Preliminary findings of a routine PMTCT Option B+ programme in a rural district in Malawi Rebecca M. Coulborn 1, Laura Triviño Duran 1, Carol Metcalf 2,

Preliminary findings of a routine PMTCT Option B+ programme in

a rural district in Malawi

Rebecca M. Coulborn1, Laura Triviño Duran1, Carol Metcalf2, Yvonne Namala1, Zengani

Chirwa3, Michael Murowa4, Kingsley Mbewa4, Daniela Garone1

1Médecins Sans Frontières (MSF), Thyolo, Malawi; 2MSF, South African Medical Unit, Cape Town, South Africa; 3Ministry of Health, HIV Unit, Lilongwe, Malawi; 4Ministry of Health, District Health Office, Thyolo, Malawi

Background July 2011: Malawi government adopted PMTCT Option B+

1. Radical simplification of PMTCT program

2. Health benefit of earlier treatment and avoiding the risks of interrupting ARTs

3. Protection from MTCT in future pregnancies

4. Protection for negative partners in

sero-discordant couples

5. Reduction in HIV related maternal mortality

Study Objectives

• To document the experience of implementing B+ in Thyolo District and important lessons learned;

• To describe the maternal outcomes of B+, specifically long-term adherence to taking cART and the incidence of subsequent pregnancies;

• To describe the infant outcomes of PMTCT B+, specifically access to HIV testing/diagnosis and incidence of HIV infection

Setting: Thyolo district

Thyolo district is located in the southwest Malawi with > 620.000 pop

In 2010 (MDHS 2010):• ANC prevalence 12-14% • Fertility rate 5.7%• 35% of PMTCT coverage

In 2012:• > 32.000 patients on ART• ~ 800 initiations a month across

31 PMTCT sites• ~80% of uptake of ANC HIV

testing

Methods• Study design: Programme evaluation carried out over the

course of routine health service provision

• Study sites: 5 health centres and 1 district hospital

• Study population: HIV+ pregnant or breastfeeding women who are eligible for PMTCT Option B+ and their infants

• Data collection: Routinely-collected data from patient cards & health facility records.

• Ethical considerations: Approved by Malawi National Health Sciences Research Committee and MSF Ethical Review Board

Preliminary results: mother status

• From April '12 – March '13:– 911 women and 279 babies

were enrolled

• Median age at enrolment: 27 years (12-43 years)

• 194/750 (26%) women delivered after enrolment

• Median time from enrolment to delivery:

13 weeks (0-27 weeks)Pregnant Breastfeeding0%

20%

40%

60%

80%

100%

82.3%

17.7%

Mother status at enrolment (n=911)

B+ initiation and eligibility WHO 2010 GL

*CD4 <350 cells/µL or WHO clinical stage 3 or 4

47.7%52.3%

ART eligibility * (n=310)

Eligible

Not eligible

52.3% increase in the ART uptake due to B+

Mother outcomes

Preliminary results: 6 month mother Viral Load

< 1000 c/ml 1000-5000 c/ml > 5000 c/ml0%

20%

40%

60%

80%

100%

97%

1% 2%

Babies outcomes: HIV testing

65.60%

34.40%

HIV testing (n=276)

Tested

Not tested 99.1%

0.9%

HIV test result (n=109)

HIV - ve

HIV +ve

Baby outcomes

LTFU: Lost-to-follow-up; RIC: Remaining in care

96.2%

5.8%

Nevirapine prophylaxis (n=107)

NVP for 6 weeksNo prophylaxis or incompleted

Conclusions• Exponential increase of PMTCT uptake

• Excellent uptake of Nevirapine prophylaxis

• Very promising low HIV new infants infections

• Uptake for HIV baby testing still not optimal.

• Lost to follow-up rates of mother and their baby, particularly after the first clinical visit, represents a challenge of the B + program

Conclusions (2)

Attention to the programmatic challenges is needed to reach the full benefit of the PMTCT B+ strategy and

to increase field effectiveness

Acknowledgements

Mothers and their babies

Malawi Ministry of Health

Malawi HIV unit

Staff in Thyolo clinics

MSF SAMU and Thyoloresearch team