Group Antenatal Care for Improving Retention of Adolescent and Young Pregnant Women Living With HIV in Kenya

Abstract

Background: Pregnant and breastfeeding adolescents and young women living with HIV (AYWLH) have lower retention in prevention of mother-to-child transmission (PMTCT) services compared to older women. Methods: We evaluated a differentiated service model for pregnant and breast feeding AYWLH at seven health facilities in western Kenya. All pregnant AYWLH <25 years presenting for antenatal care (ANC) were invited to participate in group ANC visits including health education, self-care (measuring own weight and blood pressure), and peer-led support sessions conducted by health facility nurses per national guidelines. Antiretroviral treatment (ART) register data were used to assess loss to follow-up (LTFU) among newly-enrolled pregnant adolescent (<20 years) and young women (20-24 years) living with HIV starting ART in the pre- period (January-December 2016) and post-period (during implementation; December 2017-January 2019). Poisson regression models compared LTFU incidence rate ratios (IRR) in the first six months after PMTCT enrollment and risk ratios compared uptake of six week testing for HIV-exposed infants (HEI) between the pre- and post-periods (models adjusted for known predictors of LTFU and were examined separately by age group). Results: In the pre-period, 223 (63·2%) of 353 pregnant AYWLH <25 years newly enrolled in ANC had ART information, while 320 (71·1%) of 450 in the post-period had ART data (p=0·02). A higher proportion of women in the post-period (62·8%) had known HIV-positive status at first ANC visit compared to 49·3% in the pre-period (p<0·001). Among pregnant AYWLH <20 years, the incidence rate of LTFU in the first six months after enrollment in ANC services declined from 2·36 per 100 person months (95%CI 1·06-5·25) (14·2% lost by 6 months) in the pre-period to 1·41 per 100 person months (95%CI 0·53-3·77) (6·8% by six months) in the post-period. In both univariable and multivariable analysis, AYWLH <20 years in the post-period were almost 40% less likely to be LTFU compared to the pre-period, although this finding did not meet the threshold for statistical significance (adjusted incidence rate ratio 0·62, 95%CI 0·38-1·01, p=0·057). Testing for HEI was 10% higher overall in the post-period (adjusted risk ratio 1·10, 95%CI 1·01-1·21, p=0·04). Discussion: Interventions are urgently needed to improve outcomes among pregnant and postnatal AYWLH. We observed a trend towards increased retention among pregnant adolescents during our intervention and a statistically significant increase in uptake HEI testing at six weeks. Funding Statement: This project was supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) through the US Centers for Disease Control and Prevention (CDC) under the terms of Cooperative Agreement number U2GGH00994. Declaration of Interests: None of the authors have competing interests. Ethics Approval Statement: This study was reviewed and approved by the CDC Institutional Review Board (IRB) (protocol #7011·0). The study was also approved by the IRB at the Columbia University Irving Medical Center and the Kenya Medical Research Institute (KEMRI). A waiver of consent was granted for use of routinely collected retrospective data for the evaluation.