Pilot Trial Results of Mlambe: An Economic and Relationship-Strengthening Intervention to Address Heavy Drinking and Adherence to Antiretroviral Therapy in Malawi.

We evaluated the feasibility, acceptability, and preliminary efficacy of an economic and relationship-strengthening intervention to reduce heavy alcohol use among couples living with HIV in Malawi (Mlambe). Mlambe consisted of training on financial literacy and relationship skills, combined with 1:1 matched savings accounts to invest in an income-generating activity. In a randomized controlled trial, we compared Mlambe to enhanced usual care (EUC). We enrolled 78 married couples having a partner on antiretroviral therapy (ART) who reported heavy alcohol use based on the AUDIT-C. Using targets of 75%, primary outcomes included retention rates at 10 and 15-months, session attendance rates, and satisfaction with Mlambe. Exploratory outcomes were heavy alcohol use (AUDIT-C and/or PEth positive), number of drinking days in the past month, AUDIT-C score, optimal adherence to ART (95% or higher), and viral suppression. We exceeded our targets for feasibility and acceptability metrics. Retention rates were 96% at 15-months. Session attendance and satisfaction levels were both 100%. From baseline to 15-months, Mlambe participants reported decreases in mean number of drinking days (from 6.8 to 2.1) and AUDIT-C scores (from 7.5 to 3.1); while ART adherence rates improved across the same period (from 63.2 to 73.9%). Participants in Mlambe, as compared to those in EUC, had lower rates of heavy alcohol use (89.5% vs. 97.2%) and higher rates of viral suppression (100% vs. 91.9%) at 10-months. Differences between arms were not statistically significant in this small pilot study. Mlambe was highly feasible and acceptable, and shows promise for reducing heavy alcohol use and viral non-suppression among couples with HIV in a larger efficacy study.

Barriers to accessing care for cardiometabolic disorders in Malawi: partners as a source of resilience for people living with HIV.

BACKGROUND: People living with HIV (PLWH) are at increased risk of cardiometabolic disorders (CMD). Adequate access to care for both HIV and CMD is crucial to improving health outcomes; however, there is limited research that have examined couples' experiences accessing such care in resource-constrained settings. We aimed to identify barriers to accessing CMD care among PLWH in Malawi and the role of partners in mitigating these barriers. METHODS: We conducted a qualitative investigation of barriers to CMD care among 25 couples in Malawi. Couples were eligible if at least one partner was living with HIV and had hypertension or diabetes (i.e., the index patient). Index patients were recruited from HIV care clinics in the Zomba district, and their partners were enrolled thereafter. Interviews were conducted separately with both partners to determine barriers to CMD care access and how partners were involved in care. RESULTS: Participants framed their experiences with CMD care by making comparisons to HIV treatment, which was free and consistently available. The main barriers to accessing CMD care included shortage of medications, cost of tests and treatments, high cost of transportation to health facilities, lengthy wait times at health facilities, faulty or unavailable medical equipment and supplies, inadequate monitoring of patients' health conditions, some cultural beliefs about causes of illness, use of herbal therapies as an alternative to prescribed medicine, and inadequate knowledge about CMD treatments. Partners provided support through decision-making on accessing medical care, assisting partners in navigating the healthcare system, and providing financial assistance with transportation and treatment expenses. Partners also helped manage care for CMD, including communicating health information to their partners, providing appointment reminders, supporting medication adherence, and supporting recommended lifestyle behaviors. CONCLUSIONS: Couples identified many barriers to CMD care access, which were perceived as greater challenges than HIV care. Partners provided critical forms of support in navigating these barriers. With the rise of CMD among PLWH, improving access to CMD care should be prioritized, using lessons learned from HIV and integrated care approaches. Partner involvement in CMD care may help mitigate most barriers to CMD care.

Development of an Economic and Relationship-Strengthening Intervention for Alcohol Drinkers Living with HIV in Malawi.

