Outcome expectancies toward adherence to antiretroviral therapy for pregnant and postpartum women with HIV.

OBJECTIVES: Adherence to antiretroviral therapy and retention in care significantly drop for women with HIV during the postpartum period. We have a limited understanding of how outcome expectancies influence maternal adherence and retention in care. METHODS: Women with HIV from an urban academic clinic completed in-depth interviews in the third trimester and at 3 to 9 months postpartum to evaluate outcome expectancies, facilitators, and barriers to antiretroviral therapy adherence and retention in care. Interviews were audio-recorded and analyzed for content. A codebook was created using deductive (based on the theory of reasoned action approach) and inductive (based on emergent themes) codes. RESULTS: We conducted 21 interviews with 12 women during pregnancy and 9 women during postpartum period. Participants had a mean age of 31 (standard deviation = 5.7) and most were African American (75%). Outcome expectancies centered mostly around pediatric health to prevent perinatal transmission of HIV and to be healthy to raise their children. Other outcome expectancies included preventing transmission of HIV to their partners. Social support from partners served as a strong facilitator as they helped routinize pill-taking behaviors, provided reminders, and decreased social isolation. Barriers to antiretroviral therapy adherence included depression, the disruption of scheduling routines, and the physical demands associated with the postpartum period. These barriers were accentuated for women with multiple children. CONCLUSION: Women's commitment to pediatric health was the primary motive for antiretroviral therapy adherence. Partners also served an important role. These findings suggest that interventions linking pediatric and maternal health, and partner support can improve maternal HIV treatment in the postpartum period.

Implementing Couple's Human Immunodeficiency Virus Testing and Counseling in the Antenatal Care Setting.

OBJECTIVE: To describe a pilot implementation of couple's human immunodeficiency virus (HIV) testing and counseling in an antenatal care clinic in the United States. METHODS: We used a cross-sectional study design. Couples were recruited from an antenatal care clinic of a large, urban, tertiary medical center, and were eligible if both partners agreed to receive HIV test results together and reported no coercion to participate in testing and counseling and no intimate partner violence. We assessed relationship characteristics, HIV risk-related behaviors and concordance of couples' sexual agreement (ie, mutual agreement about sexual risk behaviors that are permissible within or outside of their relationship). Acceptability of couple's HIV testing and counseling (ie, format, quality of the sessions, ability to meet their needs) was assessed after completing the session. Barriers and facilitators to couple's HIV testing and counseling were assessed at the individual-level among decliners and participants and at the clinic-level among members of the care team. RESULTS: Dyadic data were collected from 82 individuals (41 couples). Most partners (n=56, 68%) did not have a sexual agreement or had differing expectations about their sexual agreement. Partners with a concordant sexual agreement (n=26) felt more confident working with their partners on condom use when having sex outside of their relationship (P=.008) and were more likely to agree with their partner to get tested regularly for HIV or sexually transmitted infections (P=.015). Acceptability was high, with a rating of 93 or more (out of 100) among all items. Individual-level barriers to couple's HIV testing and counseling included difficulty bringing the male partner for counseling and a perception by either member of the couple that they were at low-risk for HIV. At the clinic level, need for training, staff turnover, and integration of couple's HIV testing and counseling in the clinic flow presented as barriers, whereas commitment by the clinic leadership facilitated the couple's HIV testing and counseling program. CONCLUSION: Despite barriers, couple's HIV testing and counseling can be implemented in antenatal clinics and is a highly acceptable method of HIV testing.

HIV Pre-Exposure Prophylaxis for Conception Among HIV Serodiscordant Couples in the United States: A Cohort Study.

