Can a Village Headman Use an Electronic Village Register and a Simplified Community-Based Verbal Autopsy Tool to Record Numbers and Causes of Death in Rural Malawi?

Introduction: Most people in Africa die without appearing in official vital statistics records. To improve this situation, Malawi has introduced solar-powered electronic village registers (EVR), managed by village headmen, to record birth and death information for production of vital statistics. The EVR is deployed in 83 villages in Traditional Authority Mtema, Lilongwe, which is an area without electricity. In 17 villages, village headmen were also trained to use a simple verbal autopsy (VA) tool adapted from one developed by the World Health Organization (WHO). Study objectives were to (i) document numbers and causes of death occurring in 17 villages between April 2016 and September 2017, and (ii) assess percentage measures of agreement on causes of death as recorded by village headmen using a simple VA tool and by a team of health surveillance assistant (HSA)/medical doctor using the WHO VA tool. Methods: The study was in two-parts: (i) a cross-sectional study using secondary data from the EVR; (ii) primary data collection study comparing causes of death obtained by village headmen using a simple VA tool and by HSA/medical doctor using the WHO VA tool. Results: Over 18 months, 120 deaths were recorded by EVR in 14,264 residents - crude annual death rate 5.6/1,000 population. Median age at death was 43 years with 69 (58%) deaths being in males. Death occurred at home (75%) and at health facility (25%). Malaria, diarrhoeal disease, pulmonary tuberculosis, acute respiratory infection, and stroke accounted for 56% of deaths recorded by village headmen using the simple VA tool. Causes of death between village headmen and the HSA/medical doctor team were compared for 107 deaths. There was full agreement in causes of death in 33 (31%) deaths, mostly for malaria, severe anemia, intentional self-harm, cancer, and epilepsy. Unknown-sudden death and sepsis recorded by the HSA/medical doctor team were responsible for most disagreements. Conclusion: It is feasible for village headmen in rural Malawi to use an EVR and simple VA tool to document numbers and causes of deaths. More work is needed to improve accuracy of causes of death by village headmen.

Loss to follow-up before and after initiation of antiretroviral therapy in HIV facilities in Lilongwe, Malawi.

INTRODUCTION: Although several studies have explored factors associated with loss to follow-up (LTFU) from HIV care, there remains a gap in understanding how these factors vary by setting, volume of patient and patients' demographic and clinical characteristics. We determined rates and factors associated with LTFU in HIV care Lilongwe, Malawi. METHODS: We conducted a retrospective cohort study of HIV-infected individuals aged 15 years or older at the time of registration for HIV care in 12 ART facilities, between April 2012 and March 2013. HIV-positive individuals who had not started ART (pre-ART patients) were clinically assessed to determine ART eligibility at registration and during clinic follow-up visits. ART-eligible patients were initiated on triple antiretroviral combination. Study data were abstracted from patients' cards, facility ART registers or electronic medical record system from the date of registration for HIV care to a maximum follow-up period of 24 months. Descriptive statistics were undertaken to summarize characteristics of the study patients. Separate univariable and multivariable poisson regression models were used to explore factors associated with LTFU in pre-ART and ART care. RESULTS: A total of 10,812 HIV-infected individuals registered for HIV care. Of these patients, 1,907 (18%) and 8,905 (82%) enrolled in pre-ART and ART care, respectively. Of the 1,907 pre-ART patients, 490 (26%) subsequently initiated ART and were included in both the pre-ART and ART analyses. The LTFU rates among patients in pre-ART and ART care were 48 and 26 per 100 person-years, respectively. Of the 9,105 ART patients with reasons for starting ART, 2,451 (27%) were initiated on ART because of pregnancy or breastfeeding (Option B+) status. Multivariable analysis showed that being ≥35 years and female were associated with decreased risk of LTFU in the pre-ART and ART phases of HIV care. However, being in WHO clinical stage 3 (adjusted risk ratio (aRR) 1.35, 95% confidence interval (CI): 1.20-1.51) and stage 4 (aRR 1.87, 95% CI: 1.62-2.18), body mass index ≤ 18.4 (aRR 1.24, 95% CI: 1.11-1.39) at ART initiation, poor adherence to clinic appointments (aRR 4.55, 95% CI: 4.16-4.97) and receiving HIV care in rural facilities (aRR 2.32, 95% CI: 1.94-2.87) were associated with increased risk of LTFU among ART patients. Being re-initiated on ART once (aRR 0.20, 95% CI: 0.17-0.22), more than once (aRR 0.06, 95% CI: 0.05-0.07), and being enrolled at a low-volume facility (aRR 0.25, 95% CI: 0.20-0.30) were associated with decreased risk of LTFU from ART care. CONCLUSION: A sizeable proportion of ART LTFU occurred among women enrolled during pregnancy or breast-feeding. Non- compliance to clinic and receiving ART in a rural facility or high-volume facility were associated with increased risk of LTFU from ART care. Developing effective interventions that target high-risk subgroups and contexts may help reduce LTFU from HIV care.

Integrating family planning services into HIV care: use of a point-of-care electronic medical record system in Lilongwe, Malawi.

BACKGROUND: Integrating family planning (FP) services into human immunodeficiency virus (HIV) clinical care helps improve access to contraceptives for women living with HIV. However, high patient volumes may limit providers' ability to counsel women about pregnancy risks and contraceptive options. OBJECTIVES: To assess trends in the use of contraceptive methods after implementing an  electronic medical record (EMR) system with FP questions and determine the reasons for non-use of contraceptives among women of reproductive age (15-49 years) receiving antiretroviral therapy (ART) at the Martin Preuss Center clinic in Malawi. METHODS: In February 2012, two FP questions were incorporated into the ART EMR system (initial FP EMR module) to prompt providers to offer contraceptives to women. In July 2013, additional questions were added to the FP EMR module (enhanced FP EMR) to prompt providers to assess risks of unintended pregnancies, solicit reasons for non-use of contraceptives and offer contraceptives to non-pregnant women . We conducted a retrospective, longitudinal cohort study using the EMR routinely collected data. The primary outcome was the use of any modern contraceptive method. Descriptive statistics were used to describe the study population and report trends in contraceptive use during the initial and enhanced study periods. RESULTS: Between February 2012 and December 2016, in HIV clinics, 20,253 women of reproductive age received ART, resulting in 163,325 clinic visits observations. The proportion of women using contraceptives increased significantly from 18% to 39% between February 2012 and June 2013, and from 39% to 67% between July 2013 and December 2016 (chi-square for trend p < 0.001). Common reasons reported for the non-use of contraceptives among those at risk of unintended pregnancy were: pregnancy ambivalence (n = 234, 51%) and never thought about it (n = 133, 29%). CONCLUSION: Incorporating the FP EMR module into HIV clinical care prompted healthcare workers to encourage the use of contraceptives.