Poorer adherence and loss to follow up in Kenyan women who are pregnant when enrolled to ART programmes

There are concerns that women diagnosed with HIV during pregnancy may have greater difficulty with adherence to ART than those who are already aware of their status. This may lead to increased rates of vertical transmission and the development of drug resistance.

April Bell showed findings from a retrospective analysis of data collected from January 2006 to July 2011 by the United States Agency for International Development-Academic Model Providing Access to Healthcare (USAID-AMPATH) programme in Western Kenya.

The study compared adherence rates and pregnancy outcomes between women enrolled in the programme during pregnancy and those who became pregnant after they were already enrolled. Women from both groups were ART-naïve when their pregnancy was identified. Those meeting the eligibility criteria for treatment in Kenya at the time – CD4 <200 cells/mm3 – started ART immediately and those with CD4 >200 cells/mm3 started at 28 weeks gestation.

The women enrolled during pregnancy were younger, with a median age of 27 (IQR 23.2-31.7) years (n=8926), compared to 30.8 (IQR 26.6 – 35.1) years in the group already enrolled (n=5108). At enrollment a higher proportion were married, 69.6% compared to 52% and had a higher median CD4 count 371.5 (IQR 222 – 543) cells /mm3 compared to 282 (IQR 133-461) cells/mm3 for women who became pregnant when they were already enrolled in the programme. All comparisons, p<0.0001.

The women who were pregnant at enrollment were less adherent, 89.7% compared to 93.2% with perfect adherence, and were more likely to be lost to follow up before delivery, 29.6% compared to 3.4%, both p<0.0001.

Among the women who remained in the programme post-partum, there was no difference in the rate of mother-to-child transmission, 7% compared to 8.8%, p=0.0053, or early infant death, 3.2% compared to 4.2%, p=0.032, in those enrolled during pregnancy or became pregnant after enrollment respectively.

Although this study was limited by incomplete data, the investigators were able to conclude that women who are pregnant at enrollment into an HIV care programme are at higher risk for loss to follow up and poor adherence than those already enrolled in care at the time of pregnancy.

They suggested, “Interventions targeting women newly diagnosed with HIV infection during pregnancy are necessary to improve retention and adherence to therapy”.

Bell A et al. Adherence and retention rates: a comparison of women enrolled in an ART programme during pregnancy and those who become pregnant after enrollment. 2nd International Workshop on HIV and women. 9—10 January 2012, Bethesda, MD. Oral abstract O_17.