Low engagement from HIV+ postpartum women

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HIV-positive women who have recently given birth have low rates of engagement with HIV care, investigators from the US report. A retrospective analysis of 561 HIV-positive postpartum women in Philadelphia showed that only 38% engaged with HIV care in the three months after delivery. Rates of retention in care and viral suppression after one and two years were also poor. However, early re-engagement with care after delivery was associated with a better chance of staying in care and maintaining an undetectable viral load.

“These findings suggest that a window of opportunity exists immediately after delivery during which it is possible to establish lasting HIV care for women,” comment the authors. “Postpartum disengagement from HIV care is known to occur and unfortunately has lasting implications for morbidity and mortality. Maternal health should be optimised at a time when women face competing priorities with infant health, financial, and social demands.”

Several studies have shown that HIV-positive postpartum women in the US have poor engagement with specialist HIV care. Investigators in Philadelphia wanted to establish a clearer understanding of the scale of the problem and the association between dropping out of care in the postpartum period and longer-term outcomes: retention in care and viral suppression one and two years postpartum.

They therefore designed a retrospective study involving HIV-positive women who gave birth in Philadelphia between 2005 and 2011. They identified 561 women who had 695 live births. Engagement with care was defined as a recorded CD4/viral load result within three months of delivery. Retention in care was regarded as regular CD4/viral load testing over 12 and 24 months. Viral suppression at the 12- and 24-month follow-up intervals was a viral load below 200 copies/ml.

Over half the mothers were aged between 25 and 34 years and three-quarters were black. Just over a third (35%) had been diagnosed with HIV less than two years before delivery. Engagement with HIV care during pregnancy was high, with 92% of women receiving an antiretroviral prescription or CD4/viral load test. However, rates of engagement with postpartum care were much lower, with only 38% of recent mothers attending a follow-up appointment within 90 days of delivery. During the first year after giving birth, 39% of mothers were retained in care, the figure dropping to 25% at year two.

Recent mothers who rapidly re-engaged with care were eleven times more likely to be retained in care after one year than mothers who did not reconnect with care within 90 days of delivery (AOR = 11.38; 95% CI, 7.74-16.68). Engagement with care within 90 days of giving birth was also associated with increased chances of retention in care at the 24-month follow-up point (AOR = 6.19; 95% CI, 4.04-9.5) Only 51% of mother-infant pairs had viral suppression at the time of delivery. One year later, 31% of mothers had viral suppression, increasing to 34% after two years. Women who engaged with care were significantly more likely to be suppressed one (AOR = 2.60; 95% CI, 1.82-3.73) and two years (AOR = 1.40; 95% CI, 1.01-1.95) postpartum.

Of the 695 mother-infant pairs, 97% were prescribed anti-HIV drugs during the first six weeks of life. The investigators were able to confirm that 89% of infants were HIV-negative, but 10% were lost to follow-up, 2% died before their HIV infection status could be confirmed and 2% were confirmed as HIV-infected.
Analysis of mortality records showed that 4% of the women died, and 42% of deaths were documented as HIV-related. But death during follow-up was not associated with failure to engage with or be retained in care.

“We found that postpartum HIV-infected women have low rates of retention and suppression for up to two years after delivery,” write the authors. “The most important and consistent predictor of retention and suppression was early postpartum HIV care engagement…attention on improving maternal HIV care engagement is needed. Doing so has the potential to improve health outcomes far beyond pregnancy.2

Background. 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.
Methods. 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, ART during pregnancy, timing of HIV diagnosis, previous pregnancy with HIV, adequacy of prenatal care, and postpartum HIV care engagement (≥1 CD4 or viral load (VL) test within 90 days of delivery), associated with retention in care (≥1 CD4 or VLtest 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.
Results. Overall, 38% of women engaged in HIV care within 90 days postpartum; with 39% and 31% retained in care and virally suppressed at one year postpartum, and 25% and 34% retained in care and virally suppressed at two years postpartum. In multivariable analyses, women whoengaged in HIV care within 90 days of delivery were more likely to be retained (AOR=11.38, 95%CI7.74-16.68) and suppressed (AOR=2.60, 95%CI1.82-3.73) at one year postpartum. This association persisted in the second year postpartum for both retention (AOR=6.19, 95%CI4.04-9.50) and suppression (AOR=1.40, 95%CI1.01-1.95).
Conclusions. 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.

Aidsmap material
Clinical Infectious Diseases abstract

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