Early Effects of Scaling Up Dolutegravir-Based ARV Regimens Among Children Living with HIV in Malawi.

Viral suppression (VS) in children has remained suboptimal compared to that in adults. We evaluated the impact of transitioning children weighing < 20 kg to a pediatric formulation of dolutegravir (pDTG) on VS in Malawi. We analyzed routine retrospective program data from electronic medical record systems pooled across 169 healthcare facilities in Malawi supported by the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). We included children who weighed < 20 kg and received antiretroviral therapy (ART) between July 2021-June 2022. Using descriptive statistics, we summarized demographic and clinical characteristics, ART regimens, ART adherence, and VS. We used logistic regression to identify factors associated with post-transition VS. A total of 2468 Children Living with HIV (CLHIV) were included, 55.3% of whom were < 60 months old. Most (83.8%) had initiated on non-DTG-based ART; 71.0% of these had a viral load (VL) test result before transitioning to pDTG, and 62.5% had VS. Nearly all (99.9%) CLHIV transitioned to pDTG-based regimens. Six months after the transition, 52.7% had good ART adherence, and 38.6% had routine VL testing results; 81.7% achieved VS. Post-transition VS was associated with good adherence and pre-transition VS: adjusted odds ratios of 2.79 (95% CI 1.65-4.71), p < 0.001 and 5.32 (95% CI 3.23-9.48), p < 0.001, respectively. After transitioning to pDTG, VS was achieved in most children tested within the first 6 months. However, adherence remained suboptimal post-transition and VL testing at 6 months was limited. Interventions to improve VL testing and enhance ART adherence are still needed in CLHIV on pDTG-based regimens.

Correction: Experiences of doctoral students enrolled in a research fellowship program to support doctoral training in Africa (2014 to 2018): The Consortium for Advanced Research Training in Africa odyssey.

[This corrects the article DOI: 10.1371/journal.pone.0252863.].

Understanding health systems challenges in providing Advanced HIV Disease (AHD) care in a hub and spoke model: a qualitative analysis to improve AHD care program in Malawi.

BACKGROUND: Despite tremendous progress in antiretroviral therapy (ART) and access to ART, many patients have advanced human immunodeficiency virus (HIV) disease (AHD). Patients on AHD, whether initiating ART or providing care after disengagement, have an increased risk of morbidity and mortality. The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) launched an enhanced care package using a hub-and-spoke model to optimize AHD care in Malawi. This model improves supply availability and appropriate linkage to care. We utilized a hub-and-spoke model to share health facility challenges and recommendations on the AHD package for screening and diagnosis, prophylaxis, treatment, and adherence support. METHODS: This qualitative study assessed the facility-level experiences of healthcare workers (HCWs) and lay cadres (LCs) providing AHD services to patients through an intervention package. The study population included HCWs and LCs supporting HIV care at four intervention sites. Eligible study participants were recruited by trained Research Assistants with support from the health facility nurse to identify those most involved in supporting patients with AHD. A total of 32 in-depth interviews were conducted. Thematic content analysis identified recurrent themes and patterns across participants' responses. RESULTS: While HCWs and LCs stated that most medications are often available at both hub and spoke sites, they reported that there are sometimes limited supplies and equipment to run samples and tests necessary to provide AHD care. More than half of the HCWs stated that AHD training sufficiently prepared them to handle AHD patients at both the hub and spoke levels. HCWs and LCs reported weaknesses in the patient referral system within the hub-and-spoke model in providing a linkage of care to facilities, specifically improper referral documentation, incorrect labeling of samples, and inconsistent availability of transportation. While HCWs felt that AHD registers were time-consuming, they remained motivated as they thought they provided better patient services. CONCLUSIONS: These findings highlight the importance of offering comprehensive AHD services. The enhanced AHD program addressed weaknesses in service delivery through decentralization and provided services through a hub-and-spoke model, improved supply availability, and strengthened linkage to care. Additionally, addressing the recommendations of service providers and patients is essential to improve the health and survival of patients with AHD.

Factors associated with COVID-19 vaccine receipt among mobile phone users in Malawi: Findings from a national mobile-based syndromic surveillance survey, July 2021-April 2022.

