20th International AIDS Conference - Melbourne, Australia


THAX01 Option B+: Benefits and Challenges
  Oral Abstract Session : Cross-Track
Venue: Plenary 3
Time: 24.07.2014, 16:30 - 18:00
Co-Chairs: Elaine J. Abrams, United States
Craig McClure, UNICEF

16:30
THAX0101
Abstract
Powerpoint
Webcast
Loss to follow-up among women in PMTCT Option B+ programme in Lilongwe, Malawi: understanding outcomes and reasons
H. Tweya1,2, S. Gugsa1, M. Hosseinipour3, C. Speight1, W. Ng'ambi1, M. Bokosi1, J. Chikonda4, A. Chauma4, V. Sampathkumar5, T. Mtande3, P. Khomani6, S. Phiri1
1Lighthouse Trust, Lilongwe, Malawi, 2The International Union Against Tuberculosis and Lung Disease, Paris, France, 3University of North Carolina Project, Lilongwe, Malawi, 4Ministry of Health, District Health Office, Lilongwe, Malawi, 5Mothers2Mothers, Lilongwe, Malawi, 6Baobab Health Trust, Lilongwe, Malawi

16:45
THAX0102
Abstract
Powerpoint
Webcast
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+)
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

17:00
THAX0103
Abstract
Powerpoint
Webcast
Operational challenge: linkages from prevention of mother-to-child transmission services to care and treatment services in Zambia
S. Okawa1, M. Chirwa2, N. Ishikawa3, F. Pande2, H. Kapyata2, C. Msiska2, K. Komada3,4, H. Miyamoto3,4, A. Mwango4,5
1University of Tokyo, Tokyo, Japan, 2Chongwe District Community Health Office, Ministry of Community Development, Mother and Child Health, Chongwe, Zambia, 3National Center for Global Health and Medicine, Tokyo, Japan, 4Ministry of Health Zambia - Japan International Cooperation Agency SHIMA Project, Lusaka, Zambia, 5Ministry of Health, Lusaka, Zambia

17:15
THAX0104
Abstract
Powerpoint
Webcast
Contribution of lay health providers in scaling up Option B+ interventions: a case of concerted efforts of mentor mothers through psychosocial support groups in East Central Uganda
S. Auma1,2, M. Mbule1, R. Muke1, B. Mugisha1, D. Businge2, A. Mugume2, E. Okonji1, S. Kironde2, F. Kazibwe3
1Mothers2Mothers, Cape Town, South Africa, 2JSI, Jinja, Uganda, 3JSI Research & Training Institute Inc (JSI)/STAR-EC, Jinja, Uganda

17:30
THAX0105
Webcast
Moderated discussion

Powerpoints presentations
Loss to follow-up among women in PMTCT Option B+ programme in Lilongwe, Malawi: understanding outcomes and reasons - Hannock Tweya

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+) - Joep J van Oosterhout

Operational challenge: linkages from prevention of mother-to-child transmission services to care and treatment services in Zambia - Mable Chirwa

Contribution of lay health providers in scaling up Option B+ interventions: a case of concerted efforts of mentor mothers through psychosocial support groups in East Central Uganda - Sarah Auma



Rapporteur reports

Track C report by Elizabeth Bukusi


Option B+: Benefits and Challenges

THAX0101 Loss to follow-up among women in PMTCT Option B+ programme in Lilongwe, Malawi: understanding outcomes and reasons

Hannock Tweya

          In 2011, Malawi embarked on a novel PMTCT programme known as “Option B+”

        Lifelong ART for pregnant and breastfeeding women regardless of WHO clinical stage or CD4 count

        NVP syrup for 6 weeks for infants

Option B+ resulted in a 7-fold increase in the number of women starting ART for PMTCT between the 2nd quarter of 2011 and 3rd quarter 2012

          Between September 2011 and September 2013, 2930 HIV-infected women started ART for PMTCT Option B+:

        2,458 (84%) were pregnant

          . Overall incidence of LTFU was 23.5 % per year

These LTFU were traced

·         77% had stopped taking ARV after loss to follow up.  Most had travelled so could not collect medicines (38%). 16% challenge with transport.

·         10 % did not know they were to take it for life. 10 % side effects 10 % too sick to come to clinic.

LFTU was higher than the general population for those taking ARV

47% came once and never came back to clinic

Being older (<25 years old) were less likely to be loss to follow up  and the LTFU decreased with the increase in years.

