Malawi

We investigated factors associated with unintended index pregnancy, unmet contraceptive need, future pregnancy intention and current contraceptive use among Malawian women living with HIV in the Option B+ era. Women who tested HIV positive at 4–26 weeks postpartum were enrolled into a cross-sectional study at high-volume under-5 clinics.  We enrolled 578 HIV-positive women between May 2015-May 2016; median maternal age was 28 years (y), median parity was 3 deliveries, and median infant age was 7 weeks. Overall, 41.8% women reported unintended index pregnancy, of whom 35.0% reported unmet contraceptive need and 65.0% contraceptive failure. High prevalence of unintended index pregnancy and unmet contraceptive need among HIV-positive women highlight the need for improved access to contraceptives. To help achieve reproductive goals and elimination of MTCT of HIV, integration of family planning into HIV care should be strengthened to ensure women have timely access to a wide range of family planning methods with low failure risk.

The aim of this study was to assess the uptake and determinants of HIV testing among men in Malawi. Secondary data analysis was conducted on cross–sectional household data for 7,478 men aged 15 to 54 years drawn from the 2015–16 Malawi Demographic and Health Survey. Overall, 69.9% of the participants had ever been tested for HIV. The results indicate that age, region of residence, marital status, coverage by health insurance, education and age at first sexual debut are significant predictors of HIV testing among men in Malawi. The findings suggest that HIV testing services and programmes need to target younger unmarried men aged 15–19 and men with low level or no education and expand HIV testing services to the central and southern regions of Malawi. Targeting the undiagnosed men living with HIV in a timely manner is a crucial and necessary step not only for achieving the UNAIDS 90–90–90 targets but for individuals to benefit from antiretroviral treatment and to sustainably reduce population–level HIV transmission.

In 2011, the Malawi Ministry of Health introduced option B+, a universal treatment strategy for the prevention of mother-to-child transmission (MTCT) of HIV. Under option B+, all pregnant or breastfeeding women with HIV are eligible for lifelong antiretroviral therapy (ART) regardless of clinical stage or CD4. Routine data from Malawi's prevention of MTCT option B+ programme suggest high uptake of antiretroviral therapy (ART) among pregnant women. Malawi's Ministry of Health led the National Evaluation of Malawi's PMTCT Program to obtain nationally representative data on maternal ART coverage and prevention of MTCT effectiveness. Here we present the early transmission data for infants aged 4–12 weeks and used a multistage cluster design to recruit a nationally representative sample of HIV-exposed infants and their mothers. Between October 16, 2014 and May 17, 2016, we screened for HIV in all mothers attending an under-5 vaccination or outpatient sick-child clinic with infants aged 4–26 weeks. They confirmed HIV exposure in 3542 (10·4%) of 33 980 mother (guardian)–infant pairs with infants aged 4–26 weeks. These data suggest that Malawi's decentralization of ART services has resulted in higher ART coverage and lower early MTCT. However, the uptake of services for HIV-exposed infants remains suboptimal.

The neonatal mortality rate (NMR) in Malawi has remained stagnant at around 27 per 1000 live births over the last 15 years, despite an increase in the uptake of targeted health care interventions. We used the nationally representative 2015/16 Demographic Health Survey data set to evaluate the effect of two types of maternal exposures, namely, lack of access to maternal or intra-partum care services and birth history factors, on the risk of neonatal mortality. We included 9553 women and their most recent live birth within 3 years of the survey. The sample's overall neonatal mortality rate was 18.5 per 1000 live births. The adjusted population attributable risk for first pregnancies was 3.9/1000 (P < 0.001), while non-institutional deliveries and the shortest preceding birth interval (8-24 months) each had an attributable risk of 1.3/1000 (Ps = 0.01). Having 2 or more pregnancy outcomes within the last 5 years had an attributable risk of 3/1000 (P = 0.006). Attending less than 4 ANC visits had, a relatively large attributable risk (2.1/1,000), and it was not statistically significant at alpha level 0.05.  

