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Mee P, Neuman M, Kumwenda M, Lora WS, Sikwese S, Sambo M, Fielding K, Indravudh PP, Hatzold K, Johnson C, Corbett EL, Desmond N. Experience of social harms among female sex workers following HIV self-test distribution in Malawi: results of a cohort study. BMC Infect Dis 2024; 22:978. [PMID: 38468208 PMCID: PMC10926537 DOI: 10.1186/s12879-024-09178-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 02/23/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND In Malawi, female sex workers (FSW) have high HIV incidence and regular testing is suggested. HIV self-testing (HIVST) is a safe and acceptable alternative to standard testing services. This study assessed; whether social harms were more likely to be reported after HIVST distribution to FSW by peer distributors than after facility-based HIV testing and whether FSW regretted HIVST use or experienced associated relationship problems. METHODS Peer HIVST distributors, who were FSW, were recruited in Blantyre district, Malawi between February and July 2017. Among HIVST recipients a prospective cohort was recruited. Interviews were conducted at baseline and at end-line, 3 months later. Participants completed daily sexual activity diaries. End-line data were analysed using logistic regression to assess whether regret or relationship problems were associated with HIVST use. Sexual activity data were analysed using Generalised Estimating Equations to assess whether HIVST use was temporally associated with an increase in social harms. RESULTS Of 265 FSW recruited and offered HIVST, 131 completed both interviews. Of these, 31/131(23.7%) reported initial regret after HIVST use, this reduced to 23/131(17.6%) at the 3-month follow-up. Relationship problems were reported by 12/131(9.2%). Regret about HIVST use was less commonly reported in those aged 26-35 years compared to those aged 16-25 years (OR immediate regret-0.40 95% CI 0.16-1.01) (OR current regret-0.22 95% CI 0.07 - 0.71) and was not associated with the HIVST result. There was limited evidence that reports of verbal abuse perpetrated by clients in the week following HIVST use were greater than when there was no testing in the preceding week. There was no evidence for increases in any other social harms. There was some evidence of coercion to test, most commonly initiated by the peer distributor. CONCLUSIONS Little evidence was found that the peer distribution model was associated with increased levels of social harms, however programmes aimed at reaching FSW need to carefully consider possible unintended consequences of their service delivery approaches, including the potential for peer distributors to coerce individuals to test or disclose their test results and alternative distribution models may need to be considered.
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Affiliation(s)
- Paul Mee
- Lincoln International Institute for Rural Health, College of Health and Science, University of Lincoln, Lincoln, UK.
| | - Melissa Neuman
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Moses Kumwenda
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Wezzie S Lora
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Simon Sikwese
- Pakachere Institute of Health and Development Communication, Blantyre, Malawi
| | - Mwiza Sambo
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Katherine Fielding
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Pitchaya P Indravudh
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Karin Hatzold
- Population Services International, Cape Town, South Africa
| | - Cheryl Johnson
- Global HIV, Hepatitis, STI Programmes, World Health Organization, Geneva, Switzerland
| | - Elizabeth L Corbett
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Nicola Desmond
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Simwinga M, Gwanu L, Hensen B, Sigande L, Mainga M, Phiri T, Mwanza E, Kabumbu M, Mulubwa C, Mwenge L, Bwalya C, Kumwenda M, Mubanga E, Mee P, Johnson CC, Corbett EL, Hatzold K, Neuman M, Ayles H, Taegtmeyer M. Lessons learned from implementation of four HIV self-testing (HIVST) distribution models in Zambia: applying the Consolidated Framework for Implementation Research to understand impact of contextual factors on implementation. BMC Infect Dis 2024; 22:977. [PMID: 38448832 PMCID: PMC10916003 DOI: 10.1186/s12879-024-09168-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 02/22/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Although Zambia has integrated HIV-self-testing (HIVST) into its Human Immunodeficiency Virus (HIV) regulatory frameworks, few best practices to optimize the use of HIV self-testing to increase testing coverage have been documented. We conducted a prospective case study to understand contextual factors guiding implementation of four HIVST distribution models to inform scale-up in Zambia. METHODS We used the qualitative case study method to explore user and provider experiences with four HIVST distribution models (two secondary distribution models in Antenatal Care (ANC) and Antiretroviral Therapy (ART) clinics, community-led, and workplace) to understand factors influencing HIVST distribution. Participants were purposefully selected based on their participation in HIVST and on their ability to provide rich contextual experience of the distribution models. Data were collected using observations (n = 31), group discussions (n = 10), and in-depth interviews (n = 77). Data were analyzed using the thematic approach and aligned to the four Consolidated Framework for Implementation Research (CFIR) domains. RESULTS Implementation of the four distribution models was influenced by an interplay of outer and inner setting factors. Inadequate compensation and incentives for distributors may have contributed to distributor attrition in the community-led and workplace HIVST models. Stockouts, experienced at the start of implementation in the secondary-distribution and community-led distribution models often disrupted distribution. The existence of policy and practices aided integration of HIVST in the workplace. External factors complimented internal factors for successful implementation. For instance, despite distributor attrition leading to excessive workload, distributors often multi-tasked to keep up with demand for kits, even though distribution points were geographically widespread in the workplace, and to a less extent in the community-led models. Use of existing communication platforms such as lunchtime and safety meetings to promote and distribute kits, peers to support distributors, reduction in trips by distributors to replenish stocks, increase in monetary incentives and reorganisation of stakeholder roles proved to be good adaptations. CONCLUSION HIVST distribution was influenced by a combination of contextual factors in variable ways. Understanding how the factors interacted in real world settings informed adaptations to implementation devised to minimize disruptions to distribution.
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Affiliation(s)
| | | | - Bernadette Hensen
- Department of Public Health, Sexual and Reproductive Health Group, Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | | | | | | | | | | | | | - Moses Kumwenda
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Ellen Mubanga
- National HIV/AID/STI/TB Council (NAC), Lusaka, Zambia
| | - Paul Mee
- Department of Infectious Disease Epidemiology, Medical Research Council International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Cheryl C Johnson
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Global HIV, Hepatitis and STI Programmes, World Health Organisation, Geneva, Switzerland
| | - Elizabeth L Corbett
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Karin Hatzold
- Population Services International, Johannesburg, South Africa
| | - Melissa Neuman
- Department of Infectious Disease Epidemiology, Medical Research Council International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Helen Ayles
- Zambart, Lusaka, Zambia
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Miriam Taegtmeyer
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical Infectious Diseases Unit, Liverpool University Hospitals Foundation Trust, Liverpool, UK
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Mndala L, Chapuma C, Riches J, Gadama L, Kachale F, Bilesi R, Mbewe M, Likaka A, Kumwenda M, Makuluni R, Maseko B, Ndamala C, Kuyere A, Munthali L, Phiri D, Monk EJM, Henrion MYR, Odland ML, Lissauer D. Effects of COVID-19 on Maternal and Neonatal Outcomes and Access to Antenatal and Postnatal Care, Malawi. Emerg Infect Dis 2023; 29:1990-1998. [PMID: 37640377 PMCID: PMC10521614 DOI: 10.3201/eid2910.230003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
We used national facility-level data from all government hospitals in Malawi to examine the effects of the second and third COVID-19 waves on maternal and neonatal outcomes and access to care during September 6, 2020-October 31, 2021. The COVID-19 pandemic affected maternal and neonatal health not only through direct infections but also through disruption of the health system, which could have wider indirect effects on critical maternal and neonatal outcomes. In an interrupted time series analysis, we noted a cumulative 15.4% relative increase (63 more deaths) in maternal deaths than anticipated across the 2 COVID-19 waves. We observed a 41% decrease in postnatal care visits at the onset of the second COVID-19 wave and 0.2% by the third wave, cumulative to 36,809 fewer visits than anticipated. Our findings demonstrate the need for strengthening health systems, particularly in resource-constrained settings, to prepare for future pandemic threats.
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Mukoka M, Sibanda E, Watadzaushe C, Kumwenda M, Abok F, Corbett EL, Ivanova E, Choko AT. COVID-19 self-testing using antigen rapid diagnostic tests: Feasibility evaluation among health-care workers and general population in Malawi. PLoS One 2023; 18:e0289291. [PMID: 37506068 PMCID: PMC10381081 DOI: 10.1371/journal.pone.0289291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND COVID-19 testing is critical for identifying cases to prevent transmission. COVID-19 self-testing has the potential to increase diagnostic testing capacity and to expand access to hard-to-reach areas in low-and-middle-income countries. We investigated the feasibility and acceptability of COVID-19 self-sampling and self-testing using SARS-CoV-2 Antigen-Rapid Diagnostic Tests (Ag-RDTs). METHODS From July 2021 to February 2022, we conducted a mixed-methods cross-sectional study examining self-sampling and self-testing using Standard Q and Panbio COVID-19 Ag Rapid Test Device in Urban and rural Blantyre, Malawi. Health care workers and adults (18y+) in the general population were non-randomly sampled. RESULTS Overall, 1,330 participants were enrolled of whom 674 (56.0%) were female and 656 (54.0%) were male with 664 for self-sampling and 666 for self-testing. Mean age was 30.7y (standard deviation [SD] 9.6). Self-sampling usability threshold for Standard Q was 273/333 (82.0%: 95% CI 77.4% to 86.0%) and 261/331 (78.8%: 95% CI 74.1% to 83.1%) for Panbio. Self-testing threshold was 276/335 (82.4%: 95% CI 77.9% to 86.3%) and 300/332 (90.4%: 95% CI 86.7% to 93.3%) for Standard Q and Panbio, respectively. Agreement between self-sample results and professional test results was 325/325 (100%) and 322/322 (100%) for Standard Q and Panbio, respectively. For self-testing, agreement was 332/333 (99.7%: 95% CI 98.3 to 100%) for Standard Q and 330/330 (100%: 95% CI 99.8 to 100%) for Panbio. Odds of achieving self-sampling threshold increased if the participant was recruited from an urban site (odds ratio [OR] 2.15 95% CI 1.44 to 3.23, P < .01. Compared to participants with primary school education those with secondary and tertiary achieved higher self-testing threshold OR 1.88 (95% CI 1.17 to 3.01), P = .01 and 4.05 (95% CI 1.20 to13.63), P = .02, respectively. CONCLUSIONS One of the first studies to demonstrate high feasibility and acceptability of self-testing using SARS-CoV-2 Ag-RDTs among general and health-care worker populations in low- and middle-income countries potentially supporting large scale-up. Further research is warranted to provide optimal delivery strategies of self-testing.
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Affiliation(s)
- Madalo Mukoka
- Department of Pathology, Helse-Nord Tuberculosis Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
- Public Health and Policy Group, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Euphemia Sibanda
- The Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe
| | | | - Moses Kumwenda
- Department of Pathology, Helse-Nord Tuberculosis Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
- Public Health and Policy Group, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Florence Abok
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Elizabeth L Corbett
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Elena Ivanova
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
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Saleh S, Sambakunsi H, Makina D, Chinouya M, Kumwenda M, Chirombo J, Semple S, Mortimer K, Rylance J. Personal exposures to fine particulate matter and carbon monoxide in relation to cooking activities in rural Malawi. Wellcome Open Res 2023; 7:251. [PMID: 36874568 PMCID: PMC9975423 DOI: 10.12688/wellcomeopenres.18050.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 02/23/2023] Open
Abstract
Background: Air pollution is a major environmental risk factor for cardiorespiratory disease. Exposures to household air pollution from cooking and other activities, are particularly high in Southern Africa. Following an extended period of participant observation in a village in Malawi, we aimed to assess individuals' exposures to fine particulate matter (PM 2.5) and carbon monoxide (CO) and to investigate the different sources of exposure, including different cooking methods. Methods: Adult residents of a village in Malawi wore personal PM 2.5 and CO monitors for 24-48 hours, sampling every 1 (CO) or 2 minutes (PM 2.5). Subsequent in-person interviews recorded potential exposure details over the time periods. We present means and interquartile ranges for overall exposures and summaries stratified by time and activity (exposure). We employed multivariate regression to further explore these characteristics, and Spearman rank correlation to examine the relationship between paired PM 2.5 and CO exposures. Results : Twenty participants (17 female; median age 40 years, IQR: 37-56) provided 831 hours of paired PM 2.5 and CO data. Concentrations of PM 2.5 during combustion activity, usually cooking, far exceeded background levels (no combustion activity): 97.9μg/m 3 (IQR: 22.9-482.0), vs 7.6μg/m 3, IQR: 2.5-20.6 respectively. Background PM 2.5 concentrations were higher during daytime hours (11.7μg/m 3 [IQR: 5.2-30.0] vs 3.3μg/m 3 at night [IQR: 0.7-8.2]). Highest exposures were influenced by cooking location but associated with charcoal use (for CO) and firewood on a three-stone fire (for PM 2.5). Cooking-related exposures were higher in more ventilated places, such as outside the household or on a walled veranda, than during indoor cooking. Conclusions : The study demonstrates the value of combining personal PM 2.5 exposure data with detailed contextual information for providing deeper insights into pollution sources and influences. The finding of similar/lower exposures during cooking in seemingly less-ventilated places should prompt a re-evaluation of proposed clean air interventions in these settings.
