"I do all I can but I still fail them": Health system barriers to providing Option B+ to pregnant and lactating women in Malawi.

Malawi's Option B+ program is based on a 'test and treat' strategy that places all HIV-positive pregnant and lactating women on lifelong antiretroviral therapy. The steep increase in patient load placed severe pressure on a health system that has struggled for decades with inadequate supply of health care workers (HCWs) and poor infrastructure. We set out to explore health system barriers to Option B+ by asking HCWs in Malawi about their experiences treating pregnant and lactating women. We observed and conducted semi-structured interviews (SSIs) with 34 HCWs including nine expert clients (ECs) at 14 health facilities across Malawi, then coded and analyzed the data. We found that HCWs implementing Option B+ are so overburdened in Malawi that it reduces their ability to provide quality care to patients, who receive less counseling than they should, wait longer than is reasonable, and have very little privacy. Interventions that increase the number of HCWs and upgrade infrastructure to protect the privacy of HIV-infected pregnant and lactating women and their husbands could increase retention, but facilities will need to be improved to support men who accompany their partners on clinic visits

Clinical and programmatic outcomes of HIV-exposed infants enrolled in care at geographically diverse clinics, 1997-2021: A cohort study

Background Although 1.3 million women with HIV give birth annually, care and outcomes for HIVexposed infants remain incompletely understood. We analyzed programmatic and health indicators in a large, multidecade global dataset of linked mother-infant records from clinics and programs associated with the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. Methods and findings HIV-exposed infants were eligible for this retrospective cohort analysis if enrolled at <18 months at 198 clinics in 10 countries across 5 IeDEA regions: East Africa (EA), Central Africa (CA), West Africa (WA), Southern Africa (SA), and the Caribbean, Central, and South America network (CCASAnet). We estimated cumulative incidences of DNA PCR testing, loss to follow-up (LTFU), HIV diagnosis, and death through 24 months of age using proportional subdistribution hazard models accounting for competing risks. Competing risks were transfer, care withdrawal, and confirmation of negative HIV status, along with LTFU and death, when not the outcome of interest. In CA and EA, we quantified associations between maternal/infant characteristics and each outcome. A total of 82,067 infants (47,300 EA, 10,699 CA, 6,503 WA, 15,770 SA, 1,795 CCASAnet) born from 1997 to 2021 were included. Maternal antiretroviral therapy (ART) use during pregnancy ranged from 65.6% (CCASAnet) to 89.5% (EA), with improvements in all regions over time. Twenty-four-month cumulative incidences varied widely across regions, ranging from 12.3% (95% confidence limit [CL], 11.2%,13.5%) in WA to 94.8% (95% CL, 94.6%,95.1%) in EA for DNA PCR testing; 56.2% (95% CL, 55.2%,57.1%) in EA to 98.5% (95% CL, 98.3%,98.7%) in WA for LTFU; 1.9% (95% CL, 1.6%,2.3%) in WA to 10.3% (95% CL, 9.7%,10.9%) in EA for HIV diagnosis; and 0.5% (95% CL, 0.2%,1.0%) in CCASAnet to 4.7% (95% CL, 4.4%,5.0%) in EA for death. Although infant retention did not improve, HIV diagnosis and death decreased over time, and in EA, the cumulative incidence of HIV diagnosis decreased substantially, declining to 2.9% (95% CL, 1.5%,5.4%) in 2020. Maternal ART was associated with decreased infant mortality (subdistribution hazard ratio [sdHR], 0.65; 95% CL, 0.47,0.91 in EA, and sdHR, 0.51; 95% CL, 0.36,0.74 in CA) and HIV diagnosis (sdHR, 0.40; 95% CL, 0.31,0.50 in EA, and sdHR, 0.41; 95% CL, 0.31,0.54 in CA). Study limitations include potential misclassification of outcomes in real-world service delivery data and possible nonrepresentativeness of IeDEA sites and the population of HIV-exposed infants they serve. Conclusions While there was marked regional and temporal heterogeneity in clinical and programmatic outcomes, infant LTFU was high across all regions and time periods. Further efforts are needed to keep HIV-exposed infants in care to receive essential services to reduce HIV infection and mortality

"I do all I can but I still fail them": Health system barriers to providing Option B+ to pregnant and lactating women in Malawi

Malawi's Option B+ program is based on a 'test and treat' strategy that places all HIV-positive pregnant and lactating women on lifelong antiretroviral therapy. The steep increase in patient load placed severe pressure on a health system that has struggled for decades with inadequate supply of health care workers (HCWs) and poor infrastructure. We set out to explore health system barriers to Option B+ by asking HCWs in Malawi about their experiences treating pregnant and lactating women. We observed and conducted semi-structured interviews (SSIs) with 34 HCWs including nine expert clients (ECs) at 14 health facilities across Malawi, then coded and analyzed the data. We found that HCWs implementing Option B+ are so overburdened in Malawi that it reduces their ability to provide quality care to patients, who receive less counseling than they should, wait longer than is reasonable, and have very little privacy. Interventions that increase the number of HCWs and upgrade infrastructure to protect the privacy of HIV-infected pregnant and lactating women and their husbands could increase retention, but facilities will need to be improved to support men who accompany their partners on clinic visits

A Cross-Sectional Study of Household Biomass Fuel Use among a Periurban Population in Malawi

