Selecting HIV infection prevention interventions in the mature HIV epidemic in Malawi using the mode of transmission model

<p>Abstract</p> <p>Background</p> <p>Malawi is reassessing its HIV prevention strategy in the light of a limited reduction in the epidemic. No community based incidence studies have been carried out in Malawi, so estimates of where new infections are occurring require the use of mathematical models and knowledge of the size and sexual behaviour of different groups. The results can help to choose where HIV prevention interventions are most needed.</p> <p>Methods</p> <p>The UNAIDS Mode of Transmission model was populated with Malawi data and estimates of incident cases calculated for each exposure group. Scenarios of single and multiple interventions of varying success were used to identify those interventions most likely to reduce incident cases.</p> <p>Results</p> <p>The groups accounting for most new infections were the low-risk heterosexual group - the discordant couples (37%) and those who had casual sex and their partners (a further 16% and 27% respectively) of new cases.</p> <p>Circumcision, condoms with casual sex and bar girls and improved STI treatment had limited effect in reducing incident cases, while condom use with discordant couples, abstinence and a zero-grazing campaign had major effects. The combination of a successful strategy to eliminate multiple concurrent partners and a successful strategy to eliminate all infections between discordant couples would reduce incident cases by 99%.</p> <p>Conclusions</p> <p>A revitalised HIV prevention strategy will need to include interventions which tackle the two modes of transmission now found to be so important in Malawi - <b>concurrency and discordancy</b>.</p

Using a migration systems approach to understand the link between climate change and urbanisation in Malawi

Most scholarship on rural–urban migration in Sub-Saharan Africa demonstrates that migrants tend to move in a “circular” fashion and only spend short periods of time in cities before returning home to rural villages. However, some scholars working on the impacts of climate change on migration suggest that deteriorating environmental conditions may undermine rural livelihoods and lead people to move to cities for longer periods of time. If this is true, then climate change threatens to accelerate urbanisation and lead to renewed stress on urban infrastructure. The purpose of this paper is to explore these positions and we do so by collecting survey [n = 241], in-depth interview [n = 75] and focus group [n = 123 participants] data from rural and urban Malawi. Two key results stand out as significant. The first is that migrants in Malawi's capital city tend to stay in the urban environment for longer periods of time than conventional understandings of migration would predict. The second key result is that climate change may actually lead, in the case of Malawi, to reverse (i.e urban–rural) migration. This is because many of the people in Malawi's cities depend on products produced in rural environments (e.g. food and fuelwood). If climate change undermines rural livelihoods, then many urban residents will find the basis of their livelihoods removed and will likely respond by moving back to rural villages. Overall, our results, therefore, suggest that in at least one case the effect of climate change on migration may not be to increase migration towards cities but to stimulate an exodus from cities and back to the rural countryside