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Description : Option B+ Beyond ART: Maternal Engagement in Care

Tags : Pediatrics, Child Health, pediatric practice, pediatrician, health providers, HIV-infected infants, Adolescent Transition, HIV-infected adolescents, epidemiology, south Africa, nutrition, Maternal Engagement in Care

Published on : Jul 18, 2020 | Views : 1248 | Downloads : 1

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Slide 1-

Option B+ Beyond ART: Maternal Engagement in Care Landon Myer 8th International Workshop on HIV Pediatrics 16 July 2016
Slide 2-

Outline Background: where are we with Option B+ Key concepts: thinking about maternal engagement in ART services during pregnancy & postpartum How much disengagement? Who & where? Drivers of disengagement & interventions to address Charting a way forward: where are we headed?
Slide 3-

1. Background
Slide 4-

7/16/2016 4 “Treat All” for pregnant and BF women adopted in 95% of 144 LMIC in 2016
Slide 5-

Dramatic increases in ART coverage in pregnancy with Option B+ Gupta CROI 2016; Abrams CROI 2016 Malawi national programme evaluation, 2011-2015 Swaziland stepped- wedge evaluation, 2013-2015
Slide 6-

ART initiation simplifies & delays to initiation decrease Malawi South Africa Zimbabwe Malawi Kim JAIDS 2015 Tenthani AIDS 2015 Dzangare TM&IH 2016 Myer JAIDS 2015
Slide 7-

Option B+ No turning back
Slide 8-

Benefits of Option B+ require high levels of adherence & retention Most models assume at least 80-90% of mothers initiating ART will be: retained in care adherent to ART virologically suppressed Ishikawa PLoS ONE 2014 Khanna PLoS ONE 2015 Van Deusen BMC ID 2015 Gopalappa AIDS 2014 Binghwayo PloS ONE 2013 Ciaranello CID 2013 Karnon Health Pol Plan 2016
Slide 9-

2. Key concepts
Slide 10-

(i) Constructs Blaschke Ann Rev Pharmacol Toxicol 2012 Spectrum of behaviours Eg, Pill-taking Visit attendance Care interface Separate but correlated manifestations of same underlying phenomena
Slide 11-

Non-adherence to treatment predicts discontinuation Blaschke Ann Rev Pharmacol Toxicol 2012 Adherence (%)
Slide 12-

(ii) Major life events pregnancy delivery 6 weeks 12 months 18 months repeat pregnancies years on ART Physiologic Psychological Social Economic Breastfeeding
Slide 13-

(iii) Health systems complexity Antenatal care service General adult ART service Obstetric / delivery service EID / EPI ‘Well baby’ care Differentiated models of care
Slide 14-

3. Evidence
Slide 15-

Lower retention with B+ compared with ART for eligible adults, Malawi Time from ART initiation (months) ART started during breast feeding Time from ART initiation (months) Time from ART initiation (months) Haas Lancet HIV 2016 Women initiating ART in pregnancy ~5 times more likely to have no follow-up and 1.6 times more likely to be lost to follow-up during 1st year on ART vs non-pregnant adults
Slide 16-

Option B+ retention cascade 186 health facilities, Uganda, 2014 1,868 75% 68% 65% 64% 63% 62% 58% 2,000 1,800 1,600 1,400 1,200 1,000 800 600 400 200 0 Baseline M1 (M0) M2 M3 M4 M5 M6 M7 25% of women never came back after 1st visit OHTA 2014
Slide 17-

Antepartum and Postpartum Retention: Option A vs Option B+, Swaziland Little variation in associations by site or month of observation *Adjusted risk ratios (aRR) adjusted for age, gestation at 1st ANC visit, known HIV status Abrams CROI 2016
Slide 18-

Postpartum viral rebound Routine care cohort (n=620) initiating ART in Cape Town (median gestation at initiation, 20w) 91% reach VL≤1000 copies/mL by delivery 30% rebound to VL >1000 by 12 months postpartum CR1O8 I 2016 HIV Med, in press
Slide 19-

A global phenomenon? Adams CID 2015 ; Huntington AIDS 2016 Postnatal care ‘cascade’: Philadelphia, USA, 2005-2011 31% of women receiving HIV care in pregnancy virally suppressed @ 1 year postpartum UK & Ireland cohort, 2006-2011 ~42% of women suppressed at delivery experience viral rebound @ 1 year postpartum
Slide 20-

