Background:  Prevention of perinatal HIV transmission in the United States is predicated on patients' access to and compliance with complex medical regimens. Women faced with major social barriers to care may not be successful in suppressing viral load or presenting for cesarean delivery prior to labor. This study examined whether hospitalization for directly observed therapy (DOT) enabled pregnant women with social barriers to care to achieve virologic and clinical success similar to women who adhere to outpatient therapy.

Methods: Eight HIV-infected pregnant patients who underwent DOT at a large urban tertiary care center between 1992 and 2003 were identified by chart review. All were offered in-patient DOT in the third trimester of pregnancy secondary to their inability to adhere to outpatient therapy. Using a 4:1 matching scheme:  2 HIV-infected patients who delivered both immediately before and after each DOT patient, a comparison group of 32 women was identified. The main outcome measure was success of therapeutic goals defined as:  no perinatal transmission, suppression of viral load less than 1000 copies/mL, delivery by intended route and at planned delivery site and receipt of appropriate anti-retroviral therapy in labor. Social stress was measured by factors traditionally shown to impair adherence: absence of family support, lack of disclosure of HIV status to family/friends, substance abuse, mental illness, and homelessness.

Results: Women who were selected for DOT were significantly more likely than outpatients to have social barriers to care: no family support (75% vs 28%), non-disclosure (75% vs 31%), substance abuse (75% vs 22%), mental illness (75% vs 13%), and homelessness (63% vs 9%). Despite this significantly greater degree of stress, DOT patients achieved a similar level of success (as defined above) as the women that maintained outpatient regimens, 63% vs 69% respectively, p = 0.7. No patient in either group transmitted HIV to their infant. Other outcomes showed: appropriate route of delivery (88% vs 97%), delivery at planned hospital (88% vs 94%), appropriate ARV in labor (88% vs 88%). Fewer DOT patients achieved a completely suppressed viral load, 75% vs 100%; however they were able to undergo a timely cesarean delivery when indicated.

Conclusions:  HIV-infected pregnant women with multiple social barriers to medical care can successfully achieve HIV-related therapeutic goals through in-patient directly observed therapy.

Keywords: Directly Observed Therapy; HIV; Pregnancy