Mobility and Clinic Switching Among Postpartum Women Considered Lost to HIV Care in South Africa

Abstract

Objective Retention in HIV care, particularly among postpartum women, is a challenge to national antiretroviral therapy (ART) programs. Retention estimates may be underestimated due to unreported transfers. We explored mobility and clinic switching among patients considered lost to follow-up (LTFU). Design Observational cohort study. Methods Of 788 women initiating ART during pregnancy at six public clinics in Johannesburg, South Africa, 300 (38.1%) were LTFU (no visit ≥3 months). We manually searched for these women in the South African National Health Laboratory Services database to assess continuity of HIV care. We used geographic information systems tools to map mobility to new facilities. Results Over one–third (37.6%) of women showed evidence of continued HIV care after LTFU. Of these, 67.0% continued care in the same province as the origin clinic. Compared to those who traveled outside of the province for care, these same-province “clinic shoppers” stayed out-of-care longer [median 373 days (IQR: 175–790) vs. 175.5 days (IQR: 74–371)] and had a lower CD4+ cell count upon re-entry [median 327 cells/µL (IQR: 196–576) vs. 493 cells/µL (IQR: 213–557). When considering all women with additional evidence of care as engaged in care, cohort LTFU dropped from 38.1% to 25.0%. Conclusions We found evidence of continued care after LTFU and identified local and national clinic mobility among postpartum women. Laboratory records do not show all clinic visits and manual matching may have been under- or overestimated. A national health database linked to a unique identifier is necessary to improve reporting and patient care among highly mobile populations.

“I will leave the baby with my mother”: Long‐distance travel and follow‐up care among HIV‐positive pregnant and postpartum women in South Africa

“…It is possible that respondents were presenting an optimistic scenario about continuing their care after delivery in order to appeal to the interviewer, a limitation of self‐reported data. We recently found evidence of women continuing HIV care elsewhere in South Africa after initiating ART in Johannesburg, so women may indeed visit a clinic in their “home” area, particularly if their stay is extended. South Africa has a fragmented healthcare system, and the lack of national, networked electronic medical records means that a patient presenting at a new clinic cannot access her records from the first.…”

“…It is possible that respondents were presenting an optimistic scenario about continuing their care after delivery in order to appeal to the interviewer, a limitation of self-reported data. We recently found evidence of women continuing HIV care elsewhere in South Africa after initiating ART in Johannesburg, [20] so women may indeed and there I won't get the same treatment there that I get here, so I prefer that I continue with the way I am getting treatment now. " -Participant 112, site two "I will have maternity leave for four months and I will go home.…”

Linkage to care, mobility and retention of HIV‐positive postpartum women in antiretroviral therapy services in South Africa

“…However, these benefits hinge on women initiating ART, adhering to treatment, and remaining in care in the long term. Postpartum retention is a major challenge and there is an urgent need to understand how mobility may contribute to this .…”

“…These movements may introduce challenges to the continuum of HIV care and maternal health services . In South Africa, a recent analysis found that 38% of postpartum women who were considered lost to follow‐up (LTFU) at the clinic of ART initiation were in care elsewhere, and 33% received care outside of the province where they started ART . However, there are few data on the mobility of women with mandatory movement of ART care postpartum, and there is a need to understand the specific challenges related to linkage to care and mobility after delivery in these settings.…”

MicroCOSM: a model of social and structural drivers of HIV and interventions to reduce HIV incidence in high-risk populations in South Africa

“…The model allows for the possibility that individuals may interrupt ART, and also allows for the possibility that ART may be re-initiated after an interruption. Based on recent South African studies [373–375], we assume that the annual rate of interrupting ART is 0.25 and the annual rate of resuming ART after an interruption is 0.90. This implies that modelled ART interruptions are frequent but usually of relatively short duration.…”