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+).

Monique Van Lettow,Anthony D Harries,Gabriel Mateyu,Stephen Chu,Andrew Mganga,Isabell Mayuni,Joep J Van Oosterhout,Richard Bedell,Adrienne K Chan,Teferi Beyene,Megan Landes,Vanessa Van Schoor

doi:10.7448/ias.17.1.18994

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.

Highlights

Malawi introduced a new strategy to improve the effectiveness of prevention of mother-to-child HIV transmission (PMTCT), the Option B' strategy
Not included were Zomba Central Hospital, one of the four central referral hospitals in the country, 10 facilities that had only recently started providing PMTCT Option B' services, and one health centre that was overlooked by the study team
Medical assistants Nurses/midwives Clinical officers Medical doctors HIV testing and counselling (HTC) counsellors antiretroviral therapy (ART) initiation counsellors Expert patients ART clerks Total number of staff Average number of women newly registered for antenatal care (ANC) per quartera Average number of women newly tested positive at ANC per quartera Number of women registered as having started ART (Option B') between JanÁJun 2012b Number of women registered as having started ART (Option B') between JulÁDec 2012b

Summary

Introduction

Malawi introduced a new strategy to improve the effectiveness of prevention of mother-to-child HIV transmission (PMTCT), the Option B' strategy. In 2011, Malawi introduced a new strategy to improve the effectiveness of its prevention of mother-to-child HIV transmission (PMTCT) program by providing a standardized combination antiretroviral therapy (ART) regimen to all HIV-positive pregnant and breastfeeding women, irrespective of their CD4 count or clinical stage of HIV infection, and that ART be continued lifelong This was an extension of an existing WHO recommendation for PMTCT (Option B) and Malawi’s strategy was dubbed Option B'. Upon initiation of the new strategy, practical issues about how to organize HIV care and ART provision for women in antenatal care (ANC) arose across the spectrum of often poorly staffed health facilities in Malawi Despite these challenges, initial reports demonstrated that the Option B' strategy has resulted in large increases in the number of pregnant women accessing PMTCT [4].

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