Staying on Option B+: why post-partum women are dropping out of HIV care in a Johannesburg clinic

What they wanted was to give birth; nothing else: barriers to retention in option B+ HIV care among postpartum women in South Africa.

Clouse K, Schwartz S, Van Rie A, Bassett J, Yende N, Pettifor A. J Acquir Immune Defic Syndr. 2014 Sep 1;67(1):e12-8. doi: 10.1097/QAI.0000000000000263.

Background: Women initiating antiretroviral therapy during pregnancy have high rates of dropout, particularly after delivery. We aimed to identify challenges to postpartum retention in care under Option B+, which expands antiretroviral therapy access to all HIV-positive pregnant women regardless of CD4 count.

Methodology: We performed 2 semi-structured interviews (SSI, n = 50) and 1 focus group discussion (n = 8) with HIV-positive women at Witkoppen Health and Welfare Centre, a primary care facility in Johannesburg, South Africa, that is one of the only clinics offering Option B+ in South Africa.

Results: Fifty women completed the SSI before delivery, and 48 (96%) completed the second SSI within 3 months of delivery. Median age was 28 years (interquartile range: 26-34); most women worked (62%) or had worked in the previous year (18%). Postpartum women attending HIV care perceived that barriers to HIV care after delivery among other women included the belief that mothers care more about the baby's health than their own (29.2%, 14/48), women were "ignorant" or "irresponsible" (16.7%, 8/48), negative clinic staff treatment (12.5%, 6/48), and denial or lack of disclosure of HIV status (10.4% each, 5/48). Experienced barriers included lack of money (18.0%, 9/50), work conflict (6.0%, 3/50), and negative staff treatment (6.0%, 3/50). During the focus group discussion, 3 main themes emerged: conflict with work commitment, negative treatment from health-care workers, and lack of disclosure related to stigma.

Conclusions: We identified a complex set of interconnected barriers to retaining postpartum women in HIV care under Option B+, including structural, personal, and societal barriers. The importance of postpartum HIV care for the mother's own health must be embraced by health-care workers and public health programs.

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Editor’s notes: This paper addresses a key knowledge gap which is, why do post-partum women living with HIV drop out of HIV care, despite having the opportunity to access ongoing HIV care? This paper presents the findings of a qualitative study conducted with women in a Johannesburg clinic who are being offered option B+. Option B+, seeks to initiate all HIV-positive pregnant women on lifelong highly active antiretroviral therapy (ART) regardless of CD4 count. Its success depends on the proportion of women who are retained in care and continue to adhere to treatment.

While the study found that very few women admitted that they themselves would stop taking their ART, they cited multiple reasons for other women to stop doing so. Many of these reasons have been discussed before, such as prioritising the health of their baby and having been harshly treated by healthcare workers during their delivery. A key issue identified in the paper is that once women have given birth they describe no longer having a ‘legitimate’ reason, in this case antenatal care, to continue attending a clinic. So we learn that being pregnant provides a cover to legitimise clinic attendance and women are able to receive HIV care without the risk of arousing suspicion. This is revealing about the ongoing HIV stigma and the challenges that a woman faces in explaining any regular visits to a healthcare facility to partners, family members, employers and others within their community. This illustrates the complex negotiations involved for many women in leaving their work commitments, formal or informal, to regularly attend an HIV clinic.

This paper is valuable because it shows us that unfortunately, even if costs can be waived, access may still be impeded by the persistent constraints involved in the management of non-disclosure. We may also learn a valuable methodological lesson from this study. To access information and opinions about drop-out and disengagement in HIV care, research may be more effective if studies allow individuals to talk about such issues indirectly through other people’s experiences rather than their own. This will address issues of social desirability bias in clinic based research. 

South Africa
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