Practice guidelines on pre-exposure prophylaxis (PrEP) for HIV serodiscordant couples recommend PrEP when the viral load of the partner living with HIV is either detectable or unknown. However, adherence to combination antiretroviral therapy is inconsistent, and research has found that individuals vulnerable to HIV place value on additional protective barriers. We conducted a prospective cohort study to assess the feasibility, perceptions, and adherence associated with periconceptional PrEP use among females without HIV and their male partners living with HIV across four academic medical centers in the United States. We performed descriptive statistics, McNemar's test of marginal homogeneity to assess discordance in female/male survey responses, and Spearman's correlation to determine associations between dried blood spot levels and female self-reported adherence to PrEP. We enrolled 25 women without HIV and 24 men living with HIV (one male partner did not consent to the study). Women took PrEP for a median of 10.9 months (interquartile range 3.8-12.0) and were generally adherent. In total, 87% of women (20/23) had a dried blood spot with >700 fmol/punch or ≥4 doses/week, 4% (1/23) at 350-699 fmol/punch or 2-3 doses/week, and 9% (2/23) at <350 fmol/punch or <2 doses/week (correlation between drug levels and adherence is based on prior data). Dried blood spot levels closely aligned with self-reported adherence (Spearman's rho = 0.64, p = 0.001). There were 10 pregnancies among 8 participants, 4 of which resulted in spontaneous abortions. There was one preterm delivery (36 5/7 weeks), no congenital abnormalities, and no HIV transmissions. Ten couples (40%) were either lost to follow-up or ended the study early. Overall, women attempting conception with male partners living with HIV in the United States are interested and able to adhere to PrEP as an additional tool for safer conception.

Knowledge, Attitudes, and PrEP Prescribing Practices of Health Care Providers in Philadelphia, PA.

Introduction: Preexposure prophylaxis (PrEP) is an effective biomedical intervention that has the potential to dramatically decrease the incidence of HIV but remains an underutilized method of HIV prevention. The Philadelphia Department of Public Health administered an online survey to health care providers in the Philadelphia area with the aim of characterizing PrEP attitudes, knowledge, and prescribing practices. Methods: Online surveys were distributed to 1000 providers who were recruited through distribution lists of Philadelphia medical providers between September and December 2017. A Likert-type response scale was utilized to analyze participant self-reported responses. Participant practice settings included HIV/ID, family and internal medicine, women's health, and pediatric/adolescent clinics. Results and Discussion: The response rate of the survey was 9%. Of 81 complete responses, 75% (N = 61) felt comfortable providing PrEP and 77% (N = 62) had ever written a PrEP prescription. Compared with primary care providers, HIV care providers were significantly more knowledgeable about required laboratory testing for prescribing PrEP (P = .03) and were more likely to have prescribed PrEP to more than 10 patients (P = .006). Women's health and pediatric providers reported feeling less comfortable providing PrEP to their patients (P = .0003). Conclusion: The majority of health care providers in the Philadelphia area who responded to the survey reported experience with providing PrEP to their patients. In the present study, HIV care providers were significantly more comfortable and knowledgeable about prescribing PrEP compared with providers in primary care, women's health, and/or adolescent/pediatric medicine. Results were limited by sampling bias, as providers who responded to the survey may have prior experience with PrEP. Future Health Department educational trainings need to target primary and preventive care providers, providers who have never prescribed PrEP, and providers who see few patients living with HIV.

Assessing the Acceptability of a Peer Mentor Mother Intervention to Improve Retention in Care of Postpartum Women Living with HIV.

Background: Many women living with HIV (WLWH) experience poor postpartum retention in HIV care. There are limited evidence-based interventions in the United States aimed at increasing retention of WLWH postpartum; however, evidence from low-resource settings suggest that women who receive peer mentoring experience higher retention and viral suppression postpartum. Methods: We conducted 15 semistructured interviews with pregnant or postpartum women from an urban U.S. clinic to assess factors influencing maternal adherence to antiretroviral therapy (ART) and retention in HIV care. We then assessed the acceptability of a peer intervention in mitigating barriers to sustain adherence and retention in care postpartum. Interviews were audio taped, transcribed, and analyzed. Codes were developed and applied to all transcripts, and matrices were used to facilitate comparisons across different types of participants. Results: Participants included low-income black and Hispanic women with a mean age of 31 years (range 22-42). Social support and concern for infants' well-being were strong facilitators for engaging in care. Psychosocial challenges, such as stigma and isolation, fear of disclosure, and depression, negatively influenced adherence to ART and engagement in care. Regardless of their level of adherence to ART, women felt that peer mentoring would be an acceptable intervention to reinforce skill-related ART adherence and sustain engagement in care after delivery. Conclusion: A peer mentor mother program is a promising intervention that can improve the care continuum of pregnant and postpartum women in the United States. Messaging that maximizes maternal support and women's motivation to keep their infant healthy may leverage retention in care postpartum.

