Modeling Contraception and Pregnancy in Malawi: A Thanzi La Onse Mathematical Modeling Study.

Malawi has high unmet need for contraception with a costed national plan to increase contraception use. Estimating how such investments might impact future population size in Malawi can help policymakers understand effects and value of policies to increase contraception uptake. We developed a new model of contraception and pregnancy using individual-level data capturing complexities of contraception initiation, switching, discontinuation, and failure by contraception method, accounting for differences by individual characteristics. We modeled contraception scale-up via a population campaign to increase initiation of contraception (Pop) and a postpartum family planning intervention (PPFP). We calibrated the model without new interventions to the UN World Population Prospects 2019 medium variant projection of births for Malawi. Without interventions Malawi's population passes 60 million in 2084; with Pop and PPFP interventions. it peaks below 35 million by 2100. We compare contraception coverage and costs, by method, with and without interventions, from 2023 to 2050. We estimate investments in contraception scale-up correspond to only 0.9 percent of total health expenditure per capita though could result in dramatic reductions of current pressures of very rapid population growth on health services, schools, land, and society, helping Malawi achieve national and global health and development goals.

A qualitative study on the feasibility and acceptability of institutionalizing health technology assessment in Malawi.

OBJECTIVE: The objective of this study was to assess the feasibility and acceptability of institutionalizing Health Technology Assessment (HTA) in Malawi. METHODS: This study employed a document review and qualitative research methods, to understand the status of HTA in Malawi. This was complemented by a review of the status and nature of HTA institutionalization in selected countries.Qualitative research employed a Focus Group Discussion (FGD ) with 7 participants, and Key Informant Interviews (KIIs) with12 informants selected based on their knowledge and expertise in policy processes related to HTA in Malawi.Data extracted from the literature was organized in Microsoft Excel, categorized according to thematic areas and analyzed using a literature review framework. Qualitative data from KIIs and the FGD was analyzed using a thematic content analysis approach. RESULTS: Some HTA processes exist and are executed through three structures namely: Ministry of Health Senior Management Team, Technical Working Groups, and Pharmacy and Medicines Regulatory Authority (PMRA) with varyingdegrees of effectiveness.The main limitations of current HTA mechanisms include limited evidence use, lack of a standardized framework for technology adoption, donor pressure, lack of resources for the HTA process and technology acquisition, laws and practices that undermine cost-effectiveness considerations. KII and FGD results showed overwhelming demand for strengthening HTA in Malawi, with a stronger preference for strengthening coordination and capacity of existing entities and structures. CONCLUSION: The study has shown that HTA institutionalization is acceptable and feasible in Malawi. However, the current committee based processes are suboptimal to improve efficiency due to lack of a structured framework. A structured HTA framework has the potential to improve processes in pharmaceuticals and medical technologies decision-making.In the short to medium term, HTA capacity building should focus on generating demand and increasing capacity in cost-effectiveness assessments. Country-specific assessments should precede HTA institutionalization as well as recommendations for new technology adoptions.

SARS-CoV-2 Prevalence in Malawi Based on Data from Survey of Communities and Health Workers in 5 High-Burden Districts, October 2020.

To determine early COVID-19 burden in Malawi, we conducted a multistage cluster survey in 5 districts. During October-December 2020, we recruited 5,010 community members (median age 32 years, interquartile range 21-43 years) and 1,021 health facility staff (HFS) (median age 35 years, interquartile range 28-43 years). Real-time PCR-confirmed SARS-CoV-2 infection prevalence was 0.3% (95% CI 0.2%-0.5%) among community and 0.5% (95% CI 0.1%-1.2%) among HFS participants; seroprevalence was 7.8% (95% CI 6.3%-9.6%) among community and 9.7% (95% CI 6.4%-14.5%) among HFS participants. Most seropositive community (84.7%) and HFS (76.0%) participants were asymptomatic. Seroprevalence was higher among urban community (12.6% vs. 3.1%) and HFS (14.5% vs. 7.4%) than among rural community participants. Cumulative infection findings 113-fold higher from this survey than national statistics (486,771 vs. 4,319) and predominantly asymptomatic infections highlight a need to identify alternative surveillance approaches and predictors of severe disease to inform national response.

Factors associated with HIV viral suppression among children and adults receiving antiretroviral therapy in Malawi in 2021: Evidence from the Laboratory Management Information System.

