Kenyan study reports fewer clinic visits feasible for some postpartum women with HIV

A study in Kenya reported that differentiated service delivery (DSD) models could be implemented in many women living with HIV who recently gave birth. The study found that most postpartum women maintained viral suppression and may do well with fewer clinic visits, barring enhanced service needs due to challenges such as depression or abuse.

About This Study

“HIV viral load patterns and risk factors among women in prevention of mother-to-child transmission (PMTCT) programs to inform differentiated service delivery (DSD)” was published online on Nov. 15, 2023, in Journal of Acquired Immune Deficiency Syndromes. The lead author is Wenwen Jiang, M.P.H., of the Department of Epidemiology at the University of Washington in Seattle.

Key Research Findings

Researchers assessed the feasibility of a DSD model among 761 women living with HIV enrolled in a program to prevent vertical HIV transmission in Kenya. DSD reduces the number of clinic visits for people living with HIV who are on stable antiretroviral treatment (ART) and have a viral load (VL) < 1,000 copies/mL (the World Health Organization’s definition of viral suppression for this purpose).

Median participant age was 27 years and women enrolled in the parent program at a median of 24 weeks pregnant. Participants supplied a median five VLs each, for a total of 3,359 VL measurements. Modeling VL trajectories over time, 81% of participants were unlikely to have their VL rise above 1,000 copies/mL, 6% of participants were likely to achieve viral suppression soon after giving birth and remain suppressed, and 13% of participants were likely to be non-suppressed.

Among 580 women who met DSD criteria six months after delivery, 84% maintained that status to 24 months postpartum. Viral failure in that group was associated with depression, experiences of interpersonal abuse, a nevirapine-based regimen (vs. efavirenz-based ART), drug resistance mutations, and low-level viremia between 200-1,000 copies/mL. Dolutegravir-based ART was not available at the time (2015-2017).

Discussion Highlights and Implications for Practice

Study limitations reported included limited data on comorbidities, a relatively high VL threshold, adherence measured by pill counts, and retention by missed visits. In addition, while participants were assessed for DSD eligibility, that model was not actually available to them.

The researchers commented that these results show that women living with HIV–who in low-resource settings may breastfeed for two to three years and be pregnant repeatedly–should not be excluded from DSD models. Resistance testing and screening for depression or abuse could identify women who need more intensive services, the authors pointed out. Implementation studies for determining DSD eligibility and considering each woman’s preference for visit frequency are needed, they concluded.

By Barbara Jungwirth