By: Dr. Aoife Kenny
An estimated 1.5 million HIV-positive women become pregnant every year. Effective treatment is essential for reducing their chance of severe illness or death during pregnancy as well as reducing the chance of infecting their children with HIV. The best way to prevent mother-to-child transmission (PMTCT) is to ensure that medication is taken throughout the pregnancy and breastfeeding period. PMTCT is an essential component of three Millennium Development Goals: reducing child mortality, improving maternal health, and combating HIV/AIDS.
The current World Health Organization (WHO) guidelines on PMTCT require a blood test to test the CD4 cell count to help health workers determine the best method to provide to an HIV-positive pregnant woman. This is not practical in many developing contexts, as the test may not be available and the different medication regimes can be complex.
Recognizing these issues, many countries, especially low and middle-income countries, are reviewing their PMTCT approaches. Malawi is one country at this frontier and is taking a simple, yet bold approach that is being watched eagerly by other nations that need better PMTCT solutions.
In Malawi, there are nearly one million HIV-positive, pregnant women. The country is very poor, with most of the population living in rural areas. A Malawian woman is estimated to have on average 5.6 children in her lifetime. In addition, Malawian women tend to seek antenatal care late in pregnancy and breastfeed children for an average of 23 months per child.
For PMTCT this poses a critical question: Is it feasible or reasonable to stop the medications of an HIV-positive woman, who has been on the drug regimen across her pregnancy period and duration of breastfeeding, particularly when the time between births is so short?
According to Professor Anthony Harries, the previous National Advisor in HIV Care and Treatment in the Malawian Ministry of Health, the country’s PMTCT program was not working. Recognizing the problem, the Malawi Ministry of Health began a new approach, called “option B+,” referring to the approach being a more practical version of the WHO’s “option B.” Under option B+, if a woman comes to any clinic in Malawi believing she is pregnant, both a pregnancy test and a finger-prick HIV test will be administered. If both tests are positive or there is prior knowledge of HIV-positive status, she is offered anti-HIV medication, along with the necessary counseling and support. Women are no longer required to have the CD4 blood test before treatment, removing this barrier to essential care. The medication the Malawian Ministry of Health has chosen is a single-tablet triple-therapy, which is widely considered the best option for HIV by the global health community. A woman will continue on this medication for life, improving her health outcomes beyond this and further pregnancies, as well as protecting any future children from the time of conception. Although this policy is a dramatic move, it is feasible because of the high HIV prevalence in the country and strong political commitment, according to Harries.
Of course, this policy will benefit more than just the mothers of Malawi. Extra training and skills for health workers as well as re-enforcing the message that “HIV medication is for life,” are likely to have far-reaching health implications for all Malawians. The Professor also pointed out, there will be strong monitoring and evaluation of the roll-out to provide Malawi with feedback on the program and build evidence to determine if a similar move is appropriate for other countries.
The decision, however, is expensive for several different reasons. First, a much greater number of women will receive treatment as a result of the policy. Second, the chosen medication regimen is costlier than the usual option available to citizens of developing countries and increases the yearly cost per person from about $US65 to $US176. The Ministry of Health, and many commentators, believe that the price is justified by the added benefits, including treatment being provided in only one tablet less drug-induced anemia, and treatment of hepatitis B, which is a common disease in HIV-positive people in Malawi. In addition, being the preferred medication combination for the whole country also simplifies drug purchasing and distribution.
It was originally planned that the additional resources required to implement the new policy would be funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria, but in 2011 the Global Fund announced it would cease funding new projects for the near-term because of a lack of donor support. With this disappointing turn of events, Malawi has had to compromise. The political will to support PMTCT stands, and “option B+” will still be offered to all women, but the plan to have this as the preferred treatment for all HIV patients in Malawi has been deferred until more funding can be found.
Even with the Global Fund disappointment, Malawi is proving its commitment to mothers and infants. Women will receive good, simple HIV medication from the first time they present to an antenatal clinic. They will have improved health in pregnancy and beyond, benefiting themselves as well as their families and communities. Their babies will have a greatly reduced chance of acquiring HIV.
Malawi’s straightforward, evidence-based and realistic approach is being watched keenly by the many other countries and holds hope to bring better HIV treatment to a new generation of mothers and brighter futures for their babies.
Special thanks to Professor Anthony Harries, previous National Advisor in HIV Care and Treatment in the Malawi Ministry of Health for speaking to Celebrate Solutions.
For more detailed information see this recent article in The Lancet, and the World Health Organization.
Flickr photograph courtesy of Josh Wood