Risk factors for poor adherence to antiretroviral therapy by pregnancy status in two urban cohorts of women living with HIV in the United States and South Africa
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Introduction: Many women living with HIV around the world are in their reproductive years. Adherence to antiretroviral therapy (ART) and viral suppression are of particular importance before, during, and after pregnancy to maintain maternal health and limit vertical transmission. It is important to understand what factors prevent women from adhering to their medications. Risk factors for poor adherence in pregnant and non-pregnant women were examined in two different contexts. Methods: Cohorts of HIV-infected women on ART in the United States and in South Africa were examined. Pregnancy experience in the last six months in the Unites States cohort and becoming pregnant during follow-up in the South African cohort were assessed among various other risk factors for poor adherence. Prevalence of poor adherence at baseline and endline in the South African cohort was examined; estimates were stratified by pregnancy and fertility intentions and compared using equality of proportions tests. Poisson regression models with robust variance (as an approximation of log binomial models) were used to estimate crude (PR) and adjusted (aPR) prevalence ratios and 95% confidence intervals ([,]) of risks factors for poor adherence, separately in each of the cohorts and also stratified by pregnancy status. Results: Prevalence of poor adherence declined between baseline and endline for the South African cohort of women. The greatest reduction was seen in those who had pregnancy intentions at baseline and were pregnant during follow-up (difference in percentages: 12.5% [8.5, 16.5]). The independent risk factors for poor adherence to ART among the US cohort were low CD4 count and lower level of completed education. From the analyses stratified by pregnancy status, risk factors that were different between those who experienced a pregnancy outcome and those who did not included age, race, relationship status, parity, and illicit drug use. The main risk factor for the cohort of women from South Africa was trying to conceive (aPrR=1.54 [1.10, 0.94]). Risk factors that were different between those who experienced a pregnancy during follow-up and those who did not were level of education completed, partner HIV status, parity, ability to talk to a provider, and time on HAART. Conclusions: Risk factors for poor adherence appear to differ between pregnant and non-pregnant women of reproductive age in the United States and South Africa. Self-reported poor adherence was associated with pregnancy intentions in the South African context, and further research should be conducted to assess this relationship and to develop strategies for promoting adherence in this important population.