An HIV-1 risk assessment tool for women aged 15-49 in African countries: A pooled analysis across 15 nationally representative surveys

BACKGROUND

Women in Africa disproportionately acquire HIV-1. Understanding which women are most likely to acquire HIV-1 can guide focused prevention with pre-exposure prophylaxis (PrEP). Our objective is to identify women at highest risk of HIV-1 and estimate PrEP efficiency at different sensitivity levels.

METHODS

Nationally representative data were collected from 2015-2019 from 15 population-based household surveys. This analysis included women aged 15-49 who tested HIV-1 sero-negative or had recent HIV-1. Least absolute shrinkage and selection operator regression models were fit with 28 variables to predict recent HIV-1. Models were trained on the full population and internally cross-validated. Performance was evaluated using area under the receiver-operating-characteristic curve (AUC), sensitivity, and number needed to treat (NNT) with PrEP to avert one infection.

RESULTS

Among 209,012 participants 248 had recent HIV-1 infection, representing 118 million women and 402,000 (95% CI: 309,000-495,000) new annual infections. Two variables were retained in the model: living in a subnational area with high HIV-1 viremia and having a sexual partner living outside the home. Full-population AUC was 0.80 (95% CI: 0.76-0.84); cross-validated AUC was 0.79 (95% CI: 0.75-0.84). At a sensitivity of 33%, up to 130,000 cases could be averted if 7.9 million women were perfectly adherent to PrEP; NNT would be 61. At a sensitivity of 67%, up to 260,000 cases could be averted if 25.1 million women were perfectly adherent to PrEP; the NNT would be 96.

CONCLUSIONS

This risk assessment tool was generalizable, predictive, and parsimonious with tradeoffs between reach and efficiency.

Does a blended learning implementation package enhance HIV index case testing in Malawi? A protocol for a cluster randomised controlled trial

INTRODUCTION

Index case testing (ICT) is an evidence-based approach that efficiently identifies persons in need of HIV treatment and prevention services. In Malawi, delivery of ICT has faced challenges due to limited technical capacity of healthcare workers (HCWs) and clinical coordination. Digitisation of training and quality improvement processes presents an opportunity to address these challenges. We developed an implementation package that combines digital and face-to-face modalities (blended learning) to strengthen HCWs ICT skills and enhance quality improvement mechanisms. This cluster randomised controlled trial will assess the impact of the blended learning implementation package compared with the standard of care (SOC) on implementation, effectiveness and cost-effectiveness outcomes.

METHODS AND ANALYSIS

The study was conducted in 33 clusters in Machinga and Balaka districts, in Southern Malawi from November 2021 to November 2023. Clusters are randomised in a 2:1 ratio to the SOC versus blended learning implementation package. The SOC is composed of: brief face-to-face HCW ICT training and routine face-to-face facility mentorship for HCWs. The blended learning implementation package consists of blended teaching, role-modelling, practising, and providing feedback, and blended quality improvement processes. The primary implementation outcome is HCW fidelity to ICT over 1 year of follow-up. Primary service uptake outcomes include (a) index clients who participate in ICT, (b) contacts elicited, (c) HIV self-test kits provided for secondary distribution, (d) contacts tested and (e) contacts identified as HIV-positive. Service uptake analyses will use a negative binomial mixed-effects model to account for repeated measures within each cluster. Cost-effectiveness will be assessed through incremental cost-effectiveness ratios examining the incremental cost of each person tested.

ETHICS AND DISSEMINATION

The Malawi National Health Science Research Committee, the University of North Carolina and the Baylor College of Medicine Institutional Review Boards approved the trial. Study findings will be disseminated through peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

NCT05343390.

A Patient-Centered, Combination Intervention to Support Adherence to HIV Pre-exposure Prophylaxis During Pregnancy and Breastfeeding: A Randomized Pilot Study in Malawi

BACKGROUND

Daily oral pre-exposure prophylaxis (PrEP) can reduce HIV incidence in pregnant and breastfeeding women, but adherence is essential.

METHODS

We conducted a pilot randomized trial to evaluate an intervention package to enhance antenatal and postnatal PrEP use in Lilongwe, Malawi. The intervention was based on patient-centered counseling adapted from previous PrEP studies, with the option of a participant-selected adherence supporter. Participants were locally eligible for PrEP and randomized 1:1 to intervention or standard counseling (ie, control) and followed for 6 months. Participants received the intervention package or standard counseling at enrollment, 1, 3, and 6 months. Adherence was measured through plasma and intracellular tenofovir concentrations and scored using a published algorithm. Our primary outcome was retention in care with concentrations consistent with 4-7 doses/week.

RESULTS

From June to November 2020, we enrolled 200 pregnant women with the median gestational age of 26 (interquartile range: 19-33) weeks. Study retention was high at 3 months (89.5%) and 6 months (85.5%). By contrast, across the 2 time points, 32.8% of participants retained in the study had adherence scores consistent with 2-5 doses/week while 10.3% had scores consistent with daily dosing. For the composite primary end point, no substantial differences were observed between the intervention and control groups at 3 months (28.3% vs. 29.0%, probability difference: -0.7%, 95% confidence interval: -13.3%, 11.8%) or at 6 months (22.0% vs. 26.3%, probability difference: -4.3%, 95% confidence interval: -16.1%, 7.6%).

CONCLUSIONS

In this randomized trial of PrEP adherence support, retention was high, but less than one-third of participants had pharmacologically confirmed adherence of ≥4 doses/week. Future research should focus on antenatal and postnatal HIV prevention needs and their alignment across the PrEP continuum, including uptake, persistence, and adherence.

Two strategies for partner notification and partner HIV self-testing reveal no evident predictors of male partner HIV testing in antenatal settings: A secondary analysis

BACKGROUND

To meet global targets for the elimination of mother-to-child HIV transmission, tailored approaches to HIV testing strategies need prioritizing. Herein, we sought to identify individual-level factors associated with male partner HIV testing.

METHODS

We conducted a secondary analysis of data from two parallel randomized trials of pregnant women living with HIV and those HIV-negative in Lusaka, Zambia. Across both trials, control groups received partner notification services only, while intervention groups received partner notification services plus HIV self-test kits for their partners. Associations between baseline factors and male partner testing were estimated using a probability difference. The outcome of interest was uptake of male partner HIV testing of any kind within 30 days of randomization.

RESULTS

The parent study enrolled 326 participants. Among the 151 women in the control groups, no clear associations were noted between maternal or male partner characteristics and reported uptake of male partner HIV testing. There were positive trends favouring partner testing among women who completed primary school education, had larger households (>2 members), and whose partners were circumcised. Likewise, no clear predictors of male partner testing were identified among the 149 women in the intervention groups. However, negative trends favouring no testing were noted among older, multiparous women from larger households.

CONCLUSION

No consistent predictors for male partner HIV testing across two compared strategies were observed. Our findings suggest that differentiated strategies for male partner HIV testing may not be necessary. Instead, consideration should be given to universal approaches when bringing such services to scale.

Acceptability of a Combination Adherence Strategy to Support HIV Antiretroviral Therapy and Pre-exposure Prophylaxis Adherence During Pregnancy and Breastfeeding in Malawi

In two parallel pilot studies, we implemented a combination adherence intervention of patient-centered counselling and adherence supporter training, tailored to support HIV treatment (i.e., antiretroviral therapy) or prevention (i.e., pre-exposure prophylaxis, or PrEP) during pregnancy and breastfeeding. Using a mixed-methods approach, we evaluated the intervention's acceptability. We investigated engagement, satisfaction, and discussion content via survey to all 151 participants assigned to the intervention arm (51 women living with HIV, 100 PrEP-eligible women without HIV). We also conducted serial in-depth interviews with a subgroup (n = 40) at enrollment, three months, and six months. In the quantitative analysis, the vast majority reported high satisfaction with intervention components and expressed desire to receive it in the future, if made available. These findings were supported in the qualitative analysis, with favorable comments about counselor engagement, intervention content and types of support received from adherence supporters. Overall, these results demonstrate high acceptability and provide support for HIV status-neutral interventions for antiretroviral adherence.