Some women could not be tracked down because of incorrect address – maybe they did no found to be found.

Half had stopped ART and so their infants at risk for infection.

Conclusion / Recommendation ANC and ART should enhance post test counseling and psycho social support. Youth friendly clinics for the younger women

Transfer out clinics with electronic data for ease of transfer and follow up. There is a need  to find out why women go to other clinics other than the one they are registered in .

Question : was CD4 count checked for those starting treatment

No for pregnant women they are initiated on ART regardless of CD4 count

Qs: You asked the women to give the reasons for LTFU. The reasons we give are not always the reason they know in their hearts , or they give reasons which are socially acceptable. Are there are reasons which can be investigated?

Answer : There is need to find out more . A study is being done on why these women do not come back .

Question : Did you do virologic testing on the infants and if there is effect on the children ?

Answer :No, no virologic testing done

Question :What was the loss to follow up ? Answer : the highest was  in 2011 at 25%

Question : Was there any loss to follow up for Option A ? Answer : It is unknown as it was not tracked.

THAX0102  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+)

Joep J van Oosterhout

New PMTCT guidelines  introduced in 2011. For pregnant and breast feeding women. No formal evidence base for the strategy and raised concerns over loss to follow up and drug resistance.  No guidance for integration available then so health systems had to determine how best to do this with no clear information on if this would affect uptake or retention or follow up.

There was a 750% increase in ART Uptake.  The 6 month retention rate was 83% but varied between 100 and 42% so more insight was needed on what helped retention.

Health facility survey and facility cohort reports done to ascertain uptake of testing,  ART initiation  and 6 month retention.

Association was with the  model of care, uptake of HIV testing  was at  85 and retention into care at  92 %.

A total of 141/153 health facilities were included in the study. Some were district hospitals, community hospitals, health centers and private clinics.

Four different models of care

1.       A- Women initiated and followed up in ANC until birth – number of facilities-75

2.       B- Women receive only the first dose and followed up in ART clinic – number of facilities-38

3.       C- Women referred from ANC to ART to be initated and follow up– number of facilities- 18

4.       D- Only referred and did not provide any testing but referred  – number of facilities-9

There was variation in the timing of the referrals and care within the models.

Model A had 3.4 higher times of testing uptake than model B.

Model C had a higher retention 5.4 times compared to  model B.

Between18-32 %  of the women were not tested and this seemed to be linked to the client / staff ratio and Test kits availability and  model of care

Retention was also  dependent on the model of care, the  patient volume and they type of facility

Model B had the worst care characteristics (one dose and referral).

Strengths : This as  a large operational research with real world findings and a  large data set.  It may not represent the whole of Malawi and it is cross sectional so residual confounding and attrition due to linkage of care not considered.

Conclusion : There is variation in the uptake of testing  and retention based on the model of care and the model most favorable seems to be  testing and then referral for care into the ART clinic or follow up in the ANC clinic for women and infants .

Comment – it is a limitation is the lack of attrition analysis of those tested and sent to care as high initiation with some loss to follow up of those who are not motivated  can look the same as low  initiation with high retention.

Question : Was the decision to use a specific model motivated by pressure from the MOH as the guidelines for Option B+ ? Answer : no it was not

Questions : For facility B , was it first dose or is it one month of treatment ? Answer One dose only.

Question : Integrated care would not seem to work from the model you  are presenting. Did you look at any other factors on the mother and baby beyond retention, ? Answer : No we did not , but there are other studies looking  at this. And it is important.

 

THAX0103 Operational challenge: linkages from prevention of mother-to-child transmission services to care and treatment services in Zambia

Mabel Chirwa

PMTCT in Zambia 97% coverage . But the linkages from PMTCT to ART care needs to be understand.

A prospective study in Changwe district . 11 health facilities including one referral health facility  like a mini hospital). Used 2010 WHO guidelines for Option A . 195 newly diagnosed women enrolled.

From HIV diagnosis to enrollment in HIV care.

Results : Women were 27 years old median ( 21-33). Half had primary school education and half had 1-3 children.  About half the partners were working (on the farms since this is a rural area).  They took 1-2 hours to reach the facility.  76% had  positive attitudes  towards taking ARV.

Linkage  of the 195 only 92 ( 48%) enrolled and the rest did not.  Of those linking 87 had a CD4 count.   Of those eligible, only half started on treatment

Current guidelines encourage couple counseling and to keep the pregnant and breastfeeding women in the ANC and refer the partner to the ART clinic.

