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Review 3: "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 3: "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:

  • Reliable. The main study claims are generally justified by its methods and data. The results and conclusions are likely to be similar to the hypothetical ideal study. There are some minor caveats or limitations, but they would/do not change the major claims of the study. The study provides sufficient strength of evidence on its own that its main claims should be considered actionable, with some room for future revision.


Review: The article is well constructed and the data points are  clearly defined. The analysis is clear and straightforward. While there is a fairly low LTFU, presence of VL results at baseline and 12 and 24 months is low. Those retained in care and with VL results for all periods have relatively high VLS. Those missing data points do not have robust VLS.

This study has the benefit of a strong data system at the hospital clinics of interest. There is a strong background section that highlights the data gap for Nigeria in terms of longer term outcomes for the parameters of interest among HIV + women who are significantly past the peripartum period. Given the major focus on PMTCT, it is important to document whether retention in care and VLS levels are maintained after the PMTCT and immediate post partum period. Long term VLS of women of child bearing years is important both for maternal health but also the health of their families and hence this study is important.

My main area of concern regarding the analysis is a limited discussion of structural barriers to VL testing. Individual characteristics are highlighted that are associated with VL testing but what I found odd is the high level of retention/medication adherence, and the relatively low rates of VL testing. While I recognize that the purpose of the study was to analyze individual characteristics, and the paper does mention that there may be other factors, given the discrepancy between retention and VL result availability, I think a longer discussion of possible structural barriers to testing would have been important.

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