The Game Changer: Option B+

All of the countries in which mothers2mothers (m2m) operates have adopted Option B+, a treatment protocol recommended by the World Health Organization that puts all HIV-positive pregnant and breastfeeding women on antiretroviral drugs for life. This has been a game changer in terms of how treatment is delivered, and also how m2m supports and educates our clients to stay on this lifelong commitment. We asked our Country Directors to describe the impact Option B+ is having on the ground, and what m2m’s Mentor Mothers are doing to support it.

Click on the photos below and scroll down to see what they had to say.

  • Milker Simba
  • Frida Kabaso
  • Veena Sampathkumar
  • Shungu Gwarinda
  • Sibongile Maseko
  • Marjorie Mbule

In June 2014, the Ministry of Health in Kenya launched revised PMTCT (prevention of mother-to-child transmission) national guidelines, otherwise known as rapid advice, initiating all HIV-infected pregnant and breastfeeding women on ART (antiretroviral therapy) for life. Many studies show that putting women on ART for life confers greater benefits to the mothers and significantly reduces transmission of HIV infection from mother to child. Kenya decided to abide by these findings. Towards the end of 2014, most health facilities had initiated rapid advice (Option B+), and all sites where m2m is working are currently implementing the protocol.

At first it was very difficult for clients to accept because before they had always been taught that if your CD4 is high, you didn't need ARVs (antiretroviral drugs)! But with gradual education “ART for LIFE” has changed clients' attitudes. Continuous adherence education conducted by m2m’s Mentor Mothers has made a big impact on the acceptance of Option B+ at the sites.

Nationally, the uptake on ARV adherence has improved. Option B+ has reduced prior confusion about the guidelines, making it easier for clinicians to know what to prescribe. The pill burden has greatly reduced with single pill, fixed dose combination treatment. It is also easier for Mentor Mothers to communicate health messages in support groups because they are now educating on a single regimen for clients to use.

Mentor Mothers offer initial adherence education and continuous support, including counting a client's drugs and ensuring that she has been issued the correct ones. They explain the side effects, personalising what could be a frightening prospect with stories of their own experiences and providing patient, gentle support that nurses can't provide with all their competing priorities. As a result, most women accept their status and live positively as they see their Mentor Mothers do. Women are retained in care with Mentor Mothers by their side until their babies get their last HIV test at 18 months. And most women disclose their status to their partners, making it easier for a Mentor Mother to follow up with them in case they default.

Lesotho implemented Option B+ nationally in May 2013 to increase the uptake of PMTCT (prevention of mother-to-child transmission) and also address challenges around retention in care and adherence to treatment.

Although Option B+ has been received well in Lesotho, its advantages and benefits still need to be more broadly shared with all expectant mothers so that they access medication and also remain on medication after delivery for improved quality of their own health.

To enhance the uptake of Option B+, m2m has implemented a community engagement programme that provides education and peer support through household visits to sensitise women on the importance of visiting the health facility as soon as they know they are pregnant and taking an HIV test. m2m's Mentor Mothers are playing a key role of providing education and peer support to pregnant women so they present early at the health facility and, if they test positive, immediately commence ART (antiretroviral therapy) for life. The Mentor Mothers at the health facility share with them their own experiences with HIV and PMTCT, and support them to access medication, adhere to their medication, and to stay in care.

Malawi was the first country to pioneer the Option B+ approach in 2011 to address a number of resource limitations, including the fact that the country did not have enough CD4 machines to determine the stage of a woman's HIV infection and whether she qualified for ARVs (antiretroviral drugs) under the old protocol. After the national rollout of Option B+ by December 2014, the Ministry of Health reported that 85% of women expected to be HIV positive during pregnancy had been identified and initiated onto treatment. The Malawi HIV National Programme has now reached the tipping point in the epidemic with the number of adults on ART (antiretroviral therapy) exceeding the rates of new infections!

m2m services were instrumental in the rapid scale up of Option B+ in Malawi. The programme put women on lifelong treatment on the very same day they were tested. Currently, within the Malawian national health system there is no specialised facility-based cadre of health workers responsible for HIV Testing and Counselling (HTC) or ongoing adherence to care and treatment support and counselling. In addition, the health surveillance assistants who are tasked with community support and follow up care are overburdened and increasingly facility-based. With competing time demands and a high volume of clients, clinical staff are unable to dedicate adequate time to support clients individually and address their specific needs of committing to ART for life.

m2m stepped in to provide dedicated patient support services for client education, peer support, referrals, and retention/follow up services. Through the intimacy and trusted relationships that Mentor Mothers build with their clients over time, m2m is able to combat the high levels of stigma and fear of negative repercussions that continue to prevail. m2m, has developed new service delivery improvements to address the key issues in Option B+, including a client appointment diary to improve retention of infants in care, minimising the 'non-starters' (women who take ARVs from the facility but do not actually start the medications), and improving adherence among clients.

