Impoverishing effects of catastrophic health expenditures in Malawi.

BACKGROUND: Out of pocket (OOP) health spending can potentially expose households to risk of incurring large medical bills, and this may impact on their welfare. This work investigates the effect of catastrophic OOP on the incidence and depth of poverty in Malawi. METHODS: The paper is based on data that was collected from 12,271 households that were interviewed during the third Malawi integrated household survey (IHS-3). The paper considered a household to have incurred a catastrophic health expenditure if the share of health expenditure in the household's non-food expenditure was greater than a given threshold ranging between 10 and 40%. RESULTS: As we increase the threshold from 10 to 40%, we found that OOP drives between 9.37 and 0.73% of households into catastrophic health expenditure. The extent by which households exceed a given threshold (mean overshoot) drops from 1.01% of expenditure to 0.08%, as the threshold increased. When OOP is accounted for in poverty estimation, additional 0.93% of the population is considered poor and the poverty gap rises by almost 2.54%. Our analysis suggests that people in rural areas and middle income households are at higher risk of facing catastrophic health expenditure. CONCLUSION: We conclude that catastrophic health expenditure increases the incidence and depth of poverty in Malawi. This calls for the introduction of social insurance system to minimize the incidence of catastrophic health expenditure especially to the rural and middle income population.

The value of informal care in the context of option B+ in Malawi: a contingent valuation approach.

BACKGROUND: Informal care, the health care provided by the patient's social network is important in low income settings although its monetary value is rarely estimated. The lack of estimates of the value of informal care has led to its omission in economic evaluations but this can result in incorrect decisions about cost effectiveness of an intervention. We explore the use of contingent valuation methods of willingness to pay (WTP) and willingness to accept (WTA) to estimate the value of informal care provided to HIV infected women that are accessing antiretroviral therapy (ART) under the Option B+ approach to prevention of mother-to-child transmission (PMTCT) of HIV in Malawi. METHODS: We collected cross sectional data from 93 caregivers of women that received ART care from six health facilities in Malawi. Caregivers of women that reported for ART care on the survey day and consented to participate in the survey were included until the targeted sample size for the facility was reached. We estimated the value of informal care by using the willingness to accept (WTA) and willingness to pay (WTP) approaches. Medians were used to summarize the values and these were compared by the Wilcoxon signed-rank test. RESULTS: The median WTA to provide informal care in a month was US$30 and the median WTP for informal care was US$13 and the two were statistically different (p < 0.000). Median WTP was higher in the urban areas than in the rural areas (US$21 vs. US$13, p < 0.001) and for caregivers from households from higher wealth quintile than in the lower quintile (US$15 vs. US$13, p < 0.0462). CONCLUSION: Informal caregivers place substantial value on informal care giving. In low income settings where most caregivers are not formally employed, WTP and WTA approaches can be used to value informal care. CLINICAL TRIAL NUMBER: NCT02005835.

Shifting human resources for health in the context of ART provision: qualitative and quantitative findings from the Lablite baseline study.