Malawi recommended COVID-19 vaccines for adults aged ≥18 years in March 2021. We assessed factors associated with receiving COVID-19 vaccines in Malawi as part of a telephone-based syndromic surveillance survey. We conducted telephone-based syndromic surveillance surveys with questions on COVID-19 vaccine receipt among adults (≥18 years old) upon verbal consent from July 2021 to April 2022. We used random digit dialing to select mobile phone numbers and employed electronic data collection forms on secure tablets. Survey questions included whether the respondent had received at least one dose of a COVID-19 vaccine. We used multivariable analysis to identify factors associated with COVID-19 vaccine receipt. Of the 51,577 participants enrolled; 65.7% were male. Males were less likely to receive the COVID-19 vaccine than females (AOR 0.83, 95% CI 0.80-0.86). Compared to those aged 18-24 years, older age had increased odds of vaccine receipt: 25-34 years (AOR 1.32, 95% CI 1.24-1.40), 35-44 years (AOR 2.00, 95% CI 1.88-2.13), 45-54 years (AOR 3.02, 95% CI 2.82-3.24), 55-64 years (AOR 3.24, 95% CI 2.93-3.57) and 65 years+ (AOR 3.98, 95% CI 3.52-4.49). Respondents without formal education were less likely to receive vaccination compared to those with primary (AOR 1.30, 95% CI 1.14-1.48), secondary (AOR 1.76, 95% CI 1.55-2.01), and tertiary (AOR 3.37, 95% CI 2.95-3.86) education. Respondents who thought COVID-19 vaccines were unsafe were less likely to receive vaccination than those who thought it was very safe (AOR 0.26, 95% CI 0.25-0.28). Residents of the Central and Southern regions had reduced odds of vaccine receipt compared to those in the North (AORs 0.79, (95% CI 0.74-0.84) and 0.55, (95% CI 0.52-0.58) respectively). Radio (72.6%), health facilities (52.1%), and social media (16.0%) were the more common self-reported sources of COVID-19 vaccine information. COVID-19 vaccine receipt is associated with gender, age, education, and residence. It is important to consider these factors when implementing COVID-19 vaccination programs.

Safety of Janssen Ad26.COV.S and Astra Zeneca AZD1222 COVID-19 Vaccines among Mobile Phone Users in Malawi: Findings from a National Mobile-Based Syndromic Surveillance Survey, July 2021 to December 2021.

The safety profiles of the Ad26.COV2.S and AZD1222 COVID-19 vaccines have not been described in the general population in Malawi. We present self-reported adverse events (AE) following the receipt of these vaccines in Malawi as part of a national syndromic surveillance survey. We conducted phone-based syndromic surveillance surveys among adults (≥18 years) with verbal consent. We used secure tablets through random digit dialing to select mobile phone numbers and collected data electronically. Survey questions included whether the respondent had received the COVID-19 vaccines, whether they had experienced any AE following vaccination, and the severity of the AE. We used multivariable analysis to identify factors associated with self-reported AE post-COVID-19 vaccination. A total of 11,924 (36.0%) out of 33,150 respondents reported receiving at least one dose of either Ad26.COV2.S or AZD1222 between July-December 2021; of those, 65.1% were female. About 49.2% of the vaccine recipients reported at least one AE, 90.6% of which were mild, and 2.6% were severe. Higher education level and concern about the safety of COVID-19 vaccines were associated with AE self-report (Adjusted Odds Ratio [AOR] 2.63 [95% CI 1.96-3.53] and 1.44, [95% CI 1.30-1.61], respectively), while male gender and older age were associated with reduced likelihood of AE self-report (AORs 0.81, [95% CI 0.75-0.88], 0.62 [95% CI 0.50-0.77], respectively). Ad26.COV2.S and AZD1222 vaccines are well-tolerated, with primarily mild and few severe AE among adults living in Malawi. Self-reporting of AE following COVID-19 vaccination is associated with gender, age, education, and concern about the safety of the vaccines. Recognizing these associations is key when designing and implementing COVID-19 vaccination communication messages to increase vaccination coverage.

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.

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.

Protocol to implement a syndromic surveillance survey of COVID-19 in Malawi.

Introduction: Malawi experienced two waves of COVID-19 between April 2020 and February 2021. A High negative impact of COVID-19 was experienced in the second wave, with increased hospital admissions that overwhelmed the healthcare system. This paper describes a protocol to implement a telephone-based syndromic surveillance system to assist public health leaders in the guidance, implementation, and evaluation of programs and policies for COVID-19 prevention and control in Malawi. Study design: This is a serial cross-sectional telephonic-based national survey focusing on the general population and People living with HIV and AIDS. Methods: We will conduct a serial cross-sectional telephone survey to assess self-reported recent and current experience of influenza-like illness (ILI)/COVID-19-like-illness (CLI), household deaths, access to routine health services, and knowledge related to COVID-19. Structured questionnaires will be administered to two populations: 1) the general population and 2) people living with HIV (PLHIV) on antiretroviral therapy (ART) at EGPAF-supported health facilities. Electronic data collection forms using secure tablets will be used based on randomly selected mobile numbers from electronic medical records (EMR) for PLHIV. We will use random digit dialing (RDD) for the general population to generate phone numbers to dial respondents. The technique uses computer-generated random numbers, using the 10-digit basic structure of mobile phone numbers for the two existing mobile phone companies in Malawi. Interviews will be conducted only with respondents that will verbally consent. A near real-time online dashboard will be developed to help visualize the data and share results with key policymakers. Conclusion: The designed syndromic surveillance system is low-cost and feasible to implement under COVID-19 restrictions, with no physical contact with respondents and limited movement of the study teams and communities. The system will allow estimation proportions of those reporting ILI/CLI among the general population and PLHIV on ART and monitor trends over time to detect locations with possible COVID-19 transmission. Reported household deaths in Malawi, access to health services, and COVID-19 knowledge will be monitored to assess the burden and impact on communities in Malawi.

