Retention and adherence in PMTCT programs
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Retention and adherence in PMTCT programs
PEPFAR workshop on ART in Pregnancy, Breastfeeding, and Beyond
18-20 June, 2012
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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?
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Stringer, E. M. et al. JAMA 2010;304:293-302
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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?
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Myer L et al. 19th CROI, Abs 22
N=~30,000 women from 6 South African sites
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Myer L et al. 19th CROI, Abs 22
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Myer L et al. 19th CROI, Abs 22
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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
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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
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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
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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
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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?
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• 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
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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
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Nachega J et al. Abstract 1006
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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?
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• 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?
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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)