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Mbeye-Munkhondya, Tiwonge, Smyth, Rebecca and Lavender, Tina (2021) 'Facilitators and barriers to retention in care under universal antiretroviral therapy (Option B+) for the Prevention of Mother to Child Transmission of HIV (PMTCT): A narrative review'. International Journal of Africa Nursing Sciences, Vol 15, Issue 100372.
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Abstract
Background
Mother to child transmission (MTCT) is the most significant sources of Human Immune Deficiency Virus (HIV) in children. The risk of HIV transmission from the mother to the child, during pregnancy, birthing and breastfeeding, ranges from 15 to 45% (World Health Organisation [WHO] 2018), but with prevention of mother to child transmission (PMTCT) services the risk of transmission can be reduced to 5% (WHO, 2017). In 2011, Malawi became the first country to use Option B+ in 2011 which later became the WHO recommendation for the prevention of mother to child transmission of HIV (PMTCT) in Low and Middle-income countries (WHO, 2013). With Option B+, all HIV positive pregnant and lactating women are initiated on lifelong antiretroviral therapy (ART) regardless of their clinical and immunological status (WHO, 2013). Furthermore, all babies born or lactating from such mothers are said to be HIV exposed and are enrolled in an early infant diagnosis (EID) programme where they are followed up until they are two years old.
Some of the reasons for adopting these recommendations were to increase access to ART, reduce MTCT, prolong the life and sustain the health of the mother, and reduce HIV transmission to the spouse or sexual partner. Evidence suggests that the use of ART by pregnant and lactating mothers prevents MTCT and improves maternal health (Shapiro et al., 2010; Granich et al., 2010). This is true because ARTs suppress HIV viral replication thereby drastically lowering the HIV viral load in infected persons stopping the progression of HIV disease; consequently, HIV becomes untransmissible (Bunnell et al., 2006, Granich et al., 2010. Following the adoption of Option B+, there was substantial progress in pregnant mothers receiving ART. The UNAIDS (2017a), reported that 80% of pregnant mothers living with HIV were on ART in 2017, compared with 51% who had access in 2010.
Furthermore, results from the implementation of Option B+ accounted for a significant reduction of MTCT (Haas et al., 2017; Miller, Muyindike, Matthews, Kanyesigye, & Siedner, 2017; Ng'ambi et al., 2016; Ngemu et al., 2014; Phiri et al., 2017). For instance, a retrospective cohort study utilising routinely collected HIV exposed infant data from 2012-2014 at a large HIV centre in Lilongwe, Malawi found an MTCT rate of 6.2% for infants at 24 months (Ng'ambi et al., 2016). Similarly, another retrospective study found that only 5.3% of infants from 21 large health facilities in two regions of Malawi were HIV infected at the age of 30 months (Haas et al., 2017). Additionally, UNAIDS (2017a) reported that due to the implementation of sound PMTCT services, around 1.4 million HIV infections among children were prevented between 2010 and 2018. Such progress provides evidence that ART interrupts HIV transmission. For this reason, the need for providing universal lifelong ART to all HIV pregnant and breastfeeding mothers is undisputed. However, although the above studies show a significant decrease in the MTCT risks, these studies did not capture the risks of MTCT at different time points within the PMTCT programme. A more recent Malawi national-level analysis study found that overall, the risk of MTCT was as low as 4.7% with higher rates of 11.4% if mothers miss maternal ART, infant prophylaxis ARTs and infant testing (van Lettow et al., 2018). It can be argued, therefore, that the MTCT rate can only decrease if the mothers comply with all the steps in the PMTCT cascade. Nevertheless, lost to follow up (LTFU) has been the greatest challenge in the implementation of the Option B+ programme (Haas et al., 2016; Keehn & Karfakis, 2014; Nachega et al., 2016; Tenthani et al., 2015), leaving many infants undiagnosed, significantly putting their lives at risk of dying. According to the UNAIDS (2014) gap report, only 42% of exposed infants get tested for HIV in the first two months of life. Moreover, despite getting tested, some do not receive their results, as such, they are not promptly treated (Bobrow et al., 2016).
Several studies have been conducted on LTFU from PMTCT (Bwirire et al., 2008; Kinuthia et al., 2011; Muchedzi et al., 2010; Nachega et al., 2012), but reasons for non-retention in the era of universal ART for PMTCT have not been comprehensively synthesised. For instance, a systematic review that assessed the reasons for low rates of access, initiation, and adherence to ARV drugs by mothers and HIV exposed infants in sub-Saharan Africa, identified and grouped facilitators and barriers to PMTCT as individual, partner, community and health care factors (Gourlay et al., 2015). However, this review included studies that were published between the year 2000 to 2012, (Gourlay et al., 2015) a period before the universal test and treat ART recommendation. Similarly, another systematic review examined health system barriers to and enablers of initiation, retention, and adherence of pregnant and postpartum women from 42 studies globally (Colvin et al., 2014). However, although this review was conducted in the era of Option B+, most of the studies that were included considered barriers and enablers under option A and B (Options where women were only started on lifelong ART if their CD4 count was below 350cells/mm3) and included only two papers on option B+ (Colvin et al., 2014). Recently, a mixed method review synthesised data on retention in care and identified factors associated with retention in care in the era of Option B+ (Knettel et al., 2017). The review included 22 papers on retention rates and 25 papers for factors associated with retention. The review identified younger age, initiating ART during pregnancy versus breastfeeding and initiating late in pregnancy as risk factors associated with retention (Knettel et al., 2017). They further reported that retention was compromised by stigma, fear of disclosure and lack of social support (Knettel et al., 2017). However, despite providing explicit data on Option B+ retention rates, the facilitators and barriers to option B+ uptake were not explicitly synthesised. While existing studies and reviews have considered LTFU under universal life-long ART for the PMTCT, the evidence has not been comprehensively synthesised. Therefore, a narrative synthesis of evidence surrounding retention in care under the universal life-long ART for the PMTCT was conducted to build on the above literature.
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