Long-Term Outcomes of HIV-Infected Women Receiving Antiretroviral Therapy After Transferring Out of an Integrated Maternal and Child Health Service in South Africa

Abstract

Background: Integrated maternal and child health (MCH) services improve women's postpartum antiretroviral therapy (ART) outcomes during breastfeeding; however, long-term outcomes after transfer to general ART services remain unknown. Methods: The MCH-ART trial demonstrated that maternal retention and viral suppression at 12-months postpartum were improved significantly among women randomized to integrated MCH services continued in the antenatal clinic through cessation of breastfeeding (MCH-ART arm) compared with immediate transfer to general ART services postpartum (standard of care). We reviewed electronic health records for all women who participated in the MCH-ART trial to ascertain retention and gaps in care and invited all women for a study visit 36- to 60-months postpartum including viral load testing. Results: Of 471 women in MCH-ART, 450 (96%) contributed electronic health record data and 353 (75%) completed the study visit (median 44-month postpartum). At this time, outcomes were identical in both trial arms: 67% retained in care (P = 0.994) and 56% with viral loads <50 copies/mL (P = 0.751). Experiencing a gap in care after delivery was delayed in the MCH-ART arm with 17%, 36%, and 45% of women experienced a gap in care by 12-, 24-, and 36-months postpartum compared with 35%, 48%, and 57% in the standard of care arm, respectively. Conclusions: The benefits of integrated maternal HIV and child health care did not persist after transfer to general ART services. The transfer of women postpartum to routine adult care is a critical period requiring interventions to support continuity of HIV care.

Early post-partum viremia predicts long-term non-suppression of viral load in HIV-positive women on ART in Malawi: Implications for the elimination of infant transmission

“…We additionally report that approximately 80% retained in this cohort had durable VLS to 24 months, which will confer increased benefit in preventing HIV transmission during breastfeeding and subsequent pregnancies, as well as preservation of health in mothers. However, the proportion of women achieving durable VLS in our study is higher than that reported in South Africa (70% (<50 copies/mL) at 12 months and 56% at 36-60 months (median 44 months post-partum)) [18] and in Kenya (67% (<1000 copies/mL) at 12months) [19]. These differences may be explained by diverse proportions of retention and loss to follow-up across these different settings, including that women retained to 24 months in our study may not reflect population-level VLS among all post-partum Malawian women.…”

Accelerating progress towards the elimination of mother‐to‐child transmission of HIV: a narrative review

“…Given the importance of rapid ART initiation, additional support should be given to new starters so the risk for early default is minimized. Other studies of integrated HIV and maternal‐child healthcare have largely echoed these study findings, highlighting the importance of such integrated care models over the course of pregnancy and breastfeeding to promote adherence and programme retention [60‐64].…”

Approaches to transitioning women into and out of prevention of mother‐to‐child transmission of HIV services for continued ART: a systematic review

“…Although ART initiation was substantially higher when ART was integrated into ANC, retention in ART care at six and twelve months after ART initiation was similar: 89% and 87% of women who transferred postpartum were retained at six and twelve months, respectively, compared to 80% retention at both six and twelve months among women who transferred to start ART during pregnancy [15]. When comparing transition to ART services at six weeks postpartum to transition after cessation of breastfeeding in South Africa, gaps in care were observed soon after transition in both groups with similar trajectories [27]. By 36 months postpartum, 57% of women transferred at six weeks and 45% of women transferred after weaning had experienced a gap in care.…”

“…Studies that reported retention in care after a successful transition observed that once women had transitioned to a new clinic, the majority (>60% across studies) were retained, underscoring that the transition is the vulnerable point [15,24,26,40]. Similarly, a study comparing transition point 3 with transition at six weeks postpartum versus after weaning found similar trajectories in time to loss from care in both groups after transition [27].…”