HIV-infected Postpartum Women Research Articles

Perceived Barriers to Antepartum HIV Medication Adherence in HIV Infected Pregnant Women.

Introduction Although rare, perinatal HIV transmission still occurs in the United States and most transmissions are preventable. We aim to identify patient barriers to antiretroviral therapy (ART) adherence during pregnancy and assess patient understanding of perinatal transmission. Methods This cross-sectional survey recruited HIV positive postpartum women at a large safety net hospital in Atlanta, Georgia, between January 2016 and February 2018. Survey questions included demographic characteristics, HIV history, knowledge of perinatal transmission, and ART adherence. Perinatal and HIV outcomes were assessed using chart abstraction. Results Of the 70 HIV infected postpartum women delivered at a large safety net hospital in Atlanta, GA, 45 women were eligible and consented to participate. Participating women were aged 18 to 40 years with an average age of 29 years old, 93% of participants were African-American, and 68% had ≥3 pregnancies. The majority of participants (75%) reported daily ART adherence. “Forgetting” was the most frequent reason for missing pills (57%). Thirteen women had a detectable viral load at the time of delivery and nine of those women had a viral load greater than 1000 copies/mL. Approximately 85% of women who correctly stated ART medications decrease perinatal transmission risk reported daily adherence compared with 50% of women without that knowledge (OR 5.6, 95% CI 1.17, 26.7). Almost half of women (40%) either did not know or believed a vaginal delivery, regardless of viral load, would increase their risk of perinatal transmission. Conclusion Overall, women who were diagnosed with HIV during the current pregnancy, those with planned pregnancies, and those who were on medications prior to pregnancy were more likely to report daily ART adherence. Detectable viral load at delivery is the greatest risk factor for perinatal transmission; therefore strategies to increase ART adherence are needed.

Reproductive decision-making among postpartum HIV-infected women in rural South Africa.

Despite pregnancy spacing recommendations to optimize health outcomes among mothers and neonates, unplanned pregnancy in sub-Saharan Africa is common among women living with human immunodeficiency virus (HIV) (WLHIV). This study examined factors associated with reproductive decision-making among WLHIV to inform pregnancy-planning interventions. WLHIV in rural South Africa (n = 165) were assessed at 12 months postpartum. The relative importance of factors associated with reproductive decision-making was estimated. Women were a mean of 28 years old (SD = 5.71). Risk of mother-to-child transmission (MTCT) of HIV (Mean = 0.43; SD = 0.33) had the greatest impact on decision-making, followed by partners' desires (M = 0.22; SD = 0.18), family preferences (M = 0.18; SD = 0.13), and community opinion (M = 0.17; SD = 0.13). MTCT was most important to women with greater HIV knowledge. However, WLHIV who had been diagnosed with HIV for a longer time placed more emphasis on partner preference and community opinion, and less importance on MTCT risk. Prevention of mother-to-child transmission (PMTCT) was less important to women experiencing intimate partner violence and those with depression. Findings highlight the need for tailored, focused interventions to support the unique circumstances of WLHIV and support the inclusion of families and/or partners in the counseling process. Results underscore the need for perinatal preconception counseling for women during routine HIV care.

Short-term effectiveness of a community health worker intervention for HIV-infected pregnant women in Tanzania to improve treatment adherence and retention in care: A cluster-randomized trial.