Conclusions : Predictors of enrollment , if less than 20 years old not likely ,  those sent from other centres where no HIV care  was provided at the rural health facility near them / referring them were less likely to be enrolled In HIV care and treatment

Questions :  What was used for the CD4 testing. Was it laboratory or theor point of care testing. If results returned, how were the results being sent to ?

Answer : For the patients form Non ARV sites they had to be referred for blood collection. For those at the ART sites the community volunteer sites would collect the blood, take it to the lab and bring the results back.

Question : Why was there no scale up to the health facilities  where there was no ART provision ?

Answer: This is because there is need for capacity building for the staff at the lower health facilities to ensure that they can adequately take care of the women’s health needs.

Question:  Is the ART site able to cater for both children and adults or can they only take care of adults. Answer : These take care of both adults and children, this is the static and the  mobile clinics.

 

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THAX0104 Contribution of lay health providers in scaling up Option B+ interventions: a case of concerted efforts of mentor mothers through psychosocial support groups in East Central Uganda

Sarah Auma

Barriers: There were myths among the women which including fear of side effects and for some non disclosure for young women or women in new relationships which make it difficult for uptake of option B+. 

Mentor mothers (MM) were to provide the support needed for successful roll out.

Increasing the peer mentored support groups from 28-45. MM trained in a standard package and to brain storm on options which would help retention in care and how to resolve problems. 

Back at the health facility, on review of the data,  of the 1564- only 50% were on ART and the rest had been on option A and needed to be initiated on care. Messaging was needed to be changed to give the mothers information which would encourage them to initiate care- they had been told if they were well and feeling ok they did not need ART. In the support group meetings- there was opportunity to share testimonies of those who had initiated care to encourage others to come for care.

Over 3 months, the proportion of those who started care, from 50% to 90% and the linkages have been sustained. 

The MM also linked 77% of clients to baseline CD4 testing, 93% of Mother baby pairs for PCR testing and 94% of women disclosed to spouses. .

The following months the follow up revaluated 104 had missed the follow up visit and 96% were followed up actively and traced and persuaded 86% of those missing returned to the facility for care.

Key factors for success, is the training of the mentor mothers…  They felt important and valued and went back to work with enthusiasm. A peer approach is that they were initiated at the same time as their peers and their experiences were similar.  The team work among the mentor mothers was also very useful for helping the MM. There was availability of drugs and no stock outs which made it helpful when women went to the health facility.

Conclusion : the mentor mothers were successful in linking and tracing mothers to care for Option B+ .

Question: How do you address the high rates of follow up where there is gender based violence and if the women disclosed , how was this dealt with ?

Answer: Domestic and gender based violence is a new area for the team but they are trained to identify those who are at risk and during the support group meetings they find out how the women are doing at home and provide information and identify for them where to get help and also refer them to the health workers for additional care

Question:  were these psychosocial support groups community or facility based and what challenges did they face in  encouraging women to joking the groups.

Answer : The groups are facility based. They did not have challenges with getting others to join as they share real life experiences and they shared what they were experiencing and they gave them options, they encouraged them but did not force them. Those in the support groups also shared experiences and brought others.

 

Question . From Cambodia : A peer led program from Cambodia is challenged with high turn over of volunteers. They are paid a stipend but they have to have other work. Do you have a challenge of high turn over.

Answer: The mentor mother model pays a small stipend and they are motivated due to the knowledge they get and stay on even after they are graduated from the program.

Comment  : the UN health departments should consider employing mentor mothers as an essential part of the program in high prevalence and low resource areas. Why are they not being paid. They are giving good rates but they should be regarded as an essential component rather than just being considered as a psychosocial support mechanism. Answer /comment: this is an important point and many donors/ funders are grappling with how best to deal with this

Question: for the entire panel. In Mozambique three main problems in the linkages. More than 80%   see the traditional healers before the medical care, the second is male involvement and women are reluctant to engage without partner support. The third is health care workers who do not want to be posted to the rural areas and they may not be from that part of the country and they are not treating the patients well as a result.

Answer : Traditional healers : since many pregnant women  are not sick, they do not tend to go to  Traditional healers as they tend to be well. Those with opportunistic   infections are the ones more likely to go to  the traditional health doctors before the health faculties.

For the neighborhood health committees ( around the health facilities ) they are involved in the sensitization and the male folk are engaged in his way from them , the health committees engage the male partners and encourage them to come with the  women.

