Values and preferences of women living with HIV who are pregnant, postpartum or considering pregnancy on choice of antiretroviral therapy during pregnancy

Abstract

ObjectiveTo investigate women’s values and preferences regarding antiretroviral therapy (ART) during pregnancy to inform a BMJ Rapid Recommendation.SettingPrimary studies reporting patient-reported outcomes relevant to decision-making regarding ART in any clinical and geographical setting.ParticipantsWomen living with HIV who are pregnant, postpartum or considering pregnancy.Outcome measuresQuantitative measurements and qualitative descriptions of values and preferences in relation to ART during pregnancy. We also included studies on women’s reported barriers and facilitators to adherence. We excluded studies correlating objective measures (eg, CD4 count) with adherence, or reporting only outcomes which are not expected to differ between ART alternatives (eg, access to services, knowledge about ART).ResultsWe included 15 qualitative studies reporting values and preferences about ART in the peripartum period; no study directly studied choice of ART therapy during pregnancy. Six themes emerged: a desire to reduce vertical transmission (nine studies), desire for child to be healthy (five studies), concern about side effects to the child (eight studies), desire for oneself to be healthy (five studies), distress about side effect to oneself (10 studies) and pill burden (two studies). None of the studies weighed the relative importance of these outcomes directly, but pill burden/medication complexity appears to be a lower priority for most women compared with other factors. Overall, the body of evidence was at low risk of bias, with minor limitations.ConclusionsWomen who are or may become pregnant and who are considering ART appear to place a high value on both their own and their children’s health. Evidence on the relative importance between these values when choosing between ART regimens is uncertain. There is variability in individual values and preferences among women. This highlights the importance of an individualised women-centred approach, such as shared decision-making when choosing between ART alternatives.Trial registration numberInternational Prospective Register of Systematic Reviews:CRD42017057157.

Understanding the influence of health systems on women’s experiences of Option B+: A meta-ethnography of qualitative research from sub-Saharan Africa

“…In our review, the lack of reflexivity in the included studies meant that it was difficult to assess the extent to which the discussions around clinic attendance were shaped by the nature of the relationships between the field workers and the participants. Similar concerns have been found in other reviews of qualitative research from African settings (Lytvyn et al, 2017). However, despite the absence of statements on reflexivity in many studies, we noted that authors from sub-Saharan Africa were well represented in the identified papers.…”

British HIV Association guidelines for the management of HIV in pregnancy and postpartum 2018

“…The writing group recommends that choice of therapy should always be discussed in full with every woman and be individualised for the patient, taking into account a woman's concerns and preferences , in accordance with the standard treatment guidelines. Nucleoside backbone combinations recommended by BHIVA for HIV in pregnancy include tenofovir DF/emtricitabine and abacavir/lamivudine.…”

“…Nucleoside backbone combinations recommended by BHIVA for HIV in pregnancy include tenofovir DF/emtricitabine and abacavir/lamivudine. Pregnant women may also want to consider zidovudine/lamivudine . Considerations for the backbone include side‐effect profile, frequency of dosing, interactions with the third agent, adverse outcome profiles and prior cART experience including a resistance profile where available.…”

A mega-aggregation framework synthesis of the barriers and facilitators to linkage, adherence to ART and retention in care among people living with HIV

“…For children, one high-quality review [65], one medium-quality review [41] and two lowquality reviews [68,73] contributed to the aggregation of findings. For adults, two high-quality reviews [62,65], four medium-quality reviews [43,55,61,67] and twenty low-quality reviews [44, 47, 48, 50-56, 58-68, 70-73] contributed to the findings for adherence to ART.…”