Engagement in care among women and their infants lost to follow-up under Option B+ in eSwatini

Autoři: William Reidy aff001;  Harriet Nuwagaba-Biribonwoha aff001;  Siphesihle Shongwe aff001;  Ruben Sahabo aff001;  Kieran Hartsough aff001;  Yingfeng Wu aff001;  Averie Gachuhi aff001;  Simangele Mthethwa-Hleta aff003;  Elaine J. Abrams aff001
Působiště autorů: ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America aff001;  Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, New York, United States of America aff002;  Ministry of Health, Mbabane, Eswatini aff003;  Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, United States of America aff004
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: 10.1371/journal.pone.0222959



Universal antiretroviral treatment (ART) for pregnant women with HIV, Option B+, has been adopted widely for prevention of mother-to-child HIV transmission (PMTCT). Some evidence shows high loss to follow-up (LTF) under this model. However, gaps in data systems limit this evidence. We collected additional information for women and infants LTF from Option B+ in Eswatini to assess more accurate outcomes.


LTF at 6-months postpartum was assessed using facility data. Additional data was gathered from: 1) the national ART database and paper records; 2) patient tracing; and 3) interviews and abstraction from patient-held records. Engagement in care was defined as any clinic visit within 91 days before or after 6-months postpartum or completion of a documented transfer; or, for those traced but not completing study interviews, visits at 6-months postpartum or later (for infants), or visits within 3-months of tracing (for women). Multivariable loglinear models were used to identify correlates of engagement.


One-hundred-ninety-four (44.7%) of 434 LTF women had outcomes ascertained, including 122 (62.9%) women engaged in care. Among 510 LTF infants, 265 (52.0%) had ascertained outcomes, including 143 (54.0%) engaged in care, 47 (17.7%) pregnancy losses, and 18 (6.8%) deaths. Seventy-two of 189 live infants (38.1%) with ascertained outcomes had a 6-week early infant diagnostic (EID) test. Among women with ascertained outcomes, gestational age of 20+ weeks (vs. fewer than 20 weeks, aRR 0.80; 95% CI 0.68–0.94) and age 25–29 years (vs. 15–24 years, aRR 0.81; 95% CI 0.67–0.97), were associated with lower engagement; initiating ART after first ANC visit was associated with higher engagement (vs. at first ANC visit, aRR 1.12; 95% CI 1.04–1.21). Among infants with ascertained outcomes, mother not initiating ART was associated with lower engagement (vs. ART at first ANC visit, aRR 0.71; 95% CI 0.54–0.91).


Substantial numbers of women and infants classified as LTF under Option B+ were engaged in care, though a suboptimal level of 6-week EID testing was observed. These findings highlight a need to improve coverage of routine EID testing, and improve data systems to better capture PMTCT patient outcomes.

Klíčová slova:

Age groups – Antenatal care – Antiretroviral therapy – Global health – HIV – Infants – Pregnancy – Telephones


1. Kieffer MP, Mattingly M, Giphart A, van de Ven R, Chouraya C, Walakira M, et al. Lessons Learned From Early Implementation of Option B+. JAIDS J Acquir Immune Defic Syndr. 2014;67: S188–S194. doi: 10.1097/QAI.0000000000000372 25436817

2. World Health Organisation. Use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: Programmatic update. Program Updat. 2012; 1–5. WHO/HIV/2012.6

3. Joint United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS AIDSinfo [Internet]. [cited 23 Mar 2019]. http://aidsinfo.unaids.org/

4. Ahmed S, Kim MH, Abrams EJ. Risks and benefits of lifelong antiretroviral treatment for pregnant and breastfeeding women: a review of the evidence for the Option B+ approach. Curr Opin HIV AIDS. 2013;8: 474–89. doi: 10.1097/COH.0b013e328363a8f2 23925003

5. Shaffer N, Abrams EJ, Becquet R. Option B+ for prevention of mother-to-child transmission of HIV in resource-constrained settings: great promise but some early caution. AIDS. 2014;28: 599–601. doi: 10.1097/QAD.0000000000000144 24469000

6. Tenthani L, Haas AD, Tweya H, Jahn A, Van Oosterhout JJ, Chimbwandira F, et al. Retention in care under universal antiretroviral therapy for HIV-infected pregnant and breastfeeding women ('Option B+’) in Malawi. AIDS. 2014;28: 589–598. doi: 10.1097/QAD.0000000000000143 24468999

7. Knettel BA, Cichowitz C, Ngocho JS, Knippler ET, Chumba LN, Mmbaga BT, et al. Retention in HIV Care during Pregnancy and the Postpartum Period in the Option B+ Era: Systematic Review and Meta-Analysis of Studies in Africa [Internet]. Journal of Acquired Immune Deficiency Syndromes. 2018. pp. 427–438. doi: 10.1097/QAI.0000000000001616 29287029

8. Abrams EJ, Langwenya N, Gachuhi A, Zerbe A, Nuwagaba-Biribonwoha H, Mthethwa-Hleta S, et al. Impact of universal ART for pregnant and postpartum women on ART uptake and retention. AIDS. 2019;33: 45–54.

