Lessons Learned From Early Implementation of Option B+

Mp, Kieffer; Mattingly, Martha A.; Giphart, A; R, van de Ven; Chouraya, Caspian; Walakira, M; Boon, A W; Mikusova, S; Simonds, R. J.

doi:10.1097/qai.0000000000000372

Cited by 82 publications

(57 citation statements)

References 5 publications

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“…In our study we followed women from delivery, rather than cART initiation, to assess LTFU after engagement with the healthcare system during pregnancy. In countries that have implemented Option B+ similar trends have been seen, with 12–24% of women reported LTFU or to have no follow-up by 6 months after cART initiation (Kieffer et al, 2014; Tenthani et al, 2014). Among women LTFU in our study, 56% (n=285) did not return to care after delivery.…”

Section: Discussionsupporting

confidence: 53%

“…In Malawi, 17% of women initiating cART during pregnancy were LTFU by 6 months after treatment initiation. Retention at 12 months was lower among pregnant women than among other adults initiating cART (Kieffer et al, 2014; Tenthani et al, 2014). In South Africa, 32% of women initiating cART during pregnancy were lost by 6 months postpartum (Phillips et al, 2014).…”

Section: Introductionmentioning

confidence: 87%

“…In 2013, an estimated 68% of HIV-infected pregnant women received some type of antiretroviral drug during pregnancy and delivery, doubled from 33% in 2009 (UNAIDS, 2014). In countries with a generalized HIV epidemic, the World Health Organization (WHO) now recommends lifelong cART for all pregnant and breastfeeding women (Kieffer et al, 2014; WHO, 2013). This strategy, known as Option B+(Schouten et al, 2011), has become the standard of care in many SSA countries.…”

Section: Introductionmentioning

confidence: 99%

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A risk score to identify HIV-infected women most likely to become lost to follow-up in the postpartum period

et al. 2016

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Access to lifelong combination antiretroviral therapy (cART) is expanding among HIV-infected pregnant and breastfeeding women throughout sub-Saharan Africa. For this strategy to meaningfully improve maternal HIV outcomes, retention in HIV care is essential. We developed a risk score to identify women with high likelihood of loss to follow-up (LTFU) at 6 months postpartum from HIV care, using data from public health facilities in Lusaka, Zambia. LTFU was defined as not presenting for HIV care within 60 days of the last scheduled appointment. We used logistic regression to assess demographic, obstetric, and HIV predictors of LTFU and to develop a simple risk score. Sensitivity and specificity were assessed at each risk score cut-point. Among 2,029 pregnant women initiating cART between 2009 and 2011, 507 (25%) were LTFU by 6 months postpartum. Parity, education, employment status, WHO clinical stage, duration of cART during pregnancy, and number of antenatal care visits were associated with LTFU (p-value<0.10). A risk score cut-point of 11 (42nd percentile) had 85% sensitivity (95% CI 82%, 88%) and 22% specificity (95% CI 20%, 24%) to detect women LTFU and would exclude 20% of women from a retention intervention. A risk score cut-point of 18 (69th percentile) identified the 23% of women with the highest probability of LTFU and had sensitivity 32% (95% CI 28%, 36%) and specificity 80% (95% CI 78%, 82%). A risk score approach may be useful to triage a subset of women most likely to be LTFU for targeted retention interventions.

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Section: Discussionsupporting

confidence: 53%

Section: Introductionmentioning

confidence: 87%

Section: Introductionmentioning

confidence: 99%

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A risk score to identify HIV-infected women most likely to become lost to follow-up in the postpartum period

et al. 2016

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“…7 Kenya introduced Option B+ at research sites in 2011, and adopted it as national policy in 2014. 14 …”

Section: Introductionmentioning

confidence: 99%

Implementation and Operational Research: Impact of a Systems Engineering Intervention on PMTCT Service Delivery in Côte d'Ivoire, Kenya, Mozambique: A Cluster Randomized Trial

