Objective: Option B-plus strategy was adopted
and implemented by Uganda’s Ministry of Health (MOH)in 2012. We aimed to
describe prevention of mother to child HIV Transmission (PMTCT) programmatic
findings on uptake, initiation, missed opportunities and reasons for non-initiation
of Option B-plus among HIV-infected pregnant women at Uganda’s Mulago National
Referral and Teaching Hospital.
Methods: We
extracted and evaluated routine PMTCT programmatic data collected from pregnant women
attending for the first time to either Mulago
Hospital Antenatal Care (ANC) clinics or Labor Wards (LWs) from 16th October 2012 to 31st May 2014. Data were
collected in MOH logs/forms, entered in Microsoft Access and analyzed using
Stata Version 10.1.
Conclusion: Overall,
Option-B plus ART was highly acceptable and very few women opted out over the
first 19 months of implementation of the Option B-plus programme at Mulago
Hospital in Kampala, Uganda. There is urgent need to maximize
retention in care and ART adherence.
Results: Overall,
HIV prevalence was 11.0% (7,496/68,053) among first-time ANC and LW attendees
to Mulago Hospital and of these, 30.3% (2,269/7,496) were newly diagnosed with
HIV. Of all the HIV-positive women, 89.9% (6,739/7,496) were on ART including
54.0% (4,046/7,496) initiated on Option B-plus and 36% (2,693/1496) who
presented as already being on ART. A further 3.7% (277/7,496) enrolled in a
PMTCT research study and 6.4% (480/7,496) not initiated Option B-plus. Among
the 480 non-starters: 69.3% (333/480) presented to Hospital LW but did not
progress to delivery, 13.3% (64/480)
opted to be screened for a research study but never returned for follow
up, while 17.3% (83/480) declined Option B-plus. The main reasons for opting
out were: declining to take lifelong ART; preferring to receive drugs from
another facility; and denial of HIV-positive test result.
1. Introduction
Preventing Mother-To-Child HIV Transmission (PMTCT) is crucial
to curb the global pediatric HIV epidemic and promote maternal and infant
health. The World Health Organization (WHO)PMTCT guidelines have evolved over
the years and Uganda has adopted and updated its national PMTCT guidelines
according to evolving WHO recommendations since 2003 [1,2].
In 2012, WHO updated the PMTCT guidelines and recommended that
HIV-infected women identified during pregnancy and breastfeeding could start
triple Antiretroviral Therapy (ART) irrespective of their CD4 cell count and
WHO clinical staging, and then either stop ART after complete breastfeeding
cessation (Option B) or continue to take ART for the rest of their lives
(Option B-plus) [3]. The guidelines also recommended that all HIV-exposed
infants receive 6 weeks of daily Nevirapine syrup from birth. The Option B-plus
‘Treatment as Prevention’ strategy was adopted by the Uganda Ministry of health
(MOH) in September 2012 [2]. In 2013, WHO updated the harmonized adult and
pediatric treatment guidelines and recommended either Option B or B-plus as
national PMTCT programme options [4]. With the target of achieving below
5% vertical HIV transmission, PMTCT programmes became known as elimination of
Mother-To-Child HIV Transmission (eMTCT) programmes.
The Option B-plus MTCT strategy presents advantages at several
levels. Programmatically, eligibility and treatment initiation are simplified
as CD4 cell count testing and WHO clinical staging are no longer required
before ART initiation; adult prevention and treatment ART regimens are
streamlined as they are identical; and dosing is simplified and adherence
enhanced as the recommended Option B-plus first line regimen is available in a
well-tolerated, once-daily, single-pill, fixed-dose combination. The benefits
to the woman, her infant, future infants and sexual partners include: strong
and life-long PMTCT for both current and future pregnancies; maternal HIV
treatment to keep the mother healthy and able to care for her children;
consequent reduction in maternal and infant morbidity and mortality, and a
reduction in sexual transmission to HIV-negative spouses and other sexual
partners. Further, a single message can be given to health providers and
communities regarding both eMTCT and ART, making it simpler to deliver and
easier to understand. Finally, the individual prevention and treatment benefits
result in public health benefits at the population level with reduced HIV
transmission and acquisition [5].