IntroductionCommunity health workers (CHWs) are lay workers who have the potential to enhance services to prevent mother-to-child HIV transmission (PMTCT) and improve the health of women living with HIV infection. We conducted a cluster-randomized trial of an intervention to integrate CHWs with ‘Option B+’ PMTCT services in Shinyanga Region, Tanzania.MethodsThe intervention was implemented for 11 months and included four integrated components: 1) formal linkage of CHWs to health facilities; 2) CHW-led antiretroviral therapy (ART) adherence counseling; 3) loss to follow-up tracing by CHWs; and 4) distribution of Action Birth Cards (ABCs), a birth planning tool. We cluster-randomized 32 facilities offering PMTCT services, within strata of size, to the intervention (n = 15) or comparison (standard of care, n = 17) groups. Intervention effectiveness was determined with a difference-in-differences strategy based on clinical and pharmacy data from HIV-infected postpartum women at baseline (births in 2014) and endline (births April-Oct 2015). The primary outcome was retention in care between 60 and 120 days postpartum. Secondary outcomes included ART initiation, timing of ART initiation (as measured by week of gestation), and ART adherence 90 days postpartum, measured using the medication possession ratio (MPR≥95%).ResultsIntervention and comparison facilities were similar at baseline. Data were collected from 1,152 and 678 mother-infant pairs at baseline and endline, respectively. There were no significant differences in retention in care, ART initiation, or timing of ART initiation between the intervention and control groups. Adherence (MPR≥95%) at 90 days postpartum was 11.3 percentage points higher in the intervention group in ITT analyses (95% CI: -0.7, 23.3, p = 0.06), though this effect was attenuated after adjusting for baseline imbalance (9.5 percentage points, 95% CI: -2.9, 22.0, p = 0.13). Among only sites that had the greatest fidelity to the intervention, however, we found a stronger effect on adherence (13.6 percentage points, 95% CI: 2.5, 24.6).ConclusionsDespite being feasible and acceptable, the CHW-based intervention did not have strong effects on most PMTCT indicators. CHW involvement in PMTCT programs may improve ART adherence among HIV-infected postpartum women, however, and success appears heavily dependent on program implementation.Trial registrationRegistry for International Development Impact Evaluations (RIDIE, ID 552553838b402) and ClinicalTrials.gov (NCT03058484)

HIV and reproductive healthcare in pregnant and postpartum HIV-infected women: adapting successful strategies.

Linkage and retention in care for many HIV-infected women in the postpartum period is suboptimal, which compromises long-term virologic suppression and the HIV Care Continuum. Efforts are needed to improve individual outcomes by addressing transitions in care. We summarize some successful strategies to engage and retain HIV-infected women in care during the postpartum period.

Postpartum Engagement in HIV Care: An Important Predictor of Long-term Retention in Care and Viral Suppression.

Human immunodeficiency virus (HIV)-infected women are at risk of virologic failure postpartum. We evaluated factors influencing retention in care and viral suppression in postpartum HIV-infected women. We conducted a retrospective cohort analysis (2005-2011) of 695 deliveries involving 561 HIV-infected women in Philadelphia. Multivariable logistic regression evaluated factors, including maternal age, race/ethnicity, substance use, antiretroviral therapy during pregnancy, timing of HIV diagnosis, previous pregnancy with HIV, adequacy of prenatal care, and postpartum HIV care engagement (≥ 1 CD4 count or viral load [VL] test within 90 days of delivery), associated with retention in care (≥ 1 CD4 count or VL test in each 6-month interval of the period with ≥ 60 days between tests) and viral suppression (VL ≤ 200 copies/mL at the last measure in the period) at 1 and 2 years postpartum. Overall, 38% of women engaged in HIV care within 90 days postpartum; with 39% and 31% retained in care and virally suppressed, respectively, at 1 year postpartum, and 25% and 34% retained in care and virally suppressed, respectively, at 2 years postpartum. In multivariable analyses, women who engaged in HIV care within 90 days of delivery were more likely to be retained (adjusted odds ratio [AOR], 11.38; 95% confidence interval [CI], 7.74-16.68) and suppressed (AOR, 2.60 [95% CI, 1.82-3.73]) at 1 year postpartum. This association persisted in the second year postpartum for both retention (AOR, 6.19 [95% CI, 4.04-9.50]) and suppression (AOR, 1.40 [95% CI, 1.01-1.95]). The prevalence of postpartum HIV-infected women retained in care and maintaining viral suppression is low. Interventions seeking to engage women in care shortly after delivery have the potential to improve clinical outcomes.

