Falling off the HIV treatment cascade cliff: understanding postpartum attrition to HIV care

随着时间的推移，成功地管理艾滋病毒需要继续与医疗保健系统接触。南 非洲在很大程度上承受着艾滋病毒疾病的负担，目前有700多万艾滋病毒携带者 2015年底。在夸祖鲁-纳塔尔省，大约40%登记参加产前护理的妇女是 艾滋病毒携带者是世界上艾滋病毒感染率最高的孕妇。除了专注于 预防母婴传播(PMTCT)，怀孕是让妇女终身感染艾滋病毒的独特时期 关心。产后未能继续接受艾滋病毒护理会产生许多后果。例如，女性 产后不保留在HIV护理中可能会也可能不会完成婴儿特有的母婴传播行为，增加了 有将艾滋病毒传染给婴儿的风险。不能优化母亲的健康有可能导致 与艾滋病毒有关的孤儿率上升，其风险已有很好的记录，包括 感染艾滋病毒的风险、不利的精神健康后果和经济不安全。未接受治疗的妇女 将艾滋病毒传染给男性伴侣的风险。最后，提供补充保健的机会(例如， 避孕)被怀念。虽然一些研究检查了产后母婴传播指南的遵守情况， 这些研究中很少关注母亲继续参与艾滋病毒护理，也很少研究 参与产后六个月后的护理。因此，这个应用程序的目标是研究轨迹 对产后感染艾滋病毒的妇女进行调查，以确定脱离护理的风险因素，以及 了解护理促进者可能为后续干预发展提供信息。我们的研究将在#年进行 分两个阶段。在目标1中，我们将收集500名艾滋病毒携带者在分娩后两年内的数据 以确定谁最有可能在产后期间继续接受艾滋病毒护理或脱离艾滋病毒护理。我们会 每三个月收集一次HIV RNA和自我报告的与医疗保健提供者的接触(访问Constancy) 共同初选结果。我们对障碍和促进者的评估是基于 艾滋病毒护理已经根据我们之前对这一人群的工作进行了修改。然后我们将进行个人， 为目标2对来自目标1的部分女性及其男性怀孕伴侣进行深入访谈；(1) 在至少两次连续评估中(N=12-15，基于 主题饱和)，(2)至少连续两次未实现抑制艾滋病毒RNA的妇女 评估(N=12-15，基于主题饱和度)和(3)从受抑制的艾滋病毒RNA转移过来的妇女 未抑制的艾滋病毒RNA(或相反；N=12-15，基于主题饱和度)。我们还将采访一位 每一位女性参与者的男性伴侣的子集(每组N=12-15)。此项目构建 总部设在南非德班和马萨诸塞州波士顿的现有和成功的合作者团队。这个 从该项目中学到的信息将导致更好地支持产后艾滋病毒护理的干预措施 通过告诉我们谁是最有可能脱离护理的人，以及需要干预的因素，来帮助妇女。

Successful management of HIV over time demands continued engagement with the healthcare system. South Africa bears a substantial degree of HIV disease burden, with well over 7 million people living with HIV at the end of 2015. In the province of KwaZulu-Natal, approximately 40% of women enrolled in antenatal care are living with HIV, the highest prevalence of HIV among pregnant women in the world. In addition to focusing on preventing mother to child transmission (PMTCT), pregnancy is a unique time to engage women in lifelong HIV care. There are many consequences of failing to remain in HIV care postpartum. For example, women who are not retained in HIV care postpartum may or may not complete infant specific PMTCT behaviors, increasing the risk of transmitting HIV to their infant. Failing to optimize the health of mothers has the potential to lead to increased rates of HIV related orphanhood, the risks of which have been well documented and include greater risk of HIV acquisition, adverse mental health outcomes, and economic insecurity. Women not on treatment risk transmitting HIV to male partners. Lastly, opportunities to provide complementary health care (e.g., contraception) are missed. While some studies have examined adherence to postpartum PMTCT guidelines, few of these focus on continued engagement in HIV care by the mother, and very few of them examine engagement in care beyond six months postpartum. Thus, the goal of this application is to study the trajectory of women living with HIV during the postpartum period in order to identify risk factors for falling out of care, and to learn about facilitators of care that may inform subsequent intervention development. Our study will occur in two phases. In Aim 1, we will collect data from 500 women living with HIV for a period of 2 years after delivery in order to identify who is most likely to remain in or fall out of HIV care during the postpartum period. We will collect HIV RNA and self-reported contact with a health care provider every three months (visit constancy) as co-primary outcomes. Our assessment of barriers and facilitators is informed by a socio-ecological model of HIV care that has been modified based on our prior work with this population. We will then conduct individual, in-depth interviews with a subset of women and their male pregnancy partners from Aim 1 for Aim 2; (1) women who achieved suppressed HIV RNA for at least two consecutive assessments (N=12-15, based on thematic saturation), (2) women who did not achieve suppressed HIV RNA for at least two consecutive assessments (N=12-15, based on thematic saturation), and (3) women who move from suppressed HIV RNA to unsuppressed HIV RNA (or the reverse; N=12-15, based on thematic saturation). We also will interview a subset of the male partners of each of these female participants (N= 12-15 per each group). This project builds upon and existing and successful team of collaborators based in Durban, South Africa, and Boston, MA. The information learned from this project will lead to interventions to better support HIV care among postpartum women, by informing us who is most at risk for falling out of care, and on what factors intervention is needed.