Uptake and retention in HIV care among pregnant and postpartum women living with HIV under different eras of vertical transmission prevention policies in sub-Saharan Africa: a systematic review and meta-analysis

This systematic review and meta-analysis of 82 studies across 17 sub-Saharan African countries demonstrates that the implementation of Option B+ policies significantly improved both HIV care uptake (by 8%) and retention rates (by 46%) among pregnant and postpartum women, although retention levels remain insufficient to meet UNAIDS 95-95-95 targets.

The Gist

Imagine a massive, bustling train station in Sub-Saharan Africa. The passengers are pregnant women living with HIV, and their destination is "Health and Safety." The goal is to get every single passenger on the right train (starting medication) and keep them on it all the way to the final stop (staying healthy and preventing the virus from passing to their babies).

For a long time, the station had a complicated, changing schedule. Sometimes, you had to wait for a specific ticket office to open; sometimes, the rules changed depending on the day. This was the "Pre-Option B+" era. It was like trying to catch a train where the departure times were confusing, and many people got lost, missed their ride, or got off the train too early.

Then, the station managers introduced a new, streamlined system called "Option B+". Think of this as installing an express lane with a friendly guide who says, "If you are pregnant and need this medicine, just hop on the train immediately. No waiting, no extra paperwork, no questions asked."

This paper is like a giant report card that looks at how well this new system worked between 2010 and 2025. The researchers gathered data from 17 different countries (82 different studies) to see if the new "express lane" actually helped more women get on the train and stay on it.

Here is what they found, translated into everyday terms:

1. Getting on the Train (Uptake)

Before the new system, some women missed the train or didn't know where to go. After the "Option B+" express lane opened, 8% more women successfully boarded the train.

• The Analogy: Imagine a bus stop where 100 people were waiting. Before the change, maybe 90 got on. After the change, 98 got on. It's a small but important improvement in getting people started.

2. Staying on the Train (Retention)

This is where the real magic happened. Getting on the train is one thing; staying on it for the long journey is another. Many women used to get off the train halfway through because the journey was too hard or the rules were confusing.

• The Old Days: Before the new policy, only about 37 out of 100 women stayed on the train for the full 6-month journey.
• The New Days: After the policy changed, that number jumped to 73 out of 100 women staying on the train.
• The Analogy: This is a 46% improvement. It's like upgrading a bumpy, confusing dirt road into a smooth highway. The journey became so much easier that almost twice as many people decided to stick with it.

The Bottom Line

The report concludes that the new "Option B+" policy was a huge success. It acted like a traffic light turning green, allowing more women to start treatment and keeping them safe on their journey.

However, there is still work to do.
Even though the numbers improved dramatically, the goal is to have 95 out of 100 women staying on the train and healthy. Right now, we are at about 73. It's like a marathon runner who has run a great race but hasn't quite crossed the finish line yet. The new system is working, but we need to keep fixing the bumps in the road so that every single woman can reach the finish line safely.

Technical Summary

Technical Summary: Uptake and Retention in HIV Care Under Vertical Transmission Prevention Policies in Sub-Saharan Africa

1. Problem Statement

Despite global efforts to eliminate mother-to-child transmission (MTC) of HIV, sub-Saharan Africa faces persistent challenges in ensuring that pregnant and postpartum women living with HIV (WLHIV) not only initiate antiretroviral therapy (ART) but also remain engaged in care. The region has undergone significant policy shifts, most notably the transition from earlier, complex algorithms to Option B+ (universal, lifelong ART for all pregnant and breastfeeding women regardless of CD4 count). While Option B+ was hypothesized to improve outcomes, there was a need for a comprehensive, up-to-date quantitative assessment of how these policy eras specifically impacted care uptake (initiation of ART) and retention (continued engagement post-initiation) across the diverse healthcare landscapes of sub-Saharan Africa.

2. Methodology

This study employed a rigorous systematic review and meta-analysis design covering the period from 2010 to 2025.

• Data Sources & Search Strategy: A comprehensive search was conducted across five major databases (PubMed, Embase, Cochrane Library, Scopus, and African Index Medicus) between October 2021 and May 2025.
• Eligibility Criteria:
  • Population: Pregnant and postpartum women living with HIV in sub-Saharan Africa.
  • Intervention/Exposure: Comparison of care outcomes under pre-Option B+ policies versus Option B+ implementation.
  • Study Designs: Included cohort, case-control, cross-sectional, and interventional studies.
  • Exclusions: White papers, commentaries, modeling studies, cost-effectiveness analyses, and qualitative studies were excluded to ensure quantitative robustness.
• Outcomes Measured:
  1. HIV Care Uptake: Defined as ART initiation during pregnancy or prior to the initial antenatal care (ANC) visit.
  2. Retention in Care: Defined by study authors as continued engagement in HIV care after ART initiation (or ANC entry).
• Statistical Analysis:
  • Data were synthesized via meta-analysis, stratified by policy era (pre-Option B+ vs. Option B+).
  • Comparisons utilized Relative Risk (RR) with 95% Confidence Intervals (CI).
  • Specific retention estimates were calculated at 6 and 12 months post-ART initiation.

3. Key Contributions

• Temporal Scope: This review provides the most current synthesis of data (up to 2025), capturing the long-term effects of Option B+ implementation across multiple countries.
• Granular Stratification: Unlike previous reviews that may have aggregated data broadly, this study explicitly stratified results by policy era, allowing for a direct causal inference regarding the impact of the policy shift.
• Differentiation of Metrics: The study distinctly separates uptake (entry into the system) from retention (sustained engagement), highlighting that while entry has improved, the "drop-off" rate remains a critical bottleneck.
• Geographic Breadth: The inclusion of 82 studies from 17 different countries offers a robust representation of the sub-Saharan African context, moving beyond single-country case studies.

4. Key Results

The analysis included 4,752 screened articles, with 82 studies (representing 17 countries) meeting inclusion criteria.

• Study Distribution: 60 studies reported on HIV care uptake, while 31 reported on retention outcomes.
• Impact on Uptake: The implementation of Option B+ was associated with an 8% increase in HIV care uptake (RR = 1.08; 95% CI: 1.06–1.09).
• Impact on Retention: The most significant finding was a 46% relative increase in retention rates post-Option B+ implementation (RR = 1.46; 95% CI: 1.41–1.51).
• Absolute Retention Rates:
  • Pre-Option B+: Pooled retention at 6 months post-ART initiation was 36.9% (95% CI: 13.9%–59.9%).
  • Post-Option B+: Pooled retention at 6 months rose significantly to 72.7% (95% CI: 66.3%–79.1%).

5. Significance and Conclusion

The study confirms that the adoption of Option B+ has been a pivotal driver in improving both the initiation and retention of HIV care among pregnant and postpartum women in sub-Saharan Africa. The nearly doubling of retention rates (from ~37% to ~73%) represents a major public health success.

However, the authors conclude that despite these substantial gains, retention remains suboptimal for achieving the UNAIDS 95-95-95 targets (specifically the third 95: 95% of people on treatment being virally suppressed). The gap between the current ~73% retention and the 95% target suggests that while policy simplification (Option B+) solved the entry barrier, structural, behavioral, or systemic barriers continue to cause attrition in the postpartum period. Future interventions must focus on targeted retention strategies to close this remaining gap and fully eliminate vertical transmission.