Beyond prevention of mother-to-child transmission

Kellerman, Scott E.; Ahmed, Saeed; Feeley-Summerl, Theresa; Jay, Jonathan; Kim, Maria; Phelps, B. Ryan; Sugandhi, Nandita; Schouten, Erik J; Tolle, Mike; Tsiouris, Fatima

doi:10.1097/qad.0000000000000107

Cited by 31 publications

(22 citation statements)

References 34 publications

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“…Early data from Malawi (the first country to adopt option B+) do not report on adherence or viral suppression, but about half of women eligible for ART did not initiate treatment [27] and 27% of women who initiated therapy were lost to follow-up at one year [9]. Roll-out of Option B+ is happening very quickly and is planned or considered for many sub-Saharan African countries[28]. It will be critical to understand and address challenges to adherence in the peripartum period as these programs are implemented to optimize their efficacy and cost-effectiveness.…”

Section: Discussionmentioning

confidence: 99%

HIV-Infected Ugandan Women on Antiretroviral Therapy Maintain HIV-1 RNA Suppression Across Periconception, Pregnancy, and Postpartum Periods

Matthews

Ribaudo

Kaida

et al. 2016

JAIDS Journal of Acquired Immune Deficiency Syndromes

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Background HIV-infected women risk sexual and perinatal HIV transmission during conception, pregnancy, childbirth, and breastfeeding. We compared HIV-1 RNA suppression and medication adherence across periconception, pregnancy, and postpartum periods, among women on ART in Uganda. Methods We analyzed data from women in a prospective cohort study, aged 18-49 years, enrolled at ART initiation and with ≥ 1 pregnancy between 2005-2011. Participants were seen quarterly. The primary exposure of interest was pregnancy period, including periconception (3 quarters prior to pregnancy), pregnancy, postpartum (6 months after pregnancy outcome), or non-pregnancy-related. Regression models using GEE compared the likelihood of HIV-1 RNA ≤400 copies/mL, <80% average adherence based on electronic pill caps (MEMS), and likelihood of 72-hour medication gaps across each time period. Results 111 women contributed 486 person-years of follow up. Viral suppression was present at 89% of non-pregnant, 97% of periconception, 93% of pregnancy, and 89% of postpartum visits, and was more likely during periconception (aOR 2.15) compared with non-pregnant periods. Average ART adherence was 90% (IQR 70-98%), 93% (IQR 82-98%), 92% (IQR 72-98%) and 92% (IQR 72-97%) during non-pregnant, periconception, pregnant and postpartum periods. Average adherence < 80% was less likely during periconception (aOR 0.68) and 72-hour gaps/90 days were less frequent during periconception (aRR 0.72) and more frequent postpartum (aRR 1.40). Conclusions Women with pregnancy were virologically suppressed at most visits, with an increased likelihood of suppression and high adherence during periconception follow-up. Increased frequency of 72-hour gaps suggests a need for increased adherence support during postpartum periods.

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Section: Discussionmentioning

confidence: 99%

HIV-Infected Ugandan Women on Antiretroviral Therapy Maintain HIV-1 RNA Suppression Across Periconception, Pregnancy, and Postpartum Periods

Matthews

Ribaudo

Kaida

et al. 2016

JAIDS Journal of Acquired Immune Deficiency Syndromes

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“…However, PMTCT programs have been plagued by suboptimal uptake and loss to follow-up (LTFU) along the PMTCT cascade 2–5. The “PMTCT cascade” identifies the sequence of prevention and treatment measures delivered to HIV-infected women and their infants including maternal HIV testing, and for infected mothers, CD4 + cell count (CD4) testing, dispensing of maternal and infant antiretrovirals (ARVs), diagnostic testing of infants, and follow-up throughout breastfeeding 6–8. To significantly reduce the number of new infant HIV infections, uptake and retention at each step of the PMTCT cascade needs to be greater than 90% 7…”

Section: Introductionmentioning

confidence: 99%

Implementation and Operational Research

Kim

Ahmed

Hosseinipour

et al. 2015

JAIDS Journal of Acquired Immune Deficiency Syndromes

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Objective In 2011, Malawi implemented Option B+ (B+), lifelong antiretroviral therapy (ART) for pregnant and breast-feeding women. We aimed to describe changes in service uptake and outcomes along the antenatal PMTCT cascade post B+ implementation. Design Pre/post study using routinely collected program data from two large Lilongwe-based health centers. Methods We compared testing of HIV-infected pregnant women at antenatal care, enrollment into PMTCT services, receipt of ART and six-month ART outcomes pre- (Oct 2009–Mar 2011) and post- (Oct 2011–Mar 2013) B+. Results A total of 13,926 (pre) and 14,532 (post) women presented to antenatal care. Post-B+ a smaller proportion were HIV tested (99.3% vs. 87.7% post-; p<0.0001). There were 1654 (pre) and 1535 (post) HIV-infected women identified, with a larger proportion already known to be HIV-infected (18.1% vs. 41.2% post-; p<0.001) and on ART post-B+ (18.7% vs. 30.2% post-; p<0.001). A significantly greater proportion enrolled into the PMTCT program (68.3% vs. 92.6% post-; p<0.001) and was retained through delivery post-B+ (51.1% vs. 65% post-; p<0.0001). Amongst those not on ART at enrollment there was no change in the proportion newly initiating ART/ARVs (79% vs. 81.9% post-; p=0.11); although median days to initiation of ART decreased (48d [19,130] vs. 0d [0,15.5] post-; p<0.001). Amongst those newly initiating ART, a smaller proportion was alive on ART six-months post-initiation (89.3% vs. 78.8% post-; p=0.0004). Conclusion While several improvements in PMTCT program performance were noted with implementation of B+, challenges remain at several critical steps along the cascade requiring innovative solutions to ensure an AIDS-free generation.

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“…9 Infants receive 6 weeks of nevirapine starting at birth, early infant HIV DNA polymerase chain reaction (PCR) diagnosis using dried blood spots after 6 weeks of age and clinical follow-up until determination of final infection status. 10 , 11 …”

Section: Introductionmentioning

confidence: 99%