Condom use increased after a peer group intervention implemented by community volunteers in Malawi.

BACKGROUND: HIV prevention remains a global priority, especially in sub-Saharan Africa. Our research team previously developed an evidence-based peer group program for HIV prevention called Mzake ndi Mzake (Friend to Friend). A community-engaged collaboration adapted the program for community ownership and implementation. Here we report whether this HIV prevention program, implemented by community volunteers, increased condom use among sexually active individuals in rural Malawi. METHODS: Three communities sequentially rolled out the program. Effectiveness was evaluated using a stepped wedge design. Repeated surveys 11-13 months apart were conducted between 2016 and 2019. At Time 1, no community had offered the intervention. At Time 2, the first community had offered the intervention and two had not (control group). At Time 3, two communities had offered the intervention and one had not (control group). We used two condom use indicators; condom use frequency in the last 2 months (N = 771) and condom use at last sex (N = 880). The analytical sample included all sexually active persons answering that question at one or more time points. Mixed-effects cumulative logit and Generalized Estimating Equation (GEE) models were used to model the two condom indicators over time, controlling for demographic factors, UNAIDS HIV knowledge, safer sex self-efficacy and partner communication. RESULTS: This peer group intervention implemented by trained community volunteers increased both condom use indicators at Times 2 and 3. In the final adjusted models with non-significant factors removed, condom use in the last two months increased for the intervention group vs. control group [Time 2: Adjusted Odds Ratio (AOR) = 1.59 (1.15, 2.21); Time 3: AOR 2.01 (1.23, 3.30)]. Similarly, condom use at last sex increased for the intervention group vs. control group [Time 2: AOR = 1.48 (1.08, 2.03); Time 3: AOR 1.81 (1.13, 2.90)]. Other significant predictors of greater condom use were also described. Although the intervention increased UNAIDS HIV knowledge, knowledge did not predict condom use. CONCLUSIONS: In this community-engaged implementation study, an evidence-based peer group program for HIV prevention increased condom use when delivered by trained community volunteers. Community ownership and program delivery by trained volunteers offer an innovative and cost-effective strategy to address ongoing HIV prevention needs without overburdening healthcare systems in sub-Saharan Africa. TRIAL REGISTRATION: Clinical Trials.gov NCT02765659 Registered May 6, 2016.

Primary health care preparedness to integrate diabetes care in Blantyre, Malawi: A mixed methods study.

BACKGROUND: There is limited access to diabetes care services at primary care facilities in Malawi. Assessing the capacity of facilities to provide diabetes care is an initial step to integrating services at primary care. AIM: To assess the preparedness for delivering diabetes services at primary care level within the Blantyre District Health Office (DHO) to support the response to NCD epidemic in Malawi. SETTING: Blantyre DHO primary care facilities. MATERIALS AND METHODS: A mixed methods approach nested in a national needs assessment for NCD response in Malawi was used. Fourteen primary healthcare facilities from Blantyre DHO were assessed. A tool adapted from the WHO rapid assessment questionnaire was used to identify human resource, equipment, supplies, and medication needed for comprehensive diabetes care. Descriptive statistics were done to analyze the quantitative data. Fisher's exact test was used to assess if there was a statistically significant difference between urban and rural facilities. Seventeen health care workers from the selected facilities participated in key informant interviews. Framework analysis method guided the qualitative data analysis. The quantitative and qualitative data were merged and displayed jointly. RESULTS: The quantitative assessment showed that none of the facilities assessed had capacity to provide all the interventions recommended by WHO for diabetes care at primary level. Eight (57%) of the facilities had the capacity to diagnose diabetes, monitor glucose, prevent limb amputations and manage hypoglycemia and hyperglycemia. Four themes emerged from the qualitative data: differences in level of preparedness and implementation of diabetes care; disparities in resources between urban and rural facilities; low utilization of diabetes services; and strategy and policy recommendations for improvement of diabetes care. CONCLUSION: Inadequate health financing resulted in significant disparities in the available resources between the rural and urban facilities to offer diabetes care services. There is need to develop national policies and guidelines for diabetes care to strengthen the capacity of primary care facilities to facilitate achievement of universal health coverage.

