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National HIV Transmission in 4-12 Week Olds in Malawi’s PMTCT Option B+ Program
Beth Tippett Barr1; Erik Schouten2; Joep van Oosterhout3;Sundeep K. Gupta4; Happy Phiri2; Deus Thindwa2; Christopher Blair2; Andreas Jahn5; Monique von Lettow6; for the The NEMAPP Consortium
1CDC, Harare, Zimbabwe;2Management Sciences for Hlth, Lilongwe, Malawi;3Dignitas Intl, Zomba, Malawi;4CDC, Lilongwe, Malawi;5Ministry of Hlth, Lilongwe, Malawi;6Dignitas International, Lilongwe, Malawi
Option B+ was conceptualized and implemented in Malawi in 2011. Recognizing that additional data would be needed to validate program results documented by the Ministry of Health, and to provide further detail on variation in transmission by ART coverage and timing, a two year cohort study called the National Evaluation of Malawi’s PMTCT Program (NEMAPP) was implemented in November 2014. A primary objective of NEMAPP is to measure mother-to-child-transmission (MTCT) in the era of Option B+.
NEMAPP is ongoing at 54 randomly selected health facilities in 10 districts. A stratified cluster sampling design was used to identify a nationally representative sample of 4-12 week old infants. Mothers were consecutively consented and screened for HIV while attending an under-5 clinic, and all identified HIV-exposed infants underwent HIV-1 DNA testing. This paper presents unweighted results of early infant transmission at the time of enrollment into NEMAPP.
Amongst 1,851 HIV-positive mothers of 4-12 week old infants, 98.2% reported knowing their HIV status in pregnancy. Overall MTCT was 3.9%. Among those on ART in pregnancy (coverage 93.5%) MTCT was 2.8%. Of the 6.5% of women who either never start ART, or chose to stop ART at any time during or immediately after pregnancy, MTCT was 20%. MTCT varied by timing of ART initiation: from 1.4% in the 46.5% of women on ART prior to pregnancy, to 21.3% in the 5.8% of women who had never started ART.
Overall, vertical transmission of HIV is very low under Option B+. In women who are entering pregnancy already on ART, transmission is now on a similar scale to that observed in developed nations. Any ART coverage, even when started postpartum or taken temporarily, as in the case of defaulters, results in significant reduction in transmission.