One or two years ago, the idea was radical for low-resource settings: Provide antiretroviral treatment for life for all women who were pregnant and HIV positive, thus protecting the health not only of the infants on the way, but of their future siblings, and of the mothers themselves, as well as their partners. Since 2010 the World Health Organization has recommended starting lifelong treatment for those whose immune cell counts had been lowered by the virus below the threshold 0f 350. For other women, two options were recommended, both involving treating mothers and infants only during critical times of the children’s exposure. In Malawi, a country of low income and one of the highest numbers of HIV-infected pregnant women, the idea of beginning treatment for all HIV-infected pregnant women had an additional immediate benefit: it would alleviate the need to test and monitor the state of their immune systems — their CD4 counts — a drain, if not an outright impossibility, in a place where health resources already are stretched beyond their limits.
For all of those benefits, the idea now known as “Option B+” was “bold, very bold, ” drawing criticism on several fronts, Dr. Carlos Avila mentioned in an interview with Science Speaks.
Avila, an infectious disease specialist, and a senior health economist at the Bethesda-based Abt Associates, is one of the authors of the recently released study: Cost-Effectiveness Analysis of Option B+ for HIV Prevention and Treatment of Mothers and Children in Malawi. Criticisms of the idea, he notes, have included unknowns on the effects of antiretroviral drugs on fetuses, the additional costs, and putting mothers first, “which,” Avila adds, “why not? Why not?”
The study explored the benefits of putting mothers first in a place where, out of every 100,000 women who give birth more than 500 women die, and where about 32 percent of maternal deaths are tied to HIV. While cost benefit analyses have monetary amounts as both their numerators and denominators, evaluating the benefit of saving women’s lives in that light would have been tricky in a place where women tend to be underpaid and under-represented in paid employment, Avila pointed out. Instead, the study gives a glimpse of a ripple effect of societal benefits when vulnerable women receive treatment that improves their odds. In that approach, the numerator can be seen as a series of other goals achieved — Millennial Development Goals — by preventing children from becoming orphans, and their own increased likelihoods of illness and death when that happens, preventing tuberculosis disease, transmissions and deaths by protecting women’s immune systems, and preventing transmission of HIV.
Issues of practicality and equity enter into the equation as well. Aside from the cost of monitoring the immune status of pregnant women with HIV, Avila said: “We might have all the money, but where are you going to find the doctors?” In addition, he said, while current guidelines directing treatment initiation in resource poor settings call for starting treatment when immune cell counts drop to 350, guidelines in North America and Europe recommend earlier treatment initiation. “Why should it be different in Africa?” Avila said. The study points out that the risk of developing tuberculosis increases when immune cell counts drop below 500. And, among other benefits, the study points to data from the landmark HPTN 052 study showing antiretroviral therapy to be 96 percent effective in preventing transmission to an uninfected partner in a relationship with an HIV positive person.
The exploration of benefits is comprehensive enough to require five tables and one graphic comparing approaches, but perhaps the most striking is this: With the provision of antiretroviral medicine to all HIV-positive mothers, their odds of surviving the next 10-years became four times what they had been — an improvement the authors noted that “translates into saving more than 250,000 maternal life years” (as opposed to savings of 153,000, and 172,000 life years for two approaches geared only at protecting infants).
The strategy will be expensive in the short term, but researchers concluded, “It has the potential to save significant societal resources in the long term.”
While the findings may be less applicable in settings of low prevalence and low fertility, the authors conclude their findings should be generalizable for many high-burden countries.
In the last month, Zambian and Ethiopian Ministers of Health have announced their countries, too, will adopt the Option B+ strategy.
Making the approach less of a leap than it was a few years earlier is not only this study, but the recent report from the Centers for Disease Control and Prevention showing high uptake of the program in Malawi, Avila pointed out.
“They went for this bold solution, they implemented it, and it seems, very successfully.”
Possible directions for future studies, he said, include examining the impact of reduced child and maternal illness resulting from Option B+ on clinic and other healthcare setting costs.