OBJECTIVE: To describe the prevalence of HIV viral suppression and assess the factors associated with HIV viral suppression among persons receiving antiretroviral therapy (ART) in Malawi in 2021. METHODS: Implementation study using routinely collected patient-level HIV RNA-PCR test result data extracted from the national Laboratory Management Information System (LIMS) database managed by the Department of HIV/AIDS in 2021. We calculated frequencies, proportions and odds ratios (OR) of HIV viral suppression with their associated 95% confidence intervals (95%CIs). We performed a random-effects logistic regression to determine the risk factors associated with HIV viral suppression among ART patients, controlling for the spatial autocorrelation between districts and adjusting for other variables. RESULTS: We evaluated 515,797 adults and children receiving ART and having a viral load test in 2021. Of these, 92.8% had HIV viral suppression. ART patients living in urban areas had lower likelihood of HIV viral suppression than those living in rural areas (adjusted OR [aOR] = 0.95, 95%CI: 0.92-0.99, p = 0.01). There was an increasing trend in HIV viral suppression with increasing ART duration. Routine VL monitoring samples were 39% more likely to have suppressed VL values than confirmatory HIV VL monitoring samples (aOR = 1.39; 95%CI: 1.34-1.43, p < 0.001). CONCLUSION: This is the first national analysis of Malawi HIV VL data from LIMS. Our findings show the need to particularly consider the urban residents, those below 20 years, males, those on ART for less than a year as well as those on specific ARV regimens in order to persistently suppress HIV VL and consequently achieve the goal of achieving HIV VL suppression by 2030.

Factors associated with healthcare seeking behaviour for children in Malawi: 2016.

OBJECTIVE: To characterise health seeking behaviour (HSB) and determine its predictors amongst children in Malawi in 2016. METHODS: We used the 2016 Malawi Integrated Household Survey data set. The outcome of interest was HSB, defined as seeking care at a health facility amongst people who reported one or more of a list of possible symptoms given on the questionnaire in the past two weeks. We fitted a multivariate logistic regression model of HSB using a forward step-wise selection method, with age, sex and symptoms entered as a priori variables. RESULTS: Of 5350 children, 1666 (32%) had symptoms in the past two weeks. Of the 1666, 1008 (61%) sought care at health facility. The children aged 5-14 years were less likely to be taken to health facilities for health care than those aged 0-4 years. Having fever vs. not having fever and having a skin problem vs. not having skin problem were associated with increased likelihood of HSB. Having a headache vs. not having a headache was associated with lower likelihood of accessing care at health facilities (AOR = 0.50, 95% CI: 0.26-0.96, P = 0.04). Children from urban areas were more likely to be taken to health facilities for health care (AOR = 1.81, 95% CI: 1.17-2.85, P = 0.008), as were children from households with a high wealth status (AOR = 1.86, 95% CI: 1.25-2.78, P = 0.02). CONCLUSION: There is a need to understand and address individual, socio-economic and geographical barriers to health seeking to increase access and use of health care and fast-track progress towards Universal Health Coverage.

OBJECTIF: Caractériser le comportement de recherche de santé (CRS) et déterminer ses prédicteurs chez les enfants du Malawi en 2016. MÉTHODES: Nous avons utilisé l'ensemble de données de l'Enquête intégrée de 2016 auprès des ménages du Malawi. Le résultat d'intérêt était le CRS, défini comme la recherche de soins dans un établissement de santé chez les personnes qui ont déclaré une ou plusieurs symptômes d'une liste de possibilités figurant sur le questionnaire, dans les deux dernières semaines. Nous avons appliqué un modèle de régression logistique multivariée du CRS en utilisant une méthode de sélection par étape, avec l'âge, le sexe et les symptômes entrés comme variables a priori. RÉSULTATS: Sur 5.350 enfants, 1.666 (32%) ont présenté des symptômes au cours des deux dernières semaines. Sur les 1.666, des soins ont été cherché pour 1.008 (61%) dans un établissement de santé. Les enfants âgés de 5 à 14 ans étaient moins susceptibles d'être emmenés dans des établissements de santé pour des soins de santé que ceux âgés de 0 à 4 ans. Avoir de la fièvre par rapport à ne pas en avoir et avoir un problème de peau par rapport à ne pas en avoir étaient associés à une probabilité accrue de CRS. Avoir un mal de tête par rapport à ne pas en avoir était associé à une probabilité plus faible d'accéder aux soins dans les établissements de santé (AOR = 0,50 ; IC95%: 0,26-0,96 ; P= 0,04). Les enfants des zones urbaines étaient plus susceptibles d'être emmenés dans des établissements de santé pour des soins de santé (AOR = 1,81 ; IC95%: 1,17-2,85 ; P= 0,008), tout comme les enfants de ménages ayant une position socioéconomique plus élevée (AOR = 1,96 ; IC95%: 1,13-3,40 ; P= 0,02). CONCLUSION: Il est nécessaire de comprendre et de surmonter les obstacles individuels, socioéconomiques et géographiques à la recherche de la santé pour accroître l'accès et l'utilisation des soins de santé et accélérer les progrès vers la couverture sanitaire universelle.

