Provider-led community antiretroviral therapy distribution in Malawi: Retrospective cohort study of retention, viral load suppression and costs.

BACKGROUND: Outcomes of community antiretroviral therapy (ART) distribution (CAD), in which provider-led ART teams deliver integrated HIV services at health posts in communities, have been mixed in sub-Saharan African countries. CAD outcomes and costs relative to facility-based care have not been reported from Malawi. METHODS: We performed a retrospective cohort study in two Malawian districts (Lilongwe and Chikwawa districts), comparing CAD with facility-based ART care. We selected an equal number of clients in CAD and facility-based care who were aged >13 years, had an undetectable viral load (VL) result in the last year and were stable on first-line ART for ≥1 year. We compared retention in care (alive and no period of ≥60 days without ART) using Kaplan-Meier survival analysis and Cox regression and maintenance of VL suppression (<1,000 copies/mL) during follow-up using logistic regression. We also compared costs (in US$) from the health system and client perspectives for the two models of care. Data were collected in October and November 2020. RESULTS: 700 ART clients (350 CAD, 350 facility-based) were included. The median age was 43 years (IQR 36-51), median duration on ART was 7 years (IQR 4-9), and 75$118/year vs. $108/year per person accessing care; and$133/year vs. $122/year per person retained in care. CAD decreased individual client costs compared to facility-based care:$3.20/year vs. $11.40/year per person accessing care; and$3.60/year vs. $12.90/year per person retained in care. CONCLUSION: Clients in provider-led CAD care in Malawi had very good retention in care and VL suppression outcomes, similar to clients receiving facility-based care. While health system costs were somewhat higher with CAD, costs for clients were reduced substantially. More research is needed to understand the impact of other differentiated service delivery models on costs for the health system and clients

“I would love if there was a young woman to encourage us, to ease our anxiety which we would have if we were alone”: Adapting the mothers2mothers mentor mother model for adolescent mothers living with HIV in Malawi

Pregnant and post-partum adolescent girls and young women (AGYW) living with HIV in sub-Saharan Africa experience inferior outcomes along the prevention of mother-to-child transmission of HIV (PMTCT) cascade compared to their adult counterparts. Yet, despite this inequality in outcomes, scarce data from the region describe AGYW perspectives to inform adolescent-sensitive PMTCT programming. In this paper, we report findings from formative implementation research examining barriers to, and facilitators of, PMTCT care for HIV-infected AGYW in Malawi, and explore strategies for adapting the mothers2mothers (m2m) Mentor Mother Model to better meet AGYW service delivery-related needs and preferences

High-risk human papillomavirus in HIV-infected women undergoing cervical cancer screening in Lilongwe, Malawi: a pilot study

Rates of abnormal visual inspection with acetic acid and prevalence of high-risk human papillomavirus (HPV) subtypes have not been well characterized in HIV-infected women in Malawi. We performed a prospective cohort study of visual inspection with acetic acid (N = 440) in HIV-infected women aged 25--59 years, with a nested study of HPV subtypes in first 300 women enrolled. Of 440 women screened, 9.5% (N = 42) had abnormal visual inspection with acetic acid with 69.0% (N = 29) having advanced disease not amenable to cryotherapy. Of 294 women with HPV results, 39% (N = 114) of women were positive for high-risk HPV infection. Only lower CD4 count (287 cells/mm(3) versus 339 cells/mm(3), p = 0.03) and high-risk HPV (66.7% versus 35.6%, p < 0.01) were associated with abnormal visual inspection with acetic acid. The most common high-risk HPV subtypes in women with abnormal visual inspection with acetic acid were 35 (33.3%), 16 (26.7%), and 58 (23.3%). Low CD4 cell count was associated with abnormal visual inspection with acetic acid and raises the importance of early antiretroviral therapy and expanded availability of visual inspection with acetic acid. HPV vaccines targeting additional non-16/18 high-risk HPV subtypes may have greater protective advantages in countries such as Malawi

High-risk human papillomavirus in HIV-infected women undergoing cervical cancer screening in Lilongwe, Malawi: a pilot study

INTRODUCTION: Rates of abnormal visual inspection with acetic acid (VIA) and prevalence of high-risk human papillomavirus (HPV) subtypes have not been well characterized in HIV-infected women in Malawi. METHODS: We performed a prospective cohort study of VIA (N=440) in HIV-infected women ages 25-59, with a nested study of HPV subtypes in first 300 women enrolled. Wilcoxon's Rank-Sum Test was used to compare continuous variables and Fisher's exact test was used to compare categorical variables between women with normal versus abnormal VIA. Results: Of 440 women screened, 9.5% (N=42) had abnormal VIA with 69.0% (N=29) having advanced disease not amenable to cryotherapy. Of 294 women with HPV results, 39% (N=114) of women were positive for high-risk HPV infection. Only lower CD4 count (287 cells/mm(3) vs. 339 cells/mm(3), p=0.03) and high-risk HPV (66.7% versus 35.6%, p<0.01) were associated with abnormal VIA. The most common high-risk HPV subtypes in women with abnormal VIA were 35 (33.3%), 16 (26.7%), and 58 (23.3%). CONCLUSION: Low CD4 cell count was associated with abnormal VIA and raises the importance of early ART and expanded availability of VIA. HPV vaccines targeting additional non-16/18 high-risk HPV subtypes may have greater protective advantages in countries such as Malawi

Cost per person in care and cost per person retained comparing facility- and provider-led CAD- (based on 2022 USD).

Cost per person in care and cost per person retained comparing facility- and provider-led CAD- (based on 2022 USD).</p

Viral load suppression.

