Frequency and factors associated with adherence to and completion of combination antiretroviral therapy for prevention of mother to child transmission in western Kenya

Abstract

IntroductionThe objective of this analysis was to identify points of disruption within the prevention of mother-to-child transmission (PMTCT) continuum from combination antiretroviral therapy (CART) initiation until delivery.MethodsTo address this objective, the electronic medical records of all antiretroviral-naïve adult pregnant women who were initiating CART for PMTCT between January 2006 and February 2009 within the Academic Model Providing Access To Healthcare (AMPATH), western Kenya, were reviewed. Outcomes of interest were clinician-initiated change or stop in regimen, disengagement from programme (any, early, late) and self-reported medication adherence. Disengagement was categorized as early disengagement (any interval of greater than 30 days between visits but returning to care prior to delivery) or late disengagement (no visit within 30 days prior to the date of delivery). The association between covariates and the outcomes of interest were assessed using bivariate (Kruskal-Wallis test for continuous variables and the Chi-square test for categorical variables) and multivariate logistic regression analysis.ResultsA total of 4284 antiretroviral-naïve pregnant women initiated CART between January 2006 and February 2009. The majority of women (89%) reported taking all of their medication at every visit. There were 18 (0.4%) deaths reported. Clinicians discontinued CART in 10 patients (0.7%) while 1367 (31.9%) women disengaged from care. Of those disengaging, 404 (29.6%) disengaged early and 963 (70.4%) late. In the multivariate model, the odds of disengagement decreased with increasing age (odds ratio [OR] 0.982; confidence interval [CI] 0.966–0.998) and increasing gestational age at CART initiation (OR 0.925; CI 0.909–0.941). Women receiving care at a district hospital (OR 0.794; CI 0.644–0.980) or tuberculosis medication (OR 0.457; CI 0.202–0.935) were less likely to disengage. The odds of disengagement were higher in married women (OR 1.277; CI 1.034–1.584). The odds of early disengagement decreased with increasing age at CART initiation (OR 0.902; CI 0.881–0.924). The odds of late disengagement decreased with increasing age at CART initiation (OR 0.936; CI 0.917–0.956). While they increased with higher CD4 counts at CART-initiation (OR 1.001; CI 1.000–1001) and in married women (OR 1.297; CI 1.000–1.695)ConclusionsIn a PMTCT programme embedded in an antiretroviral treatment programme with an active outreach department, the majority (67.4%) of women remained engaged and received uninterrupted prenatal CART.

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

“…Although retention-related outcome definitions vary between studies, these findings are broadly consistent with the results of previous publications indicating high levels of non-retention and/or non-adherence, particularly postpartum [ 15 , 26 , 28 – 30 ]. The rate of disengagement appeared higher in the ANC ART site post-delivery and lower in the ANC ART site prior to delivery, compared to rates among women in the general ART clinic.…”

“…Women initiating ART at later gestational ages have less time in HIV care and possibly less counselling than women who start ART earlier in pregnancy. This may influence retention, although the data are mixed [ 28 ]. While the underlying mechanisms require further investigation, it is also possible that late gestation at ART initiation reflects suboptimal health-seeking behaviour more generally [ 38 , 39 ].…”

Level of adherence and predictors of adherence to the Option B+ PMTCT programme in Tigray, northern Ethiopia

“…When compared to studies done in other countries of SubSaharan Africa, the adherence level in our study is slightly higher than those reported from Nnewi in Nigeria (78.3%), Lagos in Nigeria (80.6%), and Kisumu in Kenya (82%), but lower than that reported from western Kenya (89%). [21][22][23][24] This may reflect differences in the PMTCT option used, as most of these studies focused on Option A PMTCT; Option A is a different strategy for PMTCT care and support to Option B+. This difference could have had an effect on the adherence level, as the latter may be considered a simplified option.…”

A risk score to identify HIV-infected women most likely to become lost to follow-up in the postpartum period

“…We found that a lower level of education and being a housewife or unemployed predicted LTFU. Higher education, which may influence employment status, has been shown to improve cART adherence, as well as retention in care (Ayuo et al, 2013; Bardeguez et al, 2008; Panditrao et al, 2011). We also found that fewer ANC visits and shorter duration of cART during pregnancy predicted LTFU, which aligns with previous findings that late presentation to ANC is associated with postpartum LTFU (Panditrao et al, 2011).…”