Abstract
BackgroundWith an increasing number of countries implementing Option B+ guidelines of lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women, there is urgent need to identify effective approaches for retaining this growing and highly vulnerable population in ART care.MethodsNewly postpartum, breastfeeding women who initiated ART in pregnancy and met eligibility criteria were enrolled, and offered the choice of two options for postpartum ART care: (i) referral to existing network of community-based adherence clubs or (ii) referral to local primary health care clinic (PHC). Women were followed at study measurement visits conducted separately from either service. Primary outcome was a composite endpoint of retention in ART services and viral suppression [VS < 50 copies/mL based on viral load (VL) testing at measurement visits] at 12 months postpartum. Outcomes were compared across postpartum services using chi-square, Fisher’s exact tests and Poisson regression models. The primary outcome was compared across services where women were receiving care at 12 months postpartum in exploratory analyses.ResultsBetween February and September 2015, 129 women (median age: 28.9 years; median time postpartum: 10 days) were enrolled with 65% opting to receive postpartum HIV care through an adherence club. Among 110 women retained at study measurement visits, 91 (83%) achieved the composite endpoint, with no difference between those who originally chose clubs versus those who chose PHC services. Movement from an adherence club to PHC services was common: 31% of women who originally chose clubs and were engaged in care at 12 months postpartum were attending a PHC service. Further, levels of VS differed significantly by where women were accessing ART care at 12 months postpartum, regardless of initial choice: 98% of women receiving care in an adherence club and 76% receiving care at PHC had VS < 50 copies/mL at 12 months postpartum (p = 0.001).ConclusionThis study found comparable outcomes related to retention and VS at 12 months postpartum between women choosing adherence clubs and those choosing PHC. However, movement between postpartum services among those who originally chose adherence clubs was common, with poorer VS outcomes among women leaving clubs and returning to PHC services.Trial registrationClinicalTrials.gov NCT02417675, April 16, 2015 (retrospectively registered).
Highlights
With an increasing number of countries implementing Option B+ guidelines of lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women, there is urgent need to identify effective approaches for retaining this growing and highly vulnerable population in ART care
Compared to women retained at study measurement visits, women lost to follow-up were significantly more likely to have opted to receive postpartum HIV care from a primary health care clinic (PHC) (63% versus 37%; p = 0.005)
Comparison of primary outcome across ART services Among the 110 women retained at study measurement visits, 91 (83%) achieved the composite endpoint of engagement in care and viral suppression (VS) at 12 months postpartum, with no difference between those who originally chose adherence clubs versus those who chose PHC services (84% versus 79%, respectively; p = 0.583; Table 2)
Summary
With an increasing number of countries implementing Option B+ guidelines of lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women, there is urgent need to identify effective approaches for retaining this growing and highly vulnerable population in ART care. Shifting guidelines away from CD4-guided antiretroviral therapy (ART) eligibility (Option A) to universal ART for HIV-infected pregnant and postpartum women (Option B+) has led to a significant increase in the number of women on ART during pregnancy and breastfeeding [1]. With an increasing number of countries implementing the Option B+ strategy and in turn managing a growing number of pregnant and postpartum women on ART, there is an urgent and critical need to identify effective approaches to retaining this highly vulnerable population
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