A Swazi mother with her baby. In July Swaziland will roll out Option B+, the latest treatment recommended by the World Health Organisation for HIV positive mothers. Credit: Mantoe Phakathi/IPS

By Mantoe Phakathi
MBABANE, Jun 5 2014 (IPS)

For months, Nonkululeko Msibi could not find her voice each time she wanted to share the news to her husband. She had learned that she was infected with HIV at the age of 16 when delivering her firstborn baby at Swaziland’s Mbabane Government Hospital.

“Although I was shocked by the news, I accepted it,” Msibi told IPS. “But the most difficult part was breaking the news to my husband.”

Her biggest fear was to be thrown out of their marital home should he believe that she had brought HIV into the family.

Despite being put on antiretroviral treatment (ART) at the baby’s birth and living two kms away from the clinic, where she could easily refill her prescriptions, her daughter contracted HIV, possibly through breast milk.

“Because I did not disclose my status, I failed to convince my mother-in-law that I had to breastfeed exclusively,” said Msibi.

Her second baby is also HIV positive because, she says, the clinic failed to give her nevirapine, although the nurses knew her status.  “I don’t know why this happened,” she said.

Born and bred at rural Motshane, about 15 kilometres from the capital city of Mbabane, Msibi dropped out of school in Grade 3 and got married at the age of 15 when five months pregnant. A product of a broken family, with both her parents deceased, marriage is the most important thing in her life.

“There must be someone to look after you and your children, especially if you’re unemployed like me,” said Msibi.

So, when she received the HIV diagnosis, she imagined her world falling apart, did not tell anyone and did not follow ART properly.

But she is not the only woman in this kind of dilemma.

“We realised that some women do not return to health centres within the stipulated timelines,” said researcher Thandeka Dlamini. She and other researchers set out to find why married women start ART late or drop out.

Their study, conducted by MarxART, a project by the Swaziland National AIDS Programme (SNAP), found “distinct socio-cultural challenges faced by women before initiating ART that result in specific gendered decision making patterns.”

This matters because in July Swaziland will roll out Option B+, the latest treatment recommended by the World Health Organisation for HIV positive mothers. Option B+ consists of lifelong provision of ART to pregnant women, regardless of their CD4 count. CD4s, or helper cells, fight infections in the body.

Since last year, Option B+ has been provided to 600 women to test feasibility, acceptance and clinic readiness. Soon it will be offered to the four out of ten pregnant women who are HIV positive. Among these, women aged 30-34 showed the highest prevalence – more than half were HIV positive in 2010.

Gendered decisions

Although Swazi women have better health-seeking behaviour than men, they find it hard to deal with HIV because of socio-cultural barriers, says the study. Many HIV positive married women live in a dilemma between obeying their husbands or following the advice of the health workers

According to Dlamini, in this conservative country, where women were considered minors until not long ago, wives must obey their husbands, even if they oppose ART or prefer traditional medicine.

Dlamini said an HIV diagnosis threatens married women’s sense of security because they fear being cast out by their spouses or in-laws.

“Submission might result in death, revolt can result in life, but threatens the loss of dignity and the refuge found in a marriage, and can bring shame when a marriage fails,” said a 25-year-old married woman quoted in the study.

National HIV prevalence is 26 percent among people aged 15-49, and 5,600 women were newly infected with HIV in 2012, according to the United Nations. Two thirds of infections are among women aged 25 and over – in their married, childbearing years.

Although the 2007 Swaziland Demographic and Health Survey reports that both married and single women have a high HIV prevalence, they are faced with different choices when it comes to ART. Single women can take a decision on their own; married women can’t.

Dr Velephi Okello, senior medical officer at SNAP, said the findings will help strengthen its HIV communications strategy.

“This study has helped us understand why women are either dropping out or initiating ART late,” said Okello.

The 2013 Global Report of the Joint United Nations Programme on HIV/AIDS (UNAIDS) shows that nine out of ten Swazis remain on ART after a year. But Okello said one dropout is one too many.

“We need to understand the barriers they encounter at social level so that we help them stay on treatment,” said Okello.

Dlamini recommends empowering married women with skills to negotiate access to ART, and researching how some women successfully navigate this tricky situation.

One such woman is Msibi, now 24, who is on treatment together with her husband.

“When my firstborn fell seriously ill, I realised I had to disclose,” she said.

Counselling from health workers helped her find the voice to break her silence. Msibi approached her mother-in-law, who already suspected that the child was HIV positive. An HIV test confirmed her fears.

