Strategies for scaling up pre-ART advanced HIV disease screening at a secondary referral hospital-Malawi: a qualitative study.

BACKGROUND: Implementation of the World Health Organization (WHO) recommended Advanced HIV Disease screening package, remains poor in most settings with limited resources. More than 50% of newly diagnosed-HIV clients are missed on screening as a result of implementation barriers. It is important to mitigate the existing barriers and leverage enablers' inorder to maximize uptake of the advanced HIV disease screening. This study aimed to identify strategies for scaling up implementation of advanced HIV disease screening among newly HIV-diagnosed clients in pre-ART phase using a Consolidated Framework for Implementation Research-Expert Recommendation for Implementing Change (CFIR-ERIC) guiding tool. METHODS: A qualitative study was conducted at Rumphi district hospital in Malawi (August - September, 2023). Two sessions of Focus group discussions (FDGs) involving key stakeholders were facilitated to identify specific strategies following the initial study on exploration of barriers and facilitators of advanced HIV disease screening package. Participants comprised healthcare providers, purposively selected from key hospital departments. A deductive approach was used to analyze FDG transcripts where emerging themes were mapped with ERIC list of strategies. CFIR-ERIC Matching tool version 1.0, was used to generate an output of the most to least expert-endorsed Level 1 and Level 2 strategies. FINDINGS: About 25 key healthcare workers participated in FDGs. Overall, 6 Level 1 strategies (≥ 50% expert endorsement score) and 4 Level 2 strategies (≥ 20%, ≤ 49% expert endorsement score) were identified, targeting barriers associated with availability of resources, intervention complexity, access to knowledge and information, communication; and implementation leads. Most of the reported strategies were cross-cutting and aimed at enhancing clinical knowledge of the intervention (distributing training materials, educational meetings), developing stakeholders' interrelations (network weaving) as well as improving clinical workflow (environmental restructuring). Use of evaluative and iterative strategies such as monthly data collection for evaluation were also recommended as part of continuous improvement while an AHD coordinator was recommended to be formally appointed inorder to spearhead coordination of AHD screening services. CONCLUSION: Through the involvement of key stakeholders and the use of CFIR-ERIC matching tool, this study has identified cross-cutting strategies that if well implemented, can help to mitigate contextual barriers and leverage enablers for an improved delivery of AHD screening package.

Acceptability and feasibility of using a blended quality improvement strategy among health workers to monitor women engagement in Option B+ program in Lilongwe Malawi.

Option B + provides lifelong ART to pregnant and breastfeeding women with HIV to reduce mother-to-child transmission of HIV (eMTCT) and improve maternal health. The effectiveness of Option B + relies on continuous engagement, but suboptimal monitoring of HIV care hinders our measurements of engagement. Process mapping and quality improvement (PROMAQI) is a quality improvement strategy for healthcare workers (HCWs) to optimize complex processes such as monitoring HIV care. We assessed the acceptability and feasibility of the PROMAQI among HCWs and identified barriers and facilitators for PROMAQI implementation. A cross-sectional study using a mixed method approach was conducted from August 2021 to March 2022 across five urban health facilities participating in PROMAQI implementation n the Lilongwe district, Malawi. We assessed PROMAQI acceptability and feasibility at the end of the study. A 5-point Likert (1 = worst to 5 = best) scale tool was administered to 110 HCWs (n = 15-33 per facility) involved in PROMAQI implementationThese data were analysed using descriptive statistics Among the 110 HCWs, twenty-two (QI team (n = 11) and QI implementers (n = 11)) were purposively selected for in-depth interviews. Thematic analysis was conducted using deducted and inductive approaches. The theoretical framework for acceptability (TFA) was used to identify reasons for acceptability. The Consolidated Framework for Implementation Research (CFIR) was used to characterize the barriers and facilitators of PROMAQI implementation. HCWs recruited had a median age of 37 (32-43) years, 82.0% of whom were female. Most (42%) had completed secondary education, and 84% were nurses and community health workers. The median (IQR) acceptability and feasibility scores for the PROMAQI were 5 (IQR 4-5) and 4 (IQR 4-5), respectively. Reasons for high PROMAQI acceptability included addressing a relevant gap and improving performance. Perceived implementation barriers included poor work attitudes, time constraints, resource limitations, knowledge gaps, and workbook difficulties. The facilitators included communication, mentorship, training, and financial incentives. PROMAQI is a highly acceptable and feasible tool for monitoring engagement of women in Option B + . Addressing these barriers may optimize the implementation of PROMAQI. Scaling up PROMAQI may enhance retention in the Option B + program and facilitate eMTCT.

