"I do all I can but I still fail them": Health system barriers to providing Option B+ to pregnant and lactating women in Malawi.

Nozgechi Phiri,Malango T Msukwa,Kali Tal,Olivia Keiser,Claire Somerville,Philip Anglewicz

doi:10.1371/journal.pone.0222138

Abstract

Malawi’s Option B+ program is based on a ‘test and treat’ strategy that places all HIV-positive pregnant and lactating women on lifelong antiretroviral therapy. The steep increase in patient load placed severe pressure on a health system that has struggled for decades with inadequate supply of health care workers (HCWs) and poor infrastructure. We set out to explore health system barriers to Option B+ by asking HCWs in Malawi about their experiences treating pregnant and lactating women. We observed and conducted semi-structured interviews (SSIs) with 34 HCWs including nine expert clients (ECs) at 14 health facilities across Malawi, then coded and analyzed the data. We found that HCWs implementing Option B+ are so overburdened in Malawi that it reduces their ability to provide quality care to patients, who receive less counseling than they should, wait longer than is reasonable, and have very little privacy. Interventions that increase the number of HCWs and upgrade infrastructure to protect the privacy of HIV-infected pregnant and lactating women and their husbands could increase retention, but facilities will need to be improved to support men who accompany their partners on clinic visits.

Highlights

Malawi’s Option B+ program is a ‘test and treat’ strategy that targets pregnant and lactating women
Most of the health care workers (HCWs) (27/35) we interviewed thought understaffing in the clinics was the main challenge they faced while serving women on or about to start Option B+
[6] This confirms our finding that health facilities are understaffed posing a serious challenge to proper implementation of Option B+, a finding consistent with other studies. [5,14,23,30] For example, Tenthani et al found that overburdening HCWs may contribute to high LTFU of women in health facilities with heavy patient load

Summary

Introduction

Malawi’s Option B+ program is a ‘test and treat’ strategy that targets pregnant and lactating women. Starting in 2011, women who present for antenatal care (ANC) are tested and, if found HIV-positive, begin lifelong antiretroviral therapy (ART) without the need for CD4 count or clinical staging. Malawi adopted Option B+ to simplify ART initiation for HIV infected pregnant and lactating women considering the limited CD4 count capabilities in the health facilities. The aim of Option B+ was to reduce new HIV infections in children and promote good maternal health. [1,2] Option B+ was integrated into existing maternal, newborn and child health services [3,4], including antenatal and postpartum care, family planning, treatment of sexually transmitted infections, and cervical cancer screening. Option B+ had more than doubled the number of HIV-positive pregnant and lactating

Methods

Discussion

Conclusion