Follow-up and programmatic outcomes of HIV-exposed infants registered in a large HIV centre in Lilongwe, Malawi: 2012-2014.

OBJECTIVE: To assess follow-up and programmatic outcomes of HIV-exposed infants at Martin Preuss Centre, Lilongwe, from 2012 to 2014. METHODS: Retrospective cohort study using routinely collected HIV-exposed infant data. Data were analysed using frequencies and percentages in Stata v.13. RESULTS: Of 1035 HIV-exposed infants registered 2012-2014, 79% were available to be tested for HIV and 76% were HIV-tested either with DNA-PCR or rapid HIV test serology by 24 months of age. Sixty-five infants were found to be HIV-positive and 43% were started on antiretroviral therapy (ART) at different ages from 6 weeks to 24 months. Overall, 48% of HIV-exposed infants were declared lost-to-follow-up in the database. Of these, 69% were listed for tracing; of these, 78% were confirmed as lost-to-follow-up through patient charts; of these, 51% were traced; and of these, 62% were truly not in care, the remainder being wrongly classified. Commonest reasons for being truly not in care were mother/guardian unavailability to bring infants to Martin Preuss Centre, forgetting clinic appointments and transport expenses. Of these 86 patients, 36% were successfully brought back to care and 64% remained lost-to-follow-up. CONCLUSION: Loss to follow-up remains a huge challenge in the care of HIV-exposed infants. Active tracing facilitates the return of some of these infants to care. However, programmatic data documentation must be urgently improved to better follow-up and link HIV-positive children to ART.

Factors Associated with Hormonal and Intrauterine Contraceptive Use among HIV-Infected Men and Women in Lilongwe, Malawi: A Cross-Sectional Study.

Background. Understanding the factors associated with the use of hormonal and intrauterine contraception among HIV-infected men and women may lead to interventions that can help reduce high unintended pregnancy rates. Materials and Methods. This study is a subanalysis of a cross-sectional survey of 289 women and 241 men who were sexually active and HIV-infected and were attending HIV care visits in Lilongwe, Malawi. We estimated adjusted prevalence ratios (PRs) to evaluate factors associated with hormonal and intrauterine contraceptive use for men and women in separate models. Results and Discussion. 39.8% of women and 33.2% of men (p = 0.117) reported that they were using hormonal or intrauterine contraception at last intercourse. Having greater than 3 children was the only factor associated with hormonal and intrauterine contraceptive use among men. Among women, younger age, not wanting a pregnancy in 2 years, being with their partner for more than 4 years, and being able to make family planning decisions by themselves were associated with hormonal and intrauterine contraceptive use. Conclusions. The men and women in our study population differed in the factors associated with hormonal and intrauterine contraceptive use. Understanding these differences may help decrease unmet FP needs among HIV-infected men and women.

Understanding factors, outcomes and reasons for loss to follow-up among women in Option B+ PMTCT programme in Lilongwe, Malawi.

OBJECTIVE: To assess factors, outcomes and reasons for loss to follow-up (LTFU) among pregnant and breastfeeding women initiated on a lifelong antiretroviral therapy (ART) for PMTCT in a large antenatal clinic in Malawi. METHODS: We identified all pregnant and breastfeeding women who were initiated on ART between September 2011 and September 2013 and had missed their clinic appointment by at least 3 weeks at Bwaila Hospital, the largest antenatal clinic in Malawi. These women were traced by phone or home visits. Their true status and reasons for ART discontinuation were documented during tracing. RESULTS: A total of 2930 women started ART for PMTCT; 2458 (84%) pregnant and 472 (16%) breastfeeding, of which, 577 (20%) missed a scheduled clinic appointment. LTFU was associated with younger age, being pregnant, and earlier year of ART initiation. We successfully traced 229 (40%), of whom, 10 (4%) had died. Of the 219 women found alive, 118 (54%) had stopped taking ARV drugs, 67 (30%) had self-transferred to another ART clinic, 13 (6%) had collected drugs from other sources, 9 (4%) had treatment interruptions and 12 (5%) had other outcomes. Reasons cited for stopping ART were travel (38%), lack of transport money (16%), not understanding the initial ARV education session (10%), being too weak/sick (10%), ARV side effects (10%) and other reasons. CONCLUSION: Approximately half of the women who were traced were taking ARVs. The study emphasises the need for enhanced post-test counselling strategies, ongoing psychosocial support, provision of incentives and further decentralisation efforts of PMTCT services.

