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Phone and home visit follow-up and appointment trackers improve retention in HIV care for pregnant women and new mothers
Carole Leach-Lemens, 2016-07-26 14:00:00
Phone and home visit
follow-ups, improved use of appointment books to track attendance and
patient-held appointment calendars resulted in significant increases in
retention in care among HIV-positive pregnant and postnatal women and
HIV-exposed infants in rural Uganda, Jessica Joseph speaking on behalf of the
Clinton Access Health Initiative and the Ugandan Ministry of Health told
participants at the 21st International AIDS Conference (AIDS 2016) in Durban
The findings led to the adoption
of this model as the national standard of care for follow-up of mother-infant
pairs in all prevention of mother-to-child transmission (PMTCT) sites.
This six-month pilot study, conducted
in 2014 comprising over 800 women and more than 300 infants from 20 rural
health facilities covering six districts in four regions, resulted in a 7.5 per
cent (72.8% to 80.3%, p=0.009) increase in five-month retention in care among
Women who started ART in
pregnancy drove the increase.
Older age and having had a
CD4 test increased the likelihood of being retained in care for HIV-positive
Retention among HIV-exposed
infants increased by a significant 19.8% (41.3% to 61.1%, p=0.001) in the five-month
Simplification of prevention
of mother-to-child transmission (PMTCT) services and the adoption of Option B+
(the availability of
lifelong treatment regardless of CD4 count for HIV-positive pregnant and
breastfeeding women) in
Uganda in March 2013 has had remarkable success in preventing vertical (from
mother-to-child) transmission. Within a year of the rollout of Option B+ new
paediatric infections had almost halved.
However, poor retention along
the PMTCT cascade needs to be addressed to achieve Uganda’s goal of elimination
of new infections. Keeping mothers on
antiretrovirals, especially in the postpartum period when most infections happen,
is a serious challenge. Only 40% of mother-infant pairs were still in care at
the end of the breastfeeding period resulting in the transmission rate
quadrupling, from two per cent at six weeks to eight per cent. If retention is not adequately addressed
programme success and maternal and infant health are threatened. This is true
in Uganda as it is in other resource-poor settings where studies have shown 17%
of HIV-positive pregnant women initiated on ART do not return after their first
antenatal care visit; one third of HIV-positive women who give birth in a
clinic are lost to follow-up three months after delivery.
programme comprised four components developed with the health facilities:
appointment books: Tracked attendance for Option B+ mothers and infants in care,
and type of follow-up required (if necessary)
appointment cards: Distributed to mothers and exposed infants, documenting
current visit and indicating next visit date
follow-ups: Utilised for mothers and infants two days after a missed appointment
visits: Conducted three days after scheduled visit date if patient did not
return after phone call.
The study was
designed to evaluate the effectiveness of these follow-up activities and
improved patient management in increasing retention for both HIV-positive pregnant
and postnatal women and for HIV-exposed infants. The study compared the pre-intervention
period (June to December 2013) and the intervention period from March to August
2014. Retrospective data were collected from facility registers and appointment
care, in line with the antiretroviral therapy (ART) visit schedule, was defined
as a woman or infant in care for a minimum of five months after enrolment into
enrolled 988 women and 358 infants, of which 814 women and 332 infants were
available for evaluation at the end of the follow-up period (endline).
median age at first visit was 8.4 weeks and 7.1 weeks at baseline and endline,
respectively. Just over half were enrolled by six weeks of age at baseline and
64% at endline.
starting ART during pregnancy retention increased significantly from 68.3% to
74.8%, an increase of 7.5% (p=0.006). Infant retention in care also increased
significantly from 41.3% to 61.1% (p=0.001).
cotrimoxazole initiation also increased significantly among infants retained in
care; from 23% to 79.1%, p<0.001 and from 33.4% to 70.9%, p=0.008,
Of the 30% missed
appointments requiring follow-up, two per cent were not followed up. The return
rate with follow-up was 70% compared to only 12% among those not followed-up.
implementation of this model as part of the national Option B+ retention
monitoring scale-up will result in fewer HIV-positive infants and better health
outcomes for HIV-positive mothers.