Outcomes in HIV-infected patients who develop tuberculosis after starting antiretroviral treatment in Malawi.

A retrospective review was conducted of patients starting antiretroviral treatment (ART) at Mzuzu Central Hospital, Malawi, to identify those who developed tuberculosis (TB) within 6 months of commencing ART and document their treatment outcomes. Of 2933 patients, 22 (0.75%) developed active TB, 17 (77%) of whom had commenced ART as a result of unexplained weight loss and/or fever. Of those who developed TB, 41% successfully completed anti-tuberculosis treatment, with lower survival probabilities than patients who did not develop TB. Easier methods are needed to diagnose TB in human immunodeficiency virus-infected patients and to prevent patients from developing TB while on ART.

Reasons for loss to follow-up among mothers registered in a prevention-of-mother-to-child transmission program in rural Malawi.

This study was conducted to identify reasons for a high and progressive loss to follow-up among HIV-positive mothers within a prevention-of-mother-to-child HIV transmission (PMTCT) program in a rural district hospital in Malawi. Three focus group discussions were conducted among a total of 25 antenatal and post-natal mothers as well as nurse midwives (median age 39 years, range 22-55 years). The main reasons for loss to follow-up included: (1) not being prepared for HIV testing and its implications before the antenatal clinic (ANC) visit; (2) fear of stigma, discrimination, household conflict and even divorce on disclosure of HIV status; (3) lack of support from husbands who do not want to undergo HIV testing; (4) the feeling that one is obliged to rely on artificial feeding, which is associated with social and cultural taboos; (5) long waiting times at the ANC; and (6) inability to afford transport costs related to the long distances to the hospital. This study reveals a number of community- and provider-related operational and cultural barriers hindering the overall acceptability of PMTCT that need to be addressed urgently. Mothers attending antenatal services need to be better informed and supported, at both community and health-provider level.

Providing An audit of how patients get on to antiretroviral therapy in Malawi, and the weight gain they experience in the first six months.

An operational study was conducted in 6 public sector health facilities in the Southern Region of Malawi to determine a) drop-out rates during the referral process of patients to antiretroviral therapy (ART) and b) weight gained during the first 6 months in patients who were alive and on ART at that time. There were 738 adult HIV-infected eligible patients booked for group counseling, of whom 550 (74.5%) attended individual counseling and started ART. 16% of patients dropped out between booking and group counseling and 9.5% between group counseling and start of ART. In patients who were alive and on ART 6 months after starting, there was a gradual increase in weight with a mean gain of 6.0 kg in men and 5.0 kg in women. There was a slight increase in weight gain in patients in WHO Clinical Stage 3 and 4 compared with those in Stage 1&2, although this was only significant at 6-months between women in Stage 4 compared with women in Stage 1&2 (p <0.05). More information is needed on why patients drop out of the counseling process before starting ART, and whether weight gain is a marker for survival in the early months of ART.

Who is accessing antiretroviral therapy in Malawi? A study in the Southern Region on the occupation category "other".

As part of quarterly national reports on the scale up of antiretroviral therapy (ART), demographic and clinical characteristics are recorded including data on occupation. The largest occupational category is that of "other". As there is no information on the composition of the different occupations of patients placed in this category, a formal study was therefore conducted in 6 representative public sector facilities in the Southeastern Region of Malawi. Between January to June 2006, there were 126 adult patients recorded as "other" in the occupation column. A great variety of different occupations was recorded including no employment 30%, administration jobs 24%, general labourers 11%, builders 10%, tailors 9% and drivers 7%. A wide range of people with different jobs are accessing ART, and this should help in improving the economy of the patients as well as the country at large.

Providing insecticide treated bed nets in antiretroviral treatment clinics in Malawi: a pilot study.

HIV infection and malaria, two of the most common and important health problems in sub-Saharan Africa, have been demonstrated to have interactive pathology. In Malawi, where malaria is endemic, and antiretroviral therapy (ART) delivery is scaling up, we piloted integration of long-lasting insecticide-treated bednets (ITN) provision in three ART clinics. In July 2006, 1,910 ITNs were delivered to pilot sites, and ART clinic staff personnel were briefed on ITN provision and use of a monitoring system. Sites were assessed using a structured questionnaire in December 2006. During the pilot period, 1,282 ITNs were distributed to patients. A large proportion (70%) of ART patients at these sites received pilot study ITNs. Site adherence to the monitoring system was variable. Seventeen patients were interviewed, 14 of whom were ART patients who had received ITNs; 11 of these (79%) had slept under the net the previous night. This pilot demonstrates the feasibility of ITN distribution to patients attending ART clinics in Malawi. Programmatic and policy considerations for national roll-out include the need to: 1) adopt a standardized monitoring system, 2) develop information, education, and communication materials, 3) develop in-service training for ART clinicians, and 4) identify systems for forecasting, procuring and distributing ITNs.

WHO Stage 3 Disease Conditions and Outcomes in Patients Started on Antiretroviral Therapy in Malawi

Background: In Malawi; WHO stage 3 is the commonest reason for HIV-infected patients to be started on antiretroviral therapy (ART). The aim of the study was to document disease conditions with which patients are classified in Stage 3 and their relationship to 6-month treatment outcomes. Methodology: A retrospective survey was carried out examining ART patient treatment cards and ART registers in 6 publicsector health facilities in Southern Malawi. Results: There were 490 adult patients in Stage 3 who were started on ART; of whom 458 (93.5) were started due to one disease condition. Of these patients; symptomatic conditions (unexplained weight loss or chronic/intermittent fever for more than 1 month or chronic diarrhea for more than 1 month) were documented in 216 (47.2) patients; and active and previous tuberculosis in 148 (32.3) patients. There were no patients with oral hairy leukoplakia; severe mouth ulceration; or haematological abnormalities. At 6 months; 75of patients were alive on ART; 14were dead; 6were lost to follow-up and 4were transferred out. Adverse outcomes of death and lost to follow-up were more common in the group with a symptomatic condition (24.9) compared with the group with a specific disease condition (17.6) - OR 1.55 [95CI 0.95-2.53]. Conclusions: Nearly half the ART patients in Stage 3 started therapy due to a symptomatic condition; with outcomes inferior to those starting with a specific diagnosis. A better assessment of patients is needed so that serious; unrecognized diseases; forexample tuberculosis; are not missed before starting ART