Knowledge and perceptions about Dolutegravir and Dolutegravir counselling: a qualitative study among women living with HIV

INTRODUCTION

In 2018, the Malawi Ministry of Health adopted the recommendation to switch first-line antiretroviral therapy (ART) from an efavirenz (EFV)-based to a dolutegravir (DTG)-based regimen. Little is known about patients' experience during this transition. We conducted a qualitative study to explore DTG-related counselling challenges among providers of HIV care and factors influencing regimen switching or non-switching among women living with HIV in Lilongwe, Malawi.

METHODS

Between February-July 2020, we recruited participants who took part in DTG counselling on reasons to switch, side effects, and benefits from two government health facilities providing HIV care: Area 18 health centre and Bwaila district hospital in Lilongwe, Malawi. We purposively sampled and interviewed 8 women living with HIV who remained on an EFV-based regimen after counselling, 10 women who switched to a DTG-based regimen, and 10 HIV care providers who provided counselling about ART switching. In-depth interviews were used to explore patient's perceptions of DTG, factors affecting the decision to switch, and both patient and provider experience with counselling. Interview data was coded for themes using inductive and deductive codes. Interviews were conducted until thematic saturation was achieved. Data matrices were used for analysis and thematic extraction.

RESULTS

Most women in both groups were well versed on DTG's potential side effects and felt well counselled on the benefits of switching, such as quicker viral load suppression. Many women associated DTG with birth defects and expressed concern. However, the primary reason for not switching was concern with how the new medication would be tolerated, especially when they were satisfied with their current regimen. Almost all providers expressed difficulty providing DTG counselling. Primary reasons included feeling inadequately trained and/or not having resources to use during counselling, such as diagrams or brochures.

CONCLUSION

DTG counselling was well accepted by women; however, some felt that their concerns were not fully addressed. Providers reflected this sentiment in that they did not feel adequately trained or well-equipped to provide adequate counselling. Training on counselling for new ART regimens should be intensified and utilize patient-centered educational materials to address the concerns raised by both patients and health care providers.

Examining the feasibility of assisted index case testing for HIV case-finding: a qualitative analysis of barriers and facilitators to implementation in Malawi

Background

Assisted index case testing, in which health care workers take an active role in referring at-risk contacts of people living with HIV for HIV testing services, has been widely recognized as an evidence-based intervention with high potential to increase PLHIV status awareness. Promising evidence for the approach has led to several attempts to scale assisted index case testing throughout eastern and southern Africa in recent years. However, despite effective implementation being at the heart of any assisted index case testing strategy, there is limited implementation science research from the perspective of the HCWs who are doing the "assisting". This study examines the feasibility of assisted index case testing from the perspective of health care workers implementing the approach in Malawi.

Methods

In-depth interviews were conducted with 26 lay health care workers delivering assisted index case testing in Malawian health facilities. Interviews explored health care workers' experiences counselling index clients and tracing these clients' contacts, aiming to inform development of a blended learning implementation package. Transcripts were inductively analyzed using Dedoose coding software to identify and describe key factors influencing feasibility of assisted index case testing. Analysis included multiple rounds of coding and iteration with the data collection team.

Results

Participants reported a variety of barriers to feasibility of assisted index case testing implementation, including privacy concerns, limited time for assisted index case testing amid high workloads, poor quality contact information, logistical obstacles to tracing, and challenges of discussing sexual behavior with clients. Participants also reported several health care worker characteristics that facilitate feasibility: robust understanding of assisted index case testing's rationale and knowledge of procedures, strong interpersonal skills, positive attitudes towards clients, and sense of purpose in their work.

Conclusions

Findings demonstrate that maximizing assisted index case testing's potential to increase HIV status awareness requires adequately equipping health care workers with appropriate knowledge, skills, and support to address and overcome the many feasibility challenges that they face in implementation.

Trial Registration Number

NCT05343390 Date of registration: April 25, 2022.

Crowdsourcing to support training for public health: A scoping review

Crowdsourcing is an interactive process that has a group of individuals attempt to solve all or part of a problem and then share solutions with the public. Crowdsourcing is increasingly used to enhance training through developing learning materials and promoting mentorship. This scoping review aims to assess the literature on crowdsourcing for training in public health. We searched five medical and public health research databases using terms related to crowdsourcing and training. For this review, the concept of crowdsourcing included open calls, designathons, and other activities. We used a PRISMA checklist for scoping reviews. Each full-text was assessed by two independent reviewers. We identified 4,071 citations, and 74 studies were included in the scoping review. This included one study in a low-income country, 15 studies in middle-income countries, 35 studies in high-income countries, and 11 studies conducted in multiple countries of varying income levels (the country income level for 12 studies could not be ascertained). Nine studies used open calls, 35 used a hackathon, designathon or other "a-thon" event, and 30 used other crowdsourcing methods, such as citizen science programs and online creation platforms. In terms of crowdsourcing purpose, studies used crowdsourcing to educate participants (20 studies), develop learning materials (17 studies), enhance mentorship (13 studies) and identify trainees (9 studies). Fifteen studies used crowdsourcing for more than one training purpose. Thirty-four studies were done in-person, 31 were conducted virtually and nine used both meeting options for their crowdsourcing events. Seventeen studies generated open access materials. Our review found that crowdsourcing has been increasingly used to support public health training. This participatory approach can be a useful tool for training in a variety of settings and populations. Future research should investigate the impact of crowdsourcing on training outcomes.

Combination HIV prevention during pregnancy and the post-partum period in Malawi and Zambia: a mathematical modelling analysis

INTRODUCTION

Despite widespread success in reducing vertical HIV transmission, most antenatal care (ANC) programmes in eastern and southern Africa have not emphasized primary prevention of maternal HIV acquisition during pregnancy and lactation/breastfeeding. We hypothesized that combination HIV prevention interventions initiated alongside ANC could substantially reduce maternal HIV incidence.

METHODS

We constructed a multi-state model describing male-to-female HIV transmission in steady heterosexual partnerships during pregnancy and lactation/breastfeeding, with initial conditions based on population distribution estimates for Malawi and Zambia in 2020. We modelled individual and joint increases in three HIV prevention strategies at or soon after ANC initiation: (1) HIV testing of male partners, resulting in HIV diagnosis and less condomless sex among those with previously undiagnosed HIV; (2) initiation (or re-initiation) of suppressive antiretroviral therapy (ART) for male partners with diagnosed but unsuppressed HIV; and (3) adherent pre-exposure prophylaxis (PrEP) for HIV-negative female ANC patients with HIV-diagnosed or unknown-status male partners. We estimated the percentage of within-couple, male-to-female HIV transmissions that could be averted during pregnancy and lactation/breastfeeding with these strategies, relative to base-case conditions in which 45% of undiagnosed male partners become newly HIV diagnosed via testing, 75% of male partners with diagnosed but unsuppressed HIV initiate/re-initiate ART and 0% of female ANC patients start PrEP.

RESULTS

Increasing uptake of any single strategy by 20 percentage points above base-case levels averted 10%-11% of maternal HIV acquisitions during pregnancy and lactation/breastfeeding in the model. Joint uptake increases of 20 percentage points in two interventions averted an estimated 19%-23% of transmissions, and with a 20-percentage-point increase in uptake of all three interventions, 29% were averted. Strategies achieving 95% male testing, 90% male ART initiation/re-initiation and 40% female PrEP use reduced incident infections by 45%.

CONCLUSIONS

Combination HIV prevention strategies provided alongside ANC and sustained through the post-partum period could substantially reduce maternal HIV incidence during pregnancy and lactation/breastfeeding in eastern and southern Africa.

Adult HIV-1 incidence across 15 high-burden countries in sub-Saharan Africa from 2015 to 2019: a pooled analysis of nationally representative data

BACKGROUND

Harmonised population-based surveys with recent HIV-1 infection testing algorithms permit pooled cross-sectional estimation of HIV incidence across multiple countries. We aimed to estimate adult HIV-1 incidence rates and number of new infections by sex, age, and subregion in sub-Saharan Africa.