Management practices in facilities providing HIV services to key populations in Kenya and Malawi: A descriptive analysis of management in community-based organizations.

HIV services for key populations (KP) at higher risk of HIV infection are often delivered by community-based organizations. To achieve HIV epidemic control, countries need to scale up HIV services for KP. Little is known about the management practices of community-based organizations delivering health services. We explored the management practices and facility characteristics of community-based health facilities providing HIV services to key populations as part of the LINKAGES program in Kenya and Malawi. We collected information on management practices from 45 facilities called drop-in centers (DICs) during US Government FY 2019, adapting the World Management Survey to the HIV community-based health service delivery context. We constructed management domain scores for each facility. We then analyzed the statistical correlations between management domains (performance monitoring, people management, financial management, and community engagement) and facility characteristics (e.g., number of staff, organization maturity, service scale) using ordinary least square models. The lowest mean management domain scores were found for people management in Kenya (38.3) and financial management in Malawi (25.7). The highest mean scores in both countries were for performance monitoring (80.9 in Kenya and 82.2 in Malawi). Within each management domain, there was significant variation across DICs, with the widest ranges in scores (0 to 100) observed for financial management and community involvement. The DIC characteristics we considered explained only a small proportion of the variation in management domain scores across DICs. Community-based health facilities providing HIV services to KP can achieve high levels of management in a context where they receive adequate levels of above-facility support and oversight-even if they deliver complex services, rely heavily on temporary workers and community volunteers, and face significant financial constraints. The variation in scores suggests that some facilities may require more above-facility support and oversight than others.

Characterizing HIV status documentation among cancer patients at regional cancer centers in Malawi, Zimbabwe, and South Africa.

INTRODUCTION: In East and Southern Africa, people with HIV (PWH) experience worse cancer-related outcomes and are at higher risk of developing certain cancers. Siloed care delivery pathways pose a substantial barrier to co-management of HIV and cancer care delivery. METHODS: We conducted cross-sectional studies of adult cancer patients at public radiotherapy and oncology units in Malawi (Kamuzu Central Hospital), Zimbabwe (Parirenyatwa Group of Hospitals), and South Africa (Charlotte Maxeke Hospital) between 2018 and 2019. We abstracted cancer- and HIV-related data from new cancer patient records and used Poisson regression with robust variance to identify patient characteristics associated with HIV documentation. RESULTS: We included 1,648 records from Malawi (median age 46 years), 1,044 records from South Africa (median age 55 years), and 1,135 records from Zimbabwe (median age 52 years). Records from all three sites were predominately from female patients; the most common cancers were cervical (Malawi [29%] and Zimbabwe [43%]) and breast (South Africa [87%]). HIV status was documented in 22% of cancer records from Malawi, 92% from South Africa, and 86% from Zimbabwe. Patients with infection-related cancers were more likely to have HIV status documented in Malawi (adjusted prevalence ratio [aPR]: 1.92, 95% confidence interval [CI]: 1.56-2.38) and Zimbabwe (aPR: 1.16, 95%CI: 1.10-1.22). Patients aged ≥ 60 years were less likely to have HIV status documented (Malawi: aPR: 0.66, 95% CI: 0.50-0.87; Zimbabwe: aPR: 0.76, 95%CI: 0.72-0.81) than patients under age 40 years. Patient age and cancer type were not associated with HIV status documentation in South Africa. CONCLUSION: Different cancer centers have different gaps in HIV status documentation and will require tailored strategies to improve processes for ascertaining and recording HIV-related information in cancer records. Further research by our consortium to identify opportunities for integrating HIV and cancer care delivery is underway.

Barriers and facilitators to implementing advanced HIV disease screening at a secondary referral hospital -Malawi: a convergent parallel study.