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Affiliation(s)
- Sepeedeh Saleh
- Liverpool School of Tropical Medicine, LIVERPOOL, L3 5QA, UK
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - Henry Sambakunsi
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - Debora Makina
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - Martha Chinouya
- Liverpool School of Tropical Medicine, LIVERPOOL, L3 5QA, UK
| | - Moses Kumwenda
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - James Chirombo
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - Sean Semple
- University of Stirling, Stirling, FK9 4LA, UK
| | - Kevin Mortimer
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Jamie Rylance
- Liverpool School of Tropical Medicine, LIVERPOOL, L3 5QA, UK
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
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Mndala L, Monk EJM, Phiri D, Riches J, Makuluni R, Gadama L, Kachale F, Bilesi R, Mbewe M, Likaka A, Chapuma C, Kumwenda M, Maseko B, Ndamala C, Kuyere A, Munthali L, Henrion MYR, Masesa C, Lissauer D. Comparison of maternal and neonatal outcomes of COVID-19 before and after SARS-CoV-2 omicron emergence in maternity facilities in Malawi (MATSurvey): data from a national maternal surveillance platform. Lancet Glob Health 2022; 10:e1623-e1631. [PMID: 36155136 PMCID: PMC9553200 DOI: 10.1016/s2214-109x(22)00359-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/27/2022] [Accepted: 08/02/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Outcomes of omicron-associated COVID-19 in pregnancy have not been reported from low-resource settings, and data from sub-Saharan Africa before the emergence of omicron are scarce. Using a national maternal surveillance platform (MATSurvey), we aimed to compare maternal and neonatal outcomes of COVID-19 in Malawi during the omicron wave to the preceding waves of beta and delta. METHODS All pregnant and recently pregnant patients, up to 42 days following delivery, admitted to 33 health-care facilities throughout Malawi with symptomatic, test-proven COVID-19 during the second (beta [B.1.351]: January to April, 2021), third (delta [B.1.617.2]: June to October, 2021), and fourth (omicron [B.1.1.529]: December 2021 to March, 2022) waves were included, with no age restrictions. Demographic and clinical features, maternal outcomes of interest (severe maternal outcome [a composite of maternal near-miss events and maternal deaths] and maternal death), and neonatal outcomes of interest (stillbirth and death during maternal stay in the health-care facility of enrolment) were compared between the fourth wave and the second and third waves using Fisher's exact test. Adjusted odds ratios (ORs) for maternal outcomes were estimated using mixed-effects logistic regression. FINDINGS Between Jan 1, 2021, and March 31, 2022, 437 patients admitted to 28 health-care facilities conducting MATSurvey had symptoms of COVID-19. SARS-CoV-2 infection was confirmed in 261 patients; of whom 76 (29%) had a severe maternal outcome and 45 (17%) died. These two outcomes were less common during the fourth wave (omicron dominance) than the second wave (adjusted OR of severe maternal outcome: 3·96 [95% CI 1·22-12·83], p=0·022; adjusted OR of maternal death: 5·65 [1·54-20·69], p=0·0090) and the third wave (adjusted OR: 3·18 [1·03-9·80], p=0·044; adjusted OR: 3·52 [0·98-12·60], p=0·053). Shortness of breath was the only symptom associated with poor maternal outcomes of interest (p<0·0001), and was less frequently reported in the fourth wave (23%) than in the second wave (51%; p=0·0007) or third wave (50%; p=0·0004). The demographic characteristics and medical histories of patients were similar across the three waves. During the second and third waves, 12 (13%) of 92 singleton neonates were stillborn or died during maternal stay in the health-care facility of enrolment, compared with 0 of the 25 born in the fourth wave (p=0·067 vs preceding waves combined). INTERPRETATION Maternal and neonatal outcomes from COVID-19 were less severe during the fourth wave of the SARS-CoV-2 pandemic in Malawi, during omicron dominance, than during the preceding beta and delta waves. FUNDING Bill & Melinda Gates Foundation, Wellcome Trust, and the National Institute for Health and Care Research. TRANSLATION For the Chichewa translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Leonard Mndala
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Edward J M Monk
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi.
| | - Deborah Phiri
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Jennifer Riches
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Regina Makuluni
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Luis Gadama
- Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | | | | | - Andrew Likaka
- Malawi Blood Transfusion Services, Blantyre, Malawi; Universidade Federal de Pernambuco, Recife, Brazil
| | - Chikondi Chapuma
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Moses Kumwenda
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi; Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Bertha Maseko
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Chifundo Ndamala
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Annie Kuyere
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Laura Munthali
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Marc Y R Henrion
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK
| | - Clemens Masesa
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK
| | - David Lissauer
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi; University of Liverpool, Liverpool, UK
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Saleh S, Sambakunsi H, Makina D, Chinouya M, Kumwenda M, Chirombo J, Semple S, Mortimer K, Rylance J. Personal exposures to fine particulate matter and carbon monoxide in relation to cooking activities in rural Malawi. Wellcome Open Res 2022; 7:251. [PMID: 36874568 PMCID: PMC9975423 DOI: 10.12688/wellcomeopenres.18050.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Air pollution is a major environmental risk factor for cardiorespiratory disease. Exposures to household air pollution from cooking and other activities, are particularly high in Southern Africa. Following an extended period of participant observation in a village in Malawi, we aimed to assess individuals' exposures to fine particulate matter (PM 2.5) and carbon monoxide (CO) and to investigate the different sources of exposure, including different cooking methods. Methods: Adult residents of a village in Malawi wore personal PM 2.5 and CO monitors for 24-48 hours, sampling every 1 (CO) or 2 minutes (PM 2.5). Subsequent in-person interviews recorded potential exposure details over the time periods. We present means and interquartile ranges for overall exposures and summaries stratified by time and activity (exposure). We employed multivariate regression to further explore these characteristics, and Spearman rank correlation to examine the relationship between paired PM 2.5 and CO exposures. Results : Twenty participants (17 female; median age 40 years, IQR: 37-56) provided 831 hours of paired PM 2.5 and CO data. Concentrations of PM 2.5 during combustion activity, usually cooking, far exceeded background levels (no combustion activity): 97.9μg/m 3 (IQR: 22.9-482.0), vs 7.6μg/m 3, IQR: 2.5-20.6 respectively. Background PM 2.5 concentrations were higher during daytime hours (11.7μg/m 3 [IQR: 5.2-30.0] vs 3.3μg/m 3 at night [IQR: 0.7-8.2]). Highest exposures were influenced by cooking location but associated with charcoal use (for CO) and firewood on a three-stone fire (for PM 2.5). Cooking-related exposures were higher in more ventilated places, such as outside the household or on a walled veranda, than during indoor cooking. Conclusions : The study demonstrates the value of combining personal PM 2.5 exposure data with detailed contextual information for providing deeper insights into pollution sources and influences. The finding of similar/lower exposures during cooking in seemingly less-ventilated places should prompt a re-evaluation of proposed clean air interventions in these settings.
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Affiliation(s)
- Sepeedeh Saleh
- Liverpool School of Tropical Medicine, LIVERPOOL, L3 5QA, UK
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - Henry Sambakunsi
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - Debora Makina
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - Martha Chinouya
- Liverpool School of Tropical Medicine, LIVERPOOL, L3 5QA, UK
| | - Moses Kumwenda
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - James Chirombo
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
| | - Sean Semple
- University of Stirling, Stirling, FK9 4LA, UK
| | - Kevin Mortimer
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Jamie Rylance
- Liverpool School of Tropical Medicine, LIVERPOOL, L3 5QA, UK
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, P.O. Box 30096, Malawi
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8
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Kaswaswa K, MacPherson P, Kumwenda M, Mpunga J, Thindwa D, Nliwasa M, Mwapasa M, Odland J, Tomoka T, Chipungu G, Mukaka M, Corbett EL. Effect of patient-delivered household contact tracing and prevention for tuberculosis: A household cluster-randomised trial in Malawi. PLoS One 2022; 17:e0269219. [PMID: 36074775 PMCID: PMC9455850 DOI: 10.1371/journal.pone.0269219] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 05/15/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Household contact tracing provides TB screening and TB preventive therapy (TPT) to contacts at high risk of TB disease. However, it is resource intensive, inconvenient, and often poorly implemented. We investigated a novel model aiming to improve uptake. METHODS Between May and December 2014, we randomised patient with TB who consented to participate in the trial to either standard of care (SOC) or intervention (PACTS) arms. Participants randomised to PACTS received one screening/triage tool (adapted from WHO integrated management of adolescent and adult illnesses [IMAI] guidelines) and sputum pots for each reported household contact. The tool guided participants through symptom screening; TPT (6-months of isoniazid) eligibility; and sputum collection for contacts. Patients randomised to SOC were managed in accordance with national guidelines, that is, they received verbal instruction on who to bring to clinics for investigation using national guidelines. MAIN OUTCOME AND MEASURES The primary outcome was the proportion of adult contacts receiving treatment for TB within 3 months of randomisation. Secondary outcomes were the proportions of child contacts under age 5 years (U5Y) who were commenced on, and completed, TPT. Data were analyzed by logistic regression with random effects to adjust for household clustering. RESULTS Two hundred and fourteen index TB participants were block-randomized from two sites (107 PACTS, reporting 418 contacts; and 107 SOC, reporting 420 contacts). Overall, 62.8% of index TB participants were HIV-positive and 52.1% were TB culture-positive. 250 otherwise eligible TB patients declined participation and 6 households (10 PACTS, 6 SOC) were lost to follow-up and were not included in the analysis. By three months, nine contacts (PACTS: 6, [1.4%]; SOC: 3, [0.7%]) had TB diagnosed, with no difference between groups (adjusted odds ratio [aOR]: 2.18, 95% CI: 0.60-7.95). Eligible PACTS contacts (37/96, 38.5%) were more likely to initiate TPT by 3-months compared to SOC contacts (27/101, 26.7%; aOR 2.27, 95% CI: 1.04-4.98). U5Y children in the PACTS arm (47/81 58.0%) were more likely to have initiated TPT before the 3-month visit compared to SOC children (36/89, 41.4%; aOR: 2.31, 95% CI: 1.05-5.06). CONCLUSIONS AND RELEVANCE A household-centred patient-delivered symptom screen and IPT eligibility assessment significantly increased timely TPT uptake among U5Y children, but did not significantly increase TB diagnosis. This model needs to be optimized for acceptability, given low participation, and investigated in other low resource settings. CLINICAL TRIAL REGISTRATION TRIAL REGISTRATION NUMBER: ISRCTN81659509 https://www.isrctn.com/ISRCTN81659509?q=&filters=conditionCategory:Respiratory,recruitmentCountry:Malawi,ageRange:Mixed&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search. 19 July 2012.
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Affiliation(s)
- Kruger Kaswaswa
- College of Medicine, Blantyre, Malawi
- Malawi National TB Control Programme, Blantyre, Malawi
| | - Peter MacPherson
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Moses Kumwenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - James Mpunga
- Malawi National TB Control Programme, Blantyre, Malawi
| | - Deus Thindwa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Marriott Nliwasa
- College of Medicine, Blantyre, Malawi
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- University of Tromso, Tromso, Norway
| | | | - Jon Odland
- Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | | | | | - Mavuto Mukaka
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Elizabeth L. Corbett
- College of Medicine, Blantyre, Malawi
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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9
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Schade AT, Sibande W, Kumwenda M, Desmond N, Chokotho L, Karasouli E, Metcalfe A, Harrison WJ. “Don’t rush into thinking of walking again”: Patient views of treatment and disability following an open tibia fracture in Malawi. Wellcome Open Res 2022; 7:204. [PMID: 36110835 PMCID: PMC9453110 DOI: 10.12688/wellcomeopenres.18063.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 12/05/2022] Open
Abstract
Background: Open tibia fractures are a common injury following road traffic accidents in Malawi and can lead to long term disability. Very little is known about patients’ experiences of the healthcare system and the disability in low-income countries following this injury. The aim of the study was to explore patient experiences of treatment and disability following an open tibia fracture in Malawi.
Methods: A qualitative study was conducted using semi-structured interviews with ten patients with open tibia fractures at a central hospital in Blantyre, Malawi. A mixed deductive-inductive thematic analysis was used to identify broad themes of treatment and disability. Written informed consent was obtained from all participants. Results: Patient characteristics included an average age of 39.1 years old (22-63) and 80% were male. Broad themes found were delays in receiving treatment, change in individuals’ societal role and delayed recovery associated with pain and immobility. Conclusions: Open tibia fractures in Malawi have a devastating impact on patients and their families. Further studies are required to explore the reasons for the delays in open fracture emergency treatment.
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Affiliation(s)
- Alexander Thomas Schade
- Public Health, Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
- Clinical Trials Unit, University of Warwick, Coventry, UK
- Trauma and Orthopaedics, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Wakumanya Sibande
- Public Health, Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Moses Kumwenda
- Public Health, Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nicola Desmond
- Public Health, Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Linda Chokotho
- Trauma and Orthopaedics, Queen Elizabeth Central Hospital, Blantyre, Malawi
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10
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Saleh S, Sambakunsi H, Makina D, Kumwenda M, Rylance J, Chinouya M, Mortimer K. "We threw away the stones": a mixed method evaluation of a simple cookstove intervention in Malawi. Wellcome Open Res 2022; 7:52. [PMID: 35330615 PMCID: PMC8933645 DOI: 10.12688/wellcomeopenres.17544.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Air pollution exposure is responsible for a substantial burden of respiratory disease globally. Household air pollution from cooking using biomass is a major contributor to overall exposure in rural low-income settings. Previous research in Malawi has revealed how precarity and food insecurity shape individuals' daily experiences, contributing to perceptions of health. Aiming to avoid a mismatch between research intervention and local context, we introduced a simple cookstove intervention in rural Malawi, analysing change in fine particulate matter (PM 2.5) exposures, and community perceptions. Methods: Following a period of baseline ethnographic research, we distributed 'chitetezo mbaula', locally-made cookstoves, to all households (n=300) in a rural Malawian village. Evaluation incorporated village-wide participant observation and concurrent exposure monitoring using portable PM 2.5 monitors at baseline and follow-up (three months post-intervention). Qualitative data were thematically analysed. Quantitative analysis of exposure data included pre-post intervention comparisons, with datapoints divided into periods of combustion activity (almost exclusively cooking) and non-combustion periods. Findings were integrated at the interpretation stage, using a convergent design mode of synthesis. Results: Individual exposure monitoring pre- and post-cookstove intervention involved a sample of 18 participants (15 female; mean age 43). Post-intervention PM 2.5 exposures (median 9.9μg/m 3 [interquartile range: 2.2-46.5]) were not significantly different to pre-intervention (11.8μg/m 3 [3.8-44.4]); p=0.71. On analysis by activity, background exposures were found to be reduced post-intervention (from 8.2μg/m 3 [2.5-22.0] to 4.6μg/m 3 [1.0-12.6]; p=0.01). Stoves were well-liked and widely used by residents as substitutes for previous cooking methods (mainly three-stone fires). Commonly cited benefits related to fuel saving and shorter cooking times. Conclusions: The cookstove intervention had no impact on cooking-related PM 2.5 exposures. A significant reduction in background exposures may relate to reduced smouldering emissions. Uptake and continued use of the stoves was high amongst community members, who preferred using the stoves to cooking over open fires.
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Affiliation(s)
- Sepeedeh Saleh
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
- Malawi-Liverpool Wellcome trust Clinical Research Programme, Blantyre, Malawi
| | - Henry Sambakunsi
- Malawi-Liverpool Wellcome trust Clinical Research Programme, Blantyre, Malawi
| | - Debora Makina
- Malawi-Liverpool Wellcome trust Clinical Research Programme, Blantyre, Malawi
| | - Moses Kumwenda
- Malawi-Liverpool Wellcome trust Clinical Research Programme, Blantyre, Malawi
| | - Jamie Rylance
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
- Malawi-Liverpool Wellcome trust Clinical Research Programme, Blantyre, Malawi
| | - Martha Chinouya
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Kevin Mortimer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
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11
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Fajardo E, Watson V, Kumwenda M, Usharidze D, Gogochashvili S, Kakhaberi D, Giguashvili A, Johnson CC, Jamil MS, Dacombe R, Stvilia K, Easterbrook P, Ivanova Reipold E. Usability and acceptability of oral-based HCV self-testing among key populations: a mixed-methods evaluation in Tbilisi, Georgia. BMC Infect Dis 2022; 22:510. [PMID: 35641908 PMCID: PMC9154030 DOI: 10.1186/s12879-022-07484-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 05/18/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Hepatitis C virus self-testing (HCVST) is an additional approach that may expand access to HCV testing. We conducted a mixed-methods cross-sectional observational study to assess the usability and acceptability of HCVST among people who inject drugs (PWID), men who have sex with men (MSM) and transgender (TG) people in Tbilisi, Georgia. METHODS The study was conducted from December 2019 to June 2020 among PWID at one harm reduction site and among MSM/TG at one community-based organization. We used a convergent parallel mixed-methods design. Usability was assessed by observing errors made and difficulties faced by participants. Acceptability was assessed using an interviewer-administered semi-structured questionnaire. A subset of participants participated in cognitive and in-depth interviews. RESULTS A total of 90 PWID, 84 MSM and 6 TG were observed performing HCVST. PWID were older (median age 35 vs 24) and had a lower level of education compared to MSM/TG (27% vs 59%). The proportion of participants who completed all steps successfully without assistance was 60% among PWID and 80% among MSM/TG. The most common error was in sample collection and this was observed more often among PWID than MSM/TG (21% vs 6%; p = 0.002). More PWID requested assistance during HCVST compared to MSM/TG (22% vs 8%; p = 0.011). Acceptability was high in both groups (98% vs 96%; p = 0.407). Inter-reader agreement was 97% among PWID and 99% among MSM/TG. Qualitative data from cognitive (n = 20) and in-depth interviews (n = 20) was consistent with the quantitative data confirming a high usability and acceptability. CONCLUSIONS HCVST was highly acceptable among key populations in Georgia of relatively high educational level, and most participants performed HCVST correctly. A significant difference in usability was observed among PWID compared to MSM/TG, indicating that PWID may benefit from improved messaging and education as well as options to receive direct assistance when self-testing for HCV.
