The impact of breastfeeding on the health of HIV-positive mothers and their children in sub-Saharan Africa

OBJECTIVE: We assessed the impact of breastfeeding by women infected with human immunodeficiency virus (HIV)-1 on their morbidity and risk of mortality and on the mortality of their children. METHODS: We analysed longitudinal data from two previous randomized clinical trials of mother-to-child transmission of HIV conducted between April 2000 and March 2003 in the Republic of Malawi, Africa. Mothers infected with HIV, and their newborns, were enrolled at the time of their child's birth; they then returned for follow-up visits when the child was aged 1 week, 6-8 weeks and then 3, 6, 9, 15, 18, 21 and 24 months. Patterns of breastfeeding (classified as exclusive, mixed or no breastfeeding), maternal morbidity and mortality, and mortality among their children were assessed at each visit. Descriptive and multivariate analyses were performed to determine the association between breastfeeding and maternal and infant outcomes. FINDINGS: A total of 2000 women infected with HIV were enrolled in the original studies. During the 2 years after birth, 44 (2.2%) mothers and 310 (15.5%) children died. (Multiple births were excluded.) The median duration of breastfeeding was 18 months (interquartile range (IQR)=9.0-22.5), exclusive breastfeeding 2 months (IQR=2-3) and mixed feeding 12 months (IQR=6-18). Breastfeeding patterns were not significantly associated with maternal mortality or morbidity after adjusting for maternal viral load and other covariates. Breastfeeding was associated with reduced mortality among infants and children: the adjusted hazard ratio for overall breastfeeding was 0.44 (95% confidence interval (CI)=0.28-0.70), for mixed feeding 0.45 (95% CI=0.28-0.71) and for exclusive breastfeeding 0.40 (95% CI=0.22-0.72). These protective effects were seen both in infants who were infected with HIV and those who were not. CONCLUSION: Breastfeeding by women infected with HIV was not associated with mortality or morbidity; it was associated with highly significant reductions in mortality among their children

Intermittent Intravaginal Antibiotic Treatment of Bacterial Vaginosis in HIV-Uninfected and -Infected Women: A Randomized Clinical Trial

OBJECTIVE: Assess efficacy of intermittent intravaginal metronidazole gel treatment in reducing frequency of bacterial vaginosis (BV). DESIGN: Randomized, double-masked, placebo-controlled phase 3 trial. SETTING: Postnatal and family planning clinics of the Queen Elizabeth Central Hospital and two health centers in Blantyre, Malawi. PARTICIPANTS: Nonpregnant HIV-uninfected and -infected women. INTERVENTION: Intravaginal metronidazole treatment and placebo gels provided at baseline and every 3 mo for 1 y. OUTCOME MEASURES: Primary: Cross-sectional and longitudinal comparisons of BV frequency at baseline, 1 mo after product dispensation (post-treatment evaluation [PTE]), and every quarterly visit. Secondary: Effect of treatment on BV clearance and recurrence. RESULTS: Baseline: 842 HIV-uninfected and 844 HIV-infected women were enrolled. The frequency of BV at baseline in treatment and placebo arms, respectively, was 45.9% and 46.8% among HIV-uninfected women, and 60.5% and 56.9% among HIV-infected women. Primary outcomes: At the PTEs the prevalence of BV was consistently lower in treatment than placebo arms irrespective of HIV status. The differences were statistically significant mainly in HIV-uninfected women. Prevalence of BV was also reduced over time in both treatment and placebo arms. In a multivariable analysis that controlled for other covariates, the effect of intravaginal metronidazole treatment gel compared with placebo was not substantial: adjusted relative risk (RR) 0.90, 95% confidence interval (CI) 0.83–0.97 in HIV-uninfected women and adjusted RR 0.95, 95% CI 0.89–1.01 in HIV-infected women. Secondary outcomes: Intravaginal metronidazole treatment gel significantly increased BV clearance (adjusted hazard ratio [HR] 1.34, 95% CI 1.07–1.67 among HIV-uninfected women and adjusted HR 1.29, 95% CI 1.06–1.58 among HIV-infected women) but was not associated with decreased BV recurrence. Safety: No serious adverse events were related to use of intravaginal gels. CONCLUSION: Intermittent microbicide treatment with intravaginal gels is an innovative approach that can reduce the frequency of vaginal infections such as BV

HIV self-testing: breaking the barriers to uptake of testing among men and adolescents in sub-Saharan Africa, experiences from STAR demonstration projects in Malawi, Zambia and Zimbabwe.

INTRODUCTION: Social, structural and systems barriers inhibit uptake of HIV testing. HIV self-testing (HIVST) has shown promising uptake by otherwise underserved priority groups including men, young people and first-time testers. Here, we use characteristics of HIVST kit recipients to investigate delivery to these priority groups during HIVST scale-up in three African countries. METHODS: Kit distributors collected individual-level age, sex and testing history from all clients. These data were aggregated and analysed by country (Malawi, Zambia and Zimbabwe) for five distribution models: local community-based distributor (CBD: door-to-door, street and local venues), workplace distribution (WD), integration into HIV testing services (IHTS), or public health facilities (IPHF) and during demand creation for voluntary male medical circumcision (VMMC). Used kits were collected and re-read from CBD and IHTS recipients. RESULTS: Between May 2015 and July 2017, 628,705 HIVST kits were distributed in Malawi (172,830), Zambia (190,787) and Zimbabwe (265,091). Community-based models, the first to be established, accounted for 519,658 (82.7%) of kits distributed, with 275,419 (53.0%) used kits returned. Subsequent model diversification delivered 54,453 (8.7%) test-kits through IHTS, 23,561 (3.7%) through VMMC, 21,183 (3.4%) through IPHF and 9850 (1.7%) through WD. Men took 294,508 (48.2%) kits, and 263,073 (43.1%) went to young people (16 to 24 years). A higher proportion of male self-testers (65,577; 22.3%) were first-time testers than women (54,096; 17.1%) with this apparent in Zimbabwe (16.2% vs. 11.4%), Zambia (25.4% vs. 17.7%) and Malawi (27.9% vs. 25.9%). The highest proportions of first-time testers were in young (16 to 24 years) and older (>50 years) men (country-ranges: 18.7% to 35.9% and 13.8% to 26.8% respectively). Most IHTS clients opted for HIVST in preference to standard HTS in each of 12 delivery sites, with those selecting HIVST having lower HIV prevalence, potentially due to self-selection. CONCLUSIONS: HIVST delivered at scale using several different models reached a high proportion of men, young people and first-time testers in Malawi, Zambia and Zimbabwe, some of whom may not have tested otherwise. As men and young people have limited uptake under standard facility-and community-based HIV testing, innovative male- and youth-sensitive approaches like HIVST may be essential to reaching UNAIDS fast-track targets for 2020