BACKGROUND: Malawi continues to register HIV/AIDS mortality despite increased expansion of ART services and as well as advanced HIV screening as outlined in the 2020 -2025 Malawi National HIV Strategic Plan (NSP). This study aimed to explore factors influencing the implementation of the advanced HIV disease (AHD) screening package at Rumphi District Hospital, Malawi. METHODS: We conducted a mixed method, convergent study at a secondary referral hospital with 8 659 clients on ART. Guided by a consolidated framework for implementation research (CFIR) we conducted semi-structured Interviews with healthcare professionals, purposively selected from various key departments that were actively involved in AHD screening. Transcripts were organized and coded using NVivo 12 software with thematically predefined CFIR constructs. Newly HIV-positive client records extracted from ART cards (July -Dec, 2021) were analyzed using STATA 14 software. RESULTS: One hundred one ART records met inclusion criteria for review and analysis of which 60% (n = 61) of the newly diagnosed HIV clients had no documented results for CD4 Cell count. Barriers to AHD screening emerged from four major CFIR constructs: intervention complexity, communication, availability of resources and access to knowledge and information. The specific barriers included poor work coordination among implementers, limited resources to support the expansion of AHD screening, and knowledge gap among providers. External support from Ministry of Health implementing partners and the availability of committed focal leaders coordinating HIV programs emerged as major enablers of AHD screening package. CONCLUSION: The study has identified major contextual barriers to AHD screening including knowledge gap, poor communication systems and inadequate supporting resources. Improving uptake of AHD screening services would therefore require overcoming the existing barriers by adopting a comprehensive approach in developing barrier-tailored strategies.

Characterizing HIV status documentation among cancer patients at regional cancer centers in Malawi, Zimbabwe, and South Africa.

Introduction: In East and Southern Africa, people with HIV (PWH) experience worse cancer-related outcomes and are at higher risk of developing certain cancers. Siloed care delivery pathways pose a substantial barrier to co-management of HIV and cancer care delivery. Methods: We conducted cross-sectional studies of adult cancer patients at public radiotherapy and oncology units in Malawi (Kamuzu Central Hospital), Zimbabwe (Parirenyatwa Group of Hospitals), and South Africa (Charlotte Maxeke Hospital) between 2018-2019. We abstracted cancer- and HIV-related data from new cancer patient records and used Poisson regression with robust variance to identify patient characteristics associated with HIV documentation. Results: We included 1,648 records from Malawi (median age 46 years), 1,044 records from South Africa (median age 55 years), and 1,135 records from Zimbabwe (median age 52 years). Records from all three sites were predominately from female patients; the most common cancers were cervical (Malawi [29%] and Zimbabwe [43%]) and breast (South Africa [87%]). HIV status was documented in 22% of cancer records from Malawi, 92% from South Africa, and 86% from Zimbabwe. Patients with infection-related cancers were more likely to have HIV status documented in Malawi (adjusted prevalence ratio [aPR]: 1.92, 95% confidence interval [CI]: 1.56-2.38) and Zimbabwe (aPR: 1.16, 95%CI: 1.10-1.22). Patients aged ≥60 years were less likely to have HIV status documented (Malawi: aPR: 0.66, 95% CI: 0.50-0.87; Zimbabwe: aPR: 0.76, 95%CI: 0.72-0.81) than patients under age 40 years. Patient age and cancer type were not associated with HIV status documentation in South Africa. Conclusion: Different cancer centers have different gaps in HIV status documentation and will require tailored strategies to improve processes for ascertaining and recording HIV-related information in cancer records. Further research by our consortium to identify opportunities for integrating HIV and cancer care delivery is underway.

Knowledge and perceptions about Dolutegravir and Dolutegravir counselling: a qualitative study among women living with HIV.

INTRODUCTION: In 2018, the Malawi Ministry of Health adopted the recommendation to switch first-line antiretroviral therapy (ART) from an efavirenz (EFV)-based to a dolutegravir (DTG)-based regimen. Little is known about patients' experience during this transition. We conducted a qualitative study to explore DTG-related counselling challenges among providers of HIV care and factors influencing regimen switching or non-switching among women living with HIV in Lilongwe, Malawi. METHODS: Between February-July 2020, we recruited participants who took part in DTG counselling on reasons to switch, side effects, and benefits from two government health facilities providing HIV care: Area 18 health centre and Bwaila district hospital in Lilongwe, Malawi. We purposively sampled and interviewed 8 women living with HIV who remained on an EFV-based regimen after counselling, 10 women who switched to a DTG-based regimen, and 10 HIV care providers who provided counselling about ART switching. In-depth interviews were used to explore patient's perceptions of DTG, factors affecting the decision to switch, and both patient and provider experience with counselling. Interview data was coded for themes using inductive and deductive codes. Interviews were conducted until thematic saturation was achieved. Data matrices were used for analysis and thematic extraction. RESULTS: Most women in both groups were well versed on DTG's potential side effects and felt well counselled on the benefits of switching, such as quicker viral load suppression. Many women associated DTG with birth defects and expressed concern. However, the primary reason for not switching was concern with how the new medication would be tolerated, especially when they were satisfied with their current regimen. Almost all providers expressed difficulty providing DTG counselling. Primary reasons included feeling inadequately trained and/or not having resources to use during counselling, such as diagrams or brochures. CONCLUSION: DTG counselling was well accepted by women; however, some felt that their concerns were not fully addressed. Providers reflected this sentiment in that they did not feel adequately trained or well-equipped to provide adequate counselling. Training on counselling for new ART regimens should be intensified and utilize patient-centered educational materials to address the concerns raised by both patients and health care providers.

