Rallying around Country-Led Efforts for Option B+

Rallying around Country-Led Efforts for Option B+

This week’s Lancet returns the spotlight to Option B+, an innovative strategy for preventing mother-to-child transmission of HIV which was first developed in Malawi with technical assistance from MSH. Four letters respond to the concern that international organizations have too quickly endorsed the Option B+ approach of providing lifelong triple antiretroviral therapy (ART), irrespective of CD4 count, to pregnant women with HIV in high-burden countries.

MSH experts Scott Kellerman, Jonathan Jay and Jonathan Quick argue that “a strong case exists for expanding research on Option B+, but not for impeding countries that pursue it on the basis of available evidence and programmatic experience:”

In Malawi…the lack of CD4 testing resources impeded effective rollout of WHO Options A or B. Without timely CD4 results, both WHO regimens risk withholding therapy from women who need it.

Other countries share this limitation. Yet even where all three regimens are feasible, Option B+ might be best. Option A involves a relatively complex drug regimen compared with daily fixed-dose ART and has been operationally “difficult to implement in many low-resource settings”, according to WHO.3 Option B requires women to stop and restart ART with each pregnancy, risking increased morbidity and mortality, especially where fertility is high.

Option B+ prioritises maternal health by providing ART for life irrespective of CD4. It follows the worldwide trend towards earlier treatment initiation and offers multiple collateral benefits, including decreased horizontal transmission.

Another expert from MSH, Eric Schouten, writing with colleagues, concludes that:

Malawi made its decision on the basis of implementation evidence and local circumstances, and we believe it would have been unethical not to choose Option B+. Several countries in similar situations, including Uganda, Zambia, and Rwanda, have shown great interest and have started planning for transition to Option B+. International agencies should support this approach.

Ambassador Eric Goosby, the U.S. Global AIDS Coordinator, joins these MSH authors in supporting country-led efforts to implement Option B+. Authors from the World Health Organization commend the efforts in Malawi and clarify WHO guidelines.

MSH is proud to contribute to country-led efforts and will continue to participate in the global conversation around Option B+. As we’ve stated:

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.


Since this was posted a few days before the bombings in Boston, I just want to say how sad I feel for Boston and all the fantastic team at MSH. I was there back in the 1980s, still remember quite well and miss you all!

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