Retention in HIV Care During Pregnancy and the Postpartum Period in the Option B+ Era: Systematic Review and Meta-Analysis of Studies in Africa

Knettel, Brandon A.; Cichowitz, Cody; Ngocho, James Samwel; Knippler, Elizabeth T.; Chumba, Lilian; Mmbaga, Blandina T.; Watt, Melissa H.

doi:10.1097/qai.0000000000001616

Cited by 191 publications

(237 citation statements)

References 67 publications

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“…Our findings add to the limited literature on retention of postpartum women in Africa beyond 12 months on ART . Overall retention at 12 and 24 months after ART initiation (71% and 65% respectively) were broadly comparable to reports from other parts of sub‐Saharan Africa.…”

Section: Discussionsupporting

confidence: 80%

“…Younger age was a shared risk factor for not linking to care, more frequent mobility, non‐retention and raised VL. This adds to the substantial evidence indicating that younger HIV‐positive women are often at increased risk for poor treatment outcomes . Although associations were small, younger age, timing of presentation for ANC and relationship status could flag women requiring additional support to link to care postpartum.…”

Section: Discussionmentioning

confidence: 90%

“…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 . Reported retention in HIV care is often facility specific.…”

Section: Discussionmentioning

confidence: 99%

“…However, these benefits hinge on women initiating ART, adhering to treatment, and remaining in care in the long term. Postpartum retention is a major challenge and there is an urgent need to understand how mobility may contribute to this .…”

Section: Introductionmentioning

confidence: 99%

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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: Discussionsupporting

confidence: 80%

Section: Discussionmentioning

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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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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“…In sub‐group analyses, retention in care did not significantly worsen after Treat All implementation among those with more advanced HIV (as indicated by CD4 count) or among men and younger patients, who have traditionally been at risk of worse outcomes. Among patients referred to HIV care from maternal/prenatal clinics, there was no significant change in six‐month retention after Treat All implementation, and overall retention at six months was higher than in studies of pregnant women initiating HIV care under Option B+ programmes in other settings . Additional research is needed to determine whether the observed results reflect a population‐wide benefit of Treat All, even to at‐risk groups, or may be a function of Rwanda's already high‐performing HIV programme.…”

Section: Discussionmentioning

confidence: 87%

Early outcomes after implementation of treat all in Rwanda: an interrupted time series study

et al. 2019

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Introduction Nearly all countries in sub‐Saharan Africa have adopted policies to provide antiretroviral therapy ( ART ) to all persons living with HIV (Treat All), though HIV care outcomes of these programmes are not well‐described. We estimated changes in ART initiation and retention in care following Treat All implementation in Rwanda in July 2016. Methods We conducted an interrupted time series analysis of adults enrolling in HIV care at ten Rwandan health centres from July 2014 to September 2017. Using segmented linear regression, we assessed changes in levels and trends of 30‐day ART initiation and six‐month retention in care before and after Treat All implementation. We compared modelled outcomes with counterfactual estimates calculated by extrapolating baseline trends. Modified Poisson regression models identified predictors of outcomes among patients enrolling after Treat All implementation. Results Among 2885 patients, 1803 (62.5%) enrolled in care before and 1082 (37.5%) after Treat All implementation. Immediately after Treat All implementation, there was a 31.3 percentage point increase in the predicted probability of 30‐day ART initiation (95% CI 15.5, 47.2), with a subsequent increase of 1.1 percentage points per month (95% CI 0.1, 2.1). At the end of the study period, 30‐day ART initiation was 47.8 percentage points (95% CI 8.1, 87.8) above what would have been expected under the pre‐Treat All trend. For six‐month retention, neither the immediate change nor monthly trend after Treat All were statistically significant. While 30‐day ART initiation and six‐month retention were less likely among patients 15 to 24 versus >24 years, the predicted probability of both outcomes increased significantly for younger patients in each month after Treat All implementation. Conclusions Implementation of Treat All in Rwanda was associated with a substantial increase in timely ART initiation without negatively impacting care retention. These early findings support Treat All as a strategy to help achieve global HIV targets.

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Male partner involvement and successful completion of the prevention of mother‐to‐child transmission continuum of care in Kenya

Hampanda

Helová

Odwar

et al. 2020

Intl J Gynecology & Obste

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Objective To examine the relationship between male partner involvement (MPI) in prevention of mother‐to‐child transmission (PMTCT) activities and successful completion of the PMTCT continuum of care, which remains sub‐optimal in settings with high prevalence of HIV. Methods A cross‐sectional survey was administered in June–August 2017 to a sample of 200 postpartum Kenyan women with HIV enrolled in a parent trial. Composite PMTCT and MPI variables were created. Descriptive, simple and multivariable regression, and mediation analyses were performed. Results Of the women, 54% reported successful completion of PMTCT. Depression and internalized HIV stigma were independently associated with lower likelihood of successful completion of PMTCT (adjusted risk ratio [aRR] 0.97; 95% confidence interval [CI] 0.94–0.99; aRR 0.92; 95% CI 0.88–0.98, respectively). Each MPI activity was associated with 10% greater likelihood of successful completion of PMTCT (P < 0.05). The relationship between MPI and the successful completion of PMTCT was partially mediated through women's reduced internalized HIV stigma (β −0.03; 95%CI −0.06 to −0.00). Conclusion Greater MPI in PMTCT activities has direct and indirect effects on women's successful completion of all necessary steps across the PMTCT continuum. Reduced internalized HIV stigma is likely a key mechanism in the relationship.

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Retention in HIV Care During Pregnancy and the Postpartum Period in the Option B+ Era: Systematic Review and Meta-Analysis of Studies in Africa

Cited by 191 publications

References 67 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

Early outcomes after implementation of treat all in Rwanda: an interrupted time series study

Male partner involvement and successful completion of the prevention of mother‐to‐child transmission continuum of care in Kenya

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