Spurred by Malawis experience, Swazilands Technical Working Group began discussing Option B+ in October 2012. The initial debate was whether HIV-positive new mothers who were not sick should continue or discontinue treatment after the end of breast-feeding. In other words, should Swazilandwhich was still using Option Aswitch to Option B or Option B+? We kept throwing it back and forth: Which is better? What are the pros and cons? says Okello. Of course, there are some good things about starting [during pregnancy] and stopping [after breast-feeding].

For example, a young, recently infected pregnant woman was more likely than not to have a fairly high CD4 count, so under the previous guidelines she likely would not have begun ART therapy for another 10 years or so. Delayed treatment saved the state money, and relieved the woman of years of side effects plus the burden of adhering to the treatment regime. Nevertheless, continued treatment seemed the better route to ensure adherence generally, says Okello. Moreover, the National ART Programme was concerned about sending mixed messages, she adds.

If you start telling our population that they can start and stop, then it will compromise adherence for everybody else, because they see that people are surviving. They start, and they stop for 10 years, and theyre still fine.

Okello talks about starting and stopping treatment

Option B+ could bring into the healthcare system people--particularly those with CD4 counts above 350who would otherwise have avoided any monitoring or treatment. It was difficult to get them to even come in and be monitored, observes Okello.

We realized that we have to do something more to pull in those who are [not yet eligible for] ART to get into treatment, because they are not even keen on attending the pre-ART clinics where they get other services.

But Option B+ also raised ethical concerns. Was it right to introduce a treatment regimen that could result in a non-pregnant woman receiving treatment because she had been pregnant in the past while a never-pregnant sister or neighbor with the same or worse HIV status went without treatment? Should Swaziland prioritize pregnant women if drug shortages meant infected non-pregnant women and men were left behind? Option B+ could easily divert scarce resources from more sick people to the usually healthier HIV-positive pregnant women, says Okello. "Men in Swaziland have shown poor health-seeking behaviour and ideally we should be focusing on them with services, but with B+ we [would] spend more resources on women," she says. ^[42]

Hard realities. The discussions in the Technical Working Group quickly moved from whether Swaziland should move to Option B+ to whether it could make the move. It would mean buying more drugs, training more healthcare workers and managing more patients at a time when the budget was already strained. We are asking ourselves, if we move to [Option B+], we are surely, surely, surely going to get more people on treatment, says Okello. If we have been struggling... now, how much more do you want to overload the system?

The primary question was the cost of drugs. All told, Global Fund had provided Swaziland with $76.2 million since 2003. ^[43] Its 2011 cancellation created a shortfall of $2.1 million (18 million emalangeni) that Swaziland had to make up to finish its fiscal year. Since 2012, Swaziland had paid for all of its antiretroviral drugs. At the time, 12,000-15,000 HIV-positive people (men and women) entered the ART program each year. Based on HIV rates among pregnant women and the pregnancy rate in Swaziland, the National ART Programme estimated that 11,000 HIV-positive pregnant women per year would be eligible for treatment under Option B+. But not all of them would present as new patients: about a third were already in treatment. Of those not already in treatment, some 33 percent already qualified in a different categorytheir CD4 counts were below 350. That left some 5,000 pregnant women a year who would newly qualify for treatment under Option B+, meaning Swaziland would need between 33-41 percent more antiretroviral drugs.

There were further complications, stemming from human behavior. Several factors might reduce the effectiveness of Option B+ in Swaziland, says Dr. Harriet Nuwagaba-Biribonwoha, ICAP research director in Swaziland and an epidemiology instructor at Columbia. For example, the low rate of male circumcision and the challenge of adherence could offset gains. If patients don't adhere to their ART regimens, what is going to happen when HIV becomes resistant to the first-line medicines?she asks. Resistance required patients to switch to second-line drug regimens. "We are worried about shifting people to second line, because second line is more expensive," says Okello. "Much more, like almost 10 times more expensive than the other, first-line regimen."

Long run. Yet if Swaziland could afford the upfront costs of expanding treatment under Option B+, it would reap financial benefits over the long term because the country would have fewer new infections and would save money on treatment. Similarly, the country would need fewer doctors and nurses if there were fewer patients. Option B+ was also the most effective at reducing mother-to-child transmissions. You have to do what you can to make sure that you have a generation thats coming up thats HIV free, says Nuwagaba-Biribonwoha. She explains:

You have to struggle to keep [that generation] HIV free right into their adulthood. But at least you give them that start. I dont think that you can afford to put so many more infected children into the [population] by not doing the best you can. ^[44]

Nuwagaba-Biribonwoha on keeping a new generation free of HIV

In the big picture, moving to Option B+ would give healthcare workers and policymakers welcome experience in implementing early treatment that they could eventually use for all HIV-positive people in Swaziland, says Okello. Treating every infected person was the ultimate goal of global public health community. Implementing Option B+ would lay the groundwork for making policy decisions for when test-and-treat becomes a universal strategy, she says. Adopting Option B+ could also increase the capacity of Swazilands healthcare system in general, says Nuwagaba-Biribonwoha. Could you leverage whatever investments youve made in that particular disease in terms of systems, in terms of training, to manage other conditions that are pertinent? she asks. For example, ICAP was already using its HIV experience to address other health conditions such as mental health, non-communicable diseases and palliative care.

But as tempting as the benefits of Option B+ were, the main question was, could Swazilands already overtaxed budget handle the 33-41 percent increase in the quantity of drugs needed to treat all HIV-positive pregnant women for life? The reality is that we dont have adequate drugs, but we do want to take up the new guidelines, says Okello. People are thinking, should we or should we not? Are [we] sure we can move to [Option B+]? she says. Could the countrys decentralized healthcare system handle the change, particularly when retaining patients in treatment was already a major challenge? If Swaziland did make the move, should it roll out Option B+ aggressively or take a phased approach? Was it ethical to introduce a treatment strategy that prioritized pregnant women over other people?

El-Sadr on treatment discrepancies