Access to DSD for HIV treatment models for pregnant and breastfeeding women and adolescent girls
By Morkor Newman Owiredu, Medical Officer, World Health Organization
The Updated recommendations on service delivery for the treatment and care of people living with HIV launched by the World Health Organization (WHO) in April 2021, include pregnant and breastfeeding women among the specific populations who “may benefit more from differentiated service delivery for HIV treatment models adapted to their needs”. The guideline outlines four categories of DSD for HIV treatment models: group models managed by healthcare workers; group models managed by clients; individual models based at facilities; and individual models not based at facilities.
Previously, the term, “stable” client, excluded pregnant and breastfeeding women. WHO now defines as “established on treatment” all people living with HIV: receiving antiretroviral therapy (ART) for at least six months; who have no current illness, not including well-controlled chronic health conditions; who have a good understanding of lifelong adherence; and who demonstrate evidence of treatment success with at least one suppressed viral load result within the past six months.
Promising good practice examples of DSD models for HIV treatment among pregnant and breastfeeding women and adolescent girls were featured at a recent virtual meeting hosted by ICAP’s HIV Coverage, Quality and Impact Network (CQUIN). In South Africa, Médecins Sans Frontières (MSF), with partners, implements postnatal clubs for postpartum mother-infant pairs that show good retention and viral load suppression for the mother and optimal HIV testing uptake for the child. ICAP’s Adolescent HOPE Project reorganizes care at health facilities for pregnant and postnatal adolescent and young women (under 25 years old) living with HIV. Rather than scheduling individual visits, the young women attend monthly group visits, which include all of the recommended medical care as per Kenya’s national guidelines and also offer enhanced support services.
Before the disruptions resulting from the COVID-19 pandemic, most sub-Saharan Africa countries excluded pregnant and breastfeeding women from DSD for HIV treatment models. This meant that once women and adolescent girls established on treatment and in a DSD model became pregnant, they no longer had access to their treatment model. In addition to attending antenatal care appointments, they had to adapt to receiving their HIV treatment in a different way from what they were used to in a phase of their lives already marked by change.
In some cases, national HIV treatment guidelines allowed for limited inclusion of pregnant and breastfeeding women in specific DSD models. In Namibia, those who were “stable before the current pregnancy” could access three months of ART (multi-month dispensing, or MMD) during pregnancy. In Ghana, postpartum period women had access to MMD.
Even during the COVID-19 pandemic, when countries increasingly shifted towards MMD for ART and alignment of HIV care and management of other health conditions, very few (Eswatini, Ethiopia, Sierra Leone) updated their national guidance towards alignment of antenatal and postnatal care visits with ART refills or MMD for pregnant or postpartum women. Therefore, in a time of physical distancing and ongoing studies to determine the health impact of the pandemic, most pregnant and breastfeeding women and adolescent girls and their infants still have to access healthcare facilities on separate visits for clinical care for HIV, ART refills and psychosocial support, in addition to their antenatal and postnatal care appointments.
The UNAIDS 2025 global targets include that 95% of pregnant and breastfeeding women living with HIV have suppressed viral loads and 95% of HIV-exposed children get tested. To achieve this, it is critical that countries consider the updated WHO recommendations and ensure that pregnant and breastfeeding women established on treatment have the choice of accessing their preferred HIV treatment model aligned with, or in addition to, their antenatal and postnatal care appointments.
Jointly, we must work towards realizing women’s and adolescent girls’ sexual and reproductive health and rights, providing access to person-centred quality and integrated health services, and support women and adolescent girls in making their own informed choices.
Disclaimer: Views expressed are personal and do not necessarily reflect those of the World Health Organization and its member states
