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.

Adrienne K Chan,Emmanuel Kanike,Anthony D Harries,Richard Bedell,Ruth Manyera,Joep J Oosterhout,Isabel Mayuni,Monique Lettow,William Mlotha

doi:10.7448/ias.19.1.20672

Abstract

IntroductionData from the Option B+ prevention of mother-to-child transmission (PMTCT) program in Malawi show considerable variation between health facilities in retention on antiretroviral therapy (ART). In a programmatic setting, we studied whether the “model of care,” based on the degree of integration of antenatal care (ANC), HIV testing and counselling (HTC) and ART service provision–influenced uptake of and retention on ART.MethodsWe conducted a retrospective cohort study of pregnant women seeking ANC at rural primary health facilities in Zomba District, Malawi. Data were extracted from standardized national ANC registers, ART registers and ART master cards. The “model of care” of Option B+ service delivery was determined at each health facility, based on the degree of integration of ANC, HTC and ART. Full integration (Model 1) of HTC and ART initiation at ANC was compared with integration of HTC only into ANC services (Model 2) with subsequent referral to an existing ART clinic for treatment initiation.Results and discussionA total of 10,528 women were newly registered at ANC between October 2011 and March 2012 in 23 rural health facilities (12 were Model 1 and 11 Model 2). HIV status was ascertained in 8,572 (81%) women. Among 914/8,572 (9%) HIV-positive women enrolling at ANC, 101/914 (11%) were already on ART; of those not on treatment, 456/813 (56%) were started on ART. There was significantly higher ART uptake in Model 1 compared with Model 2 sites (63% vs. 51%; p=0.001), but significantly lower ART retention in Model 1 compared with Model 2 sites (79% vs. 87%; p=0.02). Multivariable analysis showed that initiation of ART on the same day as HIV diagnosis, but not model of care, was independently associated with reduced retention in the first six months (adjusted odds ratio 2.27; 95% CI: 1.34–3.85; p=0.002).ConclusionsHIV diagnosis and treatment on the same day was associated with reduced retention on ART, independent of the level of PMTCT service integration at ANC.

Highlights

Data from the Option B' prevention of mother-to-child transmission (PMTCT) program in Malawi show considerable variation between health facilities in retention on antiretroviral therapy (ART)
In individual patient-level data analysis of the women who were found to be HIV positive and eligible for ART, there was a significantly higher rate of ART uptake in Model 1 compared with Model 2 sites (63% vs. 51%; p 0.001)
Facility-level data Total no. of women registered at antenatal care (ANC) New ANC registrations/month/site, median (IQR) Total HIV testing done (% of women registered at ANC) Total previous HIV positives Total new HIV positives All HIV-positive women (% of women registered at ANC) HIV positives already on ART (% of previous HIV positive) 2

Summary

Introduction

Data from the Option B' prevention of mother-to-child transmission (PMTCT) program in Malawi show considerable variation between health facilities in retention on antiretroviral therapy (ART). We studied whether the ‘‘model of care,’’ based on the degree of integration of antenatal care (ANC), HIV testing and counselling (HTC) and ART service provisionÁinfluenced uptake of and retention on ART. The ‘‘model of care’’ of Option B' service delivery was determined at each health facility, based on the degree of integration of ANC, HTC and ART. Conclusions: HIV diagnosis and treatment on the same day was associated with reduced retention on ART, independent of the level of PMTCT service integration at ANC. 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]. 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

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