Adherence to antiretroviral therapy during and after pregnancy in low-income, middle-income, and high-income countries: a systematic review and meta-analysis

aDepartment of International Health bDepartment of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA cDepartment of Medicine dCentre for Infectious Diseases eCenter for Evidence-based Healthcare, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa fDepartment of Primary Care Sciences, Keele University, Staffordshire, UK gDepartment of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, Maryland, USA hHuman Sciences Research Council, Pretoria iUniversity of the Free State, Bloemfontein jDepartment of Pediatrics and Child Health, Tygerberg's Children Hospital, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa kFaculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada lTrend Research Centre, Asia University, Taichung, Taiwan mCentre for Infectious Disease Research, Lusaka, Zambia nUniversity of Alabama at Birmingham, Birmingham, Alabama, USA oAnova Health Institute, Johannesburg pSchool of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa qPediatric, Adolescent and Maternal AIDS Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA.
AIDS (London, England) (Impact Factor: 6.56). 08/2012; 26(16):2039-2052. DOI: 10.1097/QAD.0b013e328359590f
Source: PubMed

ABSTRACT OBJECTIVE:: To estimate antiretroviral therapy (ART) adherence rates during pregnancy and postpartum in high-income, middle-income, and low-income countries. DESIGN:: Systematic review and meta-analysis. METHODS:: MEDLINE, EMBASE, SCI Web of Science, NLM Gateway, and Google scholar databases were searched. We included all studies reporting adherence rates as a primary or secondary outcome among HIV-infected pregnant women. Two independent reviewers extracted data on adherence and study characteristics. A random-effects model was used to pool adherence rates; sensitivity, heterogeneity, and publication bias were assessed. RESULTS:: Of 72 eligible articles, 51 studies involving 20 153 HIV-infected pregnant women were included. Most studies were from United States (n = 14, 27%) followed by Kenya (n = 6, 12%), South Africa (n = 5, 10%), and Zambia (n = 5, 10%). The threshold defining good adherence to ART varied across studies (>80, >90, >95, 100%). A pooled analysis of all studies indicated a pooled estimate of 73.5% [95% confidence interval (CI) 69.3-77.5%] of pregnant women who had adequate (>80%) ART adherence. The pooled proportion of women with adequate adherence levels was higher during the antepartum (75.7%, 95% CI 71.5-79.7%) than during postpartum (53.0%, 95% CI 32.8-72.7%; P = 0.005). Selected reported barriers for nonadherence included physical, economic and emotional stresses, depression (especially postdelivery), alcohol or drug use, and ART dosing frequency or pill burden. CONCLUSION:: Our findings indicate that only 73.5% of pregnant women achieved optimal ART adherence. Reaching adequate ART adherence levels was a challenge in pregnancy, but especially during the postpartum period. Further research to investigate specific barriers and interventions to address them is urgently needed globally.


