Assessment of Antiretroviral therapy Initiation among pregnant Women under Option B+ Approach; Viral Load and CD4 Count Outcomes in selected Hospitals of West Zone Oromia, Ethiopia: Quantitative Prospective Cohort Study Design

Abstract Background: Antiretroviral (ART) ensuring maternal virologic suppression. While pregnant women require lifelong ART immediately they test HIV positive (“test and treat”) under Option B+ programs, eMTCT programs face challenges and information on the relationship between the time to ART initiation following HIV testing and treatment outcomes is limited in Ethiopia Methods: A quantitative prospective cohort design was employed to conduct the study. Five randomly selected Hospitals providing Option B+ services with routine viral load assessment by Oromia regional Laboratory (ORL) from January 2016 to January 2017 was randomly selected. Bivariate and multivariable analyses were conducted to determine factors affecting the time to ART initiation following an HIV test and logistic regression used to determine the correlation between time and treatment outcomes. Results: The study results produced and evidence of a mean VL (copies/ml) of 197.27 copies/ml. Respondents that were on ART for a shorter period ≤37 months had the least proportion of women 31% were suppressed with VL<1000 copies/ml compared to those on ART for >38 months (58.7%) were suppressed. The median (IQR) CD4 count change or difference among women that had initial and last CD4 was 581 cells/μl and mean of current CD4 count 629.17ceels/ml3 and more than 85.3% had increase CD4 count. Therefore, in this study identified that factors associated with viral load response were poor /fair adherence missing doses in the past month, missing appointments, baseline CD4 and maternal months on ART were statistically significant among HIV positive pregnant women that initiated lifelong ART on option B+ in Ethiopia. Conclusion: The study results demonstrated that HIV positive pregnant women Study results indicate that majority of the respondents 89.7% were suppressed of which 80.3% were undetectable (VL= 0 copies /ml3 and 85.3% had increased CD4 count and 10.3% were not suppressed (VL >1000 copies/ml). Therefore, strategies aimed at improving adherence among women on option B+ are to ensure that these women achieve adequate immunological outcomes.

3 Moreover, antiretroviral therapy (ART) coverage is much lower (20%) in developing settings like Asia, Pacific, Eastern, and Northern Africa as compared to over 90% in Eastern and Central Europe and Caribbean (1). Findings of studies in other African countries like Zimbabwe, Tanzania, and Malawi suggest that while Option B+ is expensive, it is cost effective in terms of averting infant infections (2).another study suggested that Option B+ improves the women' and infants' health outcomes (3).
Despite the rollout of interventions such as the Option B+ program, suggest that the HIV prevalence among women and new HIV pediatric infections remain disproportionately high especially in Sub-Saharan Africa. This is further aggravated by weak health systems which hinder the initiation and follow up of women initiating on lifelong ART. For example, low uptake of antenatal care (ANC) services, stigma and lack of disclosure negatively impact PMTCT programs (4). In Zambia reports that HIV-infected women attending PMTC programs present to care late in pregnancy and many are lost to follow up by six months postpartum (5). Similarly, a systematic review conducted among 44 studies in Sub-Saharan Africa assessing barriers and facilitating factors of ART in PMTCT reveals that inadequate knowledge on HIV, ART and vertical transmission; lower maternal education level, stigma, poor staffclient interactions, service accessibility, and non-facility deliveries are among the barriers or factors Option B+ includes the period from pregnancy to lactation which therefore targets both pregnant and lactating women. In this study, however, the focus will be on pregnant women that initiated ART and received option B+ services for at least 12 months. Therefore, the research statement for this study is "What is the correlation between the time to antiretroviral therapy initiation following an HIV test and treatment outcomes among HIV pregnant women that initiated ART on Option B+ for at least 12 months in healthcare facilities of Ethiopia"?

Study setting and design
The research design for this study quantitative prospective cohort descriptive design was conducted from January 2017 to March 2017, at ART clinics of governmental hospitals in West Shoa zone, Oromia Regional State, Ethiopia. Ambo town which is the capital of the zone is located 112kilometers to the west of Addis Ababa the capital of the country. According to information from the zonal health office, the total population in the zone is estimated to be 2,381,079 of which 1,214,350 of them are female.
Currently, the health system of the zone consists of 6 hospitals, 90 health centers and 447 health posts with 98% of potential health service coverage.
There are different governmental and non-governmental organizations working on HIV/AIDS in the zone. There are 5 hospitals namely Ambo hospital, Enchini Primary Hospital, Gedo Hospital, Gindaberet Hospital, Guder Primary Hospital and21 health centers are ART sites currently, there 8,439 clients on ART in West Shewa zone (Data from west Shewa zone health office, November 2016).
For the study, three public hospitals (Ambo General Hospital; 3000 clients, Gedo Hospital; 485 clients, Enchini Primary Hospital; 976 client) and were selected based on the load of the clients served in the facilities that conduct routine viral load assessment for patients on option B+ PMTCT by Oromia regional laboratory during January 2016 to January 2017. HIV positive pregnant women that initiated ART received option B+ services for 12 months and had viral load assessment will be targeted in these health facilities during the study. All Sampled pregnant HIV positive women that initiated ART under Option B+ services for at least 12 months from selected healthcare facilities in West Shoa zone.
The selection criterion was included HIV positive pregnant women that initiated ART and received Option B+ services for at least 12 months with viral load assessment selected from 3 Hospital in West Shoa Zone of Oromia region that conducted viral load assessment for patients on ART by Oromia regional laboratory during January 2017 to March 2017.