9. Garrioch R, Langlo C, Dubis AM, Cooper RF, Dubra A, Carroll J. Retention in care under universal Antiretroviral Therapy for HIV Infected Pregnant and Breastfeeding Women (“Option B+”) in Malawi. AIDS. 2014;28: 589–598. doi: 10.1097/QAD.0000000000000143 24468999

10. Haas AD, van Oosterhout JJ, Tenthani L, Jahn A, Zwahlen M, Msukwa MT, et al. HIV transmission and retention in care among HIV-exposed children enrolled in Malawi’s prevention of mother-to-child transmission programme. J Int AIDS Soc. 2017;20: 21947. doi: 10.7448/IAS.20.1.21947 28884524

11. Hauser BM, Miller WC, Tweya H, Speight C, Mtande T, Phiri S, et al. Assessing Option B+ retention and infant follow-up in Lilongwe, Malawi. Int J STD AIDS. 2017;0: 095646241772165. doi: 10.1177/0956462417721658 28750577

12. Brinkhof MWG, Pujades-Rodriguez M, Egger M, Singh S, Rachlis B. Mortality of patients lost to follow-up in antiretroviral treatment programmes in resource-limited settings: Systematic review and meta-analysis. Emery S, editor. PLoS One. 2009;4: e5790. doi: 10.1371/journal.pone.0005790 19495419

13. Wilkinson LS, Skordis-Worrall J, Ajose O, Ford N. Self-transfer and mortality amongst adults lost to follow-up in ART programmes in low- and middle-income countries: Systematic review and meta-analysis [Internet]. Tropical Medicine and International Health. 2015. pp. 365–379. doi: 10.1111/tmi.12434 25418366

14. Zürcher K, Mooser A, Anderegg N, Tymejczyk O, Couvillon MJ, Nash D, et al. Outcomes of HIV-positive patients lost to follow-up in African treatment programmes HHS Public Access. Trop Med Int Heal. 2017;22: 375–387. doi: 10.1111/tmi.12843

15. Reidy W, Agarwal M, Chege D, Lamb M, Hawken M, Mukui I, et al. Retention in Care among HIV-infected Patients Receiving or Not Receiving Antiretroviral Therapy in Eastern Africa. Clin Infect Dis. 2016;63: 426–427. doi: 10.1093/cid/ciw302 27165659

16. Tweya H, Gugsa S, Hosseinipour M, Speight C, Ng’ambi W, Bokosi M, et al. Understanding factors, outcomes and reasons for loss to follow-up among women in Option B+ PMTCT programme in Lilongwe, Malawi. Trop Med Int Heal. 2014;19: 1360–1366. doi: 10.1111/tmi.12369 25087778

17. Kiwanuka G, Kiwanuka N, Muneza F, Nabirye J, Oporia F, Odikro MA, et al. Retention of HIV infected pregnant and breastfeeding women on option B+ in Gomba District, Uganda: A retrospective cohort study. BMC Infect Dis. 2018;18. doi: 10.1186/s12879-018-3450-9 30355356

18. Clouse K, Vermund SH, Maskew M, Lurie MN, MacLeod W, Malete G, et al. Mobility and Clinic Switching Among Postpartum Women Considered Lost to HIV Care in South Africa. J Acquir Immune Defic Syndr. 2017;74: 383–389. doi: 10.1097/QAI.0000000000001284 28225717

19. R. Nkambule, H. Nuwagaba-Biribonwoha, Z. Mnisi1, T.T. Ao, C. Ginindza, Y.T. Duong, H. Patel, S. Saito, N.M. Philip, K. Brown, C. Draghi, A.C. Voetsch, K. Mabuza, A. Zwane, R. Sahabo, V. Okello, T. Dobbs, B. Parekh, C. Ryan JJ. Substantial progress in confronting the HIV epidemic in Swaziland: first evidence of national impact. 9th International AIDS Society Conference on HIV Science. Paris, France; 2017. http://programme.ias2017.org/Abstract/Abstract/5837

20. Joint United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS data 2018 [Internet]. 2018. http://www.unaids.org/sites/default/files/media_asset/unaids-data-2018_en.pdf

21. Ministry of Health S. Annual HIV programs report. 2015.

22. Reidy W, Nuwagaba-Biribonwoha H, Shongwe S, Sahabo R, Hartsough K, Mthethwa S, et al. Engagement in care and infant HIV testing among lost to follow-up Option B+ patients in Swaziland. onference on Retroviruses and Opportunistic Infections (CROI). Boston, MA; 2018.

