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

摘要 第一次在国家层面上，我们建议利用常规收集的实验室数据来开发一种 南非感染艾滋病毒的孕妇队列以一种独特的方式传播 设施。南非的艾滋病毒携带者比其他任何国家都多，几乎三分之一 接受产前护理的孕妇携带艾滋病毒。获得抗逆转录病毒治疗(ART) 自2004年国家艺术计划开始以来，艺术覆盖率大幅增加，在2004年，艺术覆盖率达到95%。 怀孕和分娩后，艾滋病毒的母婴传播大大减少。然而，我们的工作已经 证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，可能导致病毒传播、发病率和死亡率。很难做到 评估扩大获得ART护理的政策的成功程度，并评估护理的连续性，因为 缺乏国家纵向艾滋病毒护理数据库。此外，患者在未连接的设施之间的流动 这意味着自我转移往往被错误地归类为失去关爱。为了解决这一主要缺陷，我们的团队在 卫生经济和流行病学办公室(HE2RO)与南非国家卫生组织合作 2015年实验室服务利用现有的艾滋病毒相关实验室数据创建南非国家 爱滋病患者。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- 收集实验室数据以开发南非艾滋病毒携带者孕妇队列。我们建议 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， 爱滋病护理。使用与设施类型匹配的实验室测试数据，我们将确定产前护理的入口，以建立 队列，然后描述关键的治疗里程碑，包括1)参与产前护理，2)启动抗逆转录病毒治疗， 3)HIV病毒血症，以及4)产后持续的HIV护理。第二，我们将衡量 影响孕妇护理连续性的全系统因素。我们将评估扩大的政策 应用回归-间断性分析对护理连续性进行治疗获取。然后，我们将评估移动性 以及它对怀孕期间和怀孕后护理连续性的影响。第三，识别个人层面的风险因素 预防艾滋病毒护理造成的损失，以便制定有针对性的干预措施，改善艾滋病毒护理的参与度。

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.