Heavy alcohol use among people with HIV in sub-Saharan Africa is driven by household economics such as poverty and unemployment and has negative impacts on couple relationships. Multilevel interventions have the potential to reduce alcohol use and improve relationship outcomes by addressing the web of co-occurring economic, social, and dyadic factors. This objective of this study was to develop an economic and relationship-strengthening intervention for couples in Malawi, consisting of matched savings accounts with financial literacy training and a couples counseling component to build relationship skills. Informed by the ADAPT-ITT framework, we collected multiple rounds of focus group data with key stakeholders and couples to gain input on the concept, session content, and procedures, held team meetings with field staff and an international team of researchers to tailor the intervention to couples in Malawi, and refined the intervention manual and components. The results describe a rigorous adaptation process based on the eight steps of ADAPT-ITT, insights gained from formative data and modifications made, and a description of the final intervention to be evaluated in a pilot randomized clinical trial. The economic and relationship-strengthening intervention shows great promise of being feasible, acceptable, and efficacious for couples affected by HIV and heavy alcohol use in Malawi.

Supportive couple relationships buffer against the harms of HIV stigma on HIV treatment adherence.

INTRODUCTION: HIV stigma can impact couple relationships through stress or bring partners closer through shared experiences. Conversely, couple relationships may protect against the harms of stigma, including anticipated stigma on negative health outcomes. Yet few studies have assessed the potential link between HIV stigma, relationship dynamics, and antiretroviral therapy (ART) adherence. Using dyadic data from a cross-sectional study of Malawian couples living with HIV, we tested associations between anticipated stigma and: 1) relationship dynamics (e.g., trust, sexual satisfaction, communication) and partner support; and 2) self-reported ART adherence. METHODS: Heterosexual couples (211 couples, 422 individuals) with at least one partner on ART were recruited from clinics in Zomba, Malawi. Partners completed separate surveys on anticipated stigma, relationship dynamics, and ART adherence. Linear mixed models evaluated associations between anticipated stigma and relationship dynamics, and whether associations varied by gender. Generalized estimating equation models tested for associations between anticipated stigma and high ART adherence (90-100% vs. < 90%) at the individual level, and whether they were moderated by relationship dynamics at the couple level. RESULTS: Couples' relationship length averaged 12.5 years, 66.8% were HIV sero-concordant, and 95.6% reported high ART adherence. In multivariable models, sexual satisfaction (ß = -0.22, 95%CI = -0.41;-0.03, p = 0.020) and partner social support (ß = -0.02, 95%CI = -0.04;-0.01, p < 0.01) were negatively associated with anticipated stigma. Significant interaction effects showed that adherence is moderated in couples with higher partner support and sexual satisfaction such that adherence is lowest when anticipated stigma is high and social support is low, and that adherence is lowest when anticipated stigma is high and sexual satisfaction is low. CONCLUSIONS: Increased anticipated stigma is most associated with lower ART non-adherence at lower levels of social support and sexual satisfaction. Conversely, supportive and fulfilling relationships may buffer the negative association between stigma and ART adherence. Couples' interventions that focus on improving communication and support systems within couples could reduce the negative impacts of anticipated stigma on couples living with HIV.

"Then I will say that we have to marry each other": A qualitative view of premarital pregnancy as a driver of child marriage in Malawi".

Child marriage is common in Malawi, with 42.1% of women ages 20-24 marrying before age 18. Although global research on child marriage has increased in recent years, the reasons are context-specific and there is limited evidence on specific drivers of child marriage in Malawi. We explored pathways to child marriage in Mangochi and Nkhata Bay, drawing on focus groups (n=20) and in-depth interviews (n=39) with adolescent girls and parents of adolescent girls. We find that pregnancy often determines marriage timing and partner selection among adolescents, due in part to norms of adolescent dating or courtship and premarital sexual activity. Once pregnancy occurs, marriage is nearly inevitable even if the girl is under age 18. These findings have important implications for programs to delay marriage; programs must address weak motivations to prevent pregnancy and work to create alternative livelihood opportunities to foster economic self-sufficiency.

A conceptual framework for understanding child marriage, marriage markets, and marriageability.

The term 'marriageability' is used frequently in child marriage literature but is rarely defined. We propose a conceptual framework to define marriageability and use qualitative case studies to illustrate how ideas about marriageability contribute to child marriage. Pressure to capitalize on a girl's marriageability before it declines in order to secure the 'best' partner may explain why child marriage persists. We find that marriageability involves both eligibility-or perceived readiness for marriage-as well as desirability or 'value' on the marriage market. We propose that understanding marriageability in context, particularly in countries with limited evidence on interventions to address child marriage, is essential for suggesting ways interventions may critically examine notions of marriageability and disrupt pathways to child marriage.

Development and Validation of the Couple Sexual Satisfaction Scale for HIV and Sexual Health Research.