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Affiliation(s)
- Emmanuel Fajardo
- grid.452485.a0000 0001 1507 3147The Foundation for Innovative New Diagnostics (FIND), Campus Biotech, Chemin des Mines 9, 1202 Geneva, Switzerland
| | - Victoria Watson
- grid.48004.380000 0004 1936 9764Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | - Moses Kumwenda
- grid.419393.50000 0004 8340 2442Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), Blantyre, Malawi ,grid.10595.380000 0001 2113 2211College of Medicine, University of Malawi (CoM), Blantyre, Malawi
| | | | | | - David Kakhaberi
- Community-Based Organization Equality Movement, Tbilisi, Georgia
| | - Ana Giguashvili
- National Centre for Disease Control and Public Health of Georgia, Tbilisi, Georgia
| | - Cheryl C. Johnson
- grid.3575.40000000121633745Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Muhammad S. Jamil
- grid.3575.40000000121633745Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Russell Dacombe
- grid.48004.380000 0004 1936 9764Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | - Ketevan Stvilia
- National Centre for Disease Control and Public Health of Georgia, Tbilisi, Georgia
| | - Philippa Easterbrook
- grid.3575.40000000121633745Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Elena Ivanova Reipold
- grid.452485.a0000 0001 1507 3147The Foundation for Innovative New Diagnostics (FIND), Campus Biotech, Chemin des Mines 9, 1202 Geneva, Switzerland
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12
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Harrison L, Kumwenda M, Nyirenda L, Chilongosi R, Corbett E, Hatzold K, Johnson C, Simwinga M, Desmond N, Taegtmeyer M. "You have a self-testing method that preserves privacy so how come you cannot give us treatment that does too?" Exploring the reasoning among young people about linkage to prevention, care and treatment after HIV self-testing in Southern Malawi. BMC Infect Dis 2022; 22:395. [PMID: 35449095 PMCID: PMC9026576 DOI: 10.1186/s12879-022-07231-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Young people, aged 16-24, in southern Malawi have high uptake of HIV self-testing (HIVST) but low rates of linking to services following HIVST, especially in comparison, to older generations. The study aim is to explore the barriers and facilitators to linkage for HIV prevention and care following uptake of HIV self-testing among young Malawians. METHODS We used qualitative methods. Young people aged 16-24 who had received HIVST; community-based distribution agents (CBDAs) and health care workers from the linked facilities were purposively sampled from two villages in rural southern Malawi. RESULTS We conducted in-depth interviews with thirteen young people (9 female) and held four focus groups with 28 healthcare workers and CBDAs. Young people strongly felt the social consequences associated with inadvertent disclosure of HIV sero-status were a significant deterrent to linkage at their stage in life. They also felt communication on testing benefits and the referral process after testing was poor. In contrast, they valued encouragement from those they trusted, other's positive treatment experiences and having a "strength of mind". CBDAs were important facilitators for young people as they are able to foster a trusting relationship and had more understanding of the factors which prevented young people from linking following HIVST than the healthcare workers. Young people noted contextual barriers to linkage, for example, being seen on the road to the healthcare centre, but also societal gendered barriers. For example, young females and younger adolescents were less likely to have the financial independence to link to services whilst young males (aged 19-24) had the finances but lacked a supportive network to encourage linkage following testing. Overall, it was felt that the primary "responsibility" for linking to formal healthcare following self-testing is shouldered by the young person and not the healthcare system. CONCLUSIONS Young people are happy to self-test for HIV but faced barriers to link to services following a self-test. Potential interventions for improving linkage suggested by this analysis include the establishment of youth-friendly linkage services, enhanced lines of communication between young people and healthcare providers and prioritising linkage for future interventions when targeting young people following HIVST.
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Affiliation(s)
- Lisa Harrison
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Moses Kumwenda
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Lot Nyirenda
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Richard Chilongosi
- Department of HIV Prevention, Population Services International, Blantyre, Malawi
| | - Elizabeth Corbett
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Karin Hatzold
- Population Services International, Johannesburg, South Africa
| | - Cheryl Johnson
- Department of Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | | | - Nicola Desmond
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Sciences Department, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
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13
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Saleh S, Sambakunsi H, Makina D, Kumwenda M, Rylance J, Chinouya M, Mortimer K. "We threw away the stones": a mixed method evaluation of a simple cookstove intervention in Malawi. Wellcome Open Res 2022; 7:52. [PMID: 35330615 PMCID: PMC8933645 DOI: 10.12688/wellcomeopenres.17544.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Air pollution exposure is responsible for a substantial burden of respiratory disease globally. Household air pollution from cooking using biomass is a major contributor to overall exposure in rural low-income settings. Previous research in Malawi has revealed how precarity and food insecurity shape individuals' daily experiences, contributing to perceptions of health. Aiming to avoid a mismatch between research intervention and local context, we introduced a simple cookstove intervention in rural Malawi, analysing change in fine particulate matter (PM 2.5) exposures, and community perceptions. Methods: Following a period of baseline ethnographic research, we distributed 'chitetezo mbaula', locally-made cookstoves, to all households (n=300) in a rural Malawian village. Evaluation incorporated village-wide participant observation and concurrent exposure monitoring using portable PM 2.5 monitors at baseline and follow-up (three months post-intervention). Qualitative data were thematically analysed. Quantitative analysis of exposure data included pre-post intervention comparisons, with datapoints divided into periods of combustion activity (almost exclusively cooking) and non-combustion periods. Findings were integrated at the interpretation stage, using a convergent design mode of synthesis. Results: Individual exposure monitoring pre- and post-cookstove intervention involved a sample of 18 participants (15 female; mean age 43). Post-intervention PM 2.5 exposures (median 9.9μg/m 3 [interquartile range: 2.2-46.5]) were not significantly different to pre-intervention (11.8μg/m 3 [3.8-44.4]); p=0.71. On analysis by activity, background exposures were found to be reduced post-intervention (from 8.2μg/m 3 [2.5-22.0] to 4.6μg/m 3 [1.0-12.6]; p=0.01). Stoves were well-liked and widely used by residents as substitutes for previous cooking methods (mainly three-stone fires). Commonly cited benefits related to fuel saving and shorter cooking times. Conclusions: The cookstove intervention had no impact on cooking-related PM 2.5 exposures. A significant reduction in background exposures may relate to reduced smouldering emissions. Uptake and continued use of the stoves was high amongst community members, who preferred using the stoves to cooking over open fires.
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Affiliation(s)
- Sepeedeh Saleh
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
- Malawi-Liverpool Wellcome trust Clinical Research Programme, Blantyre, Malawi
| | - Henry Sambakunsi
- Malawi-Liverpool Wellcome trust Clinical Research Programme, Blantyre, Malawi
| | - Debora Makina
- Malawi-Liverpool Wellcome trust Clinical Research Programme, Blantyre, Malawi
| | - Moses Kumwenda
- Malawi-Liverpool Wellcome trust Clinical Research Programme, Blantyre, Malawi
| | - Jamie Rylance
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
- Malawi-Liverpool Wellcome trust Clinical Research Programme, Blantyre, Malawi
| | - Martha Chinouya
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Kevin Mortimer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
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14
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Saleh S, Sambakunsi H, Makina D, Kumwenda M, Rylance J, Chinouya M, Mortimer K. "We threw away the stones": a mixed method evaluation of a simple cookstove intervention in Malawi. Wellcome Open Res 2022; 7:52. [PMID: 35330615 PMCID: PMC8933645 DOI: 10.12688/wellcomeopenres.17544.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Exposure to air pollution is responsible for a substantial burden of respiratory disease globally. Household air pollution from cooking using biomass is a major contributor to overall exposure in rural low-income settings. Previous research in Malawi has revealed how precarity and food insecurity shape individuals' daily experiences, contributing to perceptions of health. Aiming to avoid a mismatch between research intervention and local context, we introduced a simple cookstove intervention in rural Malawi, analysing change in fine particulate matter (PM 2.5) exposures, and community perceptions. Methods: Following a period of baseline ethnographic research, we distributed 'chitetezo mbaula', locally made clay cookstoves, to all households (n=300) in a rural Malawian village. Evaluation incorporated village-wide participant observation and concurrent exposure monitoring using portable PM 2.5 monitors at baseline and follow-up (three months post-intervention). Qualitative data were thematically analysed. Quantitative analysis of exposure data included pre-post intervention comparisons, with datapoints divided into cooking and non-cooking ('baseline') periods. Findings were integrated at the interpretation stage, using a convergent design mode of synthesis. Results: Individual exposure monitoring pre- and post-cookstove intervention involved a sample of 18 participants (15 female; mean age 43). Post-intervention PM 2.5 exposures (median 9.9μg/m 3 [interquartile range: 2.2-46.5]) were not significantly different to pre-intervention (11.8μg/m 3 [3.8-44.4]); p=0.71. On analysis by activity, 'baseline' exposures were found to be reduced post-intervention (from 8.2μg/m 3 [2.5-22.0] to 4.6μg/m 3 [1.0-12.6]; p=0.01). Stoves were well-liked and widely used by residents as substitutes for previous cooking methods (mainly three-stone fires). Most cited benefits related to fuel saving and shorter cooking times. Conclusions: The cookstove intervention had no impact on cooking-related PM 2.5 exposures. A significant reduction in baseline exposures may relate to reduced smouldering emissions. Uptake and continued use of the stoves was high amongst community members, who preferred using the stoves to cooking over open fires.
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Affiliation(s)
- Sepeedeh Saleh
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
- Malawi-Liverpool Wellcome trust Clinical Research Programme, Blantyre, Malawi
| | - Henry Sambakunsi
- Malawi-Liverpool Wellcome trust Clinical Research Programme, Blantyre, Malawi
| | - Debora Makina
- Malawi-Liverpool Wellcome trust Clinical Research Programme, Blantyre, Malawi
| | - Moses Kumwenda
- Malawi-Liverpool Wellcome trust Clinical Research Programme, Blantyre, Malawi
| | - Jamie Rylance
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
- Malawi-Liverpool Wellcome trust Clinical Research Programme, Blantyre, Malawi
| | - Martha Chinouya
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Kevin Mortimer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
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15
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Herrmann Y, Lainati F, Castro MDM, Mwamba CP, Kumwenda M, Muyoyeta M, Broger T, Heinrich N, Olbrich L, Corbett EL, McMahon SA, Engel N, Denkinger CM. User perspectives and preferences on a novel TB LAM diagnostic (Fujifilm SILVAMP TB LAM)-a qualitative study in Malawi and Zambia. PLOS Glob Public Health 2022; 2:e0000672. [PMID: 36962216 PMCID: PMC10021253 DOI: 10.1371/journal.pgph.0000672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 05/30/2022] [Indexed: 11/18/2022]
Abstract
Widely available tuberculosis (TB) diagnostics use sputum samples. However, many patients, particularly children and patients living with HIV (PLHIV), struggle to provide sputum. Urine diagnostics are a promising approach to circumvent this challenge while delivering reliable and timely diagnosis. This qualitative study in two high TB/HIV burden countries assesses values and preferences of end-users, along with potential barriers for the implementation of the novel Fujifilm SILVAMP TB-LAM (FujiLAM, Fujifilm, Japan) urine test. Between September 2020 and March 2021, we conducted 42 semi-structured interviews with patients, health care providers (HCPs) and decision makers (DMs) (e.g., in national TB programs) in Malawi and Zambia. Interviews were transcribed verbatim and analyzed using a framework approach supported by NVIVO. Findings aligned with the pre-existing Health Equity Implementation Framework, which guided the presentation of results. The ease and convenience of urine-based testing was described as empowering among patients and HCPs who lamented the difficulty of sputum collection, however HCPs expressed concerns that a shift in agency to the patient may affect clinic workflows (e.g., due to less control over collection). Implementation facilitators, such as shorter turnaround times, were welcomed by operators and patients alike. The decentralization of diagnostics was considered possible with FujiLAM by HCPs and DMs due to low infrastructure requirements. Finally, our findings support efforts for eliminating the CD4 count as an eligibility criterion for LAM testing, to facilitate implementation and benefit a wider range of patients. Our study identified barriers and facilitators relevant to scale-up of urine LAM tests in Malawi and Zambia. FujiLAM could positively impact health equity, as it would particularly benefit patient groups currently underserved by existing TB diagnostics. Participants view the approach as a viable, acceptable, and likely sustainable option in low- and middle-income countries, though adaptations may be required to current health care processes for deployment. Trial registration: German Clinical Trials Register, DRKS00021003. URL: https://www.drks.de/drks_web/setLocale_EN.do.
