title: Characteristics and outcomes of women initiating ART during pregnancy versus breastfeeding in Option B+ in Malawi.
abstract: Malawi adopted the PMTCT strategy 'Option B+' in 2011, providing life-long ART for all HIV-infected pregnant and breastfeeding women. We explored differences in characteristics and outcomes of women initiating ART during pregnancy versus breastfeeding.
  
  
  
  We conducted a retrospective cohort analysis of women in Zomba District, southern Malawi, from January 2012- September 2013. Data were extracted from the Zomba District Observational Cohort Study, a surveillance project collecting data from standardized Ministry of Health ART monitoring tools.
  
  
  
  1986 (67.2 %) women initiated ART during pregnancy and 969 (32.8 %) during breastfeeding. Women initiating ART in breastfeeding were more likely to be > 30 years (aOR = 1.33, 95 % CI1.11-1.59, p = 0.003) and have WHO Stage 3/4 (aOR = 2.74, 95 % CI1.94-3.87, p < 0.001). Eighteen (0.6 %) deaths occurred and 942 (31.9 %) women defaulted ART. 'Early' death (< 30 days) occurred in 3 (0.1 %) women and 449 (16.4 %) women defaulted early. Death/default < 30 days was more likely among women initiating ART during pregnancy (aOR 1.62, 95 % CI1.28-2.05, p < 0.001) or < 30 years old (aOR 1.27, 95 % CI 1.02-1.57, p = 0.03) and was less likely among those with WHO Stage 3/4 (aOR 0.30, 95 % CI 0.15-0.60, p < 0.001). Using Kaplan-Meier estimators to investigate time to death/default, we showed a sharp drop in death/default-free survival probability at time zero, yet survival probability decreased in a nearly linear manner after this initial period of high default. Women under 30 years had increased rates of death/default over time (log rank test: p < 0.001), however no significant differences were observed in death/default over time associated with timing of ART initiation, documented clinical stage at initiation, health clinic size or adherence rates.
  
  
  
  Many women in Malawi started ART during breastfeeding within Option B+ and were older and had more advanced WHO Clinical Staging. This represents a missed PMTCT opportunity to initiate treatment early in pregnancy. Early defaulting is identified as a challenge within Option B+, and was more likely among younger women and those initiating ART in pregnancy. Targeted research to understand factors associated with uptake of ART during pregnancy and retention in care could improve the efficacy of Option B+ in Malawi.
authors.affiliation: Dignitas International, Zomba, Malawi. m.landes@dignitasinternational.org.|Department of Family and Community Medicine, University of Toronto, Toronto, Canada. m.landes@dignitasinternational.org.
authors.forename: M
authors.initials: M
authors.lastname: Landes
authors.affiliation: Dignitas International, Zomba, Malawi.|Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
authors.forename: S
authors.initials: S
authors.lastname: Sodhi
authors.affiliation: Dignitas International, Zomba, Malawi.
authors.forename: A
authors.initials: A
authors.lastname: Matengeni
authors.affiliation: Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
authors.forename: C
authors.initials: C
authors.lastname: Meaney
authors.affiliation: Dignitas International, Zomba, Malawi.|Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
authors.forename: M
authors.initials: M
authors.lastname: van Lettow
authors.affiliation: Dignitas International, Zomba, Malawi.|Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.
authors.forename: A K
authors.initials: AK
authors.lastname: Chan
authors.affiliation: Dignitas International, Zomba, Malawi.|Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi.
authors.forename: J J
authors.initials: JJ
authors.lastname: van Oosterhout
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities; D019380:Anti-HIV Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D001942:Breast Feeding; D004334:Drug Administration Schedule; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000517:prevention & control; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008295:Malawi; D011181:Postnatal Care; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy*; D011295:Prenatal Care; D012189:Retrospective Studies; D016019:Survival Analysis
chemical_list: D019380:Anti-HIV Agents
keywords: ART initiation; Breastfeeding; HIV; Malawi; Option B+; Pregnancy; Prevention of mother to child transmission of HIV