Barriers and facilitators to oral pre-exposure prophylaxis uptake among adolescents girls and young women at elevated risk of HIV acquisition in Lilongwe, Malawi: A qualitative study

Among the estimated 12,500 new HIV infections in Malawi among people aged 15-24 each year, 70 percent occur in Adolescent Girls and Young Women (AGYW). The Ministry of Health (MoH) in Malawi rolled out an oral Pre-Exposure Prophylaxis (PrEP) prevention program targeting populations at elevated risk of HIV acquisition, including AGYW, in 2021. Since PrEP roll-out, there has been limited research exploring the factors that influence uptake of PrEP among AGYW. This study explored the barriers and facilitators to the uptake of PrEP among AGYW at elevated risk of HIV acquisition. it was an exploratory qualitative study conducted at Kawale Health Center in Lilongwe, Malawi, in February 2023, which employed a phenomenological design. Data were collected using semi-structured in-depth interviews and vignettes from purposively sampled 20 AGYW and 10 health care workers (HCWs) based on their PrEP status (on PrEP versus not on PrEP) and involvement in PrEP provision, respectively. The data were digitally recorded, managed using NVivo software and analysed using a thematic approach guided by the Consolidated Framework for Implementation Research (CFIR). AGYW identified perceived HIV risk and vulnerability and PrEP knowledge as facilitators. HCWs identified AGYW perceived HIV risk, HCW altitudes, and availability of youth friendly service center and resources as facilitators to PrEP uptake. Barriers identified by AGYW included PrEP side effects, limited PrEP information, lack of privacy, stigma, and lack of transportation. HCWs identified limited resources and burden of work as barriers. In conclusion, PrEP's full potential as an HIV prevention tool for AGYW requires a holistic approach that considers their particular requirements, removes systemic hurdles, and guarantees access to high-quality services. In addition, there is a need to create demand to increase the uptake of PrEP

Influences on birth spacing intentions and desired interventions among women who have experienced a poor obstetric outcome in Lilongwe Malawi: a qualitative study

Abstract Background Stillbirth and neonatal mortality are very high in many low-income countries, including Malawi. Use of family planning to encourage birth spacing may optimize outcomes for subsequent pregnancies. However, reproductive desires and influences on birth spacing preferences of women who have experienced a stillbirth or neonatal death in low-resource settings are not well understood. Methods We conducted a qualitative study using 20 in-depth interviews and four focus group discussions with women who had experienced a stillborn baby or early neonatal death to explore attitudes surrounding birth spacing and potential interventions to promote family planning in this population. Qualitative data were analyzed for recurrent patterns and themes and central ideas were extracted to identify their core meanings. Results Forty-six women participated in the study. After experiencing a stillbirth or neonatal death, most women wanted to wait to become pregnant again but women with living children wished to wait for longer periods of time than those with no living children. Most women preferred birth spacing interventions led by clinical providers and inclusion of their spouses. Conclusions Many influences on family size and birth spacing were noted in this population, with the most significant influencing factor being the spouse. Interventions to promote birth spacing and improve maternal and neonatal health in this population need to involve male partners and knowledgeable health care providers to be effective. Trial registration Clinicaltrials.gov NCT02674542 Registered February 1, 2016 (retrospectively registered)

Family planning knowledge, experiences and reproductive desires among women who had experienced a poor obstetric outcome in Lilongwe Malawi: a qualitative study