METHODS

We analysed data from 13 Population-Based HIV Impact Assessment (PHIA) surveys and two additional population-based surveys done between 2015 and 2019 in 15 sub-Saharan African countries. HIV-seropositive samples from adults aged 15-59 years were tested for recent HIV-1 infection by use of an algorithm consisting of the HIV-1 limiting antigen avidity enzyme immunoassay, HIV-1 viral load, and qualitative detection of antiretroviral agents. Data were pooled across countries; sampling weights were incorporated to represent all adults in the 15 national populations. Analyses accounted for the complex sample designs. HIV incidence rates, incidence rate differences, and number of new annual infections were estimated.

FINDINGS

Among 445 979 adults sampled, 382 had recent HIV-1 infection. The estimated HIV-1 incidence rate was 3·3 per 1000 person-years (95% CI 2·6-4·0) among women and 2·0 per 1000 person-years (1·2-2·7) among men (incidence rate difference 1·3 per 1000 person-years, 95% CI 0·3-2·3). Among adults aged 15-24 years, the incidence rate was higher for women (3·5 per 1000 person-years) than men (1·2 per 1000 person-years; difference 2·3, 95% CI 0·8-3·8), but infection rates were similar between sexes in all other age groups. The HIV-1 incidence rate was 7·4 per 1000 person-years (95% CI 5·0-9·7) in southern sub-Saharan Africa, 2·3 per 1000 person-years (1·7-2·9) in the eastern subregion, and 0·9 per 1000 person-years (0·6-1·2) in the western and central subregion. 689 000 (95% CI 546 000-833 000) new HIV cases were estimated annually among the 265 million susceptible adults (61·6% in women).

INTERPRETATION

HIV-1 incidence and number of new infections differed by age, sex, and subregion. Approaches for risk stratification are needed to guide comprehensive HIV-1 prevention.

FUNDING

National Institutes of Health.

Strategies to increase couples HIV testing and counselling in sub-Saharan Africa: a systematic review

INTRODUCTION

Couple HIV testing and counselling (CHTC) is associated with measurable benefits for HIV prevention and treatment. However, the uptake remains limited in much of sub-Saharan Africa, despite an expanded range of strategies designed to promote access.

METHODS

Following PRIMSA guidelines, we conducted a systematic review to characterize CHTC uptake strategies. Five databases were searched. Full-text articles were included if they were: conducted in sub-Saharan Africa during the study period (1980-2019), targeted heterosexual couples, reported at least one strategy to promote CHTC and provided a quantifiable measure of CHTC uptake. After the initial and full-text screening, key features of the studies were abstracted and synthesized.

RESULTS

Of the 6188 unique records found in our search, 365 underwent full-text review with 29 distinct studies included and synthesized. Most studies recruited couples through antenatal care (n = 11) or community venues (n = 8) and used provider-based HIV testing (n = 25). The primary demand creation strategies included home-based CHTC (n = 7); integration of CHTC into clinical settings (n = 4); distribution of HIV self-testing kits (n = 4); verbal or written invitations (n = 4); community recruiters (n = 3); partner tracing (n = 2); relationship counselling (n = 2); financial incentives (n = 1); group education with CHTC coupons (n = 1); and HIV testing at other community venues (n = 1). CHTC uptake ranged from negligible to nearly universal.

DISCUSSION

We thematically categorized a diverse range of strategies with varying levels of intensity and resources used across sub-Saharan Africa to promote CHTC. Offering CHTC within couples' homes was the most common approach, followed by the integration of CHTC into clinical settings. Due to heterogeneity in study characteristics, we were unable to compare the effectiveness across studies, but several trends were observed, including the high prevalence of CHTC promotion strategies in antenatal settings and the promising effects of home-based CHTC, distribution of HIV self-tests and integration of CHTC into routine health services. Since 2019, an updated literature search found that combining partner notification and secondary distribution of HIV self-test kits may be an additionally effective CHTC strategy.

CONCLUSIONS

There are many effective, feasible and scalable approaches to promote CHTC that should be considered by national programmes according to local needs, cultural context and available resources.

Perspectives and experiences of Zambian pregnant and postpartum women receiving two intervention models to increase uptake of male partner HIV testing

This study explored the experiences of pregnant women who received two intervention models for increasing uptake of male partner HIV testing in antenatal settings. As part of a randomised trial, we interviewed twenty participants who received partner notification services only while 22 received the partner notification plus HIV self-testing. Thematic analysis was used to analyse the data. Partner notification services helped to initiate discussions of HIV testing with partners, influence partners to undergo testing, and encouraged disclosure of HIV status. Some women experienced difficulties engaging partners due to fear of their partner's reaction. Some partners were unable to test due to time constraints. The partner notification plus HIV self-testing intervention, stimulated discussion about HIV testing; facilitated testing for men at their convenience; addressed privacy/confidentiality, and stigma concerns; and provided the opportunity to disclose HIV status. Some women feared disclosure and retribution in case of discordance results. There were also challenges with men making follow-ups for confirmatory HIV tests. The addition of HIV self-test kits to partner notification services can expand HIV testing services to male partners, including those of HIV-negative women. Additional efforts are needed to link men to appropriate HIV prevention, care, and treatment services.

Intimate Partner Violence and Contraception among Adolescent Girls and Young Women: A Longitudinal Analysis of the Girl Power-Malawi Cohort

PURPOSE

In sub-Saharan Africa, sexually active adolescent girls and young women (AGYW) experience high rates of intimate partner violence (IPV) and low levels of contraceptive use, but the effect of IPV on contraceptive use is not well understood.

METHODS

In the Girl Power-Malawi study, AGYW aged 15-24 were recruited from 4 health centers in Lilongwe, Malawi, and followed for 1 year. At baseline, AGYW were assessed for IPV using the modified Conflict Tactics Scale. AGYW reported contraceptive method use at 6 and 12 months, characterized as barrier, non-barrier, or any modern method. Modified Poisson regression was implemented to estimate risk ratios (RRs) and 95% confidence intervals (CIs) to examine the effect of IPV on contraceptive use.

RESULTS

One thousand AGYW were enrolled, and 954 non-pregnant participants were included. Baseline prevalence of IPV with the most recent partner was 35.5% (physical), 46.2% (sexual), and 76.9% (emotional). Baseline IPV did not affect contraceptive use at 6 months (aRR [95% CI]: physical 0.98 [0.91-1.05]; sexual 1.00 [0.94-1.07]; emotional 1.03 [0.94-1.12]) or 12 months (physical 0.95 [0.89-1.02]; sexual 0.96 [0.90-1.02]; emotional 0.98 [0.91-1.05]). None of the 3 IPV categories affected contraceptive use when the outcome was restricted to either barrier or non-barrier methods.

CONCLUSIONS

In this cohort, IPV was not a key driver of contraceptive use in longitudinal analyses. Interventions are needed to address the alarming rates of IPV in this population, but addressing IPV alone might be insufficient to address low contraceptive use, and multifaceted youth-friendly health services might be necessary.

Assessing Engagement of Adolescents and Young Adults (AYA) in HIV Research: A Multi-method Analysis of a Crowdsourcing Open Call and Typology of AYA Engagement in Sub-Saharan Africa

Engagement of adolescents and young adults (AYA) in HIV research is increasing in many settings. We organized a crowdsourcing open call to solicit examples of how AYA have been engaged in HIV research in Africa and to develop an engagement typology. We formed a steering committee, promoted the open call, organized judging and recognized finalists. We used a multi-methods approach to identify emerging themes and measure engagement. We received 95 entries from individuals in 15 countries; 74 met the eligibility criteria. More than three-quarters of entries were from AYA (55/74, 74%). Four themes characterized AYA engagement: (1) AYA were co-creators in the HIV research process. (2) AYA were involved in community-level capacity building. (3) AYA were co-leaders in minor risk research. (4) AYA used digital methods to enhance engagement. Our open call identified diverse methods of AYA engagement, which can enhance strategies used to reach AYA in African HIV studies.

Factors associated with a history of treatment interruption among pregnant women living with HIV in Malawi: A cross-sectional study

Introduction

Long-term care engagement of women on antiretroviral therapy (ART) is essential to effective HIV public health measures. We sought to explore factors associated with a history of HIV treatment interruption among pregnant women living with HIV presenting to an antenatal clinic in Lilongwe, Malawi.