Male partners' support and influence on pregnant women's oral PrEP use and adherence in Malawi.

Introduction: Daily oral pre-exposure prophylaxis (PrEP) is a safe and effective HIV prevention method for pregnant and postpartum women, but adherence barriers exist. Understanding the role of male partners in supporting PrEP use may inform strategies to support PrEP adherence among pregnant and breastfeeding women. Methods: To understand male partners' involvement in women's use of PrEP, we conducted in-depth interviews with pregnant women in Lilongwe, Malawi who had recently decided to use PrEP (n = 30) and their male partners (n = 20) in the context of a PrEP adherence trial. Women were purposively recruited to ensure variation in their partners' HIV status. Interviews were conducted in Chichewa using a semistructured guide. We followed a thematic approach to analyze the interview data. Results: Most male partners were receptive to women using PrEP during pregnancy because it eased their fears of the woman and baby acquiring HIV. Men often played a key role in women's PrEP adherence by providing daily reminders and encouragement to adhere to their medication. The majority of women appreciated this support from the men as it lessened the burden of remembering to take their medications daily on their own and aided their adherence. However, several women who lacked male partner support spoke of wanting their partners to be more involved. Many men living with HIV found the mutual support beneficial for their antiretroviral therapy adherence, while men without HIV or with status unknown appreciated knowing that the family was protected. While most men were open to women continuing PrEP beyond the current study, some would only support it if women were still at risk for acquiring HIV. Conclusion: In this study, male partners were strongly motivated to support the PrEP adherence of their female partners as a way of ensuring that the pregnant women and unborn babies were protected against HIV. Promoting disclosure and tangible support that arises organically among men may be helpful, but programs to enhance this support and identify ways to support women who do not receive support from their partners or do not wish to disclose their PrEP use to partners may be needed.

Evaluating the Knowledge Change Before and After Continuing Cancer Education in Malawian Nurses.

Malawi has a high cancer incidence and mortality. Efforts to train and educate oncology nurses have been identified as an area of need. This study evaluates the educational needs of oncology nurses in Malawi and the effects of a virtual cancer education program on improving the knowledge of cancer epidemiology, treatment, and nursing care of common cancers among oncology nurses in Malawi. The educational programs consisted of four sessions at one-month intervals focused on Cancer Screening, Survivorship, Radiation Therapy, and Complementary and Alternative Therapies. A pretest-posttest design was used. Overall, there was an increase in knowledge at each session: cancer screening (47% vs 95%), survivorship (22% vs 100%), radiation therapy (66% vs 100%), and complementary and alternative therapies (63% vs 88%). Using virtual continuing education sessions is an effective tool to enhance the knowledge of oncology nurses in Malawi. These education sessions can serve as an example of how other Schools of Nursing and cancer centers in high-resource countries can collaborate with hospitals and Schools of Nursing in low- and middle-resource countries to support the advancement of oncology nursing knowledge, and ultimately, oncologic care.

Systematic review of psychosocial interventions for adult cancer patients and their family caregivers in Sub-Saharan Africa.

Cancer is becoming a public health issue in the Sub-Saharan Africa (SSA). This systematic review aims to synthesise psychosocial interventions and their effects on the health outcomes of adult cancer patients and their family caregivers in SSA. We identified eligible publications in English language from PubMed, Cumulative Index of Nursing and Allied Health Literature Plus with Full Text, Embase, APA PsycInfo, Scopus, and African Index Medicus databases. We included psychosocial interventions targeted adult cancer patients/survivors or their family caregivers in SSA. This review identified five psychosocial interventions from six studies that support adult cancer patients and their family caregivers in SSA. The interventions focused on providing informational, psycho-cognitive, and social support. Three interventions significantly improved quality of life outcomes for cancer patients and their caregivers. Significant gaps exist between the rapidly increasing cancer burdens and the limited psychosocial educational interventions supporting adult cancer patients and their families in SSA. The reviewed studies provide preliminary evidence on development and testing interventions that aim to improve patients' and caregivers' quality of life.

