Dataset Information

Differentiated models of care for postpartum women on antiretroviral therapy in Cape Town, South Africa: a cohort study.

ABSTRACT: Background: The numbers of women initiating lifelong antiretroviral therapy (ART) during pregnancy and postpartum is increasing rapidly, presenting a burden on health systems and an urgent need for scalable models of care for this population. In a pilot project, we referred postpartum women who initiated ART during pregnancy to a community-based model of differentiated ART services.

Methods: Eligible women (on ART for at least 3 months with viral load (VL)<1000 copies/mL) were offered a choice of two ART models of care: (i) referral to an existing system of community-based 'adherence clubs', operated by lay counsellors with medication collection every 2-4 months; or (ii) referral to local primary healthcare clinics (PHC) with services provided by clinicians and medication collection every 1-2 months (local standard of care for postpartum ART). For evaluation, women were followed through 6-months postpartum with VL testing separate from either ART service.

Results: Through September 2015, n = 129 women were enrolled (median age, 28 years; median time postpartum, 10 days). Overall, 65% (n = 84) chose adherence clubs and 35% (n = 45) chose PHCs; there were no demographic or clinical predictors of this choice. Location of service delivery was commonly cited as a reason for choice by women selecting either model of care; shorter waiting times, ability to receive ART from lay counsellors and less frequent appointments were motivations for choosing adherence clubs. Among women choosing adherence clubs, 15% never attended the service and another 11% attended the service but were not retained through six months postpartum. Overall, 86% of women (n = 111) remained in the evaluation through 6 months postpartum; in this group, there were no differences in VL<1000 copies/mL at six months postpartum between women choosing PHCs (88%) vs. adherence clubs (92%; p = 0.483), but women who were not retained in adherence clubs were more likely to have VL?1000 copies/mL compared to those who remained (p = 0.002).

Discussion: Adherence clubs may be a valuable model for postpartum women initiating ART in pregnancy, with good short-term outcomes observed during this critical period. To support optimal implementation, further research is needed into patient preferences for models of care, with consideration of integration of maternal and child health services, while ART adherence and retention require ongoing consideration in this population.

SUBMITTER: Myer L

PROVIDER: S-EPMC5577773 | biostudies-literature | 2017 Jul

REPOSITORIES: biostudies-literature

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Differentiated models of care for postpartum women on antiretroviral therapy in Cape Town, South Africa: a cohort study.

Myer Landon L Iyun Victoria V Zerbe Allison A Phillips Tamsin K TK Brittain Kirsty K Mukonda Elton E Allerton Joanna J Kalombo Cathy D CD Nofemela Andile A Abrams Elaine J EJ

Journal of the International AIDS Society 20170701 Suppl 4

<h4>Background</h4>The numbers of women initiating lifelong antiretroviral therapy (ART) during pregnancy and postpartum is increasing rapidly, presenting a burden on health systems and an urgent need for scalable models of care for this population. In a pilot project, we referred postpartum women who initiated ART during pregnancy to a community-based model of differentiated ART services.<h4>Methods</h4>Eligible women (on ART for at least 3 months with viral load (VL)<1000 copies/mL) were offer ...[more]

PMID: 28770593

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Project description: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 <?50 copies/mL based on viral load (VL) testing at measurement visits] at 12?months postpartum. Outcomes were compared across postpartum services using chi-square, Fisher's exact tests and Poisson regression models. The primary outcome was compared across services where women were receiving care at 12?months postpartum in exploratory analyses. RESULTS:Between February and September 2015, 129 women (median age: 28.9?years; median time postpartum: 10?days) were enrolled with 65% opting to receive postpartum HIV care through an adherence club. Among 110 women retained at study measurement visits, 91 (83%) achieved the composite endpoint, with no difference between those who originally chose clubs versus those who chose PHC services. Movement from an adherence club to PHC services was common: 31% of women who originally chose clubs and were engaged in care at 12?months postpartum were attending a PHC service. Further, levels of VS differed significantly by where women were accessing ART care at 12?months postpartum, regardless of initial choice: 98% of women receiving care in an adherence club and 76% receiving care at PHC had VS <?50 copies/mL at 12?months postpartum (p?=?0.001). CONCLUSION:This study found comparable outcomes related to retention and VS at 12?months postpartum between women choosing adherence clubs and those choosing PHC. However, movement between postpartum services among those who originally chose adherence clubs was common, with poorer VS outcomes among women leaving clubs and returning to PHC services. TRIAL REGISTRATION:ClinicalTrials.gov NCT02417675 , April 16, 2015 (retrospectively registered).

Project description:BACKGROUND:Adherence to antiretroviral therapy (ART), especially during the postpartum period, remains a major challenge in the efforts towards eliminating mother-to-child transmission of HIV. This study examined the levels and determinants of postpartum adherence to ART among mothers with HIV in the Eastern Cape, South Africa. METHODS:In this cross-sectional analytical study, we interviewed 495 postpartum women with HIV between January and May 2018. We measured postpartum adherence using six questions probing participants' adherence behaviours since child birth. We categorised the adherence behaviours into complete adherence (mothers who reported no missed episode(s) of ART since child birth) and suboptimal adherence (mothers with any missed episode(s) of ART). Adjusted and unadjusted logistic regression models were used to examine the determinants of postpartum adherence to ART. RESULTS:Overall, 63.9% reported complete adherence during the postpartum period but the rates varied by socio-demographic and behavioural characteristics. The adjusted logistic regression analysis showed that younger mothers were 70% less likely to report complete adherence to ART compared to mothers aged 40 and above. Likewise, mothers who currently use alcohol were 53% less likely to report complete postpartum adherence to ART compared to those who did not use alcohol. However, mothers who knew their partner's status were twice more likely to report complete postpartum adherence compared to those who did not. There was no statistically significant relationship between ART adherence and breastfeeding durations. CONCLUSION:Postpartum adherence to ART is suboptimal in the study setting, and younger mothers and those who use alcohol have a lower odds of complete adherence. Knowing a partner's status improves adherence, but infant feeding practices did not influence postpartum adherence behaviours. It is critical to design and strengthen interventions which target young mothers and alcohol users. Also, HIV sero-status disclosure should be encouraged among mothers to facilitate partner support.

Dataset Information

Differentiated models of care for postpartum women on antiretroviral therapy in Cape Town, South Africa: a cohort study.

Publications

Differentiated models of care for postpartum women on antiretroviral therapy in Cape Town, South Africa: a cohort study.

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