Experiences of doctoral students enrolled in a research fellowship program to support doctoral training in Africa (2014 to 2018): The Consortium for Advanced Research Training in Africa odyssey.

BACKGROUND: The Consortium for Advanced Research Training in Africa (CARTA) aims to transform higher education in Africa. One of its main thrusts is supporting promising university faculty (fellows) to obtain high quality doctoral training. CARTA offers fellows robust support which includes funding of their attendance at Joint Advanced Seminars (JASes) throughout the doctoral training period. An evaluation is critical in improving program outcomes. In this study; we, CARTA fellows who attended the fourth JAS in 2018, appraised the CARTA program from our perspective, specifically focusing on the organization of the program and its influence on the fellows' individual and institutional development. METHODS: Exploratory Qualitative Study Design was used and data was obtained from three focus group discussions among the fellows in March 2018. The data were analyzed using thematic approach within the framework of good practice elements in doctoral training-Formal Research Training, Activities Driven by Doctoral Candidates, Career Development as well as Concepts and Structures. RESULTS: In all, 21 fellows from six African countries participated and all had been in the CARTA program for at least three years. The fellowship has increased fellows research skills and expanded our research capacities. This tremendously improved the quality of our doctoral research and it was also evident in our research outputs, including the number of peer-reviewed publications. The CARTA experience inculcated a multidisciplinary approach to our research and enabled significant improvement in our organizational, teaching, and leadership skills. All these were achieved through the well-organized structures of CARTA and these have transformed us to change agents who are already taking on research and administrative responsibilities in our various home institutions. Unfortunately, during the long break between the second and the third JAS, there was a gap in communication between CARTA and her fellows, which resulted in some transient loss of focus by a few fellows. CONCLUSION: The CARTA model which builds the research capacity of doctoral fellows through robust support, including intermittent strategic Joint Advanced Seminars has had effective and transformative impacts on our doctoral odyssey. However, there is a need to maintain the momentum through continuous communication between CARTA and the fellows all through this journey.

Healthcare providers' attitudes towards care for men who have sex with men (MSM) in Malawi.

BACKGROUND: Men who have sex with men (MSM) are a priority group in Malawi's national response to Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS). There are limited data on service providers' acceptability to deliver appropriate sexual health services in relation to HIV prevention, care and treatment targeting the MSM. We assessed attitudes of healthcare providers already working, health professions students and faculty at health professions training institutions regarding the provision of MSM focused HIV related health services. METHODS: We conducted a qualitative study between April and May 2017 in Lilongwe, Malawi. We purposively recruited 15 participants (5 health service providers, 5 health professions students and 5 faculty of tertiary health training institutions) among whom individual in-depth interviews were conducted. Interviews were audio recorded, transcribed and analysed thematically. RESULTS: Participants recognized MSM as having health needs and rights. Participants generally expressed willingness to deliver appropriate healthcare because they perceived this as their professional responsibility. Participants suggested that it was the responsibility for MSM to disclose their sexual orientation and or preferences when they access care such that healthcare providers better anticipate their care needs. They suggested a need to increase the availability of MSM-centered and friendly health services as well as trained providers that are non-judgmental, non-discriminatory and have respect for people's right to health care access. CONCLUSION: Despite widespread poor attitudes against MSM in Malawi, health service providers and health professions students and faculty accepted and were willing to provide MSM-focused health services. The acceptability and willingness of health service providers, health professions students and faculty to provide health services to MSM offer hope and scope for efforts to strengthen the delivery of health services and quality of care to MSM in Malawi.

Methods and challenges in measuring the impact of national pneumococcal and rotavirus vaccine introduction on morbidity and mortality in Malawi.

