In The Lancet HIV, Beth A Tippett Barr and colleagues present national estimates of early mother-to-child transmission (MTCT) of HIV and factors associated with early MTCT from the National Evaluation of Malawi’s Prevention of MTCT Program (NEMAPP) for the period 2014–16. Among HIV-exposed infants aged 4–12 weeks, the MTCT rate was 3·7% (95% CI 2·3–6·0) and consistent across all four subnational regions. A somewhat lower prevalence was observed among infants aged 4–7 weeks than among those aged 8–12 weeks (2·9% vs 5·2%; p=0·07). As expected, the mother’s antiretroviral therapy (ART) status during pregnancy was strongly associated with MTCT prevalence: it was 2·3% (95% CI 1·3–4·0) among those who were on ART during pregnancy compared with 19·6% (14·3–26·3) among those who were not on ART (p<0·0001

Aliyu

Audet

Granich

Joseph Davey

McCoy

Mwenda

Phiri

Rosenberg

Schouten

Sinunu

Tippett Barr

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Taking Malawi's option B+ programme from a B+ to an A+

Rosenberg, N.E.

Pettifor, A.E.

Carolina Digital Repository

Taking Malawi’s option B+ programme from a B+ to an A+In The Lancet HIV, Beth A Tippett Barr and colleagues1 present national estimates of early mother-to-child transmission (MTCT) of HIV and factors associated with early MTCT from the National Evaluation of Malawi’s Prevention of MTCT Program (NEMAPP) for the period 2014–16. Among HIV-exposed infants aged 4–12 weeks, the MTCT rate was 3·7% (95% CI 2·3–6·0) and consistent across all four subnational regions. A somewhat lower prevalence was observed among infants aged 4–7 weeks than among those aged 8–12 weeks (2·9% vs 5·2%; p=0·07). As expected, the mother’s antiretroviral therapy (ART) status during pregnancy was strongly associated with MTCT prevalence: it was 2·3% (95% CI 1·3–4·0) among those who were on ART during pregnancy compared with 19·6% (14·3–26·3) among those who were not on ART (p<0·0001).Malawi pioneered its prevention of MTCT option B+ programme in late 2011 in response to the poor results of a CD4-based programme that was hindered by delays in ART access.2 Option B+ was designed for simplicity and impact, offering all pregnant and breastfeeding women free lifelong ART at diagnosis, regardless of CD4 count or clinical stage. Although no nationally representative estimates of early MTCT were available before the introduction of option B+, comparable estimates from immunisation settings were considerably higher and varied by region.3 Thus, this nationally representative study suggests a substantial decline in the prevalence of early MTCT 3–5 years after option B+ was introduced.NEMAPP has several important strengths. First, it is national in scope and uses a rigorous sampling method to obtain nationally and subnationally representative estimates. Second, mothers were recruited in under-5 vaccination and outpatient sick-child clinics, which are settings with near universal attendance in Malawi.4 Third, the authors assessed actual infant HIV infection, and not an intermediate maternal outcome or proxy. Together, these strengths resulted in the first national estimates of early MTCT under option B+. Although NEMAPP provides better estimates of early MTCT than do routine programme data, missing data are the study’s weakness. Non-participants include mothers who declined participation, were too sick to present, or were not engaged in the health-care system, as well as infants who died before clinic attendance. Although these groups might be small, they are all at higher risk of early MTCT than those who participated, suggesting that a transmission rate of 3·7% might be an underestimate. Tippett Barr and colleagues’ study highlights three sets of challenges that need to be addressed to further reduce the prevalence of early MTCT. First, of the 99 MTCT cases observed in the raw data, 52 occurred in infants whose mothers were on ART during pregnancy, suggesting challenges associated with maternal ART retention and adherence. Several barriers related to the mothers, their partners, and their communities and environments might contribute to these behaviours, and several promising evidence-based interventions are available to address them.5–8 Second, there are challenges associated with maternal HIV acquisition during pregnancy and breastfeeding. High rates of early MTCT were observed among infants whose mothers’ self-reported HIV status during pregnancy was negative (weighted proportion 20·9%, 95% CI 12·0–33·8), suggesting that some mothers are being infected during the peripartum period. Several prevention approaches exist for reducing HIV acquisition among pregnant and breastfeeding women, including pre-exposure prophylaxis,9 repeat couple testing to identify HIV-discordant couples,10 and testing and treating HIV-infected men in the general population to reduce ongoing heterosexual transmission.11Third, there are