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, Teferi Beyene, Anthony Harries, Stephen Chu, Andrew Mganga, Joep J van Oosterhout

Malawi

• new PMTCT strategy in 2011Option B+

• Implemented in other countries

• No formal evidence base and concerns about losses to follow up

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?

Chibwandira et al; MMWR 2013

• 750% increase ART pregnant & BF women 4

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

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

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

Setting

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)

Methods

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 modelsHigh HIV testing uptake >85%High retention on ART >92%

• 141/153 health facilities included in the studyResults

Characteristics (median) District Hospital

(n=4)

Community

Hospitals (n=8)

Health Centers (n=120)

Private Clinics (n=9)

Medical Doctors 2 0 0 0

Other Clinical staffClinical Officers/Nurses/Medical Assistants 50 24 3 4

Support staffCounselors/Expert Patients/ART clerks 25 15 8 3

Total number of staff per facility 77 39 11 7

Women newly registered for ANC/quarter 1025 377 265 116

Women newly registered start ART Option B+ 6-month cohort: July-Dec 2012

184 105 50 14

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)

4 Models of Care identified

PMTCT service delivery

Model D

No ANC, ART clinic (n=9)

Facilities providing both ANC and ART services (n=131)

Model B

1st dose ANC then ART clinic (n=38)

Model A

All ART in ANC (n=75)

Model C

All ART in ART clinic (n=18)

At day of ART initiation or

transfer in (n=9)

Same day at ANC (n=29)Next visit at ART (n=2)Both at ANC & ART(n=7)

Timing and place of Adherence Counseling for ART initiation

Same day at ANC (n=47)Next visit at ANC (n=12)Both at ANC (n=16)

At day of ART initiation at ART clinic (n=18)

Timing of transfer to ART- or MIP clinic

No transfer (n=9)No transfer

(n=16)at 6 wks postnatal visit

to MIP clinic (n=2)

After receiving 1st dose at ANC to ART clinic

(n=38)

at 6 wks postnatal visit: to ART clinic (n=24)to MIP clinic (n=51)

ANC indicators of health facilities by Model of Care

MODEL A

MODEL B

MODEL C

MODEL D

P-value

Women newly registered for ANC/quarter (median)

252 316 224   0.07

Women newly tested positive/quarter (median)

11 12 10   0.4

Known HIV-infected women already on ART

84% 81% 85%   0.7

HIV-infected women started ART during ANC

82% 81% 80%   0.9

Women not tested for HIV during ANC 18% 32% 30%   0.001

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

MODEL A

MODEL B

MODEL C

MODEL D

P-value

Women in cohort (median) 52 55 45 26 0.1

Women retained on ART 80% 78% 89% 92% 0.008

Defaulted 18% 20% 10% 7% 0.02

Stopped <1% <1% <1% <1% 0.6

Died 1% <1% 1% <1% 0.6

Health Facility variables associated with high HIV testing uptake at

ANCVariables ASSOCIATED Variables NOT associated

Low Client : HIV testing Staff ratio District

Client : Clinical staff ratio

Health Facility type

Number women registered in ANC

Low number of out of stock observations of HIV test kits

Model of Care applied aOR*

Model A 3.4 Model B (lowest HTC uptake rate) -Model C n s

*Controlled for all variables in the model

Health Facility variables associated with high 6-month retention

Variables ASSOCIATED Variables NOT associated

District Health Facility type

Client : Clinical staff ratio

Timing of Adherence Counseling

Availability ART/PMTCT services daily vs. not daily

Availability of ART / MIP clinic for follow up

Low number of women in Option B+ cohort

Model of Care applied aOR*Model A n s Model B (lowest retention rate) -Model C 5.4Model D n s*Controlled for all variables in the model

Discussion18-32% of pregnant women not tested for HIV at ANC HIV testing uptake associated witho Client : HIV testing staff ratio o Test kit stock outs o Model of Care

7-20% of women defaulted Option B+ by 6 monthsRetention associated witho District locationo Patient volume o Model of Care

Worse program indicators in Model BFacilities where women receive only first dose of ART at ANC

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

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

USAID and The International Union Against TB and LD for funding

Dignitas International medical program, M&E and Data departments

Acknowledgements