Incidence and correlates of tuberculosis IGRA conversion among HIV-infected postpartum women

Prevention of maternal-to-child transmission program at a tertiary care hospital in Nairobi, Kenya. The risk of acquiring Mycobacterium tuberculosis infection among peripartum human immunodeficiency virus (HIV) infected women is poorly defined. To determine the incidence of and co-factors for interferon-gamma release assay (IGRA) conversion among postpartum HIV-infected women using T-SPOT.TB. We used data and cryopreserved peripheral blood mononuclear cells from a historical cohort of HIV-infected women enrolled at 32 weeks' gestation and followed for 1 year postpartum between 1999 and 2005. Of 89 women initially IGRA-negative during pregnancy, 11 (12.4%) became positive, 53 (59.5%) remained negative and 25 (28.1%) were indeterminate at 1 year postpartum. Mean interferon-gamma (IFN-γ) response among converters increased from ~1 to >50 spot-forming cells/well (P = 0.015). IGRA conversion was significantly associated with partner HIV infection, flush toilets, maternal illness and cough during follow-up, but not maternal CD4 count or HIV viral load. The high rates of IGRA conversion seen among HIV-infected postpartum women in our study are similar to those of other groups at high risk for M. tuberculosis infection. This has important implications for M. tuberculosis infection screening strategies and provision of preventive therapy for the health of women and their infants.

Health care-seeking behaviour of HIV-infected mothers and male partners in Nairobi, Kenya

Health care-seeking behaviours of HIV-infected mothers in sub-Saharan Africa are poorly characterised and typically focus on individual health conditions rather than overall health. We conducted a qualitative study to understand how HIV-infected mothers, their male partners and their HIV-exposed infants seek medical services. We performed 32 in-depth interviews (17 female, 15 male) and four focus group discussions among HIV-infected post-partum women and their male partners in Nairobi, Kenya. We used a grounded theory approach to explore the paths followed for health-related concerns. Female participants reported that willingness to be tested for HIV influences whether women sought antenatal care and the type of facility they preferred for childbirth. The need for medical care outside regular clinic hours and securing safe transportation at night were also significant barriers to seeking care. Most men sought services from traditional healers and chemists before HIV diagnosis, and at governmental facilities afterwards. Both men and women sent infants to traditional healers for non-medical conditions such as bewitching and massage but rarely for medical conditions. Strategies to reduce HIV-related stigma and fears in antenatal and maternity settings, increase access to care after-hours and improve linkage to HIV care for men early in their infection are needed.

The association between the ratio of monocytes: lymphocytes and risk of tuberculosis among HIV-infected postpartum women.

Recent human studies support historical animal studies that suggested an association between peripheral blood monocyte:lymphocyte (ML) ratio and tuberculosis (TB) disease. To evaluate generalizability of this finding, we modeled the association between peripartum ML ratio and incident TB disease within 18 months postpartum among 1202 HIV-infected women in South Africa, Tanzania, Uganda, and Zimbabwe. The ML ratio was associated with increased risk of TB disease independently to combination antiretroviral therapy, World Health Organization stage, or CD4 count (adjusted hazard ratio = 1.22, 95% confidence interval: 1.07 to 1.4, P = 0.003 per 0.1 unit increase in ML ratio).

Effect of HIV status on fertility desire and knowledge of long-acting reversible contraception of postpartum Malawian women

