Retention in care during the first 3 years of antiretroviral therapy for women in Malawi's option B+ programme: an observational cohort study

Abstract

Background Studies of Malawi’s Option B+ programme for HIV-positive pregnant and breastfeeding women have reported high loss to follow-up during pregnancy and at the start of antiretroviral therapy (ART), but few data exist about retention during breastfeeding and after weaning. We examined loss to follow-up and retention in care in patients in the Option B+ programme during their first 3 years on ART. Methods We analysed two data sources: aggregated facility-level data about patients in Option B+ who started ART between Oct 1, 2011, and June 30, 2012, at 546 health facilities; and patient-level data from 20 large facilities with electronic medical record system for HIV-positive women who started ART between Sept 1, 2011, and Dec 31, 2013, under Option B+ or because they had WHO clinical stages 3 or 4 disease or had CD4 counts of less than 350 cells per μL. We used facility-level data to calculate representative estimates of retention and loss to follow-up. We used patient- level data to study temporal trends in retention, timing of loss to follow-up, and predictors of no follow-up and loss to follow-up. We defined patients who were more than 60 days late for their first follow-up visit as having no follow-up and patients who were more than 60 days late for a subsequent visit as being lost to follow-up. We calculated proportions and cumulative probabilities of patients who had died, stopped ART, had no follow-up, were lost to follow-up, or were retained alive on ART for 36 months. We calculated odds ratios and hazard ratios to examine predictors of no follow-up and loss to follow-up. Findings Analysis of facility-level data about patients in Option B+ who had not transferred to a different facility showed retention in care to be 76·8% (20 475 of 26 658 patients) after 12 months, 70·8% (18 306 of 25 849 patients) after 24 months, and 69·7% (17 787 of 25 535 patients) after 36 months. Patient-level data included 29 145 patients. 14 630 (50·2%) began treatment under Option B+. Patients in Option B+ had a higher risk of having no follow-up and, for the first 2 years of ART, higher risk of loss to follow-up than did patients who started ART because they had CD4 counts less than 350 cells per μL or WHO clinical stage 3 or 4 disease. Risk of loss to follow-up during the third year was low and similar for patients retained for 2 years. Retention rates did not change as the Option B+ programme matured. Interpretation Our data suggest that pregnant and breastfeeding women who start ART immediately after they are diagnosed with HIV can be retained on ART through the Option B+ programme, even after many have stopped breastfeeding. Interventions might be needed to improve retention in the first year on ART in Option B+. Funding Bill & Melinda Gates Foundation, Partnerships for Enhanced Engagement in Research Health, and National Institute of Allergy and Infectious Diseases.

Loss to Follow-Up among HIV Positive Pregnant and Lactating Mothers on Lifelong Antiretroviral Therapy for PMTCT in Rural Uganda

“…A study done in Malawi revealed the LTFU as 30% after 3 years of initiation on lifelong ART [11]. This is an indication that there is significant LTFU of mothers initiated on lifelong ART for PMTCT.…”

HIV transmission and retention in care among HIV‐exposed children enrolled in Malawi's prevention of mother‐to‐child transmission programme

“…The recent nation-wide evaluation of Malawi’s PMTCT Programme has shown that Option B+ effectively prevents antepartum and intrapartum transmission [14]; however, the Option B+ policy may prevent postpartum transmission less effectively, because many postpartum women adhere poorly to ART, or discontinue therapy before weaning of breastfeeding [8,9]. Two studies from Malawi have described the risk of postpartum HIV transmission among HIV-exposed children who were retained in care and tested for HIV [25,26].…”

“…While Option B+ successfully prevents antepartum and intrapartum mother-to-child transmission, the policy may prevent postpartum transmission less effectively, because many postpartum women adhere poorly to ART, or discontinue therapy before weaning of breastfeeding [8,9]. Children at higher risk of HIV transmission (i.e.…”

Viral Suppression and Retention in Care up to 5 Years After Initiation of Lifelong ART During Pregnancy (Option B+) in Rural Uganda

“…In Malawi, which pioneered Option B+ in 2011, 4 only two-thirds of women starting ART during pregnancy are retained in care at 3 years, 5 and loss to follow-up among women initiated on Option B+ is higher than among women initiating ART for other clinical indications, such as low CD4 cell count or advanced WHO stage. 5, 6 To date, little is known outside of Malawi about longer-term retention in care several years after the cessation of breastfeeding. Moreover, despite the critical importance of viral suppression for successful treatment, data also remain limited on virologic outcomes among women initiated on Option B+, particularly in rural sites and beyond one year postpartum.…”