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
In 2011, Malawi embarked on a novel PMTCT
programme known as “Option B+”
ART for pregnant and breastfeeding women regardless of WHO clinical stage or
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
September 2011 and September 2013, 2930 HIV-infected women started ART for
PMTCT Option B+:
(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
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
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
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
Four different models of care
A- Women initiated and followed up in ANC until
birth – number of facilities-75
B- Women receive only the first dose and
followed up in ART clinic – number of facilities-38
C- Women referred from ANC to ART to be initated
and follow up– number of facilities- 18
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
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
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
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
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
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
Question : Why was there no scale up to the health
facilities where there was no ART
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.
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
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
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
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
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
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
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
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
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
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
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 .
Sustainability is a serous issue that needs to be addressed.
Track E report by Bridget Haire
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
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.
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
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
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.