Three years Option B+ in Malawi Success and challenges of a novel programme to prevent mother-to-child transmission of HIV

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1 Three years Option B+ in Malawi Success and challenges of a novel programme to prevent mother-to-child transmission of HIV Olivia Keiser, PhD University of Bern, Switzerland okeiser@ispm.unibe.ch 1

2 Cascade during pregnancy Clinic visit HIV test HIV negative HIV positive CD4 determination cart needed cart not needed Start cart Prophylaxis Prophylaxis before Option B+: Daily AZT during pregnancy; 3TC/NVP at delivery infant: AZT syrup 2

3 «New» strategy for HIV+ pregnant women in Malawi: Option B+ Clinic visit HIV test HIV negative HIV positive CD4 determination Lifelong therapy: TDF 3TC EFV cart needed Start cart cart not needed Prophylaxis Infants: NVP syrup 6 wks PCR testing 6 wks Rapid HIV test: 12;24 mo 3

4 «Emphasis was put on the baby. For me, I was left out.» «Actually, people were happy about that Option B+. Mostly women because they knew it would save their babies» 4

5 HIV testing during antenatal care 5

6 «New» strategy for HIV+ pregnant women in Malawi: Option B+ Clinic visit HIV test HIV negative HIV positive CD4 determination cart needed cart not needed Start cart Prophylaxis 6

7 First step: HIV testing during antenatal care in Malawi ( > pre Option B+) Overall: 82% known HIV status Tenthani et al, submitted 7

8 And in Option B+ period? Q1 2014: still 82%... Quarterly programme report MOH Q

9 ART uptake 9

10 Cascade during pregnancy Clinic visit HIV test HIV negative HIV positive CD4 determination cart needed cart not needed Start cart Prophylaxis 10

11 Systematic review and meta analysis 10 studies HIV+ women CD4 measured Therapy needed Start cart 100 % 67.6% ( %) 14.6% ( %) 9.4% ( %) Wettstein et al, AIDS

12 Time trends of PMTCT MOH quarterly report Jan-Mar

13 PMTCT Coverage Year Needing PMTCT % receiving PMTCT % % % 2014, Q1* % SPECTRUM estimates; * MOH quarterly report Jan-Mar

14 Loss to follow-up 14

15 Loss to follow-up Tenthani & Haas et al, AIDS

16 Loss to follow-up: Change over time? Increase in LTF: Mainly due to decreasing nr of breastfeeding women who are less likely to get lost. Adapted from quarterly reports MOH 16

17 Loss to follow-up: clear improvement in some sites Lighthouse clinic Characteristics Adjusted Rate Ratios (95% CI) P-Value Age at ART initiation (years) < ( ) Year of B+ Implementation < ( ) ( ) Adjusted for reason of ART initiation and empolyment status Tweya et al, TMIH

18 MAP Haas et al, preliminary results 18

19 MAP Spatial clustering of loss to follow-up: Seems to be associated with HIV stigma, HIV knowledge, ethnic groups in different regions Loss to follow-up at 6 months (%) Haas et al, preliminary results 19

20 What happened to women lost? Tracing Outcomes 577 LTFU women 228 (40%) Successfully Traced 349 (60%) Not traced/ Not found Tweya et al, TMIH

21 What happened to women lost? Tracing Outcomes 577 LTFU women 228 (40%) Successfully Traced 349 (60%) Not traced/ Not found Previous tracing study among adult ART patients: 30% not found (Tweya et al, PLoS One 2013): 21

22 What happened to women lost? Tracing Outcomes 577 LTFU women 228 (40%) Successfully Traced 349 (60%) Not traced/ Not found Many not traced: Incorrect addresses in patient files -> fear of stigma and discrimination? Tweya et al, TMIH

23 What happened to women lost? Tracing Outcomes 228 Successfully Traced 9 (4%) Died 80 (35%) On ART elsewhere 134 (59%) ART stopped or never started 5 (2%) Interview refused Tweya et al, TMIH

24 Reasons for ART discontinuations (N=111) Reasons for ART discontinuation n % Travelled away 42 38% Transport costs 17 16% Limited information about ARVs 11 10% Suspected side effects of ARVs 11 10% Very weak/sick 11 10% Non-disclosure of HIV status to the spouse 9 8% Religious belief 5 5% Forgotten to take ARVs 5 5% Other reasons 49 44% Tweya et al, TMIH

25 Ongoing study Umoyo+ 25

26 Electronic database Antenatal care Maternity Infants <2 years ART database 26

27 END STILL A LONG WAY TO GO Malawi 27

28 END But the outlook is fantastic Mulanje Mountains, Malawi 28

29 Thank you! ISPM Bern: Zofia Baranczuk, Matthias Egger, Janne Estill, Andreas Haas, Catrina Mugglin, Adrian Spörri, Kali Tal, Celina Wettstein Malawi: Frank Chimbwandira, Zengani Chirwa, Oliver Gadabu, Andreas Jahn, Eustice Mhango, Dalitso Midiani, Malango Msukwa, Joep van Oosterhout, Sam Phiri, Lyson Tenthani, Hannock Tweya, Collins Zamawe. Data entry team Other countries: Mary-Ann Davies, Chris Duncombe, Landon Myer Funders: Bill and Melinda Gates Foundation, NIH - PEER, NIH - IeDEA Southern Africa, Swiss National Science Foundation 29