Retention in care of HIV‐infected pregnant and lactating women starting ART under Option B+ in rural Mozambique

Llenas-García, Jara; Wikman-Jorgensen, Philip; Hobbins, Michael; Mussa, Manuel Aly; Ehmer, Jochen; Keiser, Olivia; Mbofana, Francisco; Wandeler, Gilles

doi:10.1111/tmi.12728

Cited by 43 publications

(47 citation statements)

References 34 publications

(36 reference statements)

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“…A recent study from Malawi, using a more stringent definition of retention, found that 77% and 71% of women were retained at 12 and 24 months on ART respectively . In data from Zimbabwe and Mozambique, only 68% and 42% of women were still receiving ART 12 months after ART initiation . A recent systematic review found a pooled estimate of 76% retained at 12 months on ART in African cohorts .…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2018

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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.

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Section: Discussionmentioning

confidence: 99%

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

et al. 2018

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“…[15] Moreover, mothers who do not suffer from clinical symptoms might not feel a strong need to adhere to health care appointments and daily drug intake. Previous research suggests that mothers who initiated ART for PMTCT are more likely to drop out of care after delivery than women starting ART for their own health [12, 25]. …”

Section: Discussionmentioning

confidence: 99%

Prevention of mother-to-child transmission of HIV: Postpartum adherence to Option B+ until 18 months in Western Uganda

et al. 2017

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Since 2012, the WHO recommends Option B+ for the prevention of mother-to-child transmission of HIV. This approach entails the initiation of lifelong antiretroviral therapy in all HIV-positive pregnant women, also implying protection during breastfeeding for 12 months or longer. Research on long-term adherence to Option B+ throughout breastfeeding is scarce to date. Therefore, we conducted a prospective observational cohort study in Fort Portal, Western Uganda, to assess adherence to Option B+ until 18 months postpartum. In 2013, we recruited 67 HIV-positive, Option B+ enrolled women six weeks after giving birth and scheduled them for follow-up study visits after six, twelve and 18 months. Two adherence measures, self-reported drug intake and amount of drug refill visits, were combined to define adherence, and were assessed together with feeding information at all study visits. At six months postpartum, 51% of the enrolled women were considered to be adherent. Until twelve and 18 months postpartum, adherence for the respective follow-up interval decreased to 19% and 20.5% respectively. No woman was completely adherent until 18 months. At the same time, 76.5% of the women breastfed for ≥12 months. Drug adherence was associated with younger age (p<0.01), lower travel costs (p = 0.02), and lower number of previous deliveries (p = 0.04). Long-term adherence to Option B+ seems to be challenging. Considering that in our cohort, prolonged breastfeeding until ≥12 months was widely applied while postpartum adherence until the end of breastfeeding was poor, a potential risk of postpartum vertical transmission needs to be taken seriously into account for Option B+ implementation.

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“…In Central Mozambique, less than 45% of women were retained at 90 days after ART initiation [7,8]. It was suggested that women with ART initiation under Option B+ were significantly likelier to be lost to follow-up in the first year or have no follow-up after their first visit than those who initiated ART for their own health [9]. These reports suggest poor levels of engagement in care among women under universal ART, raising concerns pertaining to the effectiveness of the strategy, not only in terms of maternal ART outcomes, but also the programme's success in achieving eMTCT HIV targets.…”

Section: Introductionmentioning

confidence: 99%

PMTCT care cascade and factors associated with attrition in the first four years after Option B+ implementation in Mozambique

Ahoua

Tiendrebeogo

Arikawa

et al. 2019

Tropical Med Int Health

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objective To evaluate the effectiveness of the prevention of mother-to-child transmission (PMTCT) Option B+ programme in two provinces with high human immunodeficiency virus (HIV) burden in Mozambique over the first four years of programme implementation.methods We assessed the PMTCT cascade in antenatal care (ANC) from July 2013 to December 2017 using facility-level data and performed a retrospective cohort analysis with patient-level data. We compared the 12-month antiretroviral therapy (ART) retention rates between women with HIV infection who initiated ART under Option B+ ('B+ pregnant') and those who initiated ART for their own health ('own health').results A total of 916 280 pregnant women enrolled in ANC. The proportion of women with a documented HIV status increased from 93% in 2013 to 96% in 2017. The proportion of those tested HIV-positive decreased from 8% to 6% while that of those HIV-positive on ART increased from 42% to 95%. Of the 44 377 HIV-positive women included in the analysis, 35% were lost to care. 'B+ pregnant' women initiating ART in 2015 were less likely to have no follow-up (NFU) compared with 'own health' women starting ART during the same period (adjusted odds ratio: 0.77, 95% confidence interval [CI]: 0.64-0.94, P = 0.01). There was no statistical difference between the two groups during the other years in which ART was initiated. Of those returning for care after their first visit (N = 39 801), the 'B+ pregnant' women showed a higher risk of non-retention than the other group (adjusted hazard ratio: 1.14, 95% CI: 1.03-1.25) when ART was initiated in 2013. The risk decreased during the subsequent years, with no difference observed between the groups.conclusion PMTCT Option B+ programme scale-up has yielded positive results, including the maintenance of high HIV testing and ART initiation rates in ANC. Challenges still remain, however, in improving immediate engagement in care and long-term retention. Seeking alternative service delivery models to support existing health systems and prevent defaulters is required to achieve the UNAIDS 95-95-95 targets for PMTCT in Mozambique.

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Retention in care of HIV‐infected pregnant and lactating women starting ART under Option B+ in rural Mozambique

Cited by 43 publications

References 34 publications

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

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

Prevention of mother-to-child transmission of HIV: Postpartum adherence to Option B+ until 18 months in Western Uganda

PMTCT care cascade and factors associated with attrition in the first four years after Option B+ implementation in Mozambique

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