Rustagi

Gimbel

Nduati

et al. 2016

JAIDS Journal of Acquired Immune Deficiency Syndromes

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BACKGROUND Efficacious interventions to prevent mother-to-child HIV transmission (PMTCT) have not translated well into effective programs. Prior studies of systems engineering applications to PMTCT lacked comparison groups or randomization. METHODS Thirty-six health facilities in Côte d’Ivoire, Kenya, and Mozambique were randomized to usual care or a systems engineering intervention, stratified by country and volume. The intervention guided facility staff to iteratively identify and then rectify barriers to PMTCT implementation. Registry data quantified coverage of HIV testing during first antenatal care visit, antiretrovirals (ARVs) for HIV-positive pregnant women, and screening HIV-exposed infants (HEI) for HIV by 6–8 weeks. We compared the change between baseline (January 2013–January 2014) and post-intervention (January–March 2015) periods using t-tests. All analyses were intent-to-treat. RESULTS ARV coverage increased 3-fold (+13.3 percentage points [95% CI: 0.5, 26.0] in intervention vs. +4.1 [−12.6, 20.7] in control facilities) and HEI screening increased 17-fold (+11.6 [−2.6, 25.7] in intervention vs. +0.7 [−12.9, 14.4] in control facilities). In pre-specified sub-group analyses, ARV coverage increased significantly in Kenya (+20.9 [−3.1, 44.9] in intervention vs. −21.2 [−52.7, 10.4] in controls; p=0.02). HEI screening increased significantly in Mozambique (+23.1 [10.3, 35.8] in intervention vs. +3.7 [−13.1, 20.6] in controls; p=0.04). HIV testing did not differ significantly between arms. CONCLUSIONS In this first randomized trial of systems engineering to improve PMTCT, we saw substantially larger improvements in ARV coverage and HEI screening in intervention facilities compared to controls, which were significant in pre-specified sub-groups. Systems engineering could strengthen PMTCT service delivery and protect infants from HIV.

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“…Creating a flexible system in which nurses can identify those who need additional counseling could enable nurses to keep women at higher risk of LTFU within the system. Implementing and improving systems that follow mother-baby pairs through the risk period for MTCT and tracking those who do not return to the facility has become increasingly important under Option B+ [30]. …”

Section: Resultsmentioning

confidence: 99%

Lessons learned from the PMTCT program in Swaziland: challenges with accepting lifelong ART for pregnant and lactating women – a qualitative study

et al. 2016

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BackgroundSwaziland has one of the highest HIV prevalence rates in sub-Saharan Africa, 26 % of the adult population is infected with HIV. The prevalence is highest among pregnant women, at 41.1 %. According to Swaziland’s prevention of mother-to-child transmission (PMTCT) guidelines, approximately 50 % of pregnant women are eligible for antiretroviral therapy (ART) by CD4 criteria (<350 cells/ml). Studies have shown that most mother-to-child transmission and postnatal deaths occur among women who are eligible for ART. Therefore, ensuring that ART eligible women are initiated on ART is critical for PMTCT and for mother and baby survival. This study provides insight into the challenges of lifelong ART initiation among pregnant women under Option A in Swaziland. We believe that these challenges and lessons learned from initiating women on lifelong ART under Option A are relevant and important to consider during implementation of Option B+.MethodsHIV-positive, treatment-eligible, postpartum women and nurses were recruited within maternal and child health (MCH) units using convenience and purposive sampling. Participants came from both urban and rural areas. Focus group discussions (FGDs) and structured interviews using a short answer questionnaire were conducted to gain an understanding of the challenges experienced when initiating lifelong ART. Seven FGDs (of 5–11 participants) were conducted, four FGDs with nurses, two FGDs with women who initiated ART, and one FGD with women who did not initiate ART. A total of 83 interviews were conducted; 50 with women who initiated ART and 33 with women who did not initiate. Data collection with the women was conducted in the local language of SiSwati and data collection with the nurses was done in English. FGDs were audio-recorded and simultaneously transcribed and translated into English. Analysis was conducted using thematic analysis. Transcripts were coded by two researchers in the qualitative software program MAXqda v.10. Thematic findings were illustrated using verbatim quotes which were selected on the basis of being representative of a specific theme. The short-answer interview questionnaire included specific questions about the different steps in the woman’s experience initiating ART; therefore the responses for each question were analyzed separately.ResultsFindings from the study highlight women feeling overwhelmed by the lifetime commitment of ART, feeling “healthy” when asked to initiate ART, preference for short-course prophylaxis and fear of side effects (body changes). Also, the preference for nurses to determine on an individual basis the number of counseling appointments a woman needs before initiating ART, more information about HIV and ART needed at the community level, and the need to educate men about HIV and ART.ConclusionWomen face a myriad of challenges initiating lifelong ART. Understanding women’s concerns will aid in developing effective counseling messages, designing appropriate counseling structures, understanding where additional support is needed ...

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Lessons Learned From Early Implementation of Option B+

Cited by 82 publications

References 5 publications

A risk score to identify HIV-infected women most likely to become lost to follow-up in the postpartum period

A risk score to identify HIV-infected women most likely to become lost to follow-up in the postpartum period

Implementation and Operational Research: Impact of a Systems Engineering Intervention on PMTCT Service Delivery in Côte d'Ivoire, Kenya, Mozambique: A Cluster Randomized Trial

Lessons learned from the PMTCT program in Swaziland: challenges with accepting lifelong ART for pregnant and lactating women – a qualitative study

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