Timing of antiretroviral therapy and regimen for HIV-infected patients with tuberculosis: the effect of revised HIV guidelines in Malawi.

BACKGROUND: In July 2011, the Malawi national HIV program implemented the integrated antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) guidelines. Among the principle goals of the guidelines were increasing ART uptake among TB/HIV co-infected patients and treating TB/HIV patients with a different drug regimen. We, therefore, assessed the effects of the new guidelines on ART uptake, the factors associated with ART uptake and the frequency of ARV-related adverse events in TB/HIV co-infected patients. METHODS: This was an observational cohort study using routine program data. All ART-naïve adult TB/HIV co-infected patients starting TB treatment over the six months preceding and following implementation of 2011 integrated ART/PMTCT guidelines were included. RESULTS: A total of 685 adult TB/HIV co-infected patients were registered in the study; 377 (55%) before and 308 (45%) after the implementation of the new guidelines. ART uptake increased from 70% (240/308) before implementation of the new guidelines to 78% (262/377) after the inception of the new guidelines (P=0.013). The proportion of TB patients initiating ART within two weeks of starting TB treatment increased from 30% before implementation of the new guidelines to 46% after implementation of the new guidelines (p <0.001). The median time from the start of TB treatment to ART initiation dropped from 16 days (IQR 14-31) before the new guidelines to 14 days (IQR 9-20; p = 0.004) after implementing the new guidelines. Factors associated with ART uptake were enrolment in HIV care before starting TB treatment and being a retreatment TB patient. The overall frequency of ARV-related adverse events was higher in patients on d4T/3TC/NVP (35%) than those on TDF/3TC/EFV (25%) but not significantly different (P=0.052). CONCLUSION: Implementation of the 2011 Malawi Integrated ART/PMTCT guidelines was associated with an overall increase in ART uptake among TB/HIV patients and with an increase in the number of patients initiating ART within two weeks of starting their TB treatment. However, the reduction in time between initiating TB treatment and starting ART was small suggesting that further measures must be implemented to facilitate ART uptake. Early enrolment in HIV care provides opportunities for timely ART initiation among TB patients.

Predicting harmful alcohol use prevalence in Sub-Saharan Africa between 2015 and 2019: Evidence from population-based HIV impact assessment.

INTRODUCTION: Harmful alcohol use is associated with significant risks to public health outcomes worldwide. Although data on harmful alcohol use have been collected by population-based HIV Impact Assessment (PHIA), there is a dearth of analysis on the effect of HIV/ART status on harmful alcohol use in the Sub-Saharan Africa (SSA) countries with PHIA surveys. METHODS: A secondary analysis of the PHIA surveys: Namibia (n = 27,382), Tanzania (n = 1807), Zambia (n = 2268), Zimbabwe (n = 3418), Malawi (n = 2098), Namibia (n = 27,382), and Eswatini (n = 2762). Using R version 4.2, we analysed the uptake and correlates of harmful alcohol consumption in SSA. The cutoff point for statistically significant was P<0.05. RESULTS: Of the 12,460 persons, 15% used alcohol harmfully. Harmful alcohol use varied by countries and ranged from 8.7% in Malawi to 26.1% in Namibia (P<0.001). Being female or HIV-positive and on ART were associated with less-likelihood of harmful alcohol consumption however persons that were HIV-positive and not on ART was associated with higher likelihood of harmful alcohol use (OR = 1.49, 95% CI: 1.32-1.69, P<0.001). The best performing models were Lasso or Super Learner or Random Forest were the best performing models while gradient boosting models or sample mean did not perform well. CONCLUSION: Harmful alcohol use was high. Harmful alcohol use varied by countries, sex, age, HIV/ART status and marital status. Therefore, there is a need to introduce or enforce harmful alcohol use control policies in SSA through taking into account these characteristics.

The spatial spread of HIV in Malawi: An individual-based mathematical model.