Psychosocial experiences of cancer survivors and their caregivers in sub-Saharan Africa: A synthesis of qualitative studies.

OBJECTIVE: To synthesize and examine current literature on survivorship experiences and psychosocial oncologic care programs of individuals affected by cancer in sub-Saharan Africa (SSA). METHODS: This was a systematic review guided by the PRISMA 2020 guidelines. We searched 6 databases for articles published from inception to 21 October 2021. Articles were appraised using the Johanna Briggs Institute's Checklist for Qualitative Research. For data synthesis, we used the World Health Organization (WHO) quality of life framework [WHOQOL] to organize experiences into 6 domains/themes. RESULTS: Twenty-five qualitative studies were included in the synthesis. Studies focused on psychosocial care of adults (>18 years) affected by cancer in SSA. The common WHOQOL domains were social relations, spirituality/religion/personal beliefs, and psychological. CONCLUSION: Findings echo need for individuals with cancer and their caregivers. Healthcare professionals are an essential resource for information and support services that can be tailored to individuals need. This synthesis highlighted caregiver stress and stressors from the community that could impact care of individuals with cancer. A holistic approach is needed that incorporates professional and social aspects of care.

Perceptions on acceptability of the 2016 WHO ANC model among the pregnant women in Phalombe District, Malawi - a qualitative study using Theoretical Framework of Acceptability.

BACKGROUND: The World Health Organization introduced a new model of care, 'The 2016 WHO ANC Model' to overcome challenges encountered during the implementation of the Focused Antenatal Care Approach. For any new intervention to achieve its objective, it must be widely accepted by both the deliverers and recipients. Malawi rolled out the model in 2019 without carrying out acceptability studies. The objective of this study was to explore the perceptions of pregnant women and health care workers on the acceptability of 2016 WHO's ANC model in Phalombe District, Malawi using the Theoretical Framework of Acceptability. METHODOLOGY: We conducted a descriptive qualitative study between May and August 2021. The Theoretical Framework of Acceptability was used to guide the development of study objectives, data collection tools, and data analysis. We purposely conducted 21 in-depth interviews (IDIs) among pregnant women, postnatal mothers, a safe motherhood coordinator, and Antenatal care (ANC) clinic midwives, and two focus group discussions (FGDs) among Disease Control and Surveillance Assistants. All IDIs and FGDs were conducted in Chichewa, digitally recorded, and simultaneously transcribed and translated into English. Data was analysed manually using content analysis. RESULTS: The model is acceptable among most pregnant women and they reckoned that it would help reduce maternal and neonatal deaths. Support from a husband, peers, and health care workers facilitated acceptability of the model while the increased number of ANC contacts which resulted in fatigue and increased transportation cost incurred by the women was a deterrent. CONCLUSION: This study has shown that most pregnant women have accepted the model despite facing numerous challenges. Therefore, there is a need to strengthen the enabling factors and address the bottlenecks in the implementation of the model. Furthermore, the model should be widely publicised so that both intervention deliverers and recipients of care implement the model as intended. This will in turn help to achieve the model's aim of improving maternal and neonatal outcomes and creating a positive experience with health care among pregnant women and adolescent girls.

Barriers and facilitators to implementing Advanced HIV Disease screening at secondary referral hospital -Malawi: Asequential exploratory mixed method-study.

