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Retention in care under universal antiretroviral therapy for HIV-infected pregnant and breastfeeding women (‘Option B+’) in Malawi

Tenthani, Lyson*,a,b,c; Haas, Andreas D.*,b; Tweya, Hannockb,d,e; Jahn, Andreasa,c; van Oosterhout, Joep J.f; Chimbwandira, Franka; Chirwa, Zengania,c; Ng’ambi, Wingstond; Bakali, Alang; Phiri, Samd; Myer, Landonh; Valeri, Fabiob; Zwahlen, Marcelb; Wandeler, Gillesb,i,j; Keiser, Olivia*,bfor the Ministry of Health in Malawi and IeDEA Southern Africa

doi: 10.1097/QAD.0000000000000143
Epidemiology and Social

Objective: To explore the levels and determinants of loss to follow-up (LTF) under universal lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women (‘Option B+’) in Malawi.

Design, setting, and participants: We examined retention in care, from the date of ART initiation up to 6 months, for women in the Option B+ program. We analysed nationwide facility-level data on women who started ART at 540 facilities (n = 21 939), as well as individual-level data on patients who started ART at 19 large facilities (n = 11 534).

Results: Of the women who started ART under Option B+ (n = 21 939), 17% appeared to be lost to follow-up 6 months after ART initiation. Most losses occurred in the first 3 months of therapy. Option B+ patients who started therapy during pregnancy were five times more likely than women who started ART in WHO stage 3/4 or with a CD4+ cell count 350 cells/μl or less, to never return after their initial clinic visit [odds ratio (OR) 5.0, 95% confidence interval (CI) 4.2–6.1]. Option B+ patients who started therapy while breastfeeding were twice as likely to miss their first follow-up visit (OR 2.2, 95% CI 1.8–2.8). LTF was highest in pregnant Option B+ patients who began ART at large clinics on the day they were diagnosed with HIV. LTF varied considerably between facilities, ranging from 0 to 58%.

Conclusion: Decreasing LTF will improve the effectiveness of the Option B+ approach. Tailored interventions, like community or family-based models of care could improve its effectiveness.

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aDepartment of HIV and AIDS, Ministry of Health, Lilongwe, Malawi

bInstitute of Social and Preventive Medicine, University of Bern, Switzerland

cInternational Training and Education Centre for Health/Department for Global Health, University of Washington, Seattle, USA

dLighthouse Trust Clinic, Lilongwe, Malawi

eThe International Union Against Tuberculosis and Lung Disease, Paris, France

fDignitas International, Zomba

gBaobab Trust, Lilongwe, Malawi

hDivision of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, South Africa

iDepartment of Infectious Diseases, University Hospital Bern, Switzerland

jDepartment of Infectious Diseases, University of Dakar, Dakar, Senegal.

*Lyson Tenthani, Andreas D. Haas and Olivia Keiser contributed equally to the writing of this article.

Correspondence to Olivia Keiser, PhD, Institute of Social and Preventive Medicine (ISPM), Finkenhubelweg 11, 3012 Bern, Switzerland. Tel: +41 31 631 35 15; e-mail:

Received 25 June, 2013

Revised 8 November, 2013

Accepted 8 November, 2013

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