The South African National HIV Pregnancy Cohort: evaluating continuity of care among women living with HIV

摘要 在国家层面上，我们首次提出利用严格收集的实验室数据来制定一个 南非感染艾滋病毒的孕妇队列，以一种独特的方式， 设施南非的艾滋病毒感染者比其他任何国家都多，近三分之一的人感染艾滋病毒。 接受产前护理的孕妇是艾滋病毒感染者。获得抗逆转录病毒疗法的机会 自2004年国家抗逆转录病毒治疗方案启动以来，艾滋病的发病率大幅增加， 怀孕和分娩以及母婴传播艾滋病毒大大减少。然而，我们的工作 表明在怀孕期间开始抗逆转录病毒治疗的妇女退出护理的风险更高， 特别是在分娩后，导致病毒传播、发病和死亡的可能性。很难 评估扩大获得ART护理的政策的成功，并评估护理的连续性， 缺乏全国艾滋病毒纵向护理数据库。此外，患者在未连接的设施之间的移动 这意味着自我转移经常被错误地归类为失去护理。为了解决这一重大缺陷，我们的团队在 卫生经济学和流行病学办公室（HE 2 RO）与南非国家卫生部合作， 2015年，实验室服务部将利用现有的艾滋病毒相关实验室数据， HIV队列。现在，通过这个为期五年的奖项，我们建议将这个成功的项目扩大到常规使用- 收集实验室数据，以建立一个南非感染艾滋病毒的孕妇队列。我们提出 三个具体目标。首先，我们将开发和验证一个新的全国孕妇队列， 艾滋病毒护理。使用与设施类型相匹配的实验室检测数据，我们将确定产前护理的入口， 队列，然后描述关键的治疗里程碑，包括1）参与产前护理，2）开始ART， 3)艾滋病毒血症，以及4）产后期间艾滋病毒护理的连续性。第二，我们将衡量 影响孕妇护理连续性的全系统因素。我们将评估扩大 使用回归-不连续性分析，对护理连续性进行治疗。然后我们将评估流动性 及其对怀孕期间和怀孕后护理连续性的影响。第三，我们将确定个人层面的风险因素 为艾滋病毒护理的损失，以制定有针对性的干预措施，以改善对艾滋病毒护理的参与。

ABSTRACT For the first time on a national level, we propose to utilize routinely-collected laboratory data to develop a cohort of pregnant women living with HIV in South Africa in a way that is uniquely robust to transfer across facilities. South Africa is home to more people living with HIV than any other country, and nearly one in three pregnant women attending antenatal care is living with HIV. Access to antiretroviral therapy (ART) has increased substantially since the start of the national ART program in 2004, with >95% ART coverage during pregnancy and delivery, and mother-to-child transmission of HIV greatly reduced. However, our work has demonstrated that women who initiate ART during pregnancy are at heightened risk of dropping out of care, particularly after delivery, leading to the potential for viral transmission, morbidity and mortality. It is difficult to evaluate the success of policies of expanded access to ART care, and assess continuity of care, due to the lack of a national longitudinal HIV care database. In addition, patient movement between unlinked facilities means that self-transfer often is misclassified as loss to care. To address this major shortcoming, our team at the Health Economics and Epidemiology Office (HE2RO) partnered with the South African National Health Laboratory Services in 2015 to use existing HIV-related laboratory data to create the South African National HIV Cohort. Now, through this five-year award, we propose to expand this successful project to use routinely- collected laboratory data to develop a cohort of pregnant women living with HIV in South Africa. We propose three specific aims. First, we will develop and validate a novel national cohort of pregnant women accessing HIV care. Using laboratory test data matched to facility type, we will identify entry to antenatal care to build the cohort, then describe key treatment milestones, including 1) engagement in antenatal care, 2) initiation of ART, 3) HIV viremia, and 4) continuity of HIV care in the postpartum period. Second, we will measure the effect of system-wide factors impacting continuity of care among pregnant women. We will assess policies of expanded treatment access on continuity of care using regression-discontinuity analyses. We then will assess mobility and its effect on continuity of care during and after pregnancy. Third, we will identify individual-level risk factors for loss from HIV care in order to develop targeted interventions to improve engagement in HIV care.