Supporting Option B+ scale up and strengthening the prevention of mother-to-child transmission cascade in central Malawi: results from a serial cross-sectional study.
BACKGROUND
We established Safeguard the Family (STF) to support Ministry of Health (MoH) scale-up of universal antiretroviral therapy (ART) for HIV-infected pregnant and breastfeeding women (Option B+) and to strengthen the prevention of mother-to-child transmission (PMTCT) cascade from HIV testing and counseling (HTC) through maternal ART provision and post-delivery early infant HIV diagnosis (EID). To these ends, we implemented the following interventions in 5 districts: 1) health worker training and mentorship; 2) couples' HTC and male partner involvement; 3) women's psychosocial support groups; and 4) health and laboratory system strengthening for EID.


METHODS
We conducted a serial cross-sectional study using facility-level quarterly (Q) program data and individual-level infant HIV-1 DNA PCR data to evaluate STF performance on PMTCT indicators for project years (Y) 1 (April-December 2011) through 3 (January-December 2013), and compared these results to national averages.


RESULTS
Facility-level uptake of HTC, ART, infant nevirapine prophylaxis, and infant DNA PCR testing increased significantly from quarterly baselines of 66 % (n/N = 32,433/48,804), 23 % (n/N = 442/1,958), 1 % (n/N = 10/1,958), and 52 % (n/N = 1,385/2,644) to 87 % (n/N = 39,458/45,324), 96 % (n/N = 2,046/2,121), 100 % (n/N = 2,121/2,121), and 62 % (n/N = 1,462/2,340), respectively, by project end (all p < 0.001). Quarterly HTC, ART, and infant nevirapine prophylaxis uptake outperformed national averages over years 2-3. While transitioning EID laboratory services to MoH, STF provided first-time HIV-1 DNA PCR testing for 2,226 of 11,261 HIV-exposed infants (20 %) tested in the MoH EID program in STF districts from program inception (Y2) through Y3. Of these, 78 (3.5 %) tested HIV-positive. Among infants with complete documentation (n = 608), median age at first testing decreased from 112 days (interquartile range, IQR: 57-198) in Y2 to 76 days (IQR: 46-152) in Y3 (p < 0.001). During Y3 (only year with national data for comparison), non-significantly fewer exposed infants tested HIV-positive (3.6 %) at first testing in STF districts than nationally (4.1 %) (p = 0.4).


CONCLUSIONS
STF interventions, integrated within the MoH Option B+ program, achieved favorable HTC, maternal ART, infant prophylaxis, and EID services uptake, and a low proportion of infants found HIV-infected at first DNA PCR testing. Continued investments are needed to strengthen the PMTCT cascade, particularly around EID.
Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. michael_herce@med.unc.edu.|University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA. michael_herce@med.unc.edu.
Michael E
ME
Herce
Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. tiwongemtande@gmail.com.
Tiwonge
T
Mtande
HIV Unit, Ministry of Health, Government of the Republic of Malawi, P.O. Box 30377, Lilongwe 3, Malawi. frankchimbwandira@gmail.com.
Frank
F
Chimbwandira
Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. imofolo@unclilongwe.org.
Innocent
I
Mofolo
Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. 33711623@mylife.unisa.ac.za.
Christine K
CK
Chingondole
Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. nrosenbe@email.unc.edu.|University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA. nrosenbe@email.unc.edu.
Nora E
NE
Rosenberg
University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA. klanc@live.unc.edu.
Kathy E
KE
Lancaster
Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. ekamanga@unclilongwe.org.
Esmie
E
Kamanga
UNICEF Malawi, P.O. Box 30375, Lilongwe 3, Malawi. jnkhoma@unicef.org.
Jacqueline
J
Chinkonde
Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. wkumwenda@unclilongwe.org.
Wiza
W
Kumwenda
Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. gtegha@unclilongwe.org.
Gerald
G
Tegha
Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. mina_hosseinipour@med.unc.edu.|University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA. mina_hosseinipour@med.unc.edu.
Mina C
MC
Hosseinipour
Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. irving_hoffman@med.unc.edu.|University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA. irving_hoffman@med.unc.edu.
Irving F
IF
Hoffman
Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. fmartinson@unclilongwe.org.|University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA. fmartinson@unclilongwe.org.
Francis E
FE
Martinson
University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA. estein@email.unc.edu.
Eva
E
Stein
Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. charles_vanderhorst@med.unc.edu.|University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA. charles_vanderhorst@med.unc.edu.
Charles M
CM
van der Horst
D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D001942:Breast Feeding; D003430:Cross-Sectional Studies; D042241:Early Diagnosis; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000635:transmission; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008295:Malawi; D008297:Male; D056990:Post-Exposure Prophylaxis; D049590:Postpartum Period; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy*; D011295:Prenatal Care; D015397:Program Evaluation; D055815:Young Adult