1. E. McLean(1,2), J. Renju(1), J. Wamoyi(3), D. Bukenya(4), W. Ddaaki(5), K. Church(1), B Zaba(1), A. Wringe(1), ALPHA Network 1.London School of Hygiene and Tropical Medicine, London, United Kingdom; 2.Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi; 3.National Institute for Medical Research, Mwanza, Tanzania, United Republic of; 4. MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda, 5Rakai Health Sciences Program, Kalisizo, Uganda Counselled to compliance: Experiences of Option B+ for PMTCT in four health and demographic surveillance studies in sub-Saharan Africa

2. Introduction Option B+ introduced by Malawi in 2011 & added to WHO recommendations in 2012 Concerns over uptake and retention in care Opportunities to learn from Option B+ to guide test-and-treat policies Data from a 6-country qualitative study of PLHIV using in-depth interviews exploring understanding and experiences of HIV care and treatment in demographic surveillance sites 30 HIV-positive women and 15 healthcare workers in Malawi, Tanzania, and Uganda Thematic analysis guided by a Socio-ecological Model Methods

3. Results Results s HEALTH SYSTEM Persuasive techniques of HCW COMMUNITY Knowledge of treatment as prevention FAMILY Relationship with partner Relationship with family INDIVIDUAL Option B+ is to protect the baby Being newly diagnosed Leading to avoidance techniques: Discarding ART Attending new ANC Avoiding ANC Giving false information “...I refer [her] to my friend since we have different ways of handling people you may find that she accepts to be tested. If they are not on ART we counsel them and tell them the reasons why we are doing that up until they accept... From there we also go together to the clinic I always make sure she gets there…if you can send them alone sometimes they cannot go” (HCW)

4. Conclusions Option B+ appears to be viewed as a “one size fits all” public health approach with a primary aim of protecting the unborn child. Pregnant women may have benefitted from being allowed time to accept their status and be ready to initiate life long treatment Allowing HCW and women flexibility within policies may reduce some avoidance strategies viewed in this study. Some lessons learnt from Option B+ may not translate well to future ‘test-and-treat’ programmes given that the main driver for early ART initiation was to protect the infant Strengths and limitations A comparative study from 4 sites, part of a larger study using standard topic guides; able to compare sites, but small samples in each Able to access women not in care but these hardest to interview

5. Thank You This study was made possible with support from: The Wellcome Trust (085477/Z/08/Z) and The Bill and Melinda Gates Foundation (OPP1082114).