Abstract Background Perinatal mortality is unacceptably high in low-income countries, including Malawi. Use of family planning to encourage birth spacing may optimize outcomes for subsequent pregnancies. However, the reproductive desires and family planning knowledge of women who have experienced a stillbirth or neonatal death in resource-poor settings are not well understood. Methods We examined family planning knowledge, contraceptive practices and barrier to contraceptive use among women who had experienced a poor obstetric outcome at Bwaila Hospital in Lilongwe, Malawi. We performed individual in-depth interviews or through focus group discussion with women who had experienced a stillbirth or early neonatal death, 4–8 weeks after their delivery. NVivo software was used to analyze data for recurrent patterns and themes, and central ideas were extracted to identify the data’s core meanings. Results We interviewed 46 women who had experienced a poor obstetric outcome. Overall, women were aware of both modern and traditional family planning methods, and the majority were in favour of modern versus traditional methods. They also had knowledge about risks for future complications if they have a short inter-pregnancy interval. However, they faced conflict about whether to use family planning methods for their health, as suggested by their relatives and friends, or to have another child to fulfil their husband’s desire, especially among those with no living child. Some had fear about side effects, while others were concerned that use of family planning methods without involving the husband could bring misunderstandings within the family. A number of women had misconceptions about family planning methods, which also served as a barrier to their use. Conclusion Although women with a poor obstetric outcome are aware of modern family planning and its health benefits after their delivery, their decision to use a method is complicated by their own desire to protect their own health and the husband’s desire for a child, particularly among those women with no living children coupled with fear of side effects and misconceptions. These findings suggest the importance of counselling both the affected woman and her husband about the benefits of family planning use, even after a poor obstetric outcome, to jointly choose the method they feel comfortable to use and dispel any misconceptions. Trial registration Clinicaltrials.gov NCT02674542

Female adherence self-efficacy before and after couple HIV testing and counseling within Malawi's Option B+ program

Adherence self-efficacy, belief in one’s ability to adhere to daily medication, is strongly associated with antiretroviral therapy (ART) adherence and preventing mother-to-child HIV transmission. Couple-based interventions could enhance self-efficacy and adherence. We assessed the relationship between couple HIV testing and counseling (cHTC) and adherence self-efficacy using a 100-point culturally-adapted adherence self-efficacy scale (ASES). Secondarily, we explored the relationship between ASES and ART adherence. Ninety HIV-positive pregnant women at an antenatal clinic in Lilongwe, Malawi were enrolled in an observational cohort study. They were assessed with ASES immediately before and one month after receiving cHTC. Median ASES scores were 100 (IQR 95, 100) before and 100 (IQR 99, 100) after cHTC; there was a significant median difference (p = 0.02) for participants before and after cHTC. This change in ASES scores was associated with the odds of self-reported ART adherence in the full population (OR 1.1, p = 0.01), and there was a trend in the same direction for participants with imperfect baseline ASES scores (OR 1.1, p = 0.2). In our population, adherence self-efficacy and ART adherence were both quite high, and those who had room to improve in self-efficacy may have benefited from cHTC, which in turn could impact ART adherence and ultimately mother-to-child transmission

Individual, Partner, and Couple Predictors of HIV Infection among Pregnant Women in Malawi: A Case-Control Study

We aimed to understand drivers of HIV-infection in pregnant women in Malawi. The study was conducted in antenatal and labor and delivery wards. HIV-infected women and their partners (cases) were frequency matched in a 1:2 ratio based on age and screening location to HIV-uninfected women and their partners (controls) in a prevalent case–control study. Characteristics associated with female HIV infection were assessed using logistic regression modeling. At screening, HIV-infected women were more likely to have partners outside Lilongwe than HIV-uninfected women (24% vs. 0%, p < 0.0001). Case females were more likely to have HIV-infected study partners than control females (75% vs. 4%, p < 0.0001). The odds of female HIV-infection were higher if either couple member reported ≥ 2 lifetime marriages (OR 9.0, CI 2.6–30.9) or ≥ 3 lifetime partners (OR 18.0, CI 3.1–103.6) and lower if either reported past couple HIV testing and counseling (OR 0.1, CI 0.04–0.3). Targeting women with migrating partners, promoting couple HIV testing and counseling, and limiting partners could slow HIV transmission

Tonse Pamodzi: Developing a combination strategy to support adherence to antiretroviral therapy and HIV pre-exposure prophylaxis during pregnancy and breastfeeding