Improving care pathways for children with severe illness through implementation of the ASPIRE mHealth primary ETAT package in Malawi.

Providing emergency care in low resource settings relies on delivery by lower cadres of health workers (LCHW). We describe the development, implementation and mixed methods evaluation of a mobile health (mHealth) triage algorithm based on the WHO Emergency, Triage, Assessment, and Treatment (ETAT) for primary-level care. We conducted an observational study design of implementation research. Key stakeholders were engaged throughout implementation. Clinicians and LCHW at eight primary health centres in Blantyre district were trained to use an mHealth algorithm for triage. An mHealth patient surveillance system monitored patients from presentation through referral to tertiary and final outcome. A total of 209,174 children were recorded by ETAT between April 2017 and September 2018, and 155,931 had both recorded mHealth and clinician triage outcome data. Concordance between mHealth triage by lower cadres of HCW and clinician assessment was 81·6% (95% CI [81·4, 81·8]) over all outcomes (kappa: 0·535 (95% CI [0·530, 0·539]). Concordance for mHealth emergency triage was 0.31 with kappa 0.42. The most common mHealth recorded emergency sign was breathing difficulty (74·1% 95% CI [70·1, 77·9]) and priority sign was raised temperature (76·2% (95% CI [75·9, 76·6]). A total of 1,644 referrals out of 3,004 (54·7%) successfully reached the tertiary site. Both providers and carers expressed high levels of satisfaction with the mHealth ETAT pathway. An mHealth triage algorithm can be used by LCHWs with moderate concordance with clinician triage. Implementation of ETAT through an mHealth algorithm documented successful referrals from primary to tertiary, but half of referred patients did not reach the tertiary site. Potential harms of such systems, such as cases requiring referral being missed during triage, require further evaluation. The ASPIRE mHealth primary ETAT approach can be used to prioritise acute illness and support future resource planning within both district and national health system.

Condom use increased after a peer group intervention implemented by community volunteers in Malawi.

Background: HIV prevention remains a global priority, especially in sub-Saharan Africa. Our research team previously developed an evidence-based peer group program for HIV prevention called Mzake ndi Mzake (Friend to Friend). A community-engaged collaboration adapted the program for community ownership and implementation. Here we report whether this HIV prevention program, implemented by community volunteers, increased condom use among sexually active individuals in rural Malawi. Methods: Three communities sequentially rolled out the program. Effectiveness was evaluated using repeated surveys. At Time 1, no community had offered the intervention. At Time 2, the first community had offered the intervention and two had not (control group). At Time 3, two communities had offered the intervention and one had not (control group). We used two condom use indicators; condom use frequency in the last 2 months (N = 776) and condom use at last sex (N = 880). For each indicator, the sample included all sexually active persons answering that question at one or more time points. Regression analyses were used to model the two condom indicators over time, controlling for demographic factors, UNAIDS HIV knowledge, safer sex self-efficacy and partner communication. Results: This peer group intervention implemented by trained community volunteers increased both condom use indicators at Times 2 and 3. In the final regression models. Other predictors of greater condom use for at least one condom use indicator included younger age group (13-19), male gender, not married/cohabiting, high involvement in religiously affiliated activities, higher safer sex self-efficacy, and greater partner communication. Although the intervention increased UNAIDS HIV knowledge, knowledge did not predict condom use. Conclusions: This community engaged implementation study found that an evidence-based peer group program for HIV prevention increased condom use when delivered by trained community volunteers. Leveraging community strengths and human capital resources facilitated implementation of this effective HIV prevention program in rural Malawi. Community ownership and program delivery by trained local volunteers offers an innovative and cost-effective strategy to address ongoing HIV prevention needs without overburdening heathcare systems in sub. Trial registration: Clinical Trials.gov NCT02765659 Registered May 6, 2016.

