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• W3147715905 abstract "Anna Coutsoudis and colleagues1Coutsoudis A Goga A Desmond C Barron P Black V Coovadia H Is option B+ the best choice?.Lancet. 2013; 381: 269-271Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar write that countries are under pressure to switch to Option B+, but that the evidence for it is weak. On the basis of implementation evidence and the high fertility, long duration of breastfeeding, and limited capacity in laboratory services in Malawi, Option B+ is the only choice for the country. Option A and B are dependent on accessible, functional, and efficient laboratory services for CD4 count testing, and these will not be universally available in Malawi and most other countries in Africa in the foreseeable future. The choice is to implement an impractical policy and accept low coverage of services, as Malawi did until mid-2011, or, on the basis of a “public health approach”,2Gilks CF Crowley S Ekpini R et al.The WHO public health approach to antiretroviral treatment against HIV in resource-limited settings.Lancet. 2006; 368: 505-510Summary Full Text Full Text PDF PubMed Scopus (539) Google Scholar simplify the guidelines and eliminate bottlenecks known to impede universal access. We are aware of the risks involved. However, switching to Option B+ greatly improves prevention of mother-to-child transmission (figure)3Government of Malawi, Ministry of HealthIntegrated HIV program report July–September 2012.http://www.hivunitmohmw.org/Main/AntiretroviralTherapyGoogle Scholar and clearly outweighs the risks.4Schouten EJ Jahn A Midiani D et al.Prevention of mother to child transmission of HIV and the health-related Millennium Development Goals: time for a public health approach.Lancet. 2011; 378: 282-284Summary Full Text Full Text PDF PubMed Scopus (198) Google Scholar Moreover, the differences in duration on antiretroviral therapy over a lifetime between Option B+ and Option B are marginal in countries such as Malawi with a high total fertility rate (5·7) and a long duration of breastfeeding (mean 23 months).5National Statistical Office (NSO) and ICF MacroMalawi demographic and health survey 2010. NSO and ICF Macro, Zomba and Calverton2011http://www.measuredhs.com/publications/publication-fr247-dhs-final-reports.cfmGoogle Scholar In-depth assessment of the Option B+ programme is underway. Malawi made its decision on the basis of implementation evidence and local circumstances, and we believe it would have been unethical not to choose Option B+. Several countries in similar situations, including Uganda, Zambia, and Rwanda, have shown great interest and have started planning for transition to Option B+. International agencies should support this approach. We declare that we have no conflicts of interest. Is Option B+ the best choice?Advocacy of the extreme antiretroviral therapy Option B+ for pregnant women by some organisations and international agencies,1,2 particularly at the AIDS 2012 conference in Washington, DC, USA,3 with little consultation, debate, and discussion, is worrying. Supporters of Option B+ argue that it is superior owing to additional antiretroviral therapy coverage (because CD4 cell count results are not needed), additional maternal health benefits, and protection of discordant male partners. However, these benefits have not been validated due to the fast pace and single-mindedness of advocacy. Full-Text PDF Is Option B+ the best choice? – Authors' replyWith vertical HIV transmission rates plummeting even in settings with a high HIV prevalence, such as South Africa, we agree with Gottfried Hirnschall and colleagues from WHO that this is a promising time in the global response to HIV. We are heartened that WHO's review process to assess the ethics, safety, cost, and feasibility of Option B+ is underway in preparation for the release of new, consolidated guidelines. Full-Text PDF" @default.
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• W3147715905 date "2013-04-01" @default.
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• W3147715905 title "Is Option B+ the best choice?" @default.
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