Available from: Yuh-Shan Ho, Dec 18, 2013
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: In 2011, Malawi implemented Option B+ (B+), lifelong antiretroviral therapy (ART) for pregnant and breast-feeding women. We aimed to describe changes in service uptake and outcomes along the antenatal PMTCT cascade post B+ implementation. Pre/post study using routinely collected program data from two large Lilongwe-based health centers. We compared testing of HIV-infected pregnant women at antenatal care, enrollment into PMTCT services, receipt of ART and six-month ART outcomes pre- (Oct 2009-Mar 2011) and post- (Oct 2011-Mar 2013) B+. A total of 13,926 (pre) and 14,532 (post) women presented to antenatal care. Post-B+ a smaller proportion were HIV tested (99.3% vs. 87.7% post-; p<0.0001). There were 1654 (pre) and 1535 (post) HIV-infected women identified, with a larger proportion already known to be HIV-infected (18.1% vs. 41.2% post-; p<0.001) and on ART post-B+ (18.7% vs. 30.2% post-; p<0.001). A significantly greater proportion enrolled into the PMTCT program (68.3% vs. 92.6% post-; p<0.001) and was retained through delivery post-B+ (51.1% vs. 65% post-; p<0.0001). Amongst those not on ART at enrollment there was no change in the proportion newly initiating ART/ARVs (79% vs. 81.9% post-; p=0.11); although median days to initiation of ART decreased (48d [19,130] vs. 0d [0,15.5] post-; p<0.001). Amongst those newly initiating ART, a smaller proportion was alive on ART six-months post-initiation (89.3% vs. 78.8% post-; p=0.0004). While several improvements in PMTCT program performance were noted with implementation of B+, challenges remain at several critical steps along the cascade requiring innovative solutions to ensure an AIDS-free generation.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 01/2015; DOI:10.1097/QAI.0000000000000517 · 4.39 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Among HIV-infected women, perinatal depression compromises clinical, maternal, and child health outcomes. Antiretroviral therapy (ART) is associated with lower depression symptom severity but the uniformity of effect through pregnancy and postpartum periods is unknown. Methods: We analyzed prospective data from 447 HIV-infected women (18–49 years) initiating ART in rural Uganda (2005–2012). Participants completed blood work and comprehensive questionnaires quarterly. Pregnancy status was assessed by self-report. Analysis time periods were defined as currently pregnant, postpartum (0–12 months post-pregnancy outcome), or non–pregnancy-related. Depression symptom severity was measured using a modified Hopkins Symptom Checklist 15, with scores ranging from 1 to 4. Probable depression was defined as >1.75. Linear regression with generalized estimating equations was used to compare mean depression scores over the 3 periods. Results: At enrollment, median age was 32 years (interquartile range: 27–37), median CD4 count was 160 cells per cubic millimeter (interquartile range: 95–245), and mean depression score was 1.75 (s = 0.58) (39% with probable depression). Over 4.1 median years of follow-up, 104 women experienced 151 pregnancies. Mean depression scores did not differ across the time periods (P = 0.75). Multivariable models yielded similar findings. Increasing time on ART, viral suppression, better physical health, and “never married” were independently associated with lower mean depression scores. Findings were consistent when assessing probable depression. Conclusions: Although the lack of association between depression and perinatal periods is reassuring, high depression prevalence at treatment initiation and continued incidence across pregnancy and non–pregnancy-related periods of follow-up highlight the critical need for mental health services for HIV-infected women to optimize both maternal and perinatal health.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 12/2014; 67(Suppl 4):S179-S187. DOI:10.1097/QAI.0000000000000370 · 4.39 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Women living with HIV continues to encounter unintended pregnancies with a concomitant risk of mother-to-child transmission of HIV infection. Preventing unintended pregnancy among HIV-infected women is one of the strategies in the prevention of new HIV infections among children. The aim of this analysis was to assess the practice of family planning (FP) among HIV-infected women and the influence of women’s awareness of HIV positive status in the practice of FP. Methods: The analysis was made in the Malawi Demographic and Health Survey (DHS) data among 489 non-pregnant, sexually active, fecund women living with HIV. Multiple logistic regression analysis was performed using SPSS software to identify the factors associated with FP use. Adjusted odds ratios (AOR) with 95 % confidence intervals were computed to assess the association of different factors with the practice of family planning. Result: Of the 489 confirmed HIV positive women, 184 (37.6 %) reported that they knew that they were HIV positive. The number of women who reported that they were currently using FP method(s) were 251 (51.2 %). The number of women who reported unmet need for FP method(s) were 107 (21.9 %). In the multiple logistic regression analysis, women’s knowledge of HIV positive status [AOR: 2.32(1.54, 3.50)], secondary and above education [AOR: 2.36(1.16, 4.78)], presence of 3–4 alive children [AOR: 2.60(1.08, 6.28)] and more than 4 alive children [AOR: 3.03(1.18, 7.82)] were significantly associated with current use of FP. Conclusion: Women’s knowledge of their HIV-positive status was found to be a significant predictor of their FP practice. Health managers and clinicians need to improve HIV counselling and testing coverage among women of child-bearing age and address the FP needs of HIV-infected women.
    Reproductive Health 05/2015; 12(41). DOI:10.1186/s12978-015-0035-6 · 1.62 Impact Factor