Methods

We performed a cross-sectional study of pregnant women living with HIV who had a history of ART interruption presenting for antenatal care. Women were categorized as either retained in HIV treatment or reinitiating care after loss-to-follow up (LTFU). To understand factors associated with treatment interruption, we surveyed socio-demographic and partner relationship characteristics. Crude and adjusted prevalence ratios (aPR) for factors associated with ART interruption were estimated using modified Poisson regression with robust variance. We additionally present patients’ reasons for ART interruption.

Results

We enrolled 541 pregnant women living with HIV (391 retained and 150 reinitiating). The median age was 30 years (interquartile range (IQR): 25–34). Factors associated with a history of LTFU were age <30 years (aPR 1.46; 95% CI: 1.33–1.63), less than a primary school education (aPR 1.25; CI: 1.08–1.46), initiation of ART during pregnancy or breastfeeding (aPR 1.49, CI: 1.37–1.65), nondisclosure of HIV serostatus to their partner (aPR 1.39, CI: 1.24–1.58), lack of awareness of partner’s HIV status (aPR 1.41, CI: 1.27–1.60), and no contraception use at conception (aPR 1.60, CI 1.40–1.98). Access to care challenges were the most common reasons reported by women for treatment interruption (e.g., relocation, transport costs, or misplacing health documentation).

Conclusions

Interventions that simplify the ART clinic transfer process, facilitate partner disclosure, and provide counseling about the importance of lifelong ART beyond pregnancy and breastfeeding should be further evaluated for improving retention in ART treatment of women living with HIV in Malawi.

Individual and Relationship-Level Correlates of Transactional Sex Among Adolescent Girls and Young Women in Malawi: A Multilevel Analysis

Transactional sex increases HIV risk among adolescent girls and young women (AGYW). Understanding the individual and dyadic nature of transactional sex may provide evidence for risk reduction interventions. Multilevel logistic regression was used to cross-sectionally examine correlates of transactional sex among AGYW in Lilongwe, Malawi. Participants (N = 920) reported 1227 relationships. Individual-level associations were found between being divorced/widowed (AOR 5.07, 95% CI 1.93, 13.25), married (AOR 0.26, 95% CI 0.09, 0.72), or unstably housed (AOR 7.11, 95% CI 2.74, 18.47) and transactional sex. At the relationship-level, transactional sex occurred in relationships with: non-primary primary partners (AOR 4.06, 95% CI 2.37, 6.94), perceived partner concurrency (AOR 1.85, 95% CI 1.11, 3.08), and feared violence with couples HIV testing (AOR 2.81, 95% CI 1.26, 6.29), and less likely to occur in relationships with children (AOR 0.15, 95% CI 0.06, 0.38). Multiple co-occurring social and structural vulnerabilities increase transactional sex engagement warranting the need for social protection and gender transformative approaches.

Pilot-Testing a Blended Learning Package for Health Care Workers to Improve Index Testing Services in Southern Malawi: An Implementation Science Study

BACKGROUND

HIV index testing, an intervention in which HIV-positive "indexes" (persons diagnosed with HIV) are supported to recruit their "contacts" (sexual partners and children) efficiently identifies HIV-infected persons in need of treatment and HIV-uninfected persons in need of prevention. However, index testing implementation in sub-Saharan African health care settings has been suboptimal. The objective of this study was to develop and pilot test a blended learning capacity-building package to improve index testing implementation in Malawi.

METHODS

In 2019, a blended learning package combining digital and face-to-face training modalities was field tested at 6 health facilities in Mulanje, Malawi using a pre-/post- type II hybrid design with implementation and effectiveness outcomes. Health care worker (HCW) fidelity to the intervention was assessed via observed encounters before and after the training. Preliminary effectiveness was examined by comparing index testing program indicators in the 2 months before and 4 months after the training. Indicators included the mean number of indexes screened, contacts elicited, and contacts who received HIV testing per facility per month.

RESULTS

On a 30-point scale, HCW fidelity to index testing protocols improved from 6.0 pre- to 25.5 post-package implementation (P = 0.002). Index testing effectiveness indicators also increased: indexes screened (pre = 63, post = 101, P < 0.001); contacts elicited (pre = 75, post = 131, P < 0.001); and contacts who received HIV testing (pre = 27, post = 41, P = 0.014).

CONCLUSIONS

The blended learning package improved fidelity to index testing protocols and preliminary effectiveness outcomes. This package has the potential to enhance implementation of HIV index testing approaches, a necessary step for ending the HIV epidemic.

Contraceptive Conversations among Adolescent Girls and Young Women and Their Partners, Peers, and Older Female Family Members in Lilongwe, Malawi: A QualitativeAnalysis

In sub-Saharan Africa, adolescent girls and young women (AGYW) have high levels of unmet need for contraception, particularly those who are unmarried or nulliparous. Conversations with partners, peers, and family members influence AGYW contraceptive decision-making yet little is known about conversation content and impact or how they vary by relationship status and parity. This paper draws on qualitative data from 60 AGYW (aged 15-24) participating in a sexual and reproductive health study in Malawi to examine contraceptive conversation patterns among participants and their social ties. AGYW's relationship status and parity influenced whether they talked about contraceptives, who they talked to about contraceptives, and the type of contraceptives that were endorsed during conversations. Unmarried and nulliparous AGYW were less likely to discuss contraceptives with all social ties and when conversations occurred, norms and misinformation regarding nonbarrier methods were reinforced, and condoms were largely prescribed. Conversations with intimate partners often provided permission for contraceptive use while conversations with peers and older women in the family provided information on contraceptive methods. Our results highlight the unique roles that social ties play in AGYW contraceptive decision-making and suggest that existing contraceptive conversation patterns might exclude unmarried, nulliparous AGYW from accurate and comprehensive contraceptive information and options.

The 4 Youth By Youth mHealth Photo Verification App for HIV Self-testing in Nigeria: Qualitative Analysis of User Experiences

Background

Despite the global expansion of HIV self-testing (HIVST), many research studies still rely on self-reported outcomes. New HIVST verification methods are needed, especially in resource-limited settings.

Objective

This study aims to evaluate the user experience of a mobile health (mHealth) app to enhance HIVST result reporting and verification.

Methods

Semistructured, in-depth interviews were used to evaluate the user experience of the 4 Youth By Youth mHealth photo verification app for HIVST. We used a think-aloud approach, and participants performed usability tasks and completed a qualitative exit interview. The app included HIV educational resources, step-by-step video instructions for performing HIVST, a 20-minute timer, a guide on interpreting results with linkages to care, an offline version, and a photo verification system. Demographic characteristics were reported by using descriptive statistics. Qualitative data were analyzed by using thematic analysis.

Results

A total of 19 users—12 women and 7 men—with a mean age of 22 years, participated in the study. The users completed the usability tasks and successfully uploaded a photo of their test results by using the app without assistance. Four main themes were identified in the data. First, in terms of user-friendly design, the participants noted the user-friendly features of the offline version and the app’s low data use. However, some wanted the app to work in the background when using their mobile phone, and the font used should be more youth friendly. Second, in terms of ease of use, participants remarked that the app’s self-explanatory nature and instructions that guided them on how to use the app enhanced its use. Third, in terms of a user’s privacy, many participants reinforced the importance of privacy settings and tools that protect confidentiality among users. Finally, in terms of linkage to care, participants noted that the app’s linkage to care features were useful, particularly in relation to referrals to trained counselors upon the completion of the test. All the participants noted that the app provided a convenient and private means of verifying the HIV test results.

Conclusions

Our findings demonstrated the importance of engaging end users in the development phase of health technology innovations that serve youth. Clinical trials are needed to determine the efficacy of using an mHealth app to verify HIVST results among young people.

Addition of HIV self-test kits to partner notification services to increase HIV testing of male partners of pregnant women in Zambia: two parallel randomised trials

BACKGROUND

Testing men for HIV during their partner's pregnancy can guide couples-based HIV prevention and treatment, but testing rates remain low. We investigated a combination approach, using evidence-based strategies, to increase HIV testing in male partners of HIV-positive and HIV-negative pregnant women.

