Linkage to care, mobility and retention of HIV‐positive postpartum women in antiretroviral therapy services in South Africa

Abstract

IntroductionLinkage to care and mobility postpartum present challenges to long‐term retention after initiating antiretroviral therapy (ART) in pregnancy, but there are few insights from sub‐Saharan Africa. We aimed to describe postpartum linkage to care, mobility, retention and viral suppression after ART initiation in pregnancy.MethodsUsing routine electronic data we assessed HIV‐specific health contacts and clinic movements among women initiating ART in an integrated antenatal care (ANC) and ART clinic in Cape Town, South Africa. The local care model includes mandatory transfer to general ART clinics postpartum. We investigated linkage to care after leaving the integrated clinic and mobility to new clinics until 30 months on ART. We used Poisson regression to explore predictors of linkage, retention (accessing care at least once at both 12 [6 to <18] and 24 [18 to <30] months on ART), and viral suppression (HIV viral load [VL] ≤50 and ≤1000 copies/mL after 12 months on ART).ResultsAmong 617 women, 23% never linked to care; 71% and 65% were retained at 12 and 24 months on ART respectively, with 59% retained in care at both times. Those who linked (n = 485) accessed HIV care at 98 different clinics and 21% attended ≥2 clinics. Women >25 years, married/cohabiting or presenting early for ANC were more likely to link. Younger and unemployed women were more likely to attend ≥2 clinics (adjusted risk ratio [aRR] 1.10 95% confidence interval [CI] 1.02 to 1.18 and aRR 1.06 95% CI 0.99 to 1.12 respectively). Age >25 years (aRR 1.17 95% CI 1.02 to 1.33) and planned pregnancy (aRR 1.20 95% CI 1.09 to 1.33) were associated with being retained. Among 338 retained women with VL available, attending ≥2 clinics reduced the likelihood of viral suppression when defined as ≤50 copies/mL (aRR 0.81 95% CI 0.69 to 0.95). Distance moved was not associated with VL.ConclusionsThese data show that a substantial proportion of women do not link to postpartum ART care in this setting and, among those that do, long‐term retention remains a challenge. Women move to a variety of clinics and young women appear particularly vulnerable to attrition. Interventions promoting linkage and continued retention for women initiating ART during pregnancy warrant urgent consideration.

Using national laboratory data to assess cumulative frequency of linkage after transfer to community‐based HIV clinics in South Africa

“…While these rates are comparable with our estimate, these studies do not exclusively focus on cohorts of transferred or “down‐referred” patients who may face greater risks of disruption of care and loss to follow‐up. However, our estimate is also consistent with a study evaluating national retention in South Africa's HIV programme accounting for patient transfers estimating a 63% retention rate after six years and with a study using NHLS data to assess postpartum transfers to general ART clinics, which found 65% of women linked and in care at 24 months .…”

“…retention rate after six years [24] and with a study using NHLS data to assess postpartum transfers to general ART clinics, which found 65% of women linked and in care at 24 months [26].…”

HIV care continuum characteristics among people with opioid use disorder and HIV in Vietnam: baseline results from the BRAVO study

“…Married participants may also be responding to growing public health education on the importance of taking ART to reduce the chances of HIV transmission to uninfected partners [28]. To our knowledge, similar results have not been reported in Vietnam; however, research in China [29] and South Table 1 Unadjusted and adjusted associations between baseline characteristics and ART prescription and viral suppression among people with HIV and opioid use disorder in Vietnam, 2015-2019 (Continued) Africa [30] has shown that marriage may be positively associated with ART initiation. While depression is associated with suboptimal ART adherence [31] [32], studies are mixed on its potential association with ART initiation, with several studies demonstrating an absence of association [33][34][35][36][37].…”

Time of HIV diagnosis, CD4 count and viral load at antenatal care start and delivery in South Africa

“…Younger age at pregnancy, being married and attending at least two postpartum clinic visits have been cited as important for postpartum retention and viral suppression among HIV positive women in South Africa [35].…”