1. 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

2. 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.

3. 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.

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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.

12. 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%)

13. OPT-IN vs. OPT-OUT

14. 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

15. 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

16. 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

18. 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