Background With an increasing number of countries implementing Option B+ guidelines of lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women, there is urgent need to identify effective approaches for retaining this growing and highly vulnerable population in ART care. Methods Newly postpartum, breastfeeding women who initiated ART in pregnancy and met eligibility criteria were enrolled, and offered the choice of two options for postpartum ART care: (i) referral to existing network of community-based adherence clubs or (ii) referral to local primary health care clinic (PHC). Women were followed at study measurement visits conducted separately from either service. Primary outcome was a composite endpoint of retention in ART services and viral suppression [VS < 50 copies/mL based on viral load (VL) testing at measurement visits] at 12 months postpartum. Outcomes were compared across postpartum services using chi-square, Fisher’s exact tests and Poisson regression models. The primary outcome was compared across services where women were receiving care at 12 months postpartum in exploratory analyses. Results Between February and September 2015, 129 women (median age: 28.9 years; median time postpartum: 10 days) were enrolled with 65% opting to receive postpartum HIV care through an adherence club. Among 110 women retained at study measurement visits, 91 (83%) achieved the composite endpoint, with no difference between those who originally chose clubs versus those who chose PHC services. Movement from an adherence club to PHC services was common: 31% of women who originally chose clubs and were engaged in care at 12 months postpartum were attending a PHC service. Further, levels of VS differed significantly by where women were accessing ART care at 12 months postpartum, regardless of initial choice: 98% of women receiving care in an adherence club and 76% receiving care at PHC had VS < 50 copies/mL at 12 months postpartum ( p = 0.001). Conclusion This study found comparable outcomes related to retention and VS at 12 months postpartum between women choosing adherence clubs and those choosing PHC. However, movement between postpartum services among those who originally chose adherence clubs was common, with poorer VS outcomes among women leaving clubs and returning to PHC services. Trial registration ClinicalTrials.gov NCT02417675 , April 16, 2015 (retrospectively registered).
Objective: We examined the longitudinal association between women's exposure to intimate partner violence (IPV) and HIV viral load during pregnancy and postpartum.Design: Secondary analysis of an HIV-positive cohort enrolled during pregnancy at a South African antenatal clinic.Methods: Viral load was assessed at 10 study visits and analyzed continuously as log 10 copies/ml and suppression at less than 50 copies/ml. IPV was measured at three timepoints using behaviorally specific items. We used multivariate logistic regression to examine the association between IPV and viral suppression, and cross-lagged dynamic panel modeling (DPMs) to estimate the longitudinal association between IPV (lagged by 3-6 months) and log 10 viral load.Results: Of 471 women, 84% were virally suppressed by 6 weeks postpartum and 67% at 12 months postpartum. One-third reported IPV exposure. IPV victimization was not associated with viral suppression at delivery, but was associated with a reduced odds of viral suppression at 12 months postpartum (aOR ¼ 0.48, 95% CI ¼ 0.27-0.85). Findings were robust to sensitivity analyses at different timepoints and clinical cut-points. In DPMs, lagged IPV exposure was associated with higher log 10 viral load after controlling for past viral load, duration on ART, age, alcohol use, and gestation at study enrolment. Each standardized increase in IPV intensity was associated with higher log 10 viral load (standardized coefficient ¼ 0.12, 95% CI ¼ 0.05-0.23). Conclusion:Although viral suppression was widely achieved during pregnancy, suppression rates declined postpartum in this South African cohort. These data suggest IPV is longitudinally associated with elevated viral load postpartum. Interventions for reducing exposure to IPV are important for the health of women and may improve HIV care and treatment.
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.
Background There are few data on the utility of tenofovir diphosphate (TFV-DP) in dried blood spots to predict future viral load (VL) in postpartum women with HIV on antiretroviral therapy (ART). Methods We conducted a nested case-control study within a trial of postpartum ART delivery strategies. Participants started ART containing tenofovir disoproxil fumarate (TDF) in pregnancy, were <10 weeks postpartum and had a VL <400 copies/mL. VL and TFV-DP samples were taken 3-6 monthly over 24 months. Cases had >1 VL >20 copies/mL; controls were randomly sampled from women with persistent viral suppression (VS; VL <20 copies/mL). Generalized estimating equations were used to calculate likelihood odds ratios (LORs) for future VL >20 copies/mL by TFV-DP concentration at the preceding visit. Results Sixty-one cases and 20 controls contributed 365 DBS-VL pairs (median ART duration 16 months). Sensitivity and specificity of TFV-DP <700 fmol/punch to detect future viremia were 62.9% (95% CI, 54.7%–70.6%) and 89.7% [95% CI, 84.9%–93.4%], respectively. Adjusting for age, ART duration, previous VL and duration between the TFV-DP and VL measures, LORs of viremia for TFV-DP concentrations 350–699 and <350 fmol/punch versus TFV-DP >1850 fmol/punch were 3.5 (95% CI, 1.1–10.8; P=0.033) and 12.9 (95% CI, 3.6–46.6; P<0.0001), respectively. Including only samples taken during VS, the LOR of future viremia for TFV-DP concentration <350 fmol/punch versus TFV-DP >1850 fmol/punch was 9.5 (95% CI, 1.9–47.0). Conclusions TFV-DP concentrations in DBS were strongly associated with future viremia and appear useful to identify non-adherence and predict future elevated VL.
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