Evolution of antiretroviral therapy services for HIV-infected pregnant women in Cape Town, South Africa

Abstract

Background: Approaches to antiretroviral therapy (ART) in HIV-infected pregnant women have changed considerably in recent years, but there are few comparative data on the implementation of different models of service delivery.

Methods: Using routine clinic records we examined ART initiation in pregnant women attending a large antenatal care (ANC) facility between January 2010 and December 2013 in Cape Town, South Africa. Over this time six different service delivery models were implemented sequentially to provide ART in pregnancy, including the integration of ART into ANC, use of point-of-care CD4 cell count testing, and universal ART initiation for all HIV-infected pregnant women.

Results: During the study period 19,432 women sought ANC, levels of HIV testing were high (98%) and 30% of pregnant women tested HIV-positive. Integration of ART into ANC was associated with significant increases in the proportion of eligible women initiating treatment before delivery compared to referral to a separate ART clinic (p<0.001). When CD4 cell counts were used to determine ART eligibility, point-of-care testing was associated with decreased delays to ART initiation compared to laboratory-based testing (p<0.001). The strategy of universal ART led to the highest levels of ART initiation (with 92% of women starting before delivery) and the shortest delays, with 82% of women starting ART on the day of the first ANC visit.

Conclusion: Developments in service delivery models, most notably service integration and universal ART for pregnant women, have improved antenatal ART initiation dramatically in this setting. Further research is needed into how strategies for antenatal ART initiation impact maternal and child health over the long-term.

Figure 1. PMTCT ‘cascade’ during the study period, by service delivery model

Figure 2. Box plots of distribution of delays in days from first antenatal care (ANC) visit to (a) date of pre-initiation assessment among eligible women* and (b) date of ART initiation, by service delivery model

A. Delay from first ANC visit to pre-initiation assessment B. Delay from first ANC visit to ART initiation * ART eligibility as defined by the service delivery model

Figure 3

Kaplan-Meier “failure” plots of time from the start of antenatal care to ART initiation before delivery, by service delivery model, for (A) all HIV-infected pregnant women, (B) for ART-eligible women (as defined by the service delivery model), and (C) for women with CD4 cell counts ≤350 cells/μl. A. All HIV-infected pregnant women B. ART-eligible women, as defined by the service delivery model C. Women with CD4 ≤350 cells/μl

Figure 3

Kaplan-Meier “failure” plots of time from the start of antenatal care to ART initiation before delivery, by service delivery model, for (A) all HIV-infected pregnant women, (B) for ART-eligible women (as defined by the service delivery model), and (C) for women with CD4 cell counts ≤350 cells/μl. A. All HIV-infected pregnant women B. ART-eligible women, as defined by the service delivery model C. Women with CD4 ≤350 cells/μl