Option B+ was rolled out nationally in January this year across all South African provinces. One of the primary motivations was to address the challenges of maternal mortality in South Africa, where a significant percentage of cases are HIV-related. Hence, one of the goals of Option B+ is to improve the general health of HIV-positive women beyond preventing mother-to-child transmission of HIV. Another goal is to prevent women who are of reproductive age from continually stopping and starting their treatment, which can make their HIV infection more resistant to drugs. It is also aimed at reducing MTCT (mother-to-child transmission) after their babies have their first HIV test at six weeks. South Africa has done quite well at reducing MTCT rates at six weeks, but there still remain challenges of keeping more mothers on treatment after that first infant HIV test, especially through the breastfeeding period where the risk of infection is high without ARVs (antiretroviral drugs). Lifelong antiretroviral treatment can address these challenges.

Option B+ was well received at health facilities and among clients in South Africa. Right before adopting Option B+, South Africa began implementing the single pill, fixed dose combination treatment that makes it much easier for clients who are on ART to take their treatment. That helped to make the acceptance of Option B+ smoother.

Before Option B+ was rolled out in South Africa, we actually visited m2m Malawi, which had already been implementing the protocol, to understand how m2m could best support it. We looked at what data we needed to start collecting related to client treatment on Option B+, and we talked with site staff about some of the challenges they face with clients and what techniques they were using to prepare clients for lifelong treatment. We then did a very rapid training with all our site staff so that once government started rolling out Option B+ they were also up to speed with the new guidelines.

In order to get clients to commit to lifelong treatment, it is critical for them to understand the benefits for them, their babies, and their partners as well. Follow-up is also very important to make sure women have the support to adhere to and stay on treatment, and as a result we have rolled out our Active Client Follow Up programmes to all of our sites.

Swaziland began transitioning to Option B+ in 2013 and countrywide implementation began in January 2015, in all health facilities except a few private ones. That means that currently all m2m sites in Swaziland are implementing Option B+.

The government's move to adapt and rollout Option B+, which is referred to in-country as Life Long ART for Pregnant and Lactating Women (LLAPLa), was motivated by the need to attain targets contained in the national eMTCT (elimination of mother-to-child transmission) framework, as well as by the recommendations of the World Health Organization and other national and international guidelines on HIV and RMNCH (reproductive, maternal, newborn, and child health) to adopt Option B+.

National implementation started early this year and monitoring and evaluation tools have been put in place to inform what is happening on the ground. m2m’s Mentor Mothers play an important role in the health workforce in Swaziland, and hence, were an intrinsic part of the rollout and capacity-building processes. Mentor Mothers are now helping to promote and strengthen demand for ARVs (antiretroviral drugs) for life, by educating women about the importance of ARVS for life not only to prevent mother-to-child transmission, but for their own health as well. They also encourage women to start taking ARVs early in their pregnancy, and support them to stay on medication and in care.

Uganda adopted a phased approach to Option B+ rollout in September 2012 in an effort to reach eMTCT (elimination of mother-to-child transmission) targets and provide universal access to treatment in all 112 districts in the country. By the end of 2013, all 112 districts in Uganda were implementing Option B+.

Traditional approaches to PMTCT (prevention of mother-to-child transmission) require a specific CD4 cell count before initiating antiretroviral prophylaxis. Unfortunately, access to reliable CD4 testing continues to be limited in Uganda, hence a number of eligible women were not being enrolled into the PMTCT programme. The shift towards a simplified lifelong ART (antiretroviral therapy) protocol for pregnant and breastfeeding women for Uganda under Option B+ is expected to help accelerate elimination of HIV among children by timely treatment of all HIV-positive pregnant women and lactating mothers. The operational advantages of lifelong treatment in Uganda, just like in other countries, include higher protection against MTCT (mother-to-child transmission) in future pregnancies, reduced infections rates of HIV-negative male partners in discordant relationships, and the avoidance of stopping and starting ARVs (antiretroviral drugs) in high fertility settings like Uganda.

Lifelong treatment for pregnant women and lactating mothers has been embraced by both clients and service providers in Uganda. For service providers, the anxiety of having to do a CD4 test before a PMTCT mother is started on treatment has been put to rest. Clients are positive about the fact that their lives and the lives of their children are being looked after. However, the idea of 'Test and Treat' is often dreaded by newly diagnosed clients; Mentor Mothers who play a key role in supporting clients to accept this regimen immediately.

Working alongside health workers, Mentor Mothers are able to link and retain more clients on lifelong treatment by offering them health education and peer support. We have revised our Active Client Follow Up protocols to include follow up for all clients who miss their two weeks review appointment after initiation on Option B+, thus helping to make sure that women stay committed to Option B+. Over 90% of pregnant women and lactating mothers enrolled onto the m2m programme were initiated on lifelong ART in 2014.

In over two years since Option B+ was rolled out, the number of HIV-exposed infants testing positive has been greatly reduced, from 9% to 6%. According to the National PMTCT Coordinator at the AIDS Control programme, "eMTCT is no longer a dream for Uganda, it is a possibility."