METHODS

We did two parallel, unmasked randomised trials, enrolling pregnant women who had an HIV-positive test result documented in their antenatal record (trial 1) and women who had an HIV-negative test result documented in their antenatal record (trial 2) from an antenatal setting in Lusaka, Zambia. Women in both trials were randomly assigned (1:1) to the intervention or control groups using permuted block randomisation. The control groups received partner notification services only, including an adapted version for women who were HIV-negative; the intervention groups additionally received targeted education on the use of oral HIV self-test kits for their partners, along with up to five oral HIV self-test kits. At the 30 day follow-up we collected information from pregnant women about their primary male partner's HIV testing in the previous 30 days at health-care facilities, at home, or at any other facility. Our primary outcome was reported male partner testing at a health facility within 30 days following randomisation using a complete-case approach. Women also reported male partner HIV testing of any kind (including self-testing at home) that occurred within 30 days. Randomisation groups were compared via probability difference with a corresponding Wald-based 95% CI. The trial is registered at ClinicalTrials.gov (NCT04124536) and all enrolment and follow-up has been completed.

FINDINGS

From Oct 28, 2019, to May 26, 2020, 116 women who were HIV-positive (trial 1) and 210 women who were HIV-negative (trial 2) were enrolled and randomly assigned to study groups. Retention at 30 days was 100 (86%) in trial 1 and 200 (95%) in trial 2. Women in the intervention group were less likely to report facility-based male partner HIV testing in trial 1 (3 [6%] of 47 vs 15 [28%] of 53, estimated probability difference -21·9% [95% CI -35·9 to -7·9%]) and trial 2 (3 [3%] of 102 vs 33 [34%] of 98, estimated probability difference -30·7% [95% CI -40·6 to -20·8]). However, reported male partner HIV testing of any kind was higher in the intervention group than in the control group in trial 1 (36 [77%] of 47 vs 19 [36%] of 53, estimated probability difference 40·7% [95% CI 23·0 to 58·4%]) and trial 2 (80 [78%] of 102 vs 54 [55%] of 98, estimated probability difference 23·3% [95% CI 10·7 to 36·0%]) due to increased use of HIV self-testing. Overall, 14 male partners tested HIV-positive. Across the two trials, three cases of intimate partner violence were reported (two in the control groups and one in the intervention groups).

INTERPRETATION

Our combination approach increased overall HIV testing in male partners of pregnant women but reduced the proportion of men who sought follow-up facility-based testing. This combination approach might reduce linkages to health care, including for HIV prevention, and should be considered in the design of comprehensive HIV programmes.

FUNDING

National Institutes of Health.

Strategies for enhancing uptake of HIV self-testing among Nigerian youths: a descriptive analysis of the 4YouthByYouth crowdsourcing contest

INTRODUCTION

Youth are often the intended beneficiaries of HIV programs but are rarely involved in program design. Engaging youth in program design is one potential way of identifying promising approaches for HIV service delivery. The purpose of this study is to examine the feasibility of using a crowdsourcing contest to solicit ideas on ways to promote HIV self-testing (HIVST) services among Nigerian youths.

METHODS

From October-November, 2018 Nigerian youth 10-24 years old submitted ideas to a crowdsourcing contest on how to promote HIVST among their peers. Submissions were scored on feasibility, desirability, and impact, with an integer score of 1 (low) to 3 (high) in each domain. The three-domain scores were added to calculate a total score (3-9). The demographic characteristics of contestants were calculated using descriptive statistics.

RESULTS

Nine-hundred and three entries were received, 831 had unique valid responses, and 769 were eligible for scoring. Youth submitted ideas on paper (44.9%), Google Forms (39.4%), WhatsApp (9.6%), and email (6.1%). Participants' ages were 10-14 years (37%), 15-19 years (44%), and 20-24 years (22%).Approximately half were female (51.2%). Mean scores were 1.4/3.0 (SD=0.6) for feasibility, 1.4/3.0 (SD=0.6) for desirability, 1.2/3.0 (SD=0.5) for impact, and 4.0/9.0 (SD=1.5) overall. Eight percent of submissions had an overall score >7. A disproportionate share of these high-quality submissions came from email and Google submissions.

CONCLUSION

The 4 Youth by Youth crowdsourcing contest engaged a broad audience and is a feasible way to elicit potential strategies to distribute HIVST kits to other youth. Several high-quality ideas require further evaluation.

Combination adherence strategy to support HIV antiretroviral therapy and pre-exposure prophylaxis adherence during pregnancy and breastfeeding: protocol for a pair of pilot randomised trials

INTRODUCTION

To realise the expected gains from prevention of mother-to-child HIV transmission initiatives, adherence to preventative and therapeutic antiretroviral regimens is critical and interventions deployable in busy programmatic settings with a high HIV burden are needed. Based on formative research, we developed an approach that integrates patient-centred counselling and engagement of an adherence supporter for pregnant and breastfeeding women initiating HIV treatment (ie, antiretroviral therapy (ART)) or biomedical HIV prevention (ie, pre-exposure prophylaxis (PrEP)).

METHODS

Tonse Pamodzi 2 is a pilot study designed to provide acceptability, fidelity and clinical outcomes data on a set of behavioural interventions for adherence support. The study comprises two parallel randomised trials, enrolling HIV-positive pregnant women initiating ART (Trial 1, n=100) and HIV-negative pregnant women with risk of HIV acquisition and willing to initiate PrEP (Trial 2, n=200). Within each trial, participants are randomised 1:1 to either the intervention or control group. The Tonse Pamodzi adherence intervention comprises patient-centred counselling (adapted Integrated Next Step Counseling(iNSC)) and external adherence support tailored to the clinical context (ie, for ART or PrEP). Participants randomly assigned to the control group receive standard counselling based on local HIV guidelines. Participants are followed for 6 months. To assess intervention acceptability, we will employ a mixed method approach to describe participant engagement, satisfaction, and discussion content. We will audit and score recorded counselling sessions to evaluate the implementation fidelity of iNSC sessions. We will also assess clinical outcomes at 3 and 6 months for both Trial 1 (retention in care and viral suppression of HIV) and Trial 2 (retention in care, and plasma and intracellular tenofovir drug concentrations).

ETHICS AND DISSEMINATION

The study protocol was approved by the Malawi National Health Science Research Committee (19/05/2334) and the University of North Carolina at Chapel Hill Institutional Review Board (19-1060).

TRIAL REGISTRATION NUMBER

NCT04330989.

Tonse Pamodzi: Developing a combination strategy to support adherence to antiretroviral therapy and HIV pre-exposure prophylaxis during pregnancy and breastfeeding

To eliminate mother-to-child transmission of HIV (EMTCT), scalable strategies to enhance antiretroviral adherence for both antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) are needed as part of integrated HIV and maternal-child health services. We developed Tonse Pamodzi ("all of us together"), an adaptable intervention integrating biomedical and behavioral components to support HIV treatment and prevention. We describe our intervention development process, which comprised formative qualitative research, a review of the literature, and technical input from stakeholders representing the community, health systems, and policymakers. The resulting intervention, described herein, integrates patient-centered counseling and engagement of a patient-selected adherence supporter for pregnant and breastfeeding women initiating ART or PrEP. Patients receiving the intervention engage in Integrated Next Step Counseling (iNSC) sessions delivered by trained counselors to build and maintain adherence skills. Each patient also has the option of selecting an adherence supporter (partner, family member, or friend) who may participate in iNSC sessions and provide adherence support outside of these sessions. This flexible intervention is adaptable not only to ART or PrEP use, but also to the needs and preferences of each woman and the clinical context. If shown to be acceptable and feasible, the Tonse Pamodzi intervention may be an important tool in continuing efforts for EMTCT.

A designathon to co-create community-driven HIV self-testing services for Nigerian youth: findings from a participatory event

BACKGROUND

Youth are at high risk for HIV, but are often left out of designing interventions, including those focused on adolescents. We organized a designathon for Nigerian youth to develop HIV self-testing (HIVST) strategies for potential implementation in their local communities. A designathon is a problem-focused event where participants work together over a short period to create and present solutions to a judging panel.

