Prevention of mother-to-child transmission of HIV: Postpartum adherence to Option B+ until 18 months in Western Uganda

Abstract

Since 2012, the WHO recommends Option B+ for the prevention of mother-to-child transmission of HIV. This approach entails the initiation of lifelong antiretroviral therapy in all HIV-positive pregnant women, also implying protection during breastfeeding for 12 months or longer. Research on long-term adherence to Option B+ throughout breastfeeding is scarce to date. Therefore, we conducted a prospective observational cohort study in Fort Portal, Western Uganda, to assess adherence to Option B+ until 18 months postpartum. In 2013, we recruited 67 HIV-positive, Option B+ enrolled women six weeks after giving birth and scheduled them for follow-up study visits after six, twelve and 18 months. Two adherence measures, self-reported drug intake and amount of drug refill visits, were combined to define adherence, and were assessed together with feeding information at all study visits. At six months postpartum, 51% of the enrolled women were considered to be adherent. Until twelve and 18 months postpartum, adherence for the respective follow-up interval decreased to 19% and 20.5% respectively. No woman was completely adherent until 18 months. At the same time, 76.5% of the women breastfed for ≥12 months. Drug adherence was associated with younger age (p<0.01), lower travel costs (p = 0.02), and lower number of previous deliveries (p = 0.04). Long-term adherence to Option B+ seems to be challenging. Considering that in our cohort, prolonged breastfeeding until ≥12 months was widely applied while postpartum adherence until the end of breastfeeding was poor, a potential risk of postpartum vertical transmission needs to be taken seriously into account for Option B+ implementation.

Level and determinants of postpartum adherence to antiretroviral therapy in the Eastern Cape, South Africa

“…Our analysis shows that fewer than two-thirds of mothers selfreported complete adherence to ART at 18-24 months postpartum period. Even though a 100% rate of postpartum adherence is desirable, the 64% adherence level in this study is higher than the rate reported among postpartum mothers in a study in western Uganda [12] and in SSA [5]. Of concern, however, is the decline in the level of adherence among these women relative to the level reported during pregnancy [17].…”

“…Existing evidence suggests that adherence rate decline during the postnatal period after peaking during pregnancy [9][10][11]. Also, studies conducted in Uganda and Zambia suggest that adherence rate is higher among pregnant women compared to breastfeeding women [12][13][14]. Younger age, alcohol and tobacco use, higher parity, and postpartum depression are among the main factors associated with non-adherence to ART [15,16], while disclosure and partner support facilitate adherence [17,18].…”

Factors Influencing Maternal Adherence to Infant’s Nevirapine Prophylaxis in a Cross-Sectional Study Conducted at Mulago Hospital, Kampala, Uganda

“…Regarding factors that positively influenced maternal level of adherence to infants NVP prophylaxis regimen dispensation from 0-6 weeks, this study found maternal age and believe about the effectiveness of NVP in prevention of vertical transmission of HIV associated with maternal adherence. Specifically, relatively older mothers years of age were found to have higher likelihood of adherence than their counterparts who were aged [15][16][17][18][19] years. This might be due to the possibility that older mothers have accumulated more health knowledge than their younger counterparts, therefore have more HIV/AIDS illness experience and better cues to action.…”

“…A systematic review of both qualitative and quantitative studies on barriers and facilitators of ART adherence among HIV positive adults found that poor knowledge of HIV/AIDS & PMTCT services, ART and its associated demands negatively affects adherence to ART [15]. A Ugandan cross-sectional study found high levels of maternal non-adherence to ART and concluded that younger age, low parity, lower travel costs were positively associated maternal adherence, however quality of statistical analysis made the validity of the results questionable [16]. Disclosure of HIV/AIDS status to a spouse and the ART treatment support provided by spouse to women tend to improve ART adherence, and retention in ART program, however fear of negative consequences women might experience from the spouse was found to be barrier to adherence to ART [15].In a South African cross-sectional study that used reported maternal adherence to infants prophylaxis regimen at six weeks postpartum, maternal adherence to ART prior to delivery was associated with 80% reduction in non-adherence to infant's NVP prophylaxis.…”

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

“…To reach the ambitious targets of EMTCT, ART adherence and programme retention are critical; unfortunately, both present unique challenges over the course of pregnancy and breastfeeding [65‐68]. In their review of the literature, Stover, et al estimated that maternal PMTCT retention to ART programmes at 80% at time of delivery [47].…”