Disengagement of HIV‐positive pregnant and postpartum women from antiretroviral therapy services: a cohort study

Abstract

IntroductionRecent international guidelines call for expanded access to triple-drug antiretroviral therapy (ART) in HIV-positive women during pregnancy and postpartum. However, high levels of non-adherence and/or disengagement from care may attenuate the benefits of ART for HIV transmission and maternal health. We examined the frequency and predictors of disengagement from care among women initiating ART during pregnancy in Cape Town, South Africa.MethodsWe used routine medical records to follow-up pregnant women initiating ART within prevention of mother-to-child transmission of HIV services in Cape Town, South Africa. Outcomes assessed through six months postpartum were (1) disengagement (no attendance within 56 days of a scheduled visit) and (2) missed visits (returning to care 14–56 days late for a scheduled visit).ResultsA total of 358 women (median age, 28 years; median gestational age, 26 weeks) initiated ART during pregnancy. By six months postpartum, 24% of women (n=86) had missed at least one visit and an additional 32% (n=115) had disengaged from care; together, 49% of women had either missed a visit or had disengaged by six months postpartum. Disengagement was more than twice as frequent postpartum compared to in the antenatal period (6.2 vs. 2.4 per 100 woman-months, respectively; p<0.0001). In a proportional hazards model, later gestational age at initiation (HR: 1.04; 95% CI: 1.00–1.07; p=0.030) and being newly diagnosed with HIV (HR: 1.57; 95% CI: 1.07–2.33; p=0.022) were significant predictors of disengagement after adjusting for patient age, starting CD4 cell count and site of ART initiation.ConclusionsThese results demonstrate that missed visits and disengagement from care occur frequently, particularly post-delivery, among HIV-positive women initiating ART during pregnancy. Women who are newly diagnosed with HIV may be particularly vulnerable and there is an urgent need for interventions both to promote retention overall, as well as targeting women newly diagnosed with HIV during pregnancy.

Outcomes of antiretroviral therapy among younger versus older adolescents and adults in an urban clinic, Zimbabwe

“…This may be because younger adults are mobile and often migrate for work, 29 or, as most of the young adults were females identified in ANC, they may have been lost to care in the postpartum period, as shown in one South African study. 30 Among adults, we found that initiation with d4T was associated with greater attrition in comparison to TFV, probably because TFV has been shown to be safer and more effective than both d4T 21 and ZDV. 31 Both d4T and ZDV have been associated with greater mortality compared to TFV.…”

The Role of Maternal, Health System, and Psychosocial Factors in Prevention of Mother-to-Child Transmission Failure in the Era of Programmatic Scale Up in Western Kenya: A Case Control Study

“…These newly diagnosed women likely represent a vulnerable group who are yet to come to terms with their HIV-positive diagnosis and overcome barriers such as stigma and lack of disclosure. 21 They may also have additional challenges to taking the ART medications as prescribed, especially if health care workers manage them in the same way that they manage women who were diagnosed with HIV before pregnancy. 22 Increased counseling may provide these women with the psychosocial support required to navigate these barriers and equip them with information about ART and the need for adherence.…”

“…35 Strategies may also include patient-selected community-based treatment supporters to improve understanding of HIV and PMTCT particularly for newly diagnosed women. 21,39 Home visits by trained nurses or community health workers can be introduced to circumvent challenges such as expensive transport, long waiting lines, and discordant mother-infant clinic appointments, 36 and by extension enhance maternal and child outcomes. 39,41 Our finding that stigma and other psychosocial factors did not increase the odds of MTCT differs from prior studies in the region that have found that fears of HIV-related stigma and discrimination negatively impact service uptake and adherence at each step of the PMTCT cascade.…”

Exploring Perceptions and Practices of Biomedical Norms during Exclusive Breastfeeding among HIV-Positive Lactating Mothers in Mozambique

“…Studies [27,28] have also reported low adherence to antiretroviral therapy during postpartum period. The most common impediments are economic, emotional stress, depression, lack of HIV disclosure and pill burden [27,29,30].…”