Option B+ Means Treatment for Life

By Heather Mason

When Retsepile tested positive for HIV, she was immediately initiated on antiretroviral treatment to prevent transmission of the virus to her unborn child. Her baby, now 6 months, has tested negative.

Heather Mason/EGPAF

Nteboheleng lives in a cement-block house in Mafeteng, Lesotho. A soft-spoken woman with a round face and brilliant smile, Nteboheleng is 29 years old and works as a quality control officer at a local textile factory. She is studying part-time and hopes to get a higher paying job eventually.

Nteboheleng is eight months pregnant with her second child. She waited until she was four or five months along—much longer than recommended—to attend her first prenatal visit. Sitting on the sofa in her living room, she explains why.

“I was suffering to go and test [for HIV],” Nteboheleng admits. “I was suffering to know my status. But one day I told myself that I have to face this. I have to go.”

Nteboheleng had a feeling that she might be HIV-positive. The suspicious behavior of a past partner made her nervous that she had contracted the virus, but she was scared to learn the truth. “I was afraid of the psychological stress of learning my status,” she says.

Deep down, Nteboheleng knew she needed to take care of herself for the sake of her baby.  When she finally had her first prenatal visit at the maternal and child health (MCH) clinic at Mafeteng Hospital, she received an HIV test. Nteboheleng tested positive and was initiated that very day on antiretroviral treatment (ART), which will protect her unborn child from becoming infected with HIV. Lifelong treatment means that ARTs will protect her own health as well through pregnancy, childbirth, breastfeeding—and the course of her life.

“I am now okay with my status,” Says Nteboheleng. “I thought when I learned I was HIV-positive that I was going to get sick. But I am now stronger than before. Getting into treatment before I got sick … I really appreciate that.”

The Introduction of Option B+

In April 2013, the Lesotho Ministry of Health, with assistance from the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) and other partners, adopted a new set of World Health Organization (WHO) guidelines for treatment of pregnant women living with HIV. The new guidelines—designed to optimize prevention of mother-to-child transmission of HIV (PMTCT), referred to as “Option B+”—recommend that all pregnant or breastfeeding women who test HIV-positive be immediately enrolled on ART and remain on treatment for life.

Before April 2013, when Lesotho was still following the 2010 WHO guidelines, pregnant women who tested positive for HIV underwent CD4 count testing before being enrolled into any kind of treatment (CD4 cells are white blood cells that can, when measured, be an indicator of immune system strength, or disease progression). Women with CD4 counts below 350 were immediately enrolled on lifelong ART. Women with CD4 counts above 350 received a temporary antiretroviral drug regime, designed specifically to protect their baby during pregnancy, childbirth and the breastfeeding; the regimen was stopped after the baby was weaned and the mother-to-child HIV transmission risk period was over.

The WHO recommended the implementation of Option B+ guidelines in 2013  because of mounting evidence that treatment can prevent infection in serodiscordant relationships (when one partner is HIV-positive and the other is negative) and in future pregnancies.  

When a pregnant woman comes to a health clinic and tests positive for HIV, she is immediately enrolled into lifelong treatment, as Nteboheleng was, regardless of her CD4 count.

“With [the 2010 WHO guidelines], it was a bit complicated for these women to understand—this single dose [of nevirapine and AZT] during labor and delivery,” says Matau Lebese, the EGPAF nurse in charge of PMTCT and MCH integration at Mafeteng Hospital. “But now with everyone on ART, it is a bit easier because you know that everybody is enrolled…Even all of [the women], now they understand.”

“Option B+ optimizes the mother’s health while protecting the baby,” says EGPAF Country Director Appolinaire Tiam, M.D. “I love it. The focus is no longer only on the baby; the focus is also on the mother.”

Making Sure No Mother Falls Through the Cracks

Twenty-two-year-old Retsepile, who lives in Mafeteng with her husband and son, gave birth to her first child six months ago. During her first prenatal visit, at three months, Retsephile tested negative for HIV. Three months later, at her next visit, she tested again and found she was HIV-positive.