Background Malawi continues to register increased HIV/AIDs mortality despite increased expansion of ART services. One of the strategies for reducing AIDS related deaths outlined in the Malawi National HIV Strategic Plan (NSP) is scaling up screening for AHD in all antiretroviral therapy (ART) screening sites. This study investigated factors influencing the implementation of the advanced HIV disease (AHD) screening package at Rumphi District Hospital, Malawi. Methods We conducted a mixed method, sequential exploratory study from March, 2022 to July, 2022. The study was guided by a consolidated framework of implementation research (CFIR). Interviews were administered to key healthcare providers, purposively selected from various hospital departments. Transcripts were organized and coded using NVivo 12 software with thematically predefined CFIR constructs. Newly HIV-positive client records extracted from ART cards (July -Dec, 2021) were analyzed using STATA 14 which generated table of proportions, means and standard deviations. Results Out of 101 data records of the new ART clients reviewed, 60% {(n = 61) had no documented results for CD4 Cell count as a baseline screening test for AHD. Four major themes emerged as barriers: complexity of the intervention, poor work coordination, limited resources to support the expansion of point of care services for AHD, knowledge and information gap among providers. Technical support from MoH implementing partners and the availability of committed focal leaders coordinating HIV programs emerged as major facilitators of AHD screening package. Conclusion The study has identified major contextual barriers to AHD screening affecting work coordination and client linkage to care. Improving coverage of AHD screening services would therefore require overcoming the existing barriers such communication and information gaps.

Cancer-Related Stigma in Malawi: Narratives of Cancer Survivors.

PURPOSE: Stigma is an impediment across the cancer care continuum, leading to delayed presentation to care, elevated morbidity and mortality, and reduced quality of life. The goal of this study was to qualitatively examine the drivers, manifestations, and impacts of cancer-related stigma among individuals who received cancer treatment in Malawi, and to identify opportunities to address stigma. METHODS: Individuals who had completed treatment for lymphoma (n = 20) or breast cancer (n = 9) were recruited from observational cancer cohorts in Lilongwe, Malawi. Interviews explored the individual's cancer journey, from first symptoms through diagnosis, treatment, and recovery. Interviews were audio-recorded and translated from Chichewa to English. Data were coded for content related to stigma, and thematically analyzed to describe the drivers, manifestations, and impacts of stigma along the cancer journey. RESULTS: Drivers of cancer stigma included beliefs of cancer origin (cancer as infectious; cancer as a marker of HIV; cancer due to bewitchment), perceived changes in the individual with cancer (loss of social/economic role; physical changes), and expectations about the individual's future (cancer as death sentence). Cancer stigma manifested through gossip, isolation, and courtesy stigma toward family members. The impacts of cancer stigma included mental health distress, impediments to care engagement, lack of cancer disclosure, and self-isolation. Participants suggested the following programmatic needs: community education about cancer; counseling in health facilities; and peer support from cancer survivors. CONCLUSION: The results highlight multifactorial drivers, manifestations, and impacts of cancer-related stigma in Malawi, which may affect success of cancer screening and treatment programs. There is a clear need for multilevel interventions to improve community attitudes toward people with cancer, and to support individuals along the continuum of cancer care.

Opinions on integrating couple counselling and female sexual reproductive health services into Voluntary Medical Male Circumcision services in Lilongwe, Malawi.

BACKGROUND: Couples HIV Counselling and Testing (CHCT) has been found to be potentially beneficial than individual HIV Counselling and Testing for prevention and treatment of HIV. However, there are few health care opportunities for men and women to access health services together, leading to underutilization of CHCT service. Integrating female Sexual and Reproductive Health (SRH) services into male-dominated service could be more effective than trying to integrate men's health services into female-dominated health services. A potential site for male-female service integration could be Voluntary Medical Male Circumcision (VMMC) centers. METHODOLOGY: We conducted a qualitative study in Lilongwe, Malawi between June to August 2018. Twenty VMMC clients, 20 peers and 20 VMMC providers completed individual in-depth interviews to share their opinions on what they thought about integrating CHCT and other SRH Services into VMMC services. These proposed SRH services include family planning, cervical cancer screening, sexually transmitted infection management and pre-exposure prophylaxis (PrEP). Content analysis was used to analyze the results. RESULTS: All participants were receptive to integration of CHCT, and most accepted the integration of SRH services into VMMC Services. Most VMMC clients, peers and care providers said that CHCT integration would help couples to know their HIV status, prevent HIV transmission, encourage healthy relationships, and provide a chance for women to participate in VMMC counselling and wound care. However, integration of other services, such as family planning and cervical cancer screening, drew mixed opinions among participants. Most VMMC clients, peers and providers felt that integration of services would promote male involvement and increase men's knowledge in feminine sexual reproductive health services. A few providers expressed concerns over service integration, citing reasons such as overcrowding, work overload, gender mixing, and lack of provider capacity and space. Most participants supported integrating PrEP with VMMC Services and felt that PrEP would complement VMMC in HIV prevention. Few providers, peers and VMMC clients felt the addition of PrEP to VMMC services would lead to high-risk sexual activity that would then increase the risk for HIV acquisition. A few participants recommended community sensitization when integrating some of sexual reproductive health services into VMMC Services to mitigate negative perceptions about VMMC services and encourage service uptake among couples. CONCLUSION: Most participants service providers, VMMC clients and Peers were receptive to integrating SRH services, particularly HIV prevention services such as CHCT and PrEP, into male dominated VMMC services. Adequate community sensitization is required when introducing other SRH services into VMMC services.

