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Review 1: "Antiretroviral Therapy Retention, Adherence, and Clinical Outcomes among Postpartum Women with HIV in Nigeria"

Reviewers point out the relevance of the study, and only make minor comments mainly about missing data.

Published onMay 26, 2024
Review 1: "Antiretroviral Therapy Retention, Adherence, and Clinical Outcomes among Postpartum Women with HIV in Nigeria"
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key-enterThis Pub is a Review of
Antiretroviral therapy retention, adherence, and clinical outcomes among postpartum women with HIV in Nigeria
Antiretroviral therapy retention, adherence, and clinical outcomes among postpartum women with HIV in Nigeria

Abstract While research involving pregnant women with HIV has largely focused on the antepartum and intrapartum periods, few studies in Nigeria have examined the clinical outcomes of these women postpartum. This study aimed to evaluate antiretroviral therapy retention, adherence, and viral suppression among postpartum women in Nigeria. This retrospective clinical data analysis included women with a delivery record at the antenatal HIV clinic at Jos University Teaching Hospital between 2013 and 2017. Descriptive statistics quantified proportions retained, adherent (≥95% medication possession ratio), and virally suppressed up to 24 months postpartum. Among 1535 included women, 1497 met the triple antiretroviral therapy eligibility criteria. At 24 months, 1342 (89.6%) women remained in care, 51 (3.4%) reported transferring, and 104 (7.0%) were lost to follow-up. The proportion of patients with ≥95% medication possession ratio decreased from 79.0% to 69.1% over the 24 months. Viral suppression among those with results was 88.7% at 24 months, but <62% of those retained had viral load results at each time point. In multiple logistic regression, predictors of loss to follow-up included having a more recent HIV diagnosis, higher gravidity, fewer antenatal care visits, and a non-hospital delivery. Predictors of viral non-suppression included poorer adherence, unsuppressed/missing baseline viral load, lower baseline CD4+ T-cell count, and higher gravidity. Loss to follow-up rates were lower and antiretroviral therapy adherence rates similar among postpartum women at our study hospital compared with other sub-Saharan countries. Longer follow-up time and inclusion of multiple facilities for a nationally representative sample would be beneficial in future studies.

RR:C19 Evidence Scale rating by reviewer:

  • Potentially informative. The main claims made are not strongly justified by the methods and data, but may yield some insight. The results and conclusions of the study may resemble those from the hypothetical ideal study, but there is substantial room for doubt. Decision-makers should consider this evidence only with a thorough understanding of its weaknesses, alongside other evidence and theory. Decision-makers should not consider this actionable, unless the weaknesses are clearly understood and there is other theory and evidence to further support it.


Review: This real-world study of outcomes in Jos, Nigeria, helps assess where programs can be improved to increase adherence and retention for women living with HIV post-delivery.  Although it appears to largely be an urban cohort, women not getting their care at this hospital were at a higher risk of being lost to follow-up.  We do not know if they simply are getting care elsewhere or are truly lost (4 salient references: PMID: 34921515; PMCID: PMC8683971. PMID: 33948789.  PMID: 28329184; PMID: 24086627. PMCID: PMC5848300). Details as to what services are available in different settings may illuminate etiologies of suboptimal outcomes, but this seems beyond the article’s scope (Ref: PMID: 27126487; PMCID: PMC4852280). 

As long as these clinical data are interpreted within their limitations, the work will provide comparators for other programs seeking to maximize impact and minimize programmatic failures. The authors highlight limitations to which this reviewer embellishes:

  • Missing data are frequent and formal imputation modeling was not performed (though they did a useful correction as follows, “missing baseline values were categorized separately and postpartum viral load time points were combined for the analyses, and a sensitivity analysis was performed to compare those with and without postpartum viral load results.”).

  • Longer time of infection may not be a useful predictor of retention in care, but rather those women who did not leave the program or die are, by definition, more likely to be retained: ref PMID: 1805323.

  • Loss to follow-up is a highly variable metric, so use of the ref. 21 definition is an advantage. Additional sources on this important point that the authors correctly recognized are in ref: PMID: 23785113; PMCID: PMC3755641 and another paper that is similar, co-authored by Egger M, that I cannot locate.

  • Mortality seems absent; could this be clarified?

  • Results are favorably compared to other published data from sub-Saharan African data, yet PMTCT/eMTCT outcomes in Nigeria is disappointing.  Might these women who actually came for post-partum HIV care be a subset of all women living with HIV, excluding women who do not come for ANC and/or do not adhere to PMTCT regimens, and perhaps not appearing in this cohort to begin with?

Perhaps the authors could speculate further about what programmatic improvements could be made to improve process outcomes. Mnemonics, eHealth, mHealth, and other strategies may be worth mentioning.

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