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Background:
Prevention of mother-to-child transmission of HIV implementation faces significant challenges globally, particularly in the context of universal lifelong antiretroviral therapy (ART) for all HIV-infected pregnant women.
Methods:
We describe the rationale and methods of the Maternal and Child Health-Antiretroviral Therapy (MCH-ART) st...
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Background. Antiretroviral therapy (ART) initiation is critical for the prevention of mother-to-child transmission (PMTCT) of HIV. Objectives. To quantify factors that were barriers or facilitators to the initiation of ART in pregnant HIV-infected women in Swaziland. Methods. We conducted a cross-sectional survey in HIV-infected women with at least...
Background: Antiretroviral therapy (ART) initiation is critical for the prevention of mother-to-child transmission (PMTCT) of HIV.
Objectives: To quantify factors that were barriers or facilitators to the initiation of ART in pregnant HIV-infected women in Swaziland.
Methods: We conducted a cross-sectional survey in HIV-infected women with at lea...
Background:
Universal antiretroviral therapy (ART) for all pregnant/ breastfeeding women living with Human Immunodeficiency Virus (HIV), known as Prevention of mother-to child transmission of HIV (PMTCT) Option B+ (PMTCTB+), is being scaled up in most countries in Sub-Saharan Africa. In the transition to PMTCTB+, many countries face challenges wit...
Citations
... This analysis draws on data from the MCH-ART trial, which evaluated integrated services during the postpartum period. The design and primary results of the trial have been previously reported [12,34]. Briefly, the study was conducted in a primary care antenatal clinic in the community of Gugulethu, Cape Town, where an antenatal HIV prevalence of ~ 30% has been reported [35]. ...
In a randomised trial, we found that integrated maternal HIV and infant health services through the end of breastfeeding were significantly associated with the primary outcome of engagement in HIV care and viral suppression at 12 months postpartum, compared to the standard of care. Here, we quantitatively explore potential psychosocial modifiers and mediators of this association. Our findings suggest that the intervention was significantly more effective among women experiencing an unintended pregnancy but did not improve outcomes among women reporting risky alcohol use. Although not statistically significant, our results suggest that the intervention may also be more effective among women experiencing higher levels of poverty and HIV-related stigma. We observed no definitive mediator of the intervention effect, but women allocated to integrated services reported better relationships with their healthcare providers through 12 months postpartum. These findings point to high-risk groups that may benefit the most from integrated care, as well as groups for whom these benefits are hampered and that warrant further attention in intervention development and evaluation.
... The MCH-ART study evaluated the impact of integrating maternal ART and child health services postpartum (Myer et al. 2016. Immediately after delivery, participants were randomized to receive one of two postpartum models of care: the MCH-ART intervention or the local standard of care. ...
IntroductionRetaining postpartum women living with HIV in ongoing care is critical for the health of the mother–child dyad but low adherence to antiretroviral therapy (ART) and retention in HIV care are a global concern. This issue is particularly salient in South Africa, where approximately 50% of women fall out of the care cascade by 6 months postpartum. The purpose of this secondary analysis is to understand the strategies that women use to navigate HIV care during the postpartum period.Methods
This study was conducted in Gugulethu, in Cape Town, South Africa. In-depth interviews were conducted with 21 study participants at 18-months postpartum. Participants were interviewed about their perceptions and experiences of their postpartum HIV care, and barriers and facilitators to their adherence and retention.ResultsAll participants reported using care navigation strategies across a spectrum of individual, interpersonal and structural levels to remain retained in care and adherent to ART. Participants expressed the importance of individual empowerment and knowledge of treatment benefits for their HIV care. Interpersonal relationships were discussed as a pathway to access both psychosocial and tangible support. Participants described overcoming structural barriers to care through creative problem solving and identified opportunities for care delivery improvement.DiscussionParticipants described a wide range of overlapping and interconnected care navigation strategies. Consistent with the assets model, participants discussed their own capacity and that of their communities to engage in lifelong HIV care. Better understanding of potentially successful individual care navigation strategies should guide future intervention work. Trial Registration: ClinicalTrials.gov NCT01933477
... The Long-term Adherence and Care Engagement (LACE) study took place from April 2017-April 2018 as a followup study to the MCH-ART trial [33,34]. The studies took place in Gugulethu, a low-socioeconomic township in Cape Town, South Africa, with a high burden of HIV, poverty and unemployment [35].The MCH-ART trial compared a post-partum intervention of integrated maternal, HIV care and routine child care throughout the breastfeeding period to the standard of care (SOC) of immediate post-partum referral of mothers to general adult ART services and their children to separate child health services. ...
