From the capital maintenance rule to the solvency test: some thoughts on the new approach to creditor protection in Malawian company law

In July, 2013 Malawi enacted a new Companies Act [Act No. 15 of 2013] replacing the old Companies Act 19 of 1984. The Companies Act, 1984 was basically an adoption of the English Companies Act, 1948 and in line with the English law, it regulated distributions through the classical capital maintenance rule. In contrast, the new Companies Act, 2013 which came into force in May, 2016 has jettisoned the capital maintenance rule. As an alternative to that rule, the Act has introduced for the first time in Malawian company law edifice, the concept of the solvency test. Jurisdictions that have adopted the solvency test in their company law essentially have done so on the basis that company law should focus on the core risk at stake – company insolvency, and that it is meaningless to state that creditors look to the company's capital as a trust fund out which their debts would be settled. Despite having the same theoretical basis for adopting the solvency test, the manner in which the solvency test is defined and applied in a particular statute has significant effects on whether in its operation, the test affords adequate protection to the interests of creditors. This research examines the definition and application of the solvency test under the Companies Act, 2013 so as to determine whether in its operation as a financial restriction for distributions and other company transactions, it will afford adequate protection to creditors. It follows the approach used by Professor Kathleen Van der Linde in her analysis of the solvency and liquidity approach in the Companies Act, 2008. Thus, it analyses the Malawian law by focusing on the two separate elements of the test (equity solvency and balance sheet solvency) as well as other aspects of the test which are likely to raise legal interpretation issues. The twin solvency test adopted in different jurisdictions ordinarily varies in its balance sheet solvency element. Some jurisdictions such as South Africa and New Zealand utilise the net assets approach in their balance sheet test. Others such as New York and Delaware still emphasise on the trust fund doctrine and thus utilise stated capital in their balance sheet test. Malawi is a stated capital/surplus jurisdiction. Its new solvency based regime still focuses on the meaningless trust fund doctrine. The new solvency test approach in Malawi is incomplete and inadequate to fully protect creditors against opportunistic shareholder behaviour. A number of recommendations are made for an effective solvency test approach that will afford adequate protection to creditors against opportunistic shareholder behaviour

Evaluation of the quality of counselling for prevention of mother to child transmission of HIV offered to pregnant women in the copperbelt province of Zambia

Magister Public Health - MPHBackground: One study on estimating rates of mother to child transmission of HIV (MTCT) in program settings in Zambia showed significant reduction in the MTCT rate with some specific prevention of mother to child transmission of HIV (PMTCT) interventions. Prolonged breastfeeding and mixed feeding practices by HIV positive mothers increased the MTCT rate by more than double by the time the infant reached 6 to12 months of age. Although the study did not assess the quality of PMTCT counselling in antenatal care settings, literature shows that poor quality of counselling on PMTCT reduces the effectiveness of PMTCT interventions. Study aim: To evaluate the quality of PMTCT counselling offered to pregnant women attending antenatal care (ANC) services in four public health facilities in Kitwe, Copperbelt province of Zambia. Study design and data collection: This was a cross sectional descriptive study. Data was generated using qualitative research methods including document analysis and individual interviews with 22 participants using non-participant observations, client exit interviews and focus group discussions (FGDs) to collect data. The study participants were ANC attendees and PMTCT providers. Two FGDs were conducted with a total of 98 counselling observations done and 16 ANC client exit interviews. Client exit interviews were done immediately after the mothers had undergone PMTCT counselling. Results: Content for group health education (GHE) varied across the facilities. Individual pre-test, post-test and follow up counselling sessions were very short and lacked depth. A total of 41 (83.7%) pre-test observations took between 1 and 5 minutes to be conducted. In addition, several key topics including major modes of HIV transmission, MTCT and the "window period" were omitted. The counsellors' interpersonal skills were generally good but they did not consistently summarize the main issues. The 16 mothers interviewed had limited knowledge of PMTCT with only one client knowing all the MTCT modes correctly. Discussion: Quality of PMTCT counselling did not meet expectations. With a lot of key topics omitted, outcomes of PMTCT interventions may not be as good as expected. Facilities are faced with serious staff shortages and limitations with space. The few members of staff available are overworked and are not able to provide quality PMTCT counselling. Conclusion: While the PMTCT uptake was good and clients felt satisfied, the quality of PMTCT counselling is compromised. There is need to improve it and ensure optimal effectiveness of PMTCT services

Factors affecting the utilisation of electronic medical records system in Malawian central hospitals

