Improving Retention in Care Among Pregnant Women and Mothers Living With HIV: Lessons From INSPIRE and Implications for Future WHO Guidance and Monitoring

Abstract

Identifying women living with HIV, initiating them on lifelong antiretroviral treatment (ART), and retaining them in care are among the important challenges facing this generation of health care managers and public health researchers. Implementation research attempts to solve a wide range of implementation problems by trying to understand and work within real-world conditions to find solutions that have a measureable impact on the outcomes of interest. Implementation research is distinct from clinical research in many ways yet demands similar standards of conceptual thinking and discipline to generate robust evidence that can be, to some extent, generalized to inform policy and service delivery. In 2011, the World Health Organization (WHO), with funding from Global Affairs Canada, began support to 6 implementation research projects in Malawi, Nigeria, and Zimbabwe. All focused on evaluating approaches for improving rates of retention in care among pregnant women and mothers living with HIV and ensuring their continuation of ART. This reflected the priority given by ministries of health, program implementers, and researchers in each country to the importance of women living with HIV returning to health facilities for routine care, adherence to ART, and improved health outcomes. Five of the studies were cluster randomized controlled trials, and 1 adopted a matched cohort design. Here, we summarize some of the main findings and key lessons learned. We also consider some of the broader implications, remaining knowledge gaps, and how implementation research is integral to, and essential for, global guideline development and to inform HIV/AIDS strategies.

Effectiveness of a Lay Counselor–Led Combination Intervention for Retention of Mothers and Infants in HIV Care: A Randomized Trial in Kenya

“…Our results show that lay counselors who are trained, mentored, and provided with the necessary tools and job aids can improve PMTCT service delivery and outcomes, similar to findings from other studies. 15,19 Our study adds to the growing literature that lay workers can assume a multifaceted set of activities including sending phone and SMS reminders, patient facilitation, and comprehensive health education both during the antenatal and postpartum period.…”

“…Our retention (81.2%) of mother–infant pairs at 6 months postpartum in the intervention arm is within the range for studies that have evaluated single interventions, most for a much shorter duration of time. 10,11,19,29–31 We found only 3 studies that have evaluated combination interventions, integrated clinics and male involvement in Nigeria, task shifting and home visits by peer counselors in Uganda, and integrated mother–infant pair clinics and SMS reminders for community health care workers in Malawi. 32–34 In the 2 latter studies, the interventions were not superior to the SOC, probably because of high uptake of services in both the groups.…”

“…11–18 Furthermore, most studies have assessed a single intervention, rather than examining a combination of interventions, potentially limiting applicability in the field and capacity to address the multiple gaps across the PMTCT cascade. 19 Finally, while attrition is acknowledged as a critical outcome in general adult and pediatric populations, few PMTCT studies report attrition, and it has not been measured in any randomized controlled PMTCT intervention studies. There remains an urgent need to determine the most effective strategies to reduce attrition and improve health outcomes for pregnant women and their infants.…”

Tonse Pamodzi: Developing a combination strategy to support adherence to antiretroviral therapy and HIV pre-exposure prophylaxis during pregnancy and breastfeeding

“…If unaddressed, poor adherence to ART can lead to antiretroviral drug resistance, treatment failure, and HIV transmission [ 14 , 17 – 19 ]. While evidence-based interventions have improved ART adherence during pregnancy and breastfeeding [ 11 ], there remains a need for resource-appropriate and scalable approaches. Without feasible, acceptable, effective, and sustainable ART adherence support strategies, local governments will not realize the full potential of their PMTCT investments.…”

Video-Based Intervention for Improving Maternal Retention and Adherence to HIV Treatment: Patient Perspectives and Experiences

“…In Malawi, the first nation to implement lifelong ART for PWLHIV, close to 90% of PWLHIV received ART, but 12 months after ART start, only 74 % remained alive and in care [ 10 ]. This issue is not unique to Malawi, as evidence from other countries within SSA demonstrates shortfalls in adherence and retention in the setting of preventing vertical HIV transmissions [ 11 , 12 , 13 , 14 , 15 , 16 , 17 ].…”