AIDSImpact.com:: - Santa Fe, USA 2011

Abstract #392 - Feasability and acceptability of rapid ART initiation in pregnant women in Cape Town, South Africa.
Authors: Presenting Author: Ms Rose Zulliger - University of Cape Town
Additional Authors: Ms Rose Zulliger, Associate Professor Landon Myer, Associate Professor Linda-Gail Bekker,
Aim: Initiation of antiretroviral therapy (ART) in pregnancy is a critical intervention for preventing the mother to child transmission (PMTCT) of HIV infection. However there is growing evidence that existing strategies for ART initiation in pregnancy are suboptimal. Together, failure to complete referrals and delays in ART initiation result in a substantial proportion of eligible pregnant women not commencing ART before delivery. To address these concerns, we developed and implemented a novel intervention for the rapid initiation of ART in pregnancy. Here we report on an evaluation of the feasibility and acceptability of this model.
Method / Issue: The Rapid ART in Pregnancy (RAP) project began in February 2011 at a nurse-driven antenatal care service in Cape Town, South Africa. HIV counselling and testing with CD4 enumeration takes place in the antenatal care service, and all ART-eligible women (based on CD4 cell counts ≤350 cells/µl or stage III/IV) were eligible for the RAP intervention. RAP featured immediate initiation of ART the same day women received their CD4 count results through a nurse-led, doctor-supported model of care. Pregnant women received intensive counselling on HIV, PMTCT and ART, and were screened for depression and substance abuse. Safety bloodwork was taken concurrently with ART initiation and treatment was modified if abnormalities were detected. Women who missed a visit were traced, received additional counselling and follow-up phone calls. Our evaluation of RAP used a mixed method approach. A clinical record review of all RAP participants was used to describe participants at enrollment and PMTCT outcomes, while qualitative interviews with 27 participants and 13 ANC and RAP staff were used to understand the acceptability of the intervention.
Results / Comments: To date, 62 women have been rapidly initiated on ART and 97% of these women have been maintained in care. Median age at presentation was 27 years (IQR, 23-32), gestation at presentation was 23 weeks (IQR, 18-28) and education level was completion of grade 11 (IQR, 10-12) for all RAP participants. 76% of the women learned of their HIV status during their current pregnancy. 52% of the women who missed a visit were promptly brought back into the system. No association was found between missed visits and baseline depression, alcohol abuse, age at presentation, gestational age at presentation, level of education, new positive HIV awareness or disclosure status. Rapid initiation was highly acceptable to both patients and providers. Interviews with women receiving RAP highlighted the importance of counselling and communicating key messages in the short timeframe between diagnosis and ART initiation. Some providers were concerned about ART initiation before women had disclosed their HIV status.
Discussion: This preliminary evaluation suggests that the RAP project may be a feasible and acceptable model for the rapid initiation of ART in pregnancy. This approach appears safe and highly acceptable to both participants and providers. Additional research is needed around the best approach to determine treatment readiness and the most appropriate form for counselling messages during pregnancy in order to ensure women are adequately supported and maintained in care both pre- and post-partum.
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