1. Loss to follow-up among women in Option B+ PMTCT programme in Lilongwe, Malawi: Understanding outcomes and reasons
Hannock Tweya, Salem Gugsa, Mina Hosseinipour, Colin Speight, Wingston Ng’ambi, Mphatso Bokosi, Janet Chikonda, Annie Chauma, Veena Sampathkumar, Tiwonge Mtande, Sam Phiri

2. Option B+ PMTCT strategy in Malawi
Use of antiretroviral therapy in HIV-infected women significantly reduces vertical transmission; from 25% to 2%
In 2011, Malawi embarked on a novel PMTCT programme known as “Option B+”
Lifelong ART for pregnant and breastfeeding women regardless of WHO clinical stage or CD4 count
NVP syrup for 6 weeks for infants
Option B+ resulted in a 7-fold increase in the number of women starting ART for PMTCT between the 2nd quarter of 2011 and 3rd quarter 2012

3. Loss to follow-up in Option B+ PMTCT
Loss to follow-up (LTFU) from care is a considerable barrier to the effectiveness of PMTCT
27% are LTFU at 12 month nationally (Malawi HIV Report Dec 2013)
24% are LTFU in the first 6 months in facilities with high patient volume (Tenthani et al AIDS 2013)
Information on LTFU in women starting lifelong ART for PMTCT remains limited

4. Objectives
To determine factors associated with LTFU among women starting lifelong ART for PMTCT
To determine true outcomes of women who are lost to follow-up from PMTCT care
To describe reasons for LTFU from Option B+ PMTCT programme

5. Methods: Study design & Setting
We conducted a retrospective cohort study using data from
A real-time, touch screen-based, electronic Medical Records (EMR)
A patient tracing programme
Bwaila Hospital, Lilongwe
Has the busiest ANC and Maternity wings with over 14,000 ANC registrations annually
Provision of PMTCT services is a collaborative effort, led by the Lilongwe District Health Office and other partners
Starts ~110 women on ART monthly based on Option B+ criteria

6. Methods: PMTCT services
All pregnant women with unknown HIV status undergo
A group HIV counselling session
‘Opt-out’ provider-initiated HIV testing
“Expert mothers” provide psychosocial and adherence support to HIV-infected women on initial and follow-up visits
All HIV-infected women are registered in the EMR System and started on a lifelong ART on the day of HIV diagnosis
At each visit, number of remaining ARV pills and new supply are recorded and next appointment is electronically calculated
ART clinic visits are scheduled monthly

7. Methods: Tracing programme
The patient tracing programme intends to decrease treatment interruption and prevent LTFU
Tracing staff generate a list of women that miss an appointment by at least three weeks
The staff confirms the list by checking in patients files
Women who consent are traced up to three times by phone call or home visit
The staff complete standard paper forms on tracing efforts, outcomes and reasons for missing appointment

8. Methods: Analysis Tracing outcomes include:
Dead, uninterrupted therapy, treatment interruptions, self transfer out, stopped ART, never started ART and not traced
For the purpose of the tracing programme, LTFU was defined as missing a scheduled clinic appointment for at least 3 weeks.
Multivariable Poisson regression was used investigate factors associated with LTFU
1)‘silent-transfer’ if the patient had arranged the transfer independently; 2) alive on ART (with ‘treatment interruptions’ if a patient took none or fewer than the prescribed drugs before the interview date, or with ‘uninterrupted therapy’ if the patient was still taking ARVs despite missing appointment); 3) stopped ART by themselves; 4) refused to be interviewed; 5) never started ART although they collected drugs

9. Results: Patients details & LTFU
Between September 2011 and September 2013, 2930 HIV-infected women started ART for PMTCT Option B+:
2,458 (84%) were pregnant
Median age at ART initiation was 26 years (IQR 22-30)
Median follow-up of 8.2 months (IQR )
Of 2,930 women, 577 (20%) missed a scheduled clinic appointment for at least 3 weeks
272 only collected ARV’s at the time of initiation and did not return
Overall incidence of LTFU was 23.5 % per year
In terms of retention: 85% at 3 months, 82% at 6 months 79% at 12 months
14% were breastfeeding

10. Results: Factors associated with LTFU
Characteristics
Adjusted Rate
Ratios (95% CI)
P-Value
Age at ART initiation (years)
<0.001
1.29 (1.09 – .52)
25+
1.00
Reason for ART initiation
Breastfeeding
0.63 ( )
Pregnant
Employment Status
0.177
Yes
0.87 ( ) No
Year of B+ Implementation
2011
1.25 ( )
2012
2013
0.41 (

11. Results: Tracing Outcomes
577 LTFU women
228 (40%)
Successfully
Traced
349 (60%)
Not traced
/ Not found
*No significant differences between those traced or not

12. Results: Tracing Outcomes
577 LTFU women
228 (40%)
Successfully
Traced
349 (60%)
Not traced
/ Not found
67 (30%)
Self Transfer
152 (66%)
Alive not TO
9 (4%)
Died

13. Results: Tracing Outcomes
577 LTFU women
228 (40%)
Successfully
Traced
349 (60%)
Not traced
/ Not found
9 (4%)
Died
67 (30%)
Self Transfer
152 (66%)
Alive not TO
9 (6%)
ART interruption
7 (5%)
Not started ART
5 (3%)
Refused interview
118 (77%)
Stopped ART
13 (9%)
On ART Uninterrupted

14. Results: Reasons for ART discontinuations (N=111)%
Travelled away 42
38%
Transport costs 17
16%
Limited information about ARVs 11
10%
Suspected side effects of ARVs
Very weak/sick
Non-disclosure of HIV status to the spouse 9 8%
Religious belief 5 5%
Forgotten to take ARVs
Other reasons 49
44%
This would be a good opportunity to mention that

15. Discussion Overall LTFU was 23.5% per year
Higher than that reported in the general HIV-infected individuals accessing ART for personal health ( 9.3% per year)
47% of women who were lost to follow-up received ARVs once and never returned for their appointment
May suggest that a proportion of these women never started ART
Being older ( 25+ years) associated with reduced risk of LTFU
May have settled lifestyles which allow them to better manage ARVs
Likelihood of LTFU decreased with increasing year of programme implementation between 2011 and 2013
Likely due to the stabilization of the programme

16. Discussion
A sizeable proportion of women could not be traced due to incorrect addresses documented in the patient clinic files.
False physical addresses because of fear of stigma and discrimination
Among LTFU women that were traced:
Half had stopped ART, leaving their infants at high risk of HIV
A third self-transferred to another clinic, suggesting underestimation of national retention in PMTCT programme
it is likely that a considerable number of women in this study may have deliberately given a false physical addresses because of fear of stigma and discrimination through inadvertent disclosure of their HIV status

17. Recommendations
ANC/ART clinics should further enhance post-test counseling by engaging HIV testing counselors and expert mothers for ongoing counseling and psychosocial support.
Establishing targeted programmes for young women
ART clinics need to establish data linkages through which information of patients that transfer can be shared.
Further decentralization of PMTCT services with good ANC/Maternity services

18. Acknowledgments
Mother2Mother
Baobab Health Trust 18