The Rationale for Option B+ in Malawi

Dept. for HIV and AIDS, MOH, Malawi

HIV in Malawi • 14.5 million population

• 11% adult HIV prevalence

• 61,000 AIDS deaths

• 63,000 HIV+ pregn. women

• 5.7 Total Fertility Rate

• 650 health facilities

• 1 doctor and 26 nurses per 100,000 population

PMTCT

• 2002: Scale up of sdNVP at ANC, maternity

• 2007: start AZT combination prophylaxis

• Reliance on CD4 + clinical staging for ART

• 2010: Standard integrated M&E tools

– ANC cohort report: final PMTCT status / outcome

– Maternity: mother and baby status

Sound M&E Data: A Bad Awakening

No more duplication in ANC reports:

• 70% HIV status ascertained

• 38% of HIV+ received any ARVs– 40% sdNVP– 40% AZT combination– 20% ART

-

20

40

60

80

100

120

140

160

180

200

2009 2010 2011 2012 2013 2014

US

$ (

mil

lio

n)

Costs per Annum for Different Scenarios

GOM contribution to health

current scale up

early start

early start (AZT NVP)

early start (TFD EFV)

Malawi Feasibility Appraisal of 2009 WHO ART and PMTCT Guidelines

A or B… or something else?

What works:

• Unprecedented scale-up of ART

• Almost universal ANC attendance (although late)

• HIV testing at ANC

• Option A

A or B… or something else?What doesn’t work:• CD4 testing at all ANC sites

– Machines down– Need for speedy sample transportation– Poor QC results

• Referral for clinical staging• Modification of breast feeding (AFASS…)• Complicated regimen protocols• Extended use of infant syrup

Too many conditions!

Why B+?

• HIV test the only condition– Can be done at the smallest health Centre

• Simple standard regimen:– One size fits all– Simplification of supply chain

• Clear public health message: ART is for life

Why B+?

• Avoid start – stop –start approach– Birth intervals 2.5 years– Women will be eligible for ART after 3-4 years

• Making breastfeeding safe– Very few have any other option– Curtailing breastfeeding highly stigmatized– Many malnourished babies

Why B+?

• Keeping mothers alive– 6 x increase in postpartum deaths with high CD4 (1)

– ART can avert 90% of these deaths

• Preventing sexual transmission– 96% reduced transmission to partner with early

ART initiation (CD4 <500) (2)

– Who is not / will not be part of discordant relationship?

1. Hargrove JW, Humphrey JH. Mortality among HIV-positive postpartum women with high CD4 cell counts in Zimbabwe. AIDS 2010; 24: F11–142. Cohen MS, et al. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. NEJM 2011; 365 Vol6

Option B+ as the Game Changer

Consequential integration of PMTCT and ART• Efficiency gains: 1 guideline, 1 training, 1

supervision system, 1 supply chain

• Cumulative benefits– Growing proportion of HIV+ women already on

ART when getting pregnant

Option B+ as the Game Changer

The last mile of ART decentralization• ART at (almost) everybody’s doorstep• Wave of ART patient transfers• Weak staffing and infrastructure at remote HC

Universal Test & Treat• Risk of starting false positives on ART for life

Implementation of Option B+

• Additional USD 30 million for ARVs– Reprogramming of GF RCC Grant

• 4,389 health workers retrained– Massive exercise supported by PEPFAR

• 650 sites in quarterly supervision program– 65 staff for 3 weeks– USD 110,000 per round

Results: Pregnant / breastfeeding women on ARVs

1 2 3 4 1 2 3 4 12010 2011 2012

0

5,000

10,000

15,000

20,000

ARTAZT combsdNVP

Virtual Elimination of MTCT?

• Option B+ will bring us very close to virtual elimination