Barriers Associated with Adherence to Cervical Cancer Screening Among Women Living with HIV in Nkhatabay District, Malawi: A Mixed-Methods Study.

Background: Cervical cancer (CC) incidence among Women Living with HIV (WLHIV) is high compared to the general population of women. As such, the Malawi National CC guideline recommends yearly screening among WLHIV. However, only 15.9% of WLHIV were screened nationally using Visual Inspection with Acetic Acid (VIA) by 2015 and there is no data regarding adherence and barriers to yearly screening. This study assessed adherence levels and associated barriers to yearly Cervical Cancer screening (CCS) among WLHIV. Methods: A cross-sectional concurrent mixed-method study was conducted at Nkhatabay District Hospital (NBDH) and Chintheche Rural Hospital (CRH) in Malawi. A sample of 205 WLHIV participated in quantitative strand and in-depth interviews were conducted with 10 health care workers and 10 WLHIV. Quantitative data were analysed using STATA version 16. Pearson's chi-square test and Multivariate logistic regression analysis were performed. P value was set at 0.05. Qualitative data were analysed deductively following six steps of thematic analysis. Results: Only 5.4% (n=11) of the participants had been screened as required. Women aged ≥45 had 4 times the odds of being screened for CC compared to ≤30 (OR 4.18, 95% CI 0.65-26.8). WLHIV on ART > 10 years had more than 5 times the odds of being screened (OR 5.9, 95% CI 1.08-33.19) compared with those on ART <3 years. Use of male service providers (p =< 0.001), fear of the VIA procedure (p = <0.001) and lack of interest (p = <0.015) were significant barriers to adherence. Qualitative findings revealed a lack of knowledge regarding CCS protocol and the use of male providers. Conclusion: WLHIV face many challenges in accessing CCS and adherence to yearly CCS is very low. There is urgent need for targeted community awareness, scaling up of HPV tests and incorporation of CCS into routine integrated outreach services.

Association of migration and family planning use among women in Malawi: Evidence from 2019/2020 Malawi Multiple Indicators Survey.

BACKGROUND: Family planning (FP) is known to bring multiple benefits to people both individually and collectively. Individually, FP has been associated with reduction in risk of unintended pregnancy which also correlates with low child mortality rates. Child mortality rates in women with child spacing of less than two years are 45% higher compared to their counterparts with child spacing of more than two years. Several factors that predict FP utilisation among women of childbearing age have been identified but there is limited literature on how migration impacts FP utilisation in Malawi. Our current study aimed at assessing the association between migration and modern contraceptive use among women of childbearing age in Malawi. METHODS: Data for this study came from a nationally representative 2019/20 Malawi multiple cluster indicator survey (MICS). At total of 24,543 women aged 15 to 49 participated in the survey. Contraceptive prevalence rate (CPR) analyses were conducted separately on all women of childbearing age and married women. The data was analysed using the complex survey data approach by applying sampling weights to correct unequal representation of participants at cluster, district, and regional level. We used binary logistic regression to assess association between migration status and modern contraceptive use among all women of childbearing age and married women separately. We included age, age at first sex, age at marriage, region of residence, education, residence wealth index and presence of disability as confounders in our final multivariable models. RESULTS: The overall CPRs for married women and for all women of childbearing age were 64.7% and 40.5% respectively. The CPRs for all women of childbearing age were 40.5% for non-migrants and 33.0% for migrant women. For married women, CPRs were 51.5% for migrant women and 65.5% for non-migrant women. The fully adjusted odds ratios for the association between migration status and modern contraceptive use were 0.62 (0.49-0.78) for married women and 0.65 (0.52-0.80) for all women of childbearing age. CONCLUSIONS: We conclude from our findings that migrant women were significantly less likely to utilize modern contraceptive methods for both married women and all women of childbearing age. Deliberate efforts are required to ensure that migrant women of childbearing age have equal access to sexual and reproductive health services which includes family planning.

A prediction risk score for HIV among adolescent girls and young women in South Africa: identifying those in need of HIV pre-exposure prophylaxis.

