A collaboration between the Duke Global Health Institute and the Kilimanjaro Clinical Research Institute. Funded by the Fogarty International Center and the National Institute of Allergy and Infectious Diseases.
As we follow our cohort of HIV-infected women in Tanzania, it is important for us to place our research within the broader context of Option B+ implementation across Africa. Our team conducted the first systematic review synthesizing the growing body of literature describing the PMTCT care cascade in the Option B+ era in Africa. The review was guided by 2 study aims: (1) to summarize the proportion of HIV-infected pregnant women initiating and retained in HIV care and Option B+ programs at various time points after starting lifelong ART, and (2) to identify the factors associated with retention in HIV care and loss to follow-up under Option B+.
The analysis, led by Brandon Knettel and Cody Cichowitz, includes 35 articles representing more than 60,000 African women initiating ART under Option B+. Pooled estimates of retention were 72.9% at 6 months for studies reporting < 12 months of follow-up and 76.4% at 12 months for studies reporting ≥12 months of follow-up. These retention rates, which are lower than those of the general adult population, underscore the need for interventions that target the unique and complex circumstances of women initiating care under Option B+. Risk factors for poor retention included younger age, initiating antiretroviral therapy on the same day as diagnosis, initiating during pregnancy versus breastfeeding, and initiating late in the pregnancy. Retention was compromised by stigma, fear of disclosure, and lack of social support. Furthermore, the review notes the inconsistency of methods used across the studies, and in response includes recommendation for future studies measuring retention to help standardize procedures for tracking and reporting retention.
Knettel, B. A., Cichowitz, C., Ngocho, J. S., Knippler, E. T., Chumba, L. N., Mmbaga, B. T., & Watt, M. H. (2018). Retention in HIV care during pregnancy and the postpartum period in the Option B+ era: A systematic review and meta-analysis of studies in Africa. Journal of Acquired Immune Deficiency Syndromes (JAIDS) 15;77(5):427-438. doi: 10.1097/QAI.0000000000001616
Option B+ team members Melissa Watt and Cody Cichowitz traveled to Cape Town, South Africa to present at the AIDS Impact Conference, an international behavioral and psychosocial science conference addressing issues related to HIV/AIDS prevention, treatment, and care. Cody gave two oral presentations reflecting work from the B+ cohort and analysis of Kilimanjaro region medical record data. His presentations on retention in care across the PMTCT continuum under Option B+, and HIV-related shame, HIV acceptance, and attitudes about long-term ART fit well into their respective symposia, “Preventing mother-to-child transmission: new insights” and “Stigma: the invisible killer.” In addition to sharing early results from the team’s work, the conference provided valuable opportunities to meet fellow researchers, share ideas, and foster a renewed commitment to addressing the AIDS epidemic.
As part of the Masters of Science in Global Health program at the Duke Global Health Institute (DGHI), students complete a faculty-mentored, field-based research experience between the first and second years of their program. The Option B+ team was lucky to have a wonderful MSc student, Dr. Lilian Chumba, join the team during her time at DGHI. Over the summer of 2017, Lilian, a trained medical doctor from Kenya, completed qualitative data collection focusing on Aim #1 of the study, examining facility- and provider-level factors affecting Option B+ implementation. Lilian completed observation protocols at three of the Option B+ healthcare facilities, noting the clinic set up, provider-patient interactions, provider-provider interactions, clinic record keeping, and relationships among the clinic departments. She complemented these observations with 30 key informant interviews with health service providers involved in HIV care for pregnant women, including doctors, nurses, and home-based care providers.
Lilian presented preliminary findings from her project at the DGHI Student Showcase on November 1st, 2017 and will continue to analyze the data as part of her Master’s thesis. The data are crucial to understanding how the Option B+ protocol is implemented in Tanzanian healthcare facilities, and addressing the facility-level factors that support or impede successful implementation. Lilian’s work will be used to make recommendations to local clinics on how they may improve in their implementation of the Option B+ protocol, and will also inform new interventions aimed at addressing lapses in HIV care.
According to conference organizers, the one-day meeting was inspired “by the large and growing number of women in global and public health, and frustration about the lack of diversity and representation of women in global health leadership positions.”
“Women comprise as much as 75% of the health workforce in many countries and the majority of students in academic global health tracks. Yet they hold only 8 of 34 World Health Organization executive board positions and fewer than 1 in 4 global health leadership positions at the top 50 U.S. medical schools.’
Drs. Watt and Mmbaga met with other emerging and established women leaders in the field, discussed strategies to engage and support women in the workforce, and learned how to build their own leadership skills.