Rationale: The Global Burden of Disease Study suggests almost 3.5 million people die as a consequence of household air pollution every year. Respiratory diseases including chronic obstructive pulmonary disease and pneumonia in children are strongly associated with exposure to household air pollution. Smoke from burning biomass fuels for cooking, heating, and lighting is the main contributor to high household air pollution levels in low-income countries like Malawi. A greater understanding of biomass fuel use in Malawi should enable us to address household air pollution–associated communicable and noncommunicable diseases more effectively. Objectives: To conduct a cross-sectional analysis of biomass fuel use and population demographics among adults in Blantyre, Malawi. Methods: We used global positioning system–enabled personal digital assistants to collect data on location, age, sex, marital status, education, occupation, and fuel use. We describe these data and explore associations between demographics and reported fuel type. Measurements and Main Results: A total of 16,079 adults participated (nine households refused); median age was 30 years, there was a similar distribution of men and women, 60% were married, and 62% received secondary school education. The most commonly reported occupation for men and women was “salaried employment” (40.7%) and “petty trader and marketing” (23.5%), respectively. Charcoal (81.5% of households), wood (36.5%), and electricity (29.1%) were the main fuels used at home. Only 3.9% of households used electricity exclusively. Lower educational and occupational attainment was associated with greater use of wood. Conclusions: This large cross-sectional study has identified extensive use of biomass fuels in a typical sub-Saharan Africa periurban population in which women and people of lower socioeconomic status are disproportionately affected. Biomass fuel use is likely to be a major driver of existing communicable respiratory disease and the emerging noncommunicable disease (especially respiratory and cardiovascular) epidemic in this region. Our data will help inform the rationale for specific intervention studies and the development of appropriately targeted public health strategies to tackle this important and poverty-related global health problem

Long-term retention on antiretroviral therapy among infants, children, adolescents and adults in Malawi: A cohort study.

OBJECTIVES We examine long-term retention of adults, adolescents and children on antiretroviral therapy under different HIV treatment guidelines in Malawi. DESIGN Prospective cohort study. SETTING AND PARTICIPANTS Adults and children starting ART between 2005 and 2015 in 21 health facilities in southern Malawi. METHODS We used survival analysis to assess retention at clinic level, Cox regression to examine risk factors for loss to follow up, and competing risk analysis to assess long-term outcomes of people on antiretroviral therapy (ART). RESULTS We included 132,274 individuals in our analysis, totalling 270,256 person years of follow up (PYFU; median per patient 1.3, interquartile range (IQR) 0.26-3.1), 62% were female and the median age was 32 years. Retention on ART was lower in the first year on ART compared to subsequent years for all guideline periods and age groups. Infants (0-3 years), adolescents and young adults (15-24 years) were at highest risk of LTFU. Comparing the different calendar periods of ART initiation we found that retention improved initially, but remained stable thereafter. CONCLUSION Even though the number of patients and the burden on health care system increased substantially during the study period of rapid ART expansion, retention on ART improved in the early years of ART provision, but gains in retention were not maintained over 5 years on ART. Reducing high attrition in the first year of ART should remain a priority for ART programs, and so should addressing poor retention among adolescents, young adults and men

Goal directed therapy for suspected acute bacterial meningitis in adults and adolescents in sub-Saharan Africa

Background Mortality from acute bacterial meningitis (ABM) in sub-Saharan African adults and adolescents exceeds 50%. We tested if Goal Directed Therapy (GDT) was feasible for adults and adolescents with clinically suspected ABM in Malawi. Materials and methods Sequential patient cohorts of adults and adolescents with clinically suspected ABM were recruited in the emergency department of a teaching hospital in Malawi using a before/after design. Routine care was monitored in year one (P1). In year two (P2), nurses delivered protocolised GDT (rapid antibiotics, airway support, oxygenation, seizure control and fluid resuscitation) to a second cohort. The primary endpoint was composite mean number of clinical goals attained. Secondary endpoints were individual goals attained and death or disability from proven or probable ABM at day 40. Results 563 patients with suspected ABM were enrolled in the study; 273 were monitored in P1; 290 patients with suspected ABM received GDT in P2. 61% were male, median age 33 years and 90% were HIV co-infected. ABM was proven or probable in 132 (23%) patients. GDT attained more clinical goals compared to routine care: composite mean number of goals in P1 was 0·55 vs. 1·57 in P2 GDT (p<0·001); Death or disability by day 40 from proven or probable ABM occurred in 29/57 (51%) in P1 and 38/60 (63%) in P2 (p = 0·19). Conclusion Nurse-led GDT in a resource-constrained setting was associated with improved delivery of protocolised care. Outcome was unaffected. Trial registration www.isrctn.com ISRCTN9621819

Facilitators and barriers to ART adherence and retention mentioned in focus group discussions (FGDs).

<p>Facilitators and barriers to ART adherence and retention mentioned in focus group discussions (FGDs).</p

"I found that I was well and strong": Women’s motivations for remaining on ART under Option B+ in Malawi

<div><p>Most Malawian women who start ART under Option B+ are still in care three years later, a higher than average adherence rate for life-threatening chronic disease treatments, worldwide (50%). We asked 75 Malawian on ART their motivations for remaining in treatment, and what barriers they overcame. Focus groups and interviews included 75 women on ART for 6+ months, at 12 health facilities. Four main motivations for continuing ART emerged: 1) evidence that ART improved their own and their children’s health; 2) strong desire to be healthy and keep their children healthy; 3) treatment was socially supported; 4) HIV/ART counselling effectively showed benefits of ART and told women what to expect. Women surmounted the following barriers: 1) stigma; 2) health care system; 3) economic; 4) side effects. Women stayed on ART because they believed it works. Future interventions should focus on emphasizing ART’s effectiveness, along with other services they provide.</p></div

Characteristics of women on Option B+ who participated in focus group discussions and semi-structure interviews.

<p>Characteristics of women on Option B+ who participated in focus group discussions and semi-structure interviews.</p

Facilitators and barriers to ART adherence and retention mentioned in semi-structured interviews (SSIs) and focus group discussions.

<p>Facilitators and barriers to ART adherence and retention mentioned in semi-structured interviews (SSIs) and focus group discussions.</p