Engagement in antenatal and HIV care among pregnant women before and after Option B+ policy implementation in South Africa

Background. Substantial gains have been made in South Africa (SA) in the prevention of vertical transmission of HIV over the past decade. Objective. To determine whether engagement in antenatal and HIV care among pregnant women living with HIV (WLWH) differed after Option B+ implementation. Methods. We analysed cohort data from a pregnancy and birth defects surveillance system in KwaZulu-Natal (KZN). We report on two co-primary outcomes related to engagement in HIV care: (i) timing and number of antenatal care (ANC) visits during the pregnancy period; and (ii) timing of antiretroviral therapy (ART) initiation (both self-reported ART use in interviews and observed initiation of treatment in maternal records). The association of policy era on the timing of ANC presentation was assessed using log-binomial regression modelling. We also report proportions initiating ART before or during pregnancy stratified by policy era. Results. Data from 40 357 women, including 16 016 (40%) WLWH were analysed. During the Option B+ era, 24% of pregnant WLWH attended their first antenatal care visit during the first trimester, compared with 16% during the Option B era (relative risk 1.52; 95% confidence interval 1.41 - 1.64). The proportion of WLWH who initiated ART prior to pregnancy was also higher during the Option B+ era than the Option B era, though this result was limited by missing data. Conclusion. Engagement in antenatal and HIV care improved after Option B+ implementation. In the Option B+ era, SA has made significant progress toward the goal of eliminating mother-to-child transmission of HIV.