Background: The prevalence of HIV varies greatly between and within countries. We aimed to build a comprehensive mathematical modelling tool capable of exploring the reasons of this heterogeneity and test its applicability by simulating the Malawian HIV epidemic. Methods: We developed a flexible individual-based mathematical model for HIV transmission that comprises a spatial representation and individual-level determinants. We tested this model by calibrating it to the HIV epidemic in Malawi and exploring whether the heterogeneity in HIV prevalence could be reproduced. We ran the model for 1975-2030 with five alternative realizations of the geographical structure and mobility: (I) no geographical structure; 28 administrative districts including (II) only permanent inter-district relocations, (III) inter-district permanent relocations and casual sexual relationships, or (IV) permanent relocations between districts and to/from abroad and inter-district casual sex; and (V) a grid of 10 × 10km2 cells, with permanent relocations and between-cell casual relationships. We assumed HIV was present in 1975 in the districts with >10 % prevalence in 2010. We calibrated the models to national and district-level prevalence estimates. Results: Reaching the national prevalence required all adults to have at least 22 casual sex acts/year until 1990. Models II, III and V reproduced the geographical heterogeneity in prevalence in 2010 to some extent if between-district relationships were excluded (Model II; 4.9 %-21.1 %). Long-distance casual partnership mixing mitigated the differences in prevalence substantially (range across districts 4.1%-18.9 % in 2010 in Model III; 4.0%-17.6 % in Model V); with international migration the differences disappeared (Model IV; range across districts 6.9%-13.3 % in 2010). National prevalence decreased to 5 % by 2030. Conclusion: Earlier introduction of HIV into the Southern part of Malawi may cause some level of heterogeneity in HIV prevalence. Other factors such as sociobehavioural characteristics are likely to have a major impact and need investigation.

Uptake of health insurance in Malawi in 2019-2020: evidence from the multiple indicator cluster survey.

Introduction: although countries in sub-Sahara Africa (SSA) show progress in implementing various forms of health insurance, there is a dearth of information regarding health insurance in settings like Malawi. Therefore, we conducted this study to determine the uptake of health insurance and describe some of the factors associated with the prevailing uptake of health insurance in Malawi using the 2019-2020 Multiple Indicator Cluster Survey (MICS). Methods: this was a secondary analysis of the 2019-2020 MICS data. Data were analysed using frequencies and weighted percentages in Stata v.17. Furthermore, since the number of persons with health insurance is very small, we were unable to perform multivariate analysis. Results: a total of 205 (1%) of the 31259 had health insurance in Malawi in 2019-2020. Of the 205 individuals who owned health insurance, 118 (47%) had health insurance through their employers while 39 (16%) had health insurance through mutual health organizations or community-based. Men had a higher uptake of health insurance than women. The residents from urban areas were more likely to have health insurance than those in rural areas. Persons with media exposure were more likely to own health insurance as compared to their counterparts. There was an increasing trend in the uptake of health insurance by wealth of the individual with the poorest being less likely to have health insurance compared to the richest. The persons with no education were least likely to have health insurance while those with tertiary education were most likely to have health insurance. Conclusion: the uptake of health insurance in Malawi was extremely low. In order to increase the uptake of health insurance, there is a need to increase insurance coverage amongst those in formal employment, and consider minimizing the geographic, economic, and demographic barriers in accessing the health insurance.

Quality of life among type 2 diabetes mellitus patients at Kamuzu Central Hospital in Lilongwe, Malawi: A mixed-methods study.

Type II diabetes mellitus (T2DM) significantly impacts quality of life (QoL) yet data among these patients in Malawi are lacking. This study was conducted to assess QoL among patients with T2DM. A mixed-method cross-section study was conducted at Kamuzu Central Hospital (KCH), Lilongwe, Malawi. Data collection was done using a modified diabetes quality of life (MDQoL)-17 questionnaire for quantitative data while in-depth interviews and diary methods were used for qualitative data. Demographic data were summarized using descriptive statistics and inferential statistics using t-tests and ANOVA. Thematic analysis was utilized for qualitative data. A sample of 339 participants (mean age 50.3±15.5) was recruited. Overall, the mean QoL score was moderate (mean QoL 63.91±19.54). Those on health insurance had better QoL (QoL 76.71, C.I. 69.22-84.19, p-value 0.005) compared to those without health insurance. Furthermore, the absence of comorbidities was associated with having better QoL (QoL 71.18, C.I. 66.69-75.67, p-value < 0.0001). Qualitatively, T2DM was associated with patients' health status, increased stress levels, and loss of independence. There were QoL-promoting factors among T2DM patients such as diabetes health talks, having a supportive family, and following hospital advice. Inhibiting factors include drug shortages, societal perceptions, a sedentary lifestyle, stress, and despising hospital advice. Overall QoL in patients with T2DM receiving treatment at KCH is moderate. QoL of patients with T2DM is influenced by interrelated factors which require multidisciplinary team care to optimize the QoL among these patients. Health workers need to adopt a holistic approach when treating patients with T2DM, such as managing comorbidities and including assessment of QoL, behavioral change measures like physical exercises, and a healthy diet.

