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J Acquir Immune Defic Syndr. 2017 Jun 1;75 Suppl 2:S140-S148. doi: 10.1097/QAI.0000000000001357.

Impact of Facility- and Community-Based Peer Support Models on Maternal Uptake and Retention in Malawi's Option B+ HIV Prevention of Mother-to-Child Transmission Program: A 3-Arm Cluster Randomized Controlled Trial (PURE Malawi).

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*Lighthouse Trust, Lilongwe, Malawi; †Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC; ‡Department of Public Health, College of Medicine, School of Public Health and Family Medicine, University of Malawi, Malawi; §The International Union against Tuberculosis and Lung Disease, Center for Operational Research, Paris, France; ‖Research Department, Dignitas International, Zomba, Malawi; ¶Dalla Lana School of Public Health, University of Toronto, Tornoto, Canada; #University of North Carolina Project, Lilongwe, Malawi; **Malaria Alert Centre, College of Medicine, University of Malawi, Blantyre, Malawi; ††International Training and Education Center for Health (I-TECH), University of Washington, Lilongwe, Malawi; ‡‡mothers2mothers, Lilongwe, Malawi; §§Management Sciences for Health, Lilongwe, Malawi; ‖‖Department of Economics, University of Malawi, Chancellor College, Zomba, Malawi; and ¶¶Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi.



Many sub-Saharan African countries have adopted Option B+, a prevention of mother-to-child transmission approach providing HIV-infected pregnant and lactating women with immediate lifelong antiretroviral therapy. High maternal attrition has been observed in Option B+. Peer-based support may improve retention.


A 3-arm stratified cluster randomized controlled trial was conducted in Malawi to assess whether facility- and community-based peer support would improve Option B+ uptake and retention compared with standard of care (SOC). In SOC, no enhancements were made (control). In facility-based and community-based models, peers provided patient education, support groups, and patient tracing. Uptake was defined as attending a second scheduled follow-up visit. Retention was defined as being alive and in-care at 2 years without defaulting. Attrition was defined as death, default, or stopping antiretroviral therapy. Generalized estimating equations were used to estimate risk differences (RDs) in uptake. Cox proportional hazards regression with shared frailties was used to estimate hazard of attrition.


Twenty-one facilities were randomized and enrolled 1269 women: 447, 428, and 394 in facilities that implemented SOC, facility-based, and community-based peer support models, respectively. Mean age was 27 years. Uptake was higher in facility-based (86%; RD: 6%, confidence interval [CI]: -3% to 15%) and community-based (90%; RD: 9%, CI: 1% to 18%) models compared with SOC (81%). At 24 months, retention was higher in facility-based (80%; RD: 13%, CI: 1% to 26%) and community-based (83%; RD: 16%, CI: 3% to 30%) models compared with SOC (66%).


Facility- and community-based peer support interventions can benefit maternal uptake and retention in Option B+.


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