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.
Background Since 2010, the World Health Organization recommends lifelong antiretroviral treatment for all women living with HIV, and exclusive breastfeeding for six-months followed by breastfeeding until 24-months for all HIV positive mothers. Nevertheless, many mothers living with HIV do not initiate breastfeeding or stop prematurely, and many countries are still in the process of updating their national infant feeding guidelines to align with World Health Organization recommendations. We sought to understand uptake of breastfeeding and factors that influence decision-making regarding infant feeding in women living with and without HIV who receive ante- and postnatal care at a primary healthcare setting. Methods Programmatic data on infant feeding intentions and practices among women attending an ante-and postnatal clinic service at a primary care clinic in Johannesburg, South Africa were summarized using descriptive statistics. Qualitative interviews were conducted with 12 healthcare providers, 12 women living with HIV who were breastfeeding and 10 who were formula feeding. Interviews were analyzed using a content analysis approach. Results Pregnant women living with HIV were less likely to express an intent to breastfeed (71% vs 99%). During the first 6 months postpartum, mothers living with HIV were also less likely to exclusively breastfeed compared to HIV-negative mothers. Mixed messages during infant feeding counselling, social and economic factors, and fear of HIV transmission influenced women’s choices to initiate and continue breastfeeding. Conclusions As infant feeding guidelines for women living with HIV have evolved rapidly in the past 10 years, uniform messages on the low risk of mother-to-child transmission of HIV associated with breastfeeding while on ART and on introduction of complementary foods after 6 months of age are needed.
Objective To assess the acceptability and feasibility of a cell-phone based case manager intervention targeting HIV-infected pregnant women on highly-active antiretroviral therapy (HAART). Methods Pregnant women ≥36 weeks gestation attending antenatal care and receiving HAART through the Option B+ program at a primary care clinic in South Africa were enrolled into a prospective pilot intervention to receive text messages and telephone calls from a case manager through six weeks postpartum. Acceptability and feasibility of the intervention were assessed along with infant HIV testing rates and 10-week and 12-month postpartum maternal retention in care. Retention outcomes were compared to women of similar eligibility receiving care prior to the intervention. Results Fifty women were enrolled into the pilot from May-July 2013. Most (70%) were HAART-naive at time of conception and started HAART during antenatal care. During the intervention, the case manager sent 482 text messages and completed 202 telephone calls, for a median of 10 text messages and 4 calls/woman. Ninety-six percent completed the postpartum interview and 47/48 (98%) endorsed the utility of the intervention. Engagement in 10-week postpartum maternal HIV care was >90% in the pre-intervention (n=50) and intervention (n=50) periods; by 12-months retention fell to 72% and was the same across periods. More infants received HIV-testing by 10-weeks in the intervention period as compared to pre-intervention (90.0% vs. 63.3%, p<0.01). Conclusions Maternal support through a cell-phone based case manager approach was highly acceptable among South African HIV infected women on HAART and feasible, warranting further assessment of effectiveness.
Objective To describe the development and implementation of a safer conception service in a resource-limited setting. Methods Qualitative work to inform the design of a safer conception service was conducted with clients and providers at Witkoppen Health and Welfare Centre, a primary health center in Johannesburg, South Africa. Services began in July 2013, for HIV-affected participants planning conception within six months and included counseling about timed unprotected intercourse and home-based self-insemination, early initiation of combined antiretroviral therapy (cART) for HIV-infected individuals, pre-exposure prophylaxis (PrEP) for HIV-uninfected partners and circumcision for men. Participants were enrolled into an implementation science study evaluating method uptake, acceptability, and pregnancy and HIV transmission outcomes. Results Findings to-date from 51 qualitative participants and 128 clinical cohort participants (82 women and 46 men, representing 82 partnerships) are presented. All men were accompanied by female partners, whereas 56% of women attended with their male partner. Fifteen of 46 couples (33%) were in confirmed serodiscordant relationships, however of the 36 additional women attending alone, 56% were unaware of their partners’ HIV status or believed them to be HIV-uninfected. The majority of HIV-infected women (86%) and men (71%) were on cART at enrollment, however only 47% on cART were virally suppressed. Timed unprotected intercourse, self-insemination and cART were common choices for participants; few elected PrEP. Conclusions Lessons learned from early implementation demonstrate feasibility of safer conception services, however reaching discordant couples, cART-naïve infected partners, and men remain challenges. Creating demand for safer conception services among those at highest risk for HIV transmission is necessary.
Introduction: Implementation of safer conception services for HIV-affected couples within primary healthcare clinics in resource-limited settings remains limited. We review service utilization and safer conception strategy uptake during the first three years of Sakh’umndeni, which is a safer conception clinic in South Africa.Methods: Sakh’umndeni is located at Witkoppen Health and Welfare Centre, a high-volume primary healthcare clinic in northern Johannesburg. Men and women desiring to conceive in less than or equal to six months and in relationships in which one or both partners are living with HIV are eligible for safer conception services. Clients receive a baseline health assessment and counselling around periconception HIV risk reduction strategies and choose which strategies they plan to use. Clients are followed-up monthly. We describe client service utilization and uptake and continuation of safer conception methods. Factors associated with male partner attendance are assessed using robust Poisson regression.Results: Overall 440 individuals utilized the service including 157 couples in which both partners attended (55%) and 126 unaccompanied female partners. Over half of the couples (55%) represented were in serodiscordant/unknown status relationships. Higher economic status and HIV-negative status of the women increased male partner involvement, while HIV-negative status of the men decreased male involvement. Regarding safer conception strategies, uptake of antiretroviral therapy initiation (90%), vaginal self-insemination among partnerships with HIV-negative men (75%) and timed condomless intercourse strategies (48%) were variable, but generally high. Overall uptake of pre-exposure prophylaxis (PrEP) was 23% and was lower among HIV-negative men than women (7% vs. 44%, p < 0.001). Male medical circumcision (MMC) was used by 28% of HIV-negative men. Over 80% of clients took up at least one recommended safer conception strategy. Continuation of selected strategies over attempted conception attempts was >60%.Conclusions: Safer conception strategies are generally used by clients per recommendations. High uptake of strategies suggests that the proposed combination prevention methods are acceptable to clients and appropriate for scale-up; however, low uptake of PrEP and MMC among HIV-negative men needs improvement. Targeted community-based efforts to reach men unlinked to safer conception services are needed, alongside streamlined approaches for service scale-up within existing HIV and non-HIV service delivery platforms.
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