Abstract
BackgroundDespite global progress in the fight to reduce maternal mortality, HIV-related maternal deaths remain persistently high, particularly in much of Africa. Lifelong antiretroviral therapy (ART) appears to be the most effective way to prevent these deaths, but the rates of three key outcomes—ART initiation, retention in care, and long-term ART adherence—remain low. This systematic review synthesized evidence on health systems factors affecting these outcomes in pregnant and postpartum women living with HIV.MethodsSearches were conducted for studies addressing the population of interest (HIV-infected pregnant and postpartum women), the intervention of interest (ART), and the outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. A four-stage narrative synthesis design was used to analyze findings. Review findings from 42 included studies were categorized according to five themes: 1) models of care, 2) service delivery, 3) resource constraints and governance challenges, 4) patient-health system engagement, and 5) maternal ART interventions.ResultsLow prioritization of maternal ART and persistent dropout along the maternal ART cascade were key findings. Service delivery barriers included poor communication and coordination among health system actors, poor clinical practices, and gaps in provider training. The few studies that assessed maternal ART interventions demonstrated the importance of multi-pronged, multi-leveled interventions.ConclusionsThere has been a lack of emphasis on the experiences, needs and vulnerabilities particular to HIV-infected pregnant and postpartum women. Supporting these women to successfully traverse the maternal ART cascade requires carefully designed and targeted interventions throughout the steps. Careful design of integrated service delivery models is of critical importance in this effort. Key knowledge gaps and research priorities were also identified, including definitions and indicators of adherence rates, and the importance of cumulative measures of dropout along the maternal ART cascade.
Highlights
Despite global progress in the fight to reduce maternal mortality, HIV-related maternal deaths remain persistently high, in much of Africa
Why are HIV-infected pregnant and postpartum women continuing to die from HIV-related causes when effective antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) programs are increasingly available? What prevents these women from accessing treatment during and after pregnancy?
We examined the challenges specific to providing ART to pregnant women 1) who may or may not already be engaged with other health services and 2) who may be more vulnerable or have specific health needs associated with their pregnancy and up to one year after delivery
Summary
Despite global progress in the fight to reduce maternal mortality, HIV-related maternal deaths remain persistently high, in much of Africa. ART is increasingly available in the public sector health services of most countries, many pregnant or postpartum women continue to struggle to access treatment, and the rates of initiation, retention in care, and long-term adherence remain troublingly low [5,6]. There is a large and growing literature on health systems barriers to and enablers of ART This literature has identified a wide range of key factors, including long waiting times, transport costs, fears of confidentiality breaches, poor staff attitudes and fragmented service delivery platforms [7,8,9,10]. Many of these factors affect pregnant or postpartum women who need ART. We examined the challenges specific to providing ART to pregnant women 1) who may or may not already be engaged with other health services (i.e., antenatal care or PMTCT programs) and 2) who may be more vulnerable or have specific health needs associated with their pregnancy and up to one year after delivery
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