BACKGROUND: Lablite is an implementation project supporting and studying decentralized antiretroviral therapy (ART) rollout to rural communities in Malawi, Uganda and Zimbabwe. Task shifting is one of the strategies to deal with shortage of health care workers (HCWs) in ART provision. Evaluating Human Resources for Health (HRH) optimization is essential for ensuring access to ART. The Lablite project started with a baseline survey whose aim was to describe and compare national and intercountry delivery of ART services including training, use of laboratories and clinical care. METHODS: A cross-sectional survey was conducted between October 2011 and August 2012 in a sample of 81 health facilities representing different regions, facility levels and experience of ART provision in Malawi, Uganda and Zimbabwe. Using a questionnaire, data were collected on facility characteristics, human resources and service provision. Thirty three (33) focus group discussions were conducted with HCWs in a subset of facilities in Malawi and Zimbabwe. RESULTS: The survey results showed that in Malawi and Uganda, primary care facilities were run by non-physician clinical officers/medical assistants while in Zimbabwe, they were run by nurses/midwives. Across the three countries, turnover of staff was high especially among nurses. Between 10 and 20% of the facilities had at least one clinical officer/medical assistant leave in the 3 months prior to the study. Qualitative results show that HCWs in ART and non-ART facilities perceived a shortage of staff for all services, even prior to the introduction of ART provision. HCWs perceived the introduction of ART as having increased workload. In Malawi, the number of people on ART and hence the workload for HCWs has further increased following the introduction of Option B+ (ART initiation and life-long treatment for HIV positive pregnant and lactating women), resulting in extended working times and concerns that the quality of services have been affected. For some HCWs, perceived low salaries, extended working schedules, lack of training opportunities and inadequate infrastructure for service provision were linked to low job satisfaction and motivation. CONCLUSIONS: ART has been decentralized to lower level facilities in the context of an ongoing HRH crisis and staff shortage, which may compromise the provision of high-quality ART services. Task shifting interventions need adequate resources, relevant training opportunities, and innovative strategies to optimize the operationalization of new WHO treatment guidelines which continue to expand the number of people eligible for ART.

The Lablite project: a cross-sectional mapping survey of decentralized HIV service provision in Malawi, Uganda and Zimbabwe.

BACKGROUND: In sub-Saharan Africa antiretroviral therapy (ART) is being decentralized from tertiary/secondary care facilities to primary care. The Lablite project supports effective decentralization in 3 countries. It began with a cross-sectional survey to describe HIV and ART services. METHODS: 81 purposively sampled health facilities in Malawi, Uganda and Zimbabwe were surveyed. RESULTS: The lowest level primary health centres comprised 16/20, 21/39 and 16/22 facilities included in Malawi, Uganda and Zimbabwe respectively. In Malawi and Uganda most primary health facilities had at least 1 medical assistant/clinical officer, with average 2.5 and 4 nurses/midwives for median catchment populations of 29,275 and 9,000 respectively. Primary health facilities in Zimbabwe were run by nurses/midwives, with average 6 for a median catchment population of 8,616. All primary health facilities provided HIV testing and counselling, 50/53 (94%) cotrimoxazole preventive therapy (CPT), 52/53 (98%) prevention of mother-to-child transmission of HIV (PMTCT) and 30/53 (57%) ART management (1/30 post ART-initiation follow-up only). All secondary and tertiary-level facilities provided HIV and ART services. In total, 58/81 had ART provision. Stock-outs during the 3 months prior to survey occurred across facility levels for HIV test-kits in 55%, 26% and 9% facilities in Malawi, Uganda and Zimbabwe respectively; for CPT in 58%, 32% and 9% and for PMTCT drugs in 26%, 10% and 0% of facilities (excluding facilities where patients were referred out for either drug). Across all countries, in facilities with ART stored on-site, adult ART stock-outs were reported in 3/44 (7%) facilities compared with 10/43 (23%) facility stock-outs of paediatric ART. Laboratory services at primary health facilities were limited: CD4 was used for ART initiation in 4/9, 5/6 and 13/14 in Malawi, Uganda and Zimbabwe respectively, but frequently only in selected patients. Routine viral load monitoring was not used; 6/58 (10%) facilities with ART provision accessed centralised viral loads for selected patients. CONCLUSIONS: Although coverage of HIV testing, PMTCT and cotrimoxazole prophylaxis was high in all countries, decentralization of ART services was variable and incomplete. Challenges of staffing and stock management were evident. Laboratory testing for toxicity and treatment effectiveness monitoring was not available in most primary level facilities.

The economic costs of orthopaedic services: a health system cost analysis of tertiary hospitals in a low-income country.

