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Pros and Cons of Uganda’s New ARV Therapy for Pregnant Women

With a new generation of HIV treatments available, mothers on Option B+ need only take one pill per day. Credit: Jennifer McKellar/IPS

With a new generation of HIV treatments available, mothers on Option B+ need only take one pill per day. Credit: Jennifer McKellar/IPS

KAMPALA, Nov 27 2013 (IPS) - Uganda has gotten plenty of kudos and some criticism over its roll out of the new antiretroviral therapy for pregnant women and their babies, known as Option B +.

Recommended by the World Health Organisation in June 2012, Option B+ consists in life-long provision of ARV therapy to pregnant women regardless of their CD4 count. CD4s, or helper cells, fight infections in the body.

Before, under Options A and B, mother and baby were given ARVs during pregnancy and breastfeeding. Only women with CD4 counts under 350 were prescribed ARVs for life – but CD4-counting machines are expensive and scarce in Africa.

Uganda has done remarkably well. Over 70 percent of all health facilities offer Option B+ and it overshot its target of 35,000 women on treatment in the first year, reaching 50,000 by October 2013.

“We are overwhelmed by the roll out so far,” said Godfrey Esiru, national coordinator of prevention of mother-to-child transmission (PMTCT) at the Ministry of Health. “It is the cheapest option for a country with limited resources for the health sector.”

Uganda’s seroprevalence is seven percent, or some 1.5 million people, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS).

AIDS activists welcomed the roll out but voiced some concerns.

“Option B+ denies a pregnant woman the right to decide whether to join the service or not,” said Dorothy Namutamba of the International Community of Women Living with HIV/AIDs in Eastern Africa (ICWEA).

This criticism featured prominently in the focus groups organised by ICWEA in 2012 to discuss the experiences of women with Option B+ in Uganda and Malawi.

“The names Option A, B and B+ imply that pregnant women who test positive for HIV are being given a range of options to choose from, whereas in reality it is the government that chooses which option to implement,” reads the ICWEA report on the focus groups.

Young HIV positive women may not want to start lifelong ARV treatment when they still feel healthy, although the regime is simplified to one pill a day. Over time, about two out of 10 people on treatment develop resistance to ARVs and must switch to more expensive second or third-line drugs.

Activist Mulani Birimumaso and his wife have lived with HIV for 15 years. Their two daughters are HIV negative thanks to PMTCT services available in Uganda since 2001.

He worries about couples sharing the pills at home. “They have initiated Option B+ without considering that there are other HIV positive people in homes other than mothers,” he told IPS. “The husbands also need those drugs.”

The focus groups noted the risk of domestic violence arising from the inequity in treatment access for husbands.

Another concern is ARV stock outs and dependence on donor funding. Uganda plans to put 240,000 people on treatment in 2014, Musa Bugundu, UNAIDS country coordinator, told IPS.

“Of these, 190,000 will be funded by the Americans and the remaining 50,000 by the Global Fund,” he said. “Is that the way to go? We have a serious problem.”

Proscovia Ayo, of the Tororo Forum of People Living with HIV Networks in eastern Uganda, points out that the roll out has ignored the need for family planning as part of PMTCT.

“You find a mother delivering every two years, yet she is on ARV treatment. We thought Option B+ would resolve that, but it has not,” she said.

Some critics say that Option B+ could be a potential incentive to get pregnant and gain access to the three-drugs-in-one-pill daily treatment.

Cellphones and men

Shafik Malende, a researcher in a study on implementation of Option B+ in northern Gulu district, found it requires strong family cooperation.

“Engagement of communities would greatly enhance Option B+ because they would ensure adherence and follow up,” said Malende.

A study at Mulago National Referrral Hospital in Kampala in late 2012 found that out of 190 women on Option B+, only 20 percent picked up their CD4 count results.

“High rates of loss to follow-up mean increased risk of treatment failure, drug resistance and disease progression for the woman,” Namutamba explained.

These concerns are being addressed as the program is implemented across the country, Godfrey Esiru told IPS. Now, each clinic is getting a cellphone to track mothers on treatment.

He admitted some weaknesses in male involvement, but added that increased use of village health teams and peer mothers groups will encourage men to support their wives.

One advantage of Option B+ is that HIV positive pregnant women are put on treatment without a CD4 count.  “We could not move this fast with the other options because we don’t have enough CD4 machines,” Esiru explained.

Yet, looking beyond birth, women on treatment will need regular CD4 counts and viral load tests to monitor their health. Activist Augustine Sebuma, who has lived with HIV for 20 years, wondered how health workers will monitor mothers on Option B+ when their clinics lack CD4 counting machines.

“We strongly support Option B+,” reads a statement by ICWEA. “But we are gravely concerned … about two major early challenges, loss to follow-up and weak engagement of communities, which will lead to weak demand for this service.”

