Long term engagement in HIV care among postpartum women with perinatal HIV infection in the United States

Abstract

Despite growing literature on pregnancy in women with perinatally-acquired HIV infection (PHIV), little is known regarding HIV and reproductive health outcomes postpartum. We describe pregnancy, reproductive, and HIV care outcomes for 2 years postpartum among pregnant women with PHIV who delivered in a large urban health system in Atlanta, Georgia, USA from 2011-2016. We reviewed medical records of women with PHIV to estimate retention in HIV care (two HIV care visits or viral load measurements >90 days apart) and viral suppression (<200 copies/mL) at 12 and 24 months postpartum. Among 22 pregnant women with PHIV, 13 (59%) had a CD4 count of less than 300 cells/mm at the time of antenatal care entry; most (n = 13, 59%) women achieved viral suppression at time of delivery. Three quarters of women attended a postpartum HIV primary care visit, within an average of 193 (range 17-727) days. Only 4 (20%) women were retained and 3 (15%) virally suppressed at 12 postpartum, and 2 (12%) were retained and none virally suppressed at 24 months. Despite the unique challenges they face, multidisciplinary efforts are needed to engage women with PHIV during pregnancy and facilitate the transition to sustained HIV primary care in the postpartum period.

Postpartum HIV care continuum outcomes in the southeastern USA

“…(11, 32) Relying on surveillance system data may allow for improved capture of HIV care visits, in comparison to using single site institutional health records, if women transfer HIV care postpartum. However, our institution-based results were comparable to surveillance-based estimates from New York State (10, 24) and higher than those from Philadelphia (8), as well as, higher than estimates from the two other studies conducted at single institutions in Houston (32) and Atlanta (11). Additional regional differences in public health policies and infrastructure available to support pregnant and postpartum women and people living with HIV care may affect care retention.…”

“…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.…”

Improved Perinatal and Postpartum Human Immunodeficiency Virus Outcomes After Use of a Perinatal Care Coordination Team

“…In a single-center study in South Carolina, provision of HIV care during pregnancy by maternal-fetal medicine specialists with HIV training was effective in reducing maternal VL at delivery, but outcomes beyond the initial postpartum period did not significantly improve [9]. In our clinical model, we previously observed that disengagement in HIV care was common after delivery and similar to reports from other US settings, despite providing HIV care during pregnancy that was similar to the South Carolina study model, even during the preprogram period [2–4, 10]. Our care coordination team therefore improves on previously reported models of HIV/obstetric care by extending improved outcomes to at least 6 months post partum [9].…”

“…Attendance at an HIV care visit within 90 days of delivery has been shown to predict retention in HIV care and VS post partum [2, 3]. Our monthly care plans aimed for timely HIV care transition by preemptively identifying operational barriers and aligning women’s postpartum HIV visits with their infants’ colocated pediatric visits, resulting in improved VS at 6 months, with trends toward improved 12-month outcomes.…”

Being Lost to Follow-Up to Healthcare Appointments: A Concept Analysis

“…This hiatus may be unintentional or intentional. A hiatus could be unintentional and permanent, as in cases of deceased patients, or intentional and temporary in cases of patients who no longer find treatment beneficial (Meade et al, 2018) and only return when said symptoms of the starter event have exacerbated. This is often seen in cases of HIV patients who only seek treatment when the symptoms of the illness have exacerbated or other physiologic conditions arise.…”