A Systematic Review of Health System Barriers and Enablers for Antiretroviral Therapy (ART) for HIV-Infected Pregnant and Postpartum Women

Abstract

BackgroundDespite global progress in the fight to reduce maternal mortality, HIV-related maternal deaths remain persistently high, particularly in much of Africa. Lifelong antiretroviral therapy (ART) appears to be the most effective way to prevent these deaths, but the rates of three key outcomes—ART initiation, retention in care, and long-term ART adherence—remain low. This systematic review synthesized evidence on health systems factors affecting these outcomes in pregnant and postpartum women living with HIV.MethodsSearches were conducted for studies addressing the population of interest (HIV-infected pregnant and postpartum women), the intervention of interest (ART), and the outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. A four-stage narrative synthesis design was used to analyze findings. Review findings from 42 included studies were categorized according to five themes: 1) models of care, 2) service delivery, 3) resource constraints and governance challenges, 4) patient-health system engagement, and 5) maternal ART interventions.ResultsLow prioritization of maternal ART and persistent dropout along the maternal ART cascade were key findings. Service delivery barriers included poor communication and coordination among health system actors, poor clinical practices, and gaps in provider training. The few studies that assessed maternal ART interventions demonstrated the importance of multi-pronged, multi-leveled interventions.ConclusionsThere has been a lack of emphasis on the experiences, needs and vulnerabilities particular to HIV-infected pregnant and postpartum women. Supporting these women to successfully traverse the maternal ART cascade requires carefully designed and targeted interventions throughout the steps. Careful design of integrated service delivery models is of critical importance in this effort. Key knowledge gaps and research priorities were also identified, including definitions and indicators of adherence rates, and the importance of cumulative measures of dropout along the maternal ART cascade.

Factors associated with delivering premature and/or low birth weight infants among pregnant HIV-positive women on antiretroviral treatment at Dr George Mukhari Hospital, South Africa

“…4,5 However, these studies show that the uptake of ART among HIV-positive pregnant women in sub-Saharan Africa remains a challenge and is associated with a shortage of healthcare workers, the poor attitudes of healthcare workers, transport costs and long waiting times. 15 In the present study, HIV-positive mothers on ART or ARV prophylaxis and HIVnegative mothers had a lower risk of premature birth compared with HIV-positive mothers not on ART or ARV prophylaxis.…”

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

“…[16,31,32] We found that postpartum non-adherence until six months after delivery was associated with higher travel costs. Previous research similarly identified structural barriers such as long travel distance to the health facility, often linked with higher travel expenses.…”

Adherence to HIV Care After Pregnancy Among Women in Sub-Saharan Africa: Falling Off the Cliff of the Treatment Cascade

“…Existing data shows that women who are ineligible for lifetime treatment and/or have a higher CD4 count may be more likely to fall out of care during the postpartum period [40,41]. The prevailing view that PMTCT is not for the mother [33,45] may contribute to this phenomenon.…”