BMC Public Health

Background Failure to retain HIV-positive pregnant women on antiretroviral therapy (ART) leads to increased mortality for the mother and her child. This study evaluated different retention measures for women’s engagement along the continuum of care for prevention of mother-to-child transmission (PMTCT) option B+ services in Mozambique. Methods We compared ‘point’ retention (patient’s presence in care 12-month post-ART initiation or any time thereafter) with the following definitions: alive and in care 12 month post-ART initiation (Ministry of Health; MOH); attendance at a health facility up to 15-month post-ART initiation (World Health Organization; WHO); alive and in treatment at 1-, 2-, 3-, 6-, 9-, and 12-month post-ART initiation (Inter-Agency Task Team; IATT); and alive and in care 12-month post-ART initiation with ≥75% appointment adherence during follow-up (i.e. ‘appointment adherence’ retention) or with ≥75% of appointments met on time during follow-up (i.e. ‘on-time adherence’ retention). Kaplan-Meier survival curves were produced to assess variability in retention rates. We used ‘on-time adherence’ retention as our reference to estimate sensitivity, specificity, and proportion of misclassified patients. Results Considering the ‘point’ retention definition, 16,840 HIV-positive pregnant women enrolled in option B+ PMTCT services were identified as ‘retained in care’ 12-month post-ART initiation. Of these, 60.3% (95% CI 59.6–61.1), 84.8% (95% CI 84.2–85.3), and 16.4% (95% CI 15.8–17.0) were classified as ‘retained in care’ using MOH, WHO, and IATT definitions, respectively, and 1.2% (95% CI 1.0–1.4) were classified as ‘retained in care’ using the ‘≥75% on-time adherence’ definition. All definitions provided specificity rates of ≥98%. The sensitivity rates were 3.0% with 78% of patients misclassified according to the WHO definition and 4.3% with 54% of patients misclassified according to the MOH definition. The ‘point’ retention definition misclassified 97.6% of patients. Using IATT and ‘appointment adherence’ retention definitions, sensitivity rates (9.0 and 11.7%, respectively) were also low; however, the proportion of misclassified patients was smaller (15.9 and 18.3%, respectively). Conclusion More stringent definitions indicated lower retention rates for PMTCT programs. Policy makers and program managers should include attendance at follow-up visits when measuring retention in care to better guide planning, scale-up, and monitoring of interventions

PLoS One

Introduction Evidence on childbearing desire and reproductive behaviors in women living with HIV on antiretroviral therapy (ART) is scarce, particularly in West Africa. We investigated the prevalence and associated factors of childbearing desire in HIV-infected women in care in Abidjan, Côte d’Ivoire and explored whether such desires were translated into behaviors related to contraceptive use and communication with health personnel. Methods A cross-sectional survey was conducted in two HIV-care facilities in Abidjan, Côte d’Ivoire in 2015. Eligible women were non-pregnant, non-menopausal, aged 18–49 years and diagnosed as HIV-infected. The outcomes were childbearing desire, prevalence of modern contraceptive use, unmet needs for family planning and intention of the last pregnancy since HIV diagnosis. Women wishing to conceive immediately were asked whether they had discussed their desire with HIV healthcare workers. Logistic regression models were used to assess the associations between the outcomes and women’s characteristics. Results Of 1,631 women, 80% declared having childbearing desire. No association was found between women’s childbearing desire and ART status or its duration. In multivariate models, younger age, being in a stable relationship and having no or only one child were significantly associated with increased childbearing desire. Of the women wishing to conceive immediately (n = 713), only 43% reported having had fertility-related dialogue with healthcare provider. Among sexually active women wanting to avoid or delay pregnancy (n = 650), unmet needs for family planning was 40%. Regarding the last pregnancy since HIV diagnosis, one in three women reported not having wanted a baby at that time. Conclusions Pregnancy desire in women living with HIV in Abidjan was extremely high. Integration of safe conception strategies as well as improvement of contraceptive uptake among women in need of family planning are of utmost importance to ensure optimal conception and to avoid transmission of HIV to the male partner or to the forthcoming child

Ten-year attrition and antiretroviral therapy response among HIV-positive adults: a sex-based cohort analysis from eight West African countries