HIV care continuum outcomes of pregnant women living with HIV with and without depression.

Women living with HIV (WLWH) suffer from poor viral suppression and retention postpartum. The effect of perinatal depression on care continuum outcomes during pregnancy and postpartum is unknown. We performed a retrospective cohort analysis using HIV surveillance data of pregnant WLWH enrolled in perinatal case management in Philadelphia and evaluated the association between possible or definite depression with four outcomes: viral suppression at delivery, care engagement within three months postpartum, retention and viral suppression at one-year postpartum. Out of 337 deliveries (2005-2013) from 281 WLWH, 53.1% (n = 179) had no depression; 46.9% had either definite (n = 126) or possible (n = 32) depression during pregnancy. There were no differences by depression status across all four HIV care continuum outcomes in unadjusted and adjusted analyses. The prevalence of possible or definite depression was high among pregnant WLWH. HIV care continuum outcomes did not differ by depression status, likely because of supportive services and intensive case management provided to women with possible or definite depression.

Perinatal HIV Service Coordination: Closing Gaps in the HIV Care Continuum for Pregnant Women and Eliminating Perinatal HIV Transmission in the United States.

Eliminating perinatal transmission of HIV and improving the care of childbearing women living with HIV in the United States require public health and clinical leadership. The Comprehensive Care Workgroup of the Elimination of Perinatal HIV Transmission Stakeholders Group, sponsored by the Centers for Disease Control and Prevention, developed a concept of perinatal HIV service coordination (PHSC) and identified 6 core functions through (1) semistructured exploratory interviews with contacts in 11 state or city health departments from April 2011 through February 2012, (2) literature review and summary of data on gaps in services and outcomes, and (3) group meetings from August 2010 through June 2017. We discuss leadership strategies for implementing the core functions of PHSC: strategic planning, access to services, real-time case finding, care coordination, comprehensive care, and data and case reviews. PHSC provides a systematic approach to optimize services and close gaps in perinatal HIV prevention and the HIV care continuum for childbearing women that can be individualized for jurisdictions with varying needs.

Evaluating outcomes of mother-infant pairs using dolutegravir for HIV treatment during pregnancy.

OBJECTIVES: Dolutegravir (DTG), a second-generation integrase inhibitor, is an effective treatment for HIV but its safety and efficacy are not well established in pregnancy. Here, we assess maternal and infant outcomes of mother-infant pairs using DTG-containing regimens during pregnancy. METHODS: We performed a retrospective cohort analysis of pregnant women with HIV on DTG from two urban clinics in the United States, 2015-2018. Maternal outcomes included viral suppression (viral load of <20 copies/ml prior to delivery), development of resistance, and tolerability to DTG. Infant outcomes included preterm delivery (birth at <37 weeks), small for gestational age (SGA, weight <10th percentile), infant HIV status at birth, birth defect(s), and Appearance, Pulse, Grimace, Activity, Respiration (APGAR) scores. We performed a trend analysis to assess DTG use over time. RESULTS: A total of 66 women used DTG during pregnancy and the proportion on DTG increased each year: in 2015, 8% (5/60) of women were on DTG, versus 22% (15/67) in 2016, 42% (30/71) in 2017, and 59% (16/27) in 2018 (P < 0.05). Among women who delivered (n = 57), 77.2% were undetectable at delivery. There were no drug resistance and no reported side effects during pregnancy. Infants had a mean APGAR score of 8 (SD 1.5) at 1 min and 9 (SD 0.8) at 5 min; 31.6% were born prematurely and 15.8% were SGA, and 2 infants had a birth defect. No cases of HIV transmission occurred. CONCLUSION: Our findings suggest that DTG can be an effective treatment during pregnancy. Infant outcomes (preterm deliveries and birth defects) need to be investigated in larger studies.

Pregnancy planning, timing, happiness and depressive symptoms among low-income women living with and without HIV.

