Is Option B+ the best choice? Authors’ reply
(Impact Factor: 45.22).
04/2013; 381(9874):1273-4. DOI: 10.1016/S0140-6736(13)60835-1
Available from: Carol Dawson Rose
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ABSTRACT: Family planning is an important HIV prevention tool for women living with HIV (WLHIV). In Mozambique, the prevalence of HIV among women of reproductive age is 13.1% and the average fertility rate is high. However, family planning and reproductive health for WLHIV are under-addressed in Mozambique. This study explores provider descriptions of reproductive health messages in order to identify possible barriers and facilitators to successfully addressing family planning and pregnancy concerns of WLHIV.
In 2006, a Positive Health, Dignity, and Prevention program was introduced in Mozambique focused on training health care providers to work with patients to reduce their transmission risks. Providers received training on multiple components, including family planning and prevention of mother-to-child transmission (PMTCT). In-depth interviews were conducted with 31 providers who participated in the training in five rural clinics in three provinces. Data were analyzed using qualitative content analysis.
Analysis showed that providers' clinical messages on family planning, pregnancy, and PMTCT for WLHIV could be arranged along a continuum. Provider statements ranged from saying that WLHIV should not become pregnant and condoms are the only valid form of family planning for WLHIV, to suggesting that WLHIV can have safe pregnancies.
These data indicate that many providers continue to believe that WLHIV should not have children and this represents a challenge for integrating family planning into the care of WLHIV. Also, not offering WLHIV a full selection of family planning methods severely limits their ability to protect themselves from unintended pregnancies and to fully exercise their reproductive rights. Responding to the reproductive health needs of WLHIV is a critical component in HIV prevention and could increase the success of PMTCT programs.
International Journal of Women's Health 12/2014; 6:1057-67. DOI:10.2147/IJWH.S67038
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ABSTRACT: To explore the levels and determinants of loss to follow-up (LTF) under universal lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women ('Option B+') in Malawi.
We examined retention in care, from the date of ART initiation up to 6 months, for women in the Option B+ program. We analysed nationwide facility-level data on women who started ART at 540 facilities (n = 21 939), as well as individual-level data on patients who started ART at 19 large facilities (n = 11 534).
Of the women who started ART under Option B+ (n = 21 939), 17% appeared to be lost to follow-up 6 months after ART initiation. Most losses occurred in the first 3 months of therapy. Option B+ patients who started therapy during pregnancy were five times more likely than women who started ART in WHO stage 3/4 or with a CD4 cell count 350 cells/μl or less, to never return after their initial clinic visit [odds ratio (OR) 5.0, 95% confidence interval (CI) 4.2-6.1]. Option B+ patients who started therapy while breastfeeding were twice as likely to miss their first follow-up visit (OR 2.2, 95% CI 1.8-2.8). LTF was highest in pregnant Option B+ patients who began ART at large clinics on the day they were diagnosed with HIV. LTF varied considerably between facilities, ranging from 0 to 58%.
Decreasing LTF will improve the effectiveness of the Option B+ approach. Tailored interventions, like community or family-based models of care could improve its effectiveness.
AIDS (London, England) 02/2014; 28(4):589-98. DOI:10.1097/QAD.0000000000000143 · 5.55 Impact Factor
Available from: Monique van Lettow
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Malawi introduced a new strategy to improve the effectiveness of prevention of mother-to-child HIV transmission (PMTCT), the Option B+ strategy. We aimed to (i) describe how Option B+ is provided in health facilities in the South East Zone in Malawi, identifying the diverse approaches to service organization (the “model of care”) and (ii) explore associations between the “model of care” and health facility–level uptake and retention rates for pregnant women identified as HIV-positive at antenatal (ANC) clinics.
A health facility survey was conducted in all facilities providing PMTCT/antiretroviral therapy (ART) services in six of Malawi's 28 districts to describe and compare Option B+ service delivery models. Associations of identified models with program performance were explored using facility cohort reports.
Among 141 health facilities, four “models of care” were identified: A) facilities where newly identified HIV-positive women are initiated and followed on ART at the ANC clinic until delivery; B) facilities where newly identified HIV-positive women receive only the first dose of ART at the ANC clinic, and are referred to the ART clinic for follow-up; C) facilities where newly identified HIV-positive women are referred from ANC to the ART clinic for initiation and follow-up of ART; and D) facilities serving as ART referral sites (not providing ANC). The proportion of women tested for HIV during ANC was highest in facilities applying Model A and lowest in facilities applying Model B. The highest retention rates were reported in Model C and D facilities and lowest in Model B facilities. In multivariable analyses, health facility factors independently associated with uptake of HIV testing and counselling (HTC) in ANC were number of women per HTC counsellor, HIV test kit availability, and the “model of care” applied; factors independently associated with ART retention were district location, patient volume and the “model of care” applied.
A large variety exists in the way health facilities have integrated PMTCT Option B+ care into routine service delivery. This study showed that the “model of care” chosen is associated with uptake of HIV testing in ANC and retention in care on ART. Further patient-level research is needed to guide policy recommendations.
Journal of the International AIDS Society 07/2014; 17(1):18994. DOI:10.7448/IAS.17.1.18994 · 5.09 Impact Factor
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