METHODS

We organized a 72-h designathon for youth (14-24 years old) in Nigeria to design strategies to increase youth HIVST uptake. Proposals included details about HIVST kit service delivery, method of distribution, promotional strategy, and youth audience. Teams pitched their proposals to a diverse seven-member judging panel who scored proposals based on desirability, feasibility, potential impact and teamwork. We examined participants' socio-demographic characteristics and summarized themes from their HIVST proposals.

RESULTS

Forty-two youth on 13 teams participated in the designathon. The median team size was 3 participants (IQR: 2-4). The median age was 22.5 years (IQR: 21-24), 66.7% were male, 47.4% completed tertiary education, and 50% lived in Lagos State. Themes from proposals included HIVST integration with other health services, digital marketing and distribution approaches, and engaging students. Judges identified seven teams with exceptional HIVST proposals and five teams were supported for further training.

CONCLUSIONS

The designathon provided a structured method for incorporating youth ideas into HIV service delivery. This approach could differentiate HIV services to be more youth-friendly in Nigeria and other settings.

The mediating role of partner communication on contraceptive use among adolescent girls and young women participating in a small-group intervention in Malawi: A longitudinal analysis

Though effective reproductive health interventions have been developed for adolescent girls and young women (AGYW) in sub-Saharan Africa, few have explored whether specific components of the interventions are responsible for observed changes in behaviour. Data for this longitudinal mediation analysis come from a quasi-experimental, sexual and reproductive health study conducted among AGYW (age 15-24) in Malawi. We assessed the extent to which the relationship between attending communication-specific small-group sessions and contraceptive use at one-year was mediated by contraceptive communication with partners at six months, using a bootstrapping procedure to estimate indirect effects. Of 358 participants, 44% attended communication-specific small-group sessions, 37% communicated with partners about contraception at six months, and 21% used non-barrier contraception at one-year. Participants who attended communication-specific small-group sessions had increased contraceptive communication with partners at six months (aOR = 1.48, 95% CI: 1.07-2.38) and increased non-barrier contraceptive use at one-year (aOR = 3.53, 95% CI: 1.86-6.69). The relationship between attending communication-specific small-group sessions and non-barrier contraceptive use at one-year was partially mediated by contraceptive communication with partners at six months (indirect effect = 0.04, 95% CI: 0.01-0.07). Our results suggest that contraceptive communication with partners is modifiable through interventions and important for AGYW non-barrier contraceptive uptake.

Communication, social norms, and contraceptive use among adolescent girls and young women in Lilongwe, Malawi

In Malawi, 50% of adolescent girls and young women (AGYW) have had a first child by age 19 and 45% report their pregnancies as unintended or mistimed. Yet, uptake of contraception remains low. Understanding how interactions with social ties impact AGYW contraceptive use might explain low uptake beyond individual and environmental factors. Data are from Girl-Power, a study among sexually active AGYW, aged 15-24, in Malawi. We used logistic regression models to examine whether contraceptive communication and social norms (descriptive and injunctive) were associated with contraceptive use (non-barrier methods and condoms) and how associations differed across social ties (older women in the family, peers, and partners). The sample included 942 participants: 28% reported using non-barrier methods and 66% reported using condoms. Contraceptive communication with older women in the family (aOR: 1.48, 95% CI: 0.99, 2.20), peers (aOR: 3.12, 95% CI: 1.96, 4.96), and partners (aOR 5.15, 95% CI: 3.13, 8.48) was associated with non-barrier method use. Descriptive norms were associated with non-barrier methods among peers (aOR 2.57, 95% CI: 1.63, 4.96) but not among older women in the family (aOR: 1.22, 95% CI 0.80, 1.88). There were no associations among contraceptive communication, social norms, and condom use across older women in the family, peers, and partners. The findings highlight the need to consider the influence of social ties in the design of future family planning interventions and suggest that interventions that encourage interpersonal communication about contraception and target peer-based descriptive norms have the potential to impact uptake of non-barrier methods.

Identifying Adolescent Girls and Young Women at High Risk for HIV Acquisition: A Risk Assessment Tool From the Girl Power-Malawi Study

BACKGROUND

Prioritizing HIV prevention for adolescent girls and young women (AGYW) at high risk for HIV acquisition in sub-Saharan Africa (typically considered ≥3 per 100 person-years [PYs]) is urgently needed, but identifying these AGYW is challenging. We sought to assess and, if needed, enhance a risk assessment tool from the VOICE trial for identifying AGYW at high risk for HIV in Lilongwe, Malawi.

METHODS

A multisite prospective cohort study was conducted among sexually active AGYW 15 to 24 years old at 4 health centers in 2016 to 2017. The VOICE tool was first applied and then updated by excluding variables that were not predictive and adding variables that were. Incidence rates (IRs), incidence rate ratios, 95% confidence intervals (CIs), area under the receiver operating characteristic curve (AUC), sensitivity, and specificity were calculated.

RESULTS

Seven hundred ninety-five participants experienced 14 seroconversions for 672 PYs (IR, 2.08 per 100 PYs; 95% CI, 1.23-3.52). The VOICE tool had moderate predictive ability (AUC, 0.64; 95% CI, 0.52-0.75). Maintaining 2 variables (genital ulcers and vaginal discharge), removing 5 sociodemographic variables, and adding 2 variables (ever pregnant and >5-year male-female age gap) enhanced performance (AUC, 0.79; 95% CI, 0.69-0.89). Thirty-five percent had a score of 0, 41% had a score of 1 to 2, and 24% had a score >3. A score >1 resulted in 100% sensitivity, 35.9% specificity, and an IR of 3.25 per 100 PYs. A score >3 resulted in 64.3% sensitivity, 76.8% specificity, and an IR of 5.89 per 100 PYs.

CONCLUSIONS

A simple risk assessment tool identified a subset of AGYW in Malawi at high risk for HIV acquisition who may benefit from biomedical HIV prevention.

Youth engagement in HIV prevention intervention research in sub-Saharan Africa: a scoping review

INTRODUCTION

Youth engagement in HIV research is generally recognized as essential, but often neglected or minimally implemented in practice. Engagement is a process of working collaboratively with diverse groups of people to address common issues. We conducted a scoping review of youth HIV prevention interventions in sub-Saharan Africa to identify and categorize forms and levels of youth engagement across the lifespan of intervention research.

METHODS

We followed Arksey and O'Malley's framework for organizing a scoping review. We searched seven databases for related articles on identified intervention studies through May 28th 2020. Included studies focused on youth (10 to 24 years old) HIV prevention interventions in sub-Saharan Africa. Two reviewers independently examined citations and full manuscripts for inclusion. Data were extracted on study characteristics, location, description of youth engagement and extent of engagement. Youth engagement approaches were categorized based on Hart's ladder as substantial engagement (strong youth decision-making power), moderate engagement (shared decision making with adults), minimal engagement (no youth decision-making power) or no engagement.

RESULTS

We identified 3149 citations and included 112 studies reporting on 74 unique HIV interventions. Twenty-two interventions were in low-income countries, 49 in middle-income countries, and three were in both. Overall, only nine interventions (12%) had substantial or moderate youth engagement, two-thirds (48, 65%) had minimal youth engagement and 17 interventions (23%) had no youth engagement. We also identified specific engagement strategies (e.g. youth-led research, crowdsourcing) that were feasible in multiple settings and resulted in substantial engagement.

CONCLUSIONS

We found limited youth engagement in youth HIV prevention intervention studies in sub-Saharan Africa. However, several activities resulted in substantial youth engagement and could be relevant in many low-and-middle-income-country (LMIC) settings.

Tailoring youth-friendly health services in Nigeria: a mixed-methods analysis of a designathon approach

BACKGROUND

Young people in low- and middle-income countries are often neglected in designing youth-friendly health services, especially HIV testing and preventive services. Designathons, which are time-bounded co-creation events where individuals gather in teams to develop solutions to a problem, could promote youth participation and ownership of health services.

OBJECTIVE

The purpose of this study is to examine youth participation in a designathon to create youth-friendly health services in Nigeria.

