“You must leave but I didn’t want to leave”: qualitative evaluation of the integration of ART into postnatal maternal and child health services in Cape Town, South Africa

Pellowski, Jennifer; Weber, Alison Z.; Phillips, Tamsin K; Brittain, Kirsty; Zerbe, Allison; Abrams, Elaine J.; Myer, Landon

doi:10.1080/09540121.2019.1659913

Cited by 7 publications

(7 citation statements)

References 14 publications

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“…The stress of caring for a newborn can be overwhelming, leaving little time for self-care. In South Africa, women are generally transferred from obstetric care to another clinic upon delivery, resulting in potential for losses to follow-up, confusion, logistical challenges, and/or suboptimal support [17] [26].…”

Section: Discussionmentioning

confidence: 99%

“…In Mpumalanga Province, South Africa, self-reported adherence to ART was 69% among pregnant WLWH [11] and in Zimbabwe, only 40% of women were taking at least 95% of ART by pill count one year postpartum [12]. Qualitative data from sub-Saharan African sites suggest that adherence challenges for pregnant and postpartum WLWH relate to structural barriers to care, community and healthcare stigma, medication side effects, depression, substance use and the overwhelming challenges of poverty, gender norms, and life with a newborn [13][14][15][16][17][18][19][20].…”

Section: Introductionmentioning

confidence: 99%

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Adherence to HIV antiretroviral therapy among pregnant and postpartum women during the Option B+ era: 12‐month cohort study in urban South Africa and rural Uganda

et al. 2020

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Introduction We conducted a cohort study to understand patterns of anti‐retroviral therapy (ART) adherence during pregnancy, postpartum and non‐pregnancy follow‐up among women initiating ART in public clinics offering Option B+ in rural Uganda and urban South Africa. Methods We collected survey data, continuously monitored ART adherence (Wisepill), HIV‐RNA and pregnancy tests at zero, six and twelve months from women initiating ART in Uganda and South Africa, 2015 to 2017. The primary predictor of interest was follow‐up time categorized as pregnant (pregnancy diagnosis to pregnancy end), postpartum (pregnancy end to study exit) or non‐pregnancy‐related (neither pregnant nor postpartum). Fractional regression models included demographics and socio‐behavioural factors informed by the Behavioral Model for Vulnerable Populations. We evaluated HIV‐RNA at 12 months by ever‐ versus never‐pregnant status. Results In Uganda, 247 women contributed 676, 900 and 1274 months of pregnancy, postpartum and non‐pregnancy‐related follow‐up. Median ART adherence was consistently ≥90%: pregnancy, 94% (interquartile range [IQR] 78,98); postpartum, 90% (IQR 70,97) and non‐pregnancy, 90% (IQR 80,98). Poorer adherence was associated with younger age (0.98% [95% CI 0.33%, 1.62%] average increase per year of age) and higher CD4 cell count (1.01% [0.08%, 1.94%] average decrease per 50 cells/mm3). HIV‐RNA was suppressed among 91% (N = 135) ever‐pregnant and 86% (N = 85) never‐pregnant women. In South Africa, 190 women contributed 259, 624 and 1247 months of pregnancy, postpartum and non‐pregnancy‐related follow‐up. Median adherence was low during pregnancy, 74% (IQR 31,96); postpartum, 40% (IQR 4,65) and non‐pregnancy, 77% (IQR 47,92). Poorer adherence was associated with postpartum status (22.3% [95%CI 8.6%, 35.4%] average decrease compared to non‐pregnancy‐related follow‐up) and less emotional support (1.4% [0.22%, 2.58%] average increase per unit increase). HIV‐RNA was suppressed among 57% (N = 47) ever‐pregnant and 86% (N = 93) never‐pregnant women. Conclusions Women in rural Uganda maintained high adherence with 91% of ever‐pregnant and 86% of never‐pregnant women suppressing HIV‐RNA at 12 months. Women in urban South Africa struggled with adherence, particularly during postpartum follow‐up with median adherence of 40% and 57% of women with HIV‐RNA suppression at one year, suggesting a crisis for postpartum women with HIV in South Africa. Findings suggest that effective interventions should promote emotional support.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Adherence to HIV antiretroviral therapy among pregnant and postpartum women during the Option B+ era: 12‐month cohort study in urban South Africa and rural Uganda

et al. 2020

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“…Certainly, postpartum adherence challenges emerge in other South African cohorts [45][46][47][48], and IPV may be one important social factor contributing to this phenomenon. It is also possible that women's motivation to adhere to ART change postpartum, with pregnancy being a time of attentiveness to medication-taking and postpartum being characterized by competing demands of raising an infant and potential disruptions of transferring clinics for ongoing HIV care [49]. [52,53] but IPV exposure often undermines mental health gains made through such interventions [54].…”

Section: Discussionmentioning

confidence: 99%

Longitudinal association between intimate partner violence and viral suppression during pregnancy and postpartum in South African women

