Loss to follow‐up before and after delivery among women testing HIV positive during pregnancy in Johannesburg, South Africa

Abstract

Objective HIV-positive pregnant women are at heightened risk of becoming lost to follow-up (LTFU) from HIV care. We examined LTFU before and after delivery among pregnant women newly-diagnosed with HIV. Methods Observational cohort study of all pregnant women ≥18 years (N=300) testing HIV-positive for the first time at their first ANC visit between January–June 2010, at a primary healthcare clinic in Johannesburg, South Africa. Women (n=27) whose delivery date could not be determined were excluded. Results Median (IQR) gestation at HIV testing was 26 weeks (21–30). 98.0% received AZT prophylaxis, usually started at the first ANC visit. Of 139 (51.3%) patients who were ART-eligible, 66.9% (95%CI 58.8–74.3%) initiated ART prior to delivery; median (IQR) ART duration pre-delivery was 9.5 weeks (5.1–14.2). Among ART-eligible patients, 40.5% (32.3–49.0%) were cumulatively retained through six months on ART. Of those ART-ineligible at HIV testing, only 22.6% (95%CI 15.9–30.6%) completed CD4 staging and returned for a repeat CD4 test after delivery. LTFU (≥1 month late for last scheduled visit) before delivery was 20.5% (95%CI 16.0–25.6%) and, among those still in care, 47.9% (95%CI 41.2–54.6%) within six months after delivery. Overall, 57.5% (95%CI 51.6–63.3%) were lost between HIV testing and six months post-delivery. Conclusions Our findings highlight the challenge of continuity of care among HIV-positive pregnant women attending antenatal services, particularly those ineligible for ART.

Treatment Failure, Drug Resistance, and CD4 T-Cell Count Decline Among Postpartum Women on Antiretroviral Therapy in South Africa

“…In an analysis from South Africa 9.9% of the patients who achieved virologic suppression on first-line ART during pregnancy developed virologic failure a median of 16 months from ART initiation [27]. This finding from a single site non-governmental organization managed adult ART and PMTCT clinic is lower than our finding of 16% failure among those with pre-partum virologic suppression.…”

“…Depression may have contributed to poor adherence, as has been previously reported [11, 25, 26]. Financial constraints, employment, stigma, and disclosure may also have reduced adherence but were not evaluated [10, 27]. Notably, we did not observe an association with either TB treatment or having initiated ART prior to pregnancy and treatment failure.…”

Outcomes from the implementation of a counselling model supporting rapid antiretroviral treatment initiation in a primary healthcare clinic in Khayelitsha, South Africa

“…Their inclusion in the study cohort might have increased overall short-term losses to care as reported elsewhere. 30,31 Lastly, despite basic interventions to ensure fidelity, no specific data were collected to report on fidelity to the piloted model. The present study highlights useful directions for future research.…”

Acceptability and Feasibility of a Mobile Phone-Based Case Management Intervention to Retain Mothers and Infants from an Option B+ Program in Postpartum HIV Care

“…A recent South African study found that 58% of HIV-infected pregnant women testing positive for HIV during pregnancy were lost-to-care by six months postpartum (7). Although early reports from Malawi suggested that Option B+ programs can retain patients at levels comparable to retention of non-PMTCT patients (8), more recent data from across 540 Malawian health centers indicate that women who start HAART as part of the Option B+ program were five times more likely not return to the clinic after HAART initiation as compared to women who were started on treatment due to low CD4 cell counts (9).…”