Srivastava M et al.

Journal of the International AIDS Society 2018, 21:e25053

http://onlinelibrary.wiley.com/doi/10.1002/jia2.25053/full | https://doi.org/10.1002/jia2.25053

COMMENTARY

Boosting ART uptake and retention among HIV-infected pregnant

and breastfeeding women and their infants: the promise of
innovative service delivery models
Meena Srivastava1, David Sullivan1, B. Ryan Phelps1, Surbhi Modi2, and Laura N. Broyles2
Corresponding author: Meena Srivastava, U.S. Agency for International Development/Bureau for Global Health, 2100 Crystal Drive, Arlington, VA 22202, USA.
([email protected])

Abstract
Introduction: With the rapid scale-up of antiretroviral treatment (ART) in the “Treat All” era, there has been increasing empha-
sis on using differentiated models of HIV service delivery. The gaps within the clinical cascade for mothers and their infants
suggest that current service delivery models are not meeting families’ needs and prompt re-consideration of how services are
provided. This article will explore considerations for differentiated care and encourage the ongoing increase of ART coverage
through innovative strategies while also addressing the unique needs of mothers and infants.
Discussion: Service delivery models should recognize that the timing of the mother’s HIV diagnosis is a critical aspect of
determining eligibility. Women newly diagnosed with HIV require a more intensive approach so that adequate counselling and
monitoring of ART initiation and response can be provided. Women already on ART with evidence of virologic failure are also
at high risk of transmitting HIV to their infants and require close follow-up. However, women stable on ART with a suppressed
viral load before conception have a very low likelihood of HIV transmission and thus are strong candidates for multi-month
ART dispensing, community-based distribution of ART, adherence clubs, community adherence support groups and longer
intervals between clinical visits. A number of other factors should be considered when defining eligibility of mothers and
infants for differentiated care, including location of services, viral load monitoring and duration on ART. To provide differenti-
ated care that is client-centred and driven while encompassing a family-based approach, it will be critical to engage mothers,
families and communities in models that will optimize client satisfaction, retention in care and quality of services.
Conclusions: Differentiated care for mothers and infants represents an opportunity to provide client-centred care that
reduces the burden on clients and health systems while improving the quality and uptake of services for families. However,
with decreasing funding, stable HIV incidence, and aspirations for sustainability, it is critical to consider efficient, customized
and cost-effective models of care for these populations as we aspire to eliminate mother-to-child transmission of HIV.
Keywords: HIV; differentiated care; service delivery models; antiretroviral treatment; ART; pregnant and breastfeeding women;
HIV-exposed infants; prevention of mother-to-child transmission of HIV; PMTCT

Received 4 June 2017; Accepted 21 December 2017

Copyright Published 2018. This article is a U.S. Government work and is in the public domain in the USA. Journal of the International AIDS Society published by John
Wiley & Sons Ltd on behalf of International AIDS Society. This is an open access article under the terms of the Creative Commons Attribution License, which permits
use, distribution and reproduction in any medium, provided the original work is properly cited.

1 | INTRODUCTION (i.e. not eligible for differentiated service delivery models) [2].
Within this proposed WHO framework, pregnant and breast-
With the rapid scale-up of antiretroviral treatment (ART) in feeding women (PBFW) are classified as “unstable” and thus
the “Treat All” era, there has been increasing emphasis on are not eligible for less intensive follow-up given the concerns
using differentiated models of HIV service delivery. The intent for mother-to-child transmission of HIV [2]; this approach is
of this differentiation is several-fold: to improve client satisfac- also reflected in the exclusion of PBFW from recently pub-
tion and health outcomes, decrease the burden on congested lished innovative service delivery interventions [3,4]. However,
health systems, reduce costs incurred by clients and health due to the recognition that PBFW can also benefit from dif-
facilities, and develop more sustainable HIV programmes [1]. ferentiated service delivery approaches (especially PBFW
The 2016 WHO Consolidated Guidelines on the Use of stable on ART with suppressed viral loads), WHO convened a
Antiretroviral Drugs for Treating and Preventing HIV Infection consultative meeting in late 2016 to assess current evidence
outline a basic approach to differentiated care in which HIV- for differentiated care models that include PBFW (and other
infected clients are categorized as “stable” (i.e. eligible for dif- key and vulnerable populations) [5]. As a result, key considera-
ferentiated, often less intensive HIV services) or “unstable” tions and a decision framework were released at the