“I didn’t believe it at first,” says Retsepile, who was devastated to learn her status. “But I was told that this is something that happened and I have to take medication for the sake of the child. I got the pills that day.”

Retsepile was incredibly upset and may not have accepted her status if not for the support and counseling she received at the clinic. The health guidelines implemented in Lesotho ensure that women like Retsepile get the support they need, including HIV testing throughout their pregnancies, psychosocial support counseling, and immediate ART initiation, if they test HIV-positive.

Women who become HIV-positive during their pregnancies may be at especially high risk to transmit HIV to their babies due to the extremely high level of HIV virus in the blood during a new HIV infection. But Retsepile was initiated on ART immediately, reducing her risk of transmitting the virus to her child in utero or through her breast milk. Now, her six-month-old son, Boitumelo, is a lively, healthy baby who has, to date, tested HIV-negative. As long as she continues her treatment, any future children Retsepile has will also be protected from mother-to-child HIV transmission during pregnancy and breastfeeding.

HIV status aside, the reality in Lesotho is that most women have more than one child. And as Matau points out, Option B+ is the best way to protect women through multiple pregnancies.

“With the previous option, if maybe I had planned to have four children, it meant that this time I start treatment, and after delivering I stop…I start, I stop. I start I stop…Maybe there were issues of drug resistance,” says Matau. “But now with this option you don’t need to start and stop over and over again.”

Inadequate male participation is another reality for pregnant mothers in Lesotho. Retsepile’s husband, for example, has not tested for HIV and did not wish to participate in this story. Matau notes that partner involvement is still very low at Mafeteng Hospital and this is one of the biggest challenges that the MCH clinic faces. Women often do not know the HIV status of their male partners, and most partners still refuse to come for testing.

But this is another advantage of Option B+. In the case of discordant couples, enrollment of the HIV-positive partner on ART lowers the risk of transmission to the HIV-negative partner. So when the HIV status of a pregnant woman’s partner is unknown, enrolling her into lifelong treatment will help prevent HIV transmission to the partner in the event that he is negative.

Lesotho Leads the Way in Option B+

Lesotho is only the second country after Malawi to implement Option B+, nationwide, all at once – a huge task in a resource-limited country with difficult terrain. Dr. Tiam explains that unlike other countries that have struggled in their attempts to roll out Option B+, Lesotho did extensive preparation to ensure a successful transition.

“Option B+ increases the amount of drugs that you need. But the country did a good forecasting of the amount of drugs that were needed,” says Dr. Tiam. “They procured drugs for two years ahead. Since we started Option B+ there has not been stock-out of medicines [in Lesotho].”

As a co-chair of Lesotho’s PMTCT technical working group, EGPAF has played a large role in the transition, providing technical assistance to the Ministry of Health to create new guidelines, translating those guidelines into training materials, and rolling out the training materials at health facilities nationwide.

“EGPAF also has staff in the field to fill the gap in human resources,” says Dr. Tiam. Integrated PMTCT and MCH nurses, like Matau, are giving site-level mentorship at health facilities around the country and supporting Ministry of Health teams.

“I think EGPAF has made a positive impact here,” says Matau, from her office at Mafeteng Hospital. “Before, some of the employees here were not even interested to know about PMTCT. Now they are very much interested. They get committed.

“Even the clients, they are more concerned about this. They want to see that this and this and that has been done. They are trusting us.”

The Lesotho Ministry of Health’s commitment to getting HIV-positive mothers onto lifelong treatment, together with EGPAF’s technical expertise and the strong relationship between these two partners, is yielding tangible positive results: confident, healthy women who know their HIV status and know what they need to do to keep their children HIV-free and their health intact.

“At the clinic they take care of us,” says Nteboheleng. “They treat us as their families. Since I’ve learned my status I am very, very happy, and I am also talking to other women about learning their status. To be HIV-positive is not what we [used to] think.”

This information is made possible by the generous support of the American people through the United States Agency for International Development (USAID) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). The contents are the responsibility of the Elizabeth Glaser Pediatric AIDS Foundation and do not necessarily reflect the views of USAID or the United States government.