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Affiliation(s)
- Yannis Herrmann
- Division of Clinical Infectious Disease and Tropical Medicine, Centre for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Federica Lainati
- Division of Clinical Infectious Disease and Tropical Medicine, Centre for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - María Del Mar Castro
- Division of Clinical Infectious Disease and Tropical Medicine, Centre for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Chanda P Mwamba
- Centre for Infectious Disease Research in Zambia, Social & Behavioural Science Group, Lusaka, Zambia
| | - Moses Kumwenda
- Malawi-Liverpool-Wellcome Clinical Research Programme (MLW), Public Health Group, Blantyre, Malawi
| | - Monde Muyoyeta
- Centre for Infectious Disease Research in Zambia, Tuberculosis Department, Lusaka, Zambia
| | - Tobias Broger
- Division of Clinical Infectious Disease and Tropical Medicine, Centre for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Norbert Heinrich
- Division for Infectious Diseases, LMU Hospital, Munich, Germany
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Laura Olbrich
- Division for Infectious Diseases, LMU Hospital, Munich, Germany
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Elizabeth L Corbett
- London School of Hygiene and Tropical Medicine, Infectious and Tropical Diseases, London, United Kingdom
| | - Shannon A McMahon
- Heidelberg University Hospital, Heidelberg Institute of Global Health, Heidelberg, Germany
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Nora Engel
- Maastricht University, Department of Health, Ethics & Society, Research School for Public Health and Primary Care, Maastricht, The Netherlands
| | - Claudia M Denkinger
- Division of Clinical Infectious Disease and Tropical Medicine, Centre for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Partner Site Heidelberg University Hospital, Heidelberg, Germany
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16
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Saleh S, Sambakunsi H, Mortimer K, Morton B, Kumwenda M, Rylance J, Chinouya M. Exploring smoke: an ethnographic study of air pollution in rural Malawi. BMJ Glob Health 2021; 6:bmjgh-2021-004970. [PMID: 34193474 PMCID: PMC8246283 DOI: 10.1136/bmjgh-2021-004970] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 06/13/2021] [Indexed: 12/13/2022] Open
Abstract
Air pollution adversely affects human health, and the climate crisis intensifies the global imperative for action. Low-/middle-income countries (LMIC) suffer particularly high attributable disease burdens. In rural low-resource settings, these are linked to cooking using biomass. Proposed biomedical solutions to air pollution typically involve ‘improved cooking technologies’, often introduced by high-income country research teams. This ethnography, set in a rural Malawian village, aimed to understand air pollution within its social and environmental context. The results provide a multifaceted account through immersive participant observations with concurrent air quality monitoring, interviews and participatory workshops. Data included quantitative measures of individuals’ air pollution exposures paired with activity, qualitative insights into how smoke is experienced in daily life throughout the village, and participants’ reflections on potential cleaner air solutions. Individual air quality monitoring demonstrated that particulate levels frequently exceeded upper limits recommended by the WHO, even in the absence of identified sources of biomass burning. Ethnographic findings revealed the overwhelming impact of economic scarcity on individual air pollution exposures. Scarcity affected air pollution exposures through three pathways: daily hardship, limitation and precarity. We use the theory of structural violence, as described by Paul Farmer, and the concept of slow violence to interrogate the origins of this scarcity and global inequality. We draw on the ethnographic findings to critically consider sustainable approaches to cleaner air, without re-enacting existing systemic inequities.
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Affiliation(s)
- Sepeedeh Saleh
- Liverpool School of Tropical Medicine, Liverpool, UK .,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Henry Sambakunsi
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Ben Morton
- Liverpool School of Tropical Medicine, Liverpool, UK.,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Moses Kumwenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Jamie Rylance
- Liverpool School of Tropical Medicine, Liverpool, UK
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17
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Phiri MM, Makepeace E, Nyali M, Kumwenda M, Corbett L, Fielding K, Choko A, MacPherson P, MacPherson EE. Improving pathways to care through interventions cocreated with communities: a qualitative investigation of men's barriers to tuberculosis care-seeking in an informal settlement in Blantyre, Malawi. BMJ Open 2021; 11:e044944. [PMID: 34193484 PMCID: PMC8246363 DOI: 10.1136/bmjopen-2020-044944] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Men have a higher prevalence of undiagnosed tuberculosis (TB) than women and can spend up to a year longer contributing to ongoing transmission in the community before receiving treatment. Health outcomes are often worse for patients with TB living in informal settlements especially men. This study aimed to understand the barriers preventing men from seeking care for TB and cocreate interventions to address these barriers. METHODS We used qualitative research methods including in-depth interviews and participatory workshops. Researchers worked with women and men living in Bangwe, an informal settlement in Blantyre, Malawi to develop interventions that reflected their lived realities. The study took place over two phases, in the first phase we undertook interviews with men and women to explore barrier to care seeking, in the second phase we used participatory workshops to cocreate interventions to address barriers and followed up on issues emerging from the workshops with further interviews. In total, 30 interviews were conducted, and 23 participants joined participatory workshops. The team used a thematic analysis to analyse the data. RESULTS Three interconnected thematic areas shaped men's health TB seeking behaviour: precarious socioeconomic conditions; gendered social norms; and constraints in the health system. Insecurity of day labour with no provision for sick leave; pressure to provide for the household and a gendered desire not to appear weak and a severely under-resourced health system all contributed to men delaying care in this context. Identified interventions included improved patient-provider relations within the health-system, improved workers' health rights and broader social support for households. CONCLUSION Improving mens' pathways to care requires interventions that consider contextual issues by addressing individual level socioeconomic factors but also broader structural factors of gendered social dynamics and health systems environment.
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Affiliation(s)
| | - Effie Makepeace
- Media, Arts and Humanities, University of Sussex, Brighton, UK
| | - Margaret Nyali
- Department of Public Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Moses Kumwenda
- Social Science Department, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Public Health, University of Malawi College of Medicine, Blantyre, Malawi
- TB/HIV, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Liz Corbett
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Augustine Choko
- TB/HIV, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Peter MacPherson
- TB/HIV, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Eleanor Elizabeth MacPherson
- Social Science Department, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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18
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Saleh S, Sambakunsi H, Nyirenda D, Kumwenda M, Mortimer K, Chinouya M. Participant compensation in global health research: a case study. Int Health 2021; 12:524-532. [PMID: 33165559 PMCID: PMC7651450 DOI: 10.1093/inthealth/ihaa064] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/11/2020] [Accepted: 08/25/2020] [Indexed: 01/19/2023] Open
Abstract
Background Compensation for research participants can be provided for reasons including reimbursement of costs; compensation for time lost, discomfort or inconvenience; or expression of appreciation for participation. This compensation involves numerous ethical complexities, at times entailing competing risks. In the context of transnational research, often incorporating contexts of economic inequality, power differentials and post-colonialism, these issues extend into wider questions of ethical research conduct. Methods We describe experiences of conducting a community-based study of air pollution in southern Malawi incorporating ethnographic, participatory and air quality monitoring elements. Decisions surrounding participant compensation evolved in response to changing circumstances in the field. Results Attention to careful researcher–participant relationships and responsiveness to community perspectives allowed dynamic, contextualised decision-making around participant compensation. Despite widely cited risks, including but not restricted to undue influence of monetary compensation on participation, we learned that failure to adequately recognise and compensate participants has its own risks, notably the possibility of ‘ethics dumping’. Conclusions We recommend active engagement with research participants and communities with integration of contextual insights throughout, including participant compensation, as for all elements of research conduct. Equitable research relationships encompass four central values: fairness, care, honesty and respect.
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Affiliation(s)
- Sepeedeh Saleh
- Malawi-Liverpool-Wellcome Trust, Queen Elizabeth Central Hospital, College of Medicine, P.O. Box 30096, Chichiri, Blantyre 3, Malawi.,Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Henry Sambakunsi
- Malawi-Liverpool-Wellcome Trust, Queen Elizabeth Central Hospital, College of Medicine, P.O. Box 30096, Chichiri, Blantyre 3, Malawi
| | - Deborah Nyirenda
- Malawi-Liverpool-Wellcome Trust, Queen Elizabeth Central Hospital, College of Medicine, P.O. Box 30096, Chichiri, Blantyre 3, Malawi
| | - Moses Kumwenda
- Malawi-Liverpool-Wellcome Trust, Queen Elizabeth Central Hospital, College of Medicine, P.O. Box 30096, Chichiri, Blantyre 3, Malawi
| | - Kevin Mortimer
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Martha Chinouya
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
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19
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Johnson C, Kumwenda M, Meghji J, Choko AT, Phiri M, Hatzold K, Baggaley R, Taegtmeyer M, Terris-Prestholt F, Desmond N, Corbett EL. 'Too old to test?': A life course approach to HIV-related risk and self-testing among midlife-older adults in Malawi. BMC Public Health 2021; 21:650. [PMID: 33812381 PMCID: PMC8019342 DOI: 10.1186/s12889-021-10573-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 03/07/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Despite the aging HIV epidemic, increasing age can be associated with hesitancy to test. Addressing this gap is a critical policy concern and highlights the urgent need to identify the underlying factors, to improve knowledge of HIV-related risks as well as uptake of HIV testing and prevention services, in midlife-older adults. METHODS We conducted five focus group discussions and 12 in-depth interviews between April 2013 and November 2016 among rural and urban Malawian midlife-older (≥30 years) men and women. Using a life-course theoretical framework we explored how age is enacted socially and its implications on HIV testing and sexual risk behaviours. We also explore the potential for HIV self-testing (HIVST) to be part of a broader strategy for engaging midlife-older adults in HIV testing, prevention and care. Thematic analysis was used to identify recurrent themes and variations. RESULTS Midlife-older adults (30-74 years of age) associated their age with respectability and identified HIV as "a disease of youth" that would not affect them, with age protecting them against infidelity and sexual risk-taking. HIV testing was felt to be stigmatizing, challenging age norms, threatening social status, and implying "lack of wisdom". These norms drove self-testing preferences at home or other locations deemed age and gender appropriate. Awareness of the potential for long-standing undiagnosed HIV to be carried forward from past relationships was minimal, as was understanding of treatment-as-prevention. These norms led to HIV testing being perceived as a threat to status by older adults, contributing to low levels of recent HIV testing compared to younger adults. CONCLUSIONS Characteristics associated with age-gender norms and social position encourage self-testing but drive poor HIV-risk perception and unacceptability of conventional HIV testing in midlife-older adults. There is an urgent need to provide targeted messages and services more appropriate to midlife-older adults in sub-Saharan Africa. HIVST which has often been highlighted as a tool for reaching young people, may be a valuable tool for engaging midlife-older age groups who may not otherwise test.
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Affiliation(s)
- Cheryl Johnson
- Global of HIV, Hepatitis and STIs Programmes, World Health Organization, 20 Ave Appia, 1211, Geneva, Switzerland. .,Department of Clinical Research and Infectious Disease, London School of Hygiene and Tropical Medicine, London, UK.
| | - Moses Kumwenda
- Malawi Liverpool Wellcome Trust, HIV/TB Group, Blantyre, Malawi.,Helse Nord TB Initiative, College of Medicine, Blantyre, Malawi
| | - Jamilah Meghji
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Augustine T Choko
- Department of Clinical Research and Infectious Disease, London School of Hygiene and Tropical Medicine, London, UK.,Malawi Liverpool Wellcome Trust, HIV/TB Group, Blantyre, Malawi
| | | | - Karin Hatzold
- Population Services International, Johannesburg, South Africa
| | - Rachel Baggaley
- Global of HIV, Hepatitis and STIs Programmes, World Health Organization, 20 Ave Appia, 1211, Geneva, Switzerland
| | - Miriam Taegtmeyer
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.,Tropical Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Fern Terris-Prestholt
- Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicola Desmond
- Malawi Liverpool Wellcome Trust, HIV/TB Group, Blantyre, Malawi.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Elizabeth L Corbett
- Department of Clinical Research and Infectious Disease, London School of Hygiene and Tropical Medicine, London, UK.,Malawi Liverpool Wellcome Trust, HIV/TB Group, Blantyre, Malawi
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20
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Kumwenda M, Skovdal M, Wringe A, Kalua T, Kweka H, Songo J, Hassan F, Chimukuche RS, Moshabela M, Seeley J, Renju J. Exploring the evolution of policies for universal antiretroviral therapy and their implementation across three sub-Saharan African countries: Findings from the SHAPE study. Glob Public Health 2020; 16:227-240. [PMID: 33275872 PMCID: PMC7612916 DOI: 10.1080/17441692.2020.1851386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Universal antiretroviral therapy (ART) strategies have dramatically changed HIV programming across sub-Saharan Africa. We explored factors that influenced the development, adoption and implementation of universal ART policies in Tanzania, South Africa and Malawi. We conducted 26 key informant interviews and applied Kingdon's 'streams' model to explore how problems, policies and politics converged to provide a window of opportunity for universal ART roll-out. Weak health systems and sub-optimal care retention were raised as problems during Option B+ implementation, which preceded universal ART , and persisted after its implementation. The adoption and implementation of Option B+ policy facilitated the uptake of universal ART. Politics played out through pressures from different stakeholders to accelerate or slow down implementation, from governments, civil society groups, researchers and donors. Policy processes leading to universal ART were open to pressures and influence. The extraordinary financial support which enabled the widespread and rapid implementation of universal ART skewed the power balance and sometimes left little space for locally-derived solutions to respond to specific health system abilities and epidemiological contexts. Donors may be more effective if they ensure a greater focus on strengthening the whole health system as well as accounting for local contextual factors and recent policy development histories when funding policy implementation.
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Affiliation(s)
- Moses Kumwenda
- Helse Nord TB Initiative, College of Medicine, University of Malawi, Blantyre, Malawi.,Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Morten Skovdal
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Thoko Kalua
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Hadija Kweka
- Independent consultant, Dar es Salaam, United Republic of Tanzania
| | - John Songo
- Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
| | - Farida Hassan
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | | | - Mosa Moshabela
- African Health Research Institute, Durban, South Africa.,University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Janet Seeley
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,African Health Research Institute, Durban, South Africa
| | - Jenny Renju
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
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21
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Mwapasa M, Gooding K, Kumwenda M, Nliwasa M, Kaswaswa K, Sambakunsi R, Parker M, Bull S, Desmond N. "Are we getting the biometric bioethics right?" - the use of biometrics within the healthcare system in Malawi. Glob Bioeth 2020; 31:67-80. [PMID: 32921973 PMCID: PMC7448861 DOI: 10.1080/11287462.2020.1773063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Biometrics is the science of establishing the identity of an individual based on their physical attributes. Ethical concerns surrounding the appropriate use of biometrics have been raised, especially in resource-poor settings. A qualitative investigation was conducted to explore biometrics clients (n = 14), implementers (n = 12) and policy makers as well as bioethicists (n = 4) perceptions of the ethical aspects of implementing biometrics within the healthcare system in Malawi. Informed use, privacy and confidentiality as well as perceptions of benefits and harms were identified as major issues in the application of biometrics. Implementation of biometrics within the healthcare system in Malawi poses a range of potential ethical issues and practical challenges that impact on equitable uptake. There is a need for more research to explore the benefits and harms of biometrics in practice. Improved community engagement and sensitization should be a required component of biometrics introduction in Malawi.
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Affiliation(s)
| | - Kate Gooding
- Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), Blantyre, Malawi
| | - Moses Kumwenda
- College of Medicine, University of Malawi, Blantyre, Malawi.,Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), Blantyre, Malawi
| | | | | | - Rodrick Sambakunsi
- Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), Blantyre, Malawi
| | | | - Susan Bull
- The Ethox Centre, University of Oxford, Oxford, UK
| | - Nicola Desmond
- Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), Blantyre, Malawi.,Liverpool School of Tropical Medicine, Liverpool, UK
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22
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Lora WS, Desmond N, Obasi A, Kumwenda M, Taegtmeyer M, Tolhurst R, MacPherson EE. "I wanted evidence that my status had changed, so that is why I tested": experiences with HIV self-testing among female sex workers in Malawi. AIDS Care 2020; 32:206-213. [PMID: 32164420 DOI: 10.1080/09540121.2020.1739212] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
HIV testing among female sex workers (FSWs) is an established global health priority. HIV self-testing (HIVST) seems to have the potential to address issues of confidentiality, privacy and convenience among this key population. HIVST, however, may result in unintended consequences as its implementation unfolds in a complex sex work context characterised by unequal power relations, stigma and high HIV prevalence. We aimed to explore the experiences of FSWs with HIVST in the context of retesting and antiretroviral usage in Blantyre, Malawi. We used an ethnographic approach to understand meanings and views around HIVST and retesting. We found high levels of retesting, especially among those on antiretroviral, two of which received "false-negative" results. We identified three broad narratives: (1) retesting in response to experiences in the sex work context, (2) retesting driven by the desire to self-monitor HIV-negative status, and (3) retesting in the hope of sero-reversion. The FSWs' experiences indicate that the implementation of HIVST in this context is complex with potential for unintended harms such as coercive testing. HIVST programmes must include clear and appropriate messaging to reduce retesting while on ART and implement strategies to address FSW concerns and anxieties about the accuracy of their HIV-positive test results.
