Towards elimination of mother‐to‐child transmission of HIV: performance of different models of care for initiating lifelong antiretroviral therapy for pregnant women in Malawi (Option B+)

Abstract

IntroductionMalawi introduced a new strategy to improve the effectiveness of prevention of mother-to-child HIV transmission (PMTCT), the Option B+ strategy. We aimed to (i) describe how Option B+ is provided in health facilities in the South East Zone in Malawi, identifying the diverse approaches to service organization (the “model of care”) and (ii) explore associations between the “model of care” and health facility–level uptake and retention rates for pregnant women identified as HIV-positive at antenatal (ANC) clinics.MethodsA health facility survey was conducted in all facilities providing PMTCT/antiretroviral therapy (ART) services in six of Malawi's 28 districts to describe and compare Option B+ service delivery models. Associations of identified models with program performance were explored using facility cohort reports.ResultsAmong 141 health facilities, four “models of care” were identified: A) facilities where newly identified HIV-positive women are initiated and followed on ART at the ANC clinic until delivery; B) facilities where newly identified HIV-positive women receive only the first dose of ART at the ANC clinic, and are referred to the ART clinic for follow-up; C) facilities where newly identified HIV-positive women are referred from ANC to the ART clinic for initiation and follow-up of ART; and D) facilities serving as ART referral sites (not providing ANC). The proportion of women tested for HIV during ANC was highest in facilities applying Model A and lowest in facilities applying Model B. The highest retention rates were reported in Model C and D facilities and lowest in Model B facilities. In multivariable analyses, health facility factors independently associated with uptake of HIV testing and counselling (HTC) in ANC were number of women per HTC counsellor, HIV test kit availability, and the “model of care” applied; factors independently associated with ART retention were district location, patient volume and the “model of care” applied.ConclusionsA large variety exists in the way health facilities have integrated PMTCT Option B+ care into routine service delivery. This study showed that the “model of care” chosen is associated with uptake of HIV testing in ANC and retention in care on ART. Further patient-level research is needed to guide policy recommendations.

Same day HIV diagnosis and antiretroviral therapy initiation affects retention in Option B+ prevention of mother‐to‐child transmission services at antenatal care in Zomba District, Malawi

“…However, the model of integration in high prevalence, low resource contexts may also have an impact on downstream retention. Our current analysis confirms the finding from an earlier health facility-level analysis in an operational setting, where we observed that model of care had impact on retention in care [6], with worse program indicators in facilities in which women receive the first dose of ART at the ANC clinic and are then transferred to the ART clinic for ART follow-up.…”

“…Health facilities therefore made decisions about the organization of PMTCT care on the basis of factors related to their specific circumstances. A previous study describing and comparing Option B+ service delivery models in six of Malawi's twenty-eight districts using facility-level MOH cohort reports demonstrated large variability in how services had been integrated and observed associations between the organization of service delivery and both uptake of HIV testing and retention in care on ART [6]. …”

A systematic review of interventions to improve postpartum retention of women in PMTCT and ART care

“…Regarding integration of ANC and ART care, van Lettow et al . found that facilities, which require a referral between ANC and ART for all doses of ART had a higher rate of retention of women at 12 months after ART initiation than facilities where either the first or all doses of ART were provided in the ANC facility [23] (Table 8). Similarly, Weigel et al .…”

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

“…In sub-Saharan Africa, despite high antenatal care (ANC) utilization, 1 bottlenecks occur at each step of the PMTCT cascade, from HIV testing of pregnant women, to uptake of antiretrovirals (ARVs) or combination antiretroviral therapy (cART), to screening HIV-exposed infants (HEI) with HIV polymerase chain reaction (PCR) testing, to adoption and maintenance of appropriate infant feeding. 2–4 Facility-level barriers include human resources shortages, 5 lack of service integration, 3,5,6 lack of ongoing mentoring, 7 and poor patient-provider interactions. 5 Though vertical transmission rates of <1% have been achieved in high-income countries, 8 actual rates in sub-Saharan Africa are estimated to be several times higher.…”