The University of Mississippi Medical Center implemented a Postpartum Retention and Engagement Quality Improvement (QI) Initiative in 2017 to improve linkage to care, retention in care, and viral suppression among postpartum women with HIV. This evidence-informed intervention uses a combination of care coordination, printed materials, case management services, and improved collaboration and coordination between the Adult Special Care Clinic (ASCC), which provides comprehensive HIV medical care, and a Perinatal HIV Program. The comprehensive intervention significantly improved retention in HIV care and increased viral suppression at both six and 12 months postpartum.
Historically, people who accessed HIV medical care at ASCC and became pregnant received a referral to the Perinatal HIV Program and were no longer considered part of ASCC’s patient population.1 Postpartum, the Perinatal HIV Program scheduled an appointment with an HIV service provider at ASCC for continued care and provided notification via phone or mail. Review of HIV care continuum data showed that 40% of women were lost to care during the postpartum period. ASCC staff identified a number of operational and structural barriers to reengaging and retaining postpartum women with HIV in care, including lack of adequate transitional case management, lack of follow up by ASCC clinical staff, loss of health care coverage, and lack of flexibility in clinic scheduling. Additionally, women face social and structural barriers to engagement and retention in HIV care including competing priorities related to work and family obligations, lack of childcare, unreliable transportation, and lack of social support systems. To address these issues, the University of Mississippi Medical Center implemented the Postpartum Retention and Engagement QI Initiative which incorporated several previously published recommendations and best practices for the care of postpartum women with HIV to improve retention in HIV care, and ultimately viral suppression.
“Retention rates in care and viral suppression, particularly among African-American/Black women in the Southern region of the U.S., remain low.”
ASCC staff worked closely with the Perinatal HIV Program staff at the University of Mississippi Medical Center to ensure ongoing communication and coordination of care for women who transitioned to postpartum care at ASCC. ASCC staff made face-to-face visits or phone calls to inform women of the services—including mental health care, ongoing HIV treatment, medication assistance, and medical transportation—available to them after delivery. Staff ensured the continuation of medication access, in particular making sure clients covered through Medicaid while pregnant transitioned to the AIDS Drug Assistance Program (ADAP) during the postpartum period.
While clients were in Perinatal HIV Program care, ASCC staff monitored their data, including date of HIV diagnosis, estimated delivery date, and documented barriers to care. Data for clients referred from the Perinatal HIV Program were tracked in a separate encrypted spreadsheet. This intensive monitoring led ASCC to better anticipate client needs and to take the necessary steps to provide supportive services and referrals.
Pamphlets were designed specifically to address the needs of pregnant and postpartum women with HIV and to outline the services available at ASCC. These materials were written in easy-to-read language and were intended to educate women on the importance of postpartum care, improve health literacy, and facilitate communication with medical providers.
Case managers worked with clients to build trust, address barriers, and coordinate supportive services through a combination of in-person meetings and telephone calls. Individualized care plans that identified personal health goals were developed in collaboration with clients. These plans addressed social determinants of health such as housing, food, and transportation.
The intervention team used a serial cross-sectional design and compared outcomes for 30 postpartum women who were referred to ASCC prior to implementation of the intervention with 24 postpartum women who were referred to ASCC during the intervention period. There were significant improvements in retention in care and viral suppression at both six and 12 months.
Source: Hickman, A.B., Backus, K.V., Burns, P. et al. Evaluation of a postpartum linkage and retention quality improvement initiative for women living with HIV in the Deep South. J Public Health (Berl.) 30, 841–847 (2022).
“Retention in care is a critical component in the HIV care continuum for improving maternal health outcomes among postpartum women with HIV.”
Identification of barriers to retention in care. ASCC staff examined their existing referral and client navigation process and identified several operational and structural barriers that impacted how postpartum women were retained in care. These included:
- Lack of follow-up from ASCC staff
- Loss of medication and health care coverage
- Lack of childcare
- Competing priorities related to family or work
Literature review to identify promising practices. Staff found that the usual approach to referrals and case management was insufficient for meeting the needs of postpartum women with HIV, and a more proactive approach was essential for successful transitions from perinatal to postpartum care. The intervention team conducted a literature review to identify previously documented barriers and facilitators to retention in care for postpartum women with HIV, and incorporated those recommendations into their postpartum referral and engagement efforts.
“After delivery, ASCC staff would actively monitor postpartum women who were referred to ASCC to ensure they successfully linked to outpatient HIV care.”
The Postpartum Retention and Engagement QI Initiative is a low-cost intervention, using resources and staff already in place. The intervention focused on adjusting existing processes and policies to encourage a more proactive approach to linkage and engagement along the continuum of care and required few resources. The care coordination, health education, and case management services provided as part of the intervention are Ryan White HIV/AIDS Program funded services. In many locations, these services may also be reimbursable under other funding sources such as Medicaid or private health care coverage.
- Colocation of services was integral to the success of the intervention. The Perinatal HIV Program and ASCC are both housed at the same university-based health center, which allowed for greater collaboration and coordination of care.
- A combination of supports tailored to the needs of individuals may be more beneficial than any individual aspect of the intervention. Individualized care plans allow clients with specific needs to receive more intensive follow-up and personal contact.
- Extended monitoring of outcomes beyond 12 months may be important to ensuring long-term retention in care. Postpartum women with HIV still face barriers then and may need ongoing supports to stay engaged in care.