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Affiliation(s)
- Wezzie S Lora
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.,Behaviour and Health, Malawi Liverpool Wellcome Trust-Clinical Research Programme, Blantyre, Malawi.,Faculty of Life Sciences, University of Liverpool, Liverpool, UK
| | - Nicola Desmond
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.,Behaviour and Health, Malawi Liverpool Wellcome Trust-Clinical Research Programme, Blantyre, Malawi
| | - Angela Obasi
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Moses Kumwenda
- Behaviour and Health, Malawi Liverpool Wellcome Trust-Clinical Research Programme, Blantyre, Malawi
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.,Tropical Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Rachel Tolhurst
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Eleanor E MacPherson
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.,Behaviour and Health, Malawi Liverpool Wellcome Trust-Clinical Research Programme, Blantyre, Malawi
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23
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Nyirenda L, Kumar MB, Theobald S, Sarker M, Simwinga M, Kumwenda M, Johnson C, Hatzold K, Corbett EL, Sibanda E, Taegtmeyer M. Using research networks to generate trustworthy qualitative public health research findings from multiple contexts. BMC Med Res Methodol 2020; 20:13. [PMID: 31964333 PMCID: PMC6975029 DOI: 10.1186/s12874-019-0895-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 12/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Qualitative research networks (QRNs) bring together researchers from diverse contexts working on multi-country studies. The networks may themselves form a consortium or may contribute to a wider research agenda within a consortium with colleagues from other disciplines. The purpose of a QRN is to ensure robust methods and processes that enable comparisons across contexts. Under the Self-Testing Africa (STAR) initiative and the REACHOUT project on community health systems, QRNs were established, bringing together researchers across countries to coordinate multi-country qualitative research and to ensure robust methods and processes allowing comparisons across contexts. QRNs face both practical challenges in facilitating this iterative exchange process across sites and conceptual challenges interpreting findings between contexts. This paper distils key lessons and reflections from both QRN experiences on how to conduct trustworthy qualitative research across different contexts with examples from Bangladesh, Ethiopia, Kenya, Indonesia, Malawi, Mozambique, Zambia and Zimbabwe. METHODS The process of generating evidence for this paper followed a thematic analysis method: themes initially identified were refined during several rounds of discussions in an iterative process until final themes were agreed upon in a joint learning process. RESULTS Four guiding principles emerged from our analysis: a) explicit communication strategies that sustain dialogue and build trust and collective reflexivity; b) translation of contextually embedded concepts; c) setting parameters for contextualizing, and d) supporting empirical and conceptual generalisability. Under each guiding principle, we describe how credibility, dependability, confirmability and transferability can be enhanced and share good practices to be considered by other researchers. CONCLUSIONS Qualitative research is often context-specific with tools designed to explore local experiences and understandings. Without efforts to synthesise and systematically share findings, common understandings, experiences and lessons are missed. The logistical and conceptual challenges of qualitative research across multiple partners and contexts must be actively managed, including a shared commitment to continuous 'joint learning' by partners. Clarity and agreement on concepts and common methods and timelines at an early stage is critical to ensure alignment and focus in intercountry qualitative research and analysis processes. Building good relationships and trust among network participants enhance the quality of qualitative research findings.
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Affiliation(s)
- Lot Nyirenda
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Malabika Sarker
- BRAC James P. Grant School of Public Health, Dhaka, Bangladesh
- Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | | | | | | | - Karin Hatzold
- Population Services International, Johannesburg, South Africa
| | - Elizabeth L. Corbett
- Malawi Liverpool Wellcome Trust, Blantyre, Malawi
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Euphemia Sibanda
- Centre for Sexual Health and HIV AIDS Research Zimbabwe, Harare, Zimbabwe
| | - Miriam Taegtmeyer
- Department of International Public Health, LSTM, Pembroke Place, Liverpool, L3 5QA UK
- Tropical Infectious Diseases Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP UK
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Monk EJM, Kumwenda M, Nliwasa M, Mpunga J, Corbett EL. Factors affecting tuberculosis health message recall 2 years after active case finding in Blantyre, Malawi. Int J Tuberc Lung Dis 2019; 22:1007-1015. [PMID: 30092865 PMCID: PMC6086287 DOI: 10.5588/ijtld.18.0006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING: Urban slums, Blantyre, Malawi. OBJECTIVE: To explore tuberculosis (TB) community-wide active case finding (cwACF) recall and accompanying messaging 2 years after the intervention. DESIGN: This mixed-methods study used population-weighted random cluster sampling to select three cwACF-receiving and three non-cwACF-receiving neighbourhoods in Blantyre. Qualitative data were collected using 12 focus group discussions (community peer-group members) and five in-depth interviews (TB officers) with script guides based on the concepts of the Health Belief Model (HBM). Thematic analysis was used to explore transcripts employing deductive coding. Questionnaires completed by focus group participants were used to collect quantitative data, providing a ‘knowledge score’ evaluated through univariate/multivariate analysis, analysis of variance and multiple linear regression. RESULTS: Community peer-group participants (n = 118) retained high awareness and positive opinions of cwACF and recognised the relationship between early diagnosis and reduced transmission, considering cwACF to have prompted subsequent health-seeking behaviour. TB-affected individuals (personal/family: 47.5%) had significantly higher knowledge scores than unaffected individuals (P = 0.039), but only if resident in cwACF-receiving neighbourhoods (P = 0.005 vs. P = 0.582), implying effect modification between exposures, albeit statistically under-powered (P = 0.229). CONCLUSION: Consistent with epidemiological evidence and HBM theory, cwACF may have a permanent impact on knowledge and behaviour, particularly in communities with a high prevalence of TB-affected individuals. Behaviour change strategies should be explicitly included in cwACF planning and evaluation.
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Affiliation(s)
- E J M Monk
- London School of Hygiene & Tropical Medicine, London, UK
| | - M Kumwenda
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre
| | - M Nliwasa
- Department of Microbiology, College of Medicine, Blantyre
| | - J Mpunga
- National Tuberculosis Programme, Lilongwe, Malawi
| | - E L Corbett
- London School of Hygiene & Tropical Medicine, London, UK, Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre
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Choko AT, Corbett EL, Stallard N, Maheswaran H, Lepine A, Johnson CC, Sakala D, Kalua T, Kumwenda M, Hayes R, Fielding K. HIV self-testing alone or with additional interventions, including financial incentives, and linkage to care or prevention among male partners of antenatal care clinic attendees in Malawi: An adaptive multi-arm, multi-stage cluster randomised trial. PLoS Med 2019; 16:e1002719. [PMID: 30601823 PMCID: PMC6314606 DOI: 10.1371/journal.pmed.1002719] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 11/21/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Conventional HIV testing services have been less comprehensive in reaching men than in reaching women globally, but HIV self-testing (HIVST) appears to be an acceptable alternative. Measurement of linkage to post-test services following HIVST remains the biggest challenge, yet is the biggest driver of cost-effectiveness. We investigated the impact of HIVST alone or with additional interventions on the uptake of testing and linkage to care or prevention among male partners of antenatal care clinic attendees in a novel adaptive trial. METHODS AND FINDINGS An adaptive multi-arm, 2-stage cluster randomised trial was conducted between 8 August 2016 and 30 June 2017, with antenatal care clinic (ANC) days (i.e., clusters of women attending on a single day) as the unit of randomisation. Recruitment was from Ndirande, Bangwe, and Zingwangwa primary health clinics in urban Blantyre, Malawi. Women attending an ANC for the first time for their current pregnancy (regardless of trimester), 18 years and older, with a primary male partner not known to be on ART were enrolled in the trial after giving consent. Randomisation was to either the standard of care (SOC; with a clinic invitation letter to the male partner) or 1 of 5 intervention arms: the first arm provided women with 2 HIVST kits for their partners; the second and third arms provided 2 HIVST kits along with a conditional fixed financial incentive of $3 or $10; the fourth arm provided 2 HIVST kits and a 10% chance of receiving $30 in a lottery; and the fifth arm provided 2 HIVST kits and a phone call reminder for the women's partners. The primary outcome was the proportion of male partners who were reported to have tested for HIV and linked into care or prevention within 28 days, with referral for antiretroviral therapy (ART) or circumcision accordingly. Women were interviewed at 28 days about partner testing and adverse events. Cluster-level summaries compared each intervention versus SOC using eligible women as the denominator (intention-to-treat). Risk ratios were adjusted for male partner testing history and recruitment clinic. A total of 2,349/3,137 (74.9%) women participated (71 ANC days), with a mean age of 24.8 years (SD: 5.4). The majority (2,201/2,233; 98.6%) of women were married, 254/2,107 (12.3%) were unable to read and write, and 1,505/2,247 (67.0%) were not employed. The mean age for male partners was 29.6 years (SD: 7.5), only 88/2,200 (4.0%) were unemployed, and 966/2,210 (43.7%) had never tested for HIV before. Women in the SOC arm reported that 17.4% (71/408) of their partners tested for HIV, whereas a much higher proportion of partners were reported to have tested for HIV in all intervention arms (87.0%-95.4%, p < 0.001 in all 5 intervention arms). As compared with those who tested in the SOC arm (geometric mean 13.0%), higher proportions of partners met the primary endpoint in the HIVST + $3 (geometric mean 40.9%, adjusted risk ratio [aRR] 3.01 [95% CI 1.63-5.57], p < 0.001), HIVST + $10 (51.7%, aRR 3.72 [95% CI 1.85-7.48], p < 0.001), and phone reminder (22.3%, aRR 1.58 [95% CI 1.07-2.33], p = 0.021) arms. In contrast, there was no significant increase in partners meeting the primary endpoint in the HIVST alone (geometric mean 17.5%, aRR 1.45 [95% CI 0.99-2.13], p = 0.130) or lottery (18.6%, aRR 1.43 [95% CI 0.96-2.13], p = 0.211) arms. The lottery arm was dropped at interim analysis. Overall, 46 male partners were confirmed to be HIV positive, 42 (91.3%) of whom initiated ART within 28 days; 222 tested HIV negative and were not already circumcised, of whom 135 (60.8%) were circumcised as part of the trial. No serious adverse events were reported. Costs per male partner who attended the clinic with a confirmed HIV test result were $23.73 and $28.08 for the HIVST + $3 and HIVST + $10 arms, respectively. Notable limitations of the trial included the relatively small number of clusters randomised to each arm, proxy reporting of the male partner testing outcome, and being unable to evaluate retention in care. CONCLUSIONS In this study, the odds of men's linkage to care or prevention increased substantially using conditional fixed financial incentives plus partner-delivered HIVST; combinations were potentially affordable. TRIAL REGISTRATION ISRCTN 18421340.
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Affiliation(s)
- Augustine T. Choko
- TB/HIV Group, Malawi–Liverpool–Wellcome Clinical Research Programme, Blantyre, Malawi
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Elizabeth L. Corbett
- TB/HIV Group, Malawi–Liverpool–Wellcome Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Nigel Stallard
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | | | - Aurelia Lepine
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Cheryl C. Johnson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
- World Health Organization, Geneva, Switzerland
| | - Doreen Sakala
- TB/HIV Group, Malawi–Liverpool–Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Thokozani Kalua
- Department of HIV/AIDS, Ministry of Health, Lilongwe, Malawi
| | - Moses Kumwenda
- TB/HIV Group, Malawi–Liverpool–Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Desmond N, Nagelkerke N, Lora W, Chipeta E, Sambo M, Kumwenda M, Corbett EL, Taegtemeyer M, Seeley J, Lalloo DG, Theobald S. Measuring sexual behaviour in Malawi: a triangulation of three data collection instruments. BMC Public Health 2018; 18:807. [PMID: 29954360 PMCID: PMC6022416 DOI: 10.1186/s12889-018-5717-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 06/17/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND There is a need for valid approaches to measure sexual interactions to assess the impact of behavioural interventions and to predict the impact of behaviour changes. Different methods of asking about sexual behaviour often yield conflicting answers and men often report higher levels of heterosexual activity than women. To better understand self-reported sexual behaviour data and how best to collect it, we analyzed data collected as part of a larger project (ST IMPACTS) on the social and behavioural impact of introducing community-level HIV self-testing (HIVST) with counseling (semi-supervised with pre- and generic post-test counseling provided on delivery or collection of test kits) in an urban Malawian setting. METHODS Information on sexual behaviour was collected from HIV self-testers over a three-month period. Three different methods were used: retrospective face-to-face interviews (FTFI); audio computer assisted self-interviews (ACASI) and a prospective coital diary. Both retrospective instruments were used before and after the three-month study period. Frequency and cross-tabulation, as well as scatterplots, were used for exploratory analyses. Chi-square tests were used to test for differences in proportions. Spearman's correlation coefficient was used to explore associations between both continuous and ordinal variables and Wilcoxon's paired sample and Mann-Whitney test was used to test for differences in such variables or between variables. RESULTS There was reasonable agreement between the two retrospective methods although both yielded inconsistent answers e.g. with lower reported numbers of life-time sexual partners at the end than at the beginning of the study period. The diary method elicited higher reported levels of sex with multiple partners than both retrospective instruments which may be due to inadequate recall. Over the study period 37.4% of men and 19.7% of women reported multiple sexual partners using the diary. There was no clear relationship between reported sexual behaviour and HIV status (prevalence 9.6%). CONCLUSIONS Diaries may therefore have higher validity for sensitive behaviour reporting and thus be the preferred method in similar African contexts in measuring sexual behaviours.
