How it began
Malawi's HIV program started in 2002, but by 2009 its program to prevent mother-to-child transmission lagged far behind its treatment program. In 2010 the World Health Organization recommended two regimens, called Option A and Option B. According to an account by Malawi Ministry of Health staff and colleagues, it was clear that the country could not implement either without raising barriers to care, and discussions among stakeholders led to a third approach, Option B+. The Ministry of Health adopted the policy in 2011.
Before it existed
Under the earlier approaches, whether a pregnant woman with HIV received full treatment depended on her CD4 count or clinical stage, which had to be measured, and drugs given only to protect the baby were stopped afterward. Malawi's health system faced many constraints, and services for preventing transmission were separate from treatment services, which reached far more people.
How it works
Any pregnant or breastfeeding woman who tests positive for HIV starts antiretroviral therapy for life, regardless of CD4 count or clinical stage. No laboratory test is needed to decide who qualifies. To make this work, Malawi fully integrated its transmission prevention and treatment programs and doubled the number of sites offering treatment in less than a year. Women in Malawi received a single first-line combination of efavirenz, tenofovir and lamivudine.
How it spread
Option B+ was later included in World Health Organization guidelines and was eventually adopted by all 22 priority countries of the Global Plan to eliminate new HIV infections among children. Among the 21 priority countries in Africa, it facilitated the start of treatment for more than 908,000 women with HIV, and coverage of pregnant women with HIV reached 80 percent in 2015.
What lasted
The authors of the Malawi account describe Option B+ as a country-led "treat-all" program in a highly resource-constrained setting, and as a forerunner of the "test and start" approach that the World Health Organization recommended in 2015 for everyone who tests positive. Malawi later adopted treat-all for all populations. Studies in Malawi have continued to monitor uptake, retention in care and safety under the program.