... The studies took place in Gugulethu, a low-socioeconomic township in Cape Town, South Africa, with a high burden of HIV, poverty and unemployment [35].The MCH-ART trial compared a post-partum intervention of integrated maternal, HIV care and routine child care throughout the breastfeeding period to the standard of care (SOC) of immediate post-partum referral of mothers to general adult ART services and their children to separate child health services. The study design and main outcomes have been described [33,36]. The LACE study was designed as a single additional study measurement visit at 36-60 months post-partum, about 16 months after the last MCH-ART study visit, to evaluate longer-term maternal HIV treatment outcomes and child health. ...
Objectives
Mother–child pairs may separate during early life, yet the health impacts thereof are unclear. We explored the patterns and impact of separation among women living with HIV (WLHIV) and their children in South Africa.
Methods
WLHIV who had initiated antiretroviral therapy (ART) during pregnancy received HIV viral load (VL) testing and completed a timeline questionnaire of mother–child separation since delivery at 3–5 years post‐partum. Health care usage was abstracted from routine medical records. We examined associations between separation and (a) maternal health outcomes (engagement in HIV care and HIV viral suppression, [VS]) and (b) child health outcomes (post‐breastfeeding HIV testing and immunisation completion), using logistic regression.
Results
Of 346 mother–child pairs (median maternal age at antenatal ART initiation, 28 years), 24% were ever separated (median time to first separation 20 months, interquartile range [IQR] 9, 31). Most separated children were living with their grandmothers (65/83, 78%). Mothers who ever separated were younger, and more likely to be employed, and to reside in informal housing than those who never separated. Any separation reduced the odds of VS ≤ 50 copies/mL at four years post‐partum (odds ratio 0.57; 95% CI 0.34–0.93); associations were similar for VL ≤ 1000 copies/mL and maternal engagement in care. No association was found between separation and child confirmatory HIV testing or immunisation completion.
Conclusions
In this setting, mother–child separation is common in the first four years of life and appears associated with suboptimal maternal outcomes. Further research is required to understand the drivers and implications of mother–child separation.
... Pregnant and postpartum women (PPPW) are particularly vulnerable to poor retention in care [4,[13][14][15][16][17][18]. Although ART effectiveness in decreasing mortality among HIV-infected women is well-established [14,15,19], persistent societal, community, interpersonal, and individual level barriers weaken this impact [13]. ...
... Pregnant and postpartum women (PPPW) are particularly vulnerable to poor retention in care [4,[13][14][15][16][17][18]. Although ART effectiveness in decreasing mortality among HIV-infected women is well-established [14,15,19], persistent societal, community, interpersonal, and individual level barriers weaken this impact [13]. A recent systematic review and meta-analysis of studies in Africa found that pooled estimates of retention in care at one year post-initiation ranged from 66.4% to 83.1% among PPPW [20]. ...
We tested an intervention that aimed to increase retention in antiretroviral therapy (ART) among HIV-positive pregnant and postpartum women, a population shown to be vulnerable to poor ART outcomes. 133 pregnant women initiating ART at 2 hospitals in Uganda used real time-enabled wireless pill monitors (WPM) for 1 month, and were then randomized to receive text message reminders (triggered by late dose-taking) and data-informed counseling through 3 months postpartum or standard care. We assessed “full retention” (proportion attending all monthly clinic visits and delivering at a study facility; “visit retention” (proportion of clinic visits attended); and “postpartum retention” (proportion retained at 3 months postpartum). Intention-to-treat and per protocol analyses found that retention was relatively low and similar between groups, with no significant differences. Retention declined significantly post-delivery. The intervention was unsuccessful in this population, which experiences suboptimal ART retention and is in urgent need of effective interventions.
