HIV control in postpartum mothers: a turbulent time

Introduction

The management of pregnant HIV-positive women can be complex and much has been published on this. There has been less work focusing on the postpartum period. There are very few studies looking at antiretroviral therapy (ART) adherence among HIV-positive, pregnant and postpartum women and the reasons for non-adherence. ¹ There is some evidence to say that adherence to ART is better during pregnancy than during the postpartum period.^2–4 We conducted an audit looking at the management of HIV-positive women in the postpartum period.

Methods

We retrospectively reviewed the case notes of all HIV-positive women looked after in the city of Sheffield, UK who delivered between 1 January 2000 and 31 December 2011. The women were identified through the directorate’s HIV database and through a list kept by the HIV specialist midwife. Planned ART management, actual ART management, CD4 count and viral load (VL) were recorded at delivery, one month and 12 months postpartum. Psychological and social problems in the 12 months postpartum were noted and grouped into categories. We also recorded missed follow-up appointments and reasons for non-attendance, where documented. Women are usually seen within two months of delivery and three- to four-monthly thereafter. All babies born during this period were HIV negative.

Standards (from the British HIV Association (BHIVA) guidelines for the management of pregnant women)

1. The proportion of women with a CD4 count of <350 cells/µL or a previous AIDS-defining illness who continued antiretroviral therapy (ART) for 12 months postpartum (target 100%).

Results

There were 84 pregnancies involving 76 women, of whom 30.2% (23/76) had been diagnosed with HIV during the current pregnancy. Here, 78.9% (60/76) of women were Black African, 17.1% (13/76) White British and 3.9% (3/76) of other ethnicity. The remainder of the results refer to pregnancies rather than women.

Concordance with the postpartum management plan

In addition to the audit criteria, we looked at whether women followed the postpartum management plan. In 92% (77/84) of pregnancies, the women were concordant with their postpartum management plan as shown in Figure 1. Psychological or social problems including missed HIV clinic appointments were noted in 74% (62/84) of pregnancies (see Figure 2). In 27% (34/84) of cases, the women missed one or more HIV clinic appointments in the 12-month postpartum period. This is similar to the general HIV clinic non-attendance rate. Of those not adherent to their postpartum management plan, 57% (4/7) missed appointments. The most common psychological and social themes were signs of depression (21%), partner-related concerns including separation (21%), childcare problems (18%), financial difficulties (15%), housing problems (13%) and asylum issues (10%). Of the seven women who did not adhere to their postpartum management plan, all had psychological or social problems and 71% (5/7) self-reported depression. There was a statistically significant link between signs of depression and non-adherence (Chi-square test p = 0.0008). Of the women with a detectable VL, 86% (12/14) had psychological or social problems and 29% (4/14) showed signs of depression. OPEN IN VIEWER

Figure 1.

Flow chart to show treatment outcome at 12 months postpartum.

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Figure 2.

Range of psychological and social problems experienced by women in the postpartum period.

Discussion

The latest Public Health England data from 2013 found that 90% of individuals on ART achieved a VL of <200 copies/ml. ⁵ Only 84.8% (39/46) of our women on ART achieved this throughout the 12-month postpartum period. When this is considered alongside the seven women who were not adherent to their postpartum management plan, it suggests that this period is a vulnerable time. There appears to be an association between non-adherence and missed appointments but this did not reach statistical significance. As this was a retrospective audit, the reasons for non-attendance were not specifically documented. Those who missed appointments all had social or psychological problems including self-reported depression, relationship problems, alcohol problems, and a number of women stated they were struggling to cope. We follow up all patients who non-attend with phone-calls and letters to the home address and General Practitioner if appropriate.

The high rates of self-reported depression and the association between depression and non-adherence suggest that this is an area that should be targeted. Screening women for depression, in particular postnatal depression, using the Edinburgh postnatal depression scale (EPDS), could identify women who would benefit from intervention.

The variety of psychological and social issues experienced demonstrate that continuing a multidisciplinary team (MDT) approach in the postpartum period may help to improve treatment outcomes for HIV-positive mothers. We recommend that all HIV postpartum women are reviewed in an MDT forum, with access to HIV doctors, nurse specialists, paediatricians, social workers and psychology. We have found extending the pregnancy MDT meeting to include the 12-month postpartum period to be the simplest way of managing this.