Adherence with antiretroviral therapy among recently pregnant HIV-positive women in 8 African countries

BACKGROUND: Adherence to antiretroviral therapy (ART) is essential for reducing morbidity and mortality among people living with HIV and HIV transmission, particularly mother-to-child transmission for pregnant and postpartum women. This study compared self-reported ART use with antiretroviral drug (ARV) detection in blood among HIV+ women aged 15-49 who had delivered within three years before the survey, using population-based HIV surveys (PHIAs) in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia, and Zimbabwe (2015-2019), conducted by the ministries of health in collaboration with ICAP and CDC.
METHODS: Consenting participants from randomly selected households provided demographic and clinical information and blood for household HIV testing. Household HIV+ results were laboratory-confirmed. Viral load suppression (VLS) was defined as VL < 1000 cp/mL. Commonly prescribed ARVs, namely, efavirenz, nevirapine, atazanavir, and lopinavir, were assayed in dried blood spots. All analyses accounted for complex survey design, and Taylor Series Linearization methods were used for variance estimation.
RESULTS: Of all 91,728 female participants, 2,108 were included in this analysis. Most women took ARVs before their first antenatal visit, ranging from 46% (95% CI: 44%-49%) in Tanzania to 82% (95% CI: 79%-85%) in Namibia. VLS ranged from 77% (95% CI: 73%-80%) in Lesotho to 88% (95% CI: 85%-91%) in Malawi. ARVs were detected in the blood of most women who initiated ART before their first antenatal visit, ranging from 88% (95% CI: 84%-92%) in Lesotho to 94% (95% CI: 90%-98%) in Malawi.
Adjusted for other demographic characteristics, women who initiated ART before the first antenatal visit were more likely to have detectable ARVs than those who initiated ART during pregnancy (adjusted odds ratio (aOR): 2.2; 95% CI: 1.7-2.9). Women aged 35-49 were more likely to have detectable ARVs than those aged 15-24 (aOR: 2.2; 95% CI: 1.5-3.1).
CONCLUSIONS: ART adherence, proxied by ARV detection in blood, was lower among women who initiated ART during pregnancy than those who started ART before pregnancy, particularly among women aged 15-24 years. Women, particularly young women, who initiate ART during pregnancy require specific attention to enhance their own outcomes and prevent mother-to-child HIV transmission.

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