Substance Use, Demographic and Socioeconomic Factors Are Independently Associated With Postpartum HIV Care Engagement in the Southern United States, 1999-2016

Abstract

Background: Retention in care (RIC) and viral suppression (VS) are associated with reduced HIV transmission and mortality. Studies addressing postpartum engagement in HIV care have been limited by small sample size, short follow-up, and a lack of data from the Southeast United States.

Methods: HIV-positive adult women with ≥1 prenatal visit at the Vanderbilt Obstetrics Comprehensive Care Clinic from 1999 to 2015 were included. Poor RIC was defined as not having ≥2 encounters per year, ≥90 days apart; poor VS was a viral load >200 copies/mL. Modified Poisson regression was used to estimate adjusted relative risks (aRRs) of poor postpartum RIC and VS.

Results: Among 248 women over 2070 person-years of follow-up, 37.6% person-years had poor RIC and 50.4% lacked VS. Prenatal substance use was independently associated with poor RIC (aRR, 1.40; 95% confidence interval [CI], 1.08-1.80) and poor VS (aRR, 1.20; 95% CI, 1.04-1.38), and lack of VS at enrollment was associated with poor RIC (aRR, 1.64; 95% CI, 1.15-2.35) and poor VS (aRR, 1.59; 95% CI, 1.30-1.94). Hispanic women were less likely and women with lower educational attainment were more likely to have poor RIC. Women >30 years of age and married women were less likely to have poor VS.

Conclusions: In this population of women in prenatal care at an HIV primary medical home in Tennessee, women with prenatal substance use and a lack of VS at enrollment into prenatal care were at greater risk of poor RIC and lack of VS postpartum. Interventions aimed at improving postpartum engagement in HIV care among these high-risk groups are needed.

Keywords: HIV; engagement in care; postpartum; retention in care; viral suppression.

Figure 1.

Predicted poor retention in care by year of study. Circles represent point estimates for predicted poor retention in care, and whiskers represent predictive margins for observed poor retention in care after the multivariable regression model.

Figure 2.

Predicted poor viral suppression by year of study. Circles represent point estimates for predicted poor viral suppression, and whiskers represent the predictive margins for poor viral suppression after the multivariable regression model. In 2008, HIV treatment guidelines changed to recommend continuation of antiretroviral therapy after delivery, as indicated by the dotted line [25].