OBJECTIVE: This study assessed associations of sociodemographic factors and pregnancy intent and wantedness with pregnancy happiness and prenatal depressive symptoms and the relationship between prenatal depressive symptoms and pregnancy happiness. BACKGROUND: Depression is the leading cause of disability world-wide and more so for women. Women are most likely to experience depression in their child bearing years, including during pregnancy. Untreated prenatal depression, associated with unwanted pregnancies endangers the health and wellbeing of the mother and her child. Research on the association of prenatal depression with pregnancy happiness among women with low incomes in the U.S.A. is limited. For women living with HIV, associations among family planning factors, pregnancy feelings and prenatal depression have been understudied. METHODS: Sixty-four women living with HIV and 194 HIV-negative low-income pregnant women receiving care in a public university-based ob-gyn clinic with integrated HIV-care in Philadelphia between 2009 and 2012 participated in the study. The women completed a questionnaire on sociodemographic and pregnancy factors and the Center for Epidemiological Studies Depression Scale (CES-D). The independent associations of sociodemographic and pregnancy factors with pregnancy happiness and associations of these factors and pregnancy happiness with the CES-D were assessed using multivariable linear regressions. RESULTS: Women who felt the pregnancy was too soon were less happy being pregnant (p < 0.01). Prenatal depressive symptoms were inversely associated with happiness with being pregnant and completing high school (p < 0.001 for both). CONCLUSION: Health care professionals need to provide reproductive counselling and mental health for prenatal depression should explore feelings about being pregnant and being a mother.

Optimizing Delivery of HIV Preexposure Prophylaxis for Women in the United States.

Preexposure prophylaxis (PrEP) is a highly effective HIV prevention method; however, it is underutilized among women who are at risk for acquisition of HIV. Women comprise one in five HIV diagnoses in the United States, and significant racial disparities in new HIV diagnoses persist. The rate of new HIV diagnoses among black and African American women in 2015 was 16 times greater than that of white women. These disparities highlight the importance of HIV prevention strategies for women, including the use of PrEP. PrEP is the first highly effective HIV prevention method available to women that is entirely within their control. However, because so few women who may benefit from PrEP are aware of it, few women's healthcare providers offer PrEP to their patients, PrEP has not yet achieved its potential to reduce HIV infections in women. This article describes individual and systemic barriers for women related to the uptake of PrEP services; explains how providers can identify women at risk for HIV; reviews how to provide PrEP to women; and outlines client-centered models for HIV prevention services. Better access to culturally acceptable and affordable medical and social services may offer support to women for consistent and ongoing use of PrEP. This discussion may be used to inform HIV prevention activities for women and guide interventions to decrease racial/ethnic disparities in rates of HIV infection among US women.

Antiretroviral Resistance and Pregnancy Characteristics of Women with Perinatal and Nonperinatal HIV Infection.

Objective. To compare HIV drug resistance in pregnant women with perinatal HIV (PHIV) and those with nonperinatal HIV (NPHIV) infection. Methods. We conducted a multisite cohort study of PHIV and NPHIV women from 2000 to 2014. Sample size was calculated to identify a fourfold increase in antiretroviral (ARV) drug resistance in PHIV women. Continuous variables were compared using Student's t-test and Wilcoxon rank-sum tests. Categorical variables were compared using χ (2) and Fisher's exact tests. Univariate analysis was used to determine factors associated with antiretroviral drug resistance. Results. Forty-one PHIV and 41 NPHIV participants were included. Women with PHIV were more likely to have drug resistance than those with NPHIV ((55% versus 17%, p = 0.03), OR 6.0 (95% CI 1.0-34.8), p = 0.05), including multiclass resistance (15% versus 0, p = 0.03), and they were more likely to receive nonstandard ARVs during pregnancy (27% versus 5%, p = 0.01). PHIV and NPHIV women had similar rates of preterm birth (11% versus 28%, p = 0.08) and cesarean delivery (47% versus 46%, p = 0.9). Two infants born to a single NPHIV woman acquired HIV infection. Conclusions. PHIV women have a high frequency of HIV drug resistance mutations, leading to nonstandard ARVs use during pregnancy. Despite nonstandard ARV use during pregnancy, PHIV women did not experience increased rates of adverse pregnancy outcomes.

