title: Disengagement of HIV-positive pregnant and postpartum women from antiretroviral therapy services: a cohort study.
abstract: BACKGROUND
  Recent international guidelines call for expanded access to triple-drug antiretroviral therapy (ART) in HIV-positive women during pregnancy and postpartum. However, high levels of non-adherence and/or disengagement from care may attenuate the benefits of ART for HIV transmission and maternal health. We examined the frequency and predictors of disengagement from care among women initiating ART during pregnancy in Cape Town, South Africa.
  
  
  METHODS
  We used routine medical records to follow-up pregnant women initiating ART within prevention of mother-to-child transmission of HIV services in Cape Town, South Africa. Outcomes assessed through six months postpartum were (1) disengagement (no attendance within 56 days of a scheduled visit) and (2) missed visits (returning to care 14-56 days late for a scheduled visit).
  
  
  RESULTS
  A total of 358 women (median age, 28 years; median gestational age, 26 weeks) initiated ART during pregnancy. By six months postpartum, 24% of women (n=86) had missed at least one visit and an additional 32% (n=115) had disengaged from care; together, 49% of women had either missed a visit or had disengaged by six months postpartum. Disengagement was more than twice as frequent postpartum compared to in the antenatal period (6.2 vs. 2.4 per 100 woman-months, respectively; p<0.0001). In a proportional hazards model, later gestational age at initiation (HR: 1.04; 95% CI: 1.00-1.07; p=0.030) and being newly diagnosed with HIV (HR: 1.57; 95% CI: 1.07-2.33; p=0.022) were significant predictors of disengagement after adjusting for patient age, starting CD4 cell count and site of ART initiation.
  
  
  CONCLUSIONS
  These results demonstrate that missed visits and disengagement from care occur frequently, particularly post-delivery, among HIV-positive women initiating ART during pregnancy. Women who are newly diagnosed with HIV may be particularly vulnerable and there is an urgent need for interventions both to promote retention overall, as well as targeting women newly diagnosed with HIV during pregnancy.
authors.affiliation: Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; tk.phillips@uct.ac.za.
authors.forename: Tamsin
authors.initials: T
authors.lastname: Phillips
authors.affiliation: Desmond Tutu HIV Centre, Institute of Infectious Diseases & Molecular Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Thebus
authors.affiliation: Desmond Tutu HIV Centre, Institute of Infectious Diseases & Molecular Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Linda-Gail
authors.initials: LG
authors.lastname: Bekker
authors.affiliation: Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; Anova Health Institute, Johannesburg, South Africa.
authors.forename: James
authors.initials: J
authors.lastname: Mcintyre
authors.affiliation: ICAP, Mailman School of Public Health & College of Physicians & Surgeons, Columbia University, New York, United States.
authors.forename: Elaine J
authors.initials: EJ
authors.lastname: Abrams
authors.affiliation: Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Landon
authors.initials: L
authors.lastname: Myer
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D055118:Medication Adherence; D010342:Patient Acceptance of Health Care; D049590:Postpartum Period; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy*; D012189:Retrospective Studies; D013019:South Africa
chemical_list: D044966:Anti-Retroviral Agents
keywords: HIV/AIDS; South Africa; antiretroviral therapy; postpartum; pregnancy; prevention of mother-to-child transmission (PMTCT); retention