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AIDS 2014: Mothers Starting Option B+ ART in Malawi Often Lost from Care

Although Malawi’s policy of offering lifelong antiretroviral therapy (ART) to women with HIV who are pregnant or breastfeeding resulted in a 7-fold increase in women receiving treatment in 15 months, implementers are concerned by high rates of loss to follow-up, researchers reported at the 20th International AIDS Conference in Melbourne.

[Produced in collaboration with Aidsmap]

The lifelong offer of treatment regardless of CD4 cell count, known as "Option B+," was pioneered by Malawi’s Ministry of Health in order to simplify the implementation of ART for prevention of vertical transmission from mother to child.

Evaluation of retention at Malawi’s largest antenatal clinic found that 24% of mothers who initiated ART at the clinic were lost to follow-up after 1 year. Rates of loss to follow-up were higher for mothers aged 24 and under and those who initiated ART while breastfeeding or during the first year of the program, Hannock Tweya of the Lighthouse Trust told delegates. In comparison, 9% of adults who started HIV treatment on general health grounds were lost to follow-up during the same period.

Between September 2011 and September 2013, a total of 2930 women started ART, of whom 84% (2458) were pregnant and 14% (410) were breastfeeding. Median age at ART initiation was 26 years.

Of the 20% of women (577) who missed a scheduled clinic appointment, 47% (272) collected ART only at initiation and never returned.

Of those women lost to follow-up and subsequently traced, half had stopped ART and one-third had transferred to another clinic, suggesting that while loss to follow-up is higher among women who initiate treatment under the Option B+ guidance, retention may be underestimated.

Among the 40% of women (228) successfully traced, over half of those who stopped taking ART gave travel and lack of transportation as reasons for stopping treatment. Not understanding the information in the initial ART education session that medication was to be taken for life accounted for a further 10% of discontinuations, as did suspected side effects (10%). Another 10% were too weak or sick to attend the clinic again.

The sizeable proportion of women not able to be traced is likely due to them deliberately giving a false physical address because of fear of stigma and discrimination if their HIV status is inadvertently disclosed, Tweya suggested.

Tweya told delegates that these findings indicate a need for improved post-test counseling in antenatal care and ART clinics, the establishment of targeted programs and youth-friendly clinics for younger women, and further decentralization of services working to prevent vertical transmission.

Joep van Oosterhout, presenting on behalf of Dignitas International, the International Union Against Tuberculosis and Lung Disease, and the Malawi Ministry of Health, reported on which health system factors support or hinder uptake and retention among women starting Option B+ in Malawi.  

The study evaluated the relationship between health facility characteristics and retention in 141 facilities in the southeast health district. Health facility surveys and health facility cohort reports using routinely collected data were undertaken to determine uptake of testing in antenatal care, ART initiation, and 6-month retention.

The 141 health facilities comprised 4 district hospitals, 8 community hospitals, 120 health centers, and 9 private clinics.

Findings from this cross-sectional analysis showed that health facilities had integrated Option B+ into routine service delivery in diverse ways, with variations in location, timing of ART initiation, counseling, and referral. While all health facilities had to implement Option B+ into antenatal care service delivery in 2011, no specific guidance was given on how to do it.

Among the 141 health facilities surveyed the 4 models of care identified were: 

• A: facilities where women newly diagnosed with HIV are started and followed on ART at the antenatal clinic until delivery (n = 75);
• B: facilities where women receive only the first ART dose at the antenatal clinic with subsequent follow-up at the ART clinic (n = 38);
• C: facilities where women are referred from the antenatal clinic to the ART clinic for ART initiation and follow-up (n = 18);
• D: facilities serving as ART referral sites but not providing antenatal care (n = 9).

Multivariate analysis showed that health facility factors significantly associated with ART retention included district location, patient volume (lower retention with high volume), and the model of care applied.

Model C facilities where women are referred from the antenatal care clinic to an ART clinic for treatment initiation and follow-up were 5 times more likely to have high 6-month retention rates than model B facilities where women receive only the first ART dose at the antenatal clinic with subsequent follow-up at the ART clinic.

There were no differences between the models in the proportion of women newly identified in antenatal care initiating ART, at 81%. However, there was a difference in the proportion of women not tested during antenatal care. Model B facilities had the highest proportion (32%), whereas model A facilities had the lowest proportion (18%). This was associated with client-to-HIV testing staff ratio and test kit stock-outs as well as model of care.

There were no differences in the number of women in the 6-month cohort who had started ART under option B+. However, 6-month loss to follow-up ranged from 7% to 20%, with model D facilities having the highest retention rates and model B facilities the lowest.

Van Oosterhout told delegates that while this study may not be representative of all of Malawi, it offers a creative approach to operational research. Use of high-quality routine government data and a large data set provides real-world findings.

8/22/14

References

H Tweya, S Gugsa, M Hosseinipour, et al. Loss to follow-up among women in PMTCT Option B+ programme in Lilongwe, Malawi: understanding outcomes and reasons. 20th International AIDS Conference. Melbourne, July 20-25 2014. Abstract THAX0101.

M van Lettow, R Bedell, I Mayuni, JJ van Oosterhout, et al. Elimination of mother-to-child transmission of HIV: performance of different models of care initiating lifelong antiretroviral therapy for pregnant women in Malawi (Option B+). 20th International AIDS Conference. Melbourne, July 20-25 2014. Abstract THAX0102.