Is it who you are or where you live? A mixed-method exploration of associations between people and place in the context of HIV in rural Malawi

In Malawi, approximately 1 million people are infected with Human Immunodeficiency Virus (HIV). Infection rates are decreasing in urban areas; the opposite is true for rural populations. Individual-level risk factors influence patterns of HIV in Malawi. However, area-level socio-economic and access factors may play critical roles in driving HIV, and these factors are rarely investigated. To address this gap, this research uses a nationally-representative probability sample of rural Malawians linked to spatially-oriented, area-level socio-economic and access data to address two specific aims: 1) to reveal relationships between area-level factors and individual HIV status and determine whether individual risk behaviors mediate these associations using logistic regression; and, 2) to explore how relationships between area- and individual-level risks and individual HIV status vary in space using geographically weighted regression. Analysis is stratified to examine the role of gender. Area-level factors include income inequality and absolute poverty as well as proximity to roads, cities, and health clinics. Mediators include condom use, sexually transmitted infections, multiple partnerships, and, for men, paid sex. Results indicate that both people and place matter in the context of HIV in rural Malawi. Among women, high income inequality and proximity to a major road are associated with increased odds of HIV while the negative association between distance to healthcare and HIV status is mediated by individual behavior. For men, living further from a health clinic decreases the odds of HIV infection. Spatial models provide additional detail, illustrating local-level variation in these associations. Women further from health clinics, major roads, and major cities are less likely to be infected in specific geographic areas. HIV status among men is closely associated with migration patterns in distinct locations. As informed by the Political Economy of Health theory, this study confirms that area-level socio-economic and access factors influence HIV in rural Malawi. Associations vary by gender and in space and are largely not mediated by individual behavior. The findings suggest that inequality has deleterious effects on women, and that spatial isolation may lead to social isolation for both genders, decreasing HIV risk. These results could inform tailored HIV prevention efforts in rural Malawi

The who and where of HIV in rural Malawi: Exploring the effects of person and place on individual HIV status

Few spatial studies explore relationships between people and place in sub-Saharan Africa or in the context of Human Immunodeficiency Virus (HIV). This paper uses individual-level demographic and behavioral data linked to area-level, spatially-referenced socio-economic and access data to examine how the relationships between area- and individual-level risks and individual HIV status vary in rural Malawi. The Political Economy of Health framework guides interpretation. Geographically weighted regression models show significant, local-level variation indicating that area-level factors drive patterns of HIV above individual-level contributions. In distinct locations, women who live further from health clinics, major roads, and major cities are less likely to be infected. For men, HIV status is strongly associated with migration patterns in specific areas. Local-level, gender-specific approaches to HIV prevention are necessary in high risk areas

Incidence of pregnancy among women accessing antiretroviral therapy in urban Malawi: a retrospective cohort study.

Although previous studies investigated pregnancy rates among women on antiretroviral therapy (ART), incidence of, and factors associated with pregnancy among these women remain poorly understood. We, therefore, conducted a retrospective cohort study at a large public HIV clinic in Lilongwe, Malawi, between July 2007 and December 2010. At each clinic visit, pregnancy status was assessed. Time to event analysis was conducted using Poisson regression. Among 4,738 women, 589 pregnancies were observed. Pregnancy incidence was 9.3/100 person-years. After 6 months on ART, women on ART had similar total fertility rates to women in the urban population. In multivariable analysis, increasing age and advanced WHO clinical stage were associated with decreased probability of becoming pregnant while higher body mass index and longer time on ART were associated with increased probability of becoming pregnant. We recommend that ART clinics integrate comprehensive family planning services to address reproductive health needs among women on ART

Contraceptive use and pregnancy rates among women receiving antiretroviral therapy in Malawi: a retrospective cohort study

