Abrams EJ, Langwenya N, Gachuhi A, Zerbe A, Nuwagaba-Biribonwoha H, Mthethwa-Hleta S, Sahabo R, Lesosky M, Okello V, Myer L.
AIDS. 2018 Oct 4. doi: 10.1097/QAD.0000000000002027. [Epub ahead of print]

OBJECTIVE:

Universal eligibility for lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women (“Option B+”) has been widely adopted, but concerns remain. We tested the hypothesis that the change from CD4-guided ART eligibility (“Option A”), to Option B+, would improve maternal ART uptake and retention.

DESIGN:

A stepped-wedge evaluation at 12 health facilities in Swaziland.

METHODS:

Primary outcome was maternal retention: proportion of women attending clinic within 56 days of delivery (antenatal retention) and clinic attendance within 84 days of 6-months postpartum (postnatal retention). Generalized estimating equations examined impact of Option B+ versus Option A.

RESULTS:

Between 19August2013 and 29August2014, 2347 HIV-positive women, 55% (n = 1296) Option A, 45%, (n = 1051) Option B+ were included. ART initiation was observed in 36% (n = 469) of Option A women versus 94% (n = 983) under Option B+ (p < 0.001). Overall 39% (n = 912) were retained from first ANC visit through 6-months postpartum. Retention was higher under Option B+ (53%, n = 559) versus Option A (24%, n = 353) with variation by site and study month. Adjusting for age, gestational age, previous HIV diagnosis and CD4, Option B+ women were significantly more likely to be retained antenatally (aRR 1.32; 95% CI 1.18-1.49; p < 0.001) and postnatally (aRR 2.11; 95% CI 1.79-2.49) compared with Option A. Restricted to women initiating ART, retention was lower under Option B+ (57%, n = 558) versus Option A (66%, n = 309), (aRR, 0.82; 95% CI, 0.70-0.95; p < 0.0001).

CONCLUSIONS:

Compared with CD4-guided ART eligibility, universal ART resulted in substantial increases in pregnant women initiating ART and retained in care through 6-months postpartum.