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HIV-positive postpartum women who rapidly re-engage with HIV care more likely to have viral suppression in longer term
Michael Carter, 2015-08-19 08:40:00
who have recently given birth have low rates of engagement with HIV care,
investigators from the US report in the online edition of Clinical Infectious Diseases. A retrospective analysis of 561
HIV-positive postpartum women in Philadelphia showed that only 38% engaged with
HIV care in the three months after delivery. Rates of retention in care and
viral suppression after one and two years were also poor. However, early
re-engagement with care after delivery was associated with a better chance of
staying in care and maintaining an undetectable viral load.
suggest that a window of opportunity exists immediately after delivery during
which it is possible to establish lasting HIV care for women,” comment the
authors. “Postpartum disengagement from HIV care is known to occur and
unfortunately has lasting implications for morbidity and mortality. Maternal
health should be optimized at a time when women face competing priorities with
infant health, financial, and social demands.”
have shown that HIV-positive postpartum women in the US have poor engagement
with specialist HIV care. Investigators in Philadelphia wanted to establish a
clearer understanding of the scale of the problem and the association between
dropping out of care in the postpartum period and longer-term outcomes:
retention in care and viral suppression one and two years postpartum.
designed a retrospective study involving HIV-positive women who gave birth in
Philadelphia between 2005 and 2011. They identified 561 women who had 695 live
births. Engagement with care was defined as a recorded CD4/viral load result
within three months of delivery. Retention in care was regarded as regular CD4/viral
load testing over 12 and 24 months. Viral suppression at the 12- and 24-month
follow-up intervals was a viral load below 200 copies/ml.
Over half the
mothers were aged between 25 and 34 years and three-quarters were black. Just
over a third (35%) had been diagnosed with HIV less than two years before
HIV care during pregnancy was high, with 92% of women receiving an
antiretroviral prescription or CD4/viral load test.
However, rates of engagement
with postpartum care were much lower, with only 38% of recent mothers attending
a follow-up appointment within 90 days of delivery. During the first year after
giving birth, 39% of mothers were retained in care, the figure dropping to 25%
at year two.
Recent mothers who
rapidly re-engaged with care were eleven times more likely to be retained in
care after one year than mothers who did reconnect with care within 90 days of
delivery (AOR = 11.38; 95% CI, 7.74-16.68). Engagement with care within 90 days
of giving birth was also associated with increased chances of retention in care
at the 24-month follow-up point (AOR = 6.19; 95% CI, 4.04-9.5)
Only 51% of
mother-infant pairs had viral suppression at the time of delivery. One year
later, 31% of mothers had viral suppression, increasing to 34% after two years.
Women who engaged
with care were significantly more likely to be suppressed one (AOR = 2.60; 95%
CI, 1.82-3.73) and two years (AOR = 1.40; 95% CI, 1.01-1.95) postpartum.
Of the 695
mother-infant pairs, 97% were prescribed anti-HIV drugs during the first six
weeks of life. The investigators were able to confirm that 89% of infants were
HIV-negative, but 10% were lost to follow-up, 2% died before their HIV
infection status could be confirmed and 2% were confirmed as HIV-infected.
mortality records showed that 4% of the women died, and 42% of deaths were documented
as HIV-related. But death during follow-up was not associated with failure to
engage with or be retained in care.
“We found that
postpartum HIV-infected women have low rates of retention and suppression for
up to two years after delivery,” write the authors. “The most important and
consistent predictor of retention and suppression was early postpartum HIV care
engagement…attention on improving maternal HIV care engagement is needed. Doing
so has the potential to improve health outcomes far beyond pregnancy.”