BackgroundOutcomes of community antiretroviral therapy (ART) distribution (CAD), in which provider–led ART teams deliver integrated HIV services at health posts in communities, have been mixed in sub-Saharan African countries. CAD outcomes and costs relative to facility-based care have not been reported from Malawi.MethodsWe performed a retrospective cohort study in two Malawian districts (Lilongwe and Chikwawa districts), comparing CAD with facility-based ART care. We selected an equal number of clients in CAD and facility-based care who were aged >13 years, had an undetectable viral load (VL) result in the last year and were stable on first-line ART for ≥1 year. We compared retention in care (alive and no period of ≥60 days without ART) using Kaplan-Meier survival analysis and Cox regression and maintenance of VL suppression (Results700 ART clients (350 CAD, 350 facility-based) were included. The median age was 43 years (IQR 36–51), median duration on ART was 7 years (IQR 4–9), and 75% were female. Retention in care did not differ significantly between clients in CAD (89.4% retained) and facility-based care (89.3%), p = 0.95. No significant difference in maintenance of VL suppression were observed between CAD and facility-based care (aOR: 1.24, 95% CI: 0.47–3.20, p = 0.70). CAD resulted in slightly higher health system costs than facility-based care: $118/year vs.$108/year per person accessing care; and $133/year vs.$122/year per person retained in care. CAD decreased individual client costs compared to facility-based care: $3.20/year vs.$11.40/year per person accessing care; and $3.60/year vs.$12.90/year per person retained in care.ConclusionClients in provider-led CAD care in Malawi had very good retention in care and VL suppression outcomes, similar to clients receiving facility-based care. While health system costs were somewhat higher with CAD, costs for clients were reduced substantially. More research is needed to understand the impact of other differentiated service delivery models on costs for the health system and clients.</div

Ethics approval letter.

BackgroundOutcomes of community antiretroviral therapy (ART) distribution (CAD), in which provider–led ART teams deliver integrated HIV services at health posts in communities, have been mixed in sub-Saharan African countries. CAD outcomes and costs relative to facility-based care have not been reported from Malawi.MethodsWe performed a retrospective cohort study in two Malawian districts (Lilongwe and Chikwawa districts), comparing CAD with facility-based ART care. We selected an equal number of clients in CAD and facility-based care who were aged >13 years, had an undetectable viral load (VL) result in the last year and were stable on first-line ART for ≥1 year. We compared retention in care (alive and no period of ≥60 days without ART) using Kaplan-Meier survival analysis and Cox regression and maintenance of VL suppression (Results700 ART clients (350 CAD, 350 facility-based) were included. The median age was 43 years (IQR 36–51), median duration on ART was 7 years (IQR 4–9), and 75% were female. Retention in care did not differ significantly between clients in CAD (89.4% retained) and facility-based care (89.3%), p = 0.95. No significant difference in maintenance of VL suppression were observed between CAD and facility-based care (aOR: 1.24, 95% CI: 0.47–3.20, p = 0.70). CAD resulted in slightly higher health system costs than facility-based care: $118/year vs.$108/year per person accessing care; and $133/year vs.$122/year per person retained in care. CAD decreased individual client costs compared to facility-based care: $3.20/year vs.$11.40/year per person accessing care; and $3.60/year vs.$12.90/year per person retained in care.ConclusionClients in provider-led CAD care in Malawi had very good retention in care and VL suppression outcomes, similar to clients receiving facility-based care. While health system costs were somewhat higher with CAD, costs for clients were reduced substantially. More research is needed to understand the impact of other differentiated service delivery models on costs for the health system and clients.</div

Unadjusted and adjusted hazard ratios (HR) of experiencing an adverse outcome over follow-up period.

Unadjusted and adjusted hazard ratios (HR) of experiencing an adverse outcome over follow-up period.</p

Client outcomes at 14 months.

BackgroundOutcomes of community antiretroviral therapy (ART) distribution (CAD), in which provider–led ART teams deliver integrated HIV services at health posts in communities, have been mixed in sub-Saharan African countries. CAD outcomes and costs relative to facility-based care have not been reported from Malawi.MethodsWe performed a retrospective cohort study in two Malawian districts (Lilongwe and Chikwawa districts), comparing CAD with facility-based ART care. We selected an equal number of clients in CAD and facility-based care who were aged >13 years, had an undetectable viral load (VL) result in the last year and were stable on first-line ART for ≥1 year. We compared retention in care (alive and no period of ≥60 days without ART) using Kaplan-Meier survival analysis and Cox regression and maintenance of VL suppression (Results700 ART clients (350 CAD, 350 facility-based) were included. The median age was 43 years (IQR 36–51), median duration on ART was 7 years (IQR 4–9), and 75% were female. Retention in care did not differ significantly between clients in CAD (89.4% retained) and facility-based care (89.3%), p = 0.95. No significant difference in maintenance of VL suppression were observed between CAD and facility-based care (aOR: 1.24, 95% CI: 0.47–3.20, p = 0.70). CAD resulted in slightly higher health system costs than facility-based care: $118/year vs.$108/year per person accessing care; and $133/year vs.$122/year per person retained in care. CAD decreased individual client costs compared to facility-based care: $3.20/year vs.$11.40/year per person accessing care; and $3.60/year vs.$12.90/year per person retained in care.ConclusionClients in provider-led CAD care in Malawi had very good retention in care and VL suppression outcomes, similar to clients receiving facility-based care. While health system costs were somewhat higher with CAD, costs for clients were reduced substantially. More research is needed to understand the impact of other differentiated service delivery models on costs for the health system and clients.</div