STRIVE Webinar

Abigail Hatcher, PhD

Wits School of Public Health

29 May 2018

How does partner

violence influence

HIV medication in pregnancy?

South Africa is one of several countries with high

mother-to-child transmission of HIV (MTCT)

1. UNAIDS (2011) Global plan towards elimination of new HIV infections among children by 2015

Towards elimination of MTCT

Effective regimens can reduce

MTCT to as low as 1% (1, 2)

UNAIDS calls for virtual

elimination of MTCT (3) have

been echoed by stakeholders

globally:

90 % reduction in new childhood

HIV infections

50 % reduction in HIV-related

maternal deaths by 2015

1. Lehman (2009) PLoS Med 2. Mofenson (2010) New Eng J

Med 3. UNAIDS (2011)

1. Stringer, JS (2010) JAMA

Socio-ecological view of how HIV-positive pregnant

woman navigates PMTCT cascade

In sub-Saharan Africa, meta-analyses suggest 15% of

women experience IPV during pregnancy (1), an

estimate higher than other regions globally (2)

Among South

African pregnant

women, an

estimated 25 – 35%

experience IPV

during the previous

12 months (3-5).

1. Shamu S, (2011) PLoS One; 2. Devries KM, (2010) Repro Health Matters. 3. Groves AK, (2012) J

Inter-pers Violence. 4. Hoque ME, (2009) SA J of Epidemiology and Infection. 5. Mbokota M, (2003) S

Afr Med J.

Anticipated IPV is associated with refusing HIV testing (1, 2)

Male involvement predicts better adherence to NVP (3)

Physical IPV reduces women’s uptake of prenatal care (4 - 8)

History of violence decreases women’s breastfeeding (9, 10)

1. Medley (2004) Bull WHO. 2. Turan (2011) AIDS Behav. 3. Peltzer (2011) Acta Paediatr.Hatcher (2012) AIDS Behav 4. Moraes

(2010) Rev Saúde Pública 5. Koski (2011) J Health Pop Nutr 6. Perales MT (2009) 7. Heaman MI (2005) 8. Lipsky S (2005)

9. Silverman (2006) J Women’s Health 10. Lau (2007) J Midwif Women’s Health

Studies suggest a link between IPV and PMTCT:

Anticipated IPV is associated with refusing HIV testing (1, 2)

Male involvement predicts better adherence to NVP (3)

Physical IPV reduces women’s uptake of prenatal care (4 - 8)

History of violence decreases women’s breastfeeding (9, 10)

Studies suggest a link between IPV and PMTCT:

Study Characteristics

n=13 studies

Published recently (2010 – 2015)

All cross-sectional, with relatively small

samples (median n=234)

Even among those with men and women

(n=4), we analyzed woman only

1. Blackstock (2015) AIDS Pat Care STDs 2. Blank (2015) AIDS Pat Care STDs 3. Ryerson Espino (2015) AIDS Pat Care

STDs 4. Illangesekare (2012) Womens Health Issues 5. Kalokhe (2012) AIDS Pat Care STDs 6. Lopez (2010) AIDS

Educ Prev 7. Malow (2013) Aids Beh 8. Ramachandran (2010) AIDS Care 9. Rose (2010) Psych Trauma 10. Schafer

(2012) AIDS Pat Care STDs 11. Siemieniuk (2013) JAIDS 12. Sullivan (2015) AIDS Pat Care STDs 13. Trimble (2013)

JANAC

Haiti

(n=1)

U.S.

(n=11)

Canada

(n=1)

IPV is associated with …lower ART adherence

…worse viral suppression

Measurement:

How much?

To what extent is experience of recent IPV

associated with PMTCT adherence?

Randomised control trial of IPV in

pregnancy intervention

IPV screening at ANC

Women with recent IPV at

baseline randomised to:

Empowerment counseling

(~30 min) & targetted

referrals by trained Nurses

Enhanced control condition

of a referral list

Follow-up visit: 6 weeks

postpartum

May 2013 – June 2016

Eligibility over 18 years of age

are pregnant at baseline

do not exhibit an immediate safety risk (suicidality or fearing for the safety of one’s children)

Any recent physical or sexual IPV (in the past 12 months)

Setting

Hillbrow South Rand Yeoville

Quantitative Longitudinal Study

n=195

Quantitative Longitudinal Study

n=265

WHO instrument [1] (at baseline)

Past 12 months

specific acts of violence

has been used widely, including in South

African studies [2-5]

Measures

1. Garcia-Moreno (2006) Lancet. 2. Jina (2012) J Interpersonal Violence 3. Jewkes (2010) Lancet 3. Dunkele (2004) Lancet 5. Townsend (2011) Aids and Behavior 6. Giordano (2004) HIV Clin

Trials, 7. Peltzer K (2010) BMC Pub Heal, 8. Oyugi (2004) JAIDS, 9. Buscher (2011) HIV clinical trials

Primary

exposure of

interest

Primary

outcome Self-report Visual Analog Scale [6] (at follow-

up)

Final month of pregnancy

Past 30 days (postpartum)

validated in South Africa [7]

strong correlation with measures such as

MEMS and unannounced pill count [8,9]

Sociodemographics

n=195

Does IPV alter adherence?

Analysis: Comparing mean adherence for each group using Kruskill Wallis sign-rank test

Analysis: Bivariate logit models of self-reported adherence >90% with primary predictor of any recent physical/sexual IPV at baseline

IPV reduces adherence by .

USA: 32%

Zambia: 89%

South Africa: 89%

1. Yee (2018) Sexual and Reproductive Healthcare 2. Hampanda (2016) Social Science & Medicine 3. Hatcher

(2017) PhD, Wits University

Theoretical Framework

Qualitative Research N=32 women living with IPV and HIV

Oversampling of women with PMTCT

adherence challenges

My boyfriend doesn't

know about this. I just

kept it to myself. When I

come take my treatment

here by the clinic, I hide it.

Even when I drink my

tablets I would hide them.

– Mpefe, 25 years,

Pregnant

There was a time when I

was really, really down, so

I stopped taking my

medication. I completely

just stopped and I sort of

had this death wish in me

that if only this thing

would, if HIV would work

like really for us then it

would just kill me. I

stopped for three to four

months without taking my

medication.

– Dova, 32 years, Pregnant

Sometimes when I go to

the clinic he says, “Hey

you are not going to the

clinic.” He asked me too

many questions… But I

refuse. I tell him I can’t

stop going to clinic

because this is my life!

…Sometimes when I come

back to the house he

beats me.

–Kagiso, 28 years,

Postpartum

I’m doing it [PMTCT] for my baby. I don’t

want to stress myself so that I leave the

tablets - it’s better to leave that

husband and continue with my tablet.

–Zethu, 27 years, Postpartum

Qualitative Pathways

Quantitative Pathways

Thanks to: Our participants in Johannesburg ANC sites, Gauteng

Department of Health, and other partner organisations

Our research team: Nataly Woollett, Claudia Garcia-

Moreno, Christina Pallitto, Zanele Mlambo, Lele van

Eck, Charlotte Checha, Shirley Mphahlele, Marcia

Makgatle

My PhD supervisory committee: Nicola Christofides,

Janet Turan, Heidi Stoeckl

The Wits School of Public Health Interdisciplinary PhD

Programme faculty and cohort

Funders: Flemish Government