCLHIV reached by the different HIV community-based interventions were more likely to be virally suppressed than those who were not.

Discussion

To advance viral suppression, efforts should be made to ensure that all OVCLHIV are reached by community-based interventions as well as integrating food support in HIV treatment interventions.

A realist review of interventions targeting maternal health in low- and middle-income countries

Maternal mortality is disproportionately higher in low- and middle-income countries compared to other parts of the world. International research efforts are reflective of the urgency to improve global maternal outcomes. The existing literature of maternal health interventions in low- and middle-income countries targets a variety of populations and intervention types. However, there is a notable lack of systemic reviews that examine the wider contextual and mechanistic factors that have contributed to the outcomes produced by interventions. This article aims to use realist synthesis design to identify and examine the relationships between the contexts, mechanisms and outcomes of maternal health interventions conducted in low- and middle-income countries. This will inform evidence-based practice for future maternal health interventions. In May 2022, we searched four electronic databases for systematic reviews of maternal health interventions in low- and middle-income countries published in the last 5 years. We used open and axial coding of contexts, mechanisms and outcomes to develop an explanatory framework for intervention effectiveness. After eligibility screening and full-text analysis, 44 papers were included. The majority of effective interventions reported good healthcare system contexts, especially the importance of infrastructural capacity to implement and sustain the intervention. Most intervention designs used increasing knowledge and awareness at an individual and healthcare-provider level to produce intended outcomes. The majority of outcomes reported related to uptake of healthcare services by women. All mechanism themes had a relationship with this outcome. Health system infrastructure must be considered in interventions to ensure effective implementation and sustainability. Healthcare-seeking behaviours are embedded within social and cultural norms, environmental conditions, family influences and provider attitudes. Therefore, effective engagement with communities and families is important to create new norms surrounding pregnancy and delivery. Future research should explore community mobilization and involvement to enable tailored interventions with optimal contextual fit.

Antiretroviral therapy uptake and predictors of virological failure in patients with HIV receiving first-line and second-line regimens in Johannesburg, South Africa: a retrospective cohort data analysis

OBJECTIVE

This study described the demographics, treatment information and identified characteristics associated with virological failure and being lost to follow-up (LTFU) for patients with HIV on first-line and second-line antiretroviral therapy (ART) regimens in a large South African cohort.

DESIGN

A quantitative retrospective cohort study using secondary data analysis.

SETTING

Seven Johannesburg inner city facilities.

PARTICIPANTS

Unique records of 123 002 people with HIV receiving ART at any point in the period 1 April 2004 to 29 February 2020 were included.

MEASURES

Demographic characteristics, ART status, CD4 count information and retention status were collected and analysed as covariates of outcomes (viral load (VL) and LTFU).

RESULTS

Of the total study patients, 95% (n=1 17 260) were on a first-line regimen and 5% (n=5742) were on a second-line regimen. Almost two-thirds were female (64%, n=79 226). Most patients (60%, n=72 430) were initiated on an efavirenz-based, tenofovir disoproxil fumarate-based and emtricitabine-based regimen (fixed-dose combination). 91% (n=76 737) achieved viral suppression at least once since initiating on ART and 60% (n=57 981) remained in care as at the end of February 2020. Patients from the community health centre and primary healthcare clinics were not only more likely to be virally suppressed but also more likely to be LTFU. Patients on second-line regimens were less likely to reach viral suppression (adjusted OR (aOR)=0.26, CI=0.23 to 0.28) and more likely to be LTFU (aOR=1.21, CI=1.09 to 1.35). Being older (≥25 years) and having a recent CD4 cell count≥100 cells/µL were predictors of viral suppression and retention in patients on ART.

CONCLUSION

Patients on first-line regimens had higher VL suppression rates and were more likely to remain in care than those on a second-line regimen. Being younger and having low CD4 cell counts were associated with poor outcomes, suggesting priority groups for ART adherence support.

Improving access to maternal health services among rural hard-to-reach fishing communities in Uganda, the role of community health workers

OBJECTIVES

To explore whether community health worker household-based maternal health visits improve antenatal care and skilled birth attendance among hard-to-reach fishing villages on Lake Victoria, Uganda.

