Characteristics of TPT initiation and completion among people living with HIV.

BACKGROUND: TB preventive treatment (TPT) reduces morbidity and mortality among people living with HIV (PLHIV). Despite the successful scale-up of TPT in Malawi, monitoring and evaluation have been suboptimal. We utilized the Malawi Population-Based HIV Impact Assessment (MPHIA) 2020-2021 survey data to estimate TPT uptake and completion among self-reported HIV-positive persons. METHODS: We estimated the proportion of HIV-positive respondents who had ever undergone TPT, and determined the percentage of those currently on TPT who had completed more than 6 months of treatment. Bivariate and multivariable logistic regression were performed to calculate the odds ratios for factors associated with ever-taking TPT. All variables were self-reported, and the analysis was weighted and accounted for in the survey design. RESULTS: Of the HIV+ respondents, 38.8% (95% CI 36.4-41.3) had ever taken TPT. The adjusted odds of ever taking TPT were 8.0 and 5.2 times as high in the Central and Southern regions, respectively, compared to the Northern region; 1.9 times higher among those in the highest wealth quintile, and 2.1 times higher for those on antiretroviral therapy >10 years. Of those currently taking TPT, 56.2% completed >6 months of TPT. CONCLUSION: These results suggest low TPT uptake and >6 months' completion rates among self-reported HIV+ persons. Initiatives to create demand and strengthen adherence would improve TPT uptake.

CONTEXTE: Le traitement préventif de la TB (TPT) réduit la morbidité et la mortalité chez les personnes vivant avec le VIH (PVVIH). Malgré l'extension réussie du TPT au Malawi, le suivi et l'évaluation n'ont pas été optimaux. Nous avons utilisé les données de l'enquête MPHIA (Malawi Population-Based HIV Impact Assessment) 2020­2021 pour estimer l'adoption et l'achèvement du TPT parmi les personnes se déclarant séropositives. MÉTHODES: Nous avons estimé la proportion de répondants séropositifs qui avaient déjà subi un TPT et déterminé le pourcentage de ceux qui sont actuellement sous TPT et qui ont terminé plus de 6 mois de traitement. Une régression logistique bivariée et multivariable a été effectuée pour calculer les rapports de cotes des facteurs associés au fait d'avoir déjà pris un TPT. Toutes les variables étaient autodéclarées et l'analyse a été pondérée et prise en compte dans la conception de l'enquête. RÉSULTATS: Parmi les répondants séropositifs, 38,8% (IC 95% 36,4­41,3) avaient déjà pris du TPT. Les probabilités ajustées de prise de TPT étaient 8,0 et 5,2 fois plus élevées dans les régions du centre et du sud, respectivement, que dans la région du nord ; 1,9 fois plus élevées chez les personnes appartenant au quintile de richesse le plus élevé, et 2,1 fois plus élevées chez les personnes suivant une thérapie antirétrovirale depuis plus de 10 ans. Parmi ceux qui prennent actuellement un TPT, 56,2% ont terminé >6 mois de TPT. CONCLUSION: Ces résultats suggèrent un faible taux d'utilisation du TPT et des taux d'achèvement de >6 mois parmi les personnes déclarées séropositives. Des initiatives visant à créer une demande et à renforcer l'adhésion permettraient d'améliorer l'utilisation du TPT.

Health care providers acceptance of default prescribing of TB preventive treatment for people living with HIV in Malawi: a qualitative study.

BACKGROUND: Tuberculosis (TB) preventive treatment (TPT) substantially reduces the risk of developing active TB for people living with HIV (PLHIV). We utilized a novel implementation strategy based on choice architecture (CAT) which makes TPT prescribing the default option. Through CAT, health care workers (HCWs) need to "opt-out" when choosing not to prescribe TPT to PLHIV. We assessed the prospective, concurrent, and retrospective acceptability of TPT prescribing among HCWs in Malawi who worked in clinics participating in a cluster randomized trial of the CAT intervention. METHODS: 28 in-depth semi-structured interviews were conducted with HCWs from control (standard prescribing approach) and intervention (CAT approach) clinics. The CAT approach was facilitated in intervention clinics using a default prescribing module built into the point-of-care HIV Electronic Medical Record (EMR) system. An interview guide for the qualitative CAT assessment was developed based on the theoretical framework of acceptability and on the normalization process theory. Thematic analysis was used to code the data, using NVivo 12 software. RESULTS: We identified eight themes belonging to the three chronological constructs of acceptability. HCWs expressed no tension for changing the standard approach to TPT prescribing (prospective acceptability); however, those exposed to CAT described several advantages, including that it served as a reminder to prescribe TPT and routinized TPT prescribing (concurrent acceptability). Some felt that CAT may reduce HCW´s autonomy and might lead to inappropriate TPT prescribing (retrospective acceptability). CONCLUSIONS: The default prescribing module for TPT has now been incorporated into the point-of-care EMR system nationally in Malawi. This seems to fit the acceptability of the HCWs. Moving forward, it is important to train HCWs on how the EMR can be leveraged to determine who is eligible for TPT and who is not, while acknowledging the autonomy of HCWs.

