Supporting Option B+ scale up and strengthening the prevention of mother-to-child transmission cascade in central Malawi: results from a serial cross-sectional study

Abstract

BackgroundWe established Safeguard the Family (STF) to support Ministry of Health (MoH) scale-up of universal antiretroviral therapy (ART) for HIV-infected pregnant and breastfeeding women (Option B+) and to strengthen the prevention of mother-to-child transmission (PMTCT) cascade from HIV testing and counseling (HTC) through maternal ART provision and post-delivery early infant HIV diagnosis (EID). To these ends, we implemented the following interventions in 5 districts: 1) health worker training and mentorship; 2) couples’ HTC and male partner involvement; 3) women’s psychosocial support groups; and 4) health and laboratory system strengthening for EID.MethodsWe conducted a serial cross-sectional study using facility-level quarterly (Q) program data and individual-level infant HIV-1 DNA PCR data to evaluate STF performance on PMTCT indicators for project years (Y) 1 (April—December 2011) through 3 (January—December 2013), and compared these results to national averages.ResultsFacility-level uptake of HTC, ART, infant nevirapine prophylaxis, and infant DNA PCR testing increased significantly from quarterly baselines of 66 % (n/N = 32,433/48,804), 23 % (n/N = 442/1,958), 1 % (n/N = 10/1,958), and 52 % (n/N = 1,385/2,644) to 87 % (n/N = 39,458/45,324), 96 % (n/N = 2,046/2,121), 100 % (n/N = 2,121/2,121), and 62 % (n/N = 1,462/2,340), respectively, by project end (all p < 0.001). Quarterly HTC, ART, and infant nevirapine prophylaxis uptake outperformed national averages over years 2–3. While transitioning EID laboratory services to MoH, STF provided first-time HIV-1 DNA PCR testing for 2,226 of 11,261 HIV-exposed infants (20 %) tested in the MoH EID program in STF districts from program inception (Y2) through Y3. Of these, 78 (3.5 %) tested HIV-positive. Among infants with complete documentation (n = 608), median age at first testing decreased from 112 days (interquartile range, IQR: 57–198) in Y2 to 76 days (IQR: 46–152) in Y3 (p < 0.001). During Y3 (only year with national data for comparison), non-significantly fewer exposed infants tested HIV-positive (3.6 %) at first testing in STF districts than nationally (4.1 %) (p = 0.4).ConclusionsSTF interventions, integrated within the MoH Option B+ program, achieved favorable HTC, maternal ART, infant prophylaxis, and EID services uptake, and a low proportion of infants found HIV-infected at first DNA PCR testing. Continued investments are needed to strengthen the PMTCT cascade, particularly around EID.

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

“…Testing coverage levels at baseline were similar to comparable data from the most recent national reports 9–11 and post-B+ facilities in Malawi, 42 which verified the study methodology and representativeness of the study facilities. Comparable ARV coverage estimates were not available, as Mozambique’s and Côte d’Ivoire’s most recent national reports were published before Option B+ implementation.…”

Level of Quality of Option B+PMTCT Service Provision in Public Health Facilities in Mekelle Zone, Northern Ethiopia: Cross-sectional study

“…This finding was comparable with evidence from Northern and South West Ethiopia [13,16]. But lower when compared with evidence from Malawi [28]. Variation of the finding in the later study might be due to their good experience in implementing the service since it was an area in which Option B + PMTCT first piloted internationally [29].…”

Safety and efficacy of Option B+ ART in Malawi: few severe maternal toxicity events or infant HIV infections among pregnant women initiating tenofovir/lamivudine/efavirenz

“…Overall, infant outcomes were reassuring with regards to maternal‐to‐child transmission (MTCT) of HIV. MTCT occurred in only 2% of women enrolled in this cohort, comparable to MTCT among participants managed on this same regimen in other studies , and lower than the overall MTCT rate of >4% in Malawi . Most MTCT events in our cohort occurred in mother‐infant pairs where the mother had an unsuppressed viral load.…”