Despite the benefits of the Option B-plus MTCT strategy, research
and public health questions remain as to its programmatic effectiveness due to
a number of operational challenges. Option B-plus implies starting and adhering
to life-long ART by HIV-infected women. ART may carry risks of side-effects in
the short and long term including the development of virological resistance and
reduced therapeutic options [6-8]. In addition, women may not have disclosed to
partners or other family members and consequently need strong psychosocial and
economic support [9] at a time of heightened vulnerability during
pregnancy and lactation with potential risks of social harm including
discrimination and stigma [10]. To date, limited monitoring and evaluation
data are available from resource-constrained settings that have adopted the
Option B-plus MTCT strategy. In most programmes, pregnant women are routinely
counselled, tested, given their HIV result and offered lifelong ART if found
HIV-positive, all within a few hours on the same day. Women generally learn
about their HIV-positive status while seeking routine antenatal care. Issues
regarding same day ART acceptability and initiation have been raised in similar
settings. In South Africa, some of the barriers to initiation of ART identified
among pregnant women were disclosure and limited time to accept dual challenges
of being diagnosed HIV-positive among others [11]. Given these
circumstances and that the pregnant women are usually asymptomatic; it is not
clear whether or not these women are psychologically and practically prepared to
start ART for life with good adherence and retention in care. We describe
findings from a very large PMTCT programme cohort from Uganda’s National
Referral and Teaching Hospital regarding the uptake and acceptability of Option
B-plus among HIV-infected women and the reasons why some of these women did not
receive Option B-plus ART on the same day of their clinic attendance.
2. Methods
We extracted and evaluated routine PMTCT programmatic data
collected from pregnant women attending for the first time to either Mulago
Hospital Antenatal Care (ANC) clinics or Labor Wards (LWs) from 16th October
2012 to 31st May 2014. Each year, approximately 30,000 women
seek Antenatal Care (ANC) and a similar number deliver their babies at Mulago
National Referral and Teaching Hospital in Kampala, Uganda. The PMTCT programme
at Mulago began in April 2000. Routine services are offered at the multiple ANC
clinics, Labor Wards (LWs) and Post-Natal Care (PNC) clinics and include
routine HIV testing and counseling and ART initiation (or continuation) for
HIV-infected women. The Option B-plus strategy was implemented at Mulago
Hospital as of October 2012, shortly after adoption of the revised Uganda
national eMTCT/ART guidelines.
All women attending the clinics were screened to identify those
referred from other health centers with a documented/known HIV-positive test
result, including those already on ARV drugs, as well as those coming in with a
recent documented/known HIV-negative result within the last 3 months, and those
without a recent HIV-negative test. Routine free group counselling was
conducted for women requiring a further HIV test. They were then offered an HIV
test using the nationally recommended rapid HIV testing algorithm, and provided
their HIV result as part of post-test individual counseling on the same day.
All women newly diagnosed with HIV and all HIV-positive women referred from
other health centers who were not yet on ARV drugs, were given information
about the PMTCT programme and the Option B-plus recommendation to start ART for
life. They were also provided with information about relevant ongoing PMTCT
research studies, and, if interested, were referred to research staff for
further information and screening. Women already on ART were also counselled
about Option B-plus and encouraged to adhere to their medication and attend for
ongoing health care.
3. Programme Population
The programme population for this analysis consisted of pregnant
women attending Mulago Hospital ANC or LW for the first time in that pregnancy
and who were diagnosed with HIV during the time period16th October
2012 to 31st May 2014.All newly diagnosed HIV-infected women
were given information and counseled on the benefits of Option B-plus as per
the Uganda2012 Integrated National ART, eMTCT, Infant and Young Child
Feeding (IYCF) Guidelines [2].
4. Data Collection and Analysis
According to the Uganda 2012 Integrated National Guidelines on
ART, eMTCT and IYCF [2], pregnant and lactating mothers freely give
out information as part of care. PMTCT activities are routine in all
hospitals and health facilities accredited by the Uganda MOH and these
activities do not require obtaining an informed consent from human subjects
receiving PMTCT services. At Mulago, specific MOH monitoring tools were used by
PMTCT counsellors to collect data and identify clients opting out of Option
B-plus ART so as to provide follow-up and ongoing supportive counseling and
interventions to these women. These tools include HIV counselling and testing
client cards and delivery logs. There was no written or oral informed
consent obtained from patients for either the ARV treatments provided or for
the use of their data in this programme as counseling, testing and treatment
was part of a routine national MOH programme. HIV status, ART initiation and
opt out information were captured as routine. Data were extracted and reviewed
retrospectively to identify and evaluate pregnant women who attended Mulago
Hospital’s ANC clinics or LW for the first time in that pregnancy.
