Retention of HIV+ pregnant and breastfeeding women on universal antiretroviral therapy (Option B+) in Malawi

Lyson Tenthani* & Andreas Haas*, Hannock Tweya, Andreas Jahn, Joep J van Oosterhout, Frank Chimbwandira, Zengani Chirwa, Wingston Ng’ambi, Alan Bakali, Sam Phiri, Landon Myer, Fabio Valeri, Marcel Zwahlen, Gilles Wandeler*, Olivia Keiser* for the Ministry of Health in Malawi and IeDEA Southern Africa

* equal contribution

Background

Malawi pioneered “Option B+” to prevent mother-to-child transmission (PMTCT) of HIV.

(Potential) benefits• Higher PMTCT coverage • Improved PMTCT• Reduced maternal morbidity and mortality • Avoiding repeated short-course antiretroviral

exposures • Reduced transmission to serodiscordant partners

Concerns• Acceptability of ART to prevent mother-to-child

transmission• Retention and adherence among

asymptomatically HIV infected women

Methods

Facility-level data from on 21939 Option B+ patients from 540

sites

Descriptive analysis of 6 months retention

rates

Descriptive analysis of the proportion of

patients loss to follow-up per site

Meta-regression for site-level predictors of

loss to follow-up

Patient-level data from 19 sites with

EMRS

Kaplan-Meier curves for time from HIV

testing to ART start

Logistic regression & competing risk

regression for loss to follow-up

Meta-analysis & meta-regression for

site level predictors of loss to follow-up

Loss to follow-up among Option B+ patients 6 months after ART start

Site-level predictors for loss to follow-up

OR (95% CI) p-valueUrbanity 0.059 Rural 1 Mostly urban 1.29 (0.96-1.71) Urban 1.39 (0.98- 1.96) Managed 0.040 Faith-based 1 Ministry of Health 1.19 (0.94- 1.50) Private 1.17 (0.65- 2.13) Other 0.64 (0.39- 1.04) Electronic (yes/no) 1.29 (0.93- 1.77) 0.115Level of care 0.047 Health Centre 1 District Hospital 1.28 (0.97- 1.68) Central Hospital 2.70 (0.92-7.94)

Loss to follow-up among Option B+ patients 6 months after ART start

Non Electronic Electronic

Cumulative incidence of loss to follow-up

No follow-up and loss to follow-up

No follow-up visit Lost at 2nd visit Lost during months 3-8

OR (95% CI) p OR (95% CI) p SHR (95% CI) p

ART indication

Low CD4 Stage 3/4

1 <0.00 1 <0.00 1 0·1

B+ pregnant 4.8 (4.0-5.7) 2.0 (1.5-2.7) 1.2 (0.8-1.7)

B+ breastfeeding 2.1 (1.7-2.6) 1.0 (0.6-1.4) 0.8 (0.5-1.1)

Percentage of Option B+ pregnant women with no follow-up visit

. (0.00, 44.95)with estimated predictive intervalOverall (I-squared = 93.2%, p = 0.000)

19

15

12

16

5

7

102

18

13

6

1

Cohort

8

9

17

14

411

3

.11

.24

.17

.12

.23

.05

.32

.35

.24

.29

.24

.3

B+*

.22

.31

.16

.3

.26

.26

.19

18.71 (12.95, 24.47)

4.17 (0.58, 24.35)

17.03 (12.24, 23.20)

7.46 (3.14, 16.71)

8.82 (2.87, 24.04)

10.83 (6.40, 17.77)

1.72 (0.24, 11.24)

29.51 (25.06, 34.38)43.15 (36.41, 50.15)

27.03 (20.49, 34.74)

28.35 (21.19, 36.79)

13.64 (9.06, 20.01)

11.81 (7.25, 18.67)

Percent (95% CI)

14.29 (8.09, 23.99)

29.63 (19.01, 43.02)

28.47 (21.54, 36.58)

28.89 (17.57, 43.63)

1.04 (0.15, 7.02)25.68 (21.00, 31.01)

30.00 (14.14, 52.72)

18.71 (12.95, 24.47)

4.17 (0.58, 24.35)

17.03 (12.24, 23.20)

7.46 (3.14, 16.71)

8.82 (2.87, 24.04)

10.83 (6.40, 17.77)

1.72 (0.24, 11.24)

29.51 (25.06, 34.38)43.15 (36.41, 50.15)

27.03 (20.49, 34.74)

28.35 (21.19, 36.79)

13.64 (9.06, 20.01)

11.81 (7.25, 18.67)

Percent (95% CI)

14.29 (8.09, 23.99)

29.63 (19.01, 43.02)

28.47 (21.54, 36.58)

28.89 (17.57, 43.63)

1.04 (0.15, 7.02)25.68 (21.00, 31.01)

30.00 (14.14, 52.72)

-20 -10 0 10 20 30 40 50 60

* Proportion of B+ pregnant women

Time from HIV testing to ART initiation

Conclusion

• Compared to ART patients in an advanced stage of the disease Option B+ patients are at increased risk of loss to follow-up.

• Pregnant Option B+ patients are at particularly high risk to get lost.

• Most Option B+ patients who were lost started at the day of HIV testing and never came back.

• ART preparation at first visit is crucial.

• Barriers to retention in care need to be fully understood.

• Many sites with a low rate of LTF demonstrate that a good level of retention in care can be achieved.