Knowledge, Attitudes, and Acceptability of Pre-Exposure Prophylaxis among Individuals Living with HIV in an Urban HIV Clinic.

INTRODUCTION: Pre-exposure prophylaxis (PrEP) is an effective tool to reduce HIV transmission. The primary objective of this study was to assess awareness of PrEP by individuals living with HIV (HIV+) and acceptance of its use for their HIV negative (HIV-) partners. METHODS: A cross sectional survey was conducted among individuals living with HIV who received care at an urban HIV clinic between January 2013 and June 2013. The survey examined knowledge, attitudes, and acceptability of PrEP, and perception of transmission risk of HIV. Chi-Square test and Fisher's Exact test were used to compare proportions. RESULTS: Among 206 subjects living with HIV, 15.3% (32) had heard of PrEP. Men who have sex with men (MSM) were more likely to be aware of PrEP than all others (p = 0.003). Once educated about PrEP those who believed PrEP would reduce their partner's risk for HIV were more likely to recommend PrEP to their partner (p<0.001). 92% of all respondents said they would be "extremely likely/likely" to discuss PrEP use with their provider. Of 159 subjects whose main partner was HIV-, MSM (p = 0.007), male participants (p = 0.044), and those who were consistently taking meds (p = 0.049) were more likely to be aware of PrEP. Those who perceived they were at risk of transmitting HIV (p<0.001) and those who were consistently taking meds (0.049) were more likely to agree that PrEP could reduce the risk of HIV to their partners. CONCLUSION: This study illustrates a low awareness of PrEP but once educated the willingness of a cohort of individuals living with HIV to recommend PrEP to their partners. Our findings demonstrate the importance of providers informing their patients living with HIV about PrEP, as these persons are an underutilized link to support the uptake of PrEP by their HIV- partners.

Predictors of Linkage to Care for Newly Diagnosed HIV-Positive Adults.

INTRODUCTION: Linkage to care following a human immunodeficiency virus (HIV) diagnosis is critical. In the U.S. only 69% of patients are successfully linked to care, which results in delayed receipt of antiretroviral therapy leading to immune system dysfunction and risk of transmission to others. METHODS: We evaluated predictors of failure to link to care at a large urban healthcare center in Philadelphia in order to identify potential intervention targets. We conducted a cohort study between May 2007 and November 2011 at hospital-affiliated outpatient clinics, emergency departments (EDs), and inpatient units. RESULTS: Of 87 patients with a new HIV diagnosis, 63 (72%) were linked to care: 23 (96%) from the outpatient setting and 40 (63%) from the hospital setting (ED or inpatient) (p<0.01). Those who were tested in the hospital-based settings were more likely to be black (p=0.01), homeless (p=0.03), and use alcohol or drugs (p=0.03) than those tested in the outpatient clinics. Patients tested in the ED or inpatient units had a 10.9 fold (p=0.03) higher odds of failure to link compared to those diagnosed in an outpatient clinic. When testing site was controlled, unemployment (OR 12.2;p<0.01) and substance use (OR 6.4;p<0.01) were associated with failure to link. CONCLUSION: Our findings demonstrate the comparative success of linkage to care in outpatient medical clinics versus hospital-based settings. This study both reinforces the importance of routine opt-out HIV testing in outpatient practices, and demonstrates the need to better understand barriers to linkage.

Perinatal Depression and Anxiety in Women with and without Human Immunodeficiency Virus Infection.

