Back HIV Populations Pregnancy & MTCT CROI 2016: Studies Probe Retention in Care for HIV+ Women Who Start ART During Pregnancy

CROI 2016: Studies Probe Retention in Care for HIV+ Women Who Start ART During Pregnancy


Engaging lay counselors to provide a combination package of evidence-based interventions in Nyanza, Kenya, and addressing partner disclosure, as well as pre-treatment education about the benefits of antiretroviral therapy (ART) for maternal and child health in Malawi’s Option B+ program improved retention in care and reduced loss to follow-up of mothers with HIV and their infants, studies presented at the recent Conference on Retroviruses and Opportunistic Infections (CROI 2016) show.

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Poor retention in care of mothers with HIV and their infants across the prevention of mother-to-child transmission (PMTCT) and pediatric care continuum continues to undermine what is otherwise a remarkable success. If retention is not adequately addressed, program success and maternal and infant health are threatened.

In resource-poor settings, studies have shown that 17% of pregnant women with HIV who start ART do not return after their first antenatal care visit, and one-third of women with HIV who give birth in a clinic are lost to follow-up 3 months after delivery.

Reports have described the unique needs -- including treatment literacy of postpartum women with HIV -- to be addressed if they are to return to or be retained in care.

Simplification of PMTCT services and adoption of Option B+ -- the availability of lifelong treatment regardless of CD4 count for pregnant and breastfeeding women with HIV -- in many countries, notably Malawi, have had extraordinary success in significantly reducing the number of vertical (mother to child) HIV transmissions. However, loss to follow-up among women enrolled in treatment as a result of Option B+ in Malawi is as high as 29% after a year.

Several studies presented at CROI looked at reasons for loss to follow-up among mothers enrolled in antiretroviral treatment, and interventions to improve retention.

When Mothers "Lost to Follow-Up" Go Elsewhere

Kate Clouse reported on a study undertaken in South Africa that raised concerns about inconsistences in accurately measuring rates of loss to follow-up, highlighting the need for standardized guidelines across countries.

In the absence of a nationally linked health database, estimates did not account for unreported transfers.

The researchers hypothesized that so-called "clinic shoppers" (defined as seeking care at a new ART facility) and rural-urban travel after delivery artificially inflate estimates of loss to follow-up. Using a national laboratory database, they traced lost patients to assess continuity of care and update estimates of loss to follow-up. Of the third of women successfully traced, almost 50% continued care at a new facility. Of these, close to three-quarters were clinic shoppers who often suspended care for extended periods of time resulting in immunosuppression.

Family circumstances, time constraints, and distance to the clinic are some of the reasons many women will be in and out of care for extended periods of time during pregnancy and after delivery.

Clouse concluded that a better understanding of how women choose facilities, access care, and travel around the time of delivery is needed.

Improving Retention Through Active Follow-Up


While a variety of interventions to improve retention exist, a rigorous assessment of their efficacy to improve maternal and infant outcomes is lacking.

Conducted at 10 PMTCT sites in Nyanza, Kenya, between September 2013 and September 2015, the Maternal-Infant Retention for Health (MIR4HEALTH) study evaluated the effectiveness of lay counselor administrated evidence-based interventions (active patient follow-up) compared to standard of care on mother-infant retention.

At the start of antenatal care, pregnant women with HIV were randomized to active follow-up comprising lay counselor-administered individualized health education, home visits, phone and short message appointment reminders, immediate physical tracing after a missed clinic visit, and individualized adherence and retention support, compared to routine PMTCT/postnatal HIV care according to national guidelines.

Of the 340 women (170 were randomized to each arm) close to a third (106) knew they were HIV positive at enrolment (58 and 48 in the active follow-up and standard of care arms, respectively). The median age was 26 years, with median gestation age of 24 weeks and median CD4 cell count of 426 cells/mm3.

Overall, 11.5% of the pregnancies resulted in poor outcomes, with no difference between the 2 arms.

Retention of mother-infant pairs was defined as clinic attendance 6 months after birth (plus or minus 3 months). At 6 months after birth, 130 mother-infant pairs were retained in the active follow-up arm compared to 112 in the standard of care arm. Loss to follow-up was significantly lower in the active follow-up arm compared to the standard of care arm, 18.8% vs 28.2%, respectively. Older age, having disclosed to a partner, and known HIV-positive status at enrollment were associated with lower attrition. A total of 9 infants had positive HIV PCR test, 3 in the active follow-up and 6 in the standard of care arms.

Presenter Ruby Fayorsey concluded that implementing a lay counselor-led combination package of evidence-based interventions resulted in a moderate decrease in attrition among mother-infant pairs receiving PMTCT care in this high prevalence community.

Disclosure and Retention in Care

Data on which factors are linked to retention in care under Option B+ are scant. Risa Hoffman presented a case-control study undertaken in Central Malawi of women with HIV who started ART under Option B+ to look at characteristics associated with retention, with a focus on the role of disclosure, pre-ART education, and knowledge about the importance of Option B+ for maternal and child health.

Criteria for enrollment included having been out of antiretroviral care for more than 60 days with control subjects, in care for longer than 12 months, enrolled in a 3-to-1 one ratio.

A total of 50 case and 153 control subjects were enrolled. The median age was 30 years. Over 80% started ART during pregnancy at a median gestational age of 24 weeks. Of the women starting ART during pregnancy, 91% (39 out of 43) defaulted within 3 months of giving birth. 

Importantly, HIV disclosure to the primary sexual partner was the norm among women retained in care, 100% compared to 78%. In addition, the odds of being retained in care among women knowing their partner’s HIV status were more than 5-fold higher compared to women who did not know, 85% vs 53%, respectively (OR 5.20,).

Odds of retention were significantly higher among women over the age of 25, (OR 2.44). Completion of primary school provided a significant 3-fold higher odds of retention, while the odds ratio of retention among those with pre-ART education was more than 6-fold higher (OR 6.17).

Conversely, travel time to the clinic of more than 3 hours and later gestational age at the time of starting ART were associated with significantly reduced odds of retention (OR 0.13 and 0.95, respectively).

The more questions correctly answered on Option B+ knowledge, and one or more means of support while taking ART, increased the odds of retention by close to 2-fold and more than 3-fold, respectively.

After adjusting for age, schooling, and travel time to the clinic, a multivariate analysis showed that knowing the partner’s HIV status and Option B+ knowledge remained associated with retention (OR 4.07 and 1.60, respectively).

Hoffman concluded that interventions addressing partner disclosure and strengthening pre-ART education about the benefits of treatment for maternal and child health should be evaluated as strategies to improve retention in Malawi’s Option B+ program.

In a discussion of the findings, Sundeep Gupta stressed that in addition to increased decentralization and integration, monitoring, evaluation, and quality improvement systems on a large scale are needed to adequately address the multifactorial reasons for loss to follow-up.



R Fayorsey, D Chege, C Wang, et al. Randomized Trial of a Lay Counselor-Led Combination Intervention for PMTCT Retention. Conference on Retroviruses and Opportunistic Infections. Boston, February 22-25, 2016. Abstract 791.

K Clouse, SH Vermund, M Maskew, et al.  K et al.Continuity of Care Among Pregnant Women Lost to Follow-up After Initiating ART. Conference on Retroviruses and Opportunistic Infections. Boston, February 22-25, 2016. Abstract 792.

RM Hoffman, K Phiri, J Parent, et al. Disclosure and Knowledge Are Associated With Retention in Malawi's Option B+ Program. Conference on Retroviruses and Opportunistic Infections. Boston, February 22-25, 2016. Abstract 793.