There are global concerns about postpartum women’s engagement in antiretroviral therapy (ART) services and resulting viral suppression (VS). Integration of ART into the maternal and child health (MCH) platform is routine during prenatal care but postnatal services have received little attention. We evaluated the impact of an integrated MCH-ART service on mother and infant outcomes.
From Jun 2013-Dec 2014 we enrolled consecutive HIV-infected mother-infant pairs (MIP) immediately postpartum if mothers were 18+ years of age, initiated ART in the recent pregnancy at the local MCH service and were breastfeeding (BF). MIP were randomised to either: (i) postnatal retention in the integrated MCH-ART service for the duration of BF (intervention) or (ii) immediate referral to adult ART services for mothers and separate routine ‘well baby’ services for infants (control; local standard of care). The primary outcome was a combined endpoint of maternal engagement in HIV care (from medical record review) and VS<50 copies/mL at 12m postpartum (measured separately from routine care).
Overall, 472 women were randomised at a median of 5d postpartum (median age 28y; median pre-ART CD4 354 cells/uL; median duration of prenatal ART 18w; 76% and 94% of women with VS<50 and <1000 copies/mL at randomisation, respectively); characteristics did not differ by trial arm. 87% of MIP completed the study outcome visit at 12m postpartum with no difference in completion by arm. By design women in the intervention arm spent longer in the integrated MCH-ART service (8.7m vs 0.3m in control arm). The median duration of BF was significantly longer in intervention vs control (9.0m vs 3.1m, p<0.001). Among mothers in the control arm referred to adult ART services, 56% met the combined endpoint of engagement in care and VS<50 copies/mL compared to 77% of intervention mothers randomised to stay in the integrated MCH-ART service until the end of BF (absolute risk difference 21%; 95% CI: 12-30%; p<0.001). In secondary analyses the intervention improved sustained VS over time to <50 and <1000 copies/mL (Figure). MTCT by 12m was low (0.55%) and did not differ by arm (p=0.740); other infant outcomes were similar by arm.
Integrated MCH-ART services during the postnatal period lead to significant improvements in women’s engagement in HIV care and viral suppression while extending breastfeeding, providing a simple, effective intervention to promote maternal and child health outcomes in the context of HIV.