The objectives of this study were to describe the most recent pregnancy intentions and family planning preferences of HIV-infected and HIV-uninfected postpartum Malawian women, and to assess whether HIV status is associated with fertility desire and knowledge of intrauterine contraception (IUC) and the subdermal contraceptive implant. We conducted a cross-sectional analysis of the baseline characteristics of Malawian women enrolled in a prospective cohort study assessing postpartum contraceptive uptake and continuation. Women at a government hospital completed a baseline survey assessing reproductive history, family planning preferences, and knowledge of IUC and the implant. We used Pearson's chi-square tests to compare these parameters between HIV-infected and HIV-uninfected women. Modified Poisson regression was performed to assess the association between HIV status and fertility desire and knowledge about IUC and the implant. Of 634 postpartum women surveyed, HIV-infected women were more likely to report their most recent pregnancy was unintended (49% vs. 37%, p = 0.004). Nearly all women (97%) did not want a child in the next 2 years, but HIV-infected women were more likely to desire no more children (adjusted prevalence ratio [PR]: 1.59; 95% confidence interval [CI]: 1.33, 1.89). HIV-infected women were also less likely to know that IUC (adjusted PR: 0.72; 95% CI: 0.61, 0.84) and the implant (adjusted PR: 0.83; 95% CI: 0.75, 0.92) are safe during breast-feeding. Postpartum women strongly desire family spacing and many HIV-infected postpartum women desire no more children, suggesting an important role for these long-acting methods. Education about the efficacy and safety of IUC and the implant particularly during breast-feeding may facilitate postpartum use.

Maximizing benefits of new strategies to prevent mother-to-child HIV transmission without harming existing services.

Maximizing benefits of new strategies to prevent mother-to-child HIV transmission without harming existing services.

A qualitative study on factors impacting HIV care adherence among postpartum HIV-infected women in the rural southeastern USA

Declines in HIV care and treatment adherence among HIV-infected women from pregnancy to the postpartum period have significant implications for the clinical outcomes and overall well-being of HIV-infected women, especially due to immunosuppression during the postpartum period. While the overall increased risk for mortality associated with HIV care discontinuation is well established, the reasons for HIV care nonadherence among HIV-infected postpartum women are largely unknown. Eighteen HIV-infected women were recruited from four clinics in Alabama to participate in focus groups or individual interviews to discuss barriers and facilitators impacting postpartum HIV care adherence. Sessions were audio-recorded, transcribed, and coded; content analysis was used to analyze the verbatim transcripts. Mixed methods analysis procedures were used to triangulate data from three sources (focus group transcripts, individual rankings of barriers and facilitators according to the Nominal Group Technique, and individual questionnaires of sociodemographic and adherence data). The majority of participants were African-American (83.3%), single (66.7%), with more than half of the participants living on less than $1000 a month (55.6%). Barriers to retention in HIV care included access to and cost of transportation and fitting HIV care into work and childcare schedules. Facilitators to HIV care adherence included wanting to stay healthy for their own well-being as well as for the care of their children, receiving family support, and appointment reminders. The current study highlights contextual factors contributing to poor HIV care adherence among HIV-infected postpartum women. Intervention studies need to be cognizant of the specific needs of HIV-infected postpartum women to improve long-term clinical outcomes among this population, who have children.

Improving retention in the early infant diagnosis of HIV program in rural Mozambique by better service integration.

Low mother/infant retention has impeded early infant diagnosis of HIV in rural Mozambique. We enhanced the referral process for postpartum HIV-infected women by offering direct accompaniment to the location of exposed infant testing before discharge. Retrospective record review for 395 women/infants (September 2009 to June 2010) found enhanced referral was associated with higher odds of follow-up (adjusted odds ratio = 3.18, 95% confidence interval: 1.76 to 5.73, P < 0.001); and among those followed-up, earlier infant testing (median follow-up: 33 days vs. 59 days, P = 0.01) compared with women receiving standard referral. This simple intervention demonstrates benefits gleaned from attention to system improvement through service integration without increasing staff.