It was then entered in Microsoft Access and analyzed in Stata
version 10.1 (Stata Corp, College Station, Texas, USA). Among first-time
antenatal attendees and women presenting in labor without prior documented
antenatal attendance at Mulago Hospital, we aimed to establish:
· All
HIV-infected women including those newly diagnosed and those already known to
be HIV-positive.
· Those
previously started on ART for PMTCT as well as those newly initiated on Option
B-plus ART.
· Missed
opportunities or system failures which resulted in women not initiating ART.
· Those
women who opted out of or declined Option B-Plus ART and their stated reasons.
5. Results
Data on first ANC and LW attendance collected over the 19-month
study period are shown in (Figure I) for ANC attendance and (Figure II)
for LW attendance. Overall median age was 24 years (IQR: 21 - 28). The median
age of all women attending ANC for the first time was 25 years (IQR: 22 - 29
years), while the median age of all women attending LW for the first time was
23 years (IQR: 20 - 27 years).
As shown in (Figure I), a total of 44,937 women attended
Mulago Hospital ANC for the first time over the 19-month period; of these,
85.5% (38,412/44,937) were newly tested for HIV while 14.5% (6,518/44,937)
presented with a documented recent HIV test result. Overall in ANC, 10.3%
(4,606/44,937) of all women who attended for the first time were HIV-infected
with almost two-thirds (65.4% [3,012/4,606]) previously diagnosed and just over
one third (34.6% [1,594/4,606]) newly diagnosed with HIV. Of these HIV-infected
women, 40.9% (1,882/4,606) were already on ART, hence we could not initiate
them again on Option-B plus at Mulago, and a further 52.5% (2,416/4,606) were
initiated on Option B-plus ART including 1,316 women who were newly diagnosed
and 1,100 women who were already known to be HIV-infected but who were not on
ART at the time of the clinic visit. Of the remaining women, 1.0% (46/4,606)
opted out of Option B-plus for various reasons, a further 4.3% (198/4,606) enrolled
in a PMTCT research study, and 1.4% (64/4,606) opted to be screened for a PMTCT
research study but did not return for enrolment in the study or for care at
Mulago Hospital.
Similarly, as shown in (Figure II), a total of 23,116 pregnant
mothers presented for the first time at the Mulago Hospital Labour Ward (LW)
over the 19-month period; of these, 62.0% (14,338/23,116) were newly tested for
HIV while 38.0% (8,778/23,116) presented with a known HIV test result. Overall
in LW, of all women who first presented, 12.5% (2,890/23,116) were HIV-infected
with more than three-quarters (76.6% [2,215/2,890]) previously diagnosed and
less than one-quarter (23.4% [675/2,890]) newly diagnosed with HIV. Of the
2,890 HIV-infected women, 69.1% (1,996/2,890) were already on triple therapy
(Option B-plus or other ART), and a further 15.4% (445/2,890) were initiated on
Option B-plus ART in the LW. Of the remaining 449 women, 8.2% (37/449) opted
out of Option B-plus for various reasons, a further 17.6% (79/449) of women opted
to enroll in a PMTCT research study, and 74.2% (333/449) did not progress to
deliver at Mulago Hospital and were not documented to have started on Option
B-plus ART including 127 newly HIV-diagnosed and 206 with already known
HIV-positive status.
Overall, 68,053 pregnant women attended Mulago Hospital for the
first time either in ANC clinicsor in the LW and of these, 11.0% (7,496/68,053)
were HIV-infected. Of the 7,496 HIV-positive women, 69.7% (5,227/7,496) were
previously diagnosed with HIV, 30.3% (2,269/7,496) were newly diagnosed with
HIV at that visit, 51.7% (3,878/7,496) were already on ART, and 38.2% (n =
2,861/7,496) were initiated on Option B-plus ART during their first clinic
visit including 2,416 women in ANC and 445 in LW. Of the remaining 757women,11%
(83/757) opted out of Option B-plus for various reasons shown in (Figure
III); 44% (333/757) did not progress to deliver at Mulago Hospital and were not
documented to have started on Option B-plus ART; 36.6% (277/757) of women opted
to enroll in a PMTCT research study; and 8.5% (64/757) opted to be screened for
a PMTCT research study but did not subsequently return to Mulago
Hospital.