Malawi (2010): An Assessment of Practices, Knowledge and Barriers to Point of Use Water Treatment among caregivers of under five children In Malawi.

In 2008, a household survey was conducted to identify the determinants of point of use water treatment caretakers to children under the age of five. The household survey, as a follow-up study, also monitored the evaluated key behaviors. The results indicate that many positive behaviors regarding water treatment fell. Those who used WaterGuard in the last week fell from 14% to 11% between 2005 and 2008. Among those who used WaterGuard ever, 58% used in the last 24 hours in 2008. However, only 14% of households tested positively for the chlorine residual test. While WaterGuard use did fall, 9% more households in 2008 said they treated their drinking water in the past week with other chlorine products compared to 2005. Those who always treat their drinking water fell 8% between baseline and follow-up. Over one-third of respondents said they did not use WaterGuard because it was too expensive. Meanwhile, of those who used WaterGuard 35% used the correct number of capfuls but only 13% waited the correct among of time before using their drinking water. Among the OAM determinants, perceived availability increased, as did locus of control. Perceived threat fell. . The purpose of this study is to better understand the 2008 household survey results. As the findings are generally negative since WaterGuard use declines, we seek to understand several avenues in which the environment changed and may have contributed to lower WaterGuard use. </p

Malawi (2009): HIV/AIDS TRaC Survey among Evidence-based Targeted HIV Prevention (EBT Prev) Target Populations in Malawi. Round One.

BACKGROUND & RESEARCH OBJECTIVES. More than 20 years into the HIV/AIDS epidemic, Malawi faces numerous prevention challenges similar to those in other East and Southern African nations. A high HIV prevalence of 12% points to very high incidence among most at-risk groups and, increasingly, to substantial levels of transmission in the general population. In March 2009, PSI/Malawi initiated a five-year Evidence Based Targeted HIV Prevention (EBT Prev) project designed to reduce the incidence of HIV in Malawi, by targeting prevention efforts at populations and settings with high risk behaviors. The purpose of the TRaC survey among these target populations is the identification and monitoring of key behavioral determinants in the target populations that are related to condom use and partner reduction including concurrency. DESCRIPTION OF INTERVENTION. The program will target the following high risk groups fishermen/women, plantation/estate workers and vendors. The program will deliver integrated, behavior change communications activities which includes interpersonal communications, peer education, targeted outreach communications, and mass media activities to promote condoms and partner reduction among the target groups. METHODOLOGY. Study sites were identified through the PLACE methodology, in partnership with key stakeholders, notably the Ministry of Health, HIV/AIDS Unit, and approved by USAID. The following sites were chosen: Lilongwe (Urban), Zomba rural (markets), Mwanza border, Thyolo and Mulanje (plantation area) and Mangochi district (lakeshore). Each site is presumed to be representative of local HIV/AIDS related attitudes and practices for the associated target group on a national scale. In mid-2010, PSI/Malawi conducted a cross-sectional, venue-based baseline survey designed to monitor trends in condom use and concurrent partnerships. Randomly selected vendors, plantation workers, and fisher men and women were sampled from the venues within the areas mentioned above. The participants were sexually active, aged 20-49 years, and provided consent. A total of 3,075 people were interviewed including: 1,034 vendors, 1,023 plantation workers, and 1,018 fishermen and women. Logistic regression was used to assess association between health behaviors and determinants. Socio-demographic characteristics were controlled for in the analyses

Effect of computer-assisted interviewing on self-reported sexual behavior data in a microbicide clinical trial

In a microbicide safety and effectiveness trial (HPTN 035) in Malawi, 585 women completed the same questionnaire through a face-to-face interview (FTFI) and an audio computer-assisted self-interview (ACASI). Concordance between FTFI and ACASI responses ranged from 72.0% for frequency of sex in the past week to 95.2% for anal intercourse (AI) in the past 3 months. Reported gel and condom use at last sex act were marginally lower with ACASI than FTFI (73.5% vs. 77.2%, p = 0.11 and 60.9% vs. 65.5%, p = 0.05, respectively). More women reported AI with ACASI than FTFI (5.0% vs. 0.2%, p \u3c 0.001). Analyses of consistency of responses within ACASI revealed that 15.0% of participants in the condom-only arm and 28.7% in the gel arm provided at least one discrepant answer regarding total sex acts and sex acts where condom and gel were used (19.2% reported one inconsistent answer, 8.1% reported two inconsistent answers, and 1.4% reported three inconsistent answers). While ACASI may provide more accurate assessments of sensitive behaviors in HIV prevention trials, it also results in a high level of internally inconsistent responses