What Works for Women and Girls: Evidence for HIV/AIDS Interventions: Safe Motherhood and Prevention of Vertical Transmission: Antenatal Care - Treatment

This updated (2016) component of the resource What Works for Women & Girls (see Related Summaries, below) provides a public health perspective on what works for women in access and adherence to antiretroviral treatment (ART) in the context of antenatal care. It emerges from a project that is supported by the United States (US) President's Emergency Plan for AIDS Relief (PEPFAR) and is being carried out under the auspices of the US Agency for International Development (USAID)-supported Evidence Project and What Works Association. The issue is that, though ART for women living with HIV is vital to ensuring safe motherhood and reducing vertical transmission, not all pregnant women access treatment. Access to treatment in low- and middle-income countries has been hampered by availability of medications and standardised treatment eligibility criteria that traditionally prioritised prevention of HIV transmission to the infant (prevention of mother-to-child transmission, or PMTCT) over treatment for the health of the woman.

This section of "What Works" does not provide medical or clinical guidance, which is available from the World Health Organization (WHO) but, rather, an analysis of evidence that reveals some communication-centred insights. Namely:

• Treatment guidance has changed, as outlined here. One implication: "Donors, country governments, implementing partners, and communities will need to work together to develop cost efficient strategies to expand treatment for all."
• Antiretroviral medications are beneficial, but drug resistance remains a concern for women living with HIV. 2015 WHO guidelines also note that pre-exposure prophylaxis (PrEP) may be used during pregnancy and thus may be an additional HIV prevention tool to be used by women during pregnancy. Among other interventions to increase safer conception outlined here: knowledge for both men and women of when is a woman's peak fertility.
• All women living with HIV need timely access to ART, ideally prior to pregnancy. For example, women who are part of key populations, such as women who use drugs and women who are sex workers, need intensified programming to ensure ART access. Sex workers may fear health services or avoid services, due to stigma and discrimination.
• Women's lives are as important as their children's. Launched in 2011, the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive has been criticised for both a narrow focus on prenatal HIV prevention, rather than affirming the health, autonomy, and rights of women living with HIV, as well as failing to protect fundamental human rights of women living with HIV to voluntary, confidential uptake of ART with informed consent. "A global review, funded by the Gates Foundation, conducted by scientists at WHO and elsewhere, found that what matters to pregnant women globally is achieving maternal self-esteem, competence and autonomy, as well as preventing and treating illness and death (Downe et al., 2015) - and pregnant women living with HIV are no different in this regard. Community and civil society input (Shaffer et al., 2013), along with input of women living with HIV, is needed on how best to support newly diagnosed pregnant women living with HIV."
• Women need information, support, and respect in decision-making about ART. It is noted that insufficient counseling or respect for women's decision-making time can drive women away from accessing treatment. "A recent study in Ethiopia found that a key factor associated with loss to follow up on Option B+ was starting treatment on the same day as diagnosis: 28.1% of 418 pregnant women started on cART [combination ART] received cART only once and never returned to the health facility (Mitiku et al., 2016). However, in a different pilot program with intensive counseling, pregnant women living with HIV were willing to initiate within one to four days, with 97% of 100 women initiating ART prior to delivery (Myer et al., 2012). Common barriers to ART initiation included concern about side effects and the practicalities of ART, fear of stigma, partner abandonment and abuse after disclosing their status, and perceived lack of support from families and partners, and laws and policies that criminalize HIV." Women have reported wanting more counseling to make the decision to start lifelong ART. "All women, and particularly women living with HIV, need accurate information about their pregnancies and their rights. They should know that they have the right to bear children and that pregnancy does not accelerate HIV disease progression (Westreich et al., 2013 cited in Kendall and Danel, 2014)."
• Fear of disclosure and/or violence can influence treatment initiation and adherence. Because pregnant women living with HIV still remain highly stigmatised in many countries, some women are reluctant to disclose, particularly to their sexual partners (Croce-Galis et al., 2015). Pregnant women in Zimbabwe have faced violence for testing without their partner's consent (Shamu et al., 2014). A systematic review and meta-analysis of intimate partner violence (IPV) and engagement in HIV care and treatment among women found that IPV was associated with lower ART use, half the odds of self-reported ART adherence, and significantly worsened viral suppression among women (Hatcher et al., 2015). "...In the absence of specific interventions to respond to violence or promote safety, women who are at risk of violence may be better off being supported in a decision not to disclose their status" (Kennedy et al., 2015: p. 7). Little evaluated work exists on disclosure by pregnant women to other family members besides sexual partners and how this could increase support for women (Busza et al., 2012).
• Addressing gender norms and supporting women may be key to eliminating vertical transmission. A barrier to initiation, adherence, and retention on ART for pregnant women living with HIV is that she may be required to ask permission to access services (Hodgson et al., 2014; Hlarlaithe et al., 2014). "Key to gender transformative programming in Safe Motherhood and Prevention of Vertical Transmission is for women's lives to be valued - not just to keep babies healthy." Community-based support programmes for pregnant women living with HIV can be helpful. A recent study of implementation of community-based adherence clubs for stable ART patients, which provided ART to 2,133 patients, 71% female, with a strong emphasis on peer-based support and patient self management, found that one year later, only 6% of patients were lost to follow up and fewer than 2% of patients experienced viral load rebound (Grimsrud et al., 2015). How to link pregnant women postpartum to such community-based interventions remains a challenge (Onono et al., 2015).
• Additional efforts are needed to better engage men in supporting safe motherhood and prevention of vertical transmission. "Mandating men to attend antenatal care may be counterproductive and prejudice women without partners. Preparing men and women to be parents and have healthy educated children, is key to the well being of future generations." A review of gender inequality through male involvement in maternal health found 13 studies which showed that men were viewed mostly as gatekeepers for women's health and used men to facilitate health seeking behaviour by female partners; men were seen as instruments rather than people with their own needs in terms of the birth of their child (Comrie-Thomson et al., 2015).
• Progress has been made in improving maternal health, but more is needed. For example, women and their families need information on why antenatal care is important for maternal and child health and what they can expect to receive as part of antenatal care, without high costs as a barrier or long waits to access care (Mason et al., 2015). Pregnant women living with HIV will need to access care outside of maternal health services after the postpartum period. Key questions to address are: How are women transferred in and out of adult ART services before and after pregnancy? What support is needed for women who are not ready to initiate ART? What will support women to remain adherent, during pregnancy, postpartum and for the remainder of their lives? (Colvin et al., 2014).
• It is possible to eliminate vertical transmission. Between 2009 and 2015, there was a 46% decline in the number of AIDS-related deaths among women of reproductive age in the 21 priority countries (UNAIDS, 2016). "This progress demonstrates that with sustained resources and attention, it will be possible to eliminate vertical transmission."

