Retention and adherence in PMTCT programs

PEPFAR workshop on ART in Pregnancy, Breastfeeding, and Beyond

18-20 June, 2012

Key questions

• Are pregnant women on ART more or less likely to be LTFU than non-pregnant women?

• Are pregnant women typically adherent with ARVs?

• What can we do about it?

Stringer, E. M. et al. JAMA 2010;304:293-302

Key questions

• Are pregnant women on ART more or less likely to be LTFU than non-pregnant women?

• Are pregnant women typically adherent with ARVs?

• What can we do about it?

Myer L et al. 19th CROI, Abs 22

N=~30,000 women from 6 South African sites

Myer L et al. 19th CROI, Abs 22

Myer L et al. 19th CROI, Abs 22

Hazard Ratio* 95% CI

Pregnant at ART initiation 1.70 1.49-1.94

Age (years)

<25 1.38 1.19-1.61

25-29 1.17 1.02-1.32

30-34 1.01 0.89-1.14

35-49 0.97 0.86-1.11

40-44 1.0 reference

CD4 count (cells/mm3)

<50 1.0 reference

50-99 0.76 0.68-0.85

100-199 0.70 0.64.0.77

200-349 0.81 0.70-0.93

>350 0.86 0.66-1.13

Myer L et al. 19th CROI, Abs 22

ICAP cohort data

Lamb et al, 2011. HIV-positive youth at ICAP-supported HIV clinics. http://www.columbia-icap.org/news/Data Bytes/Databytes June 2011.pdf

34.6 36.240.8 41 41.2 44.5

54.658.6

67.9

0

10

20

30

40

50

60

70

80

% females 19yo who have started childbearing

DHS Data

Gartland M, Chi B et al. Abs 23LB

Short course AZT/sdNVP (SOC)ART + infant proph for BF

N: 284 rural Zambian womenP-value: 0.11

RR of MTCT or Death

RR of program failure

6 weeks 2.5 2.36 months 3.7* 1.312 months 3.5* 1.3

Key questions

• Are pregnant women on ART more or less likely to be LTFU than non-pregnant women?

• Are pregnant women typically adherent with ARVs?

• What can we do about it?

• 51 studies with over 20,000 HIV-infected pregnant women included

• Definition of “good adherence” varied across studies (>80%, >90%, >95%, 100%)

• _____ had “adequate” ART adherence.

Adherence: A pooled analysis

Nachega J et al. Abstract 1006

Adherence: A pooled analysis

• 51 studies with over 20,000 HIV-infected pregnant women on ART included

• Definition of “good adherence” varied across studies (>80%, >90%, >95%, 100%)

• 73.5% had “adequate” ART adherence.

Nachega J et al. Abstract 1006

Nachega J et al. Abstract 1006

Key questions

• Are pregnant women on ART more or less likely to be LTFU than non-pregnant women?

• Are pregnant women typically adherent with ARVs?

• What can we do about it?

• Black, V., R. M. Hoffman, et al. (2008). "Safety and efficacy of initiating highly active antiretroviral therapy in an integrated antenatal and HIV clinic in Johannesburg, South Africa." Journal of acquired immune deficiency syndromes 49(3): 276-281.

• Ciampa, P. J., J. R. Burlison, et al. (2011). "Improving retention in the early infant diagnosis of HIV program in rural Mozambique by better service integration." Journal of acquired immune deficiency syndromes 58(1): 115-119.

• Killam, W. P., B. C. Tambatamba, N. Chintu, et al. 2010. Antiretroviral Therapy in Antenatal Care to Increase Treatment Initiation in HIV Infected Pregnant Women: A Stepped-Wedge Evaluation. AIDS 24(1):85–91.

• Myer, L., R. Zulliger, et al. (2012). "Pilot programme for the rapid initiation of antiretroviral therapy in pregnancy in Cape Town, South Africa." AIDS Care.

What do we do to improve retention and adherence?

What do we do to improve retention and adherence?

• Community adherence support groups (Moz)• Facility-based social support (RSA)• SMS/phone support (Namibia)• “The field feedback loop” (Malawi)