Acceptability and challenges of rapid ART initiation among pregnant women in a pilot programme, Cape Town, South Africa

Abstract

Maternal antiretroviral therapy (ART) is a critical intervention in the prevention-of-mother-to child transmission (PMTCT) of HIV. In South Africa, many HIV-infected pregnant women commence ART late in pregnancy, and as a result, the duration of ART prior to delivery is often insufficient to prevent vertical transmission. To address this, we designed an intervention for the rapid initiation of ART in pregnancy (RAP), where patient's ART preparation occurred during rather than before treatment commencement. Here we report on the acceptability and the challenges of the RAP programme. We conducted 7 key informant and 27 semi-structured interviews with RAP participants. Participants were purposefully selected based on ART-eligibility and stage in the pregnancy to post-partum continuum. Interviews were conducted in participants' home language by trained fieldworkers, with key informant interviews conducted by the study investigators. The data were analysed using a framework analysis approach. Rapid initiation in pregnancy was acceptable to the majority of programme participants and protection of the woman's unborn child was the primary motivation for starting treatment. The key barrier was the limited time to accept the dual challenges of being diagnosed HIV-positive and eligible for life-long ART. Truncated time also limited the opportunity for disclosure to others. Despite these and other barriers, most women found the benefits of rapid ART commencement outweighed the challenges, with 91% of women initiated onto ART starting the same day treatment eligibility was determined. Many participants and key informants identified the importance of counseling and the need to make an informed, independent choice on the timing of ART initiation, based on individual circumstances. Acceptance of ART-eligibility improved with time on the programme, however, as women's principal reason for initiating ART was protection of the unborn child, monitoring and supporting adherence during the post-partum period will be critical.

Fertility Decision-Making Among Kenyan HIV-Serodiscordant Couples Who Recently Conceived: Implications for Safer Conception Planning

“…Even in relationships that lack male partner support or HIV status disclosure, knowledge and awareness of safer conception options among women who are motivated to protect their future baby may facilitate discussions about safer conception and use of safer conception strategies. [40][41][42] Both HIV-infected men and women with serodiscordant partners have been receptive to safer conception counseling as part of routine HIV care. 43 Integration of safer conception counseling and discussion of fertility desires into routine HIV care provides opportunities to introduce safer conception strategies prior to pregnancy attempts, especially to HIVinfected men who are already established in HIV care and may not otherwise receive information on safer conception.…”

Rapid initiation of antiretroviral therapy for people living with HIV

“…The HIV continuum of care is however a complex process, in which every cascade step is influenced by multiple factors, as illustrated in our conceptual model (Figure 1). The feasibility and acceptability of rapid ART initiation depends on various health system and provider factors, such as: staffing levels, skills, infrastructure and equipment, which vary across settings (Attawell 2003); as well as: social; economic; cultural; and individual drivers, including acceptance and motivation to take ART (Black 2013; Black 2014; Katirayi 2016). Initiating treatment before baseline screening test results are available could also result in a higher frequency of adverse events which may result in disengagement (Abay 2015; Chan 2016; Pilcher 2017), and regimen modification (Pilcher 2017).…”

Sexual Practices, Fertility Intentions, and Awareness to Prevent Mother-to-Child Transmission of HIV Among Infected Pregnant Women at the Yaounde Central Hospital

“…Antiretroviral therapy (ART) has been acknowledged as vital in the control and prevention of the HIV pandemic 7, 8, 9, 10, 11. With the availability of treatment options, HIV infection is increasingly becoming a chronic but manageable disease; and for infected women intending to conceive, flexible approaches such as assisted reproductive techniques are available in most developed countries 12, 13.…”