Sexual satisfaction is an important dimension of relationship quality with implications for sexual and reproductive health (SRH), and HIV prevention, care, and treatment. We developed and validated the Couple Sexual Satisfaction Scale (CSSS) with heterosexual couples in sub-Saharan Africa. Using data from qualitative interviews with 94 partnered women and men in Swaziland and Malawi, we generated a 22-item scale and administered it to 211 couples with at least one partner living with HIV in Malawi. We performed an exploratory factor analysis (EFA) to identify and confirmatory factor analysis (CFA) to test the factor structure. To assess validity, we tested for associations between the CSSS and relationship quality, consistent condom use, and intimate partner violence (IPV) using generalized estimating equations. The EFA yielded two factors, general sexual satisfaction (13-item CSSS-Gen subscale, e.g., "I am satisfied with the sweetness of sex in our relationship") and HIV-specific sexual satisfaction (4-item CSSS-HIV subscale, e.g., "My appetite for sex has gone down due to HIV"), accounting for 78% of the shared variance. The CFA supported the two-factor solution: χ2(118) = 203.60; CFI = 0.909; SRMR = 0.057; RMSEA = 0.058. Participants with higher CSSS-Gen scores reported higher coital frequency and relationship quality (intimacy, trust, unity, equality, relationship satisfaction, commitment, partner social support), and less consistent condom use, physical IPV, and emotional IPV. Participants with higher CSSS-HIV scores reported higher coital frequency and relationship quality (trust, partner support), and less consistent condom use, and sexual IPV. The CSSS demonstrated good psychometric properties and provides new opportunities to study sexual reproductive health and HIV-related health behaviors among couples in sub-Saharan Africa.

Perceptions of minimum age at marriage laws and their enforcement: qualitative evidence from Malawi.

BACKGROUND: Child marriage in Malawi is a significant problem with 42.1% of women 20-24 married by age 18. In 2017 the Malawi government formalized legislation to make marriage under age 18 illegal; violators are subject to fines. While leveraging laws to reduce child marriage is common, the enactment of laws and their enforcement has led to some novel practices. One such practice observed in Malawi is marriage withdrawal, where the community intervenes when a child marriage has taken place to force the girl to return to her natal home. METHODS: This paper is a qualitative analysis of perceptions regarding marriage withdrawal. We conducted focus group discussions and in-depth interviews with married and unmarried adolescents, parents of adolescents, and key community members in Mangochi and Nkhata Bay. Data were collected as part of an evaluation of the More Than Brides Alliance program aimed at delaying marriage and improving access to sexual and reproductive health services in Malawi. RESULTS: The knowledge that violation of marriage laws entails substantial fines is widespread and marriage withdrawals are seen by some respondents as a way of enforcing the spirit of child marriage laws while avoiding fines. Some respondents suggest that enforcement of marriage laws has an unintended effect of driving marriages underground. One important disconnect between the laws and the realities of child marriage practices in these communities is that the law holds parents responsible for the marriage and for preventing it, while parents do not necessarily exercise control, particularly when the marriage is precipitated by pregnancy. While parents and other adults view withdrawals as an acceptable resolution of a problematic child marriage, girls noted many drawbacks for withdrawn girls such as stigma and limited education and livelihood opportunities once withdrawn. CONCLUSIONS: Our exploration of perceptions about marriage laws suggest that the imposition of fines may have some unintended consequences, both driving the practice underground and encouraging practices to evade fines, and may be associated with unintended consequences for adolescent girls. Programs to address child marriage should include other approaches that address more distal drivers including poverty and lack of alternatives to child marriage. TRIAL REGISTRATION: This work is part of an RCT registered August 4, 2016 in the AEA RCT registry identified as: AEARCTR-0001463 . See: https://www.socialscienceregistry.org/trials/1463.

The Unaddressed Needs of Alcohol-Using Couples on Antiretroviral Therapy in Malawi: Formative Research on Multilevel Interventions.