BACKGROUND: In sub-Saharan Africa (SSA), adolescent girls and young women (AGYW) have the highest risk of acquiring HIV. This has led to several studies aimed at identifying risk factors for HIV in AGYM. However, a combination of the purported risk variables in a multivariate risk model could be more useful in determining HIV risk in AGYW than one at a time. The purpose of this study was to develop and validate an HIV risk prediction model for AGYW. METHODS: We analyzed HIV-related HERStory survey data on 4,399 AGYW from South Africa. We identified 16 purported risk variables from the data set. The HIV acquisition risk scores were computed by combining coefficients of a multivariate logistic regression model of HIV positivity. The performance of the final model at discriminating between HIV positive and HIV negative was assessed using the area under the receiver-operating characteristic curve (AUROC). The optimal cut-point of the prediction model was determined using the Youden index. We also used other measures of discriminative abilities such as predictive values, sensitivity, and specificity. RESULTS: The estimated HIV prevalence was 12.4% (11.7% - 14.0) %. The score of the derived risk prediction model had a mean and standard deviation of 2.36 and 0.64 respectively and ranged from 0.37 to 4.59. The prediction model's sensitivity was 16. 7% and a specificity of 98.5%. The model's positive predictive value was 68.2% and a negative predictive value of 85.8%. The prediction model's optimal cut-point was 2.43 with sensitivity of 71% and specificity of 60%. Our model performed well at predicting HIV positivity with training AUC of 0.78 and a testing AUC of 0.76. CONCLUSION: A combination of the identified risk factors provided good discrimination and calibration at predicting HIV positivity in AGYW. This model could provide a simple and low-cost strategy for screening AGYW in primary healthcare clinics and community-based settings. In this way, health service providers could easily identify and link AGYW to HIV PrEP services.

Health-related quality of life among people living with HIV in the era of universal test and treat: results from a cross-sectional study in KwaZulu-Natal, South Africa.

BACKGROUND: The World Health Organisation's (WHO) key population-based strategy for ending the human immunodeficiency virus (HIV) epidemic is universal HIV test and treat (UTT) along with pre-exposure prophylaxis (PrEP), and post-exposure prophylaxis (PEP). Despite the successful scale-up of the UTT strategy in sub-Saharan Africa (SSA), the quality of life (QoL) of people living with HIV (PLHIV) remains sub-optimal. Poor QoL in PLHIV may threaten the UNAIDS 95-95-95 programme targets. Monitoring QoL of PLHIV has become a key focus of HIV research among other outcomes so as to understand health-related QoL (HRQoL) profiles and identify interventions to improve programme performance. This study aimed to describe HRQoL profiles and identify their predictors in PLHIV in KwaZulu Natal, South Africa. METHODS: We conducted a secondary data analysis of a cross-sectional survey conducted between May and June 2022 among PLHIV (n = 105) accessing HIV services at an outpatient clinic in KwaZulu-Natal, South Africa. Socio-demographic, HRQoL (EQ-5D-5L index scores), clinical data, depressive symptoms (CES-D-10), and viral load data were collected from all participants. We examined predictors of HRQoL using generalised linear models controlling for age and sex. RESULTS: The mean age of the participants was 45 years (SD = 13). The proportion of participants with disabilities and comorbidities were 3% and 18%, respectively. Depressive symptoms were present in 49% of the participants. Participant's mean EQ-5D-5L index score was 0.87 (SD = 0.21) and ranged from 0.11 to 1.0. The mean general health state (EQ-VAS) was 74.7 (SD = 18.8) and ranged from 6 to 100. Factors that reduced HRQoL were disability (ß = -0.607, p ≤ 0.001), comorbidities (ß = - 0.23, p ≤ 0.05), presence of depressive symptoms (ß = -0.10, p ≤ 0.05), and old age (ß = -0.04, p ≤ 0.05). Factors that increased HRQoL were a good perceived health state (ß = 0.147, p ≤ 0.001) and availability of social support (ß = 0.098, p ≤ 0.05). CONCLUSION: A combination of old age (60 years and above), any disability and comorbidities had a considerable effect on HRQoL among PLHIV. Our findings support the recommendation for an additional fourth UNAIDS target that should focus on ensuring that 95% of PLHIV have the highest possible HRQoL. Psycho-social support interventions are recommended to improve the HRQoL of PLHIV.