title: Implementation and operational research: the impact of option B+ on the antenatal PMTCT cascade in Lilongwe, Malawi.
abstract: OBJECTIVE
  In 2011, Malawi implemented Option B+ (B+), lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women. We aimed to describe changes in service uptake and outcomes along the antenatal prevention of mother-to-child transmission (PMTCT) cascade post-B+ implementation.
  
  
  METHODS
  Pre/post study using routinely collected program data from 2 large Lilongwe-based health centers.
  
  
  METHODS
  We compared the testing of HIV-infected pregnant women at antenatal care, enrollment into PMTCT services, receipt of ART, and 6-month ART outcomes pre-B+ (October 2009-March 2011) and post-B+ (October 2011-March 2013).
  
  
  RESULTS
  A total of 13,926 (pre) and 14,532 (post) women presented to antenatal care. Post-B+, a smaller proportion were HIV-tested (99.3% vs. 87.7% post-B+; P < 0.0001). There were 1654 (pre) and 1535 (post) HIV-infected women identified, with a larger proportion already known to be HIV-infected (18.1% vs. 41.2% post-B+; P < 0.0001) and on ART post-B+ (18.7% vs. 30.2% post-B+; P < 0.0001). A significantly greater proportion enrolled into the PMTCT program (68.3% vs. 92.6% post-B+; P < 0.0001) and was retained through delivery post-B+ (51.1% vs. 65% post-B+; P < 0.0001). Among those not on ART at enrollment, there was no change in the proportion newly initiating ART/antiretrovirals (79% vs. 81.9% post-B+; P = 0.11), although median days to initiation of ART decreased [48 days (19, 130) vs. 0 days (0, 15.5) post-B+; P < 0.0001]. Among those newly initiating ART, a smaller proportion was alive on ART 6 months after initiation (89.3% vs. 78.8% post-B+; P = 0.0004).
  
  
  CONCLUSIONS
  Although several improvements in PMTCT program performance were noted with implementation of B+, challenges remain at several critical steps along the cascade requiring innovative solutions to ensure an AIDS-free generation.
authors.affiliation: *Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Houston, TX; †Baylor College of Medicine-Abbott Fund Children's Clinical Center of Excellence, Lilongwe, Malawi; ‡University of North Carolina School of Medicine, Chapel Hill, NC; §UNC Project, Lilongwe, Malawi; ‖Department of Medicine, Baylor College of Medicine, Houston, TX; ¶Department of Pediatrics, Epidemiology Center, Baylor College of Medicine, Houston, TX; #Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi; **ICAP-Columbia University, Mailman School of Public Health, New York, NY; and ††College of Physicians and Surgeons, Columbia University, New York, NY.
authors.forename: Maria H
authors.initials: MH
authors.lastname: Kim
authors.forename: Saeed
authors.initials: S
authors.lastname: Ahmed
authors.forename: Mina C
authors.initials: MC
authors.lastname: Hosseinipour
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Giordano
authors.forename: Elizabeth Y
authors.initials: EY
authors.lastname: Chiao
authors.forename: Xiaoying
authors.initials: X
authors.lastname: Yu
authors.forename: Chi
authors.initials: C
authors.lastname: Nguyen
authors.forename: Frank
authors.initials: F
authors.lastname: Chimbwandira
authors.forename: Peter N
authors.initials: PN
authors.lastname: Kazembe
authors.forename: Elaine J
authors.initials: EJ
authors.lastname: Abrams
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D004363:Drug Utilization; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000635:transmission*; 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