Alcohol use among HIV-positive individuals in sub-Saharan Africa directly impacts adherence to antiretroviral therapy and HIV outcomes. Few studies have examined approaches to reduce alcohol use among HIV-affected couples, despite evidence that alcohol use is a couple-level concern. We conducted a qualitative study with 23 alcohol-using couples to identify multilevel barriers and facilitators of alcohol use, and potential intervention options with couples. Data were analyzed at individual and dyadic levels using framework analysis. All couples were married and had at least one partner on ART. Men were the primary alcohol drinkers with few women reporting alcohol use. Most women tried to persuade their partners to reduce their alcohol intake and when unsuccessful, enlisted help from relatives and HIV care providers. Effective couple negotiation around men's alcohol use was constrained by negative peer influence and men's desire for friendship to cope with life stressors. Women were primarily concerned about the expense of alcohol and described how alcohol prevented the family from meeting basic needs and investing in the future. Alcohol use was described as a major barrier to ART adherence, but was also viewed as the cause of couple and family violence, extramarital partnerships, food insecurity, and poverty. We conclude that multilevel interventions based on couples' needs and preferences are urgently needed. Couple-based intervention approaches could include provider-led alcohol counseling with couples, alcohol reduction support groups for couples, couples' counseling to bolster couple communication and problem-solving around alcohol, and economic-strengthening interventions for couples.

A Dyadic Investigation of Relationship Dynamics and Depressive Symptoms in HIV-Affected Couples in Malawi.

Depression is the leading cause of disability worldwide with health implications for people living with HIV. Primary partnerships like marriage could be protective against depression but may worsen depression depending on the relationship quality. We examined depression and its association with relationship dynamics in a cross-sectional sample of 211 HIV-affected married couples in Malawi. We fit multivariable multilevel linear regression models for depressive symptoms. Men and women reported similar levels of depressive symptoms; 28% had a score indicative of probable depression. Almost half of couples had at least one partner with probable depression. In the adjusted models, equality (B = - 0.22; p < 0.01) and unity (B = - 0.94; p < 0.05) were associated with fewer depressive symptoms while individuals with more experiences of physical (B = 0.81; p < 0.01), sexual (B = 0.87; p < 0.01), and emotional violence (B = 1.52; p < 0.001) had higher levels of depressive symptoms. Couples-based interventions aiming to improve relationships may address depression, especially in settings with inadequate mental health services.

Evaluating Sampling Biases from Third-party Reporting as a Method for Improving Survey Measures of Sensitive Behaviors.

Survey participants often misreport their sensitive behaviors (e.g., smoking, drinking, having sex) during interviews. Several studies have suggested that asking respondents to report the sensitive behaviors of their friends or confidants, rather than their own, might help address this problem. This is so because the "third-party reporting" (TPR) approach creates a surrogate sample of alters that may be less subject to social desirability biases. However, estimates of the prevalence of sensitive behaviors based on TPR assume that the surrogate sample of friends is representative of the population of interest. We used sociometric data on social networks in Likoma, Malawi to examine this assumption. Specifically, we use friendship network data to investigate whether friends have similar socio-economic characteristics as index respondents, and to measure possible correlations between the likelihood of inclusion in the surrogate sample and sensitive behaviors. From these results, we suggest approaches to strengthen estimates of the prevalence of sensitive behaviors obtained from TPR.

A new approach to measuring partnership concurrency and its association with HIV risk in couples.

Empirical estimates of the association between concurrent partnerships (CP) and HIV risk are affected by non-sampling errors in survey data on CPs, e.g., because respondents misreport the extent of their CPs. We propose a new approach to measuring CPs in couples, which permits assessing how respondent errors affect estimates of the association between CPs and HIV risk. Each couple member is asked (1) to report whether s/he has engaged in CPs and (2) to assess whether his/her partner has engaged in CPs, since their couple started. Cross-tabulating these data yields multiple classifications (with varying combinations of sensitivity/specificity) of the CPs of each couple member. We then measure the association between CPs and HIV outcomes according to each classification. The resulting range of estimates is an indicator of the uncertainty associated with respondent errors. We tested this approach using data on 520 matched couples drawn from the Likoma Network Study. Results suggest that existing tests of the concurrency hypothesis are affected by significant uncertainty.

"I too have a responsibility for my partner's life": Communal coping among Malawian couples living with HIV and cardiometabolic disorders.

