Community-based adherence clubs for postpartum women on antiretroviral therapy (ART) in Cape Town, South Africa: a pilot study

Abstract

Background With an increasing number of countries implementing Option B+ guidelines of lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women, there is urgent need to identify effective approaches for retaining this growing and highly vulnerable population in ART care. Methods Newly postpartum, breastfeeding women who initiated ART in pregnancy and met eligibility criteria were enrolled, and offered the choice of two options for postpartum ART care: (i) referral to existing network of community-based adherence clubs or (ii) referral to local primary health care clinic (PHC). Women were followed at study measurement visits conducted separately from either service. Primary outcome was a composite endpoint of retention in ART services and viral suppression [VS < 50 copies/mL based on viral load (VL) testing at measurement visits] at 12 months postpartum. Outcomes were compared across postpartum services using chi-square, Fisher’s exact tests and Poisson regression models. The primary outcome was compared across services where women were receiving care at 12 months postpartum in exploratory analyses. Results Between February and September 2015, 129 women (median age: 28.9 years; median time postpartum: 10 days) were enrolled with 65% opting to receive postpartum HIV care through an adherence club. Among 110 women retained at study measurement visits, 91 (83%) achieved the composite endpoint, with no difference between those who originally chose clubs versus those who chose PHC services. Movement from an adherence club to PHC services was common: 31% of women who originally chose clubs and were engaged in care at 12 months postpartum were attending a PHC service. Further, levels of VS differed significantly by where women were accessing ART care at 12 months postpartum, regardless of initial choice: 98% of women receiving care in an adherence club and 76% receiving care at PHC had VS < 50 copies/mL at 12 months postpartum ( p = 0.001). Conclusion This study found comparable outcomes related to retention and VS at 12 months postpartum between women choosing adherence clubs and those choosing PHC. However, movement between postpartum services among those who originally chose adherence clubs was common, with poorer VS outcomes among women leaving clubs and returning to PHC services. Trial registration ClinicalTrials.gov NCT02417675 , April 16, 2015 (retrospectively registered).

Provider‐ and patient‐level costs associated with providing antiretroviral therapy during the postpartum phase to women living with HIV in South Africa: A cost comparison of three postpartum models of care

“…We took the approach of considering the costs for the mother-infant pair with the trialled models of care specifically assessing maternal (and infant) outcomes. In the PACER and MCH-ART studies, Model III was found to be the most effective in terms of retention of mother-infant pairs and maternal viral suppression at 12 months postpartum with 84% of mother-infant pairs meeting these criteria [18][19][20][21]; Model I had a 56%; and Model II had a 77% proportion [18][19][20]. As the population of adults living with HIV is not homogeneous, there is a need to consider having a combination of different models depending on the characteristics of the population or individual's phase of life.…”

“…For instance, not all patients will be eligible for CACs and may be better suited to care under Model I or II. CAC inclusion criteria being that patients should be adults, who have been on ART for 6‐12 months, be stable with a suppressed viral load, not be pregnant and should not require frequent clinical management for adherence issues or comorbidities [21]. For those eligible and attending a CAC, the less frequent visit requirement of CACs (see Table 1) and ability to send a treatment ‘buddy’ to collect ART may aid WLH who are working or who would be unable to come to the clinic as regularly [40].…”

“…The PACER study enrolled 129 postpartum breastfeeding WLH who initiated ART during their recently completed pregnancy, who met local criteria for CAC membership [20,21,28]. Eligible women were offered a choice for postpartum ART care: Model I (as described above) or Model IIIreferral directly to a CAC with their infants receiving care at well-baby clinics.…”

“…The three models in the postpartum period were the local standard of care of referral of women to general ART services and infants to well-baby clinics (Model I -Routine Care); women and infants continue to receive care through an integrated maternal and child care approach during the postpartum breastfeeding period (Model II -Integrated Care); and referral of women directly to a community-based adherence club (CAC) and infants to wellbaby clinics (Model III -Community Care). The effectiveness of these three models of care is reported in detail elsewhere [18][19][20][21]. Furthermore, the costs from this study were utilised to update the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-International and CEPAC-Pediatrics Models and inform the cost-effectiveness analysis that was undertaken and published [22].…”

“…Furthermore, the costs from this study were utilised to update the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-International and CEPAC-Pediatrics Models and inform the cost-effectiveness analysis that was undertaken and published [22]. Briefly, Model III was found to be the most effective in terms of retention of mother-infant pairs and maternal viral suppression (which was defined as HIV ribonucleic acid (RNA) <50 copies/mL) at 12 months postpartum with 84% of mother-infant pairs meeting these criteria [18][19][20][21]. Model I had a 56% and Model II had a 77% proportion of mother-infant pairs retained and virally suppressed at the 12-month mark [18][19][20].…”