Retaining HIV-infected pregnant and postpartum women in care is critical to prevent mother-to-child HIV transmission (PMTCT) and promote maternal health. New PMTCT approaches call for lifelong antiretroviral therapy (ART) for all HIV+ pregnant women (Option B+), a departure from strategies that used CD4 count to determine ART eligibility (Option A). Yet there are few implementation data on the impact of Option B+ on maternal retention in antenatal and postnatal care.
Using a stepped-wedge design the ‘Sitkulwane Lesiphephile–Safe Generations’ study compared maternal retention under Option A (based on <350 cells/µL) versus Option B+ in 10 primary care facilities across Swaziland. Pregnant HIV+ women not on ART making a first antenatal visit formed monthly facility-level cohorts that were followed through 6 months postpartum using routine health records. In analysis, the month of transition from A to B+ was excluded. Retention was defined as engagement in care within 56 days of delivery during the antenatal period and during a 3-month window before 6 months postpartum. Generalized estimating equations with a probit link were used to generate adjusted risk ratios (aRR) comparing outcomes under Options A versus B+ after accounting for age, CD4, gestation at 1st antenatal visit, and known HIV status.
2315 women were included: 45% (n=1043) under B+ and 55% (n=1272) under A. Patient characteristics were similar under B+ and A: mean age, 26 years; median gestational age at first antenatal visit, 20 weeks; median CD4, 404 cells/µL; CD4 <350, 33%. After transitioning to B+, the proportion of women receiving ART antenatally was higher (93%) vs A (30%; p<0.001). The proportion of women with CD4 <350 initiating ART antenatally also increased under B+ (94% vs 63%; p<0.001). Among all HIV+ women, 61% attended at least one visit prior to delivery: 68% under B+ vs 54% under A (aRR, 1.30; p<0.001). Overall, postpartum retention was low (37%). In the analysis of all HIV+ women, postpartum retention was significantly higher under B+ (50%) vs A (26%) (aRR, 1.54; p<0.001). However, when the analysis was restricted to women on ART, postnatal retention was somewhat lower under B+ vs A (53% vs 65%; aRR, 0.73; p<0.001).
Implementation of Option B+ greatly increased ART initiation antenatally and improved ART coverage among women with advanced HIV disease in Swaziland, but postpartum retention remains an important challenge requiring urgent intervention.