COVID-19 vaccine inequity in African low-income countries.

Equitable access and utilization of the COVID-19 vaccine is the main exit strategy from the pandemic. This paper used proceedings from the Second Extraordinary Think-Tank conference, which was held by the Health Economics and Policy Unit at the Kamuzu University of Health Sciences in collaboration with the Malawi Ministry of Health, complemented by a review of literature. We found disparities in COVID-19 vaccine coverage among low-income countries. This is also the case among high income countries. The disparities are driven mainly by insufficient supply, inequitable distribution, limited production of the vaccine in low-income countries, weak health systems, high vaccine hesitancy, and vaccine misconceptions. COVID-19 vaccine inequity continues to affect the entire world with the ongoing risks of emergence of new COVID-19 variants, increased morbidity and mortality and social and economic disruptions. In order to reduce the COVID-19 vaccination inequality in low-income countries, there is need to expand COVAX facility, waive intellectual property rights, transform knowledge and technology acquired into vaccines, and conduct mass COVID-19 vaccination campaigns.

Proposing the "Value- and Evidence-Based decision making and Practice" (VEDMAP) framework for Priority-Setting and knowledge translation in low and Middle-Income Countries: A novel framework for Decision-Making in Low-and middle income countries like Malawi.

The existence and availability of evidence on its own does not guarantee that the evidence will be demanded and used by decision and policy makers. Decision and policy-makers, especially in low-income settings, often confront ethical dilemmas about determining the best available evidence and its utilization. This dilemma can be in the form of conflict of evidence, scientific and ethical equipoise and competing evidence or interests. Consequently, decisions are made based on convenience, personal preference, donor requirements, and political and social considerations which can result in wastage of resources and inefficiency. To mitigate these challenges, the use of "Value- and Evidence-Based Decision Making and Practice" (VEDMAP) framework is proposed. This framework was developed by Joseph Mfutso-Bengo in 2017 through a desk review. It was pretested through a scoping study under the Thanzi la Onse (TLO) Project which assessed the feasibility and acceptability of using the VEDMAP as a priority setting tool for Health Technology Assessment (HTA) in Malawi. The study used mixed methods whereby it conducted a desk review to map out and benchmark normative values of different countries in Africa and HTA; focus group discussion and key informant interviews to map out the actual (practised) values in Malawi. The results of this review confirmed that the use of VEDMAP framework was feasible and acceptable and can bring efficiency, traceability, transparency and integrity in decision- policy making process and implementation.

Factors associated with long-acting and short-acting reversible contraceptives use among 10-24-years-old youths in Lilongwe, Malawi.

Background: Evidence suggests that Malawi continues to register substantial progress on key Family Planning (FP) indicators. However, FP adoption is still low among married youth (15-24 years old), only 38% of married girls use modern contraceptive methods coupled with high-unmet needs (22%) in the same age group. Objective: Identifying factors associated with long-acting (LARC) and short-acting (SARC) reversible contraceptive use among 10-24-years-old youth in Lilongwe, Malawi. Methodology: A retrospective study using secondary data from 64 youth outreach clinic sites in the Lilongwe district. A quantitative approach using secondary data that was analyzed in STATA version 14 was used. A sample of 14,954 youth who accessed FP and Reproductive Health (RH) services during youth outreach clinics were included in the study. Results: SARC uptake was higher than LARC (p < 0.01). Of the youths who accessed FP methods, LARC uptake was 25% (n = 3,735). Variations were noted in the uptake of LARC, especially on age, education level, client status occupation, and marital status. Factors associated with LARC uptake varied; new clients were almost twice likely to use LARC (AOR = 1.87, CI: 1.59-2.19, P < 0.01) while youth aged 20-24, the single, and student youth were less likely to use LARC. Compared to young women with formal occupations, students were less likely to use LARC (AOR = 0.30, CI: 0.158-0.58, P < 0.01). Related to the number of living children, youths with a living child were likely to use LARC (AOR = 6.40, CI: 3.91-10.48, P < 0.01). Conclusion: This study showed that LARC uptake in youth outreach clinics in Lilongwe is low, though increasing over time. In addition to this, this study shows that SARC uptake is high among youth compared to LARC. Furthermore, LARC uptake varied by age education, client status (new, existing, and unknown client), occupation, number of living children, and marital status, and there were variations in LARC uptake by the clinic. Current outreach services reach youth with LARC services, but gaps exist for underserved youths.