Universal antiretroviral therapy among pregnant and postpartum HIV-infected women would improve maternal health and decrease postnatal HIV transmission

In a recent issue of AIDS, the Zvitambo study group from Zimbabwe showed increased post-partum mortality among HIV-infected women with high CD4 count who were not eligible for and not receiving antiretroviral therapy (ART), compared to HIV-uninfected post-partum women from the same population [1]. In the two years post-partum, the adjusted mortality hazard ratio (95% confidence interval) was 7.3 (3.6-15.1) among HIV-infected women with baseline CD4 between 600 and 800 cells/ml, compared to the reference category of HIV uninfected women [1]. The authors therefore argued the case for early ART initiation among all pregnant and post-partum women in Africa, irrespective of CD4 count or treatment eligibility. We entirely agree with this interpretation of their findings, in particular because such a strategy would also contribute to the elimination of paediatric HIV in breastfeeding populations. To prove this point, we combined data from two cohorts in South [2] and West Africa [3] to evaluate mother-to-child transmission (MTCT) risk through breastfeeding [4]. Similar to the Zvitambo trial, maternal ART was unavailable at the time of the study in these two populations. In this pooled analysis, breastfeeding duration was a median of 6.4 months (inter-quartile range: 4.4-12.4), shorter than usually observed in African settings; postnatal transmission rates were thus similarly lower than seen elsewhere. Overall, 70% of these HIV-infected pregnant breastfeeding women had CD4 counts above 350 cells/ml (Table 1), and would therefore not have been eligible for ART for their own health according to the most recently agreed international recommendations [5]. In the absence of ART intervention, the cumulative risk of HIV transmission through breastfeeding in the first 18 months of life was substantial in this group (4.8%), despite there high CD4 count, accounting for 53% of all cases of breastfeeding transmission (the remaining 47% of postnatal transmission cases occurred among women with <350 CD4 cells/ml). Further, even women with baseline CD4 counts above 500 or above 700 cells/ml were at substantial risk of postnatal transmission (Table 1). These findings highlight the crucial need for an antiretroviral-based interventions also among women with higher CD4 counts, so that the risk of HIV transmission can be significantly reduced for all HIV-exposed infants. If ART had been provided to these women with CD4 counts over 350, the expected MTCT rate would have been at least halved, as per European experience [6]. Table 1 18-month postnatal HIV transmission risk among uninfected children at four weeks of age according to different thresholds of maternal antenatal CD4 count. Pooled analysis of the Vertical Transmission Study (South Africa, 2001-2007) and the ANRS 1202 Ditrame ... In the recently released WHO guidelines on the use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants, two options of similar efficacy are offered for women with CD4 count above the 350 CD4 treatment eligibility threshold [7]. Option A consists in providing maternal zidovudine prophylaxis from the second trimester of pregnancy until delivery, followed by daily oral nevirapine to the breastfed infant until all breastfeeding has ceased. Option B consists of the provision of maternal triple antiretroviral prophylaxis (as per ART for treatment) starting from the second trimester of pregnancy until all exposure to breast milk has ended. The new results from the Zvitambo study clearly support the initiation of triple antiretroviral prophylaxis among all pregnant women and continued throughout breastfeeding exposure, following option B, not only to prevent mother-to-child HIV transmission and enable safer breastfeeding practices, but importantly also to improve maternal health. Both eligible and ineligible women would then be receiving the same triple antiretroviral regimen, which would make this universal strategy easier to implement at a population level [8]. However, in a context where all pregnant women would be offered triple antiretroviral regimens, the question of whether and when to stop this intervention in women who are not eligible for ARV treatment according to the current international guidelines is of particular interest. The risk for maternal health of stopping maternal triple ARV prophylaxis after breastfeeding cessation among women with high CD4 count is unknown. Hence, this strategy would need to be assessed in carefully conducted field studies in terms of acceptability, efficiency and maternal and infant safety.

Intensified Case Finding for Tuberculosis in Prevention of Mother-to-Child Transmission Programs: A Simple and Potentially Vital Addition for Maternal and Child Health

The intersection of HIV and tuberculosis (TB) poses a serious threat to HIV-infected women and their children. The majority of patients with TB in sub-Saharan Africa are infected with HIV and together the overlapping epidemics synergistically accelerate illness and death. Escalating case rates increased mortality and the recent emergence of extensively drug-resistant TB highlights how catastrophic a once preventable and curable disease has become among people with HIV/AIDS. The HIV epidemic requires new strategies to control TB in high-burden areas especially as women of reproductive age are disproportionately affected by the epidemic. Intensified case finding for TB has the potential to reduce morbidity and mortality for people living with HIV especially pregnant women their families and infants. (excerpt)