BACKGROUND: Traumatic injuries are rising globally, disproportionately affecting low- and middle-income countries, constituting 88% of the burden of surgically treatable conditions. While contributing to the highest burden, LMICs also have the least availability of resources to address this growing burden effectively. Studies on the cost-of-service provision in these settings have concentrated on the most common traumatic injuries, leaving an evidence gap on other traumatic injuries. This study aimed to address the gap in understanding the cost of orthopaedic services in low-income settings by conducting a comprehensive costing analysis in two tertiary-level hospitals in Malawi. METHODS: We used a mixed costing methodology, utilising both Top-Down and Time-Driven Activity-Based Costing approaches. Data on resource utilisation, personnel costs, medicines, supplies, capital costs, laboratory costs, radiology service costs, and overhead costs were collected for one year, from July 2021 to June 2022. We conducted a retrospective review of all the available patient files for the period under review. Assumptions on the intensity of service use were based on utilisation patterns observed in patient records. All costs were expressed in 2021 United States Dollars. RESULTS: We conducted a review of 2,372 patient files, 72% of which were male. The median length of stay for all patients was 9.5 days (8-11). The mean weighted cost of treatment across the entire pathway varied, ranging from $195 ($136-$235) for Supracondylar Fractures to $711 ($389-$931) for Proximal Ulna Fractures. The main cost components were personnel (30%) and medicines and supplies (23%). Within diagnosis-specific costs, the length of stay was the most significant cost driver, contributing to the substantial disparity in treatment costs between the two hospitals. CONCLUSION: This study underscores the critical role of orthopaedic care in LMICs and the need for context-specific cost data. It highlights the variation in cost drivers and resource utilisation patterns between hospitals, emphasising the importance of tailored healthcare planning and resource allocation approaches. Understanding the costs of surgical interventions in LMICs can inform policy decisions and improve access to essential orthopaedic services, potentially reducing the disease burden associated with trauma-related injuries. We recommend that future studies focus on evaluating the cost-effectiveness of orthopaedic interventions, particularly those that have not been analysed within the existing literature.

Household resilience among fish value chain actors during the COVID-19 pandemic in Malawi.

We analyse household resilience capacities during the COVID-19 pandemic in the fishing communities along Lake Malawi by using FAO's resilience index measurement assessment (RIMA) methodology. The study is based on a sample of 400 households, and we employ the multiple indicators multiple causes (MIMIC) model to estimate resilience capacities. The model uses household food security indicators as development outcomes. Our findings show that the COVID-19 pandemic significantly reduces household food security and resilience capacity. COVID-19 shocks that significantly reduce household resilience capacities are death and illness of a household member. Important pillars for resilience building are assets, access to basic services and adaptive capacity. These findings point to the need to build assets of the households, build their adaptive capacity, and identify innovative ways of improving access to basic services to build household resilience capacities in the fishing communities. We recommend providing external support to households that have been directly affected by the pandemic through the death or illness of a member because their capacities to bounce back on their own significantly declines.

An asset-based approach to vulnerability: the case of small-scale fishing areas in Cameroon and Nigeria.

This paper analyses vulnerability to poverty of rural small-scale fishing communities using cross-section data from 295 households in Cameroon and 267 in Nigeria. We propose a vulnerability measure that incorporates the idea of asset poverty into the concept of expected poverty, which allows decomposing expected poverty into expected structural-chronic, structural-transient, and stochastic-transient poverty. The findings show that most households in our study areas are expected to be structurally-chronic and structurally-transient poor. This underlines the importance of asset formation for long-term poverty reduction strategies. Further refinements are possible with longitudinal data and information about future states of nature.

A Transdisciplinary Methodology for Introducing Solar Water Disinfection to Rural Communities in Malawi-Formative Research Findings.