We are grateful to have these two accomplished women leading our team and providing wonderful mentorship and support!
The Option B+ team achieved an important milestone today, reaching our goal of enrolling 200 clients in our cohort! This completes our study enrollment, but there is no shortage of work ahead. The team will continue to follow all 200 women, with a brief check-in after they have given birth, and completing follow-up surveys at 3, 6, and 12 months postpartum. The team will also continue to focus on the qualitative portion of the study, which involves completing interviews with a subset of 24 cohort participants at enrollment and again at 3 months postpartum. Will will also be reviewing medical record data to help us gain a comprehensive understanding of the implementation of Option B+ in the Kilimanjaro region. We are so appreciative of our hardworking team who have helped to make this happen, especially the study nurses in charge of enrolling participants and completing the study interviews. We would also like to extend a heartfelt thanks to our participants, who are dedicating their time and energy to helping us understand and improve care engagement among pregnant and postpartum women.
It was a bittersweet goodbye as the Tanzania team said farewell to Cody Cichowitz, who spent the last year in Moshi working on the project as a Doris Duke International Clinical Research Fellow. The fellowship program, sponsored by the Doris Duke Charitable Foundation, supports the training and professional development of the next generation of clinical investigators working in global health by offering a year-long mentored research opportunity in global health.
“The program not only provided a unique opportunity to engage in global health research and build practical experience, but it also created a space to learn from and work alongside Tanzanian researchers. Working in Tanzania for a year helped me develop foundational research skills, but I’m most grateful for the relationships I built and the ways in which I was able to learn about the health care system and challenges facing patients and providers.”
Cody is an invaluable member of the Option B+ team, and while the Tanzania team will miss his presence at KCMC, we look forward his continued involvement in the study. We wish him the best of luck as he returns to Johns Hopkins University to complete his MPH and MD degrees.
On May 26, 2017, the Duke Global Health Institute (DGHI) co-hosted a symposium at the Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania, where research teams shared their ongoing projects related to the prevention of mother-to-child transmission of HIV (PMTCT) in Tanzania. The symposium brought together a range of stakeholders to discuss findings and consider how research might best inform the implementation of national PMTCT guidelines.
Panels included updates on PMTCT policy guidelines, considerations of the barriers to care among HIV-infected pregnant women, strategies for capacity building in research and statistics, implementation science research on PMTCT care delivery, and presentations of ongoing research by KCMC students and trainees. The symposium welcomed representatives from the Tanzanian Ministry of Health, Elizabeth Glaser Pediatric AIDS Foundation, and several local health facilities.
The symposium was organized by the Option B+ study PIs Blandina Mmbaga, director of the Kilimanjaro Clinical Research Institute, and Melissa Watt, assistant research professor of global health at DGHI and Associate Director of the Duke Center for AIDS Research Social and Behavioral Sciences Core. The intended purpose of the meeting was to connect researchers, policy makers, and care providers working on PMTCT services. The symposium also provided an opportunity for Drs. Mmbaga and Watt to present on study progress, insights, and next steps, and for Dr. James Ngocho to share his findings on antenatal depression and anxiety among women in the B+ cohort.
“The meeting was an important step in closing the research-implementation gap in PMTCT care,” Watt noted. “The reason we do research is to improve care delivery and patient outcomes, and this symposium offered an opportunity to reflect on how we can make sure our research is serving that goal.”
Read more about the symposium and ongoing PMTCT research in Tanzania here.
Dr. James Ngocho visited the Duke team in Durham for a few days before traveling with Dr. Melissa Watt to Seattle to attend an intensive course in the Fundamentals of Implementation Science in Global Health, hosted by the University of Washington Department of Global Health. Over five days, the course covered a variety of topics such as impact evaluation, qualitative health systems research, quality improvement, and dissemination research, using case studies to provide context. We know they are excited to apply what they have learned to strengthen the Option B+ study and lay the foundation for further implementation science research at DGHI and KCRI!
It is an exciting time for the Option B+ team, as our cohort data collection is now underway! Our first participants were enrolled at the end of July, 2016 and completed their baseline surveys. Patients in the cohort are HIV-infected and are either initiating or continuing antiretroviral therapy (ART) during pregnancy. Baseline surveys are conducted in the second or third trimester of pregnancy, with follow-up surveys at 3, 6, and 12 months postpartum to measure potential individual, social, and contextual factors affecting engagement in HIV care. A subset of the women will complete in-depth interviews to help us gain a richer understanding of women’s lives and facilitators and barriers to care engagement. We are grateful to the participants who are enrolling in the cohort and look forward to working with them and our dedicated team throughout the duration of the study.