One-Year Outcomes of Women Started on Antiretroviral Therapy during Pregnancy before and after the Implementation of Option B+ in Malawi: A Retrospective Chart Review from Three Facilities

Alfred A. Kamuyango, Lisa R. Hirschhorn, Wenjia Wang, Perry Jansen, Risa M. Hoffman

Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.
Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, USA.
Department of Pathology, College of Medicine, University of Malawi, Blantyre, Malawi.
Department of Statistics, University of California, Los Angeles, USA.
Hope Medical Centre, Lilongwe, Malawi.

DOI: 10.4236/wja.2014.43039                

Abstract

Objective: To compare one-year outcomes of women started on antiretroviral therapy (ART) during pregnancy in the pre-Option B+ era to those in the Option B+ era. Methods: A retrospective chart review was performed at three sites in Malawi. Women were included in the “pre-Option B+” cohort if they started ART during pregnancy for a CD4 count < 350 cells/mm³ or WHO 3/4 condition and in the “Option B+” cohort if they started ART during pregnancy regardless of CD4 count or clinical stage. One-year outcomes were compared using Fisher’s exact and ANOVA F-tests. Results: A higher proportion of women in the pre-Option B+ cohort started ART at WHO stage 3/4 (11.9% versus 1.1%, P < 0.001), switched ART regimens (5.9% versus 0%, P = 0.002), or died in the first year after starting treatment (3.9% versus 0.5%, P = 0.05). While more women in the Option B+ cohort had poor adherence or defaulted, these differences were not significant. Conclusions: At our study sites, the transition to Option B+ has been associated with ART initiation in women with less advanced HIV infection, improved medication tolerability, and lower mortality. Further research is needed to better understand outcomes of Option B+.

Keywords

Antiretroviral Therapy, Pregnancy, Option B+, Prevention of Mother-to-Child Transmission

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	World Health Organization (2013) Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection: Recommendations for a Public Health Approach. World Health Organization, Geneva. http://www.who.int/hiv/pub/guidelines/arv2013/en/
[2]	Government of Malawi (2008) Prevention of Mother to Child Transmission of HIV and Paediatric HIV Care Guidelines. 2nd Edition, Ministry of Health, Lilongwe. http://www.aidstar-one.com/sites/default/files/PMTCT%20Guidelines%20Malawi%202008.pdf
[3]	National Statistical Office (NSO)/ICF (2011) Malawi Demographic and Health Survey 2010. NSO and ICF Macro, Zomba, Malawi and Calverton. http://www.measuredhs.com/pubs/pdf/FR247/FR247.pdf
[4]	Cooper, E.R., Charurat, M., Mofenson, L., Hanson, I.C., Pitt, J., Diaz, C., Hayani, K., Handelsman, E., Smeriglio, V., Hoff, R., Blattner, W. and Women and Infants’ Transmission Study Group (2002) Combination Antiretroviral Strategies for the Treatment of Pregnant HIV-Infected Women and Prevention of Perinatal HIV-1 Transmission. Journal of Acquired Immune Deficiency Syndromes, 29, 484-494. http://www.ncbi.nlm.nih.gov/pubmed/11981365 http://dx.doi.org/10.1097/00126334-200204150-00009
[5]	Centers for Disease Control and Prevention (CDC) (2013) Impact of an Innovative Approach to Prevent Mother-to-Child Transmission of HIV—Malawi, July 2011-September 2012. Morbidity and Mortality Weekly Report, 62, 148-151. www.cdc.gov/mmwr/preview/mmwrhtml/mm6208a3.htm
[6]	Tenthani, L., Haas, A.D., Tweya, H., Jahn, A., van Oosterhout, J.J., Chimbwandira, F., Chirwa, Z., Ng’ambi, W., Bakali, A., Phiri, S., Myer, L., Valeri, F., Zwahlen, M., Wandeler, G., Keiser, O. and Ministry of Health in Malawi and IeDEA Southern Africa (2014) Retention in Care under Universal Antiretroviral Therapy for HIV-Infected Pregnant and Breastfeeding Women (“Option B+”) in Malawi. AIDS, 28, 589-598. http://www.ncbi.nlm.nih.gov/pubmed/24468999
[7]	Coulborn, R.M., Trivino Duran, L., Metcalf, C., Namala, Y., Chirwa, Z., Murowa, M., Mbewa, K. and Garone, D. (2013) Preliminary Findings of a Routine PMTCT Option B+ Program in a Rural District in Malawi. 7th IAS Conference on HIV Pathogenesis, Treatment and Prevention, Kuala Lumpur, 30 June-3 July 2013. http://pag.ias2013.org/Abstracts.aspx?AID=2280
[8]	Ng’ambi, W.F., Tweya, H., Speight, C., Man-Bourdon, C., Hosseinpour, M. and Phiri, S. (2013) Determinants of Antiretroviral Treatment Adherence among Women Accessing PMTCT “Option B+”: A Retrospective Study at Bwaila Hospital, Malawi. 7th IAS Conference on HIV Pathogenesis, Treatment and Prevention, Kuala Lumpur, 30 June-3 July 2013. http://pag.ias2013.org/Abstracts.aspx?AID=2602
[9]	Kaplan, R., Orrell, C., Zwane, E., Bekker, L.G. and Wood, R. (2008) Loss to Follow-Up and Mortality among Pregnant Women Referred to a Community Clinic for Antiretroviral Treatment. AIDS, 22, 1679-1681. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2741732/ http://dx.doi.org/10.1097/QAD.0b013e32830ebcee
[10]	Kalembo, F.W. and Zgambo, M. (2012) Loss to Followup: A Major Challenge to Successful Implementation of Prevention of Mother-to-Child Transmission of HIV-1 Programs in Sub-Saharan Africa. ISRN AIDS, 2012, Article ID: 589817. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3767368/
[11]	Wang, B., Losina, E., Stark, R., Munro, A., Walensky, R.P., Wilke, M., Martin, D., Lu, Z., Freedberg, K.A. and Wood, R. (2011) Loss to Follow-Up in a Community Clinic in South Africa—Roles of Gender, Pregnancy and CD4 Count. South African Medical Journal, 101, 253-257. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3834586/
[12]	Nachega, J.B., Uthman, O.A., Anderson, J., Peltzer, K., Wampold, S., Cotton, M.F., Mills, E.J., Ho, Y.S., Stringer, J.S., McIntyre, J.A. and Mofenson, L.M. (2012) Adherence to Antiretroviral Therapy during and after Pregnancy in LowIncome, Middle-Income, and High-Income Countries: A Systematic Review and Meta-Analysis. AIDS, 26, 2039-2052. http://www.ncbi.nlm.nih.gov/pubmed/22951634 http://dx.doi.org/10.1097/QAD.0b013e328359590f
[13]	Rebekah Webb Consulting/ICW/GNP+ (2013) Understanding the Perspectives and/or Experiences of Women Living with HIV Regarding Option B+ in Uganda and Malawi. Global Network of People Living with HIV. http://www.gnpplus.net/assets/wbb_file_updown/2793/2013-Option-B+-Report-GNP-and-ICW.pdf