To eliminate mother-to-child transmission of HIV (EMTCT), scalable strategies to enhance antiretroviral adherence for both antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) are needed as part of integrated HIV and maternal-child health services. We developed Tonse Pamodzi ("all of us together"), an adaptable intervention integrating biomedical and behavioral components to support HIV treatment and prevention. We describe our intervention development process, which comprised formative qualitative research, a review of the literature, and technical input from stakeholders representing the community, health systems, and policymakers. The resulting intervention, described herein, integrates patient-centered counseling and engagement of a patient-selected adherence supporter for pregnant and breastfeeding women initiating ART or PrEP. Patients receiving the intervention engage in Integrated Next Step Counseling (iNSC) sessions delivered by trained counselors to build and maintain adherence skills. Each patient also has the option of selecting an adherence supporter (partner, family member, or friend) who may participate in iNSC sessions and provide adherence support outside of these sessions. This flexible intervention is adaptable not only to ART or PrEP use, but also to the needs and preferences of each woman and the clinical context. If shown to be acceptable and feasible, the Tonse Pamodzi intervention may be an important tool in continuing efforts for EMTCT

Preferences for oral and injectable PrEP among qualitative sub-study participants in HPTN 084

Background HPTN 084 compared the safety and efficacy of long-acting injectable cabotegravir (CAB) to daily oral TDF/FTC for prevention of HIV-1 in uninfected African women. Like a similar trial in MSM/TGW (HPTN 083), the trial was stopped early for efficacy, expediting the need to consider introduction strategies for different populations. We examine survey and qualitative data from a four-country sub-study to examine oral and injectable PrEP acceptability and considerations for CAB access among African women. Methods Participants completed baseline and follow-up surveys on HIV risk perception, sexual behavior. product acceptability and adherence during the blinded trial. Additionally, up to two in-depth interviews each with 73 sub-study participants explored product use and trial-related experiences, during the blinded and unblinded study periods. Using survey data, we classified participants as: engaged in female sex work (FSW), having multiple non-transactional partners, or monogamous. A study statistician identified participants’ assigned study arm. We followed a thematic analysis process to read transcripts, develop a codebook and apply codes in NVivo to transcripts with intermittent intercoder reliability checks; using Excel matrices to explore differences across risk categories and study arms. Findings Participants overwhelmingly preferred injections to pills, appreciating the ease, convenience, and privacy of a long-acting formulation. Many participants described challenges with contraceptive and/or study pill adherence, impeded by late night work, unexpected travel, or heavy drinking. Women in the TDF/FTC arm were more likely to describe side effects, compared to those in the CAB arm. Pain also varied widely by study arm. When considering post-trial access to CAB, limited PrEP knowledge, cost and concerns around stigma and poor service quality were potential access barriers. Conclusion Women’s desire for privacy and ease of use outweighed injectable concerns, resulting in a strong preference for CAB. Cost and accessibility will need to be addressed by implementation programs

A Phase 3 Trial of RTS,S/AS01 Malaria Vaccine in African Infants

Background The candidate malaria vaccine RTS,S/AS01 reduced episodes of both clinical and severe malaria in children 5 to 17 months of age by approximately 50% in an ongoing phase 3 trial. We studied infants 6 to 12 weeks of age recruited for the same trial. Methods We administered RTS,S/AS01 or a comparator vaccine to 6537 infants who were 6 to 12 weeks of age at the time of the first vaccination in conjunction with Expanded Program on Immunization (EPI) vaccines in a three-dose monthly schedule. Vaccine efficacy against the first or only episode of clinical malaria during the 12 months after vaccination, a coprimary end point, was analyzed with the use of Cox regression. Vaccine efficacy against all malaria episodes, vaccine efficacy against severe malaria, safety, and immunogenicity were also assessed. Results The incidence of the first or only episode of clinical malaria in the intention-to-treat population during the 14 months after the first dose of vaccine was 0.31 per person-year in the RTS,S/AS01 group and 0.40 per person-year in the control group, for a vaccine efficacy of 30.1% (95% confidence interval [CI], 23.6 to 36.1). Vaccine efficacy in the per-protocol population was 31.3% (97.5% CI, 23.6 to 38.3). Vaccine efficacy against severe malaria was 26.0% (95% CI, -7.4 to 48.6) in the intention-to-treat population and 36.6% (95% CI, 4.6 to 57.7) in the per-protocol population. Serious adverse events occurred with a similar frequency in the two study groups. One month after administration of the third dose of RTS,S/AS01, 99.7% of children were positive for anti-circumsporozoite antibodies, with a geometric mean titer of 209 EU per milliliter (95% CI, 197 to 222). Conclusions The RTS,S/AS01 vaccine coadministered with EPI vaccines provided modest protection against both clinical and severe malaria in young infants. (Funded by GlaxoSmithKline Biologicals and the PATH Malaria Vaccine Initiative; RTS,S ClinicalTrials.gov number, NCT00866619 .

