World AIDS Day: The Role of 'Test and Treat' in Achieving an HIV-Free Generation

World AIDS Day: The Role of 'Test and Treat' in Achieving an HIV-Free Generation

Photo Credit: Gwenn DubourthournieuPhoto Credit: Gwenn Dubourthournieu

On this World AIDS Day, we reflect on our global successes in scaling up HIV prevention and treatment efforts and averting new infections.

The “treat all” recommendation issued by the World Health Organization in 2015 was a critical milestone in the HIV response. Also known as “test and treat,” the recommendation expands antiretroviral therapy (ART) eligibility to include all people living with HIV, regardless of CD4 count, and recommends universal lifelong treatment.

This approach ensures that HIV-positive pregnant and breastfeeding women identified in antenatal care, during labor, or while breastfeeding, can benefit from the use of lifelong ART — also known as Option B+ — rather than starting and stopping treatment if they are ineligible upon cessation of breastfeeding, which is known as Option B.

The Option B+ approach simplifies treatment guidelines and prioritizes the health of pregnant women and mothers, and it has proven effective. According to UNAIDS, the number of new HIV infections among children has decreased by 56 percent globally since 2010.

Success with Option B+

MSH plays an active role in supporting governments with the adoption, initiation, and implementation of Option B+ throughout Africa.

In Malawi, MSH worked with the health ministry to design and make the case for Option B+, and Malawi successfully pioneered the approach in 2011. Initial evaluation of national data showed that in the first nine months of the program, the number of pregnant women starting ART increased six-fold. With proof of concept, international agencies such as WHO and UNICEF soon followed with their endorsement and Option B+ was rolled out to other countries in the region. This year the health ministry estimated that 83 percent of all pregnant HIV-infected women are on ART.

In Ethiopia, the adoption of Option B+ in 2012 and implementation through the USAID-funded Ethiopia Network for HIV/AIDS Treatment, Care, and Support Project (ENHAT-CS) led to a nearly 90 percent uptake of ART among HIV-positive pregnant women who accessed care in program-supported health centers in the Amhara and Tigray regions in 2014.

And through the Strengthening TB and HIV & AIDS Responses in Eastern Uganda (STAR-E) Project, more than 1,700 health workers in 154 health facilities in 12 districts have been trained to put HIV-positive pregnant and breastfeeding mothers on ART for life since Uganda formally adopted Option B+ in 2012. Analysis of dried blood spot samples from HIV-exposed infants tested in program-support sites showed a marked decline in HIV positivity.

Nigeria: The Next Frontier for Option B+

While Nigeria adopted the new test and treat recommendation in 2016, the revised national HIV treatment guidelines have yet to be distributed.

In 2015, Nigeria alone contributed to over 40 percent of all new pediatric infections globally, and only 30 percent of HIV-positive pregnant women were provided with ART, according to UNAIDS. The prevention of new pediatric infections in Nigeria and beyond remains critical to the global goal of achieving an AIDS-free generation by 2030.

As the national coordinator for the Association of Women Living with HIV in Nigeria (ASHWAN), Assumpta Reginald, said during Nigeria’s first-ever National HIV Prevention Conference, held this week in Abuja, “It is time to shift our approach from ‘save the babies and kill the mothers’ to ‘save the babies and save the mothers.’”

MSH led a roundtable discussion during this week’s conference titled “The Role of Test and Treat (Option B+) in Achieving an HIV Free Generation in Nigeria.”

We shared the lessons we have learned from supporting the implementation of Option B+ in countries across Africa, and we recommended the following five priorities for Nigeria to consider as it seeks to optimize its HIV program:

  • Coverage – In many countries where we work, women continue to go through pregnancy and deliver babies without ever visiting a health facility. It is critical that HIV-positive pregnant women are reached, identified, and retained in the system through antenatal care services. Targeted HIV testing and counseling services must be provided during pregnancy and delivery to ensure that women who need it are enrolled in lifelong ART.
  • Uptake, retention, and adherence – Ensuring a comprehensive continuum of care between antenatal care and prevention of mother-to-child transmission of HIV services, facility-based delivery, postnatal and infant care, and adult ART services is critical to retaining women in care. A clear pathway to care must be coupled with facility and community-based strategies, such as mentor mothers, to support women and mothers with ART adherence.
  • Monitoring and evaluation – High quality data collection and monitoring, combined with a learning mindset and an approach for continuous quality improvement, are critical for evaluating the impact of Option B+ and identifying areas that require strengthening. Option B+ is not a magic bullet – context matters, and programs must be responsive to their patients’ and providers’ needs.
  • Supply chains – An uninterrupted supply of HIV testing kits and antiretroviral drugs is crucial to prevention and treatment programs. The success of Option B+ relies heavily on a health system that can ensure the availability of commodities at health centers through forecasting needs, supply planning, and stock level monitoring.
  • Task shifting, supportive supervision, and mentorship – The scale-up of Option B+ is enhanced through strong support for an ever-pressured health workforce. In many countries, nurses are initiating patients on ART and managing their care while community health workers and mentor mothers are called on to support adherence and assist with patient follow-up. Supportive supervision and mentorship can improve the quality of services provided.

The adoption of test and treat in countries around the world makes access to treatment, in principle, a right available to all people living with HIV. No woman should go through pregnancy without knowing her status and accessing treatment if she wants it, and no child should be born with HIV. 

We have the tools to eliminate mother-to-child transmission of HIV and to achieve an HIV-free generation. What are we waiting for?