BACKGROUND: Untreated depression and anxiety during the perinatal period have significant consequences on maternal and infant health; however, few studies have examined perinatal depression and perinatal anxiety in women with human immunodeficiency virus (HIV) infection. The current study prospectively examined the prevalence of prenatal and postpartum depression and anxiety, and emotional support from family and friends, as well as childhood sexual abuse in women with and without HIV infection. METHODS: Between July 2009 and January 2013, 258 pregnant women receiving care in a Philadelphia hospital were enrolled, with 162 completing both the prenatal and postpartum portions of the study. The Center for Epidemiological Studies-Depression Scale (CES-D), and the State-Trait Anxiety Inventory for Adults were used to measure depression and anxiety symptoms, respectively. An independent samples t test and multiple linear regressions were used to determine associations among depression, anxiety, and pregnancy-related variables. RESULTS: Forty-nine participants (30%) were living with HIV; 113 (70%) were HIV negative. CES-D scores did not differ prenatally (p = .131) or postpartum (p = .156) between women with and without HIV. Prenatal state anxiety scores were higher in women with HIV (p = .02) but there were no differences postpartum (p = .432). In a multiple linear regression, trait anxiety predicted postpartum anxiety in the full sample (p < .001) and childhood sexual abuse predicted postpartum depression among women with HIV (p = .021). CONCLUSIONS: These findings highlight the importance of identifying and treating perinatal depression and anxiety early in the prenatal period. Results also emphasize the need for providers to be aware of childhood sexual abuse as a potential correlate for depression in women with HIV.

Risk and Protective Factors for HIV Self-disclosure among Poor African-American Women Living with HIV/AIDS.

African-American women with HIV are among the fastest growing populations with HIV. The psychosocial factors and beliefs/attitudes associated with disclosure and other un-safe sex practices are not fully understood in this population. A total of 158 HIV-positive women receiving primary care in an HIV clinic in Philadelphia who enrolled in a safe-sex intervention, completed a baseline questionnaire on their sexual activities with male partners and psychosocial factors that were potential protective/risk factors for unsafe sex. Women who were emotionally close and monogamous with their partner were most likely to disclose their HIV status and least likely to worry they had infected their partner. Women who were non-monogamous and who did not have an emotional connection to any of their partners were least likely to self-disclose. Partners were more likely to know each other's status when the woman felt she had a responsibility to talk about the importance of staying HIV-negative.

Rates and predictors of prenatal depression in women living with and without HIV.

Depression is a significant mental health and public health concern, and women living with HIV are at increased risk for depression. This risk may be especially elevated during pregnancy; however, few studies have attempted to identify rates and predictors of depression in pregnant, HIV-infected women. The purpose of the present study was to investigate rates and predictors of prenatal depression, such as history of depression, childhood sexual abuse (CSA), and social support among HIV-infected and HIV-uninfected women in Philadelphia, Pennsylvania. It was hypothesized that pregnant women with HIV will have higher rates of depressive symptoms and will exhibit a greater number of mood disorder diagnoses as compared to HIV-uninfected pregnant women. It was also hypothesized that HIV status, history of depression, CSA, and inadequate social support will emerge as predictors of depressive symptoms. A sample of 163 women, 31% (n=50) of whom were HIV-infected and 69% (n=113) of whom were HIV-uninfected, were recruited from an obstetrics/gynecology clinic affiliated with an urban university hospital. The Center for Epidemiological Studies-Depression Scale (CES-D) was used to identify depressive symptoms, and Modules A and D of the Structured Clinical Interview for DSM-IV (SCID) confirmed the presence of a mood disorder. Findings demonstrated that rates of depressive symptoms and mood disorder diagnoses during pregnancy did not differ according to HIV serostatus. History depression, CSA, and inadequate social support predicted depressive symptoms during pregnancy in this sample. Due to their association with depressive symptoms, history of depression, CSA, and inadequate social support may be important to identify during pregnancy.

Providing sensitive care for adult HIV-infected women with a history of childhood sexual abuse.

Childhood sexual abuse (CSA) is a serious public health issue. Women with HIV who have a history of CSA are at increased risk for sporadic medical treatment, nonadherence to HIV medications, and HIV risk behaviors. These associations pose a challenge to providing health care for this population and are complicated by the possible psychological sequelae of CSA, such as anxiety, depression, dissociation, and posttraumatic stress disorder. This article reviews the effects of CSA on the health status of women with HIV, barriers to treatment adherence, suggested components of trauma-sensitive medical care, and mental health approaches. A trauma-informed, trauma-sensitive care model that addresses barriers associated with health care for women with a history of CSA is suggested. Specific recommendations are offered for the provision of effective clinical care for women with HIV who also have a history of CSA to help HIV care providers better recognize and appreciate the distinct needs of this patient population.