... The three models in the postpartum period were the local standard of care of referral of women to general ART services and infants to well-baby clinics (Model I -Routine Care); women and infants continue to receive care through an integrated maternal and child care approach during the postpartum breastfeeding period (Model II -Integrated Care); and referral of women directly to a community-based adherence club (CAC) and infants to wellbaby clinics (Model III -Community Care). The effectiveness of these three models of care is reported in detail elsewhere [18][19][20][21]. Furthermore, the costs from this study were utilised to update the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-International and CEPAC-Pediatrics Models and inform the cost-effectiveness analysis that was undertaken and published [22]. ...
... Furthermore, the costs from this study were utilised to update the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-International and CEPAC-Pediatrics Models and inform the cost-effectiveness analysis that was undertaken and published [22]. Briefly, Model III was found to be the most effective in terms of retention of mother-infant pairs and maternal viral suppression (which was defined as HIV ribonucleic acid (RNA) <50 copies/mL) at 12 months postpartum with 84% of mother-infant pairs meeting these criteria [18][19][20][21]. Model I had a 56% and Model II had a 77% proportion of mother-infant pairs retained and virally suppressed at the 12-month mark [18][19][20]. ...
... Briefly, Model III was found to be the most effective in terms of retention of mother-infant pairs and maternal viral suppression (which was defined as HIV ribonucleic acid (RNA) <50 copies/mL) at 12 months postpartum with 84% of mother-infant pairs meeting these criteria [18][19][20][21]. Model I had a 56% and Model II had a 77% proportion of mother-infant pairs retained and virally suppressed at the 12-month mark [18][19][20]. Dugdale et al. (2019) found Model II to be cost-effective in comparison to Model I with an ICER of US $599 per year of life saved with the threshold being an ICER below US $903 per year of life saved [22]. Our detailed cost analysis fed into the study by Dugdale et al. (2019) and will lead into two separate upcoming papers [23,24], and for these reasons as well as the valuable content of this analysis, we felt this work necessitated a separate manuscript. ...
Objective
To compare the unit and total costs of three models of ART care for mother–infant pairs during the postpartum phase from provider and patient's perspectives: (i) local standard of care with women in general ART services and infants at well‐baby clinics; (ii) women and infants continue to receive care through an integrated maternal and child care approach during the postpartum breastfeeding period; and (iii) referral of women directly to community adherence clubs with their infants receiving care at well‐baby clinics.
Methods
Capital and recurrent cost data (relating to buildings, furniture, equipment, personnel, overheads, maintenance, medication, diagnostic tests and immunisations) were collected from a provider's perspective at six sites in Cape Town, South Africa. Patient time, collected via time‐and‐motion observation and questionnaires, was used to estimate patient perspective costs and is comprised of lost productivity time, time spent travelling and the direct cost of travelling.
Results
The cost of postpartum ART visits under models I, II and III was US 10 and US . The annual costs for the mother–infant pair utilising the average visit frequencies (a mean of 4.5, 6.9 and 6.7 visits postpartum for models I, II and III, respectively) including costs for infant immunisations, visits, medication and diagnostic tests for both mothers and infants were: I – US 335 and III – US $249. Sensitivity analysis to assess the impact of visit frequency on visit cost showed that Model I annual costs would be most costly if visit frequency was equalised.
Conclusion
This comparative analysis of three models of care provides novel data on unit costs and insight into the costs to provide ART and care to mother–infant pairs during the delicate postpartum phase. These costs may be used to help make decisions around integrated services models and differentiated service delivery for postpartum WLH and their children.
... Women living with HIV who participated in the MCH-ART study and were included in the case-control study, which has been described in detail previously, were included in this study A c c e p t e d M a n u s c r i p t [4,7,8]. Briefly, HIV+ women who initiated ART with a once-daily, fixed dose combination of tenofovir 300mg, emtricitabine 200mg or lamivudine 300mg, and efavirenz 600mg during routine antenatal care in Cape Town, South Africa and achieved undetectable viral load (VL<50), but later experienced a viremic episode (VL>1000 copies/mL) were examined. ...