METHODS

Our designathon was based on crowdsourcing principles and informed by a human-centered design approach. The designathon included an open call for Nigerian youths between 14 and 24 years to share ideas on how to promote uptake of HIV self-testing services and a three-day sprint event that brought together diverse teams to develop strategies enhancing linkage to care. Teams pitched their solutions to a panel of five independent experts who scored ideas based on the desirability, feasibility, potential impact, and teamwork. We used descriptive statistics to summarize participants' demographics and conducted a content analysis to synthesize themes from youth proposals.

RESULTS

Nine hundred seventy-six youth across Nigeria applied to join the designathon. Forty-eight youth in 13 teams participated in the designathon with a median age of 20 years (IQR: 17-22]. Boys and young men were 48.5% (446/919) of the total applicants, 62.5% (30/48) of the designathon participants, and 63.6% (7/11) of the finalists. Students, from all educational levels, represented 91.2% (841/922) of the total applicants, 88.4% (38/43) of the designathon participants, and 90.0% (9/10) of the finalists. About twenty-three percent (3/13) of the final proposals were top ranked. The three finalist approaches to optimize youth-friendly health services centered on decentralizing service delivery to young people through mobile health technologies, use of mobile tents, or peer support services.

CONCLUSIONS

Our open call engaged diverse groups of Nigerian youth, including young women and students. Our data suggest that designathons may be useful for developing tailored youth-friendly health services. Further research is needed to understand the designathon process and the effectiveness of the finalist submissions.

Socioeconomic Predictors of Transactional Sex in a Cohort of Adolescent Girls and Young Women in Malawi: A Longitudinal Analysis

Transactional sex is associated with incident HIV infection among adolescent girls and young women (AGYW) in sub-Saharan Africa. Evidence on the dimensions of socioeconomic status (SES) which predict transactional sex are mixed and primarily come from cross-sectional studies. This study examined the association between SES and transactional sex in a longitudinal cohort (n = 844) of AGYW ages 15-24 years enrolled in a quasi-experimental study in Lilongwe, Malawi. Prevalence of transactional sex was 22% at baseline, 15% at 6-months and 20% at 12-months. Being divorced or widowed, being food insecure, living in a home without electricity or running water, and having few assets were associated with transactional sex. Higher educational attainment and school enrollment were protective. Having 6-7 socioeconomic risk factors increased odds of transactional sex (AOR = 4.13, 95% CI 2.45, 6.98). Structural interventions which address multiple dimensions of SES may reduce transactional sex and ultimately prevent HIV transmission among AGYW.

HIV risk, risk perception, and PrEP interest among adolescent girls and young women in Lilongwe, Malawi: operationalizing the PrEP cascade

INTRODUCTION

As a user-controlled HIV prevention method, oral pre-exposure prophylaxis (PrEP) holds particular promise for adolescent girls and young women (AGYW). HIV prevention cascades, critical frameworks for the design and evaluation of PrEP programmes, outline the priorities of identifying individuals at greatest HIV risk and motivating them to initiate PrEP through perceived HIV risk. To inform future iterations of these cascades and PrEP delivery for AGYW, the objective of this study was to understand the level of interest in PrEP among AGYW at highest HIV risk, and the potential role of perceived risk in motivating PrEP interest.

METHODS

Using data from a cohort study of HIV-negative AGYW in Lilongwe, Malawi (February 2016 to August 2017), we assessed the relationship between epidemiologic HIV risk (risk index developed in a previous analysis) and PrEP interest, and the extent to which perceived risk explains the relationship between HIV risk and PrEP interest. We further aimed to operationalize the pre-initiation steps of the HIV prevention cascade in the study population.

RESULTS

In total, 825 AGYW were included in analyses, of which 43% met the criterion for high epidemiologic HIV risk. While epidemiologic risk scores were positively associated with PrEP interest, high numbers of AGYW both above and below the high-risk cutoff were very interested in PrEP (68% vs. 63%). Perceived risk partially explained the relationship between HIV risk and PrEP interest; greater epidemiologic HIV risk was associated with high perceived risk, which was in turn associated with PrEP interest. Many more high-risk AGYW were interested in PrEP (68%) than expressed a high level of perceived HIV risk (26%).

CONCLUSIONS

These results highlight key relationships between epidemiologic HIV risk, risk perception and interest in PrEP. While risk perception did partially explain the relationship between epidemiologic risk and PrEP interest, there may be other important motivational mechanisms that are not captured in many HIV prevention cascades. The high number of participants with risk scores below the high-risk cutoff who both expressed high perceived risk and interest in PrEP suggests that demand for PrEP among AGYW may not be well aligned with epidemiologic risk.

Assessing the Impact of a Small-Group Behavioral Intervention on Sexual Behaviors Among Adolescent Girls and Young Women in Lilongwe Malawi: A Quasi-Experimental Cohort Study

Adolescent girls and young women (AGYW) in sub-Saharan Africa are at high risk of many adverse sexual and reproductive health outcomes. Small-group interventions addressing underlying vulnerabilities may influence risky sexual behaviors associated with these adverse outcomes. Girl Power-Malawi assessed whether a facilitator-led, curriculum-driven small-group behavioral intervention impacted risky sexual behaviors among AGYW in Lilongwe, Malawi. Four Health Centers were selected; two were randomly assigned to provide the intervention. Two-hundred fifty AGYW 15-24 years old were enrolled in each clinic (N = 1000 total), followed for 1 year, and interviewed at baseline and endline. At both time points participants reported on two behaviors in the last month (vaginal sex and ≥ 2 sexual partners) and two behaviors in the last year (age-disparate relationships and transactional relationships). In intervention clinics, there were no declines in risk behaviors between baseline and endline. Endline behaviors were not less risky in intervention clinics than control clinics. This intervention did not have a positive effect on four risk behaviors over a 1-year period.

Verification of HIV Self-Testing Use and Results: A Global Systematic Review

HIV self-testing (HIVST) allows individuals to interpret and report their own test results, thus decentralizing testing. Yet, this decentralization can make it difficult to verify self-testing results, which is important for linkage to care and surveillance. The aim of this systematic review is to summarize methods for verifying HIVST use and results. We followed guidance from the Cochrane Handbook 5.1 on systematic reviews. We searched four journal databases (PubMed, Embase, Scopus, and Cochrane Library), one clinical trials database (ClinicalTrials.gov), two conference abstract databases (International AIDS Society and Conference on Retroviruses and Opportunistic Infections) and one gray literature database (OpenGrey). We included studies that verified opening of kits or test results. Two researchers independently screened articles and extracted data regarding HIVST location, method of verification, who performed verification, proportion of results verified, and primary or secondary kit distribution. The search yielded 3853 unique citations, of which 40 contained information on HIVST verification and were included. Among these 40 studies, 13 were in high-income countries, 16 were in middle-income countries, and 11 were in low-income countries. Seventeen studies included key populations and two focused on youth. Three methods verified results: supervision by a health provider, returning used test kits, and electronic transmission of photographs. One method verified opening of kits using Bluetooth sensors. Although HIVST has increased worldwide, strategies to verify self-testing results remain limited. These findings suggest a need for additional innovative strategies for verifying HIVST use and results and linkage of self-testing results to surveillance and care systems.

The relationship between intimate partner violence and probable depression among adolescent girls and young women in Lilongwe, Malawi

This analysis estimates prevalence of intimate partner violence (IPV) and its association with probable depression among adolescent girls and young women (AGYW) in Lilongwe, Malawi, and whether partner's controlling behaviour modifies this relationship. Baseline data was utilised from the Girl Power-Malawi study of 1000 15-24-year-old AGYW in Lilongwe. Emotional, physical, and sexual IPV experiences with a current or recent partner were measured using the modified Conflict Tactics Scale. Probable depression was measured by scoring ≥10 on the Centre for Epidemiologic Studies-Short Depression Scale (CES-D-10). Generalised linear models with log-link and binomial distribution estimated prevalence ratios (PR) and 95% confidence intervals (CI) for the association between IPV types and probable depression. Partner's controlling behaviour was examined as an effect modifier. Participants' mean age was 19.2 years, with 70% never-married. IPV prevalence varied for emotional (59%), physical (36%), sexual (46%), and all forms (20%). Prevalence of probable depression was 47%. AGYW who experienced each IPV type had a higher prevalence of probable depression: physical (PR:1.54, CI:1.28-1.86), sexual (1.46, CI:1.21-1.75), emotional (1.37, CI:1.14-1.64), all forms (1.72, CI:1.41-2.09). IPV and probable depression were prevalent and strongly associated, especially among AGYW reporting controlling behaviour. Interventions addressing IPV and controlling behaviour may positively impact depression among AGYW.

