BACKGROUND: Pregnancy and postpartum are challenging periods where interruptions in HIV care and treatment (starting, stopping, and returning to care over time) are common. The absence of ART is strongly associated with high viral load and vertical transmission. Understanding determinants for interruptions in care could inform interventions aimed at continuous retention to prevent negative health outcomes related to high viral load.
METHODS: The Kigali Antiretroviral and Breastfeeding Assessment for the Elimination of HIV (Kabeho) study was an observational, prospective cohort of 608 HIV-positive women enrolled in their third trimester of pregnancy or within two weeks post-delivery between April 2013 and May 2014. Multivariate logistic models adjusted for clustering by facility were used to examine the odds of an interruption (one or more missed visits followed by returning to care). Models included the following individual characteristics ascertained from interviews at enrollment: age, marital status, travel time to facility, education, CD4 results, disclosure of HIV status to partner, and household size. Facility characteristics captured during site assessments such as frequency and types of services offered were also included.
RESULTS: Women who attended facilities that offered select services had much lower odds of having an interruption as compared to women who attended facilities that did not offer those services (Table 1). None of the individual characteristics examined were associated with interruptions.

Table 1. Adjusted odds ratios and 95% confidence intervals from logistic models examining individual and facility-level characteristics among women enrolled in the Kabeho Study; Kigali, Rwanda; 2015-2017.
Facility level characteristics [individual characteristics not shown]	OR (95% CI)
ANC, PMTCT, and ART services offered all 5 days per week	0.54 (0.32, 0.92)
Services not offered all 5 days	Reference
Retention support (telephone reminders, transportation reimbursement/support, or defaulter tracing system)	0.30 (0.12, 0.76)
No retention support	Reference
Peer counseling	0.31 (0.23, 0.42)
No peer counseling	Reference
Infant feeding counseling	0.20 (0.15, 0.26)
No infant feeding counseling	Reference

CONCLUSIONS: Our study suggests that health facilities may be more effective targets for interventions to improve retention than individuals. The lack of services offered was strongly associated with interruptions. Studies aimed at assessing health care utilization and motivation may be an effective means to identify the services that most encourage continuous engagement of pregnant and postpartum women to reduce the likelihood of vertical transmission.