Despite the increasing volume of evidence demonstrating the efficacy of solar water disinfection (SODIS) as a household water treatment technology, there still appear to be significant barriers to uptake in developing countries. The potential of SODIS is often treated with skepticism in terms of effective treatment, volume, and safety, and is dismissed in preference for more accepted technologies such as ceramic filters and dose chlorination. As part of WATERSPOUTT (EU H2020 688928), our study used a transdisciplinary methodology to cocreate an innovative SODIS system in rural Malawi. The formative work focused on the design of 1) an appropriate and acceptable system and 2) a context-specific intervention delivery program using a behavior-centered design. Initial research identified specific water needs and challenges, which were discussed along with a cocreation process with potential end users, through a series of shared dialogue workshops (SDWs). Specifications from end users outlined a desire for higher volume systems (20 L) that were "familiar" and could be manufactured locally. Development of the "SODIS bucket" was then undertaken by design experts and local manufacturers, with input from end users and subject to controlled testing to ensure efficacy and safety. Concurrent data were collated using questionnaires (n = 777 households), water point mapping (n = 121), water quality testing (n = 46), and behavior change modeling (n = 100 households). These identified specific contextual issues (hydrogeology, water access, gender roles, social capital, and socioeconomic status), and behavioral determinants (normative, ability, and self-regulation factors) that informed the development and delivery mechanism for the implementation toolkit. Integr Environ Assess Manag 2020;16:871-884. © 2020 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals, Inc. on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

An evolution of socioeconomic related inequality in teenage pregnancy and childbearing in Malawi.

BACKGROUND: Teenage pregnancies and childbearing are important health concerns in low-and middle-income countries (LMICs) including Malawi. Addressing these challenges requires, among other things, an understanding of the socioeconomic determinants of and contributors to the inequalities relating to these outcomes. This study investigated the trends of the inequalities and decomposed the underlying key socioeconomic factors which accounted for the inequalities in teenage pregnancy and childbearing in Malawi. METHODS: The study used the 2004, 2010 and 2015-16 series of nationally representative Malawi Demographic Health Survey covering 12,719 women. We used concentration curves to examine the existence of inequalities, and then quantified the extent of inequalities in teenage pregnancies and childbearing using the Erreygers concentration index. Finally, we decomposed concentration index to find out the contribution of the determinants to socioeconomic inequality in teenage pregnancy and childbearing. RESULTS: The teenage pregnancy and childbearing rate averaged 29% (p<0.01) between 2004 and 2015-16. Trends showed a "u-shape" in teenage pregnancy and childbearing rates, albeit a small one (34.1%; p<0.01) in 2004: (25.6%; p<0.01) in 2010, and (29%; p<0.01) in 2016. The calculated concentration indices -0.207 (p<0.01) in 2004, -0.133 (p<0.01) in 2010, and -0.217 (p<0.01) in 2015-16 indicated that inequality in teenage pregnancy and childbearing worsened to the disadvantage of the poor in the country. Additionally, the decomposition exercise suggested that the primary drivers to inequality in teenage pregnancy and child bearing were, early sexual debut (15.5%), being married (50%), and wealth status (13.8%). CONCLUSION: The findings suggest that there is a need for sustained investment in the education of young women concerning the disadvantages of early sexual debut and early marriages, and in addressing the wealth inequalities in order to reduce the incidences of teenage pregnancies and childbearing.

Patient-level benefits associated with decentralization of antiretroviral therapy services to primary health facilities in Malawi and Uganda.

Background: The Lablite project captured information on access to antiretroviral therapy (ART) at larger health facilities ('hubs') and lower-level health facilities ('spokes') in Phalombe district, Malawi and in Kalungu district, Uganda. Methods: We conducted a cross-sectional survey among patients who had transferred to a spoke after treatment initiation (Malawi, n=54; Uganda, n=33), patients who initiated treatment at a spoke (Malawi, n=50; Uganda, n=44) and patients receiving treatment at a hub (Malawi, n=44; Uganda, n=46). Results: In Malawi, 47% of patients mapped to the two lowest wealth quintiles (Q1-Q2); patients at spokes were poorer than at a hub (57% vs 23% in Q1-Q2; p<0.001). In Uganda, 7% of patients mapped to Q1-Q2; patients at the rural spoke were poorer than at the two peri-urban facilities (15% vs 4% in Q1-Q2; p<0.001). The median travel time one way to a current ART facility was 60 min (IQR 30-120) in Malawi and 30 min (IQR 20-60) in Uganda. Patients who had transferred to the spokes reported a median reduction in travel time of 90 min in Malawi and 30 min in Uganda, with reductions in distance and food costs. Conclusions: Decentralizing ART improves access to treatment. Community-level access to treatment should be considered to further minimize costs and time.