6. Discussion
Identifying a pregnant woman’s HIV status is the key entry point
into PMTCT for HIV-infected women to receive care and treatment. These data
show over 50 percent uptake of Option B-plus ART with a few women not initiated
over the first 19 months after introduction of Option B-plus strategy at Mulago
National Referral Hospital in Kampala, Uganda. In the context of Option B-plus,
our data reveals a decreasing proportion of women who are newly diagnosed with
HIV during pregnancy. Among first-time ANC or LW visit attendees, nearly
two-thirds of HIV-positive pregnant women and more than three-quarters of HIV-positive
women presenting in labor knew their HIV status before attending. The trend for
an increasing proportion of pregnant women to know their HIV status prior to
the current pregnancy is also being widely observed in facility based data,
demographic and HIV population-based surveys [12]as well as other
resource-constrained settings [13]. The shrinking pool of newly diagnosed
women may allow PMTCT programmes to concentrate their counseling and psycho
social services on this subgroup of newly HIV-diagnosed women to support them
to accept their HIV status, access support and effectively engage in treatment.
The larger pool of women with known HIV status are likely to be at a different
stage in acceptance and disclosure, thus services for them may be more effectively
targeted at ART initiation and adherence.
In a typical eMTCT programme, including that at Mulago Hospital,
HIV-positive women are advised to start ART on the same day they are diagnosed,
so there is almost no time for them to absorb the shock of their new diagnosis
with all its social, health and other ramifications. In our programme, some
women were not initiated on ART due to a number of issues and we were able to
identify potential missed opportunities for eMTCT and maternal care. There was
a small group of women who chose to join an eMTCT research study through which
they would have accessed ARV interventions and care, however a small
proportion of them did not come back to hospital for their enrollment
appointment after screening. These women became lost to
follow-up. Efforts were made by both research and programme staff to
contact them through phone calls, tracing them using locator forms and home
visits but with no success. There were also missed opportunities to
initiate (or continue) ART among late presenters in labor ward who are at high
risk of vertical transmission. Our data indicated that 4.4% of HIV-infected
women presented to the labor ward and did not go on to deliver at that time,
and while some were documented as having received their HIV results, they had
no documentation that they received ART. Some of the reasons contributing to
this include but are not limited to the following: poor triage in LW, women in
false labour and those coming with sickness like malaria leaving LW before being
attended to by PMTCT staffs who initiate them on ART. Furthermore, nearly
two-thirds of these women knew their HIV-positive status prior to attending the
LW suggesting a double missed opportunity to start them on Option B-plus, both
prior to, and at the labor ward. Upon investigation, we found that records
management and retrieval was poor especially at night and on weekends, so that
if an antenatal client record could not be found, a new one was created in
labor ward which introduced opportunities for double-counting as well as over-
or under-estimating clinic attendance and ART coverage, which could be neither
excluded nor quantified due to the programmatic nature of our data.
