Differentiated models of care for postpartum women on antiretroviral therapy in Cape Town, South Africa: a cohort study

Abstract

Background: The numbers of women initiating lifelong antiretroviral therapy (ART) during pregnancy and postpartum is increasing rapidly, presenting a burden on health systems and an urgent need for scalable models of care for this population. In a pilot project, we referred postpartum women who initiated ART during pregnancy to a community-based model of differentiated ART services.Methods: Eligible women (on ART for at least 3 months with viral load (VL)<1000 copies/mL) were offered a choice of two ART models of care: (i) referral to an existing system of community-based ‘adherence clubs’, operated by lay counsellors with medication collection every 2–4 months; or (ii) referral to local primary healthcare clinics (PHC) with services provided by clinicians and medication collection every 1–2 months (local standard of care for postpartum ART). For evaluation, women were followed through 6-months postpartum with VL testing separate from either ART service.Results: Through September 2015, n = 129 women were enrolled (median age, 28 years; median time postpartum, 10 days). Overall, 65% (n = 84) chose adherence clubs and 35% (n = 45) chose PHCs; there were no demographic or clinical predictors of this choice. Location of service delivery was commonly cited as a reason for choice by women selecting either model of care; shorter waiting times, ability to receive ART from lay counsellors and less frequent appointments were motivations for choosing adherence clubs. Among women choosing adherence clubs, 15% never attended the service and another 11% attended the service but were not retained through six months postpartum. Overall, 86% of women (n = 111) remained in the evaluation through 6 months postpartum; in this group, there were no differences in VL<1000 copies/mL at six months postpartum between women choosing PHCs (88%) vs. adherence clubs (92%; p = 0.483), but women who were not retained in adherence clubs were more likely to have VL≥1000 copies/mL compared to those who remained (p = 0.002).Discussion: Adherence clubs may be a valuable model for postpartum women initiating ART in pregnancy, with good short-term outcomes observed during this critical period. To support optimal implementation, further research is needed into patient preferences for models of care, with consideration of integration of maternal and child health services, while ART adherence and retention require ongoing consideration in this population.

Boosting ART uptake and retention among HIV‐infected pregnant and breastfeeding women and their infants: the promise of innovative service delivery models

“…In the first model, a facility‐based educator enrolled high and low‐risk mother‐infant pairs at the postnatal 6 week visit to form postnatal clubs, which resulted in improved retention, viral load suppression of 98% for post‐partum women at six months, and zero seroconversions to HIV for infants . In the second model, post‐partum women and their HIV‐exposed infants participated in community‐based adherence clubs; this group had no differences in short‐term viral load outcomes compared to mother‐infant pairs referred to local primary healthcare clinics . Of note, one‐quarter of women in adherence clubs were not retained six months post‐partum, highlighting the need to ensure future studies not only include PBFW in differentiated care models but also evaluate transition between ART services in the post‐partum period .…”

Emerging priorities for HIV service delivery

“…Establishing peer support groups for stable ART patients both in health facilities and in the community fosters support and facilitates access to treatment [41]. Several models have been piloted and have improved outcomes for patients [42][43][44][45][46], including for children, adolescents, and breastfeeding women [47][48][49]. National HIV program managers prefer having a choice of models that can be applied in different contexts.…”

Accelerating progress towards the elimination of mother‐to‐child transmission of HIV: a narrative review

“…Healthcare staff convene patients – typically every few months – for group counselling, prescription refills and referrals to the health facility (where needed). In a cohort study of 129 women with HIV viral load <1000 copies/mL for at least three months, Myer and colleagues reported favourable outcomes with adherence groups during the postpartum period [87]. The feasibility and acceptability of the approach was confirmed via in‐depth interviews with healthcare providers and patients [88].…”