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Affiliation(s)
- Nicola Desmond
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK. .,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
| | - Nico Nagelkerke
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK.,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Wezzie Lora
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK.,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Effie Chipeta
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,College of Medicine, University of Malawi, Blantyre, Malawi
| | - Mwiza Sambo
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Moses Kumwenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,College of Medicine, University of Malawi, Blantyre, Malawi
| | - Elizabeth L Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | | | - Janet Seeley
- London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - David G Lalloo
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Sally Theobald
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
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Bedell RA, van Lettow M, Meaney C, Corbett EL, Chan AK, Heyderman RS, Anderson ST, Åkesson A, Kumwenda M, Zachariah R, Harries AD, Ramsay AR. Predictive value of C-reactive protein for tuberculosis, bloodstream infection or death among HIV-infected individuals with chronic, non-specific symptoms and negative sputum smear microscopy. Trop Med Int Health 2018; 23:254-262. [PMID: 29243878 DOI: 10.1111/tmi.13025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND C-reactive protein (CRP) is an inflammatory biomarker that may identify patients at risk of infections or death. Mortality among HIV-infected persons commencing antiretroviral therapy (ART) is often attributed to tuberculosis (TB) or bloodstream infections (BSI). METHODS In two district hospitals in southern Malawi, we recruited HIV-infected adults with one or more unexplained symptoms present for at least one month (weight loss, fever or diarrhoea) and negative expectorated sputum microscopy for TB. CRP determination for 452 of 469 (96%) participants at study enrolment was analysed for associations with TB, BSI or death to 120 days post-enrolment. RESULTS Baseline CRP was significantly elevated among patients with confirmed or probable TB (52), BSI (50) or death (60) compared to those with no identified infection who survived at least 120 days (269). A CRP value of >10 mg/L was associated with confirmed or probable TB (adjusted odds ratio 5.7; 95% CI 2.6, 14.3; 87% sensitivity) or death by 30 days (adjusted odds ratio 9.2; 95% CI 2.2, 55.1; 88% sensitivity). CRP was independently associated with TB, BSI or death, but the prediction of these endpoints was enhanced by including haemoglobin (all outcomes), CD4 count (BSI, death) and whether ART was started (death) in logistic regression models. CONCLUSION High CRP at the time of ART initiation is associated with TB, BSI and early mortality and so has potential utility for stratifying patients for intensified clinical and laboratory investigation and follow-up. They may also be considered for empirical treatment of opportunistic infections including TB.
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Affiliation(s)
- Richard A Bedell
- Dignitas International, Zomba, Malawi.,Division of Global Health, University of British Columbia, Vancouver, BC, Canada
| | - Monique van Lettow
- Dignitas International, Zomba, Malawi.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Christopher Meaney
- Department of Family & Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Elizabeth L Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,London School of Hygiene and Tropical Medicine, London, UK
| | - Adrienne K Chan
- Dignitas International, Zomba, Malawi.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Robert S Heyderman
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Suzanne T Anderson
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Ann Åkesson
- Médecins Sans Frontières - Operational Centre Brussels, Thyolo, Malawi
| | | | - Rony Zachariah
- Médecins Sans Frontières - Operational Centre Brussels, Thyolo, Malawi
| | - Anthony D Harries
- London School of Hygiene and Tropical Medicine, London, UK.,International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Andrew R Ramsay
- Division of Infection and Global Health, School of Medicine, University of St Andrews, St Andrews, UK
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Kumwenda M, Nyang'wa BT, Chikuse B, Biseck T, Maosa S, Chilembwe A, Dimba A, Mpunga J, Shaw C, Brouwer M. The second sputum sample complicates tuberculosis diagnosis for women: a qualitative study from Malawi. Int J Tuberc Lung Dis 2017; 21:1258-1263. [PMID: 29297446 DOI: 10.5588/ijtld.17.0146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING District hospital and peripheral health care facilities in Balaka District, Malawi. OBJECTIVE To identify barriers encountered by women in submitting a second sputum sample. DESIGN Focus-group discussions and semi-structured interviews. RESULTS Women encounter barriers at several levels: personal, cultural, socio-economic and health care system. Personal, cultural and socio-economic barriers include the fear of a tuberculosis (TB) diagnosis, the perception and condition of the patient, the distance and cost of travel to a health care facility, the subordinate position of women in household decision-making and the social support that women receive. Barriers at the health care system level include high patient numbers, staff shortages, the duration of the TB diagnostic process as well as the uncaring attitude and poor communication of health care workers. These barriers may apply not only to the submission of the second sample, but to health care access in general. CONCLUSION Women face multiple barriers in submitting a second sputum sample. These do not operate in isolation but instead compound each other. Although potential solutions to overcome these barriers are recognised, some have yet to be adopted. To improve TB case finding, innovative and community approaches should be adopted more rapidly.
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Affiliation(s)
- M Kumwenda
- Malawi Liverpool Wellcome Research Programme, Blantyre, Helse Nord TB Initiative, College of Medicine, Blantyre, Malawi
| | - B-T Nyang'wa
- Médecins Sans Frontières, London, UK; University College London, London, UK
| | - B Chikuse
- District Health Office, Balaka, Malawi
| | - T Biseck
- District Health Office, Balaka, Malawi
| | - S Maosa
- Sue Ryder Foundation in Malawi, Balaka, Malawi
| | - A Chilembwe
- Sue Ryder Foundation in Malawi, Balaka, Malawi
| | - A Dimba
- Ministry of Health, National Tuberculosis Programme, Blantyre, Malawi
| | - J Mpunga
- Ministry of Health, National Tuberculosis Programme, Blantyre, Malawi
| | - C Shaw
- Target Tuberculosis, Brighton, UK
| | - M Brouwer
- PHTB Consult, Tilburg, The Netherlands
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Chikovore J, Hart G, Kumwenda M, Chipungu G, Desmond N, Corbett EL. TB and HIV stigma compounded by threatened masculinity: implications for TB health-care seeking in Malawi. Int J Tuberc Lung Dis 2017; 21:26-33. [PMID: 29025482 DOI: 10.5588/ijtld.16.0925] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Urban Blantyre, Malawi. OBJECTIVE To understand why men with tuberculosis (TB) in the community remain undiagnosed. DESIGN A multi-method qualitative study applying a modified grounded theory approach. Data were gathered from March 2011 to March 2012 from 134 men and women taking part in 1) focus group discussions with community members (n = 6) and health care workers (n = 2), and 2) in-depth interviews with TB patients (n = 20, females n = 14) and chronic coughers (n = 20, women n = 8). Data were analysed inductively to identify, refine and consolidate, and verify emerging concepts and themes. RESULTS Two emerging themes highlighting compound stigma in this high human immunodeficiency virus (HIV) prevalence, low-income setting are presented. First, cough or any illness that portended a 'serious' condition were accompanied by portrayals of cough, TB and HIV as being interchangeable. Chronic coughers and TB patients described their illness in ways that foregrounded bodily decimation and rupture of social life and masculine identity. Second, 'resistance strategies' entailed resisting classification as (seriously) ill by evading or ambivalently approaching health care, or acknowledging the 'ill' status then actively pursuing health-appropriate behaviours, including changing lifestyle or adopting non-normative gender roles. CONCLUSIONS Managing patients requires 1) going beyond syndromic management based on vital signs and clinical indicators to recognising and intervening on health care-seeking related tensions to retain individuals in care, and 2) understanding and addressing TB stigma as it manifests and affects men and women differently in specific settings.
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Affiliation(s)
- J Chikovore
- HIV/AIDS, STIs & TB Program, Human Sciences Research Council, Durban, South Africa
| | - G Hart
- School of Life & Medical Sciences, University College London, London, UK
| | - M Kumwenda
- Malawi Liverpool Wellcome Trust Clinical Research Program, Blantyre, Helse Nord TB Initiative, College of Medicine, Chichiri, Blantyre, Malawi
| | - G Chipungu
- Helse Nord TB Initiative, College of Medicine, Chichiri, Blantyre, Malawi
| | - N Desmond
- Malawi Liverpool Wellcome Trust Clinical Research Program, Blantyre, Liverpool School of Tropical Medicine, Liverpool, UK
| | - E L Corbett
- Malawi Liverpool Wellcome Trust Clinical Research Program, Blantyre, London School of Hygiene and Tropical Medicine, London, UK
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Sambakunsi R, Kumwenda M, Choko A, Corbett EL, Desmond NA. 'Whose failure counts?' A critical reflection on definitions of failure for community health volunteers providing HIV self-testing in a community-based HIV/TB intervention study in urban Malawi. Anthropol Med 2016; 22:234-49. [PMID: 26762610 PMCID: PMC4720041 DOI: 10.1080/13648470.2015.1077202] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The category of community health worker applied within the context of health intervention trials has been promoted as a cost-effective approach to meeting study objectives across large populations, relying on the promotion of the concept of ‘com-munity belonging’ to encourage altruistic volunteerism from community members to promote health. This community-based category of individuals is recruited to facilitate externally driven priorities defined by large research teams, outside of the target research environment. An externally defined intervention is then ‘brought to’ the community through locally recruited community volunteers who form a bridge between the researchers and participants. The specific role of these workers is context-driven and responsive to the needs of the intervention. This paper is based on the findings from an annual evaluation of community health worker performance employed as community counsellors to deliver semi-supervised HIV self-testing (HIVST) at community level of a large HIV/TB intervention trial conducted in urban Blantyre, Malawi. A performance evaluation was conducted to appraise individual service delivery and assess achievements in meeting pre-defined targets for uptake of HIVST with the aim of improving overall uptake of HIVST. Through an empirical ‘evaluation of the evaluation’ this paper critically reflects on the position of the community volunteer through the analytical lens of ‘failure’, exploring the tensions in communication and interpretation of intervention delivery between researchers and community volunteers and the differing perspectives on defining failure. It is concluded that community interventions should be developed in collaboration with the population and that information guiding success should be clearly defined.
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Affiliation(s)
- Rodrick Sambakunsi
- a Malawi Liverpool Wellcome Trust Clinical Research Programme , Science Communication , PO Box 30096 , Chichiri , Blantyre , Malawi
| | - Moses Kumwenda
- b College of Medicine , University of Malawi , Blantyre , Malawi.,c Malawi Liverpool Wellcome Trust Clinical Research Programme , Blantyre , Malawi
| | - Augustine Choko
- c Malawi Liverpool Wellcome Trust Clinical Research Programme , Blantyre , Malawi.,d London School of Hygiene & Tropical Medicine , London , UK
| | - Elizabeth L Corbett
- c Malawi Liverpool Wellcome Trust Clinical Research Programme , Blantyre , Malawi.,d London School of Hygiene & Tropical Medicine , London , UK
| | - Nicola Ann Desmond
- c Malawi Liverpool Wellcome Trust Clinical Research Programme , Blantyre , Malawi.,e Liverpool School of Tropical Medicine , Liverpool , UK
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Kumwenda M, Desmond N, Hart G, Choko A, Chipungu GA, Nyirenda D, Shand T, Corbett EL, Chikovore J. Treatment-Seeking for Tuberculosis-Suggestive Symptoms: A Reflection on the Role of Human Agency in the Context of Universal Health Coverage in Malawi. PLoS One 2016; 11:e0154103. [PMID: 27101407 PMCID: PMC4839672 DOI: 10.1371/journal.pone.0154103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 04/08/2016] [Indexed: 11/19/2022] Open
Abstract
Tuberculosis (TB) is highly infectious and one of the leading killers globally. Several studies from sub-Saharan Africa highlight health systems challenges that affect ability to cope with existing disease burden, including TB, although most of these employ survey-type approaches. Consequently, few address community or patient perspectives and experiences. At the same time, understanding of the mechanisms by which the health systems challenges translate into seeking or avoidance of formal health care remains limited. This paper applies the notion of human agency to examine the ways people who have symptoms suggestive of TB respond to and deal with the symptoms vis-à-vis major challenges inherent within health delivery systems. Empirical data were drawn from a qualitative study exploring the ways in which notions of masculinity affect engagement with care, including men's well-documented tendency to delay in seeking care for TB symptoms. The study was carried out in three high-density locales of urban Blantyre, Malawi. Data were collected in March 2011 -March 2012 using focus group discussions, of which eight (mixed sex = two; female only = three; male only = three) were with 74 ordinary community members, and two (both mixed sex) were with 20 health workers; and in-depth interviews with 20 TB patients (female = 14) and 20 un-investigated chronic coughers (female = eight). The research process employed a modified version of grounded theory. Data were coded using a coding scheme that was initially generated from the study aims and subsequently progressively amended to incorporate concepts emerging during the analysis. Coded data were retrieved, re-read, and broken down and reconnected iteratively to generate themes. A myriad of problems were described for health systems at the primary health care level, centring largely on shortages of resources (human, equipment, and drugs) and unprofessional conduct by health care providers. Participants consistently pointed out how the problems could drive patients from promptly reporting symptoms at primary healthcare centres. The accounts suggest that in responding to illness symptoms including those suggestive of TB, patients navigate their options taking into cognisance past and current experiences with formal health systems. Understanding and factoring in the mediating role of such 'agency' is critical when implementing efforts to promote timely response to TB-suggestive symptoms.
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Affiliation(s)
- Moses Kumwenda
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi
- Helse Nord TB Initiative, College of Medicine, Blantyre, Malawi
| | - Nicola Desmond
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Graham Hart
- School of Life & Medical Sciences, University College London, London, United Kingdom
| | - Augustine Choko
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Deborah Nyirenda
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Tim Shand
- Institute for Global Health, University College London, London, United Kingdom
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elizabeth L. Corbett
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jeremiah Chikovore
- HIV/ AIDS, Sexually Transmitted Infections & TB, Human Sciences Research Council, Durban, South Africa
- * E-mail:
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Affiliation(s)
- P Nagaraja
- From the Renal Unit, Morriston Hospital, Swansea, West Glamorgan, SA6 6NL, UK and Department of Nephrology, Glan Clwyd Hospital, Rhyl, Denbighshire, LL18 5UJ, UK
| | - A Thangavelu
- From the Renal Unit, Morriston Hospital, Swansea, West Glamorgan, SA6 6NL, UK and Department of Nephrology, Glan Clwyd Hospital, Rhyl, Denbighshire, LL18 5UJ, UK
| | - H Nair
- From the Renal Unit, Morriston Hospital, Swansea, West Glamorgan, SA6 6NL, UK and Department of Nephrology, Glan Clwyd Hospital, Rhyl, Denbighshire, LL18 5UJ, UK
| | - M Kumwenda
- From the Renal Unit, Morriston Hospital, Swansea, West Glamorgan, SA6 6NL, UK and Department of Nephrology, Glan Clwyd Hospital, Rhyl, Denbighshire, LL18 5UJ, UK
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Chikovore J, Hart G, Kumwenda M, Chipungu GA, Corbett L. 'For a mere cough, men must just chew Conjex, gain strength, and continue working': the provider construction and tuberculosis care-seeking implications in Blantyre, Malawi. Glob Health Action 2015; 8:26292. [PMID: 25833138 PMCID: PMC4382597 DOI: 10.3402/gha.v8.26292] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Revised: 01/23/2015] [Accepted: 03/05/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Delay by men in seeking healthcare results in their higher mortality while on HIV or tuberculosis (TB) treatment and contributes to ongoing community-level disease transmission before going on treatment. OBJECTIVE To understand masculinity's role in delay in healthcare seeking for men, with a focus on TB-suggestive symptoms. DESIGN Data were collected between March 2011 and March 2012 in low-income suburbs in urban Blantyre using focus group discussions with community members (n=8) and health workers (n=2), in-depth interviews with 20 TB patients (female=14) and 20 uninvestigated chronic coughers (female=8), and a 3-day participatory workshop with 27 health stakeholder representatives. The research process drew to a large extent on grounded theory principles in the manner of Strauss and Corbin (1998) and also Charmaz (1995). RESULTS Role descriptions by both men and women in the study universally assigned men as primary material providers for their immediate family, that is, the ones earning and bringing livelihood and additional material needs. In a context where collectivism was valued, men were also expected to lead the provision of support to wider kin. Successful role enactment was considered key to achieving recognition as an adequate man; at the same time, job scarcity and insecurity, and low earnings gravely impeded men. Pressures to generate continuing income then meant constantly looking for jobs, or working continuously to retain insecure jobs or to raise money through self-employment. All this led men to relegate their health considerations. CONCLUSIONS Early engagement with formal healthcare is critical to dealing with TB and HIV. However, role constructions as portrayed for men in this study, along with the opportunity costs of acknowledging illness seem, in conditions of vulnerability, important barriers to care-seeking. There is a need to address hidden care-seeking costs and to consider more complex interventions, including reducing precarity, in efforts to improve men's engagement with their health.
