HIV‐positive pregnant and postpartum women's perspectives about Option B+ in Malawi: a qualitative study

Abstract

IntroductionThe implementation of lifelong antiretroviral treatment (ART) for all pregnant women (Option B+) in Malawi has resulted in a significant increase in the number of HIV-positive pregnant women initiating treatment. However, research has highlighted the challenge of retaining newly initiated women in care. This study explores barriers and facilitators that affect a woman's decision to initiate and to adhere to Option B+.MethodsA total of 39 in-depth interviews and 16 focus group discussions were conducted. Eligible women were ≥18 years old, living with HIV and either pregnant and receiving antenatal care from a study site or had delivered a child within the last 18 months, breastfed their child and received services at one of the study sites. Eligible women were identified by healthcare workers (HCWs) in the antenatal clinic and ART unit. Focus groups were also conducted with HCWs employed in these departments. Qualitative data were analyzed using Maxqda version 10 (VERBI Software, Berlin, Germany).ResultsThe general perception towards the drug regimen used in Option B+ was positive; women reported fewer side effects and acknowledged the positive benefits of ART. Women felt hopeful about prolonging their life and having an HIV-uninfected baby, yet grappled with the fact that ART is a lifelong commitment. Women and HCWs discussed challenges with the counselling services for prevention of mother-to-child HIV transmission under the new Option B+ guidelines, and many women struggled with initiating ART on the same day as learning their HIV status. Women wanted to discuss their circumstances with their husbands first, receive a CD4 count and obtain an HIV test at another facility to confirm their HIV status. HCWs expressed concern that women might just agree to take the drugs to please them. HCWs also discussed concerns around loss to follow-up and drug resistance.ConclusionsAlthough Option B+ has significantly increased the number of women initiating ART, there are still challenges that need to be addressed to strengthen initiation, adherence and retention in care. Strategies to strengthen the counselling services upon diagnosis need to be developed to improve same-day initiation of ART and long-term adherence.

“We have heard it together”: a qualitative analysis of couple HIV testing and counselling recruitment in Malawi’s Option B+ programme

“…Prior to Option B+, PMTCT patients had stronger concerns about male partner reactions, disclosure, and stigma, and greater difficulties with coping (Bwirire, 2008). Similar to other qualitative assessments conducted within Malawi’s Option B+ program, provision of ART conferred hope about positive outcomes for the infant and the woman herself (Katirayi et al, 2016, Elwell, 2016). It appears that as HIV is becoming a more manageable illness, people are approaching their own and their partners’ HIV status with greater acceptance.…”

“…This phenomenon occurs at considerably higher rates among pregnant women than among HIV-infected persons initiating ART for clinical indications, such as AIDS-defining illnesses and low CD4 count (Tenthani et al, 2014). This early loss to follow-up often stems from difficulties with disclosing an HIV-positive status to male sex partners (Kalembo et al, 2013; Elwell et al, 2016;Katirayi et al, 2016;Kim et al, 2016). Without disclosure, women have trouble taking pills out of fear of accidentally revealingtheir HIV status.…”

Rapid initiation of antiretroviral therapy for people living with HIV

“…The HIV continuum of care is however a complex process, in which every cascade step is influenced by multiple factors, as illustrated in our conceptual model (Figure 1). The feasibility and acceptability of rapid ART initiation depends on various health system and provider factors, such as: staffing levels, skills, infrastructure and equipment, which vary across settings (Attawell 2003); as well as: social; economic; cultural; and individual drivers, including acceptance and motivation to take ART (Black 2013; Black 2014; Katirayi 2016). Initiating treatment before baseline screening test results are available could also result in a higher frequency of adverse events which may result in disengagement (Abay 2015; Chan 2016; Pilcher 2017), and regimen modification (Pilcher 2017).…”

Ask women living with HIV what's needed to achieve safe pregnancies in serodifferent relationships

“…Women’s experiences also affect WHO’s new ART-drug resistance campaign [16]. Resistance may ensue [17] if women start ART and are “lost to follow up” [18,19]. Increasing evidence suggests considerable lack of retention in care during and post-pregnancy.…”

“…Increasing evidence suggests considerable lack of retention in care during and post-pregnancy. Understanding is required: neither patient-blaming language nor calls for more education, which just miss the point [18,19,20,21,22,23,24].

“I would like them to address gender violence because women are suffering in the hands of their husbands.

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