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In 2013, the WHO released a new set of guidelines on the prevention of mother to child transmission (PMTCT) of HIV/AIDS.
The new WHO guidelines suggests that all pregnant women who test positive for HIV should immediately begin a course of triple antiretroviral (ARV) drugs, regardless of CD4 cell levels. WHO now recommends that ART be initiated immediately and continued for the rest of the mother’s life. These recommendations, referred to as Option B+, are the WHO’s preferred method of addressing PMTCT in low- and middle-income countries and resource poor settings. Should this program not be feasible, given specific in-country restraints, the WHO recommendations still align with the most recent guidelines outlined in 2010.
Advantages of the new recommendations are as follows (adapted from WHO):
- Further simplification of PMTCT program- no need for CD4 testing to determine ART eligibility (as required in Option A) or whether ART should be stopped or continued after the risk of mother-to-child transmission has ceased (as in Option B) (although CD4 counts or viral load assays are still desirable for determining baseline immuno- logical status and monitoring response to treatment);
- Extended protection from mother-to-child transmission in future pregnancies from conception;
- A strong and continuing prevention benefit against sexual transmission in serodiscordant couples and partners;
- Likely benefit to the woman’s health of earlier treatment and avoiding the risks of stopping and starting triple ARVs, especially in settings with high fertility; and,
- A simple message to communities that, once ART is started, it is taken for life.
There are of course challenges and questions including important programmatic, operational and clinical challenges. There are questions about Option B+ that need to be addressed, including:
- service organization and service delivery of ART in MCH and primary care settings,
- cost and sustainability,
- ARV adherence and retention in care,
- referral mechanisms and transitions from the PMTCT programme to HIV care and treatment programmes,
- concerns about HIV drug resistance with long- term use of ART when initiated in early HIV disease,
- safety of increased ARV exposure for the fetus/infant,
- acceptability and equity.
Thus, countries implementing Option B+ or planning demonstration projects should be supported to monitor this approach closely to address these issues and assess the feasibility, cost-benefit and public health impact of Option B+.
Certainly this issue has generated a fair amount of debate - the B + option " To employ or not to employ !" Presented here are articles and opinions of renowned academics and clinicians , in addition to evidenced based studies regarding the new WHO PMTCT guidelines. It would be great to get a feel of what people out there in the field think about this issue. Go on and post up a comment regarding your thoughts and feeling about the issue!
The follwing articles are useful reading for this subject:
- ￼Is Option B+ the best choice? A Coutsoudis, A Goga, C Desmond, P Barron, V Black, H Coovadia. SAJHIVMED MARCH 2013, Vol. 14, No. 1, pp.8-10.
- Much ado over the new South African PMTCT guidelines, Chris Bateman. April 2013, Vol. 103, No. 4 SAMJ.
- The Impact of Revised PMTCT Guidelines: A View From a Public Sector ARV Clinic in Cape Town, South Africa, Marije Van Schalkwyk, Monique Ingrid Andersson, Michèle Desiré Zeier, Marina La Grange, Johannes Jakobus Taljaard and Gerhard Barnard Theron. J Acquir Immune Defic Syndr Volume 63, Number 2, June 1, 2013.
These 'consolidated' 2013 WHO guidelines for PMTCT sounds very good, especially considering the interesting evidence of its effectiveness generated from studies in Malawi. However, as indicated, the challenges of implementation and sustenance are not small. I will highlight one that has been mentioned. That of referral mechanisms and transition to HIV care and treatment programmes. As simple as this process may look, it is operationally chanllenging when considering human resource for health constraints, weak or inexistent integration of services within the MNCH platform, etc. there is the potential for cascade losses even with referrals within same faclity moving from one section to another. There is need to adddress this through perhaps operational research on best strategies of referral as well as the implications in terms of cost. Another issue relates to the lack of integration of TB and HIV care and treatment services in most of the control programs. This makes refferal difficult for newly diagnosed HIV+ mothers who may additionally need TB care or vice versa.
Lastly, the implementation of option B+ means that pregnant women who are tested positive using HIV rapid tests are placed on ARVs at least for the period when the riskof MTCT is high. The decreasing field performance characteristics of HIV rapid tests and testing algorithms have been a matter of concern recently, and WHO currently requires HIV treatment programs to retest previously HIV+ wone prior to initiating on ARVs. It is therefore important to ensure adequate quality assurance support to all testing points where HIV rapid testing is being offered in the context of Option B+ for PMTCT. The question one may ask is how many pregnant women run the risk of having a misclassified diagnosis in programs that already have up-scaled Option B+ for PMTCT.