Abstract Background In 2011, family planning (FP) services were integrated at Martin Preuss Centre (MPC), in urban Lilongwe, Malawi. To date, no previous study evaluated pregnancy rates among HIV-positive women after the integration of FP services into HIV care at the facility. In this study, we investigated whether integration of FP services into HIV clinical care led to increased use of contraceptives and decreased pregnancy rates. Methods This was a retrospective cohort analysis of HIV-positive women from 15 to 49 years of age who accessed antiretroviral therapy (ART) services at MPC. Ascertainment of FP needs, contraceptive methods and pregnancy status were done at ART initiation, and at each ART follow-up visit. Women were offered a wide range of contraceptive methods. Outcomes of interest were contraceptive use and rate of pregnancy. Incident pregnancy was ascertained through patient self-reports during clinic consultation. Trends of contraceptive use and pregnancy rates were analyzed using chi-square (χ2). Results A total of 10,472 women were included in the analysis and contributed 15,700 person-years of observation. Contraceptive use among all women receiving ART increased from 28% in 2012 to 62% in 2016 (p < 0.001). A total of 501 pregnancies occurred, including 13 multiple pregnancies, resulting in an overall pregnancy rates of 3.2 per 100 person-years. Rates of pregnancy decreased from 6.8 per 100 person-years in 2012 to 1.3 per 100 person-years in 2016 (p < 0.001). Conclusion Integration of FP services into HIV care resulted in increased contraceptive use and, subsequently, decreased pregnancy rates in women receiving ART. HIV programs should consider offering FP services to women who are receiving ART

Seasonality of cholera from 1974 to 2005: a review of global patterns

Abstract Background The seasonality of cholera is described in various study areas throughout the world. However, no study examines how temporal cycles of the disease vary around the world or reviews its hypothesized causes. This paper reviews the literature on the seasonality of cholera and describes its temporal cycles by compiling and analyzing 32 years of global cholera data. This paper also provides a detailed literature review on regional patterns and environmental and climatic drivers of cholera patterns. Data, Methods, and Results Cholera data are compiled from 1974 to 2005 from the World Health Organization Weekly Epidemiological Reports, a database that includes all reported cholera cases in 140 countries. The data are analyzed to measure whether season, latitude, and their interaction are significantly associated with the country-level number of outbreaks in each of the 12 preceding months using separate negative binomial regression models for northern, southern, and combined hemispheres. Likelihood ratios tests are used to determine the model of best fit. The results suggest that cholera outbreaks demonstrate seasonal patterns in higher absolute latitudes, but closer to the equator, cholera outbreaks do not follow a clear seasonal pattern. Conclusion The findings suggest that environmental and climatic factors partially control the temporal variability of cholera. These results also indirectly contribute to the growing debate about the effects of climate change and global warming. As climate change threatens to increase global temperature, resulting rises in sea levels and temperatures may influence the temporal fluctuations of cholera, potentially increasing the frequency and duration of cholera outbreaks

Seasonality of cholera from 1974 to 2005: a review of global patterns

BACKGROUND: The seasonality of cholera is described in various study areas throughout the world. However, no study examines how temporal cycles of the disease vary around the world or reviews its hypothesized causes. This paper reviews the literature on the seasonality of cholera and describes its temporal cycles by compiling and analyzing 32 years of global cholera data. This paper also provides a detailed literature review on regional patterns and environmental and climatic drivers of cholera patterns. DATA, METHODS, AND RESULTS: Cholera data are compiled from 1974 to 2005 from the World Health Organization Weekly Epidemiological Reports, a database that includes all reported cholera cases in 140 countries. The data are analyzed to measure whether season, latitude, and their interaction are significantly associated with the country-level number of outbreaks in each of the 12 preceding months using separate negative binomial regression models for northern, southern, and combined hemispheres. Likelihood ratios tests are used to determine the model of best fit. The results suggest that cholera outbreaks demonstrate seasonal patterns in higher absolute latitudes, but closer to the equator, cholera outbreaks do not follow a clear seasonal pattern. CONCLUSION: The findings suggest that environmental and climatic factors partially control the temporal variability of cholera. These results also indirectly contribute to the growing debate about the effects of climate change and global warming. As climate change threatens to increase global temperature, resulting rises in sea levels and temperatures may influence the temporal fluctuations of cholera, potentially increasing the frequency and duration of cholera outbreaks

Who Starts? Factors Associated with Starting Antiretroviral Therapy among Eligible Patients in Two, Public HIV Clinics in Lilongwe, Malawi