Factors associated with the risk of HIV infection among HIV-exposed infants in Malawi: 2013-2020.

BACKGROUND: Despite the availability of individual-level data of infants accessing HIV DNA-PCR testing service, there has been little in-depth analysis of such data. Therefore, we describe trends in risk of HIV infection among Malawi's HIV-exposed infants (HEI) with DNA-PCR HIV test result from 2013 to 2020. METHODS: This is an implementation study using routinely collected patient-level HIV DNA-PCR test result data extracted from the national Laboratory Management Information System database managed by the Department of HIV/AIDS between 1 January 2013 and 30 June 2020. We calculated frequencies, proportions and odds ratio (OR) with their associated 95% CI. We performed a random-effects logistic regression to determine the risk factors associated with HIV infection in infants, controlling for the spatial autocorrelation between districts and adjusting for other variables. RESULTS: We evaluated 255 229 HEI across 750 facilities in 28 districts. The HIV DNA-PCR test was performed within 2 months in 57% of the children. The overall HIV prevalence among all tested HEI between 2013 and 2020 was 7.2% (95% CI 7.1% to 7.3%). We observed a decreasing trend in the proportion of HEI that tested HIV positive from 7.0% (95% CI 6.6% to 7.4%) in 2013 to 5.7% (95% CI 5.4% to 5.9%) in 2015 followed by an increase to 9.9% (95% CI 9.6% to 10.2%) in 2017 and thereafter a decreasing trend between 2017 (i.e. 9.72% (95%CI: 9.43-10.01)) and 2020 (i.e. 3.86% (95%CI: 3.34-4.37)). The HIV prevalence increased by age of the HEI. There was spatial heterogeneity of HIV prevalence between districts of Malawi. The prevalence of HIV was higher among the HEI from the Northern region of Malawi. CONCLUSION: The main findings of the study are that the DNA test is performed within 2 months only in 57% of the children, that the decreasing trend of HIV prevalence among HEI observed up to 2015 was followed by an increase up to 2017 and a decrease afterwards, and that the risk of HIV infection increased with age at HIV testing. We summarised spatial and temporal trends of risk of HIV infection among HEI in Malawi between 2013 and 2020. There is need to ensure that all the HEI are enrolled in HIV care by 8 weeks of age in order to further reduce the risk of HIV in this population.

Socio-demographic factors associated with early antenatal care visits among pregnant women in Malawi: 2004-2016.

INTRODUCTION: In 2016, the WHO published recommendations increasing the number of recommended antenatal care (ANC) visits per pregnancy from four to eight. Prior to the implementation of this policy, coverage of four ANC visits has been suboptimal in many low-income settings. In this study we explore socio-demographic factors associated with early initiation of first ANC contact and attending at least four ANC visits ("ANC4+") in Malawi using the Malawi Demographic and Health Survey (MDHS) data collected between 2004 and 2016, prior to the implementation of new recommendations. METHODS: We combined data from the 2004-5, 2010 and 2015-16 MDHS using Stata version 16. Participants included all women surveyed between the ages of 15-49 who had given birth in the five years preceding the survey. We conducted weighted univariate, bivariate and multivariable logistic regression analysis of the effects of each of the predictor variables on the binary endpoint of the woman attending at least four ANC visits and having the first ANC attendance within or before the four months of pregnancy (ANC4+). To determine whether a factor was included in the model, the likelihood ratio test was used with a statistical significance of P< 0.05 as the threshold. RESULTS: We evaluated data collected in surveys in 2004/5, 2010 and 2015/6 from 26386 women who had given birth in the five years before being surveyed. The median gestational age, in months, at the time of presenting for the first ANC visit was 5 (inter quartile range: 4-6). The proportion of women initiating ANC4+ increased from 21.3% in 2004-5 to 38.8% in 2015-16. From multivariate analysis, there was increasing trend in ANC4+ from women aged 20-24 years (adjusted odds ratio (aOR) = 1.27, 95%CI:1.05-1.53, P = 0.01) to women aged 45-49 years (aOR = 1.91, 95%CI:1.18-3.09, P = 0.008) compared to those aged 15-19 years. Women from richest socio-economic position ((aOR = 1.32, 95%CI:1.12-1.58, P<0.001) were more likely to demonstrate ANC4+ than those from low socio-economic position. Additionally, women who had completed secondary (aOR = 1.24, 95%CI:1.02-1.51, P = 0.03) and tertiary (aOR = 2.64, 95%CI:1.65-4.22, P<0.001) education were more likely to report having ANC4+ than those with no formal education. Conversely increasing parity was associated with a reduction in likelihood of ANC4+ with women who had previously delivered 2-3 (aOR = 0.74, 95%CI:0.63-0.86, P<0.001), 4-5 (aOR = 0.65, 95%CI:0.53-0.80, P<0.001) or greater than 6 (aOR = 0.61, 95%CI: 0.47-0.79, <0.001) children being less likely to demonstrate ANC4+. CONCLUSION: The proportion of women reporting ANC4+ and of key ANC interventions in Malawi have increased significantly since 2004. However, we found that most women did not access the recommended number of ANC visits in Malawi, prior to the 2016 WHO policy change which may mean that women are less likely to undertake the 2016 WHO recommendation of 8 contacts per pregnancy. Additionally, our results highlighted significant variation in coverage according to key socio-demographic variables which should be considered when devising national strategies to ensure that all women access the appropriate frequency of ANC visits during their pregnancy.

