Retention in care under universal antiretroviral therapy for HIV-infected pregnant and breastfeeding women ('Option B+') in Malawi

Abstract

Objective: 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.

Design, setting, and participants: 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).

Results: 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%.

Conclusion: 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.

Figure 1. Inclusion of facilities and patients in different analyses

Figure 2. Cumulative incidence of outcomes on antiretroviral therapy (ART) since the introduction of Option B+

The panels show the cumulative incidence of treatment outcomes over time from the start of antiretroviral therapy in months. Treatment outcomes are compared across three groups based on patients’ indication for ART: Option B+ indication and ART start during pregnancy (A), Option B+ indication and ART start after delivery while breastfeeding (B), and WHO stage 3 or 4 and/or CD4≤350/μL (C). Estimates are derived from competing risk regression.

Figure 3. Time from HIV testing to initiation of antiretroviral therapy (ART)

Kaplan-Meier functions for the time from HIV testing to initiation of antiretroviral therapy (ART) among patients who started ART. Separate functions are shown for patient who started ART i) with Option B+ indication during pregnancy (“Option B+ pregnant”), ii) with Option B+ indication after delivery whilst breastfeeding (“Option B+ breastfeeding”), and iii) in WHO clinical stage 3 or 4 and/or CD4≤350/μL (“ART for own health).