Initiation of ART at the first health care contact during
pregnancy is only the beginning step in the eMTCT cascade. Although it is
reassuring that ART appeared highly acceptable, but there was also a small
proportion (1.1%) of HIV-positive women opting out of Option B-plus initiation
during pregnancy. The primary reason cited for opting out of Option B-plus at
Mulago was lack of interest in taking lifelong ARV drugs. Our methodology
did not allow us to explore what lay behind this response because these
women did not return for follow-up despite numerous phone calls and attempts to
engage them in care. Other studies have already raised alarm bells about
disengagement from care after ART initiation. A study carried out in South
Africa between January 2011 and September 2012 showed that 32% of
HIV-infected pregnant women initiated on ART had disengaged from care by 6
months postpartum [14]. Although there are many potential benefits of
Option B-Plus [5], other implementing sites have reported challenges associated
with this strategy. At the 7thInternational AIDS Society (IAS)
Conference on HIV Pathogenesis, Treatment and Prevention held in Kuala
Lumpur, Malaysia in 2013, speakers from Malawi and Uganda highlighted loss to
follow-up of HIV-infected women after initiation of Option B-plus as a major
implementation challenge. In Malawi, 17% of all Option B-plus patients were
reported lost to follow-up six months after ART initiation [15], and
in Uganda 18% of women initiated on ART in antenatal care and 80% initiated on
ART during labor did not return to receive their baseline CD4 results [16],
which is important to assess ART adherence and to direct ongoing counseling
support. In 2015 at the 8th IAS conference in Vancouver Canada,
an abstract presented from Malawi showed that same-day integration of HIV
diagnosis and treatment with antenatal care affected retention in Option B-plus
PMTCT services [17]. In South Africa, an observational study found that
nearly 60% of women who tested HIV-positive during pregnancy were lost to
follow-up between HIV testing and 6 months post-delivery [18].
Additional reasons for opting out of Option B-plus at Mulago
were preference for other health facility and to be prayed for rather than
taking Option B-plus ART for treating HIV infection. At the 20th IAS
Melbourne Conference in 2014, a speaker from Malawi brought to light the
outcomes and reasons for loss to follow-up among women attending the Option
B-plus program and concluded that most such women had stopped ART or
self-transferred to another clinic [19]. In our programme, we found out that
other women were living in denial of HIV-positive results and this has been a
challenge in various settings worldwide [20]. Many studies have revealed
that sociocultural factors such as religion, culture and stigma can
constitute barriers to ART access and adherence [21,22]. Self-care practices
whereby HIV-infected people use herbs and prayers to help them mitigate or even
cure HIV have also been reported as a challenge to take up appropriate
care. Musheke, et al. [23] concluded that, while self-care practices may
promote physical and psychosocial well-being and lessen AIDS-related symptoms
for a short term, these practices undermine the ability of people living with
HIV to access HIV care thereby putting them at risk of early AIDS-related
mortality.
While over 50 percent rates of acceptance of Option B-plus ART
initiation are very encouraging, we propose interventions to mitigate the
missed opportunities identified in our programme. The first is to reinforce
clinic-based efforts to educate, sensitize and strengthen counselling services
about the benefits and risks of Option B-plus so that women can make and
sustain informed rational choices with the support of their families and
communities. There is also needed to improve the longitudinal follow-up of
HIV-infected pregnant women including use of proven strategies such as short
text and phone reminders and psychosocial support from peer mothers. The second
is for an improved system of triage and referral of HIV-infected women
presenting to, or newly diagnosed in ANC and LW so that they can be retained in
care at LW and linked to appropriate care if they do not require ongoing LW
services. There is therefore urgent need to improve records management and
retrieval which, in this very large tertiary hospital, should include electronic
records management given the size of the patient population and the various
service delivery points. “At the moment, data collection is paper based and
there is a tendency of files getting lost”.
Our programme evaluation study had some limitations. We want to
point out that although the Uganda clinical guidelines of 2010 recommend four
routine antenatal care visits as follows: the first visit between 10-20 weeks
of pregnancy; the second visit between 20-28 weeks of pregnancy; the third
antenatal care visit between 28-36 weeks and fourth antenatal care visit after
36 weeks, we were not able to determine the time of gestation at which pregnant
women attended their first antenatal care [24].Due to weaknesses in the
hospital paper-based records management, there may have been a
misclassification of women as 1stattending LW and double-counting
among those who attended LW without an ANC card (when they had actually
attended ANC). Further, we recognize the possibility of a social desirability
bias with women seeking to ‘Please’ providers who are recommending Option
B-plus to them and thus not disclosing their true intentions or feelings [25].
It is reassuring that the counseling programme does allow women to express
themselves and captures some of the reasons for opting out. However, we cannot
exclude that there might not be a larger pool of clients who have also opted
out by taking ART medications home but with no intention to take them.