Perceptions of and interest in HIV pre-exposure prophylaxis use among adolescent girls and young women in Lilongwe, Malawi

BACKGROUND

Oral Pre-Exposure Prophylaxis (PrEP) is an effective HIV prevention strategy for adherent users. Adolescent girls and young women (AGYW) in sub-Saharan Africa may particularly benefit from PrEP because of the disproportionate burden of HIV in this group. Understanding potential users' perceptions of and interest in using PrEP is critical to promote the utilization of PrEP by individuals at risk of HIV.

METHODS

This qualitative investigation of AGYW's knowledge of and interest in PrEP use was conducted in the context of Girl Power, a quasi-experimental cohort study comparing four models of service delivery at four health centers in Lilongwe, Malawi. We conducted individual in-depth interviews (IDIs) with 40 HIV-negative AGYW ages 15-24 years old six months after enrolment in the parent study. An explanation of PrEP was provided to participants. Interview topics included participants' prior knowledge of, interest in, concerns about, and delivery preferences for PrEP. Analysis consisted of structural coding of interview transcripts corresponding to interview topics, summary of responses within these topics, and identification and description of emerging themes within each topic.

RESULTS

None of the AGYW had knowledge of PrEP prior to the IDIs, but once explained, a majority expressed an interest in using it due to inconsistencies in condom use, condom use errors, their own or their partners' concurrent sexual partnerships, and rape. Most AGYW hoped that PrEP would be available in youth-friendly sections of health centers for easy access and youth-friendly counselling. They suggested that discrete packaging of PrEP would be needed to ensure user privacy. Concerns about relationship destabilization and accusations of promiscuity were raised as potential barriers to use.

CONCLUSION

General interest in PrEP among AGYW was high. Discrete packaging and access to youth-friendly PrEP delivery modalities may facilitate the utilization of PrEP as a prevention strategy among sexually active AGYW. Attention to potential negative reactions from partners and community members to PrEP use will be needed when introducing PrEP to this population.

Prevalence and correlates of probable depression diagnosis and suicidal ideation among patients receiving HIV care in Lilongwe, Malawi

Background

Depression and suicide ideation among people living with HIV (PLHIV) can threaten the success of HIV care and treatment programs, particularly within high HIV prevalence settings. We describe the prevalence and correlates associated with depression and suicidal ideation among PLHIV receiving HIV care in Lilongwe, Malawi.

Methods

From July to September 2013, 206 HIV clinic patients, who were ≥18 years of age and either pre-antiretroviral therapy (ART) or established on ART for ≥6 months prior to study, participated in a survey to assess the prevalence of a likely depressive disorder and suicidal ideation using the Patient Health Questionnaire-9. We explored factors associated with depression using bivariable linear regression and suicidal ideation using bivariable log-binomial regression.

Results

The prevalence of a likely depressive disorder and suicidal ideation was 12% (95% CI: 8%, 17%) and 16% (95% CI: 11%, 21%), respectively. Pre-ART patients (β=1.17, 95% CI: 0.03, 2.30, p-value=0.04) and those with problematic alcohol use (β=0.49, 95% CI: 0.07, 0.92, p-value=0.02) were associated with a higher depression severity. Suicidal ideation was relatively common (8%, 95% CI: 5%, 13%) among those without a likely depressive disorder and significantly correlated with having no primary, secondary, or tertiary education (β=-1.52, 95% CI: -2.46, -0.59, p-value<0.01).

Conclusions

Interventions that enhance identification and management of depressive disorders and suicidal ideation should be integrated within HIV care clinics in Malawi.

The landscape for HIV pre-exposure prophylaxis during pregnancy and breastfeeding in Malawi and Zambia: A qualitative study

High HIV incidence rates have been observed among pregnant and breastfeeding women in sub-Saharan Africa. Oral pre-exposure prophylaxis (PrEP) can effectively reduce HIV acquisition in women during these periods; however, understanding of its acceptability and feasibility in antenatal and postpartum populations remains limited. To address this gap, we conducted in-depth interviews with 90 study participants in Malawi and Zambia: 39 HIV-negative pregnant/breastfeeding women, 14 male partners, 19 healthcare workers, and 18 policymakers. Inductive and deductive approaches were used to identify themes related to PrEP. As a public health intervention, PrEP was not well-known among patients and healthcare workers; however, when it was described to participants, most expressed positive views. Concerns about safety and adherence were raised, highlighting two critical areas for community outreach. The feasibility of introducing PrEP into antenatal services was also a concern, especially if introduced within already strained health systems. Support for PrEP varied among policymakers in Malawi and Zambia, reflecting the ongoing policy discussions in their respective countries. Implementing PrEP during the pregnancy and breastfeeding periods will require addressing barriers at the individual, facility, and policy levels. Multi- level approaches should be considered in the design of new PrEP programs for antenatal and postpartum populations.

What interventions are effective in improving uptake and retention of HIV-positive pregnant and breastfeeding women and their infants in prevention of mother to child transmission care programmes in low-income and middle-income countries? A systematic review and meta-analysis

OBJECTIVE

This review was conducted to identify interventions effective in improving uptake and retention of HIV-positive mothers and their infants in prevention of mother to child transmission (PMTCT) services in low-income and middle-income countries (LMICs) in order to inform programme planning.

METHODS

We conducted a systematic review of studies comparing usual care with any intervention to improve uptake and retention of HIV-positive pregnant or breastfeeding women and their children from birth to 2 years of age in PMTCT services in LMICs. Twenty-two electronic databases were searched from inception to 15 January 2018, for randomised, quasi-randomised and non-randomised controlled trials, and interrupted time series studies; reference lists of included articles were searched for relevant articles. Risk of bias was assessed using the Cochrane Effective Practice and Organisation of Care group criteria. Random-effects meta-analysis was conducted for studies reporting similar interventions and outcomes.

RESULTS

We identified 29 837 articles, of which 18 studies were included in our review. Because of heterogeneity in interventions and outcome measures, only one meta-analysis of two studies and one outcome was conducted; we found a statistically significant increase in antiretroviral therapy (ART) use during pregnancy for integration of HIV and antenatal care relative to standard non-integrated care (pooled AOR=2.69; 95% CI 1.25 to 5.78, p=0.0113). The remaining studies assessing other patient, provider or health system interventions were synthesised narratively, with small effects seen across intervention categories for both maternal and infant PMTCT outcomes based predominately on evidence with moderate to high risk of bias.

CONCLUSIONS

Evidence on the effectiveness of interventions to improve uptake and retention of mothers and infants in PMTCT care is lacking. Our findings suggest that integration of HIV and antenatal care may improve ART use during pregnancy. Future studies to replicate promising approaches are needed. Improved reporting of key methodological criteria will facilitate interpretation of findings and improve the utility of evidence to PMTCT programme planners.

PROSPERO REGISTRATION NUMBER

CRD42015020829.

Perspectives on HIV partner notification, partner HIV self-testing and partner home-based HIV testing by pregnant and postpartum women in antenatal settings: a qualitative analysis in Malawi and Zambia

INTRODUCTION

HIV testing male partners of pregnant and postpartum women can lead to improved health outcomes for women, partners and infants. However, in sub-Saharan Africa, few male partners get HIV tested during their partner's pregnancy in spite of several promising approaches to increase partner testing uptake. We assessed stakeholders' views and preferences of partner notification, home-based testing and secondary distribution of self-test kits to understand whether offering choices for partner HIV testing may increase acceptability.

METHODS

Interviewers conducted semi-structured interviews with HIV-negative (N = 39) and HIV-positive (N = 41) pregnant/postpartum