Abstract
Although several studies have documented challenges related to inadequate adherence to antiretroviral therapy (ART) and high loss to follow-up (LTFU) among Option B+ women, there is limited understanding of why these challenges occur and how to address them. This qualitative study examines women’s experiences with ART adherence and retention in care. Between July and October 2015, in-depth interviews were conducted with 39 pregnant and lactating women who initiated ART at Bwaila Hospital in Lilongwe, Malawi. Study participants included 14 in care and 25 out of care women, according to facility records. Data were analyzed using an inductive, open-coding approach to thematic analysis. Ten of the respondents (7 out of care, 3 in-care) had stopped and re-started treatment before the interview date. One of the most important factors influencing adherence and retention was the strength of women’s support systems. In contrast to women in-care, most out-of-care women lacked emotional and financial support from male partners, received minimal counseling from providers at initiation, lacked designated guardians to assist with medication refills or clinic appointments, and were highly mobile. Mobility led to difficulties in accessing treatment in new settings. The most common reasons women re-started treatment following interruptions were due to providers’ counseling and encouragement and the mother’s desire to be healthy. Improved counseling at initiation, active follow-up counseling, women’s economic empowerment interventions, promotion of peer counseling schemes and meaningful engagement of male partners can help in addressing the identified barriers and promoting sustained retention of Option B+ women.
Highlights
In 2011, Malawi introduced the Option B+ strategy for prevention of mother-to-child transmission (PMTCT), becoming the first country to offer lifelong antiretroviral therapy (ART) for all HIV-infected pregnant and lactating women regardless of their CD4 cell count or clinical stage
Recent findings have highlighted the challenges of Option B+ in regards to early loss to follow-up (LTFU)
An observational multi-facility cohort study in Malawi had comparable findings of high LTFU (22%) in the first year of implementing Option B+ [5] while a study from one facility in Malawi further clarified that 47% of LTFU women only collected their drugs at the time of initiation but never returned to the same clinic to refill their drugs [6]
Summary
In 2011, Malawi introduced the Option B+ strategy for prevention of mother-to-child transmission (PMTCT), becoming the first country to offer lifelong antiretroviral therapy (ART) for all HIV-infected pregnant and lactating women regardless of their CD4 cell count or clinical stage. An observational multi-facility cohort study in Malawi had comparable findings of high LTFU (22%) in the first year of implementing Option B+ [5] while a study from one facility in Malawi further clarified that 47% of LTFU women only collected their drugs at the time of initiation but never returned to the same clinic to refill their drugs [6]. Some of the factors associated with LTFU under Option B+ included younger age at initiation, [5,6,9] being pregnant (compared to lactating) [6], starting ART on the same day of diagnosis [4,7,9], lack of disclosure [7], missing CD4 cell counts at ART initiation [9], having less than a secondary education [7], and receiving care at high volume facilities [4,5, 9]
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