Adherence to antiretroviral treatment among pregnant and postpartum HIV-infected women

Among women with HIV infection, pregnancy is a time when maintenance of maternal health and reduction of vertical HIV transmission are primary concerns. Few studies have examined adherence to Antiretroviral Treatment (ART) during pregnancy and in the postpartum period when the demands of childcare may significantly interfere with women's self-care behaviors. This study examined ART use and adherence in HIV-infected pregnant and postpartum women participating in the Women and Infants Transmission Study (WITS-IV) in the US. Adherence was assessed through a self-report interview during the third trimester of pregnancy and six-month postpartum. Data were also collected on demographics, biomedical markers and health related symptoms. During the third trimester visit, 77% (309/399) of women completed the self-report adherence measure; 61% (188/309) reported complete adherence. Factors associated with non-adherence included advanced HIV disease status, higher HIV-RNA viral load, more health-related symptoms and alcohol and tobacco use. At six-month postpartum, 55% (220/399) completed the measure; 44% (97/220) of these women reported complete adherence. Factors associated with non-adherence during the postpartum period were ethnicity, more health-related symptoms and WITS clinical site. Results of multivariate analyses using Generalized Estimated Equation analyses across the two visits revealed that more health-related symptoms, higher HIV-RNA viral load, increased alcohol use and clinical site were independently associated with ART non-adherence. These analyses indicate that medication adherence is more likely during pregnancy than postpartum in HIV-infected women, perhaps provoked by motivation to reduce vertical transmission and/or intensive antepartum surveillance. Further investigation is warranted to clarify factors implicated in women's decision-making process regarding ART medication adherence.

Effect of Antibiotic Treatment of Subclinical Mastitis on Human Immunodeficiency Virus Type 1 RNA in Human Milk

Although subclinical mastitis is associated with increased HIV load in breast milk, it is not known whether empirical treatment with antibiotics will reduce breast milk HIV load. We examined the effect of antibiotic treatment for subclinical mastitis on HIV load in breast milk. Seventy-five HIV-infected post-partum women in Malawi with subclinical mastitis were treated with oral amoxicillin/clavulanic acid and were followed between 1 and 24 weeks later. Breastmilk HIV-1 load and sodium concentration were measured and microbiological studies were performed at presentation. At 1 week (n = 34), the proportion of women with elevated breast milk leukocyte counts decreased significantly to 41.2% (p < 0.0001) and there was a nonsignificant increase in breast milk HIV-1 RNA load (p = 0.9264) and sodium concentration (p = 0.08) in the affected breast. At 4 to 12 weeks (n = 63), breast milk HIV-1 RNA load and sodium concentration decreased significantly (p < 0.05) and 17.5% had elevated breast milk leukocyte counts. Treatment with amoxicillin/clavulanic acid was associated with a significant decrease in inflammation of the breast, but breast milk HIV load remained elevated despite a significant decrease from baseline. These findings have important implications regarding how mothers should be counselled on safety of resuming breastfeeding after resolution of subclinical mastitis.

Evaluating Programs to Prevent Mother-to-Child HIV Transmission in Two Large Bangkok Hospitals, 1999-2001

The 2 largest maternity hospitals in Bangkok implemented comprehensive programs to prevent mother-to-child HIV transmission in 1998. We conducted a cross-sectional survey of post-partum HIV-infected women in 1999 through 2001 to evaluate these programs. Women were given structured interviews at 0 to 3 days, 1 month, and 2 months postpartum. Medical records of women and their newborns were reviewed. Of 488 enrolled women, 443 (91%) had antenatal care: 391 (88%) at study hospitals and 52 (12%) elsewhere. The HIV diagnosis was first known before pregnancy for 61 (13%) women, during pregnancy for 357 (73%) women, during labor for 22 (5%) women, and shortly after delivery for 48 (10%) women. Antenatal zidovudine (ZDV) was used by 347 (71%) women, and intrapartum ZDV was used by 372 (76%) women. Twelve (55%) of the 22 women who first learned of their HIV infection during labor took intrapartum ZDV. All 495 newborn infants started prophylactic ZDV; the first dose was given within 12 hours for 491 (99%) children. Ten (2%) children were breast-fed at least once by their mother, and 10 (2%) were breast-fed at least once by someone else. Although uptake of services was high, inconsistent antenatal care, fear of stigmatization, and difficulty in disclosing HIV status prevented some women from using services.