INTRODUCTION: Sex differences have already been reported in sub-Saharan Africa for attrition and immunological response after antiretroviral therapy (ART) initiation, but follow-up was usually limited to the first two to three years after ART initiation. We evaluated sex differences on the same outcomes in the 10 years following ART initiation in West African adults. METHODS: We used cohort data of patients included in the IeDEA West Africa collaboration, who initiated ART between 2002 and 2014. We modelled no-follow-up and 10-year attrition risks, and immunological response by sex using logistic regression analysis, survival analysis with random effect and linear mixed models respectively. RESULTS: A total of 71,283 patients (65.8% women) contributed to 310,007 person-years of follow-up in 16 clinics in eight West African countries. The cumulative attrition incidence at 10-year after ART initiation reached 75% and 68% for men and women respectively. Being male was associated with an increased risk of no follow-up after starting ART (5.1% vs. 4.0%, adjusted Odds Ratio: 1.25 [95% CI: 1.15 to 1.35]) and of 10-year attrition throughout the 10-year period following ART initiation: adjusted Hazard Ratios were 1.22 [95% CI: 1.17 to 1.27], 1.08 [95% CI: 1.04 to 1.12] and 1.04 [95% CI: 1.01 to 1.08] during year 1, years 2 to 4 and 5 to 10 respectively. A better immunological response was achieved by women than men: monthly CD4 gain was 30.2 and 28.3 cells/mL in the first four months and 2.6 and 1.9 cells/μL thereafter. Ultimately, women reached the average threshold of 500 CD4 cells/μL in their sixth year of follow-up, whereas men failed to reach it even at the end of the 10-year follow-up period. The proportion of patients reaching the threshold was much higher in women than in men after 10 years since ART initiation (65% vs. 44%). CONCLUSIONS: In West Africa, attrition is unacceptably high in both sexes. Men are more vulnerable than women on both attrition and immunological response to ART in the 10 years following ART initiation. Innovative tracing strategies that are sex-adapted are needed for patients in care to monitor attrition, detect early high-risk groups so that they can stay in care with a durably controlled infection

Attitudes towards abortion and decision-making capacity of pregnant adolescents: perspectives of medicine, midwifery and law students in Accra, Ghana

Objectives: Because medical, midwifery and law students in Ghana constitute the next generation of health care and legal practitioners, this study aimed to evaluate their attitudes towards abortion and their perceptions of the decision-making capacity of pregnant adolescents. Methods: We conducted a cross-sectional survey among 340 medical, midwifery and law students. A pretested and validated questionnaire was used to collect relevant data on respondents’ sociodemographic characteristics, attitudes towards abortion and the perceived capacity and rationality of pregnant adolescents’ decisions. The χ2 test of independency and Fischer’s exact test were used where appropriate. Results: We retained 331 completed questionnaires for analysis. Respondents’ mean age was 21.0 ± 2.9 years and the majority (95.5%) were of the Christian faith. Women made up 77.9% (n = 258) of the sample. Most students (70.1%) were strongly in favour of abortion if it was for health reasons. More than three-quarters (78.0%) of the students strongly disagreed on the use of abortion for the purposes of sex selection. Most respondents (89.0%) were not in favour of legislation to make abortion available on request for pregnant adolescents, with medical students expressing a more negative attitude compared with law and midwifery students (p < 0.001). Over half of the midwifery students (52.6%) believed that adolescents should have full decision-making capacity regarding their pregnancy outcome, compared with law and medical students (p < 0.001). Conclusion: Tensions between adolescent reproductive autonomy, the accepted culture of third party involvement (parents and partners), and the current abortion law may require keen reflection if an improvement in access to safe abortion services is envisioned

Trop Med Int Health

Objective To evaluate the effectiveness of the prevention of mother‐to‐child transmission (PMTCT) Option B+ programme in two provinces with high human immunodeficiency virus (HIV) burden in Mozambique over the first four years of programme implementation. Methods We assessed the PMTCT cascade in antenatal care (ANC) from July 2013 to December 2017 using facility‐level data and performed a retrospective cohort analysis with patient‐level data. We compared the 12‐month antiretroviral therapy (ART) retention rates between women with HIV infection who initiated ART under Option B+ (‘B+ pregnant’) and those who initiated ART for their own health (‘own health’). Results A total of 916 280 pregnant women enrolled in ANC. The proportion of women with a documented HIV status increased from 93% in 2013 to 96% in 2017. The proportion of those tested HIV‐positive decreased from 8% to 6% while that of those HIV‐positive on ART increased from 42% to 95%. Of the 44 377 HIV‐positive women included in the analysis, 35% were lost to care. ‘B+ pregnant’ women initiating ART in 2015 were less likely to have no follow‐up (NFU) compared with ‘own health’ women starting ART during the same period (adjusted odds ratio: 0.77, 95% confidence interval [CI]: 0.64–0.94, P = 0.01). There was no statistical difference between the two groups during the other years in which ART was initiated. Of those returning for care after their first visit (N = 39 801), the ‘B+ pregnant’ women showed a higher risk of non‐retention than the other group (adjusted hazard ratio: 1.14, 95% CI: 1.03–1.25) when ART was initiated in 2013. The risk decreased during the subsequent years, with no difference observed between the groups. Conclusion PMTCT Option B+ programme scale‐up has yielded positive results, including the maintenance of high HIV testing and ART initiation rates in ANC. Challenges still remain, however, in improving immediate engagement in care and long‐term retention. Seeking alternative service delivery models to support existing health systems and prevent defaulters is required to achieve the UNAIDS 95‐95‐95 targets for PMTCT in Mozambique