1. “Treatment for all pregnant women:
Lessons learned and an overview of programmatic challenges”
Presented by:
Agnes Mahomva, MBChB, MPH
Country Director , EGPAF Zimbabwe
International AIDS Conference,
Durban, South Africa
July 18, 2016

2. Outline Introduction and Background Option B+ Successes
Programmatic Challenges
Lessons Learnt and Conclusion

3. HIV-positive Pregnant Women
PMTCT Drug Options
HIV-positive Pregnant Women
HIV-exposed Infant
CD4 < 350
CD4 >350
PMTCT Option
Preg
Labor/ delivery
Post-partum
Daily Drug
Duration A
ART for life
AZT from wk 14
AZT/3TC
+sdNVP
AZT/3TC for 7 d
NVP
Until stop breastfeeding (min 4-6 wk) B
ART from HIV dx
ART
ART until stop BF
NVP or AZT
Birth to age 4-6 weeks B+
 ART for life 
Source: WHO, 2013

4. Background
Option B+ is a model of treatment for all in a specific population
All pregnant and breast feeding women living with HIV
Rapid shift to initiate ART for all pregnant and breast feeding women living with HIV since 2013*
Since end of Oct 2015 all 22 Global Plan priority countries (except Nigeria) officially endorsed Option B+
National Option B+ policy implemented at >90% of all sites in 14/22
*Source: IATT Update, October 2015

5. ART Sites in Zimbabwe, 2004-June 2015
Rapid increase of ART initiating sites in 2014/15
Source: Zimbabwe MOHCC national data

6. Option B+ Successes Vertical transmission benefit
Increased coverage of ART among pregnant women
Ease of implementation/rapid roll out
Harmonized regimens
High acceptability by pregnant women
Adoption of differentiated care models
Some HSS as part of roll out

7. Option B+ Successes: ART coverage as percent of all infected adults or children (Increased coverage of ART among pregnant women)
ART coverage in pregnant women now outpacing all adults and children due to Option B+ scale-up!
Source: UNAIDS data – AIDS info (Nov 2015)

8. Acceptability: Pregnant women’s responses to B+
Option B+ Successes
Acceptability: Pregnant women’s responses to B+
Easy to accept lifelong therapy because it was similar to taking medication for diabetics or birth control
Accepted lifelong therapy for the sake of their babies
Seeing other people looking healthy on ART in their communities facilitated ART acceptance
Low pill burden: one pill a day was much easier to manage
Zim Option B+ acceptability study of 2015
Objective: To describe the acceptability of lifelong antiretroviral treatment for women recently initiated on Option B+ and women who were still on Option A
Method: Cross sectional qualitative study: In depth interviews, Focus Group Discussions (FGD) and Key Informant Interviews (KII)
Source: IAS 2016 Poster WEPEE514; Acceptability of Option B+ in Zimbabwe

9. Option B+ Successes Adoption of differentiated care models
Decentralization of ART from OI/ART sites to all MNCH facilities
OI/ART sites decongested
Nurses capacitated to initiate ART – Task shifting
Pregnant women able to access ART nearer home
Introduction of same day ART initiation supported by strengthened adherence counselling at every ANC follow up visit

10. Option B+ Programmatic Challenges
Limited investment in all HSS pillars
Leadership to see through an efficient decentralization
Financing for additional decentralized program needs
Drugs and commodities – simplified regimen yes BUT procurement and supply chain management remained a challenge
Implementation at site level not always well coordinated
Delays in revision of M&E systems and limited program impact evaluations
Loss to Follow up
Poor retention in care

11. EGPAF Tanzania: Early retention (2+ visits) in HIV care among non-pregnant vs. pregnant women, by year of enrollment
Tanzania data slide from Gretchen Antelman Oct 2014
This specifically focuses on early retention of women in care and treatment as measured by attending the clinic 2 or more times. It also compares women to women rather than women to all other adults, since men on ART are often observed to have lower retention rate than women. The 30% difference in early retention rates is dramatic and consistent over time! Loss of pregnant women occurs predominantly during early stages of treatment. This must be addressed.
Pregnancy a significant risk factor for non-retention, and this has not changed much over time.
With B+ expanding, increasing number and % of PLHIV on ART will come from PMTCT programs, and this will likely depress ART retention indicators even further.
Better understanding of how to support PMTCT mothers on ART, and long term HIV care, urgently needed.
Source: EGPAF Tanzania data

12. Lessons Learnt
Health system strengthening for all six pillars with a focus on the following was key to a smooth roll out:
District and site leadership for efficient decentralization
Drug forecast and supply chain management
Life long ART was acceptable by those not yet ill
Retention in care remained a big challenge
Loss to Follow up

13. Lessons Learnt
Introduction of innovative care models important for rapid rollout of life long ART and for follow up :
Decentralization of ART to all MNCH sites
Same day ART initiation with strengthened adherence counselling at follow up visits
Support groups to strengthen follow up and adherence after deliver and during breast feeding (eg CATS* for adolescent mothers)
*Community Adolescent Treatment Supporters (eMTCT Champions)

14. Thank you!
Tatenda