The Tingathe Surge: a multi-strategy approach to accelerate HIV case finding in Malawi.

SETTING: Nineteen health facilities in rural, southeastern Malawi. OBJECTIVE: To describe the implementation and results of a 6-week intervention to accelerate human immunodeficiency virus (HIV) case finding. DESIGN: Six HIV testing strategies were simultaneously implemented. Routinely collected data from Ministry of Health registers were used to determine the number of HIV tests performed and of new cases identified. The weekly averages of the total number of tests and new cases before and during the intervention were compared. Testing by age group and sex was described. The percentage yield of new cases was compared by testing strategy. RESULTS: Of 29 703 HIV tests conducted, 1106 (3.7%) were positive. Of the total number of persons tested, 69.5% were women and 75.5% were aged >15 years. The yield of positive test results was 3.5% among women, 4.3% among men, 4.4% among those aged >15 years and 1.5% among those aged ⩽15 years. The average weekly number of tests increased 106.7% from 3337 to 6896 (P = 0.002). The average weekly number of positive cases identified increased 51.9% from 158 to 240 (P = 0.017). The testing strategy with the highest yield resulted in a 6.0% yield; the lowest was 1.3%. The yield for all strategies, except one, was highest in adult men. CONCLUSION: A multi-strategy approach to HIV testing and counseling can be an effective means of accelerating HIV case finding.

Early infant diagnosis and outcomes in HIV-exposed infants at a central and a district hospital, Northern Malawi.

Setting: Mzuzu Central Hospital (MZCH), Mzuzu, and Chitipa District Hospital (CDH), Chitipa, Malawi. Objective: To compare management and outcomes of human immunodeficiency virus (HIV) exposed infants in early infant diagnosis (EID) programmes at MZCH, where DNA polymerase chain reaction (PCR) testing is performed on site, and CDH, where samples are sent to MZCH, between 2013 and 2014. Design: Retrospective cohort study. Results: Of infants enrolled at MZCH (n = 409) and CDH (n = 176), DNA PCR results were communicated to the children's guardians in respectively 56% and 51% of cases. The median time from sample collection to guardians receiving results was 34 days for MZCH and 56 days for CDH. In both hospitals, only half of the dried blood spot (DBS) samples were collected between 6 and 8 weeks. More guardians from MZCH than CDH received test results within 1 month of sample collection (25% vs. 10%). Among the HIV-positive infants, a higher proportion at MZCH (92%) started antiretroviral therapy than at CDH (46%). The relative risk (RR) of death was higher among infants with late DBS collection (RR 1.3, 95%CI 1.0-1.7) or no collection (RR 5.8, 95%CI 4.6-7.2), and when guardians did not receive test results (RR 8.3, 95%CI 5.7-11.9). Conclusion: EID programmes performed equally poorly at both hospitals, and might be helped by point-of-care DNA PCR testing. Better programme implementation and active follow-up might improve infant outcome and retention in care.

Contexte: Hôpital central Mzuzu (MZCH), Mzuzu, et hôpital de district de Chitipa (CDH), Chitipa, Malawi.Objectif: Comparer la prise en charge et les résultats des nourrissons exposés au virus de l'immunodéficience humaine (VIH) dans les programmes de Diagnostic précoce du nourrisson (EID) au MZCH (test ADN réaction polymérase en chaîne [PCR] fait sur place) et au CDH (échantillons envoyés au MZCH) entre 2013 et 2014.Schéma: Etude rétrospective de cohorteRésultats: Parmi les nourrissons enrôlés au MZCH (n = 409) et au CDH (n = 176), les résultats d'ADN PCR ont été communiqués aux responsables des enfants dans 56% et 51% des cas, respectivement. Le délai médian du recueil de l'échantillon à la réception des résultats par les parents a été de 34 jours pour le MZCH et de 56 jours pour le CDH. Dans les deux hôpitaux, seulement la moitié des échantillons de sang séché (DBS) a été recueillie entre 6 et 8 semaines. Plus de parents du MZCH que du CDH ont reçu les résultats du test dans le mois suivant le recueil de l'échantillon (25% contre 10%). Parmi les nourrissons VIH positifs, une proportion plus élevée au MZCH (92%) a mis en route le traitement antirétroviral comparée au CDH (46%). Le risque relatif de décès a été plus élevé parmi les nourrissons ayant eu un recueil tardif de DBS (RR 1,3 ; IC95% 1,0­1,7) ou pas de recueil (RR 5,8 ; IC95% 4,6­7,2) et quand les parents n'ont pas reçu les résultats du test (RR 8,3 ; IC95% 5,7­11,9).Conclusion: Les programmes d'EID ont été aussi peu performants dans les deux hôpitaux et pourraient être améliorés par la possibilité de réaliser sur place le test PCR ADN. Une meilleure mise en œuvre du programme et un suivi actif pourraient améliorer les résultats pour les nourrissons et leur rétention en soins.