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Affiliation(s)
- Jeremiah Chikovore
- HIV/AIDS, Sexually Transmitted Infections & TB, Human Sciences Research Council, Durban, South Africa;
| | - Graham Hart
- School of Life & Medical Sciences, University College London, London, United Kingdom
| | - Moses Kumwenda
- Helse Nord TB Initiative, College of Medicine, Blantyre, Malawi.,Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi
| | | | - Liz Corbett
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi.,London School of Hygiene and Tropical Medicine, London, United Kingdom
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Chikovore J, Hart G, Kumwenda M, Chipungu GA, Desmond N, Corbett L. Control, struggle, and emergent masculinities: a qualitative study of men's care-seeking determinants for chronic cough and tuberculosis symptoms in Blantyre, Malawi. BMC Public Health 2014; 14:1053. [PMID: 25301572 PMCID: PMC4200169 DOI: 10.1186/1471-2458-14-1053] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 09/09/2014] [Indexed: 11/13/2022] Open
Abstract
Background Men’s healthcare-seeking delay results in higher mortality while on HIV or tuberculosis (TB) treatment, and implies contribution to ongoing community-level TB transmission before initiating treatment. We investigated masculinity’s role in healthcare-seeking delay for men with TB-suggestive symptoms, with a view to developing potential interventions for men. Methods Data were collected during March 2011- March 2012 in three high-density suburbs in urban Blantyre. Ten focus group discussions were carried out of which eight (mixed sex = two; female only = three; male only = three) were with 74 ordinary community members, and two (both mixed sex) were with 20 health workers. Individual interviews were done with 20 TB patients (female =14) and 20 un-investigated chronic coughers (female = eight), and a three-day workshop was held with 27 health stakeholder representatives. Results An expectation to provide for and lead their families, and to control various aspects of their lives while facing limited employment opportunities and small incomes leaves men feeling inadequate, devoid of control, and anxious about being marginalised as men. Men were fearful about being looked at as less than men, and about their wives engaging in extramarital sex without ability to detect or monitor them. Control was a key defining feature of adequate manhood, and efforts to achieve it also led men into side-lining their health. Articulate and consistent concepts of men’s bodily strength or appropriate illness responses were absent from the accounts. Conclusions Facilitating men to seek care early is an urgent public health imperative, given the contexts of high HIV/AIDS prevalence but increasingly available treatment, and the role of care-seeking delay in TB transmission. Men’s struggles trying to achieve ideal images seem to influence their engagement with their health. Ambiguous views regarding some key masculinity representations and the embrace of less harmful masculinities raise questions about some common assumptions that guide work with men. Apparent ‘emergent masculinities’ might be a useful platform from which to support the transformation of harmful masculinity. Finally, the complex manifestations of masculinity indicate the need for interventions targeting men in health and TB control to assume supportive, multidimensional and long-term outlooks.
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Affiliation(s)
- Jeremiah Chikovore
- HIV/AIDS, Sexually Transmitted Infections & TB, Human Sciences Research Council, 750 Mary Thipe Rd, Cato Manor, Durban 4001, South Africa.
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Kumwenda M, Munthali A, Phiri M, Mwale D, Gutteberg T, MacPherson E, Theobald S, Corbett L, Desmond N. Factors shaping initial decision-making to self-test amongst cohabiting couples in urban Blantyre, Malawi. AIDS Behav 2014; 18 Suppl 4:S396-404. [PMID: 24929834 PMCID: PMC4102820 DOI: 10.1007/s10461-014-0817-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In sub-Saharan Africa, most new HIV infections occur in stable relationships, making couples testing an important intervention for HIV prevention. We explored factors shaping the decision-making of cohabiting couples who opted to self-test in Blantyre, Malawi. Thirty-four self-tested participants (17 couples) were interviewed. Motivators for HIV self-testing (HIVST) emerged at three main levels. Individual motivations included perceived benefits of access to treatment, and self-checking of serostatus in the hope of having been cured by prolonged treatment or faith-healing. HIVST was considered convenient, confidential, reassuring and an enabling new way to test with one's partner. Partnership motivations included both positive (mutual encouragement) and negative (suspected infidelity) aspects. For women, long-term health and togetherness were important goals that reinforced motivations for couples testing, whereas men often needed persuasion despite finding HIVST more flexible and less onerous than facility-based testing. Internal conflict prompted some partners to use HIVST as a way of disclosing their previously concealed HIV positive serostatus. Thus, the implementation of community-based HIVST should acknowledge and appropriately respond to decision-making processes within couples, which are shaped by gender roles and relationship dynamics.
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Affiliation(s)
- Moses Kumwenda
- Pathology and Medical Laboratory Sciences, College of Medicine, University of Malawi, Private Bag 360 Chichiri, Blantyre 3, Malawi,
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Humalda JK, Assa S, Navis GJ, Franssen CFM, De Borst MH, Ogawa H, Ota Y, Watanabe T, Watanabe Y, Nishii H, Sato A, Waniewski J, Debowska M, Wojcik-Zaluska A, Ksiazek A, Zaluska W, Guastoni CM, Turri C, Toma L, Rombola G, Frattini G, Romei Longhena G, Teatini U, Siriopol DC, Stuard S, Ciolan A, Mircescu G, Raluca D, Nistor I, Covic A, De Roij Van Zuijdewijn CL, Chapdelaine I, Nube MJ, Blankestijn PJ, Bots ML, Konings SJ, Van Den Dorpel MA, Van Der Weerd NC, Ter Wee PM, Grooteman MP, Djuric PS, Jankovic A, Tosic J, Bajcetic S, Damjanovic T, Popovic J, Dimkovic N, Dimkovic N, Marinkovic J, Djuric Z, Knezevic V, Lazarevic T, Ljubenovic S, Markovic R, Rabrenovic V, Djukanovic L, Djuric PS, Popovic J, Jankovic A, Tosic J, Radovic Maslarevic V, Dimkovic N, Mathrani V, Drew P, Chess JI, Williams AI, Robertson S, Jibani M, Aithal VI, Kumwenda M, Roberts G, Mikhail AI, Grzegorzewska AE, Ostromecki G, Mostowska A, Sowi ska A, Jagodzi ski PP, Wu HY, Chen HY, Hsu SP, Pai MF, Yang JY, Peng YS, Hirose M, Hasegawa T, Kaneshima N, Sasai F, Komukai D, Takahashi K, Koiwa F, Shishido K, Yoshimura A, Selim G, Stojceva-Taneva O, Tozija L, Dzekova-Vidimliski P, Trajceska L, Petronievic Z, Gelev S, Amitov V, Sikole A, Moon SJ, Yoon SY, Shin DH, Lee JE, Kim HJ, Park HC, Hadjiyannakos D, Filiopoulos V, Loukas G, Pagonis S, Andriopoulos C, Drakou A, Vlassopoulos D, Catarino C, Cunha P, Ribeiro S, Rocha-Pereira P, Reis F, Sameiro-Faria M, Miranda V, Bronze-Rocha E, Belo L, Costa E, Santos-Silva A, De Mauri A, Brambilla M, Chiarinotti D, Lizio D, Matheoud R, Conti N, Conte MM, Carriero A, De Leo M, Karpetas AV, Sarafidis PA, Georgianos PI, Koutroumpas G, Divanis D, Vakianis P, Tzanis G, Raptopoulou K, Protogerou A, Stamatiadis D, Syrganis C, Liakopoulos V, Efstratiadis G, Lasaridis AN, Georgianos PI, Sarafidis PA, Karpetas AV, Koutroumpas G, Divanis D, Tersi M, Tzanis G, Raptopoulou K, Protogerou A, Syrganis C, Stamatiadis DN, Liakopoulos V, Efstratiadis G, Lasaridis AN, Kuczera P, Adamczak M, Wiecek A, Bove S, Giacon B, Corradini R, Prati E, Brognoli M, Tommasi A, Sereni L, Palladino G, Moriya H, Mochida Y, Ishioka K, Oka M, Maesato K, Hidaka S, Ohtake T, Kobayashi S, Moura A, Madureira J, Alija P, Fernandes JC, Oliveira JG, Lopez M, Filgueiras M, Amado L, Miranda V, Sameiro-Faria M, Vieira M, Santos-Silva A, Costa E, Lee JE, Seok JH, Choi HY, Ha SK, Park HC, Bossola M, Laudisio A, Antocicco M, Tazza L, Colloca G, Tosato M, Zuccala G, Ettema EM, Kuipers J, Assa S, Groen H, Gansevoort RT, Stade K, Bakker SJL, Gaillard CAJM, Westerhuis R, Franssen CFM, Bacchetta J, Couchoud K, Semlali S, Sellier-Leclerc AL, Bertholet-Thomas A, Cartier R, Cochat P, Ranchin B, Kim JC, Park K, Van Ende C, Wilmes D, Lecouvet FE, Labriola L, Cuvelier R, Van Ingelgem G, Jadoul M, De Mauri A, Doriana C, Brambilla M, Matheoud R, David P, Capurro F, Brustia M, Ruva CE, De Leo M, Bossola M, Giungi S, Di Stasio E, Tazza L, Lemesch S, Leber B, Horvath A, Ribitsch W, Schilcher G, Zettel G, Tawdrous M, Rosenkranz AR, Stadlbauer-Kollner V, Matsushima H, Oyama A, Bosch Benitez-Parodi E, Baamonde Laborda E, Batista Garcia F, Perez Suarez G, Anton Perez G, Garcia Canton C, Toledo Gonzalez A, Lago Alonso MM, Checa Andres MD, Cobo G, Di Gioia C, Camacho R, Garcia Lacalle C, Ortega O, Rodriguez I, Herrero J, Oliet A, Ortiz M, Mon C, Vigil A, Gallar P, Bossola M, Pellu V, Di Stasio E, Giungi S, Nebiolo PE, Sasaki K, Yamguchi S, Hesaka A, Iwahashi E, Sakai S, Fujimoto T, Minami S, Fujita Y, Yokoyama K, Shutov E, Ryabinskya G, Lashutin S, Gorelova E, Volodicheva E, Podesta MA, Cancarini G, Cucchiari D, Montanelli A, Badalamenti S, Graziani G, Bossola M, Distasio E, Tazza L, Pchelin I, Shishkin A, Fedorova Y, Kao CC, Chu TS, Tsai TJ, Wu KD, Wu MS, Kim JC, Park K, Raikou V, Kaisidis P, Tsamparlis E, Kanellopoulos P, Boletis J, Ueda A, Hirayama A, Owada S, Nagai K, Saito C, Yamagata K. DIALYSIS. PATHOPHYSIOLOGY AND CLINICAL STUDIES. Nephrol Dial Transplant 2014. [DOI: 10.1093/ndt/gfu177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Van Londen M, Humalda JK, Aarts BM, Sanders JS, Bakker SJL, Navis GJ, De Borst MH, Pazik J, O Dak M, Lewandowski Z, Podgorska M, Sadowska A, Sitarek E, Malejczyk J, Durlik M, Drechsler C, Philstrom H, Meinitzer A, Pilz S, Tomaschitz A, Abedini S, Fellstrom B, Jardine A, Wanner C, Maerz W, Holdaas H, Halleck F, Staeck O, Neumayer HH, Budde K, Khadzhynov D, Rostaing L, Allal A, Congy N, Aarninck A, Del Bello A, Maggioni S, Debiols B, Sallusto F, Kamar N, Stolyarevich E, Artyukhina L, Kim I, Tomilina N, Zaidenov V, Kurenkova L, Keyzer CA, De Borst MH, Van Den Berg E, Jahnen-Dechent W, Navis G, Bakker SJL, Van Goor H, Pasch A, Aulagnon F, Avettand-Fenoel V, Scemla A, Lanternier F, Lortholary O, Anglicheau D, Legendre C, Zuber J, Furic-Cunko V, Basic-Jukic N, Coric M, Kastelan Z, Hudolin T, Kes P, Mikolasevic I, Racki S, Lukenda V, Orlic L, Dobrowolski LC, Verberne HJ, Ten Berge IJM, Bemelman FJ, Krediet CTP, Ferreira AC, Silva C, Remedio F, Pena A, Nolasco F, Heldal K, Lonning K, Leivestad T, Reisaeter AV, Hartmann A, Foss AE, Midtvedt K, Vlachopanos G, Kassimatis T, Zerva A, Kokkona A, Stavroulaki E, Agrafiotis A, Sanchez Sobrino B, Lafuente Covarrubias O, Karsten Alvarez S, Zalamea Jarrin F, Rubio Gonzalez E, Huerta Arroyo A, Portoles Perez J, Basic-Jukic N, Kes P, Baek CH, Kim M, Kim JS, Yang WS, Han DJ, Park SK, Zulkarnaev A, Vatazin A, Cabiddu G, Maxia S, Castellino S, Loi V, Guzzo G, Piccoli GB, Pani A, Bucsa C, Tacu D, Harza M, Sinescu I, Mircescu G, Stefan G, Alfieri CM, Laura F, Danilovic B, Cresseri D, Meneghini M, Riccardo F, Regalia A, Messa P, Panuccio V, Tripepi R, Parlongo G, Quattrone S, Leonardis D, Tripepi G, Zoccali C, Mallamaci F, Amer H, Geerdes PA, Fettes TT, Prieto M, Walker RC, Edwards BS, Cosio FG, Khrabrova M, Nabokov A, Groene HJ, Weithofer P, Kliem V, Smirnov A, Dobronravov V, Sezer S, Gurlek Demirci B, Tutal E, Guliyev O, Say N CB, Ozdemir Acar FN, Haberal M, Albugami MM, Hussein M, Alsaeed S, Almubarak A, Bel'eed-Akkari K, Go biewska JE, Tarasewicz A, D bska- lizie A, Rutkowski B, Albugami MM, Hussein M, Almubarak A, Alsaeed S, Bel'eed-Akkari K, Ailioaie O, Arzouk N, Tourret J, Mercadal L, Szumilak D, Ourahma S, Parra J, Billault C, Barrou B, Alfieri CM, Floreani R, Ulivieri FM, Meneghini M, Regalia A, Zanoni F, Croci D, Rastaldi MP, Messa PG, Keyzer CA, Riphagen IJ, Joosten MM, Navis G, Muller Kobold AC, Kema IP, Bakker SJL, De Borst MH, Santos Lascasas J, Malheiro J, Fonseca I, Martins L, Almeida M, Pedroso S, Dias L, Henriques A, Cabrita A, Vincenti F, Weir M, Von Visger J, Kopyt N, Mannon R, Deng H, Yue S, Wolf M, Halleck F, Khadzhynov, D, Schmidt D, Petereit F, Slowinski T, Neumayer HH, Budde K, Staeck O, Hernandez Vargas H, Artamendi Larranaga M, Gil Catalinas F, Ramalle Gomara E, Bello Ovalle A, Pimentel Guzman G, Coloma Lopez A, Dall Anesse C, Gil Paraiso A, Beired Val I, Sierra Carpio M, Huarte Loza E, Slubowska K, Szmidt J, Chmura A, Durlik M, Staeck O, Khadzhynov D, Schmidt D, Niemann M, Petereit F, Lachmann N, Neumayer HH, Budde K, Halleck F, Alotaibi T, Nampoory N, Gheith O, Halim M, Aboatteya H, Mansour H, Abdulkawey H, Said T, Nair P, WazNa-Jab O Ska E, Durlik M, Elias M, Caillard S, Morelon E, Rivalan J, Moal V, Frimat L, Mourad