HIV+ South African women who achieved viral suppression during routine antenatal care, but later experienced a viremic episode (viral load>1000 copies/mL), were examined for presence of ARVs and classified as ‘non-adherers’ or ‘suboptimal adherers’. Women were tested for drug-resistance mutations (DRM) at several time points, and underwent viral load testing 36-60 months postpartum. Suboptimal adherers were more likely to have DRM detected at their viremic episode (p=0.03), and a subsequent viremic time point (p=0.05). There was no difference in levels of viral suppression 36-60 months later in women with DRM detected versus women who had no evidence of DRM (p=0.5).
... Conducted between February 2015 and October 2016, the Postpartum Adherence Clubs to Enhance Support (PACER) study (ClinicalTrials.gov NCT02417675) was a component of the MCH-ART study (NCT01933477), a multicomponent implementation science study evaluating strategies for delivering HIV care and treatment services during pregnancy and the postpartum period [21]. The aim of the PACER study was to pilot and evaluate the enrollment of postpartum women into a network of adherence clubs for receipt of ART care. ...
... The aim of the PACER study was to pilot and evaluate the enrollment of postpartum women into a network of adherence clubs for receipt of ART care. The study took place around the Midwife-Obstetric Unit of the Gugulethu Community Health Centre, a setting characterized by high levels of poverty and a high antenatal HIV prevalence [21]. In this setting, Option B+ guidelines were rolled out during 2013. ...
... The design and results of the parent MCH-ART study have been previously described [21,22]. The study included a randomized trial of postpartum ART services, comparing (i) an integrated postnatal care service within the MCH setting for HIV-infected mothers and their infants for the duration of breastfeeding to (ii) the local standard of care, immediate referral to adult ART services for mothers and separate 'well baby' services for infants. ...
Abstract Background 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. Methods Newly 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
... This is due to individual and social-level factors, including poor understanding of HIV, ART and Prevention of Mother-to-Child Transmission (PMTCT), lack of support, fear of disclosure, stigma, poor access to services and health worker attitudes. Poor adherence or retention during pregnancy and the breastfeeding period increase the risk of mother to child HIV transmission and may jeopardise maternal health [1]. ...
... Special thanks to all the staff and patients in PNC. 1 Médecins Sans Frontières, Brussels, Belgium. 2 ...
Background:
The Post Natal Club (PNC) model assures comprehensive care, including HIV and Maternal and Child Health care, for postpartum women living with HIV and their infants during an 18-month postnatal period. The PNC model was launched in 2016 in Town Two Clinic, a primary health care facility in Khayelitsha, South Africa. This qualitative research study aims to understand how participation in PNCs affected knowledge transmission, peer support, behaviour change and satisfaction with the care provided.
Methods:
We conducted ten in-depth interviews; three focus group discussions and participant observation with PNC members, health-care workers and key informants selected through purposive sampling. Seventeen PNC members between 21 and 38 years old, three key informants and seven staff working in PNC participated in the research. All participants were female, except for one of the three key informants who was male. Data was collected until saturation. The data analysis was performed in an inductive way and involved an iterative process, using Nvivo11 software.
Results:
PNC members acquired knowledge on HIV, ART, adherence, infant feeding, healthy eating habits, follow up tests and treatment for exposed infants. Participants believed that PNC created strong relationships among members and offered an environment conducive to sharing experience and advice. Most interviewees stated that participating in PNC facilitated disclosure of their HIV status, enhanced support network and provided role models. PNC members said that they adapted their behaviour based on advice received in PNCs related to infant feeding, ART adherence, monitoring of symptoms and stimulation of early childhood development. The main benefits were believed to be comprehensive care for mother-infant pairs, time-saving and the peer dynamic. The main challenge from the perspective of key informants was the sustainability of dedicating human resources to PNC.
Conclusion:
The PNC model was believed to improve knowledge acquisition, behaviour change and peer support. Participants, staff and the majority of key informants expressed a high level of satisfaction with the PNC model. Sustainability and finding adequate human resources for PNCs remained challenging. Strategies to improve sustainability may include handing over some PNC tasks to members to increase their sense of ownership.
