title: Effectiveness of community-based support for pregnant women living with HIV: a cohort study in South Africa.
abstract: Antiretroviral treatment (ART) initiation in HIV-infected pregnant women in sub-Saharan Africa (SSA) remains inadequate, and there is a severe shortage of professional healthcare workers in the region. The effectiveness of community support programmes for HIV-infected pregnant women and their infants in SSA is unclear. This study compared initiation of maternal antiretrovirals and infant outcomes amongst HIV-infected pregnant women and their infants who received and did not receive community-based support (CBS) in a high HIV-prevalence setting in South Africa. A cohort study, including HIV-infected pregnant women and their infants, was conducted at three sentinel surveillance facilities between January 2009 and June 2012, utilising enhanced routine clinical data. Through home visits, CBS workers encouraged uptake of interventions in the ART cascade, provided HIV-related education, ART initiation counselling and psychosocial support. Outcomes were compared using Kaplan-Meier analyses and multivariable Cox and log-binomial regression. Amongst 1105 mother-infant pairs included, 264 (23.9%) received CBS. Amongst women eligible to start ART antenatally, women who received CBS had a reduced risk of not initiating antenatal ART, 5.4% vs. 30.3%; adjusted risk ratio (aRR) = 0.18 (95% CI: 0.08-0.44; P < .0001). Women who received CBS initiated antenatal ART with less delay after the first antenatal visit, median 26 days vs. 39 days; adjusted hazard ratio (aHR) = 1.57 (95% CI: 1.15-2.14; P = .004). Amongst women who initiated antenatal zidovudine (ZDV) to prevent vertical transmission, women who received CBS initiated ZDV with less delay, aHR = 1.52 (95% CI: 1.18-2.01; P = .001). Women who received CBS had a lower risk of stillbirth, 1.5% vs. 5.4%; aRR = 0.24 (95% CI: 0.07-1.00; P = .050). Pregnant women living with HIV who received CBS had improved antenatal triple ART initiation in eligible women, women initiated ART and ZDV with shorter delays, and had a lower risk of stillbirth. CBS is an intervention that shows promise in improving maternal and infant health in high HIV-prevalence settings.
authors.affiliation: a Kheth'Impilo , Cape Town , South Africa.
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Fatti
authors.affiliation: a Kheth'Impilo , Cape Town , South Africa.
authors.forename: Najma
authors.initials: N
authors.lastname: Shaikh
authors.affiliation: b Department of Paediatrics and Child Health , Red Cross War Memorial Children's Hospital, University of Cape Town , Cape Town , South Africa.
authors.forename: Brian
authors.initials: B
authors.lastname: Eley
authors.affiliation: a Kheth'Impilo , Cape Town , South Africa.
authors.forename: Ashraf
authors.initials: A
authors.lastname: Grimwood
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D003153:Community Health Services; D055812:Community-Based Participatory Research; D003376:Counseling; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D007223:Infant; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy*; D011256:Pregnancy Outcome; D037841:Pregnant People / Q000523:psychology*; D011295:Prenatal Care; D015995:Prevalence; D013019:South Africa / Q000453:epidemiology; D016896:Treatment Outcome; D014505:Urban Population; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents
keywords: Pregnancy; South Africa; antiretroviral treatment; community-based support; lay health workers; prevention of mother-to-child transmission of HIV