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IAS 2013: Women Who Start Option B+ ART During Pregnancy Often Lost to Follow-up

Women who begin HIV treatment during pregnancy or while breastfeeding, prior to the CD4 cell threshold previously recommended for starting treatment (350 cells/mm³), were significantly more likely to be lost to follow-up than women who started treatment at the general treatment threshold, Malawian researchers reported at the recent 7th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention in Kuala Lumpur.

[Produced in collaboration with Aidsmap.com]

Initiating antiretroviral therapy (ART) during pregnancy or while breastfeeding when an HIV positive woman has a high CD4 count (above 350 cells/mm³) is referred to as Option B+ in World Health Organization (WHO) and national guidelines.

Option B+ was first conceived and implemented in Malawi, where the national ART program had already been functioning well using a public health approach which did not depend heavily on CD4 testing to determine who should initiate treatment. Malawi envisioned that Option B+ would be easier to implement due to its simple 'one size fits all' approach which would enable women to access antiretroviral treatment in settings with poor access to CD4 testing.

The analysis presented at the conference by Lyson Tenthani looked at the outcomes for all women in Malawi who started treatment in the fourth quarter of 2011 and the first quarter of 2012. A total of 21,939 patient records from 540 sites were included.

In total, 17% of all Option B+ patients were lost to follow-up 6 months after ART initiation. Option B+ patients who initiated antiretrovirals during pregnancy were 5 times more likely to not return to the clinic after their initial visit than patients who started with a low CD4 cell count or with WHO clinical stage 3 or 4 disease (OR 5.2).

Option B+ patients who started treatment while breastfeeding, were twice as likely to miss their first follow-up visit (OR 2.3).

Pregnant Option B+ patients who initiated antiretrovirals on the day they were diagnosed as HIV-infected were less likely to return to clinics than pregnant Option B+ patients who started subsequently (OR 1.7).

Altogether, 37% of the sites performed well, with fewer than 10% of all patients lost to follow-up 6 months after ART initiation. However, 33% of the sites had a loss-to-follow-up rate of more than 20%.

Loss to follow-up was somewhat higher at sites operated by the Ministry of Health, compared to sites managed by faith-based organizations (OR 1.2). Patients receiving antiretrovirals at central hospitals were 2.7 times more likely to be lost to follow-up than those treated at health centers (OR 2.7).

Option B+ in Uganda

A study of women starting treatment according to Option B+ guidelines in the antenatal clinic and labor ward at Mulago National Referral Hospital in Kampala, Uganda, found that women who enrolled on Option B+ in the antenatal clinic were more likely to return for care than those who enrolled in labor wards.

A total of 190 women tested HIV positive and 92% started on antiretroviral treatment in the antenatal clinic between October 17 and December 31, 2012. A total of 82% (155 of 190) returned to receive their CD4 count results. In addition, 162 women started on antiretroviral treatment after labor began. Only 20 of these women (12%) returned to receive their CD4 results.

Mulago National Referral Hospital rolled out Option B+ in October 2012. Newly diagnosed HIV positive women in antenatal clinics started antiretrovirals on the same day, and blood was drawn to assess CD4 cell counts and to determine baseline kidney and liver function. Women were given an appointment 2 weeks later to receive their results. Those diagnosed during labor were given antiretrovirals and asked to return after 2 weeks for CD4 tests and blood chemistry. At this visit, they were given another 2-week appointment to receive results.

This analysis is limited as the study is of a referral hospital, and women started on treatment in labor wards could have shifted their care to closer and more convenient ARV centers.

"There is a critical need to determine the dynamics that affect follow-up among women, more especially among women initiated on ART during labor or delivery," said Emily Namara-Lugolobi, one of the authors of the study.

8/7/13

References

LN Tenthani, AD Haas, H Tweya, et al. Roll-out of universal antiretroviral therapy for HIV-infected pregnant and breastfeeding women ('Option B+') in Malawi: factors influencing retention in care. 7th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention. Kuala Lumpur, June 30-July 3, 2013.Abstract WELBD01.

E Namara Lugolobi, Z Namukwaya, P Musoke, et al.Retention in care among women initiated on Option B plus in the Antenatal Clinic (ANC) and labour ward at Mulago National referral hospital Kampala, Uganda. 7th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention. Kuala Lumpur, June 30-July 3, 2013. Abstract TUAC0102.