... This nested case-control study took place within a larger study evaluating ART use in pregnant and breastfeeding women that has been detailed previously [13]. In brief, the study took place at a large, public-sector primary care community health center in a high-prevalence setting [14]. ...
Background:
Elevated viral load (VL) early after antiretroviral therapy (ART) initiation appears frequently in pregnant and postpartum women living with human immunodeficiency virus; however the relative contributions of pre-ART drug resistance mutations (DRMs) vs nonadherence in the etiology of elevated VL are unknown.
Methods:
Within a cohort of women initiating ART during pregnancy in Cape Town, South Africa, we compared women with elevated VL after initial suppression (cases, n = 80) incidence-density matched to women who maintained suppression over time (controls, n = 87). Groups were compared on pre-ART DRMs and detection of antiretrovirals in stored plasma.
Results:
The prevalence of pre-ART DRMs was 10% in cases and 5% in controls (adjusted odds ratio [aOR], 1.53 [95% confidence interval {CI}, .4-5.9]); all mutations were to nonnucleoside reverse transcriptase inhibitors. At the time of elevated VL, 19% of cases had antiretrovirals detected in plasma, compared with 87% of controls who were suppressed at a matched time point (aOR, 131.43 [95% CI, 32.8-527.4]). Based on these findings, we estimate that <10% of all elevated VL in the cohort may be attributable to pre-ART DRMs vs >90% attributable to ART nonadherence.
Conclusions:
DRMs account for a small proportion of all elevated VL among women occurring in the 12 months after ART initiation during pregnancy in this setting, with nonadherence appearing to drive most episodes of elevated VL. Alongside the drive for access to more robust antiretroviral agents in resource-limited settings, there is an ongoing need for effective strategies to support ART adherence in this patient population.
... To address this aim, we conducted a secondary analysis using data from HIV-infected women enrolled in the Strategies to Optimize ART Services for maternal and child health (MCH-ART) trial and a parallel cohort of HIV-uninfected pregnant women (HIV-unexposed-uninfected study) conducted in Cape Town, South Africa. Details of both studies have been published previously (le Roux et al., 2019;Myer et al., 2016;Myer et al., 2018). Briefly, the two cohorts had similar inclusion and exclusion criteria, enrolling HIV-infected pregnant women initiating ART and HIV-uninfected pregnant women who were > 18 years of age between March 2013 and August 2015 at their first antenatal care (ANC) visit at a primary care center in Gugulethu in Cape Town. ...
In South Africa, up to 40% of pregnant women are living with human immunodeficiency virus (HIV), and 30–45% are obese. However, little is known about the dual burden of HIV and obesity in the postpartum period. In a cohort of HIV‐uninfected and HIV‐infected pregnant women initiating antiretroviral therapy in Cape Town, South Africa, we examined maternal anthropometry (weight and body mass index [BMI]) from 6 weeks through 12 months postpartum. Using multinomial logistic regression, we estimated associations between baseline sociodemographic, clinical, behavioural, and HIV factors and being overweight–obese I (BMI 25 to <35), or obese II‐III (BMI >35), compared with being underweight or normal weight (BMI <25), at 12 months postpartum. Among 877 women, we estimated that 43% of HIV‐infected women and 51% of HIV‐uninfected women were obese I‐III at enrollment into antenatal care, and 51% of women were obese I‐III by 12 months postpartum. On average, both HIV‐infected and HIV‐uninfected women gained, rather than lost, weight between 6 weeks and 12 months postpartum, but HIV‐uninfected women gained more weight (3.3 kg vs. 1.7 kg). Women who were obese I‐III pre‐pregnancy were more likely to gain weight postpartum. In multivariable analyses, HIV‐infection status, being married/cohabitating, higher gravidity, and high blood pressure were independently associated with being obese II‐III at 12 months postpartum. Obesity during pregnancy is a growing public health concern in low‐ and middle‐income countries, including South Africa. Additional research to understand how obesity and HIV infection affect maternal and child health outcomes is urgently needed.
