Improving postpartum retention in care for women living with HIV in the United States

Abstract

Research findings have consistently demonstrated that women living with HIV in the United States and globally experience declines in medication adherence and retention in care after giving birth. A number of studies have identified factors associated with postpartum retention in care, but the evidence base for interventions to address the problem and close this gap in the HIV care continuum is limited. Furthermore, the majority of studies have been conducted in low-resource or moderate-resource countries and may be less applicable or require adaptation for use in high resource countries. In the United States, up to two-thirds of women drop out of care after delivery and are unable to maintain or achieve viral suppression postpartum, at a time when maternal and pediatric health are closely linked. We conducted a critical review of the literature to identify existing gaps regarding maternal retention in the United States and conceptualize the problem through the lens of the integrated and ecological models of health behavior. This review describes existing barriers and facilitators to retention in HIV care postpartum from published studies and suggests steps that can be taken, using a multilevel approach, to improve maternal retention. We propose five core action steps related to increasing awareness of the problem of poor postpartum retention, addressing needs for improved care coordination and case management, and using novel approaches to adapt and implement peer support and technology-based interventions to improve postpartum retention and clinical outcomes of women living with HIV.

“In the United States, we say, ‘No breastfeeding,’ but that is no longer realistic”: provider perspectives towards infant feeding among women living with HIV in the United States

“…The survey revealed that 70% of provider respondents were concerned about post‐partum ART adherence, although this emerged only as a secondary finding in the semi‐structured interviews. Several retrospective cohort U.S. studies demonstrate poor post‐partum retention in care and viral suppression , which represents real‐world scenarios in contrast to the highly supported and well‐resourced breastfeeding clinical trials. The WHO acknowledges this concern and advises skilled counselling and adherence support for post‐partum women .…”

Postpartum HIV care continuum outcomes in the southeastern USA

“…Policies including health care coverage through Medicaid and safety net programs for those without health insurance may be relevant to observed differences, including the relatively higher retention rates observed in New York State and in our cohort. (10,12,24) This study included WLWH living in North Carolina which is disproportionately affected by the HIV epidemic, with high HIV-related morbidity and mortality rates in comparison to other US regions. (25) In response, the North Carolina Division of Public Health has long supported innovative public health programs including early HIV detection and linkage to HIV care.…”

“…Although limited, the studies conducted in the United States to date suggest that women may not receive optimal HIV care postpartum. (8)(9)(10)(11)(12) Furthermore, postpartum ART adherence may also be lower than ART adherence during pregnancy leading to lower virologic suppression rates following childbirth. (13)(14)(15)(16)(17) The HIV care continuum model describes the stages from HIV testing and diagnosis through HIV RNA suppression, with recent United States estimates suggesting that as few as 30% of people living with HIV (PLWH), and 26% of women living with HIV (WLWH), have undetectable HIV RNA levels.…”

HIV care continuum outcomes of pregnant women living with HIV with and without depression

“…The lack of association between depression and care continuum outcomes in the perinatal period that we observed is likely due to the support provided by PCM or through PCM initiated linkage to mental health programs or other community resources. Interventions aimed at improving retention and viral suppression of pregnant or postpartum WLWH are lacking (Momplaisir et al, 2018); it is therefore important to note that WLWH who receive intensive PCM do not experience worse outcomes than women with no depression.…”

“…Depression can be a strong predictor of non-adherence to antiretroviral therapy (ART) (Ammassari, Antinori, Aloisi, Trotta, & Murri, 2004; Springer, Dushaj, & Azar, 2012) and may contribute to poor maternal outcomes at delivery and postpartum (Alder, Fink, Bitzer, Hösli, & Holzgreve, 2007; Goedhart et al, 2010). Previous studies have shown that WLWH have poor viral suppression at delivery (Momplaisir et al, 2015) and poor retention in HIV care postpartum (Adams, Brady, Michael, Yehia, & Momplaisir, 2015; Momplaisir, Storm, Nkwihoreze, Jayeola, & Jemmott, 2018). The impact of depression on HIV care outcomes during pregnancy and postpartum has not been well described.…”