The Influence of Postpartum Retention in Care on Mortality in Women Living with HIV Public
McBroom, Jade (Spring 2022)
Abstract
Postpartum women living with HIV have been found to have poor retention in care and may be at greater risk for mortality and morbidity in comparison to their HIV negative counterparts. In addition, the evidence of worse outcomes within Southern states of higher HIV morbidity and mortality warrants further investigation. Therefore, the purpose of this investigation was to describe mortality and retention in care as well as factors impacting retention in care, viral suppression, and mortality using the Andersen Behavioral Model. Data was from the Women’s Interagency HIV Study, a national, longitudinal, epidemiological cohort study. Participants (n=283) were HIV positive females, of child-bearing age who had a live birth post enrollment. Retention was adaptively defined as two healthcare visits in a twelve-month period. Survival analysis was used to examine mortality. Logistic regression modeling was used to examine predisposing and enabling factors including age, race, marital status, education, income/employment, depression, substance use, social support, housing, and health insurance coverage. Rates of having an optimal outcome (retained and virally suppressed) remained steady at around 25% over the ten-year period. Nearly 15% of the participants experienced mortality during the study period. Participants who were not married, had an income of $18,000 or less, no social support, did not live in their own house or apartment, and no reported insurance coverage significantly decreased the odds of being retained over time. High income and no history of substance use were found to be protective against mortality. Lastly, retention did not have a significant association or impact on mortality. Findings suggest that both predisposing and enabling factors influence retention, but the directions of these associations vary depending on which outcome is examined and which postpartum year. Regional differences were difficult to analyze related to the small Southern sample size (n=11). Efforts to increase retention should focus on enabling factors such as insurance and housing that can be changed rather than predisposing factors. Future interventions could also target postpartum engagement especially in the first year postpartum to encourage lifelong retention and HIV viral suppression to prevent poor outcomes like mortality.
Table of Contents
Contents
Chapter 1: Introduction……………………………………………………………………………………..1
Statement of the Problem…………………………………………………………………………..2
Perinatal HIV exposure...............................................................………………………….2
History of HIV in Pregnancy……………………………………………………………...3
Pregnancy and HIV treatment adherence…………………………………………………5
Definitions of Retention in Care, Estimates, and Limitations of Measuring.......................6
HIV Care Continuum and Women......................................................................................7
Postpartum, HIV-positive women’s challenges with treatment adherence.........................9
HIV in the South: Important Factors to Consider..............................................................10
Purpose of the Study.......................................................................................................................12
Women’s Interagency HIV Study......................................................................................14
Significance of Research....................................................................................................14
Andersen Behavioral Model of Health Services Use......................................................................15
Figure 2. Andersen Behavioral Model 2000s. (Andersen, 2008) ..................................................17
Application of Andersen’s Behavioral Model of Health Services Use.............................18
Key Constructs...................................................................................................................21
Figure 3. ABM for Postpartum Retention in Care and Mortality for WLWH..................22
Chapter 2: Background and Significance.....................................................................................................24
Pregnancy and the Postpartum Period Among WLWH.................................................................24
Postpartum Mortality in WLWH....................................................................................................28
Option B+........................................................................................................................................31
Table 1. Follow-up Recommendations of the Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission.........................................................................32
HIV in the Deep South....................................................................................................................33
Factors Associated with Poor Retention in Care............................................................................38
Figure 3. Andersen Behavioral Model of Health Services Use for Postpartum Retention in Care and Mortality for WLWH...............................................................................................................39
Gaps in the Literature......................................................................................................................46
Chapter 3: Methods......................................................................................................................................48
Overview.........................................................................................................................................48
Aims and Hypotheses.....................................................................................................................49
Setting and Sample.........................................................................................................................50
Figure 4. Flowchart of women enrolled in the Women's Interagency HIV Study (WIHS) since 1994, illustrating the inclusion criteria for participants......................................................................................................................................52
Instrumentation and Materials........................................................................................................52
Outcome Measures..........................................................................................................................53
Table 2............................................................................................................................................54
Independent Variables....................................................................................................................55
Table 3............................................................................................................................................57
Data Management...........................................................................................................................61
Data Analysis..................................................................................................................................64
Ethical Considerations....................................................................................................................70
Difficulties and Limitations............................................................................................................70
Chapter 4: Results........................................................................................................................................74
General Participant Demographics.................................................................................................74
General Characteristics...................................................................................................................75
Postpartum Interval.........................................................................................................................76
Table 4............................................................................................................................................77
Table 5............................................................................................................................................78
Aim 1 Results..................................................................................................................................82
Survivor Function Estimates............................................................................................................................82
Table 6...............................................................................................................................83
Table 7...............................................................................................................................84
Table 8...............................................................................................................................84
Table 9...............................................................................................................................85
Aim 2 Results..................................................................................................................................85
Hypothesis 2.1: Retention and Viral Suppression........................................................................................................................86
Table 10.............................................................................................................................86
Table 11.............................................................................................................................86
Table 12.............................................................................................................................87
Table 13.............................................................................................................................88
Table 14.............................................................................................................................89
Table 15.............................................................................................................................90
Longitudinal Logistic Regression of Covariates and Retention............................................................................................................................90
Table 16.............................................................................................................................91
Southern and Non-Southern Sites Retention............................................................................................................................93
Table 17.............................................................................................................................94
Table 18.............................................................................................................................94
Hypothesis 2.2: Southern Sites and Retention and Viral Status........................................95
Table 19.............................................................................................................................95
Retention/Viral Status Odds Ratios (ORs) with Covariates..............................................95
Aim 3: Survival Probabilities and Cox Regression Models...........................................................96
Table 20.............................................................................................................................97
Table 21.............................................................................................................................98
Table 22.............................................................................................................................98
Table 23.............................................................................................................................99
Figure 6. Income Kaplan Meier Curve............................................................................100
Figure 7. Substance use Kaplan Meier Curve..................................................................101
Chapter 5: Discussion................................................................................................................................102
Sample Characteristics..................................................................................................................102
General Demographic Characteristics.............................................................................102
Table 24. Sample characteristics versus national surveillance........................................104
Aim 1: Time from date of last delivery to death...........................................................................105
Mortality and Predisposing Factors.................................................................................105
Aim 2: Postpartum Retention and Viral Suppression: Likelihood of Optimal Outcomes............106
Retention in healthcare....................................................................................................106
Characteristics of Participants with Low Retention.......................................................................................................................................107
Understanding Long-Term Retention and Predisposing/Enabling Factors.....................109
Retention and Viral Suppression..................................................................................................110
Retention as a Predictor of Viral Suppression.................................................................110
Viral Suppression and Retention Over Time...................................................................112
Significant Factors in the Andersen Behavioral Model................................................................116
Predisposing Factors in the Framework...........................................................................116
Enabling Factors in the Framework.................................................................................119
Aim 3: Retention as a Predictor of Mortality................................................................................121
Revised Andersen Behavioral Model...........................................................................................122
Figure 8. Final Andersen Behavioral Model for this Study..........................................................122
Study’s Strengths..........................................................................................................................122
Study’s Limitations.......................................................................................................................123
Implications...................................................................................................................................124
Research Implications......................................................................................................124
Clinical Implications........................................................................................................126
References…………..................................................................................................................................127
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