A peer group intervention implemented by community volunteers increased HIV prevention knowledge.

BACKGROUND: HIV prevention knowledge levels are low in sub-Saharan Africa. In our efficacy study, the Mzake ndi Mzake (Friend-to-Friend; hereafter Mzake) 6-session peer group intervention, delivered by health workers, improved HIV prevention knowledge and other outcomes in Malawi. To expand HIV prevention approaches, this implementation study tested whether the intervention remained effective when implemented by trained community volunteers. HIV prevention knowledge findings are presented. METHODS: Using a stepped wedge design, three communities implemented the Mzake program sequentially in randomly assigned order. Repeated surveys assessed outcomes, and participants served as controls until they completed the program. At Time 2, Community 1 became the intervention group, and at Time 3, Communities 1 and 2 were the intervention group. HIV prevention knowledge, the primary outcome, was assessed through two indicators: UNAIDS comprehensive knowledge (UNAIDS Knowledge), defined as correctly answering five HIV prevention questions (Yes/No), and a 9-item HIV/PMTCT Knowledge Index (number correct). Multivariate generalized estimating equation logistic regression (UNAIDS Knowledge) and mixed-effects regression models (HIV/PMTCT Knowledge Index) were used to assess knowledge controlling for five sociodemographic factors. RESULTS: In bivariate analyses of UNAIDS Knowledge, more persons answered correctly in the intervention group than the control group at Time 2 (56.8% vs. 47.9%, p < 0.01), but the difference was not significant at Time 3. In logistic regression, there was a significant linear increase in the proportion who correctly answered all questions in the control group, but the increase was significantly higher in the intervention group (log-odds estimate = 0.17, SE = 0.06, p-value < 0.01). The HIV/PMTCT Knowledge Index scores increased over time for both groups, but in the intervention group the increase was significantly higher than the control group (0.11 at Time 2; 0.21 at Time 3). In youth and adult subsamples analyses, the intervention was highly effective in increasing knowledge for youth, but not for adults. CONCLUSION: This implementation study showed that Mzake was effective in increasing HIV prevention knowledge when delivered by community members. Community approaches offer an important strategy to increase HIV prevention in rural communities without burdening healthcare systems. TRIAL REGISTRATION: ClinicalTrials.gov NCT02765659. Registered 06/05/2016.

Prevalence and associated factors of intimate partner violence amongst women attending prevention of mother to child transmission services in Blantyre, Malawi.

BACKGROUND: Intimate partner violence (IPV) during the perinatal period and when one is HIV-positive is a great concern because of the physical and mental impacts it has on health and on adherence to prevention of mother to child transmission (PMTCT) services. However, factors associated with IPV amongst perinatal women on PMTCT services are not adequately explored in Malawi. The aim of this study was to estimate the various types of IPV and the associated factors amongst HIV-positive pregnant and postnatal women in selected health centres in Blantyre district. METHODS: In this cross-sectional study, we recruited 200 HIV-positive women from antenatal, postnatal and antiretroviral therapy (ART) clinics from four selected primary care facilities of Blantyre district. Data were collected between March and May 2018. RESULTS: A total of 50% of the participants reported to have experienced either physical, psychological or sexual violence from their partner in the last 12 months. The multivariate logistic regression model showed that feelings about safety of the relationship and depression were the only factors that were consistently associated with IPV in the last 12 months (p = 0.001, Pseudo R2 = 0.20). CONCLUSION: The presence of depression and safety concerns amongst our study participants calls for serious prioritisation of psychological interventions and risk assessment in the management of HIV-positive perinatal mothers who report IPV cases.

"Youth Photovoice": Promoting Youth-Driven Community Changes for HIV Prevention in Rural Malawi.

