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‘I wanted to safeguard the baby’: a qualitative study to understand the experiences of Option B+ for pregnant women and the potential implications for ‘test-and-treat’ in four sub-Saharan African settings
  1. Estelle McLean1,2,
  2. Jenny Renju2,
  3. Joyce Wamoyi3,
  4. Dominic Bukenya4,
  5. William Ddaaki5,
  6. Kathryn Church2,
  7. Basia Zaba2,
  8. Alison Wringe2
  1. 1Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
  2. 2Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
  3. 3National Institute for Medical Research, Mwanza, Tanzania
  4. 4Medical Research Council/Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda.
  5. 5Rakai Health Sciences Program, Kalisizo, Uganda
  1. Correspondence to Estelle McLean, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK; estelle.mclean{at}


Objective To explore what influences on engagement with Option B+ in four sub-Saharan African settings.

Methods In-depth interviews were conducted in 2015, with 22 HIV-positive women who had been pregnant since Option B+ was available, and 15 healthcare workers (HCWs) involved in HIV service delivery. Participants were purposely selected from four health and demographic surveillance sites in Malawi, Tanzania and Uganda. A thematic content analysis was conducted to investigate what influenced engagement with Option B+.

Results Feeling ‘ready’ was key to pregnant women accepting antiretroviral treatment (ART) on the same day as diagnosis at antenatal clinic; this was influenced by previous knowledge of HIV-positive status, interactions with HCWs and relationship with their partners. The desire to protect their unborn infant was the main issue that motivated women to initiate treatment, temporarily over-riding barriers to starting ART. Many HCWs recognised that pressurising women into starting ART may lead them to stop treatment following delivery. However, their own responsibility to protect the infant sometimes drove HCWs to use strong persuasive techniques to initiate pregnant women onto ART as early as possible, occasionally causing women to disengage.

Conclusions Protecting the baby superseded feelings of unpreparedness for lifelong ART and may explain poor retention observed in Option B+ programmes. Women may benefit from more time to accept their status, and counselling on the long-term value of ART beyond the pregnancy and breastfeeding period. Strategies to promote readiness for same-day initiation of lifelong treatment are urgently needed, and may provide important lessons for universal test-and-treat implementation.

  • HIV

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  • Contributors The study was conceived by BZ, AW and KC. AW and KC designed the protocol and study tools, which were adapted and implemented in the different settings by EM, JW, DB and WD. Initial analyses were conducted by EM, JR, JW, DB and WB. Final analyses were conducted by EM and JR. The manuscript was drafted by EM, with input from all authors. All authors read and approved the final manuscript.

  • Funding The Bottlenecks study was funded by the Bill and Melinda Gates Foundation (OPP1082114). In addition, AW is funded by a Population Health Scientist award, jointly funded by the UK Medical Research Council (MRC) and the UK Department for International Development (DFID) under the MRC/DFID Concordat agreement, and is also part of the EDCTP2 programme supported by the European Union. Research undertaken in Kisesa (Tanzania) and reported in this publication was supported by the National Institute of Allergy and Infectious Diseases, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institute on Drug Abuse, National Cancer Institute and the National Institute of Mental Health, in accordance with the regulatory requirements of the National Institutes of Health under Award Number U01AI069911East Africa IeDEA Consortium. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

  • Competing interests None declared.

  • Ethics approval Ethical approval was granted by the London School of Hygiene and Tropical Medicine (#10389) and the relevant ethics boards at each of the study settings: Malawi National Health Sciences Research Committee #15/5/1427; Tanzania Medical Research Coordination Committee MR/53/100/370; Uganda National Council for Science and Technology HS1857 and Office of the President ADM154/212/01. Informed and written consent was obtained from all participants.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Data sharing statement Access to the data may be provided on request from Dr Alison Wringe

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