23. Eswatini G of the K of. Swaziland HIV Incidence Measurement Survey 2 (SHIMS2) 2016–2017. Final Report. Mbabane; 2019.

24. Ministry of Health M. Malawi Population-Based HIV Impact Assessment (MPHIA) 2015–2016: Final Report [Internet]. Lilongwe; 2018. http://phia.icap.columbia.edu

25. Ministry of Health U. Uganda Population-based HIV Impact Assessment (UPHIA) 2016–2017: Final Report [Internet]. Kampala; 2019. http://health.go.ug/docs/UPHIA

26. Geng EH, Glidden DV, Emenyonu N, Musinguzi N, Bwana MB, Neilands TB, et al. Tracking a sample of patients lost to follow-up has a major impact on understanding determinants of survival in HIV-infected patients on antiretroviral therapy in Africa. Trop Med Int Heal. 2010;15: 63–69. doi: 10.1111/j.1365-3156.2010.02507.x 20586962

27. Sullivan TR, Lee KJ, Ryan P, Salter AB. Multiple imputation for handling missing outcome data when estimating the relative risk. BMC Med Res Methodol. 2017;17. doi: 10.1186/s12874-017-0414-5 28877666

28. Essajee S, Bhairavabhotla R, Penazzato M, Kiragu K, Jani I, Carmona S, et al. Scale-up of early infant HIV diagnosis and improving access to pediatric HIV care in global plan countries: Past and future perspectives. J Acquir Immune Defic Syndr. 2017;75: S51–S58. doi: 10.1097/QAI.0000000000001319 28398997

29. Innes S, Lazarus E, Otwombe K, Liberty A, Germanus R, Van Rensburg AJ, et al. Early severe HIV disease precedes early antiretroviral therapy in infants: Are we too late? J Int AIDS Soc. 2014;17. doi: 10.7448/IAS.17.1.18914 24925044

30. Gugsa S, Potter K, Tweya H, Phiri S, Sande O, Sikwese P, et al. Exploring factors associated with ART adherence and retention in care under Option B+ strategy in Malawi: A qualitative study. PLoS One. 2017;12. doi: 10.1371/journal.pone.0179838 28636669

31. Whiteside A, Hickey A, Ngcobo N, Tomlinson J. What is driving the HIV / AIDS epidemic in Swaziland, and what more can we do about it? Final Report for the National Emergency Response Committee on HIV/AIDS (NERCHA) and United Nations Programme on HIV/AIDS (UNAIDS). 2003.

32. Woelk G, Berhan AY, Kudiabor K, Mukaminega M, On J, Nyirabahizi E, et al. A secondary analysis of retention across the PMTCT cascade in selected countries: Rwanda, Malawi, Kenya, and Swaziland [Internet]. Washington DC; 2015. http://www.hivcore.org/Pubs/4CntryPMTCTRetention_Rprt.pdf

33. Phillips TK, Clouse K, Zerbe A, Orrell C, Abrams EJ, Myer L. Linkage to care, mobility and retention of HIV-positive postpartum women in antiretroviral therapy services in South Africa. J Int AIDS Soc. 2018;21: e25114. doi: 10.1002/jia2.25114 30027583

34. Phillips TK, McNairy ML, Zerbe A, Myer L, Abrams EJ. Implementation and Operational Research: Postpartum Transfer of Care Among HIV-Infected Women Initiating Antiretroviral Therapy During Pregnancy. J Acquir Immune Defic Syndr. 2015;70: e102–9. doi: 10.1097/QAI.0000000000000771 26470033

35. Wilkinson LS, Skordis-Worrall J, Ajose O, Ford N. Self-transfer and mortality amongst adults lost to follow-up in ART programmes in low- and middle-income countries: Systematic review and meta-analysis [Internet]. Tropical Medicine and International Health. 2015. pp. 365–379. doi: 10.1111/tmi.12434 25418366

36. Low-Beer D, Beusenberg M, Hayashi C, Calleja T, Marsh K, Mamahit A, et al. Monitoring HIV Treatment and the Health Sector Cascade: From Treatment Numbers to Impact. AIDS Behav. 2017;21: 15–22. doi: 10.1007/s10461-017-1754-1 28401415

37. Silvestre E. Implementing Swaziland’s Client Management Information System. Chapel Hill, North Carolina; 2017.

38. World Health Organization. Three interlinked patient monitoring systems for HIV care/ART, MCH/PMTCT (including malaria prevention during pregnancy), and TB/HIV: standardized minimum data set and illustrative tools [Internet]. 2012. http://www.who.int/tb/dots/r_and_r_forms/en/index.html

Článek vyšel v časopise


2019 Číslo 10