A systematic review of individual and contextual factors affecting ART initiation, adherence, and retention for HIV-infected pregnant and postpartum women.
BACKGROUND
Despite progress reducing maternal mortality, HIV-related maternal deaths remain high, accounting, for example, for up to 24 percent of all pregnancy-related deaths in sub-Saharan Africa. Antiretroviral therapy (ART) is effective in improving outcomes among HIV-infected pregnant and postpartum women, yet rates of initiation, adherence, and retention remain low. This systematic literature review synthesized evidence about individual and contextual factors affecting ART use among HIV-infected pregnant and postpartum women.


METHODS
Searches were conducted for studies addressing the population (HIV-infected pregnant and postpartum women), intervention (ART), and outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. Individual and contextual enablers and barriers to ART use were extracted and organized thematically within a framework of individual, interpersonal, community, and structural categories.


RESULTS
Thirty-four studies were included in the review. Individual-level factors included both those within and outside a woman's awareness and control (e.g., commitment to child's health or age). Individual-level barriers included poor understanding of HIV, ART, and prevention of mother-to-child transmission, and difficulty managing practical demands of ART. At an interpersonal level, disclosure to a spouse and spousal involvement in treatment were associated with improved initiation, adherence, and retention. Fear of negative consequences was a barrier to disclosure. At a community level, stigma was a major barrier. Key structural barriers and enablers were related to health system use and engagement, including access to services and health worker attitudes.


CONCLUSIONS
To be successful, programs seeking to expand access to and continued use of ART by integrating maternal health and HIV services must identify and address the relevant barriers and enablers in their own context that are described in this review. Further research on this population, including those who drop out of or never access health services, is needed to inform effective implementation.
Independent Consultant, Bingley, United Kingdom.
Ian
I
Hodgson
Independent Consultant, Dar es Salaam, Tanzania.
Mary L
ML
Plummer
Center for Health Services, Management Sciences for Health, Arlington, Virginia, USA.
Sarah N
SN
Konopka
Centre for Infectious Disease Epidemiology and Research (CIDER), Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
Christopher J
CJ
Colvin
Center for Health Services, Management Sciences for Health, Arlington, Virginia, USA.
Edna
E
Jonas
United States Agency for International Development (USAID)/Africa Bureau, Washington, D.C., USA.
Jennifer
J
Albertini
USAID/Bureau for Global Health (BGH)/Office of HIV/AIDS, Washington, D.C., USA.
Anouk
A
Amzel
USAID/BGH/Office of Health, Infectious Diseases, and Nutrition, Washington, D.C., USA.
Karen P
KP
Fogg
D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D003469:Culture; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D055118:Medication Adherence; D049590:Postpartum Period; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy* / Q000453:epidemiology; D012307:Risk Factors