RATIONALE: HIV and cardiometabolic disorders including hypertension and diabetes pose a serious double threat in Malawi. Supportive couple relationships may be an important resource for managing these conditions. According to the theory of communal coping, couples will more effectively manage illness if they view the illness as "our problem" (shared illness appraisal) and are united in shared behavioral efforts. METHODS: This study qualitatively investigated communal coping of 25 couples living with HIV and hypertension or diabetes in Zomba, Malawi. Partners were interviewed separately regarding relationship quality, shared illness appraisal, communal coping, and dyadic management of illness. RESULTS: Most participants (80%) were living with HIV, and more than half were also living with hypertension. Most participants expressed high levels of unity and the view that illness was "our problem." In some couples, partners expected but did not extend help and support and reported little collaboration. Communal coping and dyadic management were strongly gendered. Some women reported a one-sided support relationship in which they gave but did not receive support. Women were also more likely to initiate support interactions and offered more varied support than men. In couples with poor relationship quality and weak communal coping, dyadic management of illness was also weak. Partner support was particularly crucial for dietary changes, as women typically prepared meals for the entire family. Other lifestyle changes that could be supported or hindered by a partner included exercise, stress reduction, and medication adherence. CONCLUSION: We conclude that gendered power imbalances may influence the extent to which couple-level ideals translate into actual communal coping and health behaviors. Given that spouses and families of patients are also at risk due to shared environments, we call for a shift from an illness management paradigm to a paradigm of optimizing health for spouses and families regardless of diabetes or hypertension diagnosis.

Mlambe economic and relationship-strengthening intervention for alcohol use decreases violence and improves relationship quality in couples living with HIV in Malawi.

INTRODUCTION: A syndemic of unhealthy alcohol use, intimate partner violence (IPV), and economic insecurity threatens to derail progress towards UNAIDS 95-95-95 targets in sub-Saharan Africa. We developed a combined economic and relationship-strengthening intervention called Mlambe to reduce unhealthy alcohol use and increase adherence to antiretroviral therapy for couples in Malawi. This study evaluates the additional impact of Mlambe on IPV and relationship dynamics. METHODS: In a pilot randomized controlled trial, 78 married couples (156 individuals) living with HIV and reporting unhealthy alcohol use based on the AUDIT-C (at least one partner) were recruited from HIV care clinics in Zomba, Malawi. The intervention arm (39 couples) received a 10-month program consisting of incentivized savings accounts with financial literacy education, relationship education, and couples counseling sessions to build relationship skills. The control arm (39 couples) received enhanced usual care (EUC) with brief alcohol counseling. We used linear mixed-effects models to assess the effects of Mlambe on relationship quality (e.g., constructive communication, unity, sexual satisfaction) and IPV (physical, sexual, and emotional) by including fixed effects for treatment arm and a random effect for dyad, and tested whether effects on IPV and relationship quality differed by gender. RESULTS: At 10- and 15-month follow-up visits, couples in the Mlambe arm showed greater increases in couple communication, unity, sexual satisfaction, intimacy, and trust (Cohen's d ranged from 0.36 to 0.56; p < 0.05) as compared to EUC. Couples in the Mlambe arm also showed significant decreases in physical and emotional IPV (Cohen's d ranged from 0.33 to 0.49; p < 0.05) as compared to EUC. Subsequent moderation analyses indicated that women reported significantly greater improvements in relationship quality than men, except for sexual satisfaction (p < 0.05), and greater declines in physical IPV than men (p < 0.05). CONCLUSIONS: Mlambe resulted in significant improvements in relationship quality and decreased IPV in couples, particularly for women who as a group reported lower relationship quality at baseline. Economic and relationship-strengthening interventions have potential to disrupt harmful syndemics of violence, substance use, and poverty among couples living with HIV. CLINICAL TRIAL NUMBER: NCT#04906616.

Disability transitions and health expectancies among adults 45 years and older in Malawi: a cohort-based model.