G, Rerolle JP, Legendre C, Mousson C, Delahousse M, Pouteil-Noble C, Dantal J, Cassuto E, Subra JF, Lang P, Thervet E, Roosweil D, Molnar MZ, Fornadi K, Ronai KZ, Novak M, Mucsi I, Scale TM, Robertson S, Kumwenda M, Jibani M, Griffin S, Williams AJ, Mikhail A, Jeong JC, Koo TY, Jeon HJ, Han M, Oh KH, Ahn C, Yang J, Bancu I, Canas L, Juega J, Malumbres S, Guermah I, Bonet J, Lauzurica R, Basso E, Messina M, Daidola G, Mella A, Lavacca A, Manzione AM, Rossetti M, Ranghino A, Ariaudo C, Segoloni GP, Biancone L, Whang E, Son SH, Kwon H, Kong JJ, Choi WY, Yoon CS, Ferreira AC, Silva C, Aires I, Ferreira A, Remedio F, Nolasco F, Ratkovic M, Basic Jukic N, Gledovic B, Radunovic D, Prelevic V, Stefan G, Garneata L, Bucsa C, Harza M, Sinescu I, Mircescu G, Tacu D, Aniort J, Kaysi S, Mulliez A, Heng AE, Su owicz J, Wojas-Pelc A, Ignacak E, Janda K, Krzanowski M, Miarka P, Su owicz W, Filipov JJ, Zlatkov BK, Dimitrov EP, Svinarov DA, Champion L, Renoux C, Randoux C, Du Halgouet C, Azeroual L, Glotz D, Vrtovsnik F, Daugas E, Musetti C, Battista M, Cena T, Izzo C, Airoldi A, Magnani C, Stratta P, Fiskvik I, Holte H, Bentdal O, Holdaas H, Erkmen Uyar M, Sezer S, Bal Z, Guliyev O, Colak T, Gurlek Demirci B, Ozdemir Acar N, Haberal M, Kara E, Ahbap E, Basturk T, Koc Y, Sakaci T, Sahutoglu T, Akgol C, Sevinc M, Unsal A, Seyahi N, Abdultawab K, Alotaibi T, Gheith O, Mansour H, Halim M, Nair P, Said T, Balaha M, Elsayed A, Awadeen W, Nampoory N, Hwang JC, Jiang MY, Lu YH, Weng SF, Madziarska K, Zmonarski SC, Augustyniak-Bartosik H, Magott-Procelewska M, Krajewska M, Mazanowska O, Banasik M, Penar J, Weyde W, Boraty Ska M, Klinger M, Swarnalatha G, Narendranath L, Shanta Rao G, Sawhney A, Subrahmanyam L, Kumar S, Jeon H, Hakim A, Patel U, Shrivastava S, Banerjee D, Kimura T, Yagisawa T, Nanmoku K, Kurosawa A, Sakuma Y, Miki A, Nukui A, Lee CH, Oh IH, Park JS, Watarai Y, Narumi S, Goto N, Hiramitsu T, Tsujita M, Yamamoto T, Kobayashi T, Muniz Pacios L, Molina M, Cabrera J, Gonzalez E, Garcia Santiago A, Aunon P, Santana S, Polanco N, Gutierrez E, Jimenez C, Andres A, Mohammed M, Hammam M, Housawi A, Goldsmith DJ, Cronin A, Frame S, Smalcelj R, Canoz MB, Yavuz DD, Altunoglu A, Yavuz R, Colak T, Haberal M, Tong A, Hanson CS, Chapman JR, Halleck F, Budde K, Papachristou C, Craig J, Zheng XY, Han S, Wang LM, Zhu YH, Zeng L, Zhou MS, Guliyev O, Erkmen Uyar M, Sezer S, Bal Z, Colak T, Gurlek Demirci B, Ozdemir Acar N, Haberal M, Ranghino A, Diena D, De Rosa FG, Faletti R, Barbui AM, Guarnaccia C, Corcione S, Messina M, Ariaudo C, Segoloni GP, Biancone L, Patel R, Murray PD, Moiseev A, Kalachik A, Harden PN, Norby G, Mjoen G, Holdaas H, Gilboe IM, Shi Y, Luo L, Cai B, Wang T, Tao Y, Wang L, Erkmen Uyar M, Sezer S, Bal Z, Guliyev O, Tutal E, Gurlek Demirci B, Ozdemir Acar N, Haberal M, Di Vico MC, Messina M, Mezza E, Giraudi R, Nappo A, Boaglio E, Ranghino A, Fop F, Segoloni GP, Biancone L, Carta P, Dattolo E, Buti E, Zanazzi M, Villari D, Di Maria L, Santoro G, Li Marzi V, Minetti EE, Nicita G, Carta P, Zanazzi M, Buti E, Antognoli G, Dervishi E, Vignali L, Caroti L, Di Maria L, Minetti EE, Dorje C, Kovacevic G, Hammarstrom C, Strom EH, Holdaas H, Midtvedt K, Reisaeter AV, Alfieri CM, Floreani R, Meneghini M, Regalia A, Zanoni F, Vettoretti S, Croci MD, Rastaldi MP, Messa P, Heldal K, Lonning K, Reisaeter AV, Bernklev T, Midtvedt K, Strakosha A, Pasko N, Nasto F, Cadri V, Dedei A, Thereska N. TRANSPLANTATION CLINICAL 2. Nephrol Dial Transplant 2014. [DOI: 10.1093/ndt/gfu180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Littrell M, Murphy L, Kumwenda M, Macintyre K. Gogo Care and Protection of Vulnerable Children in Rural Malawi: Changing Responsibilities, Capacity to Provide, and Implications for well-being in the Era of HIV and AIDS. J Cross Cult Gerontol 2012; 27:335-55. [DOI: 10.1007/s10823-012-9174-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bedell RA, Anderson STB, van Lettow M, Akesson A, Corbett EL, Kumwenda M, Chan AK, Heyderman RS, Zachariah R, Harries AD, Ramsay AR. High prevalence of tuberculosis and serious bloodstream infections in ambulatory individuals presenting for antiretroviral therapy in Malawi. PLoS One 2012; 7:e39347. [PMID: 22761767 PMCID: PMC3382251 DOI: 10.1371/journal.pone.0039347] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 05/23/2012] [Indexed: 11/29/2022] Open
Abstract
Background Tuberculosis (TB) and serious bloodstream infections (BSI) may contribute to the high early mortality observed among patients qualifying for antiretroviral therapy (ART) with unexplained weight loss, chronic fever or chronic diarrhea. Methods and Findings A prospective cohort study determined the prevalence of undiagnosed TB or BSI among ambulatory HIV-infected adults with unexplained weight loss and/or chronic fever, or diarrhea in two routine program settings in Malawi. Subjects with positive expectorated sputum smears for AFB were excluded. Investigations Bacterial and mycobacterial blood cultures, cryptococcal antigen test (CrAg), induced sputum (IS) for TB microscopy and solid culture, full blood count and CD4 lymphocyte count. Among 469 subjects, 52 (11%) had microbiological evidence of TB; 50 (11%) had a positive (non-TB) blood culture and/or positive CrAg. Sixty-five additional TB cases were diagnosed on clinical and radiological grounds. Nontyphoidal Salmonellae (NTS) were the most common blood culture pathogens (29 cases; 6% of participants and 52% of bloodstream isolates). Multivariate analysis of baseline clinical and hematological characteristics found significant independent associations between oral candidiasis or lymphadenopathy and TB, marked CD4 lymphopenia and NTS infection, and severe anemia and either infection, but low positive likelihood ratios (<2 for all combinations). Conclusions We observed a high prevalence of TB and serious BSI, particularly NTS, in a program cohort of chronically ill HIV-infected outpatients. Baseline clinical and hematological characteristics were inadequate predictors of infection. HIV clinics need better rapid screening tools for TB and BSI. Clinical trials to evaluate empiric TB or NTS treatment are required in similar populations.
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Kumwenda M, Tom S, Chan AK, Mwinjiwa E, Sodhi S, Joshua M, van Lettow M. Reasons for accepting or refusing HIV services among tuberculosis patients at a TB-HIV integration clinic in Malawi. Int J Tuberc Lung Dis 2012; 15:1663-9. [PMID: 22118175 DOI: 10.5588/ijtld.10.0741] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING In Malawi, human immunodeficiency virus (HIV) prevalence among newly registered tuberculosis (TB) patients is 60-70%. In 2008, an integrated TBHIV clinic was established at a central hospital in Zomba. Despite the integration of TB-HIV activities and improved HIV service uptake, unacceptably high proportions of HIV-positive TB patients are still not receiving antiretroviral therapy (ART). OBJECTIVE To identify factors that motivate or discourage TB patients from accepting HIV services. DESIGN Retrospective analysis of patients registered for TB treatment (not yet on ART) between April 2008 and March 2009; qualitative interviews of 99 patients on TB treatment. RESULTS Of 1773 newly registered TB patients who were not already on ART at the time of TB registration, 86% accepted HIV testing and counselling. Among HIV-positive TB patients, 38% started ART during or after anti-tuberculosis treatment. Young adults aged 15- 24 years were least likely to initiate ART. Motivation for accepting ART during TB treatment included prospects of regaining good health and longer life, and counselling by health care providers. Barriers to ART uptake included not being offered ART, high CD4 count, drug stockouts and fear of drug toxicities/interactions. CONCLUSION Several factors that undermine uptake of ART have been highlighted; targeted measures urgently need to be addressed by TB-HIV programmes to overcome these barriers.
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Abu-Ain M, Aazem S, Morton C, Kumwenda M, Griffiths D, Jacob A. A rare potentially treatable cause of bilateral optic disc swelling. BMJ Case Rep 2010; 2010:2010/oct12_2/bcr0320102835. [PMID: 22789833 DOI: 10.1136/bcr.03.2010.2835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Rapid onset bilateral optic disc swelling generally indicates an intracranial problem-that is, papilloedema. However, when there is also visual loss, disease affecting the optic nerves themselves must be considered. We present the diagnostic problem of a patient with optic disc swelling and progressive visual loss. Investigations finally revealed hypocalcaemia secondary to primary hypoparathyroidism. With treatment a marked improvement in vision occurred. This reversible rare cause of optic disc swelling should not be forgotten.
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Affiliation(s)
- M Abu-Ain
- Department of Ophthalmology, Royal Gwent Hospital, Newport, UK
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Maida MJ, Daly CC, Hoffman I, Cohen MS, Kumwenda M, Vernazza PL. Prevalence of hepatitis C infection in Malawi and lack of association with sexually transmitted diseases. Eur J Epidemiol 2001; 16:1183-4. [PMID: 11484810 DOI: 10.1023/a:1010920426795] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
To investigate the role of sexual transmission for Hepatitis C virus (HCV) we studied its prevalence in sub-Saharan Africa where sexually transmitted diseases (STDs) are prevalent. Overall, HCV prevalence was 3.9% and similar in 206 STD patients, 127 dermatology patients, and 100 blood donors. No association with HIV or syphilis was observed. Despite high prevalence of STDs, sexual transmission does not appear to significantly contribute to HCV transmission in Malawi.
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Affiliation(s)
- M J Maida
- Lilongwe Central Hospital, Ministry of Health and Population, Malawi
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Kalra PA, Kumwenda M, MacDowall P, Roland MO. Questionnaire study and audit of use of angiotensin converting enzyme inhibitor and monitoring in general practice: the need for guidelines to prevent renal failure. BMJ 1999; 318:234-7. [PMID: 9915733 PMCID: PMC27706 DOI: 10.1136/bmj.318.7178.234] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To determine the current pattern of use of angiotensin converting enzyme inhibitor and monitoring of renal function in general practice and to audit all admissions to a regional renal unit for uraemia related to use of these drugs. DESIGN Postal questionnaire sent to 400 general practitioners; audit of clinical notes of all patients receiving these drugs in one large general practice; audit of all cases of uraemia (creatinine concentration >500 micromol/l) related to treatment presenting to hospital renal services over 12 months. SETTING General practices in the North Wales health authority and one in central Manchester. Regional renal unit in Salford. MAIN OUTCOME MEASURES Proportion of general practitioners who regularly monitored renal function before and after initiation of angiotensin converting enzyme inhibitors. Indications for treatment and details of monitoring of renal function in patients receiving these drugs. Incidence of related uraemia and evidence of comorbid disease, other aetiological factors, delayed detection, and patient outcome. RESULTS 277 (69%) general practitioners replied; 235 (85%) checked renal function before but only 93 (34%) after the start of treatment, and 42 (15%) never checked renal function. Angiotensin converting enzyme inhibitors were prescribed for 162 patients from a total of 3625 aged >35 years (mean age 66.4 (SD 15.9) years). Monitoring of renal function occurred before treatment in 55 (45%) and after start of treatment in 35 (29%) of the 122 patients treated in general practice. Angiotensin converting enzyme inhibitors could be causally implicated in 9 (7%) of 135 admissions for uraemia (mean age 74.2 (7. 2) v 62.1 (2.1) years; P<0.01). 3 patients had renovascular disease and 6 had congestive cardiac failure with another intercurrent illness. Renal function had not been checked in any patient after the start of treatment; mean duration of illness before admission was 10.5 (3.2) days. Mean length of hospital stay was 20.9 (10.4) days; there were 8 survivors. CONCLUSION Cases of uraemia related to treatment with angiotensin converting enzyme inhibitors are still encountered and are often detected late because of lack of judicious monitoring of renal function in vulnerable, often elderly, patients, especially at times of intercurrent illness. Guidelines for appropriate monitoring of renal function may help to minimise the problem.
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Affiliation(s)
- P A Kalra
- Department of Renal Medicine, Hope Hospital, Salford M6 8HD
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