title: Towards elimination of mother-to-child transmission of HIV: performance of different models of care for initiating lifelong antiretroviral therapy for pregnant women in Malawi (Option B+).
abstract: BACKGROUND
  Malawi introduced a new strategy to improve the effectiveness of prevention of mother-to-child HIV transmission (PMTCT), the Option B+ strategy. We aimed to (i) describe how Option B+ is provided in health facilities in the South East Zone in Malawi, identifying the diverse approaches to service organization (the "model of care") and (ii) explore associations between the "model of care" and health facility-level uptake and retention rates for pregnant women identified as HIV-positive at antenatal (ANC) clinics.
  
  
  METHODS
  A health facility survey was conducted in all facilities providing PMTCT/antiretroviral therapy (ART) services in six of Malawi's 28 districts to describe and compare Option B+ service delivery models. Associations of identified models with program performance were explored using facility cohort reports.
  
  
  RESULTS
  Among 141 health facilities, four "models of care" were identified: A) facilities where newly identified HIV-positive women are initiated and followed on ART at the ANC clinic until delivery; B) facilities where newly identified HIV-positive women receive only the first dose of ART at the ANC clinic, and are referred to the ART clinic for follow-up; C) facilities where newly identified HIV-positive women are referred from ANC to the ART clinic for initiation and follow-up of ART; and D) facilities serving as ART referral sites (not providing ANC). The proportion of women tested for HIV during ANC was highest in facilities applying Model A and lowest in facilities applying Model B. The highest retention rates were reported in Model C and D facilities and lowest in Model B facilities. In multivariable analyses, health facility factors independently associated with uptake of HIV testing and counselling (HTC) in ANC were number of women per HTC counsellor, HIV test kit availability, and the "model of care" applied; factors independently associated with ART retention were district location, patient volume and the "model of care" applied.
  
  
  CONCLUSIONS
  A large variety exists in the way health facilities have integrated PMTCT Option B+ care into routine service delivery. This study showed that the "model of care" chosen is associated with uptake of HIV testing in ANC and retention in care on ART. Further patient-level research is needed to guide policy recommendations.
authors: Dignitas International, Zomba, Malawi; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; m.vanlettow@dignitasinternational.org.
authors: Monique
authors: M
authors: van Lettow
authors: Dignitas International, Zomba, Malawi.
authors: Richard
authors: R
authors: Bedell
authors: Dignitas International, Zomba, Malawi.
authors: Isabell
authors: I
authors: Mayuni
authors: Dignitas International, Zomba, Malawi.
authors: Gabriel
authors: G
authors: Mateyu
authors: Dignitas International, Zomba, Malawi; Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
authors: Megan
authors: M
authors: Landes
authors: Dignitas International, Zomba, Malawi; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Canada.
authors: Adrienne K
authors: AK
authors: Chan
authors: Dignitas International, Zomba, Malawi.
authors: Vanessa
authors: V
authors: van Schoor
authors: Dignitas International, Zomba, Malawi.
authors: Teferi
authors: T
authors: Beyene
authors: International Union Against Tuberculosis and Lung Disease, Paris, France; Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK.
authors: Anthony D
authors: AD
authors: Harries
authors: Zonal Health Office, Malawi Ministry of Health, Zomba, Malawi.
authors: Stephen
authors: S
authors: Chu
authors: Department of HIV and AIDS, Malawi Ministry of Health, Lilongwe, Malawi.
authors: Andrew
authors: A
authors: Mganga
authors: Dignitas International, Zomba, Malawi.
authors: Joep J
authors: JJ
authors: van Oosterhout
mesh_terms: D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000517:prevention & control* / Q000635:transmission; D006302:Health Services Research; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008295:Malawi; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy*
chemical_list: D044966:Anti-Retroviral Agents
keywords: Malawi; Option B+; PMTCT; model of care; retention; service delivery model