Uptake of prevention of mother-to-child-transmission using Option B+ in northern rural Malawi: a retrospective cohort study

Abstract

To identify points of dropout on the pathway from offering HIV testing to maintenance on antiretroviral therapy (ART), following the introduction of the Option B+ policy for pregnant women in Malawi (lifelong ART for HIV-positive mothers and 6 weeks nevirapine for the infants), a retrospective cohort study within a demographic surveillance system in northern Malawi. Women living in the demographic surveillance system who initiated antenatal care (ANC) between July 2011 (date of policy change) and January 2013, were eligible for inclusion. Women who consented were interviewed at home about their health facility attendance and care since pregnancy, including antenatal clinic (ANC) visits, delivery and postpartum care. Women's reports, patient-held health records and clinic health records were manually linked to ascertain service use. Among 395 women, 86% had tested for HIV before the pregnancy, 90% tested or re-tested at the ANC visit, and <1% had never tested. Among 53 mothers known to be HIV-positive before attending ANC, 15 (28%) were already on ART prior to pregnancy. Ten women tested HIV-positive for the first time during pregnancy. Of the 47 HIV-positive mothers not already on ART, 26/47 (55%) started treatment during pregnancy. All but five women who started ART were still on treatment at the time of study interview. HIV testing was almost universal and most women who initiated ART were retained in care. However, nearly half of eligible pregnant women not on ART at the start of ANC had not taken up the invitation to initiate (lifelong) ART by the time of delivery, leaving their infants potentially HIV-exposed.

HIV-Infected Ugandan Women on Antiretroviral Therapy Maintain HIV-1 RNA Suppression Across Periconception, Pregnancy, and Postpartum Periods

“…Modeling data suggest the cost-effectiveness of the Option B+ strategy, but the benefits are lost if the risk of HIV-1 RNA failure increases by even 2.4% [26]. Early data from Malawi (the first country to adopt option B+) do not report on adherence or viral suppression, but about half of women eligible for ART did not initiate treatment [27] and 27% of women who initiated therapy were lost to follow-up at one year [9]. Roll-out of Option B+ is happening very quickly and is planned or considered for many sub-Saharan African countries[28].…”

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

“…Existing early literature has shown that barriers to successful implementation throughout the cascade of Option B+ services may affect the uptake and adherence to ART by pregnant women, the follow-up of HIV-exposed infants and the long-term retention of this patient population [3,4]. Considerable variation in retention on ART of Option B+ women exists between health facilities [4].…”

“…Considerable variation in retention on ART of Option B+ women exists between health facilities [4]. Urgent research priorities at the national level with the Malawi Ministry of Health (MOH) have been identified that include evaluation of barriers and facilitators to uptake of lifelong ART and long-term retention by largely asymptomatic and newly diagnosed HIV-positive women seeking antenatal care (ANC) [5].…”

Highlights from this issue

“…Having skated over the surface of these papers, I will draw your attention to an equally fascinating range of articles on topics ranging from prevention of mother to child transmission of HIV,11 Human papillomavirus vaccination in women attending English sexual health clinics,12 partnership factors affecting the use of condoms in heterosexuals;13 the sexual health of female sex workers,14 estimation of sexual mixing15 and HPV viral load and persistence in HIV positive men 16…”