Coverage of highly active antiretroviral therapy among postpartum women in Malawi

The expanding services of antiretroviral treatment (ART) in sub-Saharan Africa provide unique opportunities to reduce HIV/AIDS-related morbidity and mortality. In these settings, HIV prevalence among antenatal women remains high and treating eligible pregnant or breastfeeding women with antiretrovirals can substantially reduce transmission of HIV from the mother to her infant. However, identification of women eligible for treatment and ensuring access to ART services is challenging. In this analysis, we used data from a large clinical trial (the PEPI-Malawi study, 2004-09) to prevent mother-to-child transmission of HIV through extended antiretroviral prophylaxis of infants to examine barriers for wider coverage with highly active antiretroviral treatment (HAART) of postpartum women. Maternal HAART was not part of the original PEPI-Malawi clinical trial but became available through a government programme during the course of the study. Therefore, eligible women (CD4 cell count <250) who participated in the PEPI-Malawi trial were counselled and referred to the government ART clinics to initiate HAART. Of 3335 women who enrolled in the PEPI-Malawi study, 803 (24%) were eligible for HAART based on CD4 cell count. The proportion of women newly initiating HAART at the ART clinic remained low and constant (<20%) throughout the study period. However, the cumulative proportion of women receiving HAART increased substantially over time (29% in 2005 to 69% in 2009). Similarly, counselling and referral of eligible women substantially increased and became 100% during the last two years. There were no statistically significant differences in characteristics of eligible women who received or did not receive HAART postpartum. Despite limitations of not being able to obtain detailed data, the main barriers appeared to be related to the health-care system delivery of ART services. Issues of physical space, more personnel and better delivery need to be addressed to increase access to HAART in these settings.