Shifting to the long view: engagement of pregnant and postpartum women living with HIV in lifelong antiretroviral therapy services

ABSTRACT

Introduction: The advent of policies promoting lifelong antiretroviral therapy (ART) for all pregnant and postpartum women living with HIV has shifted focus from short-term prevention of mother-to-child transmission (PMTCT) to lifelong engagement in ART services. However, disengagement from care threatens the long-term treatment and prevention benefits of lifelong ART.

Areas covered: A framework for considering the unique aspects of ART for pregnant and postpartum women is presented along with a review of the literature on maternal engagement in care in sub-Saharan Africa and a discussion of potential interventions to sustain engagement in lifelong ART.

Expert opinion: Engaging women and mothers in ART services for life is critical for maternal health, PMTCT, and prevention of sexual transmission. Evidence-based interventions exist to support engagement in care but most focus on periods of mother-to-child transmission risk. In the long term, life transitions and health-care transfers are inevitable. Thus, interventions that can reach beyond a single facility or provide a bridge between health services should be prioritized. Multicomponent interventions will also be essential to address the numerous intersecting barriers to sustained engagement in ART services.

KEYWORDS:

• HIV
• antiretroviral therapy
• pregnancy
• postpartum
• engagement in care
• retention
• adherence

Article highlights

• The optimum benefits of lifelong ART for pregnant and postpartum women can only be realized with sustained engagement in lifelong ART services, yet many women disengage from care over time.

• Antenatal care and integrated postpartum mother and child care provide ideal platforms to support PMTCT and an opportunity to intervene on other health concerns. These and other platforms should be leveraged to promote sustained engagement in ART services.

• To date few intervention studies have followed women beyond 12 months, predominantly covering the pregnancy and breastfeeding periods. Significant heterogeneity in duration of follow-up, outcome definitions and methods of outcome assessment make it difficult to compare the efficacy of different interventions.

• Engagement in ART care is dynamic and linked to life transitions and intersecting individual, social and health system factors. Combination interventions addressing these intersecting factors are needed to support engagement in care beyond pregnancy and breastfeeding.

• Interventions that optimize linkage between health services at transfer steps and intervention platforms that extend beyond a single health facility, such as community-based interventions, mHealth technologies, facility linked health information systems and empowering women through education and counseling, should be prioritized.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

T Phillips receives partial funding from The South African Department of Science and Technology/National Research Foundation (DST-NRF), Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa.