PMTCT care cascade and factors associated with attrition in the first four years after Option B+ implementation in Mozambique

Abstract

objective To evaluate the effectiveness of the prevention of mother-to-child transmission (PMTCT) Option B+ programme in two provinces with high human immunodeficiency virus (HIV) burden in Mozambique over the first four years of programme implementation.methods We assessed the PMTCT cascade in antenatal care (ANC) from July 2013 to December 2017 using facility-level data and performed a retrospective cohort analysis with patient-level data. We compared the 12-month antiretroviral therapy (ART) retention rates between women with HIV infection who initiated ART under Option B+ ('B+ pregnant') and those who initiated ART for their own health ('own health').results A total of 916 280 pregnant women enrolled in ANC. The proportion of women with a documented HIV status increased from 93% in 2013 to 96% in 2017. The proportion of those tested HIV-positive decreased from 8% to 6% while that of those HIV-positive on ART increased from 42% to 95%. Of the 44 377 HIV-positive women included in the analysis, 35% were lost to care. 'B+ pregnant' women initiating ART in 2015 were less likely to have no follow-up (NFU) compared with 'own health' women starting ART during the same period (adjusted odds ratio: 0.77, 95% confidence interval [CI]: 0.64-0.94, P = 0.01). There was no statistical difference between the two groups during the other years in which ART was initiated. Of those returning for care after their first visit (N = 39 801), the 'B+ pregnant' women showed a higher risk of non-retention than the other group (adjusted hazard ratio: 1.14, 95% CI: 1.03-1.25) when ART was initiated in 2013. The risk decreased during the subsequent years, with no difference observed between the groups.conclusion PMTCT Option B+ programme scale-up has yielded positive results, including the maintenance of high HIV testing and ART initiation rates in ANC. Challenges still remain, however, in improving immediate engagement in care and long-term retention. Seeking alternative service delivery models to support existing health systems and prevent defaulters is required to achieve the UNAIDS 95-95-95 targets for PMTCT in Mozambique.

Supporting the implementation of guidelines to prevent mother-to-child-transmission of HIV in Malawi: a multi-case study

“…Study findings on implementation of Option B+ guidelines are similar to previous studies confirming progress on HIV testing and lifelong ART for HIV-infected pregnant and breastfeeding women and persistent gaps in HIV testing for exposed infants 1,8,[21][22][23] . One factor that may contribute to this gap is the finding that HIV+ women are more likely to be lost to follow up when they were started on ART in compliance with Option B+ guidelines (i.e, they are pregnant) as compared to those who are started on ART in response to physical symptoms 22 .…”

“…Study findings on implementation of Option B+ guidelines are similar to previous studies confirming progress on HIV testing and lifelong ART for HIV-infected pregnant and breastfeeding women and persistent gaps in HIV testing for exposed infants 1 , 8 , 21 – 23 . One factor that may contribute to this gap is the finding that HIV+ women are more likely to be lost to follow up when they were started on ART in compliance with Option B+ guidelines (i.e, they are pregnant) as compared to those who are started on ART in response to physical symptoms 22 . Additional factors that may contribute to this gap include health workers' negative attitudes towards HIV positive women, lack of capacity to collect blood samples from exposed babies, poor follow up of babies born at home, and structural barriers such as poverty, lack of transportation, work conflicts, and fear of disclosure and HIV related stigma 22 , 23 .…”

Measuring retention in care for HIV-positive pregnant women in Prevention of Mother-to-Child Transmission of HIV (PMTCT) option B+ programs: the Mozambique experience

“…HIV-positive women are followed-up in MCH services until the final HIV status of the exposed infant is determined [18]. More detailed descriptions of the PMTCT program settings and data sources are described elsewhere [19].…”

Measuring retention in care for HIV-positive pregnant women in Prevention of Mother-to-Child Transmission of HIV (PMTCT) option B+ programs: the Mozambique experience

“…HIV-positive women are followed-up in MCH services until the final HIV status of the exposed infant is determined (19). More detailed descriptions of the PMTCT program settings and data sources are described elsewhere (20).…”