BackgroundLighthouse Trust operates two, public, integrated HIV clinics, Lighthouse (LH) and Martin Preuss Center (MPC), in Lilongwe, Malawi. Approximately 20% of patients eligible for antiretroviral therapy (ART) do not start ART. We explore individual and geographic factors that influence whether ART-eligible patients initiate ART.MethodsAdult patients eligible for ART between 2008–2011 were included. Analysis was stratified by clinic. Using logistic regression, we evaluated factors associated with initiating ART including gender, age, body mass index (BMI), employment, tuberculosis (TB), eligible at initial registration, WHO stage, CD4, months in pre-ART care (from initial registration to eligibility date), and patient neighborhood distance to clinic.ResultsOf 14,216 study patients, 4841 were from LH; 9285 were from MPC. At LH and MPC, respectively, median age was 34.2 and 33.8 years; median BMI was 22.0 and 20.6; and median distance was 5.6 and 4.9 Km. In multivariate models, odds of starting ART was highest among those older than 35 years and those eligible for ART based on WHO stages 3–4 vs. those in WHO stages 1–2 with CD4<250. Patients with 1–12 months in pre-ART were at least 11 times more likely to start ART than peers with less pre-ART time. At LH, living 2.5–5 Km from the clinic increased the likelihood of starting ART over patients living closer.ConclusionsLength of the pre-ART period is the most significant predictor of starting ART among eligible patients. Better understanding of motivation for retention in pre-ART care may reduce attrition along the treatment cascade

Local Environmental Predictors of Cholera in Bangladesh and Vietnam

Environmental factors have been shown to be related to cholera and thus might prove useful for prediction. In Bangladesh and Vietnam, temporal cholera distributions are related to satellite-derived and in-situ environmental time series data in order to examine the relationships between cholera and the local environment. Ordered probit models examine associations in Bangladesh; probit models examine associations at 2 sites in Vietnam. Increases in ocean chlorophyll concentration are related to an increased magnitude of cholera in Bangladesh. Increases in sea surface temperature are most influential in Hue, Vietnam, whereas increases in river height have a significant role in Nha Trang, Vietnam. Cholera appearance and epidemic magnitude are related to the local environment. Local environmental parameters have consistent effects when cholera is regular and more prevalent in endemic settings, but in situations where cholera epidemics are rare there are differential environmental effects

Integrating family planning services into HIV care: use of a point-of-care electronic medical record system in Lilongwe, Malawi

Background: Integrating family planning (FP) services into human immunodeficiency virus (HIV) clinical care helps improve access to contraceptives for women living with HIV. However, high patient volumes may limit providers’ ability to counsel women about pregnancy risks and contraceptive options

Integrating reproductive health services into HIV care: strategies for successful implementation in a low-resource HIV clinic in Lilongwe, Malawi

BackgroundLighthouse Trust operates two public HIV testing, treatment and care clinics in Lilongwe, Malawi, caring for over 26 000 people living with HIV, 23 000 of whom are on antiretroviral treatment (ART). In August 2010, Lighthouse Trust piloted a step-wise integration of sexual and reproductive health (SRH) services into routine HIV care at its Lighthouse clinic site. The objectives were to increase uptake of family planning (FP), promote long-term reversible contraceptive methods, and increase access, screening and treatment for cervical cancer using visual inspection with acetic acid.Methods and resultsPatients found integrated SRH/ART services acceptable; service availability appeared to increase uptake. Between August 2010 and May 2014, over 6000 women at Lighthouse received FP education messages. Of 859 women who initiated FP, 55% chose depot medroxyprogesterone acetate, 19% chose an intrauterine contraceptive device, 14% chose oral contraceptive pills, and 12% chose an implant. By May 2014, 21% of eligible female patients received cervical cancer screening: 11% (166 women) had abnormal cervical findings during screening for cervical cancer and underwent further treatment.ConclusionsSeveral lessons were learned in overcoming initial concerns about integration. First, our integrated services required minimal additional resources over those needed for provision of HIV care alone. Second, patient flow improved during implementation, reducing a barrier for clients seeking multiple services. Lastly, analysis of routine data showed that the proportion of women using some form of modern contraception was 45% higher at Lighthouse than at Lighthouse's sister clinic where services were not integrated (42% vs 29%), providing further evidence for promotion of SRH/ART integration