Mobility and Clinic Switching Among Postpartum Women Considered Lost to HIV Care in South Africa.

This version is the Accepted Manuscript, and was published in final edited form as: J Acquir Immune Defic Syndr. 2017 April 01; 74(4): 383–389. doi:10.1097/QAI.0000000000001284OBJECTIVE: Retention in HIV care, particularly among postpartum women, is a challenge to national antiretroviral therapy programs. Retention estimates may be underestimated because of unreported transfers. We explored mobility and clinic switching among patients considered lost to follow-up (LTFU). DESIGN: Observational cohort study. METHODS: Of 788 women initiating antiretroviral therapy during pregnancy at 6 public clinics in Johannesburg, South Africa, 300 (38.1%) were LTFU (no visit ≥3 months). We manually searched for these women in the South African National Health Laboratory Services database to assess continuity of HIV care. We used geographic information system tools to map mobility to new facilities. RESULTS: Over one-third (37.6%) of women showed evidence of continued HIV care after LTFU. Of these, 67.0% continued care in the same province as the origin clinic. Compared with those who traveled outside of the province for care, these same-province "clinic shoppers" stayed out-of-care longer {median 373 days [interquartile range (IQR): 175-790] vs. 175.5 days (IQR: 74-371)} and had a lower CD4 cell count on re-entry [median 327 cells/μL (IQR: 196-576) vs. 493 cells/μL (IQR: 213-557). When considering all women with additional evidence of care as engaged in care, cohort LTFU dropped from 38.1% to 25.0%. CONCLUSION: We found evidence of continued care after LTFU and identified local and national clinic mobility among postpartum women. Laboratory records do not show all clinic visits and manual matching may have been under- or overestimated. A national health database linked to a unique identifier is necessary to improve reporting and patient care among highly mobile populations

Patient retention at key milestones after HIV diagnosis at a primary healthcare clinic offering early antiretroviral therapy initiation in Johannesburg, South Africa

A significant challenge to the impact of South Africa's national ART program is poor patient retention. We report retention in early HIV care among patients at Witkoppen Health and Welfare Centre in Johannesburg, South Africa, using data obtained via file review and electronically. We look first at multiple stages of early HIV care among newly-diagnosed, non-pregnant adults (N=842). Retention from HIV testing to CD4 staging was 69.8% (95%CI 66.7-72.9%). For patients initially ART-ineligible (n=221), 57.4% (95%CI 49.5-65.0%) returned for a repeat CD4 within 12 months. Among those ART-eligible (n=589), 73.5% (95%CI 69.0-77.6%) were retained between CD4 staging and ART initiation. Retention increased with time on ART, from 80.2% (95%CI 75.3-84.5%) at 6 months to 95.3% (95%CI 91.7-97.6%) between 6-12 months. Cumulative retention from HIV diagnosis to 12 months on ART was 36.9% (95%CI 33.0-41.1%) for those ART-eligible and 43.0% (95%CI 36.4-49.8%) from diagnosis to repeat CD4 testing within one year among those ART-ineligible. We examined loss to follow-up (LTFU) before and after delivery among pregnant women newly-diagnosed with HIV (N=273). Of 139 (51.3%) ART-eligible patients, 66.9% (95%CI 58.8-74.3%) initiated ART prior to delivery and overall, 40.5% (32.3-49.0%) were cumulative retained through six months on ART. Of those ART-ineligible at HIV diagnosis, only 21.1% (95%CI 14.6-29.0%) were retained through a repeat CD4 test after delivery. LTFU (≥1 month late) before delivery was 20.5% (95%CI 16.0-25.6%) and, among those still in care, 47.9% (95%CI 41.2-54.6%) within six months after delivery. The study clinic has offered ART initiation at CD4 & ≤350 cells/μl since 2010. We compared 12-month patient outcomes for those who presented and initiated ART at baseline CD4 values & ≤200 versus 201-350 cells/μl (N=1430). Among men and non-pregnant women, initiating at 201-350 cells/μl was associated with 26-42% reduced LTFU (≥3 months late) compared to those initiating at ≤200. We found no CD4 effect among pregnant women. As countries expand HIV testing and ART programs, success will depend on linkage to and retention in care, especially during the period prior to ART initiation. Our findings highlight the additional challenge of continuity of care among HIV-positive pregnant women and adults ineligible for ART.Doctor of Philosoph

Consistent use of a combination product versus a single product in a safety trial of the diaphragm and microbicide in Harare, Zimbabwe.

BACKGROUND: We examined the use and acceptability of a combination product (diaphragm and gel) compared to a single product (gel) during a 6-month safety trial in Zimbabwe. STUDY DESIGN: Women were randomized to the use of a diaphragm with gel or the use of gel alone, in addition to male condoms. Ever use and use of study product on the last act of sexual intercourse were assessed monthly by Audio Computer-Assisted Self-Interviewing. Acceptability, correct use and consistent use (use at every sexual act during the previous 3 months) were measured on the last visit by face-to-face interview. Predictors of consistent use were examined using multivariate logistic regression analyses. RESULTS: In this sample of 117 sexually active, monogamous, contracepting women, rates of consistent use were similar in both groups (59.7% for combination method vs. 56.4% for gel alone). Product acceptability was high, but was not independently associated with consistent use. Independent predictors of consistent use included age [adjusted odds ratio (AOR)=1.08; 95% confidence interval (95% CI)=1.01-1.16], consistent condom use (AOR=3.85; 95% CI=1.54-9.63) and having a partner who approves of product use (AOR=2.66; 95% CI=1.10-6.39). CONCLUSIONS: Despite high reported acceptability and few problems with the products, the participants reported only moderate product adherence levels. Consistent use of condoms and consistent use of products were strongly associated. If observed in other studies, this may bias the estimation of product effectiveness in future trials of female-controlled methods

