Option B+ has enabled Malawi to make significant progress towards 90-90-90

In four years, Malawi’s treatment cascade for pregnant women has been transformed so that the proportion of women with HIV who are diagnosed has gone from 49 to 80%, and the proportion who are virally suppressed has jumped from 2 to 48%, the Conference on Retroviruses and Opportunistic Infections (CROI 2016) in Boston heard this week.

The country’s creation and implementation of an Option B+ programme for pregnant women shows what can be achieved by a ‘treat all’ programme and the kind of health system reforms needed to deliver UNAIDS’ 90-90-90 targets, Andreas Jahn of the Malawian Ministry of Health told delegates.

“The constraints that we face in Malawi have actually been a very fertile ground for innovation.” Andreas Jahn

The 90-90-90 target set by UNAIDS encourages countries to aim to achieve (by 2020): diagnosis of 90% of people living with HIV; initiation of treatment by 90% of diagnosed people; viral suppression in 90% of people on treatment.

Option B+ was first conceived and implemented in Malawi and offers antiretroviral therapy (ART) to all pregnant women with HIV, regardless of CD4 cell count or disease stage, with the intention that therapy will be continued after the pregnancy ends. It was designed to be a simple approach to implement in the context of extremely limited resources.

Since Malawi introduced Option B+ in 2011, the benefits of early initiation of ART have become better understood and the World Health Organization now recommends that all people living with HIV are offered ART, regardless of CD4 cell count.

In the first half of 2011 – just before Option B+ was introduced – the coverage of ART was “abysmal”, Jahn said. Of all pregnant women living with HIV, an estimated 49% were diagnosed, 3% were receiving treatment, 2% were still in care after a year and 2% were virally suppressed.

Just four years later, in the first half of 2015, 80% of women living with HIV were diagnosed, 78% were receiving treatment, 60% were still in care after a year and 48% were virally suppressed.

If current trends continue, Malawi may be able to achieve 90-90-90 by the year 2020.

Option B+ is also preventing mother to child transmission of HIV. A presentation earlier in the week showed that in those women who had already begun ART before their current pregnancy (just under half of the sample), the transmission rate was 1.4% – comparable to that in many developed countries. Across the whole sample it was 4.1%.

Implementing treatment for all

In a talk the previous day, Andreas Jahn outlined some of the factors that have helped make the implementation of Option B+ a success. Importantly, it had been designed with the limitations of the country’s health system in mind. “The constraints that we face in Malawi have actually been a very fertile ground for innovation,” he said.

Malawi is a small and densely populated country of 17 million people, one million of whom are living with HIV. Health facilities are basic and more than half the health workforce are health extension workers with limited training. The country would need to devote 8% of its Gross Domestic Product (GDP) to provide HIV treatment for all those who need it.

In order to implement Option B+, antiretroviral therapy became available in all the country’s healthcare facilities which offered antenatal services. The number of ART sites was doubled, bringing ART within walking distance of most patients. “Probably the decentralisation has had a greater impact on coverage than the relaxation of ART eligibility alone,” Jahn said.

To decongest clinics, appointments and prescriptions were offered every three months rather than every month and there were no ‘diagnostic hurdles’ to jump before treatment could be started.

Guidelines have been kept very simple, in line with the workforce’s level of training. But Jahn said that the success of task shifting and decentralisation in the country has hinged upon supportive supervision of health facilities – all sites are visited by experienced nurses and clinicians four times a year. Peripheral services which are new to ART provision would struggle without this support, he said.

The visits include physical counts of the ARVs in stock which, along with other reforms to supply management, have helped prevent stock-outs. The Ministry of Health is able to monitor stock levels for all commodities at all sites for any given day; Jahn stressed that active management of the supply chain is needed.

While Malawi is largely dependent on international donors, the Global Fund’s requirements for accountability in the use of commodities have promoted efficiency and its grant cycles have encouraged longer-term planning.

In terms of challenges, Jahn noted that even in the context of an easily accessible population of pregnant women (almost all of whom attend an antenatal care facility), the target of diagnosing 90% had still not been reached. He blamed interruptions in the availability of test kits and staff shortages for this.

Only around half of those starting therapy have had their HIV-positive status verified with a confirmatory test. With the only requirement for ART initiation being an HIV-positive diagnosis, a single test result should not be relied upon – the consequences for a person who is in fact HIV-negative taking lifelong ART are considerable.

Finally, retention in care is not as good as hoped and has not improved since Option B+ was introduced in 2011. Around 77% remain in care after six months, 72% after twelve months and 68% after two years. There is a great deal of variability between sites; Jahn suggested that inadequate education and preparation for treatment in antenatal services may sometimes be to blame for poor retention. He acknowledged that an HIV diagnosis during pregnancy can be particularly challenging.