BOSTON — Initiation of the Option B+ program has dramatically reduced incidence of mother-to-child HIV transmission in Malawi, one of the poorest countries in the world and one of the countries hardest hit by the HIV epidemic.                                            

Sundeep Gupta, MD, MPH, CDC country director for Malawi, presented two-year results from the National Evaluation of Malawi’s Prevention of Mother to Child Transmission (PMTCT) Program cohort study during a plenary session at CROI 2016.

Among 1,851 HIV-positive mothers with 4-12 week old infants, overall MTCT was 4.1%. In 2011, Malawi implemented Option B+, which provided lifelong antiretroviral therapy for all HIV-positive women who were pregnant or breastfeeding regardless of CD4 count, so nearly all women in the study (93.5%) were on antiretroviral therapy during pregnancy. MTCT for those women was just 2.8%.

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“These results represent a validation of Malawi’s approach, which has now been adopted by most countries in sub-Saharan Africa and become WHO policy,” he said. “This is dramatic progress that Malawi is very excited about, toward achieving the UNAIDS goal of elimination of mother to child transmission, which is a transmission rate of less than 5%.”

Dr Gupta said the MTCT may be as high as 5% because population estimates of antiretroviral coverage is based on old data. However, even a transmission rate of 5% would be about one-fifth of what would expected without any intervention.

Researchers found that the timing of therapy initiation had a major impact on MTCT. The 46.5% of women who initiated antiretroviral therapy prior to pregnancy had an MTCT of just 1.4% compared to 21.3% in the women who never started therapy (5.8%).

Dr Gupta said 6.5% of women in the study either did not start antiretroviral therapy or chose to stop therapy at any time during or immediately after pregnancy. MTCT was 20% for those women.

An estimated 1 million Malawians have HIV. According to the 2014 UNAIDS Gap Report, nearly 13% of women have the virus compared with about 8% of men.

After Malawi implemented Option B+, the country saw a nearly eightfold increase in the number of these women receiving antiretroviral therapy.

Researchers began the National Evaluation of Malawi’s PMTCT Program (NEMAPP) study in November 2014 to explore the effects of Plan B+. The study is ongoing at 54 randomly selected clinics in 10 districts.

Dr Gupta said his team will report updated findings as the infants in the study stop breastfeeding.


1. Barr BT. 35LB. National HIV Transmission in 4-12 Week Olds in Malawi’s PMTCT Option B+ Program. Presented at: CROI 2016. Feb. 22-25, 2016. Boston.