Co-enrolling family members improves retention of women on antiretroviral therapy

Family matters: co-enrollment of family members into care is associated with improved outcomes for HIV-infected women initiating antiretroviral therapy.

Myer L, Abrams EJ, Zhang Y, Duong J, El-Sadr WM, Carter RJ. J Acquir Immune Defic Syndr. 2014 Dec 1;67 Suppl 4:S243-9. doi: 10.1097/QAI.0000000000000379.

Background: Although there is widespread interest in understanding how models of care for delivering antiretroviral therapy (ART) may influence patient outcomes, family-focused approaches have received little attention. In particular, there have been few investigations of whether the co-enrollment of HIV-infected family members may improve adult ART outcomes over time.

Methods: We examined the association between co-enrollment of HIV-infected family members into care and outcomes of women initiating ART in 12 HIV care and treatment programs across sub-Saharan Africa. Using data from the mother-to-child transmission (MTCT) Plus Initiative, women starting ART were categorized according to the co-enrollment of an HIV-infected partner and/or HIV-infected child within the same program. Mortality and loss to follow-up were assessed for up to 5 years after women's ART initiation.

Results: Of the 2877 women initiating ART included in the analysis, 31% (n = 880) had at least 1 HIV-infected family member enrolled into care at the same program, including 24% (n = 689) who had an HIV-infected male partner, and 10% (n = 295) who had an HIV-infected child co-enrolled. There was no significant difference in the risk of death of women by family co-enrollment status (P = 0.286). However, the risk of loss to follow-up was greatest among women who did not have an HIV-infected family member co-enrolled (19% after 36 months on ART) compared with women who had an HIV-infected family member co-enrolled (3%-8% after 36 months on ART) (P < 0.001). These associations persisted after adjustment for demographic and clinical covariates and were consistent across countries and care programs.

Discussion: These data provide novel evidence for the association between adult outcomes on ART and co-enrollment of HIV-infected family members into care at the same program. Interventions that build on women's family contexts warrant further consideration in both research and policies to promote retention in ART services across sub-Saharan Africa.

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Editor’s notes: With the dramatic increase in the number of people on antiretroviral therapy (ART) over the last decade, further understanding of the impact of different service delivery models on treatment outcomes (including death and retention-in-care) is needed. Previous studies have compared health systems approaches such as primary care versus hospital delivery, task-shifting to nurses and community-based approaches. This study is one of the first to focus on the impact of family-focused approaches on adult outcomes. In this large multi-country study of women enrolled in prevention of mother-to-child transmission programmes, co-enrolment of a family member living with HIV was not associated with mortality among women, but co-enrollment was associated with an approximate halving of the risk of being lost to follow up. This association was consistent across different sub-groups of age, parity, partner status and location. The strength and consistency of the finding highlights the central role that family and social support can play in shaping health-seeking behaviours among people living with HIV. Further research would include the effect of co-enrolment on treatment outcomes among men, and exploration of specific aspects of co-enrolment, such as disclosure. 

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