A Systematic Review of Individual and Contextual Factors Affecting ART Initiation, Adherence, and Retention for HIV-Infected Pregnant and Postpartum Women

Abstract

BackgroundDespite progress reducing maternal mortality, HIV-related maternal deaths remain high, accounting, for example, for up to 24 percent of all pregnancy-related deaths in sub-Saharan Africa. Antiretroviral therapy (ART) is effective in improving outcomes among HIV-infected pregnant and postpartum women, yet rates of initiation, adherence, and retention remain low. This systematic literature review synthesized evidence about individual and contextual factors affecting ART use among HIV-infected pregnant and postpartum women.MethodsSearches were conducted for studies addressing the population (HIV-infected pregnant and postpartum women), intervention (ART), and outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. Individual and contextual enablers and barriers to ART use were extracted and organized thematically within a framework of individual, interpersonal, community, and structural categories.ResultsThirty-four studies were included in the review. Individual-level factors included both those within and outside a woman’s awareness and control (e.g., commitment to child’s health or age). Individual-level barriers included poor understanding of HIV, ART, and prevention of mother-to-child transmission, and difficulty managing practical demands of ART. At an interpersonal level, disclosure to a spouse and spousal involvement in treatment were associated with improved initiation, adherence, and retention. Fear of negative consequences was a barrier to disclosure. At a community level, stigma was a major barrier. Key structural barriers and enablers were related to health system use and engagement, including access to services and health worker attitudes.ConclusionsTo be successful, programs seeking to expand access to and continued use of ART by integrating maternal health and HIV services must identify and address the relevant barriers and enablers in their own context that are described in this review. Further research on this population, including those who drop out of or never access health services, is needed to inform effective implementation.

‘Let Food Be Your Medicine’: a model for HIV nutrition services

“…Not all hospitals were able to implement the program in a consistent manner: the inability of the Khon Kaen Hospital to host camps, due to non-disclosure of HIV status by PLHIV, being a prime example. This does however present an opportunity to address non-disclosure with PLHIV since the benefits of disclosure and consequent family support are well documented [32][33][34]. It should be noted, however, that the nutrition conference for HCP hosted by the Khon Kaen Hospital would appear to be a successful alternative to camps since it has resulted in the provision of nutrition services to some 700 PLHIV.…”

A qualitative analysis of the barriers to antiretroviral therapy initiation among children 2 to 18 months of age in Swaziland

“…Research focused on barriers to ART initiation among HIV-positive infants in resource-limited settings have identified several barriers, the most common barriers identified were financial constraints, fear of disclosing the child’s status to family members and friends, lack of spousal involvement and fear of stigma (Aluisio, Richardson, Bosire, Mbori-Ngacha, & Farquhar, 2011; Boender et al 2012; Byamugisha et al 2011; Coetzee, Kagee, & Bland, 2014; Donahue, Dube, & Dow, 2012; Feucht, Kinzer and Kruger, 2007; Hodgson et al 2014; Yeap et al 2010). Some of the mothers in these studies mentioned that if the husband or father knew of the child’s HIV status he would try to keep the child from taking the medications; therefore, many mothers keep the clinic visits and medication a secret, but this can prove to be challenging when the mother needs to administer the medicine to the child.…”

“…For caregivers who also live with HIV, many do not want the child to experience the discrimination or stigma that they have experienced. Problems associated with health facilities and provision of health care services to women and children living with HIV such as patient blaming, rudeness and breach of confidentiality have also been identified as barriers to ART initiation (Hodgson et al 2014; Yeap 2010)…”

Improved long-term antiretroviral treatment outcomes amongst patients receiving community-based adherence support in South Africa

“…Secondly, greater disclosure, reductions in perceived stigma, and improvement in psychosocial problems likely contribute to improved adherence (Hodgson et al, 2014;Lowther, Selman, Harding, & Higginson, 2014). Thirdly, community support widens the "community safety net" and harnesses social capital, a powerful social force determining ART patient retention (Foster, 2007;Hickey et al, 2015;Ware et al, 2009).…”