MSH Supports Growing International Acceptance of Option B+, Encourages Country Adoption, Further Research

Drs Scott Kellerman (left) and Erik Schouten at "Prevention of Vertical Transmission and Beyond: How to Identify, Enroll and Retain Children in Treatment Programmes in Resource-Limited Settings?" a satellite session at XIX International AIDS Conference on Sunday, July 22, 2012. (Photo credit: S. Holtz/MSH)

Drs Scott Kellerman (left) and Erik Schouten at “Prevention of Vertical Transmission and Beyond: How to Identify, Enroll and Retain Children in Treatment Programmes in Resource-Limited Settings,” a satellite session at XIX International AIDS Conference on Sunday, July 22, 2012. (Photo credit: S. Holtz/MSH)

Cross-posted on MSH.org

July 31, 2012 – As the international community gathered for the XIX International AIDS Conference last week, HIV & AIDS experts and key organizations voiced their support for a new approach to preventing mother-to-child transmission of HIV: Option B+.

Option B+ calls for antiretroviral therapy (ART) for life for all HIV-positive pregnant women, regardless of CD4 levels.

The government of Malawi, with the support of MSH, adapted the World Health Organization (WHO) guidelines on preventing mother-to-child transmission, to the needs of Malawi. Current WHO guidelines (2010) distinguish between treatment and prevention (known as “prophylaxis”) and rely on accurate CD4 counts to determine ARV regimens.

Unable to quickly and accurately ensure results from CD4 counts on HIV-positive women, and struggling to adjust treatment regimens given the high fertility rates and frequent pregnancies, Malawi elected to combine ART with PMTCT in a new approach they dubbed Option B which offers lifelong treatment to all HIV-positive pregnant women, regardless of their CD4 levels. The Malawi Ministry of Health devised this approach with support of MSH’s Basic Support for Institutionalizing Child Survival (BASICS) program, funded by USAID.

Dr. Erik Schouten of MSH and colleagues described the bold, new approach in a Lancet article in July, 2011. Option B+ puts women and children first, and, as Schouten and colleagues argue, will likely be cost-effective for countries, like Malawi, in the long-term.

In April, 2012, the World Health Organization (WHO) released a programmatic update on “Use of ARVs for Treating Pregnant Women and Preventing HIV Infection in Infants” (PDF). In the executive summary, the WHO said:

Now a new, third option (Option B+) proposes further evolution—not only providing the same triple ARV drugs to all HIV-infected pregnant women beginning in the antenatal clinic setting but also continuing this therapy for all of these women for life. Important advantages of Option B+ include: further simplification of regimen and service delivery and harmonization with ART programmes, protection against mother-to-child transmission in future pregnancies, a continuing prevention benefit against sexual transmission to serodiscordant partners, and avoiding stopping and starting of ARV drugs. While these benefits need to be evaluated in programme settings, and systems and support requirements need careful consideration, this is an appropriate time for countries to start assessing their situation and experience to make optimal programmatic choices.

Since July, 2011, MSH has helped trained a cadre of 3,366 health workers in Malawi. Within the first year of implementation in Malawi, the number of HIV-positive pregnant women starting ARV treatment has increased six-fold from 1,200 per quarter prior to implementation, to 7,200 in the quarter ending in June 2012. MSH is currently working on a cost-benefit analysis, and is studying the efficacy and challenges of option B+ scale up for preventing vertical transmission in Malawi.

Now others are following Malawi’s lead, particularly in light of Ambassador Eric Goosby’s and UNAIDS’ Michel Sidibe’s call for eliminating pediatric HIV by 2015 (PDF). Earlier this year, Uganda announced its intention to adopt Option B+; UNICEF began a thorough review of the approach; and other countries have expressed a strong interest in moving toward including Option B+ in their strategies for decreasing vertical HIV transmission.

Throughout the XIX International AIDS Conference, researchers and global health leaders touted the benefits of Option B+, and discussed the potential for combining ART and PMTCT in other countries. At a satellite session on Sunday, July 22, leaders from UNICEF, the International AIDS Society (IAS) and MSH discussed Option B+ for preventing vertical transmission. Dr Chewe Luo, Senior Programme Advisor at UNICEF, discussed the topic in depth during her plenary speech on July 25. And in the closing words of the conference, two rapporteurs gave a hat-tip to Option B+, displaying early data from Malawi, provided by Dr Erik Schouten of MSH.

“Option B+ is a game-changer and one of the most exciting developments in decreasing vertical transmission and pediatric HIV in recent years. In short, it calls for treating the mother, preventing vertical transmission to the child, and continuing to treat the mother. It offers the promise of much reduced vertical transmission rates while simultaneously decreasing maternal morbidity and mortality from HIV,” says Dr. Scott Kellerman, MSH’s global technical lead on HIV & AIDS.

MSH is thrilled that the global momentum toward Option B+ is building. Option B+ may not be right for every country or every situation, but in Malawi – and likely in many more countries – Option B+ will prove efficacious and cost-effective in not only protecting babies, but also in treating HIV-positive women. MSH is proud to have been a part of the inception of this idea and looks forward to working with our broad network of HIV & AIDS programs throughout sub-Saharan Africa and the world, using our technical capacity and research ability to investigate the operational issues that need to be addressed and understood for optimal implementation and scale-up of this approach.

Learn more about Option B+:
For additional information or to arrange for a press interview, please contact Barbara Ayotte, Director of Strategic Communications, at 617.852.6011 or bayotte@msh.org.

