20th International AIDS Conference - Melbourne, Australia


THAX0102 - Oral Abstract Session

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+)

Presented by Joep J van Oosterhout (Malawi).

M. van Lettow1,2, R. Bedell3, I. Mayuni3, G. Mateyu3, M. Landes3,4, A.K. Chan2,3, V. van Schoor3, T. Beyene3, A.D. Harries5,6, S. Chu7, A. Mganga8, J.J. van Oosterhout3

1Dignitas International, Research, Zomba, Malawi, 2University of Toronto, Dalla Lana School of Public Health, Toronto, Canada, 3Dignitas International, Zomba, Malawi, 4University of Toronto, Department of Family and Community Medicine, Toronto, Canada, 5International Union Against Tuberculosis and Lung Disease, Paris, France, 6London School of Hygiene and Tropical Medicine, London, United Kingdom, 7Malawi Ministry of Health, Zonal Health Office, Zomba, Malawi, 8Ministry of Health, Department of HIV and AIDS, Lilongwe, Malawi

Background: In 2011 Malawi introduced a new strategy to improve the effectiveness of its PMTCT program, coined Option B+. This strategy has since been implemented in other countries in the region, despite lack of an evidence base and concerns about losses to follow up. Insight into factors that determine retention in care is sparse.
Methods: We conducted a survey in all health facilities providing PMTCT/ART services in 6 of Malawi''s 28 districts to identify the different approaches to Option B+ service delivery (models of care). We explored associations of the identified models of care with program performance, using routinely collected, facility level cohort data of pregnant women newly identified as HIV-infected at antenatal care (ANC) clinics.
Results: Among 141 health facilities, 4 models of care were identified: A) facilities (n=75) where newly identified HIV-infected women are initiated and followed on ART at ANC clinic until delivery; B) facilities (n=38) where women receive only the first ART dose at ANC clinic, with subsequent follow up at ART clinic; C) facilities (n=18) where women are referred from ANC to ART clinic for ART initiation and follow-up; D) facilities (n=9) serving as ART referral sites (not providing ANC).
The proportion of women tested for HIV during ANC was highest in model A facilities [82%(95%CI:78-85)] and lowest in model B facilities [68%(95%CI:61-74)]. The proportion of women starting ART was 81% (95%CI:78-85), with no difference between models. Highest 6-month retention rates were found in models C and D [90%(95%CI:86-94)] and lowest in model B facilities [78%(95%CI:74-84)]. In multivariable analysis, health facility factors significantly associated with ART retention were district location, patient volume (lower retention with higher volume) and the model of care applied. Model C facilities were 5 times more likely than model B to have high 6-month retention rates.
Conclusions: A variety exists in the way health facilities have integrated PMTCT Option B+ care into routine service delivery, and the model of care chosen appears to be associated with uptake of HIV testing in ANC and retention in care on ART. Further research is needed to ascertain which individual factors determine acceptance of and adherence to lifelong treatment.

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