title: Retention in care during the first 3 years of antiretroviral therapy for women in Malawi's option B+ programme: an observational cohort study.
abstract: BACKGROUND
  Studies of Malawi's option B+ programme for HIV-positive pregnant and breastfeeding women have reported high loss to follow-up during pregnancy and at the start of antiretroviral therapy (ART), but few data exist about retention during breastfeeding and after weaning. We examined loss to follow-up and retention in care in patients in the option B+ programme during their first 3 years on ART.
  
  
  METHODS
  We analysed two data sources: aggregated facility-level data about patients in option B+ who started ART between Oct 1, 2011, and June 30, 2012, at 546 health facilities; and patient-level data from 20 large facilities with electronic medical record system for HIV-positive women who started ART between Sept 1, 2011, and Dec 31, 2013, under option B+ or because they had WHO clinical stages 3 or 4 disease or had CD4 counts of less than 350 cells per μL. We used facility-level data to calculate representative estimates of retention and loss to follow-up. We used patient-level data to study temporal trends in retention, timing of loss to follow-up, and predictors of no follow-up and loss to follow-up. We defined patients who were more than 60 days late for their first follow-up visit as having no follow-up and patients who were more than 60 days late for a subsequent visit as being lost to follow-up. We calculated proportions and cumulative probabilities of patients who had died, stopped ART, had no follow-up, were lost to follow-up, or were retained alive on ART for 36 months. We calculated odds ratios and hazard ratios to examine predictors of no follow-up and loss to follow-up.
  
  
  RESULTS
  Analysis of facility-level data about patients in option B+ who had not transferred to a different facility showed retention in care to be 76·8% (20 475 of 26,658 patients) after 12 months, 70·8% (18,306 of 25,849 patients) after 24 months, and 69·7% (17,787 of 25,535 patients) after 36 months. Patient-level data included 29,145 patients. 14,630 (50·2%) began treatment under option B+. Patients in option B+ had a higher risk of having no follow-up and, for the first 2 years of ART, higher risk of loss to follow-up than did patients who started ART because they had CD4 counts less than 350 cells per μL or WHO clinical stage 3 or 4 disease. Risk of loss to follow-up during the third year was low and similar for patients retained for 2 years. Retention rates did not change as the option B+ programme matured.
  
  
  CONCLUSIONS
  Our data suggest that pregnant and breastfeeding women who start ART immediately after they are diagnosed with HIV can be retained on ART through the option B+ programme, even after many have stopped breastfeeding. Interventions might be needed to improve retention in the first year on ART in option B+.
  
  
  BACKGROUND
  Bill & Melinda Gates Foundation, Partnerships for Enhanced Engagement in Research Health, and National Institute of Allergy and Infectious Diseases.
authors.affiliation: Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland. Electronic address: andreas.haas@ispm.unibe.ch.
authors.forename: Andreas D
authors.initials: AD
authors.lastname: Haas
authors.affiliation: Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland; International Training & Education Center for Health Malawi (I-TECH), Lilongwe, Malawi.
authors.forename: Lyson
authors.initials: L
authors.lastname: Tenthani
authors.affiliation: Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland; The Baobab Health Trust, Lilongwe, Malawi.
authors.forename: Malango T
authors.initials: MT
authors.lastname: Msukwa
authors.affiliation: Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland.
authors.forename: Kali
authors.initials: K
authors.lastname: Tal
authors.affiliation: International Training & Education Center for Health Malawi (I-TECH), Lilongwe, Malawi; Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi.
authors.forename: Andreas
authors.initials: A
authors.lastname: Jahn
authors.affiliation: The Baobab Health Trust, Lilongwe, Malawi.
authors.forename: Oliver J
authors.initials: OJ
authors.lastname: Gadabu
authors.affiliation: Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland.
authors.forename: Adrian
authors.initials: A
authors.lastname: Spoerri
authors.affiliation: Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi.
authors.forename: Frank
authors.initials: F
authors.lastname: Chimbwandira
authors.affiliation: Dignitas International, Zomba, Malawi; Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi.
authors.forename: Joep J
authors.initials: JJ
authors.lastname: van Oosterhout
authors.affiliation: Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland.
authors.forename: Olivia
authors.initials: O
authors.lastname: Keiser
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D001942:Breast Feeding; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000517:prevention & control / Q000635:transmission; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D059012:Lost to Follow-Up; D008295:Malawi; D000068101:Maternal-Child Health Services / Q000706:statistics & numerical data; D016017:Odds Ratio; D010352:Patient Dropouts / Q000706:statistics & numerical data*; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy*; D016016:Proportional Hazards Models; D012307:Risk Factors; D055815:Young Adult; D016903:Drug Monitoring
chemical_list: D019380:Anti-HIV Agents