Option B+: In obstacle courses to lifelong antiretroviral treatment, hurdles are higher for pregnant women, study says

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Work conflicts, hidden HIV status, and bad treatment by staff are among the hurdles keeping women living with HIV from continuing antiretroviral treatment for life following childbirth, according to a article published last month ahead of print in the Journal of Acquired Immune Deficiency Syndromes.

The study described in “What they wanted was to give birth; nothing else” : Barriers to retention in Option B+ HIV care among postpartum women in South Africa, sought to identify reasons for high rates of dropping out of care among women who began antiretroviral treatment during pregnancy. Researchers interviewed women living with HIV receiving prenatal care at one of the few clinics in South Africa offering HIV-infected pregnant women the option of beginning lifelong antiretroviral treatment regardless of immune cell count. While countries that include Malawi and Uganda have adopted that choice for women receiving antiretroviral treatment for prevention of mother to child transmission, South Africa offers antiretroviral treatment during breastfeeding for women with immune cell counts higher than 350 per cubic milliliter of blood. The study was prompted in part by findings in Malawi that women starting antiretroviral treatment because of pregnancy and under Option B+ were five times likelier than women who started antiretroviral treatment because of low immune cell counts to be lost to follow-up care.

Researchers interviewed 50 pregnant HIV-infected women, interviewed 48 of them a second time in the weeks following childbirth, and held a focus group discussion with eight more HIV-infected women who had given birth in the last year. The majority of the women worked or had worked in the last year, nearly half as maids, and earned a median monthly pay of about $250, in U.S. dollars. The median travel time to the clinic where women reported for followup care was 30 minutes. Women also reported long waits once at clinics, with limited open hours to adapt to work schedules.

Secrecy — from employers to whom women anticipated explaining the need to take time away from work, as well as from domestic partners and family members — added to the challenge of repeated returns to clinics to receive and remain on treatment. Continuing stigma surrounding HIV intensified judgmental responses from clinic staff, and others, researchers noted. In addition, the authors wrote, “women receive strong messages that a new mother need not seek care for herself after delivery and if she does, she may be viewed with suspicion.”

Researchers also noted that the clinic where they conducted the study served recent immigrants from surrounding countries, and that moving, within and outside of the country also complicate care. They suggest nationwide electronic health records could help support continued treatment.

The obstacles, the authors conclude, between mothers living with HIV and antiretroviral treatment for the sake of their own health are built of practical, personal, societal, and structural components that countries planning to offer lifelong treatment to child-bearing women with HIV should plan to address.

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