Supporting Option B+ scale up and strengthening the prevention of mother-to-child transmission cascade in central Malawi: results from a serial cross-sectional study

Abstract

Background: We established Safeguard the Family (STF) to support Ministry of Health (MoH) scale-up of universal antiretroviral therapy (ART) for HIV-infected pregnant and breastfeeding women (Option B+) and to strengthen the prevention of mother-to-child transmission (PMTCT) cascade from HIV testing and counseling (HTC) through maternal ART provision and post-delivery early infant HIV diagnosis (EID). To these ends, we implemented the following interventions in 5 districts: 1) health worker training and mentorship; 2) couples' HTC and male partner involvement; 3) women's psychosocial support groups; and 4) health and laboratory system strengthening for EID.

Methods: We conducted a serial cross-sectional study using facility-level quarterly (Q) program data and individual-level infant HIV-1 DNA PCR data to evaluate STF performance on PMTCT indicators for project years (Y) 1 (April-December 2011) through 3 (January-December 2013), and compared these results to national averages.

Results: Facility-level uptake of HTC, ART, infant nevirapine prophylaxis, and infant DNA PCR testing increased significantly from quarterly baselines of 66 % (n/N = 32,433/48,804), 23 % (n/N = 442/1,958), 1 % (n/N = 10/1,958), and 52 % (n/N = 1,385/2,644) to 87 % (n/N = 39,458/45,324), 96 % (n/N = 2,046/2,121), 100 % (n/N = 2,121/2,121), and 62 % (n/N = 1,462/2,340), respectively, by project end (all p < 0.001). Quarterly HTC, ART, and infant nevirapine prophylaxis uptake outperformed national averages over years 2-3. While transitioning EID laboratory services to MoH, STF provided first-time HIV-1 DNA PCR testing for 2,226 of 11,261 HIV-exposed infants (20 %) tested in the MoH EID program in STF districts from program inception (Y2) through Y3. Of these, 78 (3.5 %) tested HIV-positive. Among infants with complete documentation (n = 608), median age at first testing decreased from 112 days (interquartile range, IQR: 57-198) in Y2 to 76 days (IQR: 46-152) in Y3 (p < 0.001). During Y3 (only year with national data for comparison), non-significantly fewer exposed infants tested HIV-positive (3.6 %) at first testing in STF districts than nationally (4.1 %) (p = 0.4).

Conclusions: STF interventions, integrated within the MoH Option B+ program, achieved favorable HTC, maternal ART, infant prophylaxis, and EID services uptake, and a low proportion of infants found HIV-infected at first DNA PCR testing. Continued investments are needed to strengthen the PMTCT cascade, particularly around EID.

Fig. 1

Technical Approach. Safeguard the Family approach to addressing gaps along the antenatal and early postnatal prevention of mother-to-child transmission of HIV cascade

Fig. 2

Safeguard the Family catchment area. The 5 districts within the Republic of Malawi served by Safeguard the Family (Malawi country map source: http://www.mappery.com/Malawi-Map-2)

Fig. 3

HIV testing & counseling (HTC) uptake. Quarterly comparison of antenatal clinic HTC uptake in the Safeguard the Family catchment area compared to the national average for project years 1 to 3 (April 2011 through December 2013)

Fig. 4

Couples’ HIV testing & counseling (HTC) uptake. Annual uptake of couples’ HTC in the Safeguard the Family catchment area for project years 1 to 3 (April 2011 through December 2013)

Fig. 5

Option B+ uptake. Quarterly comparison of maternal combination antiretroviral therapy / Option B+ uptake among HIV-infected pregnant women presenting to antenatal care clinics in the Safeguard the Family catchment area compared to the national average for project years 1 to 3 (April 2011 through December 2013)

Fig. 6

Infant nevirapine prophylaxis uptake. Quarterly comparison of infant nevirapine prophylaxis uptake among HIV-infected pregnant women presenting to antenatal care clinics in the Safeguard the Family catchment area compared to the national average for project years 1 to 3 (April 2011 through December 2013)