Despite these limitations, the analyses also have a number of
strengths, including the data available on the large numbers of women from this
large and long standing PMTCT programme who provided reasons for opting out of
option B-plus which are included in these analyses. Moreover, as Mulago
hospital attendees account for a substantial subgroup of all women attending
ANC and delivering each year at the national level in Uganda, we believe that
this program evaluation provides valuable insights into the acceptability,
feasibility and effectiveness of implementing Option B-plus in similar settings
within and outside Uganda. It also points to opportunities to improve our
implementation strategies. Further studies are required to evaluate Option
B-plus implementation comprehensively, including evaluations of mother-infant
retention in care, adherence and virologic suppression during pregnancy and
breastfeeding, and linkages to ongoing reproductive and HIV care as well as
infant HIV-free survival at Mulago Hospital and in other settings.
7. Conclusions
The results of this retrospective data analysis show that over
the first 19 months of implementation of the Option B-plus program for eMTCT at
Mulago National Referral Hospital in Kampala, Uganda, uptake of Option B-plus
was very high with a very small subgroup of around 1% of HIV-positive women who
chose to opt out from Option B-Plus ART.
Data from this eMTCT programme evaluation underscore the urgent
need to strengthen pre-pregnancy interventions given the large and increasing
proportion of women with known HIV positive status prior to their current
pregnancy. Efforts to improve records management and longitudinal follow-up of
HIV-positive pregnant women are also essential to improve care and evaluate
program effectiveness. Documentation, care and referral systems need to be
improved so that all eligible HIV-infected women are offered Option B-plus and
women referred between antenatal, labor and postnatal services receive
continuity of care and are counted just once.
Among the many women who started Option B-plus, it will also be
critical to evaluate individual ART adherence and viral suppression, systematic
linkages between PMTCT, reproductive health and ongoing HIV care; and effective
longitudinal monitoring systems to support continued care through any further
pregnancies and for the women’s lifetime.
8. Acknowledgements
The authors would like to thank all the PMTCT program mothers,
the Mulago Hospital staff; Professor Josaphat Byamugisha, Head, Department of
Obstetrics and Gynaecology, College of Health Sciences, Makerere University,
Uganda and the Uganda Ministry of Health. We also thank all our colleagues at
the Makerere University-Johns Hopkins University (MU-JHU) Research
Collaboration.
Figure I: HIV
status and Option B-plus Initiation Among Women Attending ANC for the
First-Time at Mulago Hospital from 16/10/2012
to 31/5/2014, N = 44,937.
Figure
II: HIV Status and Initiation of Option B-plus Among
Women Presenting for the First-Time at Mulago Hospital Labor Wards from 16/10/2012 to 31/5/2014, N = 23,116.
Figure III: Reasons for Opting-Out of Option B-plus among HIV-positive Women Attending Mulago Hospital Antenatal or Labor Services (N=83).
- Uganda Ministry of Health (2003)
Policy for reduction of mother-to-child HIV transmission in Uganda: 1-26.
- MOH (2012) Integrated National ART eMTCT Infant and Young Child
Feeding Guidelines Uganda.
- World Health Organization (2012)
Programmatic update use of antiretroviral drugs for treating pregnant women and
preventing HIV infection in infant’s executive summary Geneva World Health
Organization: 1-8.
- World Health Organization (2013)
Consolidated guidelines on general HIV care and the use of antiretroviral drugs
for treating and preventing HIV infection recommendations for a public health
approach. World Health Organization: 1-272.
- World
Health Organization (2010) Antiretroviral
drugs for treating pregnant women and preventing HIV infection in infants:
recommendations for a public health approach-2010 version. World Health
Organization.
- Viani RM, Peralta L, Aldrovandi G,
Kapogiannis BG, Mitchell R, et al. (2006) Prevalence of primary HIV-1 drug
resistance among recently infected adolescents a multicenter adolescent
medicine trials network for HIV/AIDS interventions study. Journal of Infectious
Diseases 194:1505-1509.
- Adams J, Patel N, Mankaryous N,
Tadros M, Miller CD (2010) Nonnucleoside reverse transcriptase inhibitor
resistance and the role of the second-generation agents. Annals of
Pharmacotherapy 44:157-165.
- UK Collaborative Group on HIV Drug
Resistance UK CHIC study group (2010) Long-term probability of detecting
drug-resistant HIV in treatment-naive patients initiating combination
antiretroviral therapy. Clinical Infectious Diseases 50:1275-1285.
