Monitoring Patient Adherence and Follow-up in Option B+ Program: Understanding Healthcare Workers' Practices, Challenges, and Facilitators in Lilongwe, Malawi.

Background: Option B+ aims to prevent mother-to-child transmission of HIV by providing lifelong antiretroviral therapy (ART) to pregnant and breastfeeding women living with HIV (PBWHIV). Identifying and reengaging PBWHIV who disengage or fail to initiate ART is essential for the success of Option B+. However, the process is often suboptimal, leading to challenges such as misclassification of patients as lost to follow-up. Healthcare workers (HCWs) are pivotal for monitoring engagement, but little is known about their monitoring practices. This study aimed to explore how HCWs monitor women's engagement in Option B+ services.

Methods: A qualitative study was conducted in five high-volume health facilities in Lilongwe, Malawi. Thirty HCWs responsible for monitoring women in Option B+ were purposively selected as key informants. Semistructured interviews were conducted between March and June 2021. Thematic analysis employing deductive and inductive coding methods was utilized. The Consolidated Framework for Implementation Research was used to map gaps, strategies, barriers, and facilitators of monitoring.

Results: Monitoring was described as tracking a PBWHIV from HIV diagnosis to initiation of ART to subsequent ART visits for up to 2 years postpartum. The gaps included timing variations in tracing. No procedures to follow up formal transfer-outs or management of silent transfers during emergency ART refills were identified. Strategies identified included interfacility collaboration, record review, tracing, escorting women during initial visits, and self-reports. Technological innovations, such as WhatsApp groups, were highlighted as game changers in interfacility collaboration when tracking women's movements. Barriers included resource constraints (human and operational), poor work attitudes, and challenges faced by women (partner support, stigma, and HCW rapport). The facilitators included implementing partner support, leadership, and strategies such as education and tracing.

Conclusion: Addressing resource constraints, women's relationship dynamics for self-management, HCWs' attitudes, and standardizing tracing protocols are crucial for effective monitoring. Leveraging instant messaging for clinic coordination may enhance tracing. Further research and interventions should target identified gaps to promote effective monitoring in similar settings.