Retention in care under universal antiretroviral therapy for HIV-infected pregnant and breastfeeding women ('Option B+') in Malawi.
OBJECTIVE
To explore the levels and determinants of loss to follow-up (LTF) under universal lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women ('Option B+') in Malawi.


METHODS
We examined retention in care, from the date of ART initiation up to 6 months, for women in the Option B+ program. We analysed nationwide facility-level data on women who started ART at 540 facilities (n = 21,939), as well as individual-level data on patients who started ART at 19 large facilities (n = 11,534).


RESULTS
Of the women who started ART under Option B+ (n = 21,939), 17% appeared to be lost to follow-up 6 months after ART initiation. Most losses occurred in the first 3 months of therapy. Option B+ patients who started therapy during pregnancy were five times more likely than women who started ART in WHO stage 3/4 or with a CD4 cell count 350 cells/μl or less, to never return after their initial clinic visit [odds ratio (OR) 5.0, 95% confidence interval (CI) 4.2-6.1]. Option B+ patients who started therapy while breastfeeding were twice as likely to miss their first follow-up visit (OR 2.2, 95% CI 1.8-2.8). LTF was highest in pregnant Option B+ patients who began ART at large clinics on the day they were diagnosed with HIV. LTF varied considerably between facilities, ranging from 0 to 58%.


CONCLUSIONS
Decreasing LTF will improve the effectiveness of the Option B+ approach. Tailored interventions, like community or family-based models of care could improve its effectiveness.
Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi.|Institute of Social and Preventive Medicine, University of Bern, Switzerland.|International Training and Education Centre for Health / Department for Global Health, University of Washington, Seattle, USA.
Lyson
L
Tenthani
Institute of Social and Preventive Medicine, University of Bern, Switzerland.
Andreas D
AD
Haas
Institute of Social and Preventive Medicine, University of Bern, Switzerland.|Lighthouse Trust Clinic, Lilongwe, Malawi.|The International Union Against Tuberculosis and Lung Disease, Paris, France.
Hannock
H
Tweya
Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi.|International Training and Education Centre for Health / Department for Global Health, University of Washington, Seattle, USA.
Andreas
A
Jahn
Dignitas International, Zomba, Malawi.
Joep J
JJ
van Oosterhout
Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi.
Frank
F
Chimbwandira
Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi.|International Training and Education Centre for Health / Department for Global Health, University of Washington, Seattle, USA.
Zengani
Z
Chirwa
Lighthouse Trust Clinic, Lilongwe, Malawi.
Wingston
W
Ng'ambi
Baobab Trust, Lilongwe, Malawi.
Alan
A
Bakali
Lighthouse Trust Clinic, Lilongwe, Malawi.
Sam
S
Phiri
Centre for Infectious Disease Epidemiology and Research, School of Public Health & Family Medicine, University of Cape Town, South Africa.
Landon
L
Myer
Institute of Social and Preventive Medicine, University of Bern, Switzerland.
Fabio
F
Valeri
Institute of Social and Preventive Medicine, University of Bern, Switzerland.
Marcel
M
Zwahlen
Institute of Social and Preventive Medicine, University of Bern, Switzerland.|Department of Infectious Diseases, University Hospital Bern, Switzerland.
Gilles
G
Wandeler
Institute of Social and Preventive Medicine, University of Bern, Switzerland.
Olivia
O
Keiser
D000293:Adolescent; D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D001942:Breast Feeding; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006302:Health Services Research; D006801:Humans; D059012:Lost to Follow-Up; D008295:Malawi; D008875:Middle Aged; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy*; D055815:Young Adult
D044966:Anti-Retroviral Agents