1. The Rationale for Option B+ in Malawi
Dept. for HIV and AIDS, MOH, Malawi

2. 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

3. 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

4. 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

5. Malawi Feasibility Appraisal of 2009 WHO ART and PMTCT Guidelines

6. 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

7. 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

8. Too many conditions!

9. Why B+? HIV test the only condition Simple standard regimen:
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

10. Why B+? Avoid start – stop –start approach Making breastfeeding safe
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

11. Why B+? Keeping mothers alive Preventing sexual transmission
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?
Hargrove JW, Humphrey JH. Mortality among HIV-positive postpartum women with high CD4 cell counts in Zimbabwe. AIDS 2010; 24: F11–14
Cohen MS, et al. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. NEJM 2011; 365 Vol6

12. 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

13. 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

14. 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

15. Results: Pregnant / breastfeeding women on ARVs

16. Virtual Elimination of MTCT?
Option B+ will bring us very close to virtual elimination