The Impact of Routine Counseling and Testing with an Opt-Out Strategy Compared to Voluntary Counseling and Testing in the Implementation of PMTCT Services in Lilongwe, Malawi Zimba C1, Kamanga E1, , Chilongozi D1, Martinson FEA1, Meme J4, Kayambo F3, Hoffman I2, Maida A5, Mofolo I1, Spensley A6, Moses A1, Nkhoma J1 and van der Horst C2 1UNC Project, Lilongwe Malawi, 2University of North Carolina, Chapel Hill, NC 3Malawi National AIDS Commission, 4UNICEF Malawi, 5Malawi Ministry of Health, 6EGPAF

Background UNC Project works with Malawi Ministry of Health providing PMTCT services at the 4 Antenatal Clinics in Lilongwe District. Began April 2002 using an Opt-In Strategy. In April 2005 UNC Project piloted an Opt-Out methodology following Malawi MOH recommendation.

Sites of Operation The program operates at: Bottom Hospital Kawale Health Centre Area 25 Health Centre Area18 Health Centre. 20,000 new ANC visits each year.

Overall Objective To reduce the risk of MTCT of HIV through integration of HIV/AIDS education, Routine Counseling Testing and NVP prophylaxis to mother/Infant pairs into the existing maternal and child health care delivery system.

Program Components HIV/PMTCT Education to communities Routine HIV counseling and testing to pregnant women Provision of comprehensive Antenatal care (Hgb, RPR, Tetanus Tx, Vitamins, Fe, SP) Cotrimoxazole to HIV + Mothers (May 2006) CD4 count for mothers (July 2006) Provision of comprehensive Obstetric care

Program components (Cont) Provision of sd NVP to mother at week 32 Administration of prophylaxis to infant (sd NVP) at delivery Provision of comprehensive Post natal care for mother and child (vaccinations) Cotrimoxazole (Bactrim) prophylaxis for the child (6 weeks to HIV diagnosis at 12 to 18 months) Support group for HIV infected and lactating mothers

Opt-in Method (Prior to April ‘05) Daily sensitization of PMTCT in antenatal clinics waiting areas Small group (8-12 women) counseling then Individual pre-testing counseling (≤ 1hour) Individual oral informed consent for VCT Testing and Post-test counseling Advised to deliver at the hospital or clinic to get infant NVP for prophylaxis

Opt-Out Method Continued waiting room sensitization Newly registered ANC women counseled in small groups of about 8-12 women /group GROUP HIV counseling where ALL offered HIV test Women not interested offered opportunity to decline test but they still received ANC services for the day Testing done on one-on-one basis Previously registered antenatal attendees who opted out at their initial visit, are offered the opportunity to participate on return visits

For Both Opt-in and Opt-out Rapid tests by finger prick on one to one basis Rapid tests are Determine + UNIGOLD in parallel Concordant + results are recorded as HIV + Concordant HIV – are recorded so as negative Bioline is tie breaker if the results are discordant Individual post test counseling for all tested for HIV At week 32 maternal NVP dose given to mother to take home

OPT-OUT STRATEGY HIV Infected mothers return at 32 weeks gestation: Infant feeding counseling Encouraged to come to clinic for infant single dose NVP syrup within the first 72 hours of life

OPT-OUT Vs OPT-IN The study compared data between the last 9 months of the opt-in method and the first 9 months of the opt-out strategy of PMTCT implementation.

Results Opt in July 04-March 05 15,343 11689 (76.2%) 11674 (76.1%) METHOD NEW ANC HIV COUNSELED TESTED HIV POSITIVE Opt in July 04-March 05 15,343 11689 (76.2%) 11674 (76.1%) 1736 (14.85%) Opt out April 2005-Dec 2005 14,749 14495 (98.3%) 14491 2092 (14.44%)

OPT-IN vs. OPT-OUT

Conclusion 24% of clients refuse VCT with Opt-IN. The uptake of HIV counseling , Testing and NVP prophylaxis to mother/infant pairs has greatly improved utilizing Opt-Out method

Recommendations Routine counseling/testing standardized nationwide using OPT-OUT method sd NVP given at diagnosis to increase uptake Pre packing NVP syrup for babies to administer at home

Future Goals Use Lilongwe District PMTCT Program as model for nationwide expansion Improve system to follow-up mothers receiving HIV positive results is needed Incorporation of Traditional Birth Attendants in PMTCT Program Increase male involvement Provision of mosquito nets to all clients Incorporation of Ready To Use Food for early weaning

Acknowledgements EGPAF, USAID and UNICEF, UNC Center for AIDS Research for funding Malawi MOH and the Lilongwe DHO World Food Program UNC Project Staff both in the U.S and Malawi The community and our clients for accepting the services provided