Marco de referencia: El Hospital Central de Mzuzu (MZCH) y el Hospital Distrital de Chitipa (CDH), en Malawi.Objetivo: Comparar el manejo y los desenlaces clínicos de los lactantes expuestos al virus de la inmunodeficiencia humana (VIH) en los programas de diagnóstico temprano del lactante (EID) en el MZCH (realización local de pruebas mediante la reacción en cadena de la polimerasa a partir de ADN [PCR-ADN]) y el CDH (muestras enviadas al MZCH) del 2013 al 2014.Método: Fue este un estudio retrospectivo de cohortes.Resultados: De los lactantes inscritos en el MZCH (n = 409), el resultado de la prueba PCR-ADN se comunicó a la persona encargada del niño en un 56% de los casos; esta proporción fue 51% en los lactantes inscritos en el CDH (n = 176). La mediana del lapso entre la obtención de la muestra y la entrega de los resultados a los encargados fue 34 días en el MZCH y 56 días en el CDH. En ambos hospitales, solo la mitad de las muestras de sangre seca (DBS) se recogió en 6 a 8 semanas. Más tutores de los lactantes en el MZCH que en el CDH recibieron el resultado de la prueba en el primer mes después de haber aportado la muestra (25% contra 10%). De los lactantes con resultado positivo frente al VIH, inició tratamiento antirretrovírico una mayor proporción de los niños atendidos en el MZCH (92%) que en el CDH (46%). El riesgo relativo (RR) de mortalidad fue más alto en los lactantes en quienes se obtuvo la muestra de DBS tardíamente (RR 1,3; IC95% de 1,0 a 1,7), en quienes no se obtuvo (RR 5,8; IC95% de 4,6 a 7,2) y cuando los tutores no recibieron los resultados (RR 8,3; IC95% de 5,7 a 11,9).Conclusión: El desempeño de los programas EID fue igualmente deficiente en ambos hospitales y se podría mejorar con la práctica de la prueba PCR-ADN en el momento de la atención. Una mejor ejecución del programa y un seguimiento activo contribuiría a obtener desenlaces clínicos más favorables en los lactantes y a retenerlos en los servicios de atención.

Biopsy case mix and diagnostic yield at a Malawian central hospital.

Cancer is a major disease burden worldwide resulting in high morbidity and mortality. It is the leading cause of mortality in developed countries and is one of the three leading causes of death for adults in developing countries. Pathological examination of tissue biopsies with histological confirmation of a correct cancer diagnosis is central to cancer care. Without an accurate and specific pathologic diagnosis, effective treatment cannot be planned or delivered. In addition, there are marked geographical variations in incidence of cancer overall, and of the specific cancers seen. Much of the published literature on cancer incidence in developing countries reflects gross estimates and may not reflect reality. Performing baseline studies to understand these distributions lays the groundwork for further research in this area of cancer epidemiology. Our current study surveys and ranks cancer diagnoses by individual anatomical site at Queen Elizabeth Central Hospital (QECH) which is the largest teaching and referral hospital in Malawi. A retrospective study was conducted reviewing available pathology reports over a period of one full year from January 2010 to December 2010 for biopsies from patients suspected clinically of having cancer. There were 544 biopsies of suspected cancer, taken from 96 anatomical sites. The oesophagus was the most common biopsied site followed by breast, bladder, bone, prostate, bowel, and cervical lymph node. Malignancies were found in biopsies of the oesophagus biopsies (squamous cell carcinoma, 65.1%; adenocarcinoma, 11.6%), breast (57.5%), bladder (squamous cell carcinoma, 53.1%) and stomach (37.6%). Our study demonstrates that the yield of biopsy for clinically suspected malignancy was greater than 50% for the 11 most common sites and provides a current survey of cancer types by site present in the population reporting to our hospital.

Information; education and communication messages and materials: survey report

The main objective of the survey was to take an inventory of all IEC materials and messages currently in use throughout the country. The findings showed that: a) knowledge of health workers and their clients on key messages in most critical programme areas was low; b) some peripheral units were underserved in the supply of IEC materials; c) most units experienced storage problems for IEC materials; and d) most health workers lacked basic skills in effective use of IEC materials