Exploring the Experiences of Women and Health Care Workers in the Context of PMTCT Option B Plus in Malawi.

INTRODUCTION: Malawi has embarked on a "test-and-treat" approach to prevent mother-to-child transmission (PMTCT) of HIV, known as "Option B+," offering all HIV-infected pregnant and breastfeeding women lifelong antiretroviral therapy (ART) regardless of CD4 count or clinical stage. A cross-sectional qualitative study was conducted to explore early experiences surrounding "Option B+" for patients and health care workers (HCWs) in Malawi. METHODS: Study participants were purposively selected across 6 health facilities in 3 regional health zones in Malawi. Semi-structured interviews were conducted with women enrolled in "Option B+" (n = 24), and focus group discussions were conducted with HCWs providing Option B+ services (n = 6 groups of 8 HCWs). Data were analyzed using a qualitative thematic coding framework. RESULTS: Patients and HCWs identified the lack of male involvement as a barrier to retention in care and expressed concerns at the rapidity of the test-and-treat process, which makes it difficult for patients to "digest" a positive diagnosis before starting ART. Fear regarding the breach of privacy and confidentiality were also identified as contributing to loss to follow-up of women initiated under the Option B+. Disclosure remains a difficult process within families and couples. Lifelong ART was also perceived as an opportunity to plan future pregnancies. CONCLUSIONS: As "Option B+" continues to be rolled out, novel interventions to support and retain women into care must be implemented. These include providing space, time, and support to accept a diagnosis before starting ART, engaging partners and families, and addressing the need for peer support and confidentiality.

Impact of decentralisation of antiretroviral therapy services on HIV testing and care at a population level in Agago District in rural Northern Uganda: results from the Lablite population surveys.

Background: We conducted unlinked cross-sectional population-based surveys in Northern Uganda before and after antiretroviral therapy (ART) provision (including Option B+ [lifelong ART for pregnant/breast-feeding women]) at a local primary care facility (Lira Kato Health Centre [HC]). Prior to decentralisation, people travelled 56-76 km round-trip for ART; we aimed to evaluate changes in uptake of HIV-testing, ART coverage and access to ART following decentralisation. Methods: A total of 2124 adults in 1351 households in two parishes closest to Lira Kato HC were interviewed using questionnaires between March and April 2013 and 2123 adults in 1229 households between January and March 2015. Results: Adults reporting HIV-testing in the last year increased from 1077/2124 (50.7%) to 1298/2123 (61.1%) between surveys (p<0.001). ART coverage increased from 74/136 (54.4%) self-reported HIV-positive adults in 2013 to 108/133 (81.2%) in 2015 (p<0.001). Post-decentralisation, 47/108 (43.5%) of those on ART were in care at Lira Kato HC (including 37 new initiations). Most of the remainder (47/61, 77%) started ART prior to any ART provision at Lira Kato HC; the most common reason given for not accessing ART locally was concern about drug-stock-outs (30/59, 51%). Conclusions: HIV-testing and ART coverage increased after decentralisation combined with Option B+ roll-out. However, patients on ART before decentralisation were reluctant to transfer to their local facility.

Impact of Facility- and Community-Based Peer Support Models on Maternal Uptake and Retention in Malawi's Option B+ HIV Prevention of Mother-to-Child Transmission Program: A 3-Arm Cluster Randomized Controlled Trial (PURE Malawi).