Achieving UNAIDS 90-90-90 targets for pregnant and postpartum women in sub-Saharan Africa: progress, gaps and research needs

The implementation of the 2013 World Health Organization Option B+ recommendations for HIV treatment during pregnancy has helped drive significant progress in achieving universal treatment for pregnant and postpartum women in sub-Saharan Africa (SSA). Yet, critical research and implementation gaps exist in achieving the UNAIDS 90-90-90 targets. To help guide researchers, programmers and policymakers in prioritising these areas, we undertook a comprehensive review of the progress, gaps and research needs to achieve the 90-90-90 targets for this population in the Option B+ era, including early infant HIV diagnosis (EID) for HIV-exposed infants. Salient areas where progress has been achieved or where gaps remain include: (1) knowledge of HIV status is higher among people with HIV in southern and eastern Africa compared to western and central Africa (81% versus 48%, UNAIDS); (2) access to antiretroviral therapy (ART) for pregnant women has doubled in 22 of 42 SSA countries, but only six have achieved the second 90, and nearly a quarter of pregnant women initiating ART become lost to follow-up; (3) viral suppression data for this population are sparse (estimates range from 30% to 98% peripartum), with only half of women maintaining suppression through 12 months postpartum; and (4) EID rates range from 15% to 62%, with only three of 21 high-burden SSA countries testing >50% HIV-exposed infants within the first 2 months of life. We have identified and outlined promising innovations and research designed to address these gaps and improve the health of pregnant and postpartum women living with HIV and their infants

High mobile phone ownership, but low Internet and email usage among pregnant, HIV-infected women attending antenatal care in Johannesburg

We investigated mobile phone usage amongst HIV-positive pregnant women attending antenatal services in a primary care clinic in Johannesburg (n=50). We conducted a semi-structured interview and asked them about their mobile phone, Internet and email use. The median age of the women was 28 years, 36% had moved one or more times in the past year, and most were employed or recently employed, albeit earning low wages. Nearly all women (94%) reported that they did not share their phone and 76% of the SIM cards were registered to the woman herself. The median time with the current phone was one year (range 1 month–6 years) and the median time with the current phone number was three years (range 1 month–13 years). Even though 42% of the participants were from outside South Africa, they all had mobile phone numbers local to South Africa. About one-third of respondents reported Internet use (30%) and about one-fifth reported using email (18%). Overall, 20% accessed the Internet and 10% accessed email on their mobile phone. Mobile phone interventions are feasible amongst HIV-positive pregnant women and may be useful in prevention of mother-to-child transmission of HIV (PMTCT). Email and Internet-based interventions may not yet be appropriate

Initiating antiretroviral therapy when presenting with higher CD4 cell counts results in reduced loss to follow-up in a resource-limited setting

OBJECTIVE: In August 2011, South Africa expanded its adult antiretroviral therapy (ART) guidelines to allow treatment initiation at CD4 cell values 350 cells/μl or less. Mortality and morbidity are known to be reduced when initiating at higher CD4 levels; we explored the impact on patient loss to follow-up. DESIGN: An observational cohort study. METHODS: We analyzed routine data of 1430 adult patients initiating ART from April to December 2010 from a Johannesburg primary healthcare clinic offering ART initiation at CD4 cell count 350 cells/μl or less since 2010. We compared loss to follow-up (≥3 months late for the last scheduled visit), death, and incident tuberculosis within 1 year of ART initiation for those initiating at CD4 cell values 200 or less versus 201-350 cells/μl. RESULTS: : Half (52.0%) of patients presented in the lower CD4 cell group [≤200 cells/μl, median: 105 cells/μl, interquartile range (IQR): 55-154] and initiated ART, and 48.0% in the higher group (CD4 cell count 201-350 cells/μl, median: 268 cells/μl, IQR: 239-307). The proportion of women and pregnant women was greater in the high CD4 cell group; the lower CD4 cell group included more patients with prevalent tuberculosis. Among men and nonpregnant women, initiating at 201-350 cells/μl was associated with 26-42% reduced loss to follow-up compared to those initiating 200 cells/μl or less. We found no CD4 cell effect among pregnant women. Risk of mortality [adjusted hazard ratio (aHR) 0.34, 95% confidence interval (CI) 0.13-0.84] and incident tuberculosis (aHR 0.44, 95% CI 0.23-0.85) was lower among the higher CD4 cell group. CONCLUSION: This is one of the first studies from a routine clinical setting to demonstrate South Africa's 2011 expansion of ART treatment guidelines can be enacted without increasing program attrition

Implementation of Xpert MTB/RIF for routine point-of-care diagnosis of tuberculosis at the primary care level

as a first-line diagnostic for TB in patients suspected of HIV-associated TB or multidrug-resistant (MDR) TB.1 South Africa, the first country to roll out the assay, opted to place the instruments at centralised microscopy centres and reference laboratories of the National Health Laboratory Service, mainly owing to cost considerations and to allow rapid roll-out.2 Xpert MTB/RIF (Xpert)’s short turnaround time and simplicity raised potential for point-of-care (POC) use.3,4 The motivation for POC technology (be it HIV, CD4 or TB testing) is to provide same-day results, hasten treatment initiation, and avoid loss to follow-up during the diagnostic process. Little is known about POC use of Xpert at primary healthcare level, and operational research is needed before its use at the peripheral level can be recommended.3,5 In July 2011, we launched Xpert as the initial, routine, POC diagnostic for all TB suspects at Witkoppen Health and Welfar