“But that made it easy for me to disclose to my husband, who found it difficult to accept at first, but eventually he did,” she said. Later he trained as an HIV/AIDS counsellor at the local clinic, and the couple now helps each other follow ART carefully.

Excerpt:

With Option B+, pregnant women are started on lifelong antiretroviral therapy regardless of their CD4 count. Credit: Miriam Gathigah/IPS

By Miriam Gathigah
NAIROBI, May 26 2014 (IPS)

Kenya’s health sector has been facing significant challenges, ranging from a shortage of health care providers to a series of labour strikes. The problems have not only disrupted health services, but have HIV experts divided on whether to roll out Option B+ nationwide or just to pilot it in high volume facilities such as major referral hospitals. 

Option B+ is the latest treatment option recommended by the World Health Organisation for HIV positive mothers.

In the earlier Options A and B, mother and baby were given antiretrovirals (ARVs) during pregnancy and breastfeeding; only women with CD4 counts under 350 were prescribed ARVs for life. CD4s, or helper cells, fight infections in the body.

Option B+ consists of lifelong provision of ARV therapy to pregnant women, regardless of their CD4 count.

Dr John Ong’ech, assistant director at Kenyatta National Hospital, told IPS that when discussion begun in 2013 on whether to start option B+ in Kenya, “at the national policy level, people were divided on whether to roll out Option B+ fully.”

Currently, Option B+ is only available in the two major referral hospitals, Kenyatta National Hospital (KNH) in Nairobi province, the Moi Referral Hospital in the Rift Valley province, and in a few mission and district hospitals.

“There are those who felt that we need to first fix systems in the health sector,” said Ong’ech.

“To begin patients on Option B+, you need clinicians because there are things to be considered, such as drug toxicity, at the treatment entry point, after which nurses can manage,” he added.

In 2013, nearly 20,000 HIV positive pregnant women were given Option B+ lifelong ARV therapy.  Another 55,860 should be enrolled to achieve 100 percent coverage, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS).

Human resource crisis

Maurice Okoth, a clinician at a prevention of mother-to-child transmission (PMTCT) centre in Nyanza province, told IPS that Option B+ is not just a matter of ensuring drug availability.

“Clinic records must be organised, they must show if patients are defaulting and how these defaulters can be tracked. This is nearly impossible at the moment due to understaffing. We are facing a human resource crisis in the health sector,” he said

Kenya has some 36,000 nurses in the public and private sector but needs at least 80,000 more, according to government statistics.

Ong’ech agrees: “If you have adherence problems among the HIV patients that you are already treating, there is no need to roll out Option B+ because it will only get worse.”

The Director of Medical Services, Dr Simon Mueke, acknowledges that the disruption of health services due to labour unrest has affected PMTCT services.

In December 2011, doctors went on strike demanding more money for the health sector. In March 2012, nurses staged a two-week long strike, and five months later doctors stopped working for nearly three weeks. More strikes took place in 2013. A strike by doctors and nurses is looming in 2014 if government does not hire more staff.

Not surprisingly, PMTCT coverage fell by 20 percent in 2011 and 2012, according to UNAIDS.

Price and logistics

The price tag and the logistics of rolling out Option B+ nationwide are additional challenges.

Onge’ch says that, while ARVs are generally available across Kenya, “the country needs to come up with a cost effective way of procuring the additional drugs for Option B+.”

In ARV treatment, the actual cost of drugs represents less than 30 percent of the total. The new single-pill, fixed-dose regime costs about 180 dollars per patient per year, according to the Ministry of Health, and is expected to cost even less in the future.

“It is health care systems and the actual delivery of the services that take the remaining 70 to 80 percent,” said Okoth. “You need more laboratory services and viral load testing to ensure that they [women] are adhering to the treatment.”

Distance from home to the clinic is a problem. In Kisumu, Nyanza province, the average distance to the health facility is about 5.8 km while in Mandera, North Eastern Province, it is 20 kms, explained Okoth.

But Maya Harper, country director for UNAIDS Kenya, told IPS that Option B+ is a cost effective measure: “In the long run, it reduces the burden on the health system and on poor women. Placing women on and off treatment when they are pregnant is much more expensive.”
Beyond health infrastructure problems, Dr. Dave Muthama, from the Elizabeth Glaser Paediatric AIDS Foundation, says that stigma ”remains one of the major obstacles.“

At KNH, Ong’ech daily sees how stigma affects patients: some get the ARVs but do not take them while others refuse to collect the drugs for fear of being found out.

Poverty is another barrier, said Muthama: “Mothers do not adhere to the PMTCT visits because (…) while at the clinic, they are missing out on economically gainful activities.”

