Patterns of post-partum HIV care engagement

The antenatal care setting is a key entry point for HIV testing and initiation of lifetime antiretroviral therapy (ART) for women with HIV. In contrast to pregnancy, when HIV care engagement and participation in programmes to prevent mother-to-child transmission are typically high, the post-partum period can present unique barriers and added complexities, which compromise engagement after delivery.^1-4 Not enough is known about patterns of post-partum care engagement for different populations of women with HIV.

In The Lancet HIV, Hajra Okhai and colleagues⁵ used a large, representative national dataset, the UK Collaborative HIV Cohort Study, to assess changes in HIV care engagement before, during, and after pregnancy among women with HIV. They included 1116 matched pairs of pregnant and non-pregnant women with HIV (median age 34 years [IQR 30–38]; 80·1% Black African, 12·5% white).

Livebirths were confirmed on the basis of reporting to the National Surveillance of HIV in Pregnancy and Childhood. Women with a recorded pregnancy from Jan 1, 2000, to Dec 31, 2017 (first livebirth after diagnosis only) were eligible for inclusion, while women with pre-term deliveries were excluded. Using sophisticated statistical techniques, the authors assessed the degree to which changes in engagement were specific to pregnancy by matching women on key characteristics, including ethnicity, year of conception, age, CD4 cell count, viral suppression, and ART use. Pseudo conception and pseudo pregnancy dates for the matched control participants were determined based on the stratification of follow-up periods into consecutive monthly intervals. Another methodological strength of Okhai and colleagues’ analysis was their use of the Retention and Engagement Across Care services algorithm, which integrated individual clinical status information to estimate the amount of time until patients’ next scheduled follow-up appointment.

Results indicated that among women who had a pregnancy, the odds of HIV care engagement increased during and after pregnancy relative to before pregnancy. The slight increase in care engagement in the pseudo pregnancy stage among matched controls was smaller than the increase seen among pregnant women during the same stage, and there was no corresponding increase among control participants in the post-partum period. The finding that engagement during pregnancy increased aligns with existing data; however, the documented increases in care engagement during the post-partum period are promising, raising questions about the specific ways in which this setting (ie, a national health system with extensive guidelines and resources) facilitates increased engagement. The strategies used by the UK system,⁶ which Okhai and colleagues describe as “multidisciplinary and holistic”, could help explain study findings. These guidelines, proposed by the British HIV Association in 2018, not only include specific strategies for managing obstetric care, neonatal care, post-partum care, and hepatitis virus co-infection, they also address psychosocial care for pregnant and post-partum women, with attention paid to the unique psychosocial needs of women who are diagnosed with HIV during pregnancy and to the detection of antenatal and post-partum depression.

The study begins to answer important questions about post-partum HIV care engagement in a high-income setting, yet other important questions remain. Care engagement before pregnancy might or might not have been suboptimal in this sample; this information is not provided. Furthermore, optimal care—which varies based on an individual’s health history and the context in which women receive services—can be difficult to define and put into practice. Women with pregnancy loss or adverse birth outcomes and women who were diagnosed with HIV during their pregnancies were not included in the sample. These women and other key subpopulations (eg, recent immigrants or those who have not disclosed their HIV status) might be at substantial risk for attrition from HIV care, and they require further study.⁷

Pregnancy is clearly an opportunity to help women engage in HIV care and plan for continued engagement after birth. Supporting long-term care engagement after delivery will probably require care models that identify individuals who are at elevated risk for poor engagement and target services to support those groups. Contextual factors specific to the UK and other high-income countries, such as increased societal flexibility around medical appointments during pregnancy and the integration of HIV care with antenatal services, might not routinely exist in low-income and middle-income countries, in which post-partum engagement in HIV care is an essential long-term strategy for decreasing HIV incidence. Longitudinal data (ie, beyond 12 months post partum) are also needed, as factors associated with engagement in the first 3 months post partum could differ from those at 18 months or 24 months, and in cases of subsequent pregnancy. Although these data provide a compelling case for exploring adoption of the strategies implemented by the UK, studies on the drivers of care engagement by high-income versus low-income and middle-income settings are still needed (although some studies are already ongoing).⁸ Research that assesses these associations will need to ensure that groups of women at risk for attrition are identified.