Background In Malawi, paper-based medical record-keeping has been observed to exacerbate challenges related to accessing patient records and patient tracking. Despite the introduction of electronic medical record (EMR) systems in 2001, paper-based records continue to be in use. Some health workers prefer paper-based records to EMRs. This study assessed factors that affect the use of EMRs in Malawi, particularly at Queen Elizabeth and Kamuzu Central Hospitals. It further investigated the reasons why paper-based records are still in use despite the numerous associated disadvantages. The extent to which EMRs contribute to patient care was also analysed.Methods In this cross-sectional study, 111 randomly selected health workers were interviewed, using a semistructured questionnaire, at the 2 largest central hospitals in Malawi, where EMRs were first introduced in the country. Focus group discussions were conducted to gather further information on factors identified during the individual interviews.Results and conclusions Differences in age, gender, and previous computer experience were not associated with differences in EMR usage. However, education and employment levels has a positive association with EMR usage. Hardware and connectivity problems, as well as lack of training and managerial support negatively affected the use of EMRs. EMRs were found to improve data quality and efficiency in patient management

Dosage of Sulfadoxine–Pyrimethamine and Risk of Low Birth Weight in a Cohort of Zambian Pregnant Women in a Low Malaria Prevalence Region

In Lusaka, Zambia, where malaria prevalence is low, national guidelines continue to recommend that all pregnant women receive sulfadoxine–pyrimethamine (SP) for malaria prophylaxis monthly at every scheduled antenatal care visit after 16 weeks of gestation. Human immunodeficiency virus (HIV)–positive women should receive co-trimoxazole prophylaxis for HIV and not SP, but many still receive SP. We sought to determine whether increased dosage of SP is still associated with a reduced risk of low birth weight (LBW) in an area where malaria transmission is low. Our secondary objective was to determine whether any association between SP and LBW is modified by receipt of antiretroviral therapy (ART). We analyzed data routinely collected from a cohort of HIV-positive pregnant women with singleton births in Lusaka, Zambia, between February 2006 and December 2012. We used a log-Poisson model to estimate the risk of LBW by dosage of SP and to determine whether the association between SP and LBW varied by receipt of ART. Risk of LBW declined as the number of doses increased and appeared lowest among women who received three doses (adjusted risk ratio [ARR] = 0.78; 95% confidence interval [CI] = 0.64–0.95). In addition, women receiving combination ART had a higher risk of delivering an LBW infant compared with women receiving no treatment or prophylaxis (ARR = 1.18; 95% CI = 1.09–1.28), but this risk was attenuated among women who were receiving SP (risk ratio = 1.09; 95% CI = 0.99–1.21). SP was associated with a reduced risk of LBW in HIV-positive women, including those receiving ART, in a low malaria prevalence region

Two strategies for partner notification and partner HIV self-testing reveal no evident predictors of male partner HIV testing in antenatal settings: A secondary analysis

BackgroundTo meet global targets for the elimination of mother-to-child HIV transmission, tailored approaches to HIV testing strategies need prioritizing. Herein, we sought to identify individual-level factors associated with male partner HIV testing.MethodsWe conducted a secondary analysis of data from two parallel randomized trials of pregnant women living with HIV and those HIV-negative in Lusaka, Zambia. Across both trials, control groups received partner notification services only, while intervention groups received partner notification services plus HIV self-test kits for their partners. Associations between baseline factors and male partner testing were estimated using a probability difference. The outcome of interest was uptake of male partner HIV testing of any kind within 30 days of randomization.ResultsThe parent study enrolled 326 participants. Among the 151 women in the control groups, no clear associations were noted between maternal or male partner characteristics and reported uptake of male partner HIV testing. There were positive trends favouring partner testing among women who completed primary school education, had larger households (>2 members), and whose partners were circumcised. Likewise, no clear predictors of male partner testing were identified among the 149 women in the intervention groups. However, negative trends favouring no testing were noted among older, multiparous women from larger households.ConclusionNo consistent predictors for male partner HIV testing across two compared strategies were observed. Our findings suggest that differentiated strategies for male partner HIV testing may not be necessary. Instead, consideration should be given to universal approaches when bringing such services to scale

Sexual Risk Behaviors for HIV/AIDS in Chuuk State, Micronesia: The Case for HIV Prevention in Vulnerable Remote Populations

BACKGROUND: After the first two cases of locally-acquired HIV infection were recognized in Chuuk State, Federated States of Micronesia (FSM), a public health response was initiated. The purpose of the response was to assess the need for HIV education and prevention services, to develop recommendations for controlling further spread of HIV in Chuuk, and to initiate some of the prevention measures. METHODOLOGY/PRINCIPAL FINDINGS: A public health team conducted a survey and rapid HIV testing among a sample of residents on the outer islands in Chuuk. Local public health officials conducted contact tracing and testing of sex partners of the two locally-acquired cases of HIV infection. A total of 333 persons completed the survey. The majority knew that HIV is transmitted through unprotected sexual contact (81%), injection drug use (61%), or blood transfusion (64%). Sexual activity in the past 12 months was reported among 159 participants, including 90 females and 69 males. Compared to women, men were more likely to have had multiple sex partners, to have been drunk during sex, but less likely to have used a condom in the past 12 months. The two men with locally acquired HIV infection had unprotected anal sex with a third Chuukese man who likely contracted HIV while outside of Chuuk. All 370 persons who received voluntary, confidential HIV counseling and testing had HIV negative test results. CONCLUSIONS/SIGNIFICANCE: Despite the low HIV seroprevalence, risky sexual behaviors in this small isolated population raise concerns about the potential for rapid spread of HIV. The lack of knowledge about risks, along with stigmatizing attitudes towards persons infected with HIV and high risk sexual behaviors indicate the need for resources to be directed toward HIV prevention in Chuuk and on other Pacific Islands