Sample size determination and Sampling procedure
The required sample size was determined using Statecalc program of the EPI INFO version 7.1.0 statistical package with a 50% rate of viral suppression based on limited data with a precision of +/-5% and Confidence limits as % of 95. By considering correction formula, since the total population was less than 10000 which as was 1860, the final sample size was 318. The final size with a nonresponse rate of 5% was 334. All hospitals found in West Shoa Zone of Oromia region that providing ART services was identified and randomly selected by computer generated methods to be included in the study. The number of study respondents was be allocated proportionally for the five Health centers, based on their total number of ART clients'positive pregnant women who initiated ART under option B+ for at least 12 months to participate in the study.

Operational definitions
Treatment outcomes in the study this concept were included desired results following therapy or treatment outcomes among pregnant women that initiated ART under Option B+ programs for at least 12 months in Ethiopia which was CD4 count viral suppression (among women)

Data collection tools and procedures
The data collection tool will include a structured questionnaire (translated) and chart or medical records abstraction tool adopted from similar surveys and modified for the study. Questions in the chart abstraction were adopted from the HIV care card used for clinical management of clients receiving HIV care and treatment. Data on both the questionnaires and abstraction forms were collected by trained research assistants and data abstractors. At the completion of abstraction at the health facilities, tools were checked for completeness and completed tools were collected by the team leaders and stored in safe and locked cabinets accessed only by the researcher.

Data management and Analysis
The returned questionnaires were checked for completeness, cleaned manually, coded and entered into EPI INFO 7.1.0 version and then transferred to SPSS windows version 20.0 for further analysis.
Frequencies mean and standard deviation was used to summarize descriptive statistics of the data and text, tables and graphs were used for data presentation. Bivariate analysis was used primarily to check which variables have an association with the dependent variable individually. Variables which are found to have an association with the dependent variables were then entered into Multiple Logistic regression for controlling the possible effect of confounders and finally, the variables which have significant association was identified on the basis of AOR, with 95%CI and p-value to fit into the final regression model.

6
The respondents' mean age was 30.78 years (n=319) with a standard deviation (SD) of ±6.56 years. The majority of the respondents were initiated on the recommended ART regimen for option B+ with 65% (n=207) TDF+3TC+EFV.
Other respondents were initiated on AZT+3TC+EFV 3.8 % (n=12). None of the respondents were initiated on 2nd line regimen.

Time to ART from HIV test
In the study, all the 319 (100%) respondents were assessed for time to ART following HIV testing. The mean time in months among the 31.7% (n=101) women that delayed (did not start on the same day) initiating ART following an HIV test. The results of the respondents' time to ART start following HIV testing are exhibited in figure 1

Viral suppression
The study results produced an evidence of a mean VL (copies/ml) of 197.27 copies/ml.
Respondents that were on ART for a shorter period ≤37 months had the least proportion of women 31% were suppressed with VL<1000 copies/ml compared to those on ART for >38 months (58.7%) were suppressed.

CD4 count response
The median (IQR) CD4 count change or difference among women that had initial and last CD4 was 581 cells/μl and mean CD4 count 629.17ceels/ml 3 . Out of the total 319 respondents that were assessed for CD4 response, more than 85.3% had increase CD4 count. Among the women that had decreased or no change in CD4, only five individual had no CD4 count change (difference between the initial and last CD4 count was zero).
Out of 319 respondents included in the final model (p<0.05), factors that were independently associated with increased HIV viral load copies/ml included women that poor /fair adherence to ART drugs compared to those that good (coef. -1.390, 95% CI; -2.059 to -0.721, p<0.001). For each additional increase in time to ART from HIV testing in months, HIV VL copies/ml increased by 0.018 copies/ml (95% Confidence interval (CI) 0.002 to 0.035, p=0.03). Therefore, in this study, missing doses in the past month, missing appointments, baseline CD4 and maternal months on ART were statistically significant.
Predictors of CD4 count response at multivariate level Out of 319 respondents included in the final model (p=0.001), increased gestational age at ART start, maternal age in years and adherence on medication were independently associated with CD4 response or immunological outcomes among HIV pregnant women initiated on lifelong ART on option B+. Improved CD4 response was associated with increased gestational age at ART start (coef.

