Introduction

www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Retention in care among women initiated on Option B plus in the Antenatal Clinic (ANC) and labour ward at Mulago National Referral Hospital, Kampala Uganda

Authors: Emily Namara-Lugolobi, Zikulah Namukwaya, Philippa Musoke, Ayoub Kakande, Joyce Matovu, Sarah Kamya, Medius Kyarimpa,Jennifer Namusobya, Josaphat Byamugisha, Mary Glenn Fowler.


Introduction

• Globally, paediatric HIV infections have decreased by 43% from 2003 to 2011 (UNAIDS)

• In 2012, The World Health Organisation (WHO) gave interim recommendations for same day HIV testing and triple ARVs for PMTCT (Option B) with consideration of continuing ARVS as treatment for the rest of the woman’s life (Option B+)

• This is regarded by WHO to be a more effective strategy to achieve the UNAIDS’ target of virtual elimination by 2015 compared to previous guidelines.

• Uganda adopted WHO option B+ guidelines in September 2012.

• Potential challenges with this strategy include retention of pregnant and post partum women in long term care; and risk of waning adherence among a generally healthy population of HIV infected pregnant and post partum women who do not yet meet country treatment criteria.


Introduction

• Retention in care is essential to monitor adverse reactions to ART, adherence and response to treatment

• This is vital to maintain the success of Option B+

• The objectives of this program evaluation were

– To determine the proportion HIV infected pregnant and postpartum women who had returned for the first visit by two, four, six or twelve weeks after initiation on Option B+

– To compare the return rates between those initiated on Option B+ in ANC and at the labour ward.


Mulago PMTCT Programme• The PMTCT Program at

Mulago National referral Hospital was started in 2000.

• It offers routine “opt-out” same day HIV testing in its 3 antenatal clinics (ANC) and 3 labour wards

• Over 33,000 pregnant women are screened each year and about 10% are HIV Infected


The PMTCT Programme

• HIV positive women are enrolled in the PMTCT program and receive comprehensive HIV/AIDS services which include

– Antiretrovirals for PMTCT and treatment

– Management of opportunistic infections

– Cotrimoxazole prophylaxis

– Supportive counselling

– Psychosocial support groups


Methods: Option B+ implementation in ANC

• The Mulago PMTCT Programme rolled out Option B+ on 17th Oct in the ANC and on 25th Oct 2012 in labour wards

• Women were initiated on ART the same day of HIV diagnosis and given drug supply for one month

• Baseline investigations– CD4 cell count , CBC, Renal and Liver

function tests.

• One to two weeks appointment to receive lab results and further comprehensive care


Methods: Implementing option B+ on the busy labour wards

• HIV infected women identified at labour ward were offered single dose NVP and then counselled to start ART there after

• They were asked to return for CD4 cell count, liver and renal function test results within six weeks after delivery

• This follow-up visit remains critical for evaluation of CD4 cell count, adverse reactions to ART, adherence and supportive counselling, clinical evaluation and management of opportunistic infections


Methods: Strategies to improve long term retention in care

• Ongoing counselling by midwives and counsellors

• Peer counselling

• Phone calls after missed appointments

• Home visits by peer mothers and a health visitor to those not reached by phone


Monitoring and Evaluation Methods

• We reviewed data to determine the number of women who were initiated on Option B+ between

– 17th October 2012 and 28th February 2013 in ANC – 25th October 2012 and 28th February 2013 in labour ward

• We also determined the number of women who had returned for the first visit within the first three months after B+ initiation

• The retention rate was determined as • women who returned for the first visit X 100 women initiated on Option B+


Demographic characteristicsVARIABLE ANC n(%, 95% CI) LABOUR WARD n(%,

95% CI)CD4 Count0 – 350351 – 500>500

121(28.3%, 24.1 – 32.8)99(23.1%, 19.2 – 27.4)146(34.1%, 29.6 – 38.8)

14(9.3%, 5.3-15.5)6(4.1%, 1.5 – 8.1)23(15.6%, 10.2-22.5)

Age<2020 – 29>30

51(11.9%, 9.0 – 15.4)296(69.2%,64.5 – 73.5)81(18.9%, 15.3 – 23.0)

25(17.0%, 11.3-24.1)99(67.4%,59.1-74.8)23(15.7%, 10.2-22.5)

Marital statusMarriedSingleWidowed/Divorced

408(95.3%,92.9 – 97.1)15(3.5%, 2.0 – 5.7)3(0.7%, 0.1 – 2.0)

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Demographic characteristics

VARIABLE ANC n(%, 95% CI) LABOUR WARD n(%, 95% CI)

Gravidity12 – 45 - 9

29(24.3%,4.6 – 9.6)203(47.4%, 42.6 – 52.3)33(7.7%, 5.3 – 10.7)

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Educational statusNone/PrimarySecondaryTertiary

104(24.3%,20.3 – 28.6)141(32.9%, 28.5 – 37.6)26(6.1%, 4.4 – 8.8)

11(7.5%, 3.8-13.0)9(6.1%,2.8-11.3)0

EmploymentEmployedNot employed

127(29.7%, 25.4 – 34.2)145(33.9%,29.4 – 38.6)

10(6.8%, 3.3-12.2)11(7.5%, 3.8-13.0)


Initial Results of first months of Option B+ Rollout at Mulago Hospital

2weeks 4weeks 6weeks 12 weeks0

10

20

30

40

50

60

70

80

90

ANCLabour ward


Reported Maternal Adherence to taking ARVs

• Most women report good adherence to ART

• Challenges encountered in implementing Option B+ have been presented else where (see poster presentation by Joyce Matovu)

Common reasons reported for poor adherence include• Denial/disclosure issues

• Adverse reactions to ART

• Transport problems

• Feeling well

• Women who get abortions, those who deliver still births and those who opt not to breast feed often feel they do not need ART


Conclusions• The majority of women initiating triple ARVS during pregnancy

returned within six weeks after initiation on ART whereas follow up was quite low for women first identified at labor/delivery

• However, about 20% and 70% of women initiated on ART in ANC and labour ward respectively were lost to follow up after the initial visit.

• Drug refill scheduled at one month could have influenced adherence to early (two week) appointments

• Limitations of analyses: – this being a referral Hospital, women initiated at labour ward could have

shifted their care at closer, more convenient ART centres– we do not yet have data on longer term follow up after risk of MTCT is over

following cessation of breastfeeding– we have only self report data on ART drug adherence


Recommendations

There is critical need

• To determine the dynamics that affect follow up among women more especially among women initiated on ART during labour/delivery

• To track linkage to other centres for proper follow up

• To find innovative ways to improve retention in care and treatment

• To monitor long term adherence to optimise maternal treatment outcomes and in PMTCT

• To assess emergence of ART resistance within programs rolling out B+


Acknowledgements• The Clients in the Mulago PMTCT programme

• The administration and staff of Mulago National Referral Hospital

• Makerere University – Johns Hopkins University Research Collaboration, Kampala Uganda

• Makerere University Joint AIDS Program

• The Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda

• Centres for Disease Control and Prevention

• U.S. President’s Emergency Plan for AIDS Relief

Introduction

Documents

pmtct option b

option b guidelines

option b implementation

option b plus

success of option b

pregnant women

labour wards women

womans life option b