We conducted a cross-sectional analysis of 33,744 mother–infant pairs to estimate the use and outcomes of the Malawian programme for the prevention of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV). Most women used the Malawian programme for the prevention of MTCT. The risk of MTCT increased if any of the four main steps in the programme were missed.

A cross-sectional qualitative study was conducted to explore early experiences surrounding "Option B+" for patients and health care workers in Malawi. As "Option B+" continues to be rolled out, novel interventions to support and retain women in care must be implemented. These include providing space, time, and support to accept a diagnosis before starting ART, engaging partners and families, and addressing the need for peer support and confidentiality.

This article presents Malawi’s experience with designing and implementing Option B+ and provides complementary narratives from Cameroon and Tanzania. Operationalizing Option B+ required several critical considerations, including the complete integration of ART and PMTCT programs, systematic reduction of barriers to facilitate doubling the number of ART sites in less than a year, building consensus with stakeholders, and securing additional resources. During the planning and implementation process, several lessons were learned which are considerations for countries transitioning to “treat-all”: Comprehensive change requires effective government leadership and coordination; national clinical guidelines must accommodate health system limitations; ART services and commodities should be decentralized within facilities; the general public should be well informed about major changes in the national HIV program; and patients should be educated on clinic processes to improve program monitoring.

In Malawi, health-system constraints meant that only a fraction of people infected with human immunodeficiency virus (HIV) and in immediate need of antiretroviral treatment (ART) received treatment. In 2004, the Malawian Ministry of Health launched plans to scale-up ART nationwide, adhering to the principle of equity to ensure fair geographical access to therapy. A public health approach was used with standardized training and treatment and regular supervision and monitoring of the programme. Before the scale-up, an estimated 930 000 people in Malawi were HIV-infected, with 170 000 in immediate need of ART. About 3000 patients were on ART in nine clinics. By December 2015, cumulatively 872 567 patients had been started on ART from 716 clinics, following national treatment protocols and using the standard monitoring system. Strong national leadership allowed the ministry of health to implement a uniform system for scaling-up ART and provided benchmarks for implementation on the ground. New systems of training staff and accrediting health facilities enabled task-sharing and decentralization to peripheral health centres and a standardized approach to starting and monitoring ART. A system of quarterly supervision and monitoring, into which operational research was embedded, ensured stocks of drug supplies at facilities and adherence to national treatment guidelines.

Abstract The scale-up of antiretroviral therapy (ART) in Malawi was based on a public health approach adapted to its resource-poor setting, with principles and practices borrowed from the successful tuberculosis control framework. From 2004 to 2015, the number of new patients started on ART increased from about 3,000 to over 820,000.

We reviewed literature on HIV and tuberculosis in sub-Saharan African prisons published between 2011 and 2015, and identified data from only 24 of the 49 countries in the region. Where data were available, they were frequently of poor quality and rarely nationally representative. Prevalence of HIV infection ranged from 2·3% to 34·9%, and of tuberculosis from 0·4 to 16·3%; detainees nearly always had a higher prevalence of both diseases than did the non-incarcerated population in the same country.We identified barriers to prevention, treatment, and care services in published work and through five case studies of prison health policies and services in Zambia, South Africa, Malawi, Nigeria, and Benin. These barriers included severe financial and human-resource limitations and fragmented referral systems that prevent continuity of care when detainees cycle into and out of prison, or move between prisons. These challenges are set against the backdrop of weak health and criminal-justice systems, high rates of pre-trial detention, and overcrowding. A few examples of promising practices exist, including routine voluntary testing for HIV and screening for tuberculosis upon entry to South African and the largest Zambian prisons, reforms to pre-trial detention in South Africa, integration of mental health services into a health package in selected Malawian prisons, and task sharing to include detainees in care provision through peer-educator programmes in Rwanda, Zimbabwe, Zambia, and South Africa. However, substantial additional investments are required throughout sub-Saharan Africa to develop country-level policy guidance, build human-resource capacity, and strengthen prison health systems to ensure universal access to HIV and tuberculosis prevention, treatment, and care of a standard that meets international goals and human rights obligations.

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