For Muthama, full elimination of HIV transmission to babies requires social structures to support HIV positive mothers.

“The society needs to go through the same four stages that most people who test positive for HIV go through: denial, anger, acceptance and coping,” he said.

Excerpt:

By Amy Fallon
KAMPALA, May 7 2014 (IPS)

Every morning at six a.m. before he goes to school, and every night at six p.m. after he gets home from school, Emmanuel, 11, knows what he must do: take his antiretroviral pills.

“They are very sour,” says the shy and gentle boy, who was born with HIV and is cared for by his elderly grandmother, his parents having died from AIDS when he was one year old.

“But I don’t mind taking the medicine. I’m used to it now,” he told IPS.

Emmanuel may be taking his medicine properly, but for many of the 35,500 children in Uganda on HIV treatment, daily ARVs are too much of a bitter pill to swallow, especially if they don’t understand why they need them.

Healing hug: Counsellor Cathy Kakande empowers HIV-positive children with medicine, information and lots of love. Credit: Amy Fallon/IPS

The Young Lives study presented by Ugandan researcher Rachel Kuwuma at a conference in Cape Town in December found that not knowing why they needed medicine was a big reason for non-adherence in young people.

“At first I didn’t know why I was taking drugs and didn’t put much effort into it so sometimes I would just throw it away…in the toilet,” Mika, 11, is quoted in the research, which looked at HIV-positive children in Uganda and Zimbabwe over two years.

In Uganda, in 2012, just one in three children who needed ARVs received them, according to United Nations data.

Cathy Kakande works for Namugongo Fund for Special Children, a Ugandan group providing Emmanuel with the drugs for free. She is also a counsellor to the boy and his grandmother. Kakande told IPS that Uganda’s policy is not to reveal their HIV status to children until they reach 13 years of age.

“We told Emmanuel ‘this is your life, so if you don’t take the medicine you’ll die’,” says Kakande. “He takes it because he’s supposed to.”

But children will be children, and Dr. Edward Bitarakwate, the Uganda director of Elizabeth Glaser Paediatric AIDS Foundation, says not knowing can lead to a child refusing to co-operate.

“Some types of medicine taste horrible and if you’ve not told the child that they have a chronic condition that needs to be treated, that can be a problem,” he says.

Some children living with HIV are told by their carers they have tuberculosis (TB) and other diseases.

“The child is, like, ’man, this TB, I’ve read about it, I can’t have TB for five years,'” Bitarakwate tells IPS.

In Uganda, like in many other African countries deeply impacted by AIDS, children’s drug taking is commonly mediated through carers. If a parent, sibling or guardian is discriminated against or fearful of being shunned for being HIV-positive or having an HIV-positive child, they may be reluctant to give ARVs or not be open about it.

This is but one of many reasons why the scale-up of ARV treatment in Africa is leaving children behind. In 21 high-burden African countries, only 34 percent of eligible children received ARV therapy compared to 68 percent of adults.

“Some mums don’t want to be seen carrying a shopping bag full of medicines,” says Bitarakwate.

It is worse when the child acquired HIV from the parents, he says: “There’s that guilt.”

Like the virus, self-stigmatisation can be transmitted: “The child grows up and finds out ‘I’ve got this terrible disease and my parents won’t even tell me about because it’s a bad thing’,” says Bitarakwate.

Emmanuel’s grandmother fears telling her neighbours near the Kampala house she rents about her HIV-positive grandson, says Kakande.

Not only is she scared, she’s also burdened financially. “She earns just 800 Ugandan shillings (less than a dollar) a day from selling sugarcane and struggles to pay the rent,” says Kakande.“They have only one meal a day. Sometimes Emmanuel takes his medicine just with water.”

ARVS on an empty stomach can cause nausea. Lack of food is listed as one reason why children don’t take drugs in the Young Lives study.

Other factors are not knowing the reason, fear of being seen by others, fear of being scolded, failure to meet expectations of adults, and loss of hope in life among children repeatedly ill.

The study concluded that adherence problems in children were commonly shaped by their social context and implicate their carers.

Waiting for a miracle

“One very, very common challenge” that this and other research ignore is the influence of Uganda’s born-again, Pentecostal churches, says Jacquelyne Alesi, programme director of the Uganda Network of Young People Living with HIV/AIDS.

“We’ve lost over 10 kids that way,” Alesi tells IPS. “They stopped asking for medicine because they believed they were going to be prayed for and they were going to be healed.”

Emmanuel has two more years until he officially learns that he has HIV.