METHODS

This quasi-experimental 18-month prospective study involved 486 consenting women aged 15-49 years, who were pregnant or had a pregnancy outcome in the past 6 months, from 6 island fishing communities. The community health worker household-based intervention (community health workers' household visits to provide counseling, blood pressure measurement, anemia, and HIV testing) involved 243 women from three fishing communities. Random effects logistic regression was used to determine the association between the community health worker intervention and antenatal care and skilled birth attendance among women who had at least 5 months of pregnancy or childbirth at follow-up.

RESULTS

Almost all women accepted the community health worker intervention (90.9% (221/243)). Hypertension was at 12.5% (27/216) among those who accepted blood pressure measurements, a third (33.3% (9/27)) were pregnant. HIV prevalence was 23.5% (52/221). Over a third (34.2% (69/202)) of women tested had anemia (hemoglobin levels less than 11 g/dL). The community health worker intervention was associated with attendance of first antenatal care visit within 20 weeks of pregnancy (adjusted odd ratio = 2.1 (95% confidence interval 0.6-7.6)), attendance of at least four antenatal care visits (adjusted odd ratio = 0.9 (95% confidence interval 0.4-2.0)), and skilled birth attendance (adjusted odd ratio = 0.5 (95% confidence interval 0.1-1.5)), though not statistically significant.

CONCLUSION

Community health workers have a crucial role in improving early antenatal care attendance, early community-based diagnosis of anemia, hypertensive disorders, and HIV among women in these hard-to-reach fishing communities.

Effects of behavioural interventions on postpartum retention and adherence among women with HIV on lifelong ART: the results of a cluster randomized trial in Kenya (the MOTIVATE trial)

INTRODUCTION

Retention in HIV care and adherence to antiretroviral therapy (ART) during pregnancy and postpartum for women living with HIV (WLWH) are necessary to optimize health outcomes for women and infants. The objective of this study was to evaluate the impact of two evidenced-based behavioural interventions on postpartum adherence and retention in WLWH in Kenya.

METHODS

The Mother-Infant Visit Adherence and Treatment Engagement (MOTIVATE) study was a cluster-randomized trial enrolling pregnant WLWH from December 2015 to August 2017. Twenty-four health facilities in southwestern Kenya were randomized to: (1) standard care (control), (2) text-messaging, (3) community-based mentor mothers (cMM) or (4) text-messaging and cMM. Primary outcomes included retention in care and ART adherence at 12 months postpartum. Analyses utilized generalized estimating equations and competing risks regression. Per-protocol analyses examined differences in postpartum retention for women with high versus low levels of exposure to the interventions.

RESULTS

We enrolled 1331 pregnant WLWH (mean age 28 years). At 12 months postpartum, 1140 (85.6%) women were retained in care, 96 women (7.2%) were lost-to-follow-up (LTFU) and 95 (7.1%) were discontinued from the study. In intention-to-treat analyses, the relative risk of being retained at 12-months postpartum was not significantly higher in the intervention arms versus the control arm. In time-to-event analysis, the cMM and text arm had significantly lower rates of LTFU (hazard ratio 0.44, p = 0.019). In per-protocol analysis, the relative risk of 12-month postpartum retention was 24-29% higher for women receiving at least 80% of the expected intervention compared to the control arm; text message only risk ratio (RR) 1.24 (95% confidence interval [CI] 1.16-1.32, p<0.001), cMM only RR 1.29 (95% CI 1.21-1.37, p<0.001) and cMM plus text RR 1.29 (1.21-1.37, p<0.001). Women LTFU were younger (p<0.001), less likely to be married (p<0.001) and more likely to be newly diagnosed with HIV during pregnancy (p<0.001). Self-reported ART adherence did not vary by study arm.

CONCLUSIONS

Behavioural interventions using peer support and text messages did not appear to improve 12-month postpartum retention and adherence in intention-to-treat analyses. Higher levels of exposure to the interventions may be necessary to achieve the desired effects.