ABSTRACT: To meet the Joint United Nations Programme on HIV/AIDS global goal of no new HIV infections by 2030, it is imperative to reduce new infections among youth. Youth Photovoice was a 10-month, participatory, community-action research project developed to engage rural Malawi youth in an HIV prevention project focused on community-level outcomes. In this study, we describe how participants in Youth Photovoice engaged adults and community leaders to implement action plans, as well as the community and individual changes that occurred as a result of these collaborative efforts. Youth Photovoice participants, their parents, and local leaders in the community participated in focus groups and individual interviews. Community-level changes, such as moving initiation ceremonies to churches and changes to local business practices, were observed, along with increased community and parental involvement in youth monitoring for local events and activities. This youth-led project led to changes in the community environment that reduced exposure to situations supporting unsafe sex, uncovered ways that youth can lead collaborations with adults, and informed the implementation of plans for community action.

Developing Action Plans in Youth Photovoice to Address Community-Level HIV Risk in Rural Malawi.

Youth-driven approaches to HIV prevention can engage youth and improve health outcomes. Photovoice has been used to engage youth in identifying the assets and challenges in their communities. In sub-Saharan Africa, youth remain vulnerable to HIV infection. This article describes a photovoice project, named Youth Photovoice, conducted in rural Malawi, which focused on community places and situations relating to risky sexual behaviors that place youth at risk of HIV infection. Twenty-four youth, ages 13-17 (12 males and 12 females), participated in Youth Photovoice. During the photovoice process, youth identified five community situations and places that put them at risk of unsafe sex and thus HIV infection: initiation ceremonies, isolated places, community celebrations, local businesses such as bars and rest houses, and church-sponsored activities. Youth used a systematic action planning process to develop action plans. They presented their action plans to local leaders and parents. Parents and leaders responded positively and agreed to help the youth carry out their plans. If their plans to address community situations that put them at risk of unsafe sex succeed, there will be a direct impact on reducing the risk of HIV infection among youth. Youth Photovoice provided the opportunity for youth to obtain new skills, build new partnerships, and present their ideas to community leaders. Integrating this action planning process into photovoice helped to guide the youth toward actualizing their HIV prevention plans in their community. This process can increase the effectiveness of photovoice initiatives to address other community issues in a wide variety of settings.

A hybrid design testing a 3-step implementation model for community scale-up of an HIV prevention intervention in rural Malawi: study protocol.

BACKGROUND: Scaling-up evidence-based behavior change interventions can make a major contribution to meeting the UNAIDS goal of no new HIV infections by 2030. We developed an evidence-based peer group intervention for HIV prevention and testing in Malawi that is ready for wider dissemination. Our innovative approach turns over ownership of implementation to rural communities. We adapted a 3-Step Implementation Model (prepare, roll-out and sustain) for communities to use. Using a hybrid design, we simultaneously evaluate community implementation processes and program effectiveness. METHODS: Three communities in southern Malawi begin implementation in randomly-assigned order using a stepped wedge design. Our evaluation sample size of 144 adults and 144 youth per community provides sufficient power to examine primary outcomes of condom use and HIV testing. Prior to any implementation, the first participants in all three communities are recruited and complete the Wave 1 baseline survey. Waves 2-4 surveys occur after each community completes roll-out. Each community follows the model's three steps. During Prepare, the community develops a plan and trains peer group leaders. During Roll-Out, peer leaders offer the program. During Sustain, the community makes and carries out plans to continue and expand the program and ultimately obtain local funding. We evaluate degree of implementation success (Aim 1) using the community's benchmark scores (e.g, # of peer groups held). We assess implementation process and factors related to success (Aim 2) using repeated interviews and observations, benchmarks from Aim 1 and fidelity assessments. We assess effectiveness of the peer group intervention when delivered by communities (Aim 3) using multi-level regression models to analyze data from repeated surveys. Finally, we use mixed methods analyses of all data to assess feasibility, acceptability and sustainability (Aim 4). DISCUSSION: The project is underway, and thus far the first communities have enthusiastically begun implementation. We have had to make several modifications along the way, such as moving from rapid-tests of STIs to symptoms screening by a nurse due to problems with test reliability and availability. If successful, results will provide a replicable evidence-based model for future community implementation of this and other health interventions. TRIAL REGISTRATION: Clinical Trials.gov NCT02765659 Registered May 6, 2016.

