Postpartum continuity of care for women with HIV: Option B+ policy impact and limitations in South Africa

IntroductionPostpartum disengagement from HIV care is high, leading to adverse maternal outcomes and risk of transmission through breastfeeding. In January 2015, South Africa implemented Option B+, a policy extending lifelong antiretroviral therapy (ART) eligibility to all pregnant women living with HIV (PWLWH) regardless of CD4 count. We assessed the impact of Option B+ on postpartum continuity of care for PWLWH and identified predictors of disengagement in the Option B+ era. MethodsWe linked maternal data from Rahima Moosa Mother and Child Hospital in Johannesburg, South Africa, to HIV laboratory records from the National Health Laboratory Service. Using quasi-experimental designs (difference-in-differences, DID; regression-discontinuity, RD), we estimated the causal effect of Option B+ on postpartum retention in HIV care, defined as any HIV lab result 6-24 months after delivery. PWLWH with CD4 >500 cells/L were newly eligible for lifelong ART under Option B+ ("treatment" group); PWLWH with CD4 [≤]350 cells/L served as "controls" as their eligibility for lifelong ART was unchanged by the policy. We also assessed predictors of postpartum disengagement from care in the Option B+ era. ResultsWe included 1,684 women delivering 01/07/2013-30/06/2016, of which 14% delivered in the pre-Option B+ period. Option B+ was associated with a 19% increase (95% CI: 6%-33%) in postpartum retention for treatment group, relative to controls. We observed a 29% jump (95% CI: 7%-52%) in retention at the policy threshold in the treatment group. In the Option B+ era, PWLWH initiating ART during pregnancy had 76% lower odds of retention than those already on ART (OR: 0.24, 95% CI: 0.18-0.32). ConclusionOption B+ improved retention among PWLWH newly eligible for lifelong ART. Still, despite lifelong ART eligibility, women initiating ART during pregnancy exhibited significantly lower retention than those already on treatment, highlighting the need for further support to sustain care in this group. Key messagesO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIPostpartum HIV care attrition is high among pregnant women living with HIV (PWLWH). C_LIO_LIThe World Health Organization (WHO) published guidelines for preventing mother-to-child transmission of HIV, with Option B+ being the most recent guideline that extended lifelong ART eligibility to all PWLWH regardless of CD4 count. C_LIO_LIExisting research has reported suboptimal retention rates under Option B+, but has not specifically examined the impact on the population who gained eligibility under the new policy. C_LI What this study addsO_LIThis study examined postpartum HIV care retention among PWLWH with high CD4 counts - the group newly eligible for lifelong ART under Option B+. C_LIO_LIWe used quasi-experimental methods to estimate the causal effect of Option B+ by comparing PWLWH who delivered just before vs. just after the Option B+ policy was implemented, and we explored drivers of postpartum attrition from care. C_LIO_LIWe demonstrated that Option B+ significantly increased HIV care retention in PWLWH with high CD4 counts; but that further efforts will be needed to support retention in care among PWLWH starting ART during pregnancy. C_LI How this study might affect research, practice, and policyO_LISimplification of ART eligibility and expanded access to ART led to improvements in HIV care retention among PWLWH. C_LIO_LIHowever, PWLWH who initiated ART during pregnancy still experience high rates of attrition, highlighting the need for targeted interventions to support sustained care engagement for this group. C_LI