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Srivastava M et al. Journal of the International AIDS Society 2018, 21:e25053
http://onlinelibrary.wiley.com/doi/10.1002/jia2.25053/full | https://doi.org/10.1002/jia2.25053

International AIDS Society Conference in 2017. This updated are strong candidates for multi-month ART dispensing, com-
guidance provides potential criteria for inclusion of PBFW in munity-based distribution of ART, adherence clubs, community
differentiated care models with a particular focus on clinically adherence support groups and longer intervals between HIV
stable PBFW who are on ART at conception [6,7]. Despite clinical visits [5].
recent WHO guidance and the complexities of ante-, peri- and A number of factors should be considered when defining
postnatal care, a number of country programmes are reluctant eligibility of PBFW and infants for differentiated care. One
to consider any PBFW for less intensive HIV service delivery consideration is the location of ANC and HIV services. Ideally,
models even as the international community seeks to find PBFW have access to an integrated, “one-stop shop” model,
ways to offer less intensive HIV services to stable clients. but for women already on ART at pregnancy, providing ANC
With the global expansion of “Option B+” for prevention of services in ART clinics is not the norm in resource-con-
mother-to-child HIV transmission (PMTCT) and “Treat All” strained settings. HIV providers in ART clinics are rarely
policies for people living with HIV, the number of women on trained to provide routine obstetric care, so women are often
ART in resource-constrained settings has increased substan- referred to ANC for services, including HIV care and treat-
tially; as a result, in many countries, at least half of HIV- ment. While this approach is still somewhat integrated, PBFW
infected women presenting to antenatal (ANC) care know lose their “home” ART clinic and must temporarily re-establish
their HIV status and are stable on first-line ART. Among care in a different setting with a different provider. Although
these, the vast majority are virally suppressed [8]. As a result some PBFW may prefer this approach, it can be advanta-
of such PMTCT successes, new paediatric HIV infections have geous to keep stable PBFW on ART in their “home” clinic
declined by 50% since 2010; however, the absolute number during pregnancy. It is recommended that if stable PBFW on
of newly HIV-infected children remains unacceptably high [9]. ART are enrolled and choose to remain in a differentiated
Data from PMTCT and maternal and child health programmes care model, they should be allowed to do so while still
continue to reveal substantial programmatic challenges such attending ANC services [6,7]. For those newly diagnosed with
as poor adherence to ART, high loss to follow-up of post-par- HIV, enrolling in differentiated care cannot be recommended
tum women, poor uptake of infant virologic testing and high until they meet basic criteria of “stability.” These considera-
mother-to-child transmission of HIV during breastfeeding tions also apply to breastfeeding mothers and HIV-exposed
[9,10]. The gaps within the PMTCT cascade for PBFW and infants.
their infants suggest that current service delivery models are Another key factor in differentiated care for PBFW is
not meeting families’ needs and prompt a re-consideration of access to HIV viral load monitoring. PBFW should be priori-
how services are provided. This article will explore considera- tized for viral load monitoring so that viraemia can be identi-
tions for differentiated care for PBFW and their infants and fied and acted upon quickly to prevent HIV transmission. By
encourage the ongoing increase of ART coverage through using viral load criteria to define stability, provider attention
innovative strategies while still addressing the unique needs can be focused on PBFW with higher risk of transmission (as
of this group. evidenced by an elevated viral load). In settings where viral
load monitoring is not available, special consideration can be
given to women with rising or stable CD4 per WHO guideli-
2 | DISCUSSION
nes, although such immunologic criteria are inferior and all
efforts should be focused on providing the gold standard viral
2.1 | Factors to consider in defining stable PBFW
load monitoring [2].
and infants
WHO recommends at least 12 months on ART for non-
In an effort to provide a more nuanced approach to differenti- pregnant adults before being considered “stable” [2]. Given
ated care, the large umbrella term of “HIV-infected pregnant the duration of pregnancy and breastfeeding, this is a rea-
and breastfeeding women” should be explored in greater sonable approach for newly diagnosed PBFW and stable
detail. This dyad should not be grouped together and deemed criteria should align with what has already been estab-
inherently “unstable” in all contexts and circumstances. As the lished by WHO for non-pregnant adults living with HIV
pregnancy and breastfeeding period can extend nearly three [6,7]. Upon delivery of the infant, every effort should be
years in resource-constrained settings, many women and made to foster a “one-stop shop” care approach to enable
infants will have prolonged periods of restricted access to dif- mother-infant pairs to receive coordinated comprehensive
ferentiated care models with this approach, especially in areas care. For stable HIV-infected breastfeeding women and
of high fertility. their infants, a decreased frequency of clinic visits has the
Service delivery models should recognize that the timing of potential to improve the observed high loss to follow-up in
the mother’s HIV diagnosis is a critical aspect of determining this population. However, as new rhythms of clinical care
eligibility for differentiated care. Women newly diagnosed with develop to improve retention, it is important to anticipate
HIV during ANC, delivery or breastfeeding inherently require and avoid potentially detrimental impacts on the uptake of
a more intensive approach so that adequate counselling and standard postnatal care, immunizations and timely infant
monitoring of ART initiation and response can be provided. virologic testing, especially as coverage of early infant test-
Women on ART with evidence of virologic failure are also at ing and diagnosis at 6 to 8 weeks of age is inadequate in
high risk of transmitting HIV to their infants and require close most countries in sub-Saharan Africa. Models for breast-
follow-up, especially since infants require enhanced prophy- feeding women must therefore include components to
laxis per the 2016 WHO guidelines [2]. However, women track infants closely until a final seronegative status can
stable on ART with a suppressed viral load before conception be established or, for HIV-positive infants, ART has been
have a very low likelihood of HIV transmission [11] and thus initiated.

