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

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

doi:10.7448/ias.19.1.20672

Cited by 71 publications

(86 citation statements)

References 12 publications

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“…The lower retention on ART that we observed among pregnant and breastfeeding women aligns with results of previous studies of Option B+ women in Malawi [24] showing that they were at a higher risk of being lost to follow-up, especially early in the course of ART [24]. Long travel distance to the clinic, lack of transport money, developing side effects, inability to reach the clinic due to severe illness and non-comprehension of ART education [30], ART initiation on the day of HIV testing [31], models of HIV care at the health facility [32] and non-disclosure of HIV status between spouses [33] were identified as barriers for pregnant and breastfeeding mothers to remain engaged in HIV care. Eligibility criteria for ART and HIV management guidelines were the same for pregnant and breastfeeding women before and after UTT implementation in Malawi.…”

Section: Discussionsupporting

confidence: 89%

Retention on antiretroviral therapy during Universal Test and Treat implementation in Zomba district, Malawi: a retrospective cohort study

et al. 2019

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IntroductionSince June 2016, the national HIV programme in Malawi has adopted Universal Test and Treat (UTT) guidelines requiring that all persons who test HIV positive will be referred to start antiretroviral therapy (ART). Although there is strong evidence from clinical trials that early initiation of ART leads to reduced morbidity and mortality, the impact of UTT on retention on ART in real‐life programmatic settings in Africa is not yet known.MethodsWe conducted a retrospective cohort study in Zomba district, Malawi to compare ART outcomes of patients who initiated ART under 2016 UTT guidelines and those who started ART prior to rollout of UTT (pre‐UTT). We analysed data from 32 rural and urban health facilities of various sizes. Cox proportional hazards modelling was used to determine the independent risk factors of attrition from ART at 12 months. All analyses were adjusted for clustering by health facility using a robust standard errors approach.ResultsAmong 1492 patients (mean age 34.4 years, 933 (63%) female) who initiated ART during the study period, 501 were enrolled in the pre‐UTT cohort and 911 during UTT. At 12 months, retention on ART in the UTT cohort was higher than in the pre‐UTT cohort 83.0% (95% confidence interval (CI): 81.0% to 85.0%) versus 76.2% (95% CI 73.9% to 78.5%). Adolescents, aged 10 to 19 years (adjusted hazard ratio (aHR) 1.53; 95% CI 1.01 to 2.32), and women who were pregnant or breastfeeding at ART initiation (aHR 1.87; 95% CI 1.30 to 2.38) were at higher risk of attrition in the combined pre‐UTT and UTT cohort.ConclusionsRetention on ART was nearly 6% higher after UTT introduction. Young adults and women who were pregnant or breastfeeding at the start of ART were at increased risk of attrition, emphasizing the need for targeted interventions for these groups to achieve the 90‐90‐90 UNAIDS targets in the UTT era.

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Section: Discussionsupporting

confidence: 89%

Retention on antiretroviral therapy during Universal Test and Treat implementation in Zomba district, Malawi: a retrospective cohort study

et al. 2019

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“…Given that other observational studies have reported higher risk of attrition in same-day initiates [31, 34], we included this factor in the analysis as a possible predictor of attrition. Although no association was discovered, we still suggest that caution should be taken with same-day ART initiation as a public health approach and patient readiness should be taken into account [35].…”

Section: Discussionmentioning

confidence: 99%

Challenges and successes in the implementation of option B+ to prevent mother-to-child transmission of HIV in southern Swaziland

et al. 2018

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BackgroundUniversal antiretroviral therapy (ART) for all pregnant/ breastfeeding women living with Human Immunodeficiency Virus (HIV), known as Prevention of mother-to child transmission of HIV (PMTCT) Option B+ (PMTCTB+), is being scaled up in most countries in Sub-Saharan Africa. In the transition to PMTCTB+, many countries face challenges with proper implementation of the HIV care cascade. We aimed to describe the feasibility of a PMTCTB+ approach in the public health sector in Swaziland.MethodsLifelong ART was offered to a cohort of HIV+ pregnant women aged ≥16 years at the first antenatal care (ANC1) visit in 9 public sector facilities, between 01/2013 and 06/2014. The study enrolment period was divided into 3 phases (early: 01–06/2013, mid: 07–12/2013 and late: 01–06/2014) to account for temporal trends. Kaplan-Meier estimates and Cox proportional-hazards regression models were applied for ART initiation and attrition analyses.ResultsOf 665 HIV+ pregnant women, 496 (74.6%) initiated ART. ART initiation increased in later study enrolment phases (mid: aHR: 1.41; later: aHR: 2.36), and decreased at CD4 ≥ 500 (aHR: 0.69). 52.9% were retained in care at 24 months. Attrition was associated with ANC1 in the third trimester (aHR: 2.37), attending a secondary care facility (aHR: 1.98) and ART initiation during later enrolment phases (mid aHR: 1.48; late aHR: 1.67). Of 373 women eligible, 67.3% received a first VL. 223/251 (88.8%) were virologically suppressed (< 1000 copies/mL). Of 670 infants, 53.6% received an EID test, 320/359 had a test result recorded and of whom 7 (2.2%) were HIV+.ConclusionsPMTCTB+ was found to be feasible in this setting, with high rates of maternal viral suppression and low transmission to the infant. High treatment attrition, poor follow-up of mother-baby pairs and under-utilisation of VL and EID testing are important programmatic challenges.

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“…More than 12% of the women had no education, 63% were unemployed and 56% were in a couple or married. The median gestational age at ART initiation for the 'B+ pregnant' women was 25 weeks (IQR: [19][20][21][22][23][24][25][26][27][28][29]. The median follow-up time under ART was 13 months (IQR: .…”

Section: Attrition Risk At 12 Months After Art Initiationmentioning

confidence: 99%

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

Ahoua

Tiendrebeogo

Arikawa

et al. 2019

Tropical Med Int Health

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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.

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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

Cited by 71 publications

References 12 publications

Retention on antiretroviral therapy during Universal Test and Treat implementation in Zomba district, Malawi: a retrospective cohort study

Retention on antiretroviral therapy during Universal Test and Treat implementation in Zomba district, Malawi: a retrospective cohort study

Challenges and successes in the implementation of option B+ to prevent mother-to-child transmission of HIV in southern Swaziland

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

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