Some of the communication-related findings of what works:

• Peer counseling by mother mentors may improve treatment adherence among pregnant women living with HIV. Several examples from the research are presented. To cite one: "A cluster randomized controlled trial in South Africa found that peer mentors supporting women living with HIV and their infants resulted in significantly fewer depressive symptoms and fewer underweight babies, as well as greater adherence to the guidance at the time on prevention of vertical transmission....Eight clinics were randomized for pregnant women living with HIV to either receive standard of care or an intervention with peer mentors of women living with HIV who had received training. There were eight meetings that discussed establishing healthy routines; adhering to ART; couple disclosure; consistent condom use; and infant bonding. Peer mentors were trained, and had weekly supervision. After twelve months, outcomes for 181 women in the standard of care and 106 women who attended at least one session with peer mentors was analyzed (Rotheram-Borus et al., 2014)."
• Community health workers and community-based support can increase uptake of safe motherhood interventions for women living with HIV and reduce vertical transmission. Several examples from the research are presented. To cite one: "A pilot program in South Africa with 50 pregnant women living with HIV who had support from case managers and text messages were statistically significantly more likely (90% vs. 63%) to have had their infants tested for HIV postpartum than a comparison group of 50 pregnant women living with HIV. All women had a cell phone. In the intervention group, case managers who were lay counselors, sent a pre-scripted text message until six weeks post-partum. Case managers also made a phone call prior to delivery and two phone calls postpartum. Women could request a phone call at no charge from the case manager. The program cost US$364 in cell communication over four months plus US$29 per cell phone for the case manager. Women found the intervention acceptable and that it provided needed emotional support as well as a resource to ask questions. Messages included, 'A healthy baby starts with a healthy mother! Be sure to take your tablets every day. ...Congratulations on your new baby. I hope this is a special time for you' (Schwartz et al., 2015b: 2032)."

Various gaps are identified with regard to programming that imply the need for communication-specific approaches. For example: "Strategies need to be identified to empower women to create demand for improved maternal health services and challenge violations of their rights in facility-based childbirth. This is a particularly acute need for women living with HIV." Furthermore: "Strategies, including legal strategies, are needed to empower pregnant women living with HIV to ask questions, be properly informed and to challenge stigma, disrespect and abuse. Consequences for violating patient confidentiality, redress for women with HIV facing discrimination in facilities, and stigma reduction efforts are needed to increase adherence to cART, prior to, during and post pregnancy, including training for providers." It is also noted that: "Interventions are needed for male involvement that do not such reinforce harmful gender norms or increase risk for violence, stigma or discrimination. 'Evidence for effectiveness of male involvement in PMTCT programs is scant' (Beckham et al., 2015: 67)."

Related Summaries:
What Works for Women & Girls
What Works for Women and Girls: Evidence for HIV/AIDS Interventions