Maternal health factors and early pediatric antiretroviral therapy influence the rate of perinatal HIV-1 disease progression in children.

To determine the relationship of maternal health factors and infant antiretroviral treatment to the risk of pediatric disease progression to AIDS or death by 24 months of age. Prospective perinatal HIV-1 transmission and pediatric natural history study. Urban medical centers in four cities in the USA. A total of 2656 pregnant and postpartum HIV-infected women enrolled in the Perinatal AIDS Collaborative Transmission Study (PACTS) and 360 children determined to be HIV-infected. Pediatric AIDS or death by 24 months of age. Children born to mothers with class C disease, CD4 cell count < 200 x 106/l, or HIV-1 RNA viral load > 100 000 copies/ml progressed more rapidly than children born to mothers with less advanced disease. In a multivariate analysis, there was an increased risk of progression if mothers had Class C disease [relative risk (RR), 1.7; 95% confidence interval (CI), 1.0-2.7] or HIV-1 RNA > 100 000 copies/ml (RR, 2.4; 95% CI, 1.2-4.6) controlling for child antiretroviral therapy and year of birth. Earlier years of birth significantly increased the likelihood of rapid progression (P = 0.01) in this multivariate model. Children who received combination antiretroviral therapies with a protease inhibitor or non-nucleoside reverse transcriptase inhibitor were significantly less likely to progress compared with those receiving no therapy (P = 0.03). HIV-1-infected infants born to women with advanced HIV-1 disease were at increased risk for rapid disease progression. More recent birth year and early treatment with potent antiretroviral therapy significantly diminished the likelihood of developing AIDS or dying during early childhood.

Antiretroviral use and pharmacy-based measurement of adherence in postpartum HIV-infected women.

Antiretroviral treatment for HIV-infected women is standard during pregnancy to prevent vertical transmission, but data on postpartum therapy for the mother are lacking. The objective of this study was to examine the impact of provider and patient characteristics on receipt of antiretroviral therapy and pharmacy-based measurement of adherence by postpartum HIV-infected women. This was a retrospective cohort study. The study included 2,648 New York State Medicaid-enrolled HIV-infected women who delivered from January 1993 through October 1996 and were followed up through September 1997. From Medicaid claims in the first postpartum year, the study examined any prescribed antiretroviral therapy and, among women treated >2 months, adherence, defined as > or =80% days covered by prescribed therapy from first to last antiretroviral prescription. Antiretroviral therapy was prescribed for 681 (26%) study women. Of 292 women treated >2 months, 28% were adherent on the basis of the pharmacy-based measure. The proportion of treated women was highest in 1996 (40%), and adherence was best in 1995 (44%) when most women took monotherapy. The adjusted odds ratios (AORs) of treatment were 1.67 (95% CI, 1.24 to 2.25) for women receiving HIV-focused services and 2.71 (95% CI, 1.99 to 3.69) for women with a provider in an HIV-related specialty. The AORs of adherence were greater for women with HIV-focused services (2.13; 95% CI, 1.05 to 4.30) and for former illicit drug users versus nonusers (2.40; 95% CI, 1.05 to 5.50). This population-based pharmacy analysis reveals improving antiretroviral use but continuing poor pharmacy-based adherence by postpartum HIV-infected women. Receipt of HIV-focused services appears to be particularly beneficial in increasing the likelihood of treatment and adherence.