Poor follow-up rates among HIV+ SA mothers

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Only half of HIV-positive mothers in townships near Cape Town, South Africa, who received antenatal care and prevention of mother-to-child transmission (PMTCT) services are receiving antiretroviral therapy (ART) 36 months after giving birth, investigators report. The study involved 324 HIV-positive women. Almost all received PMTCT care but only a third were consistently linked to HIV care in the 36 months after giving birth, and only 53% were taking ART three years after the birth of their child. “These are disturbing data,” comment the investigators.

Between 26%-30% of pregnant women in Cape Town, South Africa, are HIV-positive. PMTCT services are generally integrated into antenatal care. However, after giving birth, mothers with HIV are required to establish links with routine HIV services.

South Africa is planning to implement the B+ protocol. This guarantees lifelong ART to all HIV-positive mothers. But research suggests that follow-up rates among HIV-positive mothers are poor. For instance, in Johannesburg, 30% of mothers were lost to HIV care in the first twelve months after giving birth. Investigators therefore designed a study analysing rates of re-engagement with HIV care in the 36 months after giving birth among mothers with HIV living in Cape Town townships.

Recruitment took place between May 2009 and September 2010. The expectant mothers were an average of 26 years old and were recruited during the 26th week of pregnancy. Approximately a fifth were employed and 56% were living with a partner. Most lived in informal housing, and although 90% had electricity in their homes, only 53% had running water and 55% sanitation. Half the women reported they’d gone hungry in the previous week. Two-thirds already had children.

At recruitment, 26% of women were already HIV-positive and 92% of participants learnt their HIV status for the first time while receiving antenatal care during this pregnancy. Three years after giving birth, 13 mothers had died and 23 (6%) of their children were confirmed as HIV-positive. Almost all (93%) participants had received antenatal care and PMTCT services.

Six months after delivery, 45% of women had sought care at a HIV clinic and 70% of these individuals were taking ART. Follow-up after 18 months showed that 53% of recent mothers had attended a HIV clinic; 89% of these women were taking HIV medications. At 36 months, 63% were in HIV care and 85% of these patients were in receipt of ART. Less than a third (31%) of women were linked to care at all three follow-up intervals. Of the surviving mothers, 53% were receiving ART 36 months after the birth of their child.

“B+ regimens may improve re-engagement,” comment the authors. “But the poor follow-up rates in PMTCT trials, the failure to integrate HIV into primary healthcare clinics in Africa, and HIV stigma…must be anticipated.”

Prevent-mother-to-child-transmission services are integrated into antenatal care in South Africa, but postbirth care is at HIV clinics. Almost all mothers living with HIV (MLH) in 24 township neighborhoods (n = 324) reported engagement in HIV care from pregnancy to 36 months after birth. Less than half re-engaged in HIV care at 6 months (45%), 52.5% at 18 months, and 62.5% at 36 months. Most were prescribed antiretroviral drugs if re-engaged in care, yet only about half (53%) are on antiretroviral drugs at 36 months after birth. Implementation of option B+ will require substantially better engagement in care.

Aidsmap material
AIDS abstract

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