“When we disclose their status, they [children] may segregate themselves,” says Kakande. “It’s our role to empower them. But for young positives, this is really very difficult.”

Dr Solomie Jebessa, a senior technical advisor at the African Network for Care of Children Affected by HIV/AIDS (ANECCA), says the consequences of children not taking their medicine properly can be fatal because the disease progresses much faster in children compared to adults.

“We’re losing a lot of children before getting them into the healthcare system,” she tells IPS.

Stigma can be equally, if not more devastating than the virus, says Dr Jebessa, who has worked with HIV-positive children in Uganda and Ethiopia.

From her experience, school clubs and activities where young people facing the same challenges can interact are crucial.

“There is a high need for organised psycho-social care in Africa,” she says. “A lot has to be done to make these kids comfortable at school and at the community level.”

Excerpt:

Keeping HIV-positive children on medication remains a difficult task. Credit: Miriam Gathigah/IPS

By Miriam Gathigah
NAIROBI, Jan 10 2014 (IPS)

Thanks to antiretroviral drugs, HIV-positive children can now live to adulthood. Yet a significant number of children living with HIV in Kenya will die due to delay in receiving anti-retroviral drugs (ARVs), inconsistent use of ARVs or, simply, no ARVs.

Seven-year-old Melvis* lives in Kisumu Ndog, in Nairobi’s sprawling Kibera slum, with his 75-year-old grandmother, Sabina. His mother died of AIDS three years ago. He has been taking ARVs most of his short life.“We have many more sites diagnosing children than sites where they can access ART services." -- Dr. Lucy Matu

“Keeping him on medication is difficult,” says Sabina.

Sometimes the clinic runs out of drugs, sometimes granny forgets to give him the pills, which must be taken every day at the same time to keep the virus at bay. “My memory is not as good as it used to be,” she says.

And Melvis’ drug regime requires a good memory: daily, but at different times, he must swallow three ARV pills, two of the antibiotic to prevent opportunistic infections, and sometimes anti-malarial pills.

Drug containers are colour-coded to help his illiterate granny. “Even with the colours, I still get confused,” she laments.

In its sixth Children and AIDS Stocktaking Report launched on Nov. 29, the United Nations Children’s Fund (UNICEF) says that, although there are more children on treatment, children are not benefitting as much as adults from progress made in low and middle-income countries in ARV coverage.

In these countries, ARV coverage for children under 15 years has consistently been half that of adults – 34 percent of children compared with 64 percent of adults in 2012.

“There is no technical justification why infants and young children cannot benefit equally from HIV prevention and treatment advances in Kenya,” says Ulrike Gilbert, UNICEF HIV coordinator in Nairobi.

Avoidable deaths

Dr. Lucy Matu, director of technical services at the Elizabeth Glaser Pediatric AIDS Foundation, explains that Kenya has some 4,700 sites offering prevention of mother-to-child transmission, but only 1,800 providing antiretroviral therapy (ART) services for kids.

“We have many more sites diagnosing children than sites where they can access ART services,” she says.

HIV diagnosis for children under two requires specialised laboratories, of which there are six in the country. “Correct and timely HIV diagnosis for young children has been slow,” Matu told IPS.

This shortage of paediatric treatment sites partly explains why, among 150,000 children eligible for ART in 2012, almost six out of 10 were not receiving it, according to the Progress Report 2013 of the Joint United Nations Programme on HIV/AIDS (UNAIDS).

At six percent, HIV prevalence in Kenya is in moderate decline, says UNAIDS, with 13,000 newly infected children in 2012, down from 23,000 in 2009.

In the absence of ART, one-third of HIV-positive babies will die before their first birthday and more than half before their second birthday.

Matu notes that many health care workers don’t know how to deal with HIV in children: “They go around in circles without informing the parent or guardian that the child is HIV-infected until it is too late to save the child’s life.”

Some parents and health workers believe that the survival of HIV-positive children is so poor that their early death must be accepted, Matu adds.

Many barriers

The UNICEF report lists several barriers to paediatric ART. Among them are limited availability of fixed-dose ARV combinations, poor palatability of recommended drug formulations for infants, lack of technology to test HIV infection among children under 18 months and fewer ART options for children than for adults.

Of the 22 ARVs approved by the United States Food and Drug Administration, five are not approved for use in children and another six are not available in paediatric formulations, according to UNAIDS.

Mary Naliaka, a health worker in paediatric AIDS with the Ministry of Health, explains that effective ART for kids requires a complex treatment formula.

“Changing dosage as a child grows is a major challenge,” she says. “One needs complex calculations to guide the adjustment.”