The health care givers satisfaction is a critical component of the health care given. If the health care workers re unhappy it makes for difficult health care facilities/systems.  The health care workers may not always mention that they are disgruntled.  And the women may also not mention that they are not treated well  it as they do not want it to affect their next visit.

The male involvement is an issue as the ANC clinics are not designed to be friendly for the male to visit the clinic. So now  ( In Malawi) there are by laws so that a woman has to bring a letter from the chief  if the husband does not bring her to the ANC, to ensure that the men come. But such methods should be used with caution so that the women are not discouraged from coming to clinic at all

 

Questions. India country office PMTC program. How do you sustain the mentor mother program for the long run ?  Since they are paid or given a stipend. Secondly -how can the spouses be brought and what if the spouses die before the mothers deliver?

Mentor mothers are graduated back to the program after one or two years.  There is engagement of the Ministry of health or the health facility at the local and other levels to have them volunteer as volunteers and as expert patients. They do the work even without the money- because many have a passion after their own health improves or is maintained.

Qs. The outcomes, is there an evaluation to compare the mothers support groups and those not attending especially during the option A. I am from Ethiopia and we are adopting option B+ and with the things that are needed the Mentor mothers are good. But some of those in the groups are not well educated and there is a bias towards those who are poor for these purposes of such volunteer opportunities .

Answer Uganda : there has been comparison of PCR uptake and disclosure and those in the support group have better uptake and more disclosure.

Comment : in Malawi there is a program for comparing mentor mothers at health facility and at the community based expert models and the results will be out some time in the future to shed light on optimal support for B+ and how best to do retention.

There is a need for good systems and retention for women and children

 

Question : There seems to be that younger age is a higher loss to follow up and ARV uptake and even HIV testing. What would be the response needed for these  younger age groups ?

Answer : This issue of age has come up severally -  there are no specific programs for young women but there is a need for youth friendly ANC services to make them more comfortable , this may attract them and improve retention.

Some places have an adolescent group, so the static sites have a specific day for the younger women and seen with the pediatrics. They are not comfortable with the older women and they seem to attend better when with their own age mates who are younger. For the mobile clinics it is a challenge as they have to see everyone when they go for outreach and this still needs to be done.

This is the same as ART programs even when not pregnant, younger patients have poorer retention.

Comment – Uganda : Peer fathers have been used to provide support and talk to fellow men and they have helped reduced gender based violence. Young mothers and youth corners and specific groups that allow the younger mothers to be free and be part of a specific group has helped in retaining the younger women .

 Comment : Sustainability is a serous issue that needs to be addressed.   

 

 




Track E report by Bridget Haire


Summary: This session featured 3 presentations on the implementation of prevention of mother-to-child programs – WHO Option B+  (includes life long triple combination antiretroviral therapy,) in two instances, and Option A (includes triple combination if the women has a CD4 counts equal to or less than 350) in the third. The common thread in these papers was high rates of loss to follow up in the study populations. In addition there was a presentation on Mentor Mothers, an innovative program that trains women with HIV who have recently given birth to provide support (including adherence to medication support), education and mentoring to other pregnant women with HIV.

 

Hannock Tweya presented on Loss to follow-up among women in PMTCT Option B+ program in Lilongwe, Malawi: understanding outcomes and reasons.

Dr Tweya said that while access to ARV increased access 7 fold by the introduction of Option B+, there were high levels of loss to follow-up. Travelling issues, transport costs, limited information about ARV, suspected side effects, feeling very weak or sick and non-disclosure of HIV to spouse were reasons associated with being lost to follow-up, as was younger maternal age. More systematic support, youth friendly services and innovative transport systems all have potential to help women to keep accessing treatment.

 Joep van Oosterhout  also presented  on data from Malawi in a presentation on Option B+ . This study looked at services models for provision of Option B+, and their relative rates of loss to follow up. The service models included:

1. Women initiated and followed up in ANC until birth (75 facilities)

2.  Women receive only the first dose and followed up in ART clinic (38 facilities)

3.  Women referred from ANC to ART to be initiated and follow up (18 facilities)

4.   Only referred and did not provide any testing but referred (9 facilities)

There was variation in the timing of the referrals and care within the models. The first model of care had 3.4 higher times of testing uptake than number. Retention in Model 3 was 5.4 times higher than model 2 .

Results were counter intuitive, in that there was less loss to follow-up in women who were referred to local clinics for ART, and highest loss to follow up was in women referred to local clinics after provision of the first does in an antenatal setting.

