Role of integrated care in optimizing perinatal care delivery and virologic control in pregnant people with HIV during the COVID-19 pandemic

Abstract

Studies suggest the coronavirus 2019 (COVID-19) pandemic affected longitudinal care of pregnant people and people with HIV (PWH); however, the extent of changes in care delivery and virologic control of pregnant PWH during the pandemic remain unclear.1, 2 Multidisciplinary integrated care is one proposed mechanism to maintain stability and efficacy of care provision in the general obstetric population and PWH.3 We compared antenatal virologic control in a US integrated care clinic for pregnant PWH before versus during the COVID-19 pandemic to identify any pandemic-related disruptions that may inform future perinatal care delivery for this population. This retrospective cohort study included adult pregnant PWH who delivered ≥20 weeks' gestation and received care at a multidisciplinary integrated care obstetric infectious disease (OB ID) clinic (comprised of dedicated physicians, nurses, pharmacists, laboratory technicians, social workers, therapists), excluding those whose prenatal care overlapped both epochs. Pregnant PWH predominately received antiretroviral therapy (ART) prescriptions through mail-order pharmacy and had access to extended case management through Mother and Child Alliance (MACA) of Illinois. The primary outcome was viral suppression at delivery (nondetectable HIV RNA viral load by 36 weeks' gestation or within 4 weeks of delivery). Secondary outcomes included measures of adherence to perinatal care (prenatal/postpartum visit attendance and telehealth use) and additional measures of antepartum virologic control (mean viral load, self-reported ART adherence, directly observed therapy [DOT] required, time to achieve viral suppression, viral rebound after prior suppression). We compared outcomes between pregnant PWH who initiated prenatal care in or after March 2020 and delivered through March 2022, versus a referent sample that delivered from January 2016 through December 2019 (pre-pandemic epoch). A propensity score was used in multivariable regression models to control for relevant confounders (employment, immigrant status, ART use pre-pregnancy) across epochs. Among 86 eligible pregnant PWH, 26 (30.2%) delivered during the pandemic. This OB ID integrated care model of perinatal care delivery promoted high rates of viral suppression at delivery in the pre-pandemic and pandemic epochs (49/60, 81.7% vs. 26/26, 100%), with similar mean viral load across epochs (Figure 1). Median overall number of prenatal visits during the pandemic (11.5, interquartile range [IQR] 8-13) and pre-pandemic epochs (11, IQR 7-13) were similar (propensity score-adjusted beta-coefficient 1.10, 95% confidence interval [CI] -1.32-3.51), as was the frequency of postpartum visit attendance (25/26, 96.2% vs. 57/60, 95.0%; propensity score-adjusted adjusted odds ratio [aOR] 0.87, 95% CI 0.001-3.22). While telehealth was not used pre-pandemic, 42.3% (11/26) and 15.4% (4/26) of pregnant PWH had 1 and ≥2 prenatal visit(s) via telehealth in the pandemic, respectively, otherwise all visits were in-person; only 34.6% (9/26) had a telehealth, in lieu of in-person, postpartum visit during the pandemic. Similar proportions of pregnant PWH reported missing >5 doses of ART following prenatal care initiation (3/26, 11.5% vs. 19/58, 32.8%; aOR 0.36, 95% CI 0.06-2.10) and required DOT to support ART adherence (3/26, 11.5% vs. 7/60, 11.7%; aOR 0.75, 95% CI 0.11-5.13) in the pandemic versus pre-pandemic epochs. We did not identify differences in time to achieve viral suppression among PWH with viremia at prenatal care initiation, nor frequency of viral rebound in the overall cohort (Table 1). In a multidisciplinary integrated care OB ID clinic, pregnant PWH maintained stable HIV virologic control, with stable prenatal and postpartum visit adherence, during the pandemic compared to pre-pandemic. It is highly likely that access to multidisciplinary integrated care facilitated this observation. Supported by a coordinated network of clinical providers and community-based resources, MACA case managers are further positioned to assist pregnant PWH with transportation, cellular service, insurance coverage, drug assistance program enrollment, etc. that are critical for access to clinic and telehealth appointments, remote DOT (i.e. daily phone/video calls and/or text message reminders reinforcing ART adherence), and medications. Pre-pandemic literature affirms the association between integrated care and improved patient outcomes, including stability in ART adherence, in a similar cohort of pregnant PWH experiencing social vulnerability.4, 5 Our findings demonstrate the importance of continued multidisciplinary care coordination throughout the COVID-19 pandemic for pregnant PWH, a population subject to multiplicative adverse effects of a single disruption to their care. Study limitations include small sample size, limited generalizability to those without access to the multidisciplinary services unique to this clinic, and inability to assess outcomes in higher-risk individuals who did not engage in care during the pandemic. However, it is important to highlight the lack of overt compromise to HIV virologic control achieved with stable provision of integrated care to this cohort of pregnant PWH throughout the pandemic, which otherwise compounded socioeconomic and health inequities among vulnerable populations.