 

On Day 3, Three Women, Three Calls: Keep Mothers Alive, Make Women Count, Invest in Programs for Girls

XIX International AIDS Conference (AIDS 2012) Washington D.C. Wednesday Plenary Session Linda H.ScruggsAIDS Alliance for Children, Youth and FamiliesUnited StatesUSA and Canada © IAS/Ryan Rayburn - Commercialimage.net

XIX International AIDS Conference (AIDS 2012) Washington DC, Wednesday Plenary Session, Linda H. Scruggs. © IAS/Ryan Rayburn – Commercialimage.net

Day three of the XIX International AIDS Conference opened with an impassioned plenary by three powerful women speakers, calling for more concerted action for women and girls living with HIV, particularly adolescent girls.

Dr Chewe Luo, Senior Advisor HIV/AIDS, UNICEF, spoke about the Global Plan to Eliminate New HIV Infections in Children by 2015 and Keeping Their Mothers Alive. Targets of the plan include: 1) Reducing infections in children by 90%. (In 2011, 333,000 children were infected with HIV, with 29% of new infections in Democratic Republic of the Congo, Nigeria and Malawi.) 2) Reducing HIV-related maternal deaths of women during pregnancy, delivery or post-delivery, by 50% by 2015.  3) Eliminating mother-to-child-transmission.

Luo highlighted the benefits of giving triple therapy or single dose Nevirapene throughout breast feeding; this could reduce mother-to-child-transmission to less than 5%. She described pilot studies in 11 countries and improvements in access to antiretrovirals (ARVs) for women: from 48% in 2010 to 57% in 2011. Despite improvements in Eastern and Southern Africa, the Caribbean, Eastern Europe and Central Asia, “we still need to do better in Western Africa,” she said. The decline in HIV infections in children was roughly 10.8%  from 2010 to 2011 but, “this is not enough,” said Luo. “We should have reached 20% by now.”

She cautioned that treatment should have started earlier for pregnant women and cited several options that countries have, mostly based on cost: Option A and B which are treatment therapies for the mother for a limited time and the newer Option B+ which provides triple ART for pregnant women for life.

“We will not achieve the goal of eliminating PMTCT without some serious innovations. And that’s what this strategy [Option B+] is about,” said Luo.

OPTION B PLUS: BOLD CHOICE TO SAVE MOTHERS WITH HIV IN MALAWI

Malawi is the first country to implement Option B+. “We need to look at PMTCT as a component of ART and access treatment early,” said Luo. “This is the bottom line for me.”

“Option B+ must be scaled up. I applaud Malawi for being so bold.” Benefits of Option B+ include reduced infant HIV infection.

Luo then turned her attention to the “unacceptable” percentage of children not receiving ART. “We are failing to reach children,” she said.

She ended with a call to action. We need to: 1) simplify our prevention approach and integrate PMTCT and ART programs at the community level; 2) introduce innovative approaches to reach adolescent girls and pregnant teens; 3) change treatment regimens for children; and 4) collaborate with community groups.

GENDER EQUITY AND EMPOWERMENT: LINDA’S STORY

Linda Scruggs, a consultant and a woman living with AIDS, delivered an inspirational account of her own struggles and brought her rousing comprehensive agenda to “Make Women Count” and end gender discrimination and stigma to a standing ovation. Scruggs told many stories of both gender inequity and gender empowerment.

“For the last 20 years, women have been asking for an international platform for their rights, to count us in. Today I stand to give us direction and a recipe for change. We want women  to work with women that have the tools for us, by us, with us. … It is not enough to create a task force or write a paper, what we need is to be part of the solution. We are the Mothers of the Earth.”

Linda reflected: “What does a woman with no self- esteem look like?  What does a woman whose uncle molested her look like? What is a woman who can’t read or write, broken and voiceless? That woman was me.”

Linda told stories of women, broken or affected by disease. “We are at the table and a force to be reckoned with. We need a big change and need to create jobs and training for HIV positive women.”

UNFINISHED AGENDA: PROTECTING  ADOLESCENT GIRLS

Dr. Geeta Rao Gupta, Deputy Executive Director of UNICEF, also made the case to turn the tide for adolescent girls and highlighted the need for gender equality. Adolescent girls aged 15 to 24 bear the brunt of the epidemic. Of the 4.8 million young people with AIDS, 3 million of them are girls.

The challenges of adolescent girls are immense: early sexual debut, child marriage, increased risk of HIV and STIs, sexual violence, and risk of early pregnancy and HIV infection. Many are forced early into transactional sex to survive or they depend on older men to survive. Most lack basic information on condoms or sex education.

Geeta offered recommendations to accelerate the pace of protection for adolescent girls:

  1. We need relevant national plans for high impact with emphasis on girls. Few country plans include anything about adolescent girls.
  2. We need to educate girls — empower them to make choices.
  3. We need to start early; make adolescents visible in routine data systems and follow their health status after age 5. (Right now, they don’t appear in the data unless they get pregnant or contract HIV and then they are included with adult data.)
  4. We need to invest in innovations to reach adolescent girls through social media and networks.
  5. We need to engage with adolescents as partners.

As Anthony Lake of UNICEF has so eloquently said: “We invest so much in keeping girls alive in their first decade of life. We must not lose them in the second.”

We need a world that is AIDS-free and fair for all women and girls. That must be our legacy.

Barbara Ayotte is MSH’s director of strategic communications.