Human rights and ethical dilemmas in the implementation of Option B+ in Malawi Alister C. Munthali, Blessings Chinsinga and John Kadzandira Centre for Social Research Blessings Kaunda-Khangamwa and Francis Masiye College of Medicine Bagrey Ngwira Malawi Polytechnic

Background and objective In July 2011 the Ministry of Health introduced Option B+ which involves the initiation on ART for all pregnant and lactating women found HIV+ regardless of their CD4 count. Option B+ aims at eliminating transmission of HIV through mother to child transmission. Critics of Option B+ have argued that it poses potential threats to patient rights concerning consent, confidentiality and counseling. This study aimed at determining the human rights and ethical issues surrounding Option B+. Study conducted in 14 districts: 28 health facilities, 42 interviews with service providers; 84 interviews with women on Option B+ or those who have ever accessed Option B+ and their spouses; 28 interviews with community leaders; 64 FGDs with men and women; and 42 FGDs with women on Option B+; and 18 key informants.

Human rights and ethical issues surrounding Option B+ Should pregnant women be prioritised – critics say that this is unjust as there are others who equally require treatment. Most study participants, men, women, traditional and health workers have no problems in prioritising pregnant women: there is enormous support for this programme because it prevents HIV transmission to the baby. Men also want to get children especially male children in order to continue their lineage. However, there were a few voices of dissent: they call for provision of ART to both the wife and the husband if both of them are found HIV+. It is unfair just to provide treatment to women. There can be tension in such homes where both the husband and wife are HIV+ and only the wife receives ART. There were very few informants who reported that they were forced participate in Option B+.

Human rights and ethical issues surround Option B+ The high acceptance of the programme is based on information provided to them and clients are able to make informed decisions. There are, however, concerns about the quality of counselling that goes on in health facilities: health workers do not spend quality time with their clients. While we consider the rights of women to make their own decisions we also need to think about the rights of the unborn baby: do these babies have the right to health and the right to be born HIV free?

Conclusions The implementation of Option B+ in Malawi is a success story despite ethical and human rights concerns about the programme. The majority of the study participants did not have any issues with prioritisation of pregnant and lactating women in the delivery of ART services. Currently Malawi is implementing universal ART using a phased approach. While pregnant and lactating women make their own decisions about being tested for HIV, being enrolled on Option B+ based on information given, there are some elements of coercion in the delivery of Option B+. The desire to have HIV- babies also drives mothers to participate in Option B+. There are some key challenges in delivery of Option B+ (e.g. lack of male involvement, long distances to health facilities, negative attitudes of health workers and loss to follow up) which need to be urgently addressed.