BACKGROUND: Falling fertility and increasing life expectancy contribute to a growing elderly population in sub-Saharan Africa (SSA); by 2060, persons aged 45 y and older are projected to be 25% of SSA's population, up from 10% in 2010. Aging in SSA is associated with unique challenges because of poverty and inadequate social supports. However, despite its importance for understanding the consequences of population aging, the evidence about the prevalence of disabilities and functional limitations due to poor physical health among older adults in SSA continues to be very limited. METHODS AND FINDINGS: Participants came from 2006, 2008, and 2010 waves of the Malawi Longitudinal Survey of Families and Health, a study of the rural population in Malawi. We investigate how poor physical health results in functional limitations that limit the day-to-day activities of individuals in domains relevant to this subsistence-agriculture context. These disabilities were parameterized based on questions from the SF-12 questionnaire about limitations in daily living activities. We estimated age-specific patterns of functional limitations and the transitions over time between different disability states using a discrete-time hazard model. The estimated transition rates were then used to calculate the first (to our knowledge) microdata-based health expectancies calculated for SSA. The risks of experiencing functional limitations due to poor physical health are high in this population, and the onset of disabilities happens early in life. Our analyses show that 45-y-old women can expect to spend 58% (95% CI, 55%-64%) of their remaining 28 y of life (95% CI, 25.7-33.5) with functional limitations; 45-y-old men can expect to live 41% (95% CI, 35%-46%) of their remaining 25.4 y (95% CI, 23.3-28.8) with such limitations. Disabilities related to functional limitations are shown to have a substantial negative effect on individuals' labor activities, and are negatively related to subjective well-being. CONCLUSIONS: Individuals in this population experience a lengthy struggle with disabling conditions in adulthood, with high probabilities of remitting and relapsing between states of functional limitation. Given the strong association of disabilities with work efforts and subjective well-being, this research suggests that current national health policies and international donor-funded health programs in SSA inadequately target the physical health of mature and older adults.

Should home-based HIV testing and counseling services be offered periodically in programs of ARV treatment as prevention? A case study in Likoma (Malawi).

To reduce HIV incidence, prevention programs centered on the use of antiretrovirals require scaling-up HIV testing and counseling (HTC). Home-based HTC services (HBHTC) increase HTC coverage, but HBHTC has only been evaluated during one-off campaigns. Two years after an initial HBHTC campaign ("round 1"), we conducted another HBHTC campaign ("round 2") in Likoma (Malawi). HBHTC participation increased during round 2 among women (from 74 to 83%, P < 0.01). New HBHTC clients were recruited, especially at ages 25 and older. Only 6.9% of women but 15.9% of men remained unreached by HBHTC after round 2. HIV prevalence during round 2 was low among clients who were HIV-negative during round 1 (0.7%), but high among women who received their first ever HIV test during round 2 (42.8%). The costs per newly diagnosed infection increased significantly during round 2. Periodically conducting HBHTC campaigns can further increase HTC, but supplementary interventions to enroll individuals not reached by HBHTC are needed.

Community-based empowerment program to delay marriage: Results from the More Than Brides Alliance intervention in India, Malawi, Mali and Niger.

The More Than Brides Alliance (MTBA) implemented an intervention in India, Malawi, Mali and Niger from 2017 to 2020. The holistic community-based program included girls' clubs focused on empowerment and sexual and reproductive health knowledge; work with parents and educators; community edutainment events; and local-, regional-, and national-level advocacy efforts related to child marriage. Using a cluster randomized trial design (India and Malawi), and a matched comparison design (Niger and Mali), we evaluated the effectiveness of the program on age at marriage among girls ages 12-19 in intervention communities. Repeat cross sectional surveys were collected at baseline (2016/7), midline after approximately 18 months of intervention (2018), and endline (2020). Impact was assessed using difference-in-difference (DID) analysis, adjusted for the cluster design. We find that the intervention was successful at reducing the proportion of girls ages 12-19 married in India (-0.126, p < .001). Findings in the other countries did not show impact of the intervention on delaying marriage. Our findings suggest that the MTBA program was optimized to succeed in India, in part because it was built on an evidence base that relies heavily on data from South Asia. The drivers of child marriage in India may be substantially different from those in Malawi, Mali, and Niger and require alternate intervention approaches. These findings have implications for those designing programs outside of South Asia and suggest that programs need to consider context-specific drivers and whether and how evidence-based programs operate in relation to those drivers. Trial registration: This work is part of an RCT registered August 4, 2016 in the AEA RCT registry identified as: AEAR CTR-0001463. See: https://www.socialscienceregistry.org/trials/1463.

"High blood pressure comes from thinking too much": Understandings of illness among couples living with cardiometabolic disorders and HIV in Malawi.

