examining option b-plus1 these world health organization estimates include 399 000 adverse birth...
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Examining Option B-Plus: Is it the Panacea We Had Hoped For?
Grace John-Stewart
MTCT PROGRESS RETENTION AND ADHERENCE
MCH AND HIV INFLUENCES INTERVENTION APPROACHES
Globally, 80% pregnant women received ART
Source: UNAIDS 2018 estimates.
Additional progress needed to hit 2020 target
New HIV infections among children (aged 0–14 years), global, 2000–2017 and 2020 target
1 These World Health Organization estimates include 399 000 adverse birth outcomes in 2012 and 368 000 adverse birth outcomes in 2016.2 Previous estimates of mother-to-child transmission rates did not capture the retention on antiretroviral therapy of pregnant women and the ongoing high levels of incident infections among pregnant and breastfeeding women.
700 000
500 000
400 000
600 000
300 000
200 000
100 000
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2020
2017
2018
2019
Num
ber
of n
ew H
IV
infe
ctio
ns
180,000 new infant infections in 2018
Persistent risk of postnatal MTCT
MTCT PROGRESS RETENTION AND ADHERENCE
MCH AND HIV INFLUENCES INTERVENTION APPROACHES
• Retention1 • <25-75% at 12 mos
• Adherence2
• 30 to ~50% at 12 mos
• Suppression3
• 84% at 6 mos in Malawi
• EID4
• <50%
1. Miller AIDS Pt Care & STD 2017, Atanga Trop Med Int Health 2017, 2. Erlwanger JAIDS 2017,3. Hosseinipour JAIDS 2017, 4. UNAIDS 2016, Get on the fast track.
Postpartum engagement in care Myer JAIDS 2017
Weak evidence base, inconsistent retention measures, text reminders may improve early retention
10 studies, 3 mHealth, 4 integration, 3 other
Stigma, disclosure, distance, food deprivation, HIV knowledge influenced ART adherence
• 1274 postpartum women
• 4-26 weeks pp
94% knew HIV status
97% on ART
• 9% of suppressed had LLVL
88% suppressed• Suppressed 0.9%• LLVL 7%• Unsuppressed 14%
Transmission
MTCT PROGRESS RETENTION AND ADHERENCE
MCH AND HIV INFLUENCES INTERVENTION APPROACHES
ANCImmunizationsVitaminsMalaria prophylaxisBirth planningNutritionBreastfeedingDeliveryInfant CareMaternal Care
HIV testingART adherencePill refillViral load measuresTB prophylaxisInfant ARVsInfant HIV testing
HIV care
Pregnancy
HIV careFP
Pregnancy
2005 2010 2015 20200
10
20
30
40
50
60
70
80
90
100
Increasing Proportion of Women are ART-experienced prior to PMTCT
New ART ART experienced
Estimated increases
HIV care
Pregnancy
HIV careFP
Pregnancy
Integrate fertility and pregnancy planning into HIV care and HIV care into PMTCT with seamless transitions
MTCT PROGRESS RETENTION AND ADHERENCE
MCH AND HIV INFLUENCES INTERVENTION APPROACHES
Mother
Clinic
Peer Partner
Clin Infect Dis 2019
Interventions to engage male partners and peers, address adolescents and maternal motivation/knowledge are needed
MTCT PROGRESS RETENTION AND ADHERENCE
MCH AND HIV INFLUENCES INTERVENTION APPROACHES
Mother
Clinic
Peer Partner
mHealth to improve PMTCT retention and adherence
HIV mhealth systemAdapt for PMTCT
New system designed for PMTCT or HIV in
women
MCH mhealth systemAdapt for PMTCT
PMTCT cascade and mHealth intersections
HIV counseling for lifelong
ART
ART adherence
and retention
Long-term care or repeat
pregnancy
Infant EID and referral
Antenatal care Delivery Postnatal care
Information, motivation
Reminders,encouragement
Navigation, linkage
Reminders, results
Design Approach Postpartum Follow-up
Odeny 2014
RCTn-=188
14 SMS 8 wksRR 1.66, p=0.04
Kebaya2014
RCTN=150
Biweekly calls
10 wksRR 1.86, p<0.0001
Schwartz2015
Pre-postN=100
Text and calls
12 monthRR 1.03, p=0.81
Messaging improves early retention
Messaging improves EID uptake
Selected PMTCT mHealth studies
Message topics
Design, size Frequency Outcomes or Findings
End
Kassaye EGPAF, cluster RCT (AIDS Res and Treatment 2016)
Multiple approaches
Cluster RCT SMS 3-6 per week
No effect on maternal ARV uptake, EID
2016
TEXT-IT Randomized stepped wedge
14 SMS at q 1-2 weekly
Retention 1 yrEID 8 wks pp
2017
HITS 2.0 Provider alerts, women messages
RCT 162 retention 12 wks and EID, preg ART adherence
2018
WelTel WelTel ‘shida’ with escalation call
RCT, 600 weekly Retention 24 m pp, ART adherence, CEA
Mobile WAChX 2 way or 1 way SMA vs. control
RCT 875 weekly Retention 24 m pp, ART, VL, CEA
2020
RCTs in progress on PMTCT long-term retention, adherence and viral suppression
Mobile WACh-XUnger, Kinuthia, Ronen, Perrier
+
Two-
way
ar
m ++O
ne-w
ay
arm
Con
trol
arm • Mobile WACh – MCH
• Mobile WAChX PMTCT• 3 arm RCT• Enrollment
complete• Follow-up ongoing• Completion 2020
Mobile WACh system designed for MCHHybrid computer-human SMS system
• Automated, scheduled SMS (1-way)• Human reads responses & replies (2-way)
Perrier et al. CHI 2015, Unger et al. BJOG 2018
SMS messaging acceptableDesire for
• Visit reminders• Education• Encouragement, support• Praise• Discretion
Photo with permission
• Women like 2-way SMS• Push messages kindle
conversations• SMS useful for confidential
topics• Can provide ‘real-time’
advice• Issues can inform clinic
counseling• Providers gain skills
MTCT PROGRESS RETENTION AND ADHERENCE
MCH AND HIV INFLUENCES INTERVENTION APPROACHES
Mother
Clinic
Peer Partner
AcknowledgementsUniversity of NairobiBhavna ChohanBrain Khasimwa
Kenyatta National HospitalJohn KinuthiaDaniel MatemoLusi OsbornEmma MukenyiCelestine AdogoRose OnyangoGeorgina MugodoDyphna KeruboJael MangiraConciliah MogarikaSusan AtienoGrace OchiengNaomi MomanyiBeatrice AtienoAdhiambo BrenderAnne OpereColleta OnungaJanet AdhiamboWinnie Achieng
NIH/NICHD 5 R01 R01 Mobile WACh-XNIH/NICHD 5 K24 HD054314-08
Families in the studies
Community Advisory BoardMembers
University of WashingtonGrace John-StewartJennifer UngerKeshet RonenTrevor PerrierAlison DrakeMargaret ThompsonBrian DeRenziElizabeth HarringtonBarb RichardsonWenwen Jiang