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Malawi

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Malawi

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  1. Elimination of Mother to Child Transmission of HIV: Performance of Different Models of Care when Initiating Lifelong ART for Pregnant Women in Malawi (Option B+)Monique van Lettow, Richard Bedell, Isabell Mayuni, Gabriel Mateyu, Megan Landes, Adrienne Chan Vanessa van Schoor, TeferiBeyene, Anthony Harries, Stephen Chu, Andrew Mganga, Joep J van Oosterhout

  2. Malawi • new PMTCT strategy in 2011 Option B+ • Implemented in other countries • No formal evidence base and concerns about losses to follow up

  3. Option B+ in Malawi - Learning by Doing • No guidelines for integrating Option B+ into the routine service • Different approaches had to be considered for: • Location, timing ART • Adherence counseling • Follow-up after delivery or breastfeeding • Would this affect uptake, adherence, retention?

  4. Chibwandiraet al; MMWR2013 • 750% increase ART pregnant & BF women

  5. Nation wide HF level data: • 6-month retention 83% • Great variation between health facilities: 100 – 42% Limited insight into factors determining uptake and retention AIDS 2014

  6. Study Aims • Describe the diversity of approaches to service organization (models of care)for the delivery of Option B+ to pregnant women in health facilities in Malawi • Explore associations between the model of care and program indicators at health facility level: - uptake HIV testing in ANC - uptake ART - retention on ART

  7. Setting South East Health Zone • 6 out of 28 districts 3.5 million inhabitants • Integrated HIV care services in 153 facilities, out of 588 facilities nationwide • 154,000 pregnancies annually 14.6% HIV-infected

  8. Methods 1. Health Facility survey staff, ART initiation location, adherence counselling, follow-up and transfer  identify models of care 2. Health facility cohort reports to ascertain: - Uptake of HIV testing and ART initiation pregnant women in ANC (July 2012-June 2013) - Cohort survival outcome data to evaluate 6-month outcomes women registered as having started ART under Option B+ (July 2012-Dec 2012)

  9. 3. Associations between identified models of care and: I. Uptake of HIV testing and ART among pregnant women II. 6- month treatment outcomes  descriptive analyses and logistic regression models High HIV testing uptake >85% High retention on ART >92%

  10. Results • 141/153 health facilities included in the study

  11. 4 Models of Care identified A: Facilities where women are initiated and followed on ART at ANC clinic until giving birth (n=75) B: Facilities where women receive only the first dose of ART at ANC clinic, then follow up at ART clinic (n=38) C: Facilities where women are referred from ANC to the ART clinic for ART initiation and follow-up (n=18) D: Facilities serving as ART referral sites (n=9) (not providing ANC)

  12. PMTCT service delivery Facilities providing both ANC and ART services (n=131) Model A All ART in ANC (n=75) Model C All ART in ART clinic (n=18) Model D No ANC, ART clinic (n=9) Model B 1st dose ANC then ART clinic (n=38) Timing and place of Adherence Counselingfor ART initiation Same day at ANC (n=47)Next visit at ANC (n=12)Both at ANC (n=16) Same day at ANC (n=29)Next visit at ART (n=2)Both at ANC & ART(n=7) At day of ART initiation at ART clinic (n=18) At day of ART initiation or transfer in (n=9) Timing of transfer to ART- or MIP clinic No transfer (n=16)at 6 wkspostnatal visit to MIP clinic (n=2) No transfer (n=9) After receiving 1st dose at ANCto ART clinic (n=38) at 6 wkspostnatal visit: to ART clinic (n=24)to MIP clinic (n=51)

  13. ANC indicators of health facilities by Model of Care

  14. 6-Month ART outcomes of health facilities by Model of Care

  15. Health Facility variables associated with high HIV testinguptake at ANC *Controlled for all variables in the model

  16. Health Facility variables associated with high 6-month retention *Controlled for all variables in the model

  17. Discussion 18-32% of pregnant women not tested for HIV at ANC HIV testing uptake associated with • Client : HIV testing staff ratio • Test kit stock outs • Model of Care 7-20% of women defaulted Option B+ by 6 months Retention associated with • District location • Patient volume • Model of Care Worse program indicators in Model BFacilities where women receive only first dose of ART at ANC

  18. Strengths and Limitations Strengths: • Operational research – high quality routine government data: real world findings about Option B+ implementation • Large dataset (141 facilities) Limitations: • Results may not be representative for whole Malawi • Health facility level data only (not patient level) • Cross sectional study design • Residual confounding • Attrition due to linkage of care not studied • Models of Care C and D

  19. Conclusions • Varieties in the way health facilities have integrated Option B+ care into routine service delivery • Model of Care is associated with uptake of HIV testing in ANC and retention in care on ART • Further patient-level research is needed to guide policy recommendations

  20. USAID and The International Union Against TB and LD for fundingDignitas International medical program, M&E and Data departments Acknowledgements

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