Cardiometabolic disorders (CMD) such as hypertension and diabetes are increasingly prevalent in sub-Saharan Africa, placing people living with HIV at risk for cardiovascular disease and threatening the success of HIV care. Spouses are often the primary caregivers for people living with CMD, and understanding patients' and partners' conceptions of CMD could inform care. We conducted semi-structured interviews with 25 couples having a partner living with HIV and either hypertension or diabetes. Couples were recruited from HIV clinics in Malawi and were interviewed on beliefs around symptoms, causation, prevention, and treatment for CMD. Data were analyzed at the individual and dyadic levels using framework analysis and Kleinman's theory of explanatory models as a lens. On average, participants were 51 years old and married for 21 years. Approximately 57%, 14%, and 80% had hypertension, diabetes, and HIV. Couples endorsed a combination of biomedical explanatory models (beliefs around physical and mental health) and traditional explanatory models (beliefs around religion and natural remedies), although tended to emphasize the biomedical model. Half of couples believed stress was the main cause of hypertension. For diabetes, diet was believed to be a common cause. In terms of prevention, dietary changes and physical activity were most frequently mentioned. For disease management, medication adherence and diet modifications were emphasized, with some couples also supporting herbal remedies, stress reduction, and faith in God as strategies. Participants were generally more concerned about CMD than HIV due to poor access to CMD medications and beliefs that CMD could lead to sudden death. Within couples, partners often held many of the same beliefs but diverged around which etiological or preventive factors were most important (e.g., stress versus diet) and the best diet for CMD. Health education programs should involve primary partners to build knowledge of CMD and address overlap with HIV, and reinforce accurate information on lifestyle factors for the prevention and treatment of CMD.

Bidirectional Violence Is Associated with Poor Engagement in HIV Care and Treatment in Malawian Couples.

Growing evidence suggests that intimate partner violence (IPV) is a barrier to engagement in HIV care. Bidirectional IPV-being both a perpetrator and victim-may be the most common pattern of IPV, yet no research has examined its effect on engagement in care, which could identify couples in most need of interventions. Married couples (N = 211) with at least one partner on antiretroviral therapy were recruited from HIV clinic waiting rooms in Zomba, Malawi. Partners completed separate surveys on physical, sexual, and emotional IPV, medication adherence, and appointment attendance. We created categorical variables indicating no violence, perpetrator-only, victim-only, and bidirectional violence. Generalized estimating equation regression models tested for associations between IPV and engagement in care. The bidirectional pattern represented 25.4%, 35.5%, and 34.0% of all physical, sexual, and emotional IPV. Physical IPV victimization-only (adjusted odds ratio [AOR]: 0.28, 95% confidence interval [CI]: 0.08, 0.92) was associated with lower adherence, but the association was stronger for bidirectional physical IPV (AOR: 0.10, 95% CI: 0.02, 0.51). Bidirectional sexual IPV was also associated with lower adherence (AOR: 0.14, 95% CI: 0.02, 0.80). Bidirectional physical IPV (AOR: 4.04, 94% CI: 1.35, 12.14) and emotional IPV (AOR: 3.78, 95% CI: 1.78, 8.05) were associated with missing 1+ appointment. Interventions to address the health effects of bidirectional IPV, which may be greater than victim-only or perpetrator-only IPV, should intervene with both partners to break cycles of violence. Couple-based interventions may be a viable option by intervening on both partners' trauma and aggression simultaneously.

Women underestimate the age of their partners during survey interviews: implications for HIV risk associated with age mixing in northern Malawi.

BACKGROUND: Age mixing may explain differences in HIV prevalence across populations in sub-Saharan countries, but the validity of survey data on age mixing is unknown. METHODS: Age differences between partners are frequently estimated indirectly by asking respondents to report their partner's age. Partner's age can also be assessed directly by tracing partners and asking them to report their own age. We use data from 519 relationships, collected in Likoma (Malawi), in which both the partners were interviewed and tested for HIV. In these relationships, age differences were assessed both indirectly and directly, and estimates could thus be compared. We calculate the specificity and sensitivity of the indirect method in identifying age-homogenous/age-disparate relationships in which the male partner is less/more than 5 or 10 years older than the respondent. RESULTS: Women were accurate in identifying age-homogenous relationships, but not in identifying age-disparate relationships (specificity ≈90%, sensitivity = 24.3%). The sensitivity of the indirect method was even lower in detecting partners older than the respondent by 10+ years (9.6%). Among 43 relationships with an HIV-infected partner included in this study, there were about 3 times more age-disparate relationships according to direct measures of partner's age than according to women's reports of their partner's age (17% vs. 46%). CONCLUSIONS: Women's survey reports of their partner's age significantly underestimate the extent of and the HIV risk associated with age mixing in this population. Future studies of the effect of sexual mixing patterns on HIV risk in sub-Saharan countries should take reporting biases into account.