Antiretroviral therapy (ART)
adherence levels among pregnant women with HIV, in both high- and
low-income countries, during pregnancy and especially after giving birth are
significantly below what is recommended for viral suppression and prevention of
drug resistance, according to a report published this month in the advance
online edition of AIDS.
a pooled analysis of 51 studies, involving over 20,000 women from the United States, Kenya,
South Africa and Zambia, only
73.5% of pregnant women with HIV attained adequate adherence to ART during
and after pregnancy (defined as equal to or greater than 80%), Jean B Nachega
and colleagues report.
pooled proportion of women with adequate adherence was greater during pregnancy
than after giving birth, 75.7% (95% CI: 71.5-79.7%) compared to 53% (95% CI:
barriers at the individual level included: physical, economic and social
stressors, depression (notably after giving birth), alcohol or drug use and
frequency of ART dosage or pill burden.
disclosure of HIV status and strong social support was linked to high ART
adherence, so where safe and feasible both should be encouraged.
prevention of mother-to-child transmission (PMTCT) programmes move toward
universal lifelong ART for all pregnant women with HIV (World Health
Organization [WHO] Option B+) the likelihood of multi-class drug resistance for
both the mother and the child will increase and the safety and scale-up of
these programmes be compromised.
goal of the elimination of mother-to-child transmission (eMTCT) by 2015 will
also be weakened; virtual elimination depends not only on access and
availability to the most effective regimens but also on women’s ability to take
the drugs appropriately and provide their infants with complete prophylactic
authors stress “the critical and urgent need to assist HIV providers to more
reliably monitor adherence and develop evidence-based interventions to improve
and/or maintain adherence…”
Of the estimated 1.4 million women with HIV who give birth each year, 91% live
in sub-Saharan Africa. ART during and after
pregnancy is essential for the mother’s own health as well as preventing
transmission of HIV to the child.
WHO 2010 guidelines for ART to treat pregnant women and prevent
transmission to the child in resource-poor settings included recommendations
for more complex combination ART regimens as well as continuation of ART
prophylaxis throughout breastfeeding, whether the mother needed it for her own
health or not. Rapid scale-up and the availability of more effective regimens
led WHO to set the goal of virtual eMTCT by 2015.
is critical for virologic and clinical success and remains of concern in high-
and low-income countries. Poor adherence can lead to treatment-limiting drug
For women who are
pregnant or breastfeeding, non-adherence increases the risk of virologic
failure, maternal disease progression, development of drug resistance and risk
for vertical (mother-to-child) transmission.
is evidence that newer antiretroviral regimens achieve viral suppression at
lower levels of adherence (70 to 80%) than older regimens, because of increased potency and longer drug
half-lives, so forgiving the odd missed ART dose. Nonetheless, consistent
adherence over time is linked to better virological outcomes.
the limited data and absence of a systematic review, the authors chose to
conduct a meta-analysis to estimate the proportion of women with adequate ART
adherence during pregnancy and after delivery in high-, middle- and low-income
Fifty-one studies involving 20,153 women with HIV were identified. Forty-eight studies
reporting 71 adherence estimates were included in the meta-analysis. The
remaining three reported ART adherence as a mean or median so were excluded.
The studies took place between 1986 and 2011 and reported between 1998 and
to three-quarters (74%) were observational and 26% were RCTs looking at PMTCT
studies were from the United States
(n=14, 27%) followed by Kenya
with six (12%), and South Africa
(10%) and Zambia
(10%) both with five.
half (45%) included pregnant women on triple ART, while 15 (29%) and 12 (24%)
reported adherence while on zidovudine and single-dose nevirapine, respectively.
threshold to define good adherence varied across the studies (greater than 80%,
greater than 90%, greater than 95% and 100%).
authors believe this to be the first systematic review and meta-analysis
summarising the available data on ART adherence during and after pregnancy.
cite a recent literature review of gender and ART adherence in high-income
countries which, while not addressing pregnancy issues, concluded that being female
was linked to poorer adherence than in men. They suggest this is linked to family
and caretaking responsibilities. Women with HIV often first learn of their
diagnosis during their pregnancy, so are dealing with the diagnosis when ART is
findings confirm the challenge of achieving optimal adherence during pregnancy
and after delivery.
authors suggest that better adherence during pregnancy than after delivery is
due to the mother’s concern for the health of the foetus and transmission of
the virus to the child. Yet, they note that even during pregnancy adherence was
lower than what is thought necessary for viral suppression and prevention of
sickness', nausea and vomiting commonly affect over 70% of pregnant women in
early pregnancy; heartburn is common later in pregnancy. These can adversely
affect adherence. The mother may also be concerned that
ART may harm the foetus.
Post-partum depression (PPD), the authors note, is a part “of major depressive
disorder that crosses cultures and affects 13% of women.” They cite a
systematic review that found PPD was 31.3% (95% CI: 21.3%-43.5%) higher among
women in resource-poor countries compared to those in resource-rich countries.
studies in this review reported that reduced ART adherence was linked to advanced
AIDS, pregnancy-related symptoms, HIV itself, as well as toxicity of the ART
findings also suggest “evaluation and management of mental health and illicit
drug use during and after pregnancy be a high priority for health-care workers
in charge of all HIV-infected pregnant women.”
monitoring and adherence support is critical for the safe and effective scale
up of PMTCT.
authors suggest that non-medical personnel can play an important role but
evidence is lacking about the effectiveness and cost-effectiveness of such
interventions; some observational studies have suggested peer support can
improve adherence among pregnant women.
role of peer mentors in South
Africa to improve maternal adherence during
pregnancy and at the time of birth is currently being evaluated. Similarly, a
trial looking at the role of male involvement is in process.
simplified regimens for ease of use and with better tolerability will improve
adherence in this population.
authors conclude “It is crucial to monitor ART adherence…Reaching adequate ART
adherence levels was a challenge in pregnancy, but especially during the
post-partum period. Further research to investigate specific barriers and
interventions to address them are urgently needed globally…to ensure the
long-term efficacy of such an approach for both maternal health and PMTCT.”