Two-year contraceptive continuation rates among immediate postpartum implant users at a district hospital in Malawi: a prospective cohort study.

OBJECTIVE: To compare 2-year continuation rates in Malawian women undergoing immediate postpartum insertion of the levonorgestrel implant or etonorgestrel implant. STUDY DESIGN: We followed 159 women who underwent immediate postpartum levonorgestrel implant or etonorgestrel implant insertion at Kasungu District Hospital for up to 2 years. RESULTS: We analyzed continuation data on 145 (92.4%) implant users. The 2-year continuation rates were 93.4 (95% CI 86.5-96.8) for levonorgestrel implant and 96.3 (95% CI: 76.5-99.5) for etonorgestrel implant (p=.268). CONCLUSIONS: Immediate postpartum implant insertion of both the levonorgestrel and etonorgestrel implant had high continuation rates at 2 years in Malawian women. IMPLICATIONS: Immediate postpartum implant insertion of both the levonorgestrel and etonorgestrel implant had continuation rates of over 90% at 2 years among our population of Malawian women. Both implants should be offered routinely to eligible and interested women prior to hospital discharge after delivery.

Soya, maize, and sorghum-based ready-to-use therapeutic food with amino acid is as efficacious as the standard milk and peanut paste-based formulation for the treatment of severe acute malnutrition in children: a noninferiority individually randomized controlled efficacy clinical trial in Malawi.

Background: Development of more cost-effective ready-to-use therapeutic food (RUTF) is a global public health priority. To date, previous lower-cost recipes have been less effective than the standard peanut and milk (PM)-based RUTF, particularly in children aged <24 mo.Objective: We aimed to compare the efficacy of the PM-RUTF to a milk-free soya, maize, and sorghum (FSMS)-RUTF enriched with crystalline amino acids without cow milk powder and a milk, soya, maize, and sorghum (MSMS)-RUTF containing 9.3% skim cow milk powder.Design: This nonblinded, 3-arm, parallel-group, simple randomized controlled trial enrolled Malawian children with severe acute malnutrition.Results: In intention-to-treat analyses, FSMS-RUTF showed noninferiority for recovery rates in children aged 24-59 mo (Δ: -1.9%; 95% CI: -9.5%, 5.6%) and 6-23 mo (Δ: -0.2%; 95% CI: -7.5%, 7.1%) compared with PM-RUTF. MSMS-RUTF also showed noninferiority for recovery rates in children aged 24-59 mo (Δ: 0.0%; 95% CI: -7.3%, 7.4%) and 6-23 mo (Δ: 0.6%; 95% CI: -4.3%, 5.5%). Noninferiority in recovery rates was also observed in per-protocol analyses. For length of stay in the program (time to cure), both FSMS-RUTF in children aged 24-59 mo (Δ: 2.8 d; 95% CI: -0.8, 6.5 d) and 6-23 mo (Δ: 3.4 d; 95% CI: -1.2, 8.0 d) and MSMS-RUTF in children aged 24-59 mo (Δ: 0.2 d; 95% CI: -3.1, 3.6 d) and 6-23 mo (Δ: 1.2 d; 95% CI: -3.4, 5.8 d) were not inferior to PM-RUTF. FSMS-RUTF was also significantly better than PM-RUTF at increasing hemoglobin and body iron stores in anemic children, with mean hemoglobin increases of 2.1 (95% CI: 1.6, 2.6) and 1.3 (95% CI: 0.9, 1.8) and mean body iron store increases of 2.0 (95% CI: 0.8, 3.3) and 0.1 (95% CI: -1.1, 1.3) for FSMS-RUTF and PM-RUTF, respectively.Conclusions: FSMS-RUTF without milk is efficacious in the treatment of severe acute malnutrition in children aged 6-23 and 24-59 mo. It is also better at correcting iron deficiency anemia than PM-RUTF. This trial was registered at www.pactr.org as PACTR201505001101224.