In a country where 35 percent of children suffer from malnutrition, “measuring the right dosage against the weight of the child can be daunting,” Naliaka told IPS.

For children in boarding schools, the lack of disclosure hurts treatment effectiveness. “If the school nurse is unaware of the child’s HIV status, they are unable to support them,” says Naliaka.

Matu says that parents, especially mothers struggling to accept their own HIV-positive diagnosis, find it difficult to take their children for HIV testing and feel guilty of passing on the virus.

The government estimates that 1.1 million children have lost one or both parents to AIDS; Many live with their elderly, illiterate and poor grandparents.

Although the Ministry of Health plans to reach 40 percent of caregivers of orphans through local community health workers who will teach them HIV care and provide food parcels, this help is yet to reach Sabina and Melvis.

Despite his hard life, Melvis has a sunny disposition and is energetic. He hawks pan-fried nuts in Kibera after school while Sabina sells deep fried potatoes near her shanty: “This is how we survive.”

*Not his real name. Family name omitted to protect privacy.

A CD4 testing machine. Research by the University of Zimbabwe shows that female patients with high CD4 counts have developed a nevirapine toxicity. Credit: Jennifer Mckellar/IPS

By Ignatius Banda
CAPE TOWN, South Africa, Dec 9 2013 (IPS)

New research suggests that some AIDS patients are developing drug intolerance and severe side effects and will now have to switch to new, more expensive antiretroviral regimens.

Researchers in Zimbabwe, Uganda, Nigeria and Malawi say some patients on the first-line antiretroviral drugs nevirapine and efavirenz (EFZ) are showing signs of being intolerant to the two drugs.

Daniel Sibanda, a University of Zimbabwe researcher, said while not many studies had been carried out on drug intolerance and side effects of antiretroviral therapy (ART), new research had found that there are toxicity concerns for some patients.

“Our research has found that female patients with high CD4 Counts had developed nevirapine toxicity,” Sibanda told the 17th International Conference on AIDS and STIs in Africa currently taking place in Cape Town, South Africa. “This means they must switch to other drug regimes but these could be expensive alternatives.” 

These new concerns come just as Zimbabwe adopts new World Health Organisation (WHO) guidelines, which revised the recommended threshold for enrolling patients on ART from a CD4 count of 350 to 500. The new guidelines have expanded the number of Zimbabweans needing ART from around 800,000 to more than 1.2 million, according to the Ministry of Health and Child Welfare.

The challenge of paying for this expanded treatment coverage is complicated by the possibility that some patients will need different medication.

“These (nevirapine) are first line drugs and when patients are then switched to other drugs because of toxicity this could present problems for a country such as Zimbabwe because these drugs are expensive and are not available as free ARVs,” Sibanda told IPS.

In Malawi, one of the countries with the highest number of people living with HIV, according to the United Nations Joint United Nations Programme on HIV/AIDS, some patients are experiencing side effects from EFZ.

Dr. Colin Speight, of Kamuzu Central Hospital in Lilongwe, said the observed side effects include dizziness, insomnia and vivid dreams, psychosis, confusion, rash and abnormal gait.

“EFZ was promoted as the new wonder drug in Malawi, and while most patients had no side effects, mild side effects were common,” Speight told IPS.

While the number of patients experiencing problems remains small, according to Speight, there are not many feasible alternatives for treating them.

“What we [are] now aiming for in Malawi is to try to find a regimen that will work best for as many people as possible. You are never going to get one drug which everyone will tolerate,” he said.

Early this year, there was an outcry among AIDS patients and activists in Malawi who were pressing the government to source new drugs after several complained of experiencing different side effects.

One option to deal with the side effects and reduce the toxicity of ART could be reducing the dosage patients take, Dr. Jackson Mukonzo, a Ugandan researcher from Kampala’s Makerere University, told the conference.

But Prof. Tandakha Dieye of Dakar University’s Department of Immunology warned that health workers and patients needed to weigh concerns over toxicity against the drug’s ability to prolong life.

“Toxicity does not always occur as soon as a patient takes the drug; it may take long to develop or even appear 20 years later,” Dieye told IPS. “The benefits are higher than the risks … we must find a balance between toxicity and the benefit of the drugs.”

On a continent where many people living with HIV are already unable to access life-prolonging antiretroviral medication, the challenge of drug intolerance threatens effective measures to control the AIDS epidemic.

Further research to determine both the causes and extent of drug intolerance is called for. Researchers, health care practitioners and government officials can then devise plans to overcome the problem.

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

By Wambi Michael
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.”