Hatcher

Brittain

Phillips

et al. 2020

Aids

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Objective: We examined the longitudinal association between women's exposure to intimate partner violence (IPV) and HIV viral load during pregnancy and postpartum.Design: Secondary analysis of an HIV-positive cohort enrolled during pregnancy at a South African antenatal clinic.Methods: Viral load was assessed at 10 study visits and analyzed continuously as log 10 copies/ml and suppression at less than 50 copies/ml. IPV was measured at three timepoints using behaviorally specific items. We used multivariate logistic regression to examine the association between IPV and viral suppression, and cross-lagged dynamic panel modeling (DPMs) to estimate the longitudinal association between IPV (lagged by 3-6 months) and log 10 viral load.Results: Of 471 women, 84% were virally suppressed by 6 weeks postpartum and 67% at 12 months postpartum. One-third reported IPV exposure. IPV victimization was not associated with viral suppression at delivery, but was associated with a reduced odds of viral suppression at 12 months postpartum (aOR ¼ 0.48, 95% CI ¼ 0.27-0.85). Findings were robust to sensitivity analyses at different timepoints and clinical cut-points. In DPMs, lagged IPV exposure was associated with higher log 10 viral load after controlling for past viral load, duration on ART, age, alcohol use, and gestation at study enrolment. Each standardized increase in IPV intensity was associated with higher log 10 viral load (standardized coefficient ¼ 0.12, 95% CI ¼ 0.05-0.23). Conclusion:Although viral suppression was widely achieved during pregnancy, suppression rates declined postpartum in this South African cohort. These data suggest IPV is longitudinally associated with elevated viral load postpartum. Interventions for reducing exposure to IPV are important for the health of women and may improve HIV care and treatment.

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“…Not having HIV treatment providers available at the clinic every day was another barrier for women starting ART in pregnancy [41]. Access to ANC and HIV care, or child health services and HIV care, in the same clinic and preferably on the same day was reported to be a facilitator of successful transition [41,47,54].…”

Section: Characteristics Of the Clinicmentioning

confidence: 99%

“…Fear of stigma and disclosure were also associated with not successfully transitioning in quantitative studies [22,24,46]. Women in South Africa expressed reluctance to leave integrated PMTCT services to continue ART and fear about needing to transfer [47]. Stigma and fear of disclosure were also highlighted as barriers by providers in the context of linking pregnant adolescents to HIV services in Kenya [48] and as reasons for not using referral letters provided during community identification of pregnant women in Tanzania [31].…”

Section: Fearmentioning

confidence: 99%

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

Phillips

Teasdale

Geller

et al. 2020

J. Intern. AIDS Soc.

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Introduction Women living with HIV are required to transition into the prevention of mother‐to‐child transmission of HIV (PMTCT) services when they become pregnant and back to ART services after delivery. Transition can be a vulnerable time when many women are lost from HIV care yet there is little guidance on the optimal transition approaches to ensure continuity of care. We reviewed the available evidence on existing approaches to transitioning women into and out of PMTCT, outcomes following transition and factors influencing successful transition. Methods We searched PubMed and SCOPUS, as well as abstracts from international HIV‐focused meetings, from January 2006 to July 2020. Studies were included that examined three points of transition: pregnant women already on ART into PMTCT (transition 1), pregnant women living with HIV not yet on ART into treatment services (transition 2) and postpartum women from PMTCT into general ART services after delivery (transition 3). Results were grouped and reported as descriptions of transition approach, comparison of outcomes following transition and factors influencing successful transition. Results & discussion Out of 1809 abstracts located, 36 studies (39 papers) were included in this review. Three studies included transition 1, 26 transition 2 and 17 transition 3. Approaches to transition were described in 26 studies and could be grouped into the provision of information at the point of transition (n = 8), strengthened communication or linkage of data between services (n = 4), use of transition navigators (n = 12), and combination approaches (n = 4). Few studies were designed to directly assess transition and only nine compared outcomes between transition approaches, with substantial heterogeneity in study design, setting and outcomes. Four themes were identified in 25 studies reporting on factors influencing successful transition: fear, knowledge and preparedness, clinic characteristics and the transition requirements and process. Conclusions This review highlights that, despite the need for women to transition into and out of PMTCT services for continued ART in many settings, there is very limited evidence on optimal transition approaches. Ongoing operational research is required to identify sustainable and acceptable transition approaches and service delivery models that support continuity of HIV care during and after pregnancy.

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“You must leave but I didn’t want to leave”: qualitative evaluation of the integration of ART into postnatal maternal and child health services in Cape Town, South Africa

Cited by 7 publications

References 14 publications

Adherence to HIV antiretroviral therapy among pregnant and postpartum women during the Option B+ era: 12‐month cohort study in urban South Africa and rural Uganda

Adherence to HIV antiretroviral therapy among pregnant and postpartum women during the Option B+ era: 12‐month cohort study in urban South Africa and rural Uganda

Longitudinal association between intimate partner violence and viral suppression during pregnancy and postpartum in South African women

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

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