4 The WHO emphasizes the importance of all HIV infected women having access to life-long treatment if they are clinically or immunologically eligible for it. For those pregnant women who did not require it for their own health there were two options; A and B, see Table (Table 2).4 In 2010 a further option, B+ was introduced which advocates life-long treatment for all HIV positive pregnant or breastfeeding

women, irrespective of their clinical stage or CD4 GSK-3 activation count.4 and 5 In June 2013, WHO issued new guidance which now excludes option A and recommends one simplified triple regimen for all pregnant women irrespective of their CD4 count (option B+), this would then continue lifelong for all or just for those who meet the eligibility

criteria (option B).12 This decision was made on the evidence that whilst trials have shown similar efficacy between Option A and B, the complexities of the former have hindered the up-scaling of PMTCT in many low-resource countries.12 Countries have to make a programmatic choice between ‘option B’ and ‘B+’, as there is not yet the evidence to detail the overall impact of lifelong treatment in this scenario.12 Countries that have the capacity to monitor CD4 count, with concentrated epidemics and where the option of alternative feeding is safe, option B may still be considered (Table 1).12 This WHO programmatic update 2012, suggests that option B and specifically B+ are preferable over option A.13 Both B and B+ start women on a triple ARV regimen which carries more assurance that those eligible for INK 128 datasheet treatment will get a fully suppressive regimen. The ability to use the same regimen for ART and PMTCT simplifies drug forecasting, procurement, supply and stock monitoring and is less confusing for the women.13 Option B+ has several advantages such as not requiring CD4 counts to determine eligibility for ART or to decide whether or when ADAMTS5 to stop once the risk of MTCT is over.5 and 13 It

also offers protection for future pregnancies by remaining on ART from conception as well as offering ongoing protection to sero-discordant couples.5 and 13 Early treatment before women meet the immunological or clinical criteria for ART would have an advantageous affect on their health (65% reduced risk of contracting TB whilst on ART irrespective of CD4 count7) and may reduce drug resistance if they are not starting and stopping ART regularly, especially in areas of high birth rates.9 It also reinforces the message that ART is intended for lifelong treatment and therefore may improve compliance.9 Results from Malawi where option B+ has been implemented since the third quarter of 2011, show that there has been a dramatic increase in the number of new ART initiations in pregnant women from the 4th quarter of 2011 through to 2012.