BACKGROUND: Many sub-Saharan African countries have adopted Option B+, a prevention of mother-to-child transmission approach providing HIV-infected pregnant and lactating women with immediate lifelong antiretroviral therapy. High maternal attrition has been observed in Option B+. Peer-based support may improve retention. METHODS: A 3-arm stratified cluster randomized controlled trial was conducted in Malawi to assess whether facility- and community-based peer support would improve Option B+ uptake and retention compared with standard of care (SOC). In SOC, no enhancements were made (control). In facility-based and community-based models, peers provided patient education, support groups, and patient tracing. Uptake was defined as attending a second scheduled follow-up visit. Retention was defined as being alive and in-care at 2 years without defaulting. Attrition was defined as death, default, or stopping antiretroviral therapy. Generalized estimating equations were used to estimate risk differences (RDs) in uptake. Cox proportional hazards regression with shared frailties was used to estimate hazard of attrition. RESULTS: Twenty-one facilities were randomized and enrolled 1269 women: 447, 428, and 394 in facilities that implemented SOC, facility-based, and community-based peer support models, respectively. Mean age was 27 years. Uptake was higher in facility-based (86%; RD: 6%, confidence interval [CI]: -3% to 15%) and community-based (90%; RD: 9%, CI: 1% to 18%) models compared with SOC (81%). At 24 months, retention was higher in facility-based (80%; RD: 13%, CI: 1% to 26%) and community-based (83%; RD: 16%, CI: 3% to 30%) models compared with SOC (66%). CONCLUSIONS: Facility- and community-based peer support interventions can benefit maternal uptake and retention in Option B+.

Viral Suppression and HIV Drug Resistance at 6 Months Among Women in Malawi's Option B+ Program: Results From the PURE Malawi Study.

BACKGROUND: In 2011, Malawi launched Option B+, a program of universal antiretroviral therapy (ART) treatment for pregnant and lactating women to optimize maternal health and prevent pediatric HIV infection. For optimal outcomes, women need to achieve HIVRNA suppression. We report 6-month HIVRNA suppression and HIV drug resistance in the PURE study. METHODS: PURE study was a cluster-randomized controlled trial evaluating 3 strategies for promoting uptake and retention; arm 1: Standard of Care, arm 2: Facility Peer Support, and arm 3: Community Peer support. Pregnant and breastfeeding mothers were enrolled and followed according to Malawi ART guidelines. Dried blood spots for HIVRNA testing were collected at 6 months. Samples with ART failure (HIVRNA ≥1000 copies/ml) had resistance testing. We calculated odds ratios for ART failure using generalized estimating equations with a logit link and binomial distribution. RESULTS: We enrolled 1269 women across 21 sites in Southern and Central Malawi. Most enrolled while pregnant (86%) and were WHO stage 1 (95%). At 6 months, 950/1269 (75%) were retained; 833/950 (88%) had HIVRNA testing conducted, and 699/833 (84%) were suppressed. Among those with HIVRNA ≥1000 copies/ml with successful amplification (N = 55, 41% of all viral loads > 1000 copies/ml), confirmed HIV resistance was found in 35% (19/55), primarily to the nonnucleoside reverse transcriptase inhibitor class of drugs. ART failure was associated with treatment default but not study arm, age, WHO stage, or breastfeeding status. CONCLUSIONS: Virologic suppression at 6 months was <90% target, but the observed confirmed resistance rates suggest that adherence support should be the primary approach for early failure in option B+.

Measuring and Valuing Informal Care for Economic Evaluation of HIV/AIDS Interventions: Methods and Application in Malawi.

BACKGROUND: Economic evaluation studies often neglect the impact of disease and ill health on the social network of people living with HIV (PLHIV) and the wider community. An important concern relates to informal care requirements which, for some diseases such as HIV/AIDS, can be substantial. OBJECTIVES: To measure and value informal care provided to PLHIV in Malawi. METHODS: A modified diary that divided a day into natural calendar changes was used to measure informal care time. The monetary valuation was undertaken by using four approaches: opportunity cost (official minimum wage used to value caregiving time), modified opportunity cost (caregiver's reservation wage), willingness to pay (amount of money caregiver would pay for care), and willingness to accept (amount of money caregiver would accept for providing care to someone else) approaches. Data were collected from 130 caregivers of PLHIV who were accessing antiretroviral therapy from six facilities in Phalombe district in southeast Malawi. RESULTS: Of the 130 caregivers, 62 (48%) provided informal care in the survey week. On average, caregivers provided care of 8 h/wk. The estimated monetary values of informal care provided per week were US $1.40 (opportunity cost), US $2.41 (modified opportunity cost), US $0.40 (willingness to pay), and US $2.07 (willingness to accept). CONCLUSIONS: Exclusion of informal care commitments may be a notable limitation of many applied economic evaluations. This work demonstrates that inclusion of informal care in economic evaluations in a low-income context is feasible.