Perceptions of cervical cancer and motivation for screening among women in Rural Lilongwe, Malawi: A qualitative study.

INTRODUCTION: Cervical cancer is the leading cause of cancer death among women in Malawi. Low awareness of cervical cancer and negative perceptions of screening can prevent women from participating in preventative strategies. We sought to explore perceptions and motivations for screening among women who participated in a cervical cancer screen-and-treat pilot study in rural Malawi. MATERIALS AND METHODS: We conducted a qualitative sub-study of a community-based cervical cancer screen-and-treat pilot study in rural Lilongwe between July-August 2017. From October 2017-February 2018, 17 women who underwent screening using visual inspection with acetic acid (VIA) and same-day thermal ablation treatment were recruited at their 12-week follow-up visit post treatment to participate in this qualitative sub-study. Semi-structured interview guides that explored baseline knowledge of cervical cancer, perceptions, and motivation for screening were used for in-depth interviews (IDIs). IDIs were conducted in the local language, Chichewa, translated and transcribed to English. Data was analyzed using NVivo® V12.0. RESULTS: Findings included fatalistic views on cancer, but limited knowledge specific to cervical cancer. Misconceptions of cervical cancer screening were common; however, there was a unique understanding of screening as prevention (i.e., finding and treating early disease to prevent progression to worsening disease). This understanding appeared to stem from HIV prevention concepts known to the community. Motivations for screening included desire to know one's health status, convenience of community-based screening, and peer encouragement. CONCLUSION: Despite limited knowledge of cervical cancer and misconceptions of screening, the concept of screening for prevention, desire to know one's health status, convenient access, and peers' influence were motivators for participation in screening. Cervical cancer screen-and-treat programs in high HIV prevalence areas should consider utilizing language that parallels HIV prevention language to communicate the need for cervical cancer screening and treatment and utilize prevention concepts that may already be familiar to women living there.

Quality of life among patients with cancer and their family caregivers in the Sub-Saharan region: A systematic review of quantitative studies.

Guided by the World Health Organization quality of life (WHOQOL) framework, this systematic review aimed to examine evidence about the prevalence and severity of QOL-related health problems and their influencing factors in Sub-Saharan Africa (SSA). We identified eligible publications in English language from PubMed, Cumulative Index of Nursing and Allied Health Literature Plus with Full Text, Embase, APA PsycInfo, Scopus, and African Index Medicus databases. We included quantitative descriptive studies that measured overall and subdomains of QOL as the outcome in adult patients/survivors with cancer in SSA. Twenty-six descriptive cross-sectional studies (27 papers) that were conducted since 1988 in different SSA countries among patients with various types of cancer met our inclusion criteria. We found inconsistencies in how the prevalence and severity of QOL-related health problems have been researched and reported across studies, which complicated comparing findings and drawing conclusions. The most common factors that influenced the overall and subdomains of QOL included coping; internal and external locus of control; symptoms and symptom management; and religious beliefs and religious care. Demographics (e.g., age and marital status), cancer-related factors (cancer stage and type of treatment), and social determinants of health (e.g., education, access to information and resources, financial distress, and urban vs rural residency) also impacted QOL and its subdomains. Our findings indicate the significant need for recognizing and managing QOL-related problems for cancer patients and caregivers in SSA. Research needs to use culturally adapted, standardized assessment tools and analysis approaches to better understand the QOL challenges this population faces. Comprehensive supportive care is needed to address the complex QOL issues in resource-limited SSA.

Barriers to follow-up after an abnormal cervical cancer screening result and the role of male partners: a qualitative study.