 As a questioner pointed out, consideration of the number initiated into treatment when considering these outcomes. For example, if 100% of women are initiated into treatment but only 50% continue, this is the same result in term of effectiveness as if 50% of women are initiated (as can happen if the women are referred off site to another facility), and 100% of them  continue to adhere.

 Mabel Chirwa from Zambia presented a paper entitled Operational challenges: linkages from prevention of mother to child transmission services in Zambia to care and treatment services.At the time of this research, there was 97% ARV coverage Zambia, using 2010 WHO option A. This paper looked at the transition and linkages from PMTCT to general ART services.

Dr Chirwa reported on this prospective study in Changwe district. The participants were 195 women newly diagnosed with HIV, attending 11 different health facilities.

Results: Women were 27 years old median ( 21-33). Half had primary school education and half had 1-3 children.  About half the partners were working (on the farms since this is a rural area).  They took 1-2 hours to reach the facility. 

Linkage  of the 195: only 92 ( 48%) enrolled and the rest did not.  Of those who were linked, 87 had a received a CD4 count result.   Only half of those eligible started on treatment.

Conclusions: Women who were less than 20 years old were less likely to enroll for ART. Women who were sent from other centres where no HIV care was provided at the rural health facility near them were less likely to be enrolled in HIV care and treatment.

Sarah Auma reported on the contribution of lay health providers in scaling up Option B+ interventions: a case of concerted efforts of mentor mothers through psychosocial support groups in East Central Uganda (Mentor Mother program)

Barriers to treatment uptake included fear of side effects from ART, and young women and women in new relationships were also afraid of disclosing to partners, which can affect uptake of option B+. 

Mentor mothers were recruited from women who had recently had babies while living with HIV. They were trained to provide the support needed for successful roll out of Option B+.

The mentor mother recruits were MM trained in a standard package of approaches to help retention in care. There were also facilitated brainstorming sessions to capture innovative ideas and insights from the mentor mother recruits.

In the support group meetings there was opportunity to share experiences and stories of those who had initiated care, to encourage others to take up care.

Past messaging on Option A, where women had been told they did not need ARV if they were well, needed to be addressed in order to support the implementation of Option B+. (Under Option A access to ART was linked to CD4 count whereas under Option B+, ART is indicated for life in women with HIV.)

Over 3 months, the proportion of those who started care rose from 50% to 90% and the linkages have been sustained. 

This program was evaluated as being highly successful, and in question time Dr Auma discussed the passion that the women in the program felt for their work. While they were paid a small stipend, she said there energy and commitment was not linked to monetary compensation.

Audience member Dr Susan Paxton suggested in question time that the value of this program was such that the women should in fact be paid professional wages.

Conclusion: the mentor mothers program was were successful in linking other new mothers into care and sustaining that care for Option B+ .

 

 

 




Track B report by Sabrina Kitaka



Dr. H. Tweya (Malawi) presented a retrospective study on loss to follow up (LTFU) among women initiating option B + in Lilongwe (Malawi) between 2011 and 2013. There was a considerable loss to follow up of 27% in the first year, which gradually decreased to 9%. Breastfeeding women were more likely to be lost to follow up compared to pregnant women. Average loss to follow up was 23.3%. The commonest reason for loss to follow up was distance from the health facility. Age more than 25 years was protective to LTFU.

Dr. J. Van Osterhout (Malawi) described the performance of four different models of care for initiating lifelong HAART for preventing mother to child transmission (PMTCT) in Malawi, based on the lack of proper guidelines or strategies during implementation of a program called “Option B+” that started in 2011. It was a cross sectional study. Over all, 7-20% of mothers defaulted on Option B+. Various facilities have integrated Option B+ into routine service delivery but more patient level research is needed.

 Dr. M. Chirva from Zambia presented a prospective study reviewing linkage from PMTCT (using option A) to care and treatment services . Overall, 52% of the mothers were not linked to care. A number of infants remain in an unknown status and at risk of delayed diagnosis and treatment initiation.

 Dr. S. Auma(Uganda) reported a program review in which the Mothers to Mothers Initiative to support PMTCT uptake, retention in care and linkage to other services in Eastern Uganda was described. The intervention increased retention from 41.2%to 98% within the 3 months study period. Mentor Mothers also linked clients to other services like CD4 testing, child testing, and spouse disclosure.




   

    The organizers reserve the right to amend the programme.