Perceived health-related quality of life among patients living with cancer at Kamuzu Central Hospital in Malawi

Abstract Patients living with cancer and their families experience several challenges that affect their health-related quality of life (HRQOL). Perceived factors affecting quality of life (QOL) among people living with cancer have rarely been studied. We aimed at exploring the factors perceived to be associated with health-related quality of life among people living with cancer attending to a National Cancer Centre at Kamuzu Central Hospital in Malawi. Between May and June 2022, we conducted a qualitative study to assess perceptions and the in-depth lived experiences for people living with cancer, caregivers and healthcare workers at the cancer center on health-related quality of life. We purposively selected and interviewed thirteen participants. Interviews were transcribed, coded using NVivo 12 and analyzed using thematic analysis. Two broad categories of emerging themes of quality of life were identified. These included: (a) individual level factors such as experiences with diagnosis and treatment, changes on physical, psychological and social health, support received, benefits and challenges, (b) facility level factors such as availability of resources, relationship with providers, satisfaction with cancer care, facility organization, facilitators and barriers to improved quality of life. This study has highlighted the importance of physical, psychological, and social factors as key determinants perceived to be affecting health-related quality of life among patients living with cancer and their caregivers at the National Cancer Centre, Kamuzu Central Hospital in Malawi. The QOL challenges experienced by patients and their caregivers, implied that cancer care interventions should consider a holistic approach to cover for all dimensions of life in order to improve health-related quality of life among patients living with cancer.</jats:p

Family planning knowledge, experiences and reproductive desires among women who had experienced a poor obstetric outcome in Lilongwe Malawi: a qualitative study

Abstract Background Perinatal mortality is unacceptably high in low-income countries, including Malawi. Use of family planning to encourage birth spacing may optimize outcomes for subsequent pregnancies. However, the reproductive desires and family planning knowledge of women who have experienced a stillbirth or neonatal death in resource-poor settings are not well understood. Methods We examined family planning knowledge, contraceptive practices and barrier to contraceptive use among women who had experienced a poor obstetric outcome at Bwaila Hospital in Lilongwe, Malawi. We performed individual in-depth interviews or through focus group discussion with women who had experienced a stillbirth or early neonatal death, 4–8 weeks after their delivery. NVivo software was used to analyze data for recurrent patterns and themes, and central ideas were extracted to identify the data’s core meanings. Results We interviewed 46 women who had experienced a poor obstetric outcome. Overall, women were aware of both modern and traditional family planning methods, and the majority were in favour of modern versus traditional methods. They also had knowledge about risks for future complications if they have a short inter-pregnancy interval. However, they faced conflict about whether to use family planning methods for their health, as suggested by their relatives and friends, or to have another child to fulfil their husband’s desire, especially among those with no living child. Some had fear about side effects, while others were concerned that use of family planning methods without involving the husband could bring misunderstandings within the family. A number of women had misconceptions about family planning methods, which also served as a barrier to their use. Conclusion Although women with a poor obstetric outcome are aware of modern family planning and its health benefits after their delivery, their decision to use a method is complicated by their own desire to protect their own health and the husband’s desire for a child, particularly among those women with no living children coupled with fear of side effects and misconceptions. These findings suggest the importance of counselling both the affected woman and her husband about the benefits of family planning use, even after a poor obstetric outcome, to jointly choose the method they feel comfortable to use and dispel any misconceptions. Trial registration Clinicaltrials.gov NCT02674542