INTRODUCTION: Cervical cancer is the leading cause of cancer deaths among women in Malawi, but preventable through screening. Malawi primarily uses visual inspection with acetic acid (VIA) for screening, however, a follow-up for positive screening results remains a major barrier, in rural areas. We interviewed women who underwent a community-based screen-and-treat campaign that offered same-day treatment with thermocoagulation, a heat-based ablative procedure for VIA-positive lesions, to understand the barriers in accessing post-treatment follow-up and the role of male partners in contributing to, or overcoming these barriers. METHODS: We conducted in-depths interviews with 17 women recruited in a pilot study that evaluated the safety and acceptability of community-based screen-and-treat programme using VIA and thermocoagulation for cervical cancer prevention in rural Lilongwe, Malawi. Ten of the women interviewed presented for post-treatment follow-up at the healthcare facility and seven did not. The interviews were analysed for thematic content surrounding barriers for attending for follow-up and role of male partners in screening. RESULTS: Transportation was identified as a major barrier to post-thermocoagulation follow-up appointment, given long distances to the healthcare facility. Male partners were perceived as both a barrier for some, that is, not supportive of 6-week post-thermocoagulation abstinence recommendation, and as an important source of support for others, that is, encouraging follow-up attendance, providing emotional support to maintaining post-treatment abstinence and as a resource in overcoming transportation barriers. Regardless, the majority of women desired more male partner involvement in cervical cancer screening. CONCLUSION: Despite access to same-day treatment, long travel distances to health facilities for post-treatment follow-up visits remained a major barrier for women in rural Lilongwe. Male partners were identified both as a barrier to, and an important source of support for accessing and completing the screen-and-treat programme. To successfully eliminate cervical cancer in Malawi, it is imperative to understand the day-to-day barriers women face in accessing preventative care.

Stigma, Social Support, and Sexual Behavior Among Female Sex Workers at Risk for HIV in Malawi.

Lack of social support and sex work stigma may hinder STI/HIV prevention for female sex workers (FSW). We explored the associations between sex work stigma and social support with sexual behaviors in Malawi. In 2017, 150 HIV-negative, venue-based FSW completed a behavioral survey containing sex work stigma items and social support. Linear binomial regression models were used to estimate prevalence differences of inconsistent condom use and substance use before sex by social support and stigma. A majority (93%) reported sex work-related internalized stigma. About 50% reported family or friend isolation. Social support was high (mean index: 86.53). Inconsistent condom use and substance use before sex had little to no association with stigma and social support. Malawian FSW largely internalize stigma and experience isolation from family and friends yet have high levels of social support. Large-scale evaluations should investigate the role of stigma and social support in STI/HIV prevention for FSW.

Women's experiences in a community-based screen-and-treat cervical cancer prevention program in rural Malawi: a qualitative study.

BACKGROUND: Malawi has the world's highest cervical cancer incidence and mortality due to high rate of HIV coupled with inadequate screening and treatment services. The country's cervical cancer control program uses visual inspection with acetic acid (VIA) and cryotherapy, but screening is largely limited by poor access to facilities, high cost of cryotherapy gas, and high loss-to-follow-up. To overcome these limitations, we implemented a community-based screen-and-treat pilot program with VIA and thermocoagulation. Through a qualitative study, we explore the experiences of women who underwent this community-based pilot screening program. METHODS: We implemented our pilot program in rural Malawi and conducted an exploratory qualitative sub-study. We conducted in-depth interviews with women who were treated with thermocoagulation during the program. We used semi-structured interviews to explore screen-and-treat experience, acceptability of the program and attitudes towards self-sampling for HPV testing as an alternative screening method. Content analysis was conducted using NVIVO v12. RESULTS: Between July - August 2017, 408 participants eligible for screening underwent VIA screening. Thirty participants had VIA positive results, of whom 28 underwent same day thermocoagulation. We interviewed 17 of the 28 women who received thermocoagulation. Thematic saturation was reached at 17 interviews. All participants reported an overall positive experience with the community-based screen-and-treat program. Common themes were appreciation for bringing screening directly to their villages, surprise at the lack of discomfort, and the benefits of access to same day treatment immediately following abnormal screening. Negative experiences were rare and included discomfort during speculum exam, long duration of screening and challenges with complying with postprocedural abstinence. Most participants felt that utilizing self-collected HPV testing could be acceptable for screening in their community. CONCLUSIONS: Our exploratory qualitative sub-study demonstrated that the community-based screen-and-treat with VIA and thermocoagulation was widely accepted. Participants valued the accessible, timely, and painless thermocoagulation treatment and reported minimal side effects. Future considerations for reaching rural women can include community-based follow-up, cervical cancer education for male partners and self-sampling for HPV testing.