PARTNERSHIPS FOR ENHANCED ENGAGEMENT IN RESEARCH (PEER) HEALTH
Cycle 1

Introducing "Option B+" in Malawi: Impact on Child Outcomes

Principal Investigator: Frank Chimbwandira, Ministry of Health, Malawi
NIH-Supported Collaborator: Matthias Egger, University of Bern
Title of NIH Award: International Epidemiologic Databases to Evaluate AIDS-Southern Africa (IeDEASA)
Dates: May 2013 - April 2018

Project Overview

In September 2011, Malawi introduced the “Option B+” strategy to prevent mother-to-child transmission (MTCT) of HIV and started all pregnant and breastfeeding women on lifelong antiretroviral therapy (ART), regardless of their clinical condition or CD4 cell count. Option B+ may also reduce maternal morbidity and mortality, decrease transmission between serodiscordant partners, and raise the rate of child survival by reducing HIV mother-to-child transmission and improving maternal health. However, concerns have been raised about the implementation of Option B+, acceptance of ART, and adherence and retention in care among Option B+ patients, who typically initiate ART in the early asymptomatic stage of an HIV infection. This PEER research project evaluated the Option B+ program in Malawi, identifying challenges to program success by determining and describing the individual-, community- and health-system-level factors that limit or increase ART uptake, adherence. and retention in care.

Researchers analyzed the effects of introducing Option B+ on HIV MTCT rates, HIV testing in infants, ART initiation in children, ART adherence, loss to follow-up, and treatment changes among women who started ART with an Option B+ indication. Researchers also examined the associations between PMTCT interventions and mother and child outcomes, such as HIV testing rates and obstetric and newborn complications.
 

Research team members working from paper medical records.	A team member works on the digitization of paper medical records using a camera - a necessary step to perform probabilistic record linkage.

Final Summary of Project Activities

The PEER team digitized routinely collected paper-based antenatal care (ANC), maternity (MAT), and HIV-exposed infants (HEC) records from 13 district hospitals, 2 central hospitals, 3 mission hospitals, and 3 large health centers in central and southern Malawi. Data was double entered and cleaned. Researchers also conducted focus groups and qualitative interviews with Option B+ patients and health care providers. Key findings from the study included the following: 

• There was a low rate of confirmed MTCT after the introduction of Option B+, but due to poor retention only about one-half of HIV-infected children were diagnosed.
• One-third of women in the Option B+ program adhered inadequately during pregnancy and breastfeeding, especially soon after delivery.
• Women who stayed on ART through breastfeeding are motivated to continue lifelong ART.
• HIV-exposed uninfected infants born in the Option B+ period experienced faster weight gain than infants born before Option B+.
• Option B+ was more expensive than Option B, but despite the higher costs, Option B+ will likely become a cost-effective strategy in the long term.
• Compared to women who started ART in WHO clinical stage 3 or 4 or with low CD4 cell count, Option B+ patients who started ART during pregnancy were at a five times higher risk to be lost to follow-up at the first follow-up visit.
• Retention on ART across all age groups improved in the early years but remained constant thereafter, despite the burden posed by expansion of ART coverage on the healthcare system.
• The researchers found no association between stillbirth and timing of ART initiation.