The effect of illicit financial flows on time to reach the fourth Millennium Development Goal in Sub-Saharan Africa: a quantitative analysis.

OBJECTIVES: This paper sets out to estimate the cost of illicit financial flows (IFF) in terms of the amount of time it could take to reach the fourth Millennium Development Goal (MDG) in 34 African countries. DESIGN: We have calculated the percentage increase in gross domestic product (GDP) if IFFs were curtailed using IFF/GDP ratios. We applied the income (GDP) elasticity of child mortality to the increase in GDP to estimate the reduction in time to reach the fourth MDG in 34 African countries. PARTICIPANTS: children aged under five years. SETTINGS: 34 countries in SSA. MAIN OUTCOME MEASURES: Reduction in time to reach the first indicator of the fourth MDG, under-five mortality rate in the absence of IFF. RESULTS: We found that in the 34 SSA countries, six countries will achieve their fourth MDG target at the current rates of decline. In the absence of IFF, 16 countries would reach their fourth MDG target by 2015 and there would be large reductions for all other countries. CONCLUSIONS: This drain on development is facilitated by financial secrecy in other jurisdictions. Rich and poor countries alike must stem the haemorrhage of IFF by taking decisive steps towards improving financial transparency.

Improving PMTCT uptake and retention services through novel approaches in peer-based family-supported care in the clinic and community: a 3-arm cluster randomized trial (PURE Malawi).

In July 2011, Malawi introduced an ambitious public health program known as "Option B+," which provides all HIV-infected pregnant and breastfeeding women with lifelong combination antiretroviral therapy, regardless of clinical stage or CD4 count. Option B+ is expected to have benefits for HIV-infected women, their HIV-exposed infants, and their HIV-uninfected male sex partners. However, these benefits hinge on early uptake of prevention of mother-to-child transmission, good adherence, and long-term retention in care. The Prevention of mother-to-child transmission Uptake and REtention (PURE) study is a 3-arm cluster randomized controlled trial to evaluate whether clinic- or community-based peer support will improve care-seeking and retention in care by HIV-infected pregnant and breastfeeding women, their HIV-exposed infants, and their male sex partners, and ultimately improve health outcomes in all 3 populations. We describe the PURE Malawi Consortium, the initial work conducted to inform the trial and interventions, the trial design, and the analysis plan. We then discuss concerns and expected contributions to Malawi and the region.

Income and child mortality in developing countries: a systematic review and meta-analysis.

OBJECTIVE: We aimed to quantify the relationship between national income and infant and under-five mortality in developing countries. DESIGN: We conducted a systematic literature search of studies that examined the relationship between income and child mortality (infant and/or under-five mortality) and meta-analysed their results. SETTING: Developing countries. MAIN OUTCOME MEASURES: Child mortality (infant and /or under-five mortality). RESULTS: The systematic literature search identified 24 studies, which produced 38 estimates that examined the impact of income on the mortality rates. Using meta-analysis, we produced pooled estimates of the relationship between income and mortality. The pooled estimate of the relationship between income and infant mortality before adjusting for covariates is -0.95 (95% CI -1.34 to -0.57) and that for under-five mortality is -0.45 (95% CI -0.79 to -0.11). After adjusting for covariates, pooled estimate of the relationship between income and infant mortality is -0.33 (-0.39 to -0.26) while the estimate for under-five mortality is -0.28 (-0.37 to -0.19). If a country has an infant mortality of 50 per 1000 live births and the gross domestic product per capita purchasing power parity increases by 10%, the infant mortality will decrease to 45 per 1000 live births. CONCLUSION: Income is an important determinant of child survival and this work provides a pooled estimate for the relationship.