BACKGROUND: Pneumonia and gastroenteritis are leading causes of vaccine-preventable childhood morbidity and mortality. Malawi introduced pneumococcal conjugate and rotavirus vaccines to the immunisation programme in 2011 and 2012, respectively. Evaluating their effectiveness is vital to ensure optimal implementation and justify sustained investment. METHODS/DESIGN: A national evaluation platform was established to determine vaccine effectiveness and impact in Malawi. Impact and effectiveness against vaccine-type invasive pneumococcal disease, radiological pneumonia and rotavirus gastroenteritis are investigated using before-after incidence comparisons and case-control designs, respectively. Mortality is assessed using a prospective population cohort. Cost-effectiveness evaluation is nested within the case-control studies. We describe platform characteristics including strengths and weaknesses for conducting vaccine evaluations. DISCUSSION: Integrating data from individual level and ecological methods across multiple sites provides comprehensive information for policymakers on programme impact and vaccine effectiveness including changes in serotype/genotype distribution over time. Challenges to robust vaccine evaluation in real-world conditions include: vaccination ascertainment; pre-existing rapid decline in mortality and pneumococcal disease in the context of non-vaccine interventions; and the maintenance of completeness and quality of reporting at scale and over time. In observational non-randomised designs ascertainment of vaccine status may be biased particularly in infants with fatal outcomes. In the context of multiple population level interventions targeting study endpoints attribution of reduced incidence to vaccine impact may be flawed. Providing evidence from several independent but complementary studies will provide the greatest confidence in assigning impact. Welcome declines in disease incidence and in child mortality make accrual of required sample sizes difficult, necessitating large studies to detect the relatively small but potentially significant contribution of vaccines to mortality prevention. Careful evaluation of vaccine effectiveness and impact in such settings is critical to sustaining support for vaccine programmes. Our evaluation platform covers a large population with a high prevalence of HIV and malnutrition and its findings will be relevant to other settings in sub-Saharan Africa.

Effectiveness of a monovalent rotavirus vaccine in infants in Malawi after programmatic roll-out: an observational and case-control study.

BACKGROUND: Rotavirus is the main cause of severe acute gastroenteritis in children in Africa. Monovalent human rotavirus vaccine (RV1) was added into Malawi's infant immunisation schedule on Oct 29, 2012. We aimed to assess the impact and effectiveness of RV1 on rotavirus gastroenteritis in the 2 years after introduction. METHODS: From Jan 1, 2012, to June 30, 2014, we recruited children younger than 5 years who were admitted into Queen Elizabeth Central Hospital, Blantyre, Malawi, with acute gastroenteritis. We assessed stool samples from these children for presence of rotavirus with use of ELISA and we genotyped rotaviruses with use of RT-PCR. We compared rotavirus detection rates in stool samples and incidence of hospital admittance for rotavirus in children from Jan 1 to June 30, in the year before vaccination (2012) with the same months in the 2 years after vaccination was introduced (2013 and 2014). In the case-control portion of our study, we recruited eligible rotavirus-positive children from the surveillance platform and calculated vaccine effectiveness (one minus the odds ratio of vaccination) by comparing infants with rotavirus gastroenteritis with infants who tested negative for rotavirus, and with community age-matched and neighbourhood-matched controls. FINDINGS: We enrolled 1431 children, from whom we obtained 1417 stool samples (99%). We detected rotavirus in 79 of 157 infants (50%) before the vaccine, compared with 57 of 219 (40%) and 52 of 170 (31%) in successive calendar years after vaccine introduction (p=0·0002). In the first half of 2012, incidence of rotavirus hospital admission was 269 per 100,000 infants compared with 284 in the same months of 2013 (rise of 5·8%, 95% CI -23·1 to 45·4; p=0·73) and 153 in these months in 2014 (a reduction from the prevaccine period of 43·2%, 18·0-60·7; p=0·003). We recruited 118 vaccine-eligible rotavirus cases (median age 8·9 months; IQR 6·6-11·1), 317 rotavirus-test-negative controls (9·4 months; 6·9-11·9), and 380 community controls (8·8 months; 6·5-11·1). Vaccine effectiveness for two doses of RV1 in rotavirus-negative individuals was 64% (95% CI 24-83) and community controls was 63% (23-83). The point estimate of effectiveness was higher against genotype G1 than against G2 and G12. INTERPRETATION: Routine use of RV1 reduced hospital admissions for several genotypes of rotavirus in children younger than 5 years, especially in infants younger than 1 year. Our data support introduction of rotavirus vaccination at the WHO recommended schedule, with continuing surveillance in high-mortality countries. FUNDING: Wellcome Trust, GlaxoSmithKline Biologicals.