challenges in identifying HIV-exposed infants and engaging them in care. Less than half of HIV-exposed infants in the analysis were enrolled in an exposed infant care clinic at the time of study screening, despite presenting to a health facility. This finding underscores the need to strengthen the infant steps of the prevention of MTCT cascade. Integration of routine maternal retesting and point-of-care, early infant diagnosis procedures into immunisation clinics are promising steps for rapidly identifying those in need of services.12,13 Similar improvements in Malawi’s antenatal programme, including integration of routine maternal testing and elimination of laboratory delays, have been integral to the success of option B+ along the early steps of the prevention of MTCT cascade. Published Online November 19, 2018 http://dx.doi.org/10.1016/S2352-3018(18)30320-5See Articles page e688This study shows that the prevalence of early vertical transmission under Malawi’s option B+ programme was low only a few years after it was introduced. To achieve further declines, attention needs to be paid to HIV-infected women who experience challenges along the ART cascade, uninfected women who are at the highest risk of HIV acquisition, and HIV-exposed infants in need of care. These steps are important for Malawi and other high-prevalence settings that have followed Malawi’s lead in adopting option B+. *Nora E Rosenberg, Audrey E Pettifor Department of Health Behavior (NER) and Department of Epidemiology (AEP), University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7440, USA; and University of North Carolina Project–Malawi, Lilongwe, Malawi (NER) ora_rosenberg@unc.eduNER is supported, in part, by the National Institute of Health through grants R00 MH104154 and P30 AI50410. The funder had no part in the writing of this manuscript or in the decision to submit for publication. We declare no competing interests. 1 Tippett Barr BA, van Lettow M, van Oosterhout JJ, et al. National estimates and risk factors associated with early mother-to-child transmission of HIV after implementation of option B+: a cross-sectional analysis. Lancet HIV 2018; published online Nov 19. http://dx.doi.org/10.1016/S2352-3018(18)30316-3.2 Schouten EJ, Jahn A, Midiani D, et al. Prevention of mother-to-child transmission of HIV and the health-related Millennium Development Goals: time for a public health approach. Lancet 2011; 378: 282–84.3 Sinunu MA, Schouten EJ, Wadonda-Kabondo N, et al. Evaluating the impact of prevention of mother-to-child transmission of HIV in Malawi through immunization clinic-based surveillance. PLoS One 2014; 9: e100741.4 National Statistical Office, The DHS Program. Malawi Demographic and Health Survey 2015–16. 2017. https://dhsprogram.com/pubs/pdf/FR319/FR319.pdf (accessed Nov 14, 2018).5 McCoy SI, Njau PF, Fahey C, et al. Cash vs food assistance to improve adherence to antiretroviral therapy among HIV-infected adults in Tanzania. AIDS 2017; 31: 815–25.6 Phiri S, Tweya H, van Lettow M, et al. Impact of facility- and community-based peer support models on maternal uptake and retention in Malawi’s option B+ HIV prevention of mother-to-child transmission program: a 3-arm cluster randomized controlled trial (PURE Malawi). J Acquir Immune Defic Syndr 2017; 75 (suppl 2): S140–48.7 Aliyu MH, Blevins M, Audet CM, et al. Integrated prevention of mother-to-child HIV transmission services, antiretroviral therapy initiation, and maternal and infant retention in care in rural north-central Nigeria: a cluster-randomised controlled trial. Lancet HIV 2016; 3: e202–11.8 Audet CM, Blevins M, Chire YM, et al. Engagement of men in antenatal care services: increased HIV testing and treatment uptake in a community participatory action program in Mozambique. AIDS Behav 2016; 20: 2090–100.9 Joseph Davey DL, Bekker LG, Gorbach PM, Coates TJ, Myer L. Delivering preexposure prophylaxis to pregnant and breastfeeding women in sub-Saharan Africa: the implementation science frontier. AIDS 2017; 31: 2193–97.10 Rosenberg NE, Hauser BM, Ryan J, Miller WC. The effect of HIV counselling and testing on HIV acquisition in sub-Saharan Africa: a systematic review. Sex Transm Infect 2016; 92: 579–86.11 Granich RM, Gilks CF, Dye C, De Cock KM, Williams BG. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet 2009; 373: 48–57.12 Chi BH, Bolton-Moore C, Holmes CB. Prevention of mother-to-child HIV transmission within the continuum of maternal, newborn, and child health services. Curr Opin HIV AIDS 2013; 8: 498–503.13 Mwenda R, Fong Y, Magombo T, et al. Significant patient impact observed upon implementation of point-of-care early infant diagnosis technologies in an observational study in Malawi. Clin Infect Dis 2018; 67: 701–07.

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Taking Malawi's option B+ programme from a B+ to an A+

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