Publication Spotlight: Lessons Learned From Early Implementation of Option B+

On Dec. 1, 2014, World AIDS Day, the Journal of Acquired Immune Deficiency Syndromes (JAIDS) published a supplement, Bridging Gaps Between HIV, Maternal and Reproductive Healthcare in Sub-Saharan Africa: Evidence for Action.

The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) contributed an article to this JAIDS supplement analyzing early lessons learned with the implementation of Option B+, as recommended in the World Health Organization (WHO) 2013 Consolidated Antiretroviral Guidelines. Option B+ recommends initiation of lifelong antiretroviral treatment (ART) for all pregnant and lactating women living with HIV to reduce risk of mother-to-child transmission of HIV and to maintain the good health of mothers.

Meghan Mattingly, a technical officer with EGPAF’s department of Medical and Scientific Affairs, was one of the authors of the published manuscript, “Lessons Learned from Early Implementation of Option B+: The Elizabeth Glaser Pediatric AIDS Foundation Experience in 11 African Countries.” Below, she shares some of the article’s key takeaways.

What prompted the development of this manuscript?

The WHO has emphasized the need to closely monitor the implementation of Option B+ to identify programmatic and health system challenges. In light of this, we reviewed EGPAF’s multicountry experience supporting ministries of health with Option B+ implementation across 11 African countries. This review and analysis is intended to inform stakeholders involved in scaling up Option B+.

What have been some of the findings?

EGPAF’s early experiences with Option B+ implementation demonstrate promise. Continued program evaluation is needed, as is attention to counseling and support for HIV-positive women around initiation of lifetime antiretroviral therapy (ART) in pregnancy and lactation. These are some of our specific findings:

• Rapid increase in access to ART for HIV-positive pregnant women. Our review found that adaptation and implementation of Option B+ in supported countries was rapid —with several countries beginning to implement this approach even before the release of the WHO guidelines in July 2013. By the end of 2013, most EGPAF-supported country programs were reaching at least 50% of HIV-positive pregnant women in ANC with ART, even in countries that chose a phased approach to national scale-up of Option B+.
• Expansion of the health work force is necessary. In addition to training and mentorship needed to bring existing health staff up to speed on new treatment guidelines, scaling up Option B+ has required an expansion of the health workforce. For example, to implement Option B+ in Uganda, the Ministry of Health recruited more than 8,000 additional health care workers (mostly nurses and midwives).
• Counseling for ART uptake and adherence. To reap the benefits of Option B+ for both the mother and the infant, early ART uptake, adherence throughout the mother-to-child transmission risk period, and lifelong retention in care, are critical. Preliminary results of EGPAF studies have highlighted the importance of counseling and support provided to pregnant women in increasing their acceptance of lifelong ART.

How will these findings affect the focus of future program implementation or further areas of research?

• Effective models for counseling, male engagement, and community support. It is important to evaluate the most effective strategies to ensure support for women around initiation of and adherence to lifetime ART in the context of pregnancy and lactation. Areas for further evaluation include new counseling models, such as sequenced counseling messages which introduce ART first as a PMTCT tool, and then the benefits of lifelong ART, as well as models for male engagement and community support to facilitate acceptance of lifelong ART.
• Tracking systems to facilitate long-term adherence and retention. Improved tracking systems are needed to facilitate long-term follow-up of mother-baby pairs and to understand outcomes of Option B+ implementation.

EGPAF will continue to support country programs to achieve optimal outcomes in their PMTCT programs through national level policy discussions, health care worker capacity building, supportive supervision, and community engagement. Option B+ holds potential to facilitate country-level movement toward eliminating pediatric HIV and AIDS.

For more information on how EGPAF supports countries in the adaptation and implementation of Option B+, read the Option B+ issue of EGPAF’s technical newsletter, Haba Na Haba.