Challenges and successes in the implementation of option B+ to prevent mother-to-child transmission of HIV in southern Swaziland

Abstract

BackgroundUniversal antiretroviral therapy (ART) for all pregnant/ breastfeeding women living with Human Immunodeficiency Virus (HIV), known as Prevention of mother-to child transmission of HIV (PMTCT) Option B+ (PMTCTB+), is being scaled up in most countries in Sub-Saharan Africa. In the transition to PMTCTB+, many countries face challenges with proper implementation of the HIV care cascade. We aimed to describe the feasibility of a PMTCTB+ approach in the public health sector in Swaziland.MethodsLifelong ART was offered to a cohort of HIV+ pregnant women aged ≥16 years at the first antenatal care (ANC1) visit in 9 public sector facilities, between 01/2013 and 06/2014. The study enrolment period was divided into 3 phases (early: 01–06/2013, mid: 07–12/2013 and late: 01–06/2014) to account for temporal trends. Kaplan-Meier estimates and Cox proportional-hazards regression models were applied for ART initiation and attrition analyses.ResultsOf 665 HIV+ pregnant women, 496 (74.6%) initiated ART. ART initiation increased in later study enrolment phases (mid: aHR: 1.41; later: aHR: 2.36), and decreased at CD4 ≥ 500 (aHR: 0.69). 52.9% were retained in care at 24 months. Attrition was associated with ANC1 in the third trimester (aHR: 2.37), attending a secondary care facility (aHR: 1.98) and ART initiation during later enrolment phases (mid aHR: 1.48; late aHR: 1.67). Of 373 women eligible, 67.3% received a first VL. 223/251 (88.8%) were virologically suppressed (< 1000 copies/mL). Of 670 infants, 53.6% received an EID test, 320/359 had a test result recorded and of whom 7 (2.2%) were HIV+.ConclusionsPMTCTB+ was found to be feasible in this setting, with high rates of maternal viral suppression and low transmission to the infant. High treatment attrition, poor follow-up of mother-baby pairs and under-utilisation of VL and EID testing are important programmatic challenges.

Feasibility of antiretroviral therapy initiation under the treat‐all policy under routine conditions: a prospective cohort study from Eswatini

“…The time period-2 was associated with higher ART initiation in both interventions. Associations of temporal trends with patient outcomes have been reported previously from sub-Saharan Africa [39][40][41][42][43][44][45][46]. First, in our setting, expanding treatment eligibility increased the pool of treatment eligible patients, likely resulting in increasing ART initiations under SOC.…”

Programmatic outcomes and impact of rapid public sector antiretroviral therapy expansion in adults prior to introduction of the WHO treat‐all approach in rural Eswatini

“…2010 WHO treatment eligibility recommendations) and pilot interventions for treatment expansion were introduced before becoming WHO policy (e.g. phase‐in of PMTCT option B+ and treat‐all). This allowed an increasing number of PLHIV to start treatment before presenting with advanced HIV disease, possibly resulting in a less sick and clinically more easy to manage treatment cohort.…”

“…Thereafter, from 2011 to 2012, HIV services were consolidated, and community‐based HIV testing and routine viral load monitoring were introduced (period‐3). Then, in 2013 and 2014 (period‐4), ART eligibility was further extended in Nhlangano health cluster by phasing in the prevention of mother‐to‐child transmission (PMTCT) option B+ approach in 01/2013 and universal ART provision irrespective of immunological criteria (treat‐all) in 10/2014. All services were provided free of charge by the Ministry of Health and Médecins Sans Frontières (MSF).…”

Decreased risk of HIV‐associated TB during antiretroviral therapy expansion in rural Eswatini from 2009 to 2016: a cohort and population‐based analysis

“…A modelling study suggested that ART programmes are needed to sustain high levels of ART adherence and good immunologic response to avert TB rebound [14]. TB rebound was not detected in this setting, with viral load suppression rates in ART patients being ≥84% [26,31]. Calendar year interacted with HIV and ART status.…”