1. Retention of HIV+ pregnant and breastfeeding women on universal antiretroviral therapy (Option B+) in Malawi Lyson Tenthani* & Andreas Haas*, Hannock Tweya, Andreas Jahn, Joep J van Oosterhout, Frank Chimbwandira, Zengani Chirwa, Wingston Ng’ambi, Alan Bakali, Sam Phiri, Landon Myer, Fabio Valeri, Marcel Zwahlen, Gilles Wandeler*, Olivia Keiser* for the Ministry of Health in Malawi and IeDEA Southern Africa * equal contribution

2. Background Malawi pioneered “Option B+” to prevent mother- to-child transmission (PMTCT) of HIV. (Potential) benefits Higher PMTCT coverage Improved PMTCT Reduced maternal morbidity and mortality Avoiding repeated short-course antiretroviral exposures Reduced transmission to serodiscordant partners Concerns Acceptability of ART to prevent mother-to-child transmission Retention and adherence among asymptomatically HIV infected women

3. Methods Facility-level data from on 21939 Option B+ patients from 540 sites Descriptive analysis of 6 months retention rates Descriptive analysis of the proportion of patients loss to follow-up per site Meta-regression for site-level predictors of loss to follow-up Patient-level data from 19 sites with EMRS Kaplan-Meier curves for time from HIV testing to ART start Logistic regression & competing risk regression for loss to follow-up Meta-analysis & meta-regression for site level predictors of loss to follow-up

4. Loss to follow-up among Option B+ patients 6 months after ART start

5. Site-level predictors for loss to follow-up OR (95% CI)p-value Urbanity 0.059 Rural1 Mostly urban1.29 (0.96-1.71) Urban1.39 (0.98- 1.96) Managed 0.040 Faith-based1 Ministry of Health1.19 (0.94- 1.50) Private1.17 (0.65- 2.13) Other0.64 (0.39- 1.04) Electronic (yes/no)1.29 (0.93- 1.77)0.115 Level of care 0.047 Health Centre1 District Hospital1.28 (0.97- 1.68) Central Hospital2.70 (0.92-7.94)

6. Loss to follow-up among Option B+ patients 6 months after ART start Non Electronic Electronic

7. Retention on antiretroviral therapy (ART) “B+ pregnant” “B+ breastfeeding” “ART for own health” “Pregnant & ART for own health”

8. Cumulative incidence of loss to follow-up

9. No follow-up and loss to follow-up No follow-up visitLost at 2nd visit Lost during months 3-8 OR (95% CI)p pSHR (95% CI)p ART indication Low CD4 Stage 3/4 1<0.001 10·1 B+ pregnant4.8 (4.0-5.7) 2.0 (1.5-2.7) 1.2 (0.8-1.7) B+ breastfeeding2.1 (1.7-2.6) 1.0 (0.6-1.4) 0.8 (0.5-1.1)

10. Percentage of Option B+ pregnant women with no follow-up visit

11. Time from HIV testing to ART initiation

12. Conclusion Compared to ART patients in an advanced stage of the disease Option B+ patients are at increased risk of loss to follow-up. Pregnant Option B+ patients are at particularly high risk to get lost. Most Option B+ patients who were lost started at the day of HIV testing and never came back. ART preparation at first visit is crucial. Barriers to retention in care need to be fully understood. Many sites with a low rate of LTF demonstrate that a good level of retention in care can be achieved.