 
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  • Israel Kalyesubula

    I am not a MOH spokesperson but I would like to respond to some of these concerns as a paediatrician who has been looking after HIV infected children for a very long time.
    “Option B+ denies a pregnant woman the right to decide whether to join the service or not,” said Dorothy Namutamba of the ICWEA. This method of saving the lives of children is quite new. We cannot leave it to the teenagers or even other persons who have no adequate experience with it to make the decision. Some responsible person has to come up with the best option for the unborn child. Where this was done paediatric HIV is not seen.
    “The names Option A, B and B+ imply that pregnant women who test positive for HIV are being given a range of options to choose from, whereas in reality it is the government that chooses which option to implement,” reads the ICWEA report on the focus groups. The ICWEA focus groups should remember that these options are not about choices. They stand for evolution or stages PMTCT. Of the three types of PMTCT mentioned the last one B+ tops them all. Therefore, one should not think that women are being pressed to go with a choice they detest.
    Young HIV positive women may not want to start lifelong ARV treatment when they still feel healthy, although the regime is simplified to one pill a day. Over time, about two out of 10 people on treatment develop resistance to ARVs and must switch to more expensive second or third-line drugs. If Uganda feared resistance and did not avail ARVs to her people, during the time when no second line medicines were in her reach, no person would have received these life saving medicines. Today we have the second line and the third line drugs what should prevent us from saving the future generation. It is enough to explain to the young ladies that waiting for signs and symptoms worse that treating before going down. One might find it hard to recover when treatment is availed to save a situation.
    Activist Mulani Birimumaso and his wife have lived with HIV for 15 years. Their two daughters are HIV negative thanks to PMTCT services available in Uganda since 2001.
    He worries about couples sharing the pills at home. “They have initiated Option B+ without considering that there are other HIV positive people in homes other than mothers,” he told IPS. “The husbands also need those drugs.” Mulani should join the Godfrey Eseru to share his experience of the 15 yr living with HIV. Let him come up with talk shows to let men learn that they are responsible for their families’ health. But surely who in Uganda does not know that every effort has been done, to the extent of ding HIV testing in the homes, to identify those in need of HIV treatment?
    The focus groups noted the risk of domestic violence arising from the inequity in treatment access for husbands. I don’t know whether violence is limited to HIV infected persons. The focus groups should really bend on limiting violence in all aspects of life. Remember we are talking about saving children.
    Another concern is ARV stock outs and dependence on donor funding. Uganda plans to put 240,000 people on treatment in 2014, Musa Bugundu, UNAIDS country coordinator, told IPS. Musa we have given ARVs provided by donors ever since we started doing so. This is not the best but it is what we are having let us cross the bridge when we come to it.
    “Of these, 190,000 will be funded by the Americans and the remaining 50,000 by the Global Fund,” he said. “Is that the way to go? We have a serious problem.” I thank PEPFER for this. 80% of the PEPFER funds come to Uganda. Let us be grateful and hopeful that they will not let us down at the point we shall need them most.
    Proscovia Ayo, of the Tororo Forum of People Living with HIV Networks in eastern Uganda, points out that the roll out has ignored the need for family planning as part of PMTCT. We are talking about giving life to children. Whether there is option B+ or not women want to deliver. When they do so will they give birth to a healthy baby? Ayo. Learn that what the MOH is doing is if a couple infected with HIV decide to deliver will they get a healthy child?
    “You find a mother delivering every two years, yet she is on ARV treatment. We thought Option B+ would resolve that, but it has not,” she said. This is vague. How did you think Option B+ would solve recurrent deliveries? Again this is about choices. If mothers on ARVs or those who are due to start them hunger for children let them get HIV free babies.
    Some critics say that Option B+ could be a potential incentive to get pregnant and gain access to the three-drugs-in-one-pill daily treatment. This is the first line option to all adults and adolescents in Uganda. You need not be pregnant to start on it.
    Shafik Malende, a researcher in a study on implementation of Option B+ in northern Gulu district, found it requires strong family cooperation. Let this be everyone’s responsibility. The families inclusive.
    “Engagement of communities would greatly enhance Option B+ because they would ensure adherence and follow up,” said Malende. I like this. Let LC1 to LCV join in to inform their gatherings at every opportunity.
    A study at Mulago National Referrral Hospital in Kampala in late 2012 found that out of 190 women on Option B+, only 20 percent picked up their CD4 count results. How many came for their treatments? In any case how many will benefit from hearing figures of CD4+?
    “High rates of loss to follow-up mean increased risk of treatment failure, drug resistance and disease progression for the woman,” Namutamba explained. We think that Village Teams, TASO teams, Community Based Care should look into this. Just call upon MOH to support them.
    Yet, looking beyond birth, women on treatment will need regular CD4 counts and viral load tests to monitor their health. Activist Augustine Sebuma, who has lived with HIV for 20 years, wondered how health workers will monitor mothers on Option B+ when their clinics lack CD4 counting machines. How have they monitored you for these 20 years? The people looking after you are the very people who will be responsible for the women. Share with the women how ART has helped you to stay healthy for these year.

  • Tom Muyunga Mukasa

    I worked with Ugandan rural based communities from 1997-2011 promoting HIV response best practices. My prayer was: I wished the medical doctors and allied health workers were given/funded to do HIV related care, community talks and empowered logistically to engage with grass roots! I came across so much bias and generalizations by persons whose organizations had so much money (but whose knowledge of HIV stopped at saying what “HIV” stands for) to be used to “say something.” How I reasoned with them and in the process ruffled some hairs! This is when I realized something new in Uganda: Many activists who are not medically trained have done tremendous work in the HIV world.I do not deny that. Over years, they have gained experience and exposure that they can afford to get away with misnomers! Anyway…. communities should be empowered to discuss HIV and its ramifications. Community members be trained under the “task shifting” plans. Communities should be able to establish and maintain post test support mechanisms. One such mechanism is partners in prevention-PIP. It is my hope that all will put in effort to make life happy at family/household, community, local government and central government level. Let us be like the good surgeons who after a surgery, propose post surgery care practices. HIV -related life preserving practices are hygienic practices. Much like hand washing or teeth brushing.

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