The impact of expanded access to antiretroviral treatment on engagement in HIV care and viral suppression among pregnant women living with HIV in South Africa

BACKGROUND: Timing of engagement in HIV care in relation to pregnancy impacts maternal outcomes and the risk of vertical transmission of HIV. Option B+, a policy that mandates offering all pregnant women living with HIV (PWLH) lifelong antiretroviral therapy (ART) irrespective of their CD4 count, has been adopted across sub-Saharan Africa, including South Africa since 2015. This study aimed to assess the impact of expanded access to ART on engagement in HIV care and viral suppression among pregnant women in South Africa. METHODS: This observational study used data from pregnant women living with HIV who delivered at Rahima Moosa Mother and Child Hospital in Johannesburg, South Africa from 2013-2017. Linkage to a national HIV laboratory cohort (the NHLS National HIV cohort) was used to ascertain engagement in HIV care prior to antenatal care (ANC) entry and viral load outcomes. Analyses were stratified by the pre-Option B+ (2013-2014), Option B+ (2015-31 Aug 2016) and Universal Test and Treat (post-01 Sept 2016) eras. We compared engagement rates before and during the Option B+ era and assessed factors associated with HIV care engagement and viral suppression. Risk ratios were estimated using log-binomial regression. RESULTS: Among 4,865 PWLH, 65% had evidence of prior engagement in HIV care. Prior engagement in care was higher during the Option B+ (64%) and UTT (71%) eras compared to the pre-Option B+ era (55%). Younger women (18-24 years) were less likely to engage in HIV care than those aged 25-34 years (aRR 0.8, 95% CI: 0.6-0.9). Women with CD4 counts