Discussion
Time on ART is an important predictor of treatment outcomes among women who initiate ART under option B+. Most importantly, the initial period during ART initiation is associated with poor outcomes like reduced viral suppression. The proportion of suppressed respondents with VL <1000copies/ml was lowest 31% among those on ART for <37 compared to those on ART for 38-70 months 58.7%) and majority of the respondents 89.7% were suppressed of which 80.3% were undetectable (VL= 0 copies /ml3. Detectable VL or none suppression is highest among women that enroll on option B+ with ≤ 4 months of ART (7). The results of this study emphasized the need to intensify support for HIV pregnant women on option B+ during the early months of ART initiation.
Most of the respondents in the study at the start of ART presented with high CD4 count with a median of 349.68 cells/µL and IQR (1-1012) and less advanced WHO Treatment stage with 96.9% (n=309) staged as WHO stage 1 and 3.1% (n=10) as stage 2, report that 70.5% of breastfeeding and pregnant women on option B+ in Northeast Ethiopia initiate ART with WHO clinical stage 1 and 6.6% with stage 2 (8) In Haiti, 92% of women have clinical stage 1 or 2 among the 68% of option B+ clients (8). This study 11.6% were WHO stage 3 and 6.9 % were stage 4. In Malawi (10) (11).
In this study, 61.4% (n=196) respondents had CD4 counts <350 cell/ul at baseline which implied that there were women on option B+ that initiated ART with a low CD4 count and recent last six month CD4 count indicated that only 14.7%( n=47) were less than 350 cell/ul this leads to improved immune recovery. Women on option B+ that initiate ART with low CD4 count at ART start, therefore, would benefit from getting a baseline CD4 cell count.
Concerning VL suppression, the study results revealed a median viral load (copies/ml) of 3.62 copies/ml with IQR (3.00-12.01copies/ml) compared to a median viral load (copies/ml) in study respondents. The study consisted of ART naïve pregnant women while the study had both naïve and ART-experienced participants and ARV-naive pregnant women are more likely to achieve viral loads <1000 copies/ml compared to those who are ARV-experienced (4).
The study results also indicated that majority of the women 89.7% (n=286) HIV pregnant women have suppressed with VL <1000 copies/ml compared to 10.3% (n=33) that were not suppressed (VL >1000 copies/ml). The high viral suppression rates were comparable to another study conducted in Uganda with 96% (67/70) pregnant and lactating women on option B+ suppressed at 6 months, 93.1% (174/187) at 12 months and 95.8% (479/500) at 24 months with suppression VL<1,000 copies/ml (12) and also report a viral suppression rate (VL<1,000 copies/ml) of 90% (n=448) among pregnant and breastfeeding women enrolled on option B+ in 13 large health facilities in Malawi (10).
In this study, decreased CD4 count or immunologic failure was associated with fair/poor adherence to  (14) Alternatively in a systematic and meta-analysis study in low and middle-income countries report that adherence is higher during pregnancy (75•7%, 95% CI 71•5-79•7%) compared to the postpartum (53•0%, 95% 32.8% to 72•7%) (p=0•005) period (15). These differences could be caused by the different regimen used in the two studies. Moreover, a regimen with reduced pill burden, easier dosing, and better tolerability may also enhance ART adherence among pregnant women (16).
Various PMTCT programmes use different methods for measuring adherence. However, common measures include self and proxy reports, pill counts, pharmacy refills, electronic drug monitoring, virologic markers (CD4 counts, viral loads) and blood draws for drug concentrations.On the other hand report a higher proportion of 87.1% (95% CI 82.6-90.7%) among HIV-positive pregnant women on option B+ with adequate adherence in Tigray, northern Ethiopia reports a similar percentage of 95.9% (306) among women on option B+ with good adherence compared to 12.1% (n=23) with poor adherence in Amhara region, North East Ethiopia (17). A much higher proportion of pregnant and breastfeeding women on option B+ (91.4%) have good adherence to ART (≥95% adherence) (MSPH 2015:10). Ensuring adequate adherence to ART among women who initiate lifelong ART on option B+ is essential for an improved immunological response. This would consequently contribute to the reduction of MTCT. Strategies targeting to address issues that hinder adherence among HIV positive pregnant women on ART are essential for improved immunological outcomes.
Most studies indicated similar findings in which older individuals are more likely to have immunological failure compared to those that are younger. In Ethiopia, report that immunological treatment failure is associated with old age (18). Furthermore, in North-West Ethiopia, each unit increase in years is associated with a 3.3% cell/mm3 decrease in the log of change of CD4 cell count (0.0098, 0.0899); p=0.0264] (13]). Patients with lower CD4 cell count at ART initiation and more advanced age (> 40 vs <40 years) demonstrate a decline in CD4 cell count from baseline to 12, 24, and 36 months of follow-up (14) Findings in seven countries in Sub-Saharan Africa and Thailand suggest that lower CD4 cell increase is  [1]). In Abidjan, immunological failure is three times higher in patients ≥15 years of age that had baseline CD4 cell count of ≥200/mm3 (19).
While the study results did not elicit any statistically significant results between time to ART start following HIV testing and immunologic response, the results indicated that delay in initiating ART following HIV testing among pregnant women on option B+ is associated with decreasing CD4 count response (coef -0.225; 95% CI-3.503 to 3.013; p=0.882) which is in agreement with some studies which suggest that delayed ART initiation is associated with poor treatment outcomes.
On the contrary, suggest that immunological treatment failure is associated with lower baseline CD4 count and higher educational status (18). According to conducted in Addis Ababa showed that women with lower CD4 count before ART initiation<200 cells/mm3 are 0.023 times less likely to achieve good immunological outcome compared to those with CD4 count ≥200 cells/mm3 (AOR=0.023, 95% CI= (0.003 -0.190), p=0.000 among women who start HAART before or during pregnancy in a Hospital in Addis Ababa.