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Srivastava M et al. Journal of the International AIDS Society 2018, 21:e25053
http://onlinelibrary.wiley.com/doi/10.1002/jia2.25053/full | https://doi.org/10.1002/jia2.25053

Division of Global HIV & TB, U.S. Centers for Disease Control and Prevention,
2.2 | Building on models that are working Atlanta, GA, USA

Although there is encouraging anecdotal evidence supporting

inclusion of PBFW in differentiated care, there is limited expe- COMPETING INTERESTS
rience and data. In Cote d’Ivoire, integration of ANC and post- The authors declare that they have no competing interests.
natal care services at the ART clinic for women who become
pregnant while on ART resulted in improved post-partum AUTHORS’ CONTRIBUTIONS
retention and reduced mother-to-child transmission of HIV at BRP and SM conceived the topic for the commentary. MS, DS and LNB devel-
six weeks after birth [12]. There are two existing models in oped the initial outline and draft. All authors reviewed and provided revisions to
South Africa that include post-partum women and their HIV- the draft. MS incorporated revisions and coordinated approval from all authors
exposed infants. In the first model, a facility-based educator prior to submission.
enrolled high and low-risk mother-infant pairs at the postnatal
6 week visit to form postnatal clubs, which resulted in ACKNOWLEDGEMENTS
improved retention, viral load suppression of 98% for post- The authors thank Dr. Robert Ferris (USAID) and Dr. Shannon Hader (CDC) for
partum women at six months, and zero seroconversions to their expert review of the manuscript.
HIV for infants [13]. In the second model, post-partum women
and their HIV-exposed infants participated in community- FUNDING
based adherence clubs; this group had no differences in short-
term viral load outcomes compared to mother-infant pairs This publication was supported by the U.S. President’s Emergency Plan for AIDS
Relief through the U.S. Agency for International Development and the U.S. Cen-
referred to local primary healthcare clinics [14]. Of note, one-
ters for Disease Control and Prevention.
quarter of women in adherence clubs were not retained six
months post-partum, highlighting the need to ensure future
studies not only include PBFW in differentiated care models DISCLAIMER
but also evaluate transition between ART services in the post- The findings and conclusions in this report are those of the authors and do not
partum period [14]. necessarily represent the official position of participating federal agencies,
To provide differentiated care that is client-centred and dri- including the U.S. Agency for International Development and the U.S. Centers
ven, it will be critical to engage mothers and communities in for Disease Control and Prevention.
models that will optimize client satisfaction, retention in care
and quality of services. Each country context and setting will
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