Six-Month Mortality among HIV-Infected Adults Presenting for Antiretroviral Therapy with Unexplained Weight Loss, Chronic Fever or Chronic Diarrhea in Malawi.

In sub-Saharan Africa, early mortality is high following initiation of antiretroviral therapy (ART). We investigated 6-month outcomes and factors associated with mortality in HIV-infected adults being assessed for ART initiation and presenting with weight loss, chronic fever or diarrhea, and with negative TB sputum microscopy

Predictive value of C-reactive protein for tuberculosis, bloodstream infection or death among HIV-infected individuals with chronic, non-specific symptoms and negative sputum smear microscopy.

BACKGROUND: C-reactive protein (CRP) is an inflammatory biomarker that may identify patients at risk of infections or death. Mortality among HIV-infected persons commencing antiretroviral therapy (ART) is often attributed to tuberculosis (TB) or bloodstream infections (BSI). METHODS: In two district hospitals in southern Malawi, we recruited HIV-infected adults with one or more unexplained symptoms present for at least one month (weight loss, fever or diarrhoea) and negative expectorated sputum microscopy for TB. CRP determination for 452 of 469 (96%) participants at study enrolment was analysed for associations with TB, BSI or death to 120 days post-enrolment. RESULTS: Baseline CRP was significantly elevated among patients with confirmed or probable TB (52), BSI (50) or death (60) compared to those with no identified infection who survived at least 120 days (269). A CRP value of >10 mg/L was associated with confirmed or probable TB (adjusted odds ratio 5.7; 95% CI 2.6, 14.3; 87% sensitivity) or death by 30 days (adjusted odds ratio 9.2; 95% CI 2.2, 55.1; 88% sensitivity). CRP was independently associated with TB, BSI or death, but the prediction of these endpoints was enhanced by including haemoglobin (all outcomes), CD4 count (BSI, death) and whether ART was started (death) in logistic regression models. CONCLUSION: High CRP at the time of ART initiation is associated with TB, BSI and early mortality and so has potential utility for stratifying patients for intensified clinical and laboratory investigation and follow-up. They may also be considered for empirical treatment of opportunistic infections including TB

Micronutrient fortification to improve growth and health of maternally HIV-unexposed and exposed Zambian infants: a randomised controlled trial

Background: The period of complementary feeding, starting around 6 months of age, is a time of high risk for growth faltering and morbidity. Low micronutrient density of locally available foods is a common problem in low income countries. Children of HIV-infected women are especially vulnerable. Although antiretroviral prophylaxis can reduce breast milk HIV transmission in early infancy, there are no clear feeding guidelines for after 6 months. There is a need for acceptable, feasible, affordable, sustainable and safe (AFASS by WHO terminology) foods for both HIV-exposed and unexposed children after 6 months of age. Methods and Findings: We conducted in Lusaka, Zambia, a randomised double-blind trial of two locally made infant foods: porridges made of flour composed of maize, beans, bambaranuts and groundnuts. One flour contained a basal and the other a rich level of micronutrient fortification. Infants (n = 743) aged 6 months were randomised to receive either regime for 12 months. The primary outcome was stunting (length-for-age Z < -2) at age 18 months. No significant differences were seen between trial arms overall in proportion stunted at 18 months (adjusted odds ratio 0.87; 95% CI 0.50, 1.53; P = 0.63), mean length-for-age Z score, or rate of hospital referral or death. Among children of HIV-infected mothers who breastfed <6 months (53% of HIV-infected mothers), the richly-fortified porridge increased length-for-age and reduced stunting (adjusted odds ratio 0.17; 95% CI 0.04, 0.84; P = 0.03). Rich fortification improved iron status at 18 months as measured by hemoglobin, ferritin and serum transferrin receptors. Conclusions: In the whole study population, the rich micronutrient fortification did not reduce stunting or hospital referral but did improve iron status and reduce anemia. Importantly, in the infants of HIV-infected mothers who stopped breastfeeding before 6 months, the rich fortification improved linear growth. Provision of such fortified foods may benefit health of these high risk infants

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London