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Slide 21-

Countries with documented challenges in engagement of pregnant & postpartum women on ART, 2008-2016 Countries with at least one published/presented study
Slide 22-

4. Drivers & interventions
Slide 23-

4. Drivers & interventions WARNING
Slide 24-

4. Drivers & interventions WARNING The absence of data available on these topics may cause discomfort.
Slide 25-

Understanding drivers of disengagement Clinical & biological Socio-demographic & psychological Health services & systems
Slide 26-

Clinical & biological factors Do side effects (SE) contribute to disengagement? Burden of symptoms/SE in HIV+ pregnant women on universal ART: >90% for most SE classes Difficult to distinguish aetiology Total SE burden associated with non-adherence Qualitative evidence: SE cited as one reason for discontinuation (Malawi) Kim PLoS ONE 2016 Phillips PLoS ONE in press
Slide 27-

Sociodemographic & psychological factors “Risk factor” data heterogeneous & contextual Some consistency: Younger, recent HIV diagnosis, cost/transport, unintended pregnancy Mixed evidence: ART “readiness”? Partner involvement? Disclosure? Depression/mental illness? Tweya TM&IH 2014 Mattheson JIAS 2014 Clouse JAIDS 2014 Koss JAIDS 2016 Price STI 2014 Hoffman CROI 2016
Slide 28-

Health services & health factors Structure of health services shapes ability of patients to engage in care Women may be particularly vulnerable in navigating different health services during pregnancy & postpartum Phillips JAIDS 2015 Phillips JIAS 2014
Slide 29-

Impact of model of care on retention District-level health facility survey & cohort analysis, Malawi 4 distinct models of care identified Site of antenatal ART Site of postnatal ART & timing of transfer 10-20% of women defaulted Option B+ by 6 months postpartum Strong associations with model of care Retention lowest in facilities with ART initiation in ANC, then referral for separate follow-up Van Lettow JIAS 2014
Slide 30-

What do we know about the drivers of disengagement? Insights scattered Gaps loom large Factors diverse across contexts Policies are universal People are not No single universal driver to target for intervention
Slide 31-

Interventions to support adherence & retention Clinical & biological Socio-demographic & psychological Health services & systems
Slide 32-

Enhanced patient education & counselling? etting? Enh Incre Text m ing engagement of women in MCH s anced peer support on ART? ealth worker home support? ased male partner involvement? essage reminders / mHealth? ctly observed therapy (DOT)? munity-based ‘adherence clubs’? Conditional cash transfers? Case manager systems? Fatti AIDS Care 2016 Foster JAIDS 2014 Mwapasa JAIDS 2014 Schwartz MCHJ 2015 Yotebieng Lancet HIV 2015 Zerbe IAC 2016 Herlihy JAIDS 2015 Rosenberg Lancet HIV 2015 Aliyu Lancet HIV 2016 Fayorsey CROI 2016 Nachega Pat Pref Adh 2016 Many ideas to promote engagement Ongo Exciting implementation science Few data from “Option B+” era Lay h Duration & effect sizes are modest Most interventions target a single, Dire specific issue Com  Little multicomponent thinking
Slide 33-

Health Services & Health Systems: How to provide universal ART Understanding models of care for delivering universal ART during pregnancy & postpartum What features of services can address women’s needs & promote adherence/retention? How to deliver ART at scale & with efficiency in severely resource-limited health systems? Tailoring services to women’s needs Health systems constraints
Slide 34-

5. Where are we headed?
Slide 35-

5. Where are we headed?
Slide 36-

Is this unique to HIV / ART?
Slide 37-

Research Policies & services Advocacy
Slide 38-

Retention research agenda Individual-level questions Why do some patients disengage from care, and others are retained over the long-term? What groups of factors can we promote through multicomponent intervention packages? Health services & systems questions What approaches to delivering care optimise health outcomes with lowest cost and greatest coverage? Linking maternal & child health over long-term? Balance individual vs public health approaches
Slide 39-

Are we missing advocacy?
Slide 40-

Acknowledgements Elaine Abrams, Kirsty Brittain Nei-Yuan Hsiao Victoria Iyun Nontokozo Langwenya James McIntyre Lynne Mofenson Jasantha Odayar Tamsin Phillips Steve Reynolds Agnes Ronan MCH-ART study team NICHD: R01HD074558 MRC: MR/M007464/1

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