Estimating the health burden of road traffic injuries in Malawi using an individual-based model.

BACKGROUND: Road traffic injuries are a significant cause of death and disability globally. However, in some countries the exact health burden caused by road traffic injuries is unknown. In Malawi, there is no central reporting mechanism for road traffic injuries and so the exact extent of the health burden caused by road traffic injuries is hard to determine. A limited number of models predict the incidence of mortality due to road traffic injury in Malawi. These estimates vary greatly, owing to differences in assumptions, and so the health burden caused on the population by road traffic injuries remains unclear. METHODS: We use an individual-based model and combine an epidemiological model of road traffic injuries with a health seeking behaviour and health system model. We provide a detailed representation of road traffic injuries in Malawi, from the onset of the injury through to the final health outcome. We also investigate the effects of an assumption made by other models that multiple injuries do not contribute to health burden caused by road accidents. RESULTS: Our model estimates an overall average incidence of mortality between 23.5 and 29.8 per 100,000 person years due to road traffic injuries and an average of 180,000 to 225,000 disability-adjusted life years (DALYs) per year between 2010 and 2020 in an estimated average population size of 1,364,000 over the 10-year period. Our estimated incidence of mortality falls within the range of other estimates currently available for Malawi, whereas our estimated number of DALYs is greater than the only other estimate available for Malawi, the GBD estimate predicting and average of 126,200 DALYs per year over the same time period. Our estimates, which account for multiple injuries, predict a 22-58% increase in overall health burden compared to the model ran as a single injury model. CONCLUSIONS: Road traffic injuries are difficult to model with conventional modelling methods, owing to the numerous types of injuries that occur. Using an individual-based model framework, we can provide a detailed representation of road traffic injuries. Our results indicate a higher health burden caused by road traffic injuries than previously estimated.

Potential impact of intervention strategies on COVID-19 transmission in Malawi: a mathematical modelling study.

BACKGROUND: COVID-19 mitigation strategies have been challenging to implement in resource-limited settings due to the potential for widespread disruption to social and economic well-being. Here we predict the clinical severity of COVID-19 in Malawi, quantifying the potential impact of intervention strategies and increases in health system capacity. METHODS: The infection fatality ratios (IFR) were predicted by adjusting reported IFR for China, accounting for demography, the current prevalence of comorbidities and health system capacity. These estimates were input into an age-structured deterministic model, which simulated the epidemic trajectory with non-pharmaceutical interventions and increases in health system capacity. FINDINGS: The predicted population-level IFR in Malawi, adjusted for age and comorbidity prevalence, is lower than that estimated for China (0.26%, 95% uncertainty interval (UI) 0.12%-0.69%, compared with 0.60%, 95% CI 0.4% to 1.3% in China); however, the health system constraints increase the predicted IFR to 0.83%, 95% UI 0.49%-1.39%. The interventions implemented in January 2021 could potentially avert 54 400 deaths (95% UI 26 900-97 300) over the course of the epidemic compared with an unmitigated outbreak. Enhanced shielding of people aged ≥60 years could avert 40 200 further deaths (95% UI 25 300-69 700) and halve intensive care unit admissions at the peak of the outbreak. A novel therapeutic agent which reduces mortality by 0.65 and 0.8 for severe and critical cases, respectively, in combination with increasing hospital capacity, could reduce projected mortality to 2.5 deaths per 1000 population (95% UI 1.9-3.6). CONCLUSION: We find the interventions currently used in Malawi are unlikely to effectively prevent SARS-CoV-2 transmission but will have a significant impact on mortality. Increases in health system capacity and the introduction of novel therapeutics are likely to further reduce the projected numbers of deaths.