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landesPublished in Canadian Family | Cara Smusiak | May 2014

Dr. Megan Landes, Researcher with Dignitas International

It’s a revolutionary idea in sub-Saharan Africa: Don’t just provide antiretroviral therapy (ART) to HIV-positive women during pregnancy and while they’re breatsfeeding, as the World Health Organization recommends – offer it to them for life. In 2011, Malawi became the first resource-limited nation to take this bold step – and Toronto-based physician and researcher had a hand in this shift.

Dr. Landes has long been interested in the prevention of mother-to-child transmission of HIV. After completing an elective program in Lesotho, a landlocked country inside the borders of South Africa, in 2005, at the height of the AIDS epidemic, she headed to the University of Toronto. Later, in 2010, looking to do some part-time research, she travelled to Malawi for a six-month stint as a volunteer doctor for Dignitas International, a Canadian organization dedicated to improving treatment and care for people living with HIV/AIDS. While there, she also analyzed mother-to-child transmission data.

Dr. Landes examined data on a cohort of HIV-positive mothers who were given a single dose of antiretroviral drug at the time of delivery (as were the babies); the mothers were then asked to follow up and have their child tested for HIV. Dr. Landes found that only about 19 percent made it to the final step, where a toddler is tested and diagnosed – “which is pretty abysmal,” she notes. Worse yet, transmission rates remained very high, at about 24-25 percent. “That’s almost akin to doing nothing,” she explains. “It really highlighted the fact that there needed to be some kind of system change in Malawi.”

That same year, the WHO developed guidelines for prevention of mother-to-child transmission, with two options: Option A involved providing pregnant with ART until delivery or seven days postpartum (depending on the drugs); Option B involved providing ART until one week after baby stops breastfeeding. But in Malawi, where women tend to have about five children, 18 months to two years apart, moms would be going on and off drugs for upwards of a decade. So, armed with various studies, including Dr. Landes’ 2010 research for Dignitas, Malawi improved upon Option B+, announcing it would roll out a lifelong program they called Option B+.

This was a “revolutionary” move, says Dr. Landes, adding that it will have a great impact on transmission rates if pregnant women participate. “We’re able to get them on the therapy, and if they stay on the therapy, their viral load is reduced far enough that they really have a much higher chance of being able to prevent their babies from getting HIV, either during delivery or breastfeeding,” she says. Though similar to standard care in wealthy nations, Malawi’s policy is a leap forward for maternal health, says Dr. Landes. “What they did was – I think for one of the first times – really prioritize women’s health, and women are getting preferential access to a life-saving therapy,” she says.

All of this hits closer to home now that Dr. Landes has a 10-month-old daughter. “Even though you can have empathy for your patients, I appreciate their struggles and how much they have to go through in order to protect their own children.”

After that first volunteer trip, Dr. Landes became a part-time researcher for Dignitas. Since becoming pregnant in 2012, she’s been following the rollout of Option B+ from Toronto, and early numbers are positive, with a 748 percent increase in the number of pregnant and breastfeeding women starting ART after Option B+ was offered compared to before. More important, 77 percent of those women were still on the therapy a year later.

If the program continues to be a success, it will yield a number of benefits. First and foremost, it will prevent HIV transmission to babies, says Dr. Landes, adding that this is essential to hopes of creating an AIDS-free generation. The program also benefits maternal health. Mothers who are receiving long-term treatment will live longer, which means they can care for their children longer. This is vital in a country where annual AIDS deaths number in the tens of thousands and where, in 2012, there were an estimated 770,000 AIDS orphans.

Thought these numbers are staggering, there has been great improvement,” she says. “From that beginning in 2005, being in Lesotho [where] everybody was coming in quite sick, to now, [when] the population you’re engaging with is women who’ve got HIV but they’re on medication and they’re leading relatively normal lives, it is incredibly encouraging to see that shift.”

Later this year, Dr. Landes will be heading back to Malawi to launch a new large-scale research project – with her daughter in tow, if possible. “She needs to be old enough that she can take malaria prophylaxis. That’s something I need to investigate and sort out, but I will definitely have her in Malawi at some point.”

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