Characteristics and outcomes of women initiating ART during pregnancy versus breastfeeding in Option B+ in Malawi

Abstract

BackgroundMalawi adopted the PMTCT strategy ‘Option B+’ in 2011, providing life-long ART for all HIV-infected pregnant and breastfeeding women. We explored differences in characteristics and outcomes of women initiating ART during pregnancy versus breastfeeding.MethodsWe conducted a retrospective cohort analysis of women in Zomba District, southern Malawi, from January 2012- September 2013. Data were extracted from the Zomba District Observational Cohort Study, a surveillance project collecting data from standardized Ministry of Health ART monitoring tools.Results1986 (67.2 %) women initiated ART during pregnancy and 969 (32.8 %) during breastfeeding. Women initiating ART in breastfeeding were more likely to be > 30 years (aOR = 1.33, 95 % CI1.11–1.59, p = 0.003) and have WHO Stage 3/4 (aOR = 2.74, 95 % CI1.94–3.87, p < 0.001).Eighteen (0.6 %) deaths occurred and 942 (31.9 %) women defaulted ART. ‘Early’ death (< 30 days) occurred in 3 (0.1 %) women and 449 (16.4 %) women defaulted early. Death/default < 30 days was more likely among women initiating ART during pregnancy (aOR 1.62, 95 % CI1.28–2.05, p < 0.001) or < 30 years old (aOR 1.27, 95 % CI 1.02–1.57, p = 0.03) and was less likely among those with WHO Stage 3/4 (aOR 0.30, 95 % CI 0.15–0.60, p < 0.001).Using Kaplan-Meier estimators to investigate time to death/default, we showed a sharp drop in death/default-free survival probability at time zero, yet survival probability decreased in a nearly linear manner after this initial period of high default. Women under 30 years had increased rates of death/default over time (log rank test: p < 0.001), however no significant differences were observed in death/default over time associated with timing of ART initiation, documented clinical stage at initiation, health clinic size or adherence rates.ConclusionsMany women in Malawi started ART during breastfeeding within Option B+ and were older and had more advanced WHO Clinical Staging. This represents a missed PMTCT opportunity to initiate treatment early in pregnancy. Early defaulting is identified as a challenge within Option B+, and was more likely among younger women and those initiating ART in pregnancy. Targeted research to understand factors associated with uptake of ART during pregnancy and retention in care could improve the efficacy of Option B+ in Malawi.

Incidence and Predictors of Loss-to-follow-up Among Pregnant and Breastfeeding Women on Option B+ PMTCT Program in Northwest Ethiopia: a Retrospective Follow-up Study.

“…The current study includes the recent year data at which most strategies as a country level were implemented to decrease LTFU like bringing services closer to communities by expanding ART sites to above 1,500 Health facilities, increasing service provision by expanding trained health personnel in order to decrease waiting times at the facility than the previous study(2013, 2014 and 2015).The variation could also be explained by the difference in study setting, since this study was conducted at one referral hospital whereas, a study conducted in Northeast Ethiopia was done in four hospital and ten health centers. Studies showed that magnitude of lost to follow up varied according to level of health institutions (23,29). Moreover, the lower incidence of LTFU in the current study might be due to the fact that different programs/measures were implemented in the country in recent years to decrease the rate of LTFU among HIV infected women.…”

“…Various literatures reported that LTFU can be affected by various factors, including socio-demographic and economics, behavioral and clinical variables. Reports from Africa indicated that, maternal age less than 25 years (12,13,15,21,26,27,32), less than 26 years (33), and less than 30 (23) were statistically signi cant positive predictor for LTFU. Moreover, Educational status (15,28), Marital status (19), unemployment status (34), number of pregnancies (13), religious reasons, and partner HIV status (12,16) were a signi cant predictor for LTFU.…”

“…Another retrospective cohort study in Myanmar showed that pregnant women's LTFU rate was 7 per 1000 person-years under option B+ PMTCT programs (11). A retrospective follow-up study in different African countries showed that the incidence of LTFU among pregnant and lactating mothers under option B+ program were still high which ranges from 16% to 53.7 (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26). Previous studies in Ethiopia showed that the rate of LTFU among women under Option B+ program varied region to region.…”

“…In addition, studies showed that the baseline low CD4 cell counts and high viral load measurement were positively associated with LTFU among women in PMTCT services (36,37). Moreover, advanced WHO clinical stages ( III/IV) was positively signi cant risk factors for poor retention of care (23).…”

Unpacking Loss to Follow-Up Among HIV-Infected Women Initiated on Option B+ In Northern Tanzania: A Retrospective Chart Review

“…Our study supports others in suggesting that being younger at ART initiation reduces retention in care. 11,[17][18][19] Several factors may contribute to poor retention among younger women, including reduced readiness for ART, decreased knowledge of the benefits of PMTCT, as well as stronger feelings of internalised and perceived stigma. 20,21 Older women may have more social support within partnerships and families which allow them to better manage ART.…”