Conclusions
The mean CD4 at ART start was 349.68 cells/µL and IQR (1-1012). Out of the 319 respondents that had current CD4 count > 350 cells/µL 272(85.3%) while initiated ART with CD4 cell counts ≤ 350 cells/µL were 61.4%. The median (IQR) CD4 count change or difference among women that had initial and last CD4 was 581 cells/μl and mean CD4 count 629.17ceels/ml3 and more than 85.3% had to increase CD4 count.
Study results indicate that majority of the respondents 89.7% were suppressed of which 80.3% were undetectable (VL= 0 copies /ml3 and majority of them 85.3% had increase CD4 count. When dichotomized, 89.7% (n=286) HIV pregnant women were suppressed with VL <1000 copies/ml versus 10.3% (n=33) that were not suppressed (VL >1000 copies/ml). Therefore, in this study identified that factors associated with viral load response were poor /fair adherence missing doses in the past month, missing appointments, baseline CD4 and maternal months on ART were statistically significant. WHO stage, missed doses in the past month, CD4 counts, maternal months on ART and adherence were associated with viral suppression and missing doses in the past month, missing appointments, baseline CD4 and maternal months on ART were statistically significant.
The results also illustrated that delayed ART initiation following HIV testing among HIV positive pregnant women would result in increased viral copies. Improved CD4 response was associated with increased gestational age at ART start. Alternatively, decreasing CD4 count was associated with increased age and fair/poor adherence to medication. The significant results included factors that hindered the process of ART initiation and compliance to medication such as minimal male participation during PMTCT; missing clinic appointments due to traveling away from home or taking a trip and work-related issues; missing doses due to traveling away from home, forgetting and lack of food.
The results of this study were also guided policy and current protocol modification in the area of Option B+ implementation especially in low-resource countries that face challenges due to weak health systems and to contextualize it.
Analyzing the relationship between factors that influence ART initiation and treatment outcomes among these women through empirical processes was provide awareness, guidance, and suggestions on viable approaches or strategies that health providers can employ to support women and their infants during ART initiation.
FMOH would be better to decentralize ART care and laboratory services to zonal level to increases access to health facilities Trained peer support groups established to support women that enroll on lifelong ART. Improved partner participation and support to women enrolled in option B+ programmes.
Male partners support the women to initiate and adhere to lifelong ART Therefore, strategies aimed at improving adherence among women on option B+ are to ensure that these women achieve adequate immunological outcomes.
Prospective studies that aim at further understanding the factors associated with treatment outcomes like viral change, LTFU and immunological outcomes among women who initiate on lifelong ART including the outcomes among children is beneficial in developing strategies to further support women on option B+.

Funding
This study was supported by the Ambo University, College of medicine and health sciences research and community service. The funder had no role in the design, data collection, analysis and interpretation of results in this study.

Availability of data and material
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Authors' Contributions
Dereje Bayissa Demissie, Gizachew Abdissa Bulto, Wagi Tosisa Mekuria and Fikru Negassa Dufera conceptualized the study, designed the study instrument and conducted the data analysis and wrote the first draft and final draft of the manuscript. DBD Approved the research proposal with some revisions, participated in data analysis, revised subsequent drafts of the paper and involved in critical review of the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate
The study have been performed in accordance with the Declaration of Helsinki and approved by Ambo University. Formal letter of cooperation was written to respective hospitals /health centers by Ambo University. The right to refuse was respected and information collected from this research project was kept confidential and the collected information was stored in a file, without the name of the study participant.

Competing interests
The author(s) declare that they have no competing interests including financial or funding.  Of Newly diagnosed and started on ART during a recent pregnancy