- Turan JM, Nyblade L (2013) HIV-related stigma as a barrier to achievement of
global PMTCT and maternal health goals: a review of the evidence. AIDS and
Behavior 17: 2528-2539.
- deLoenzien M (2008) Implementation
of a continuum of care for people living with HIV/AIDS in Hanoi Vietnam. Sante
19:141-148.
- Black S, Zulliger R, Marcus R, Mark
D, Myer L, Bekker LG (2014)
Acceptability and challenges of rapid ART initiation among pregnant women in a
pilot programmeCape Town South Africa. AIDS care 26: 736-741.
- Uganda (2011) Demographic and Health
Survey: 1-315.
- Kim MH, Ahmed S, Hosseinipour MC,
Giordano TP, Chiao EY, et al. (2015) Implementation and operational research:
the impact of option B+ on the antenatal PMTCT cascade in Lilongwe Malawi.
Journal of acquired immune deficiency syndromes 68: e77-e83.
- Phillips T, Thebus E, Bekker LG,
Mcintyre J, Abrams EJ, et al. (2014) Disengagement of HIV-positive pregnant and
postpartum women from antiretroviral therapy services a cohort study. Journal
of the International AIDS Society 17: 19242.
- Tethani LN, Haas AD, Tweya H, Jahn
A, van Oosterhout JJ, et al.
(2013) Roll-out of universal antiretroviral therapy for HIV-infected pregnant
and breastfeeding women (“Option B+”) in Malawi: factors influencing retention
in care. In: Proceedings of the 7th IAS Conference on HIV Pathogenesis,
Treatment and Prevention Malaysia Kuala Lumpur.
- Lugolobi EN, Namukwaya Z, Musoke P,
Kakande A, Matovu J, et al. (2013) Retention
in care among women initiated on Option B plus in the Antenatal Clinic (ANC)
and labour ward at Mulago National referral hospital Kampala, Uganda. In:
Proceedings of the 7th IAS Conference on HIV Pathogenesis, Treatment and
Prevention in Malaysia Kuala Lumpur.
- Chan AK, Kanike E, Bedell R, Mayuni
I, Manyera R, et al. (2015) Same day integration of HIV diagnosis and treatment
with antenatal care affects retention in Option B+ PMTCT services in Zomba
District Malawi. J Int AIDS Soc 19: 20672.
- Clouse K, Pettifor A, Shearer K,
Maskew M, Bassett J, et al. (2013) Loss to follow‐up before and after delivery among women testing HIV
positive during pregnancy in Johannesburg South Africa. Tropical Medicine &
International Health 18: 451-460.
- Tweya H (2014) Loss to follow-up among women in PMTCT Option B+
programme in Lilongw Malawi: understanding outcomes and reasons. In:
proceedings of the 20th International AIDS Conference in Australia. Melbourne
20-25 July 2014 Melbourne.
- Nakigozi G, Atuyambe L, Kamya M,
Makumbi FE, Chang LW, et al. (2013) A qualitative study of barriers to
enrollment into free HIV care: perspectives of never-in-care HIV-positive
patients and providers in Rakai Uganda. Bio Med research
international 2013: 1-7.
- Chindedza M, Mutseyekwa F,
Chideme-Munodawafa A (2013) Perceived barriers to accessing and achieving
adherence in antiretroviral therapy among HIV patients at a rural mission
hospital in Zimbabwe. European Scientific Journal 9: 277-287.
- Roura M, Nsigaye R, Nhandi B, Wamoyi
J, Busza J, et al. (2010) Driving the devil away qualitative insights into
miraculous cures for AIDS in a rural Tanzanian ward. BMC public health 10: 427.
- Musheke M, Bond V, Merten S (2013)
Self-care practices and experiences of people living with HIV not receiving
antiretroviral therapy in an urban community of Lusaka Zambia implications for
HIV treatment programmes. AIDS research and therapy 10:12.
- Ministry of Health (2010) Uganda Clinical Guidelines: antenatal
care. Revised first edition: 325.
- Ngarina M, Tarimo EA, Naburi H, Kilewo C, Mwanyika-Sando M, et al. (2014) Women’s preferences regarding infant or maternal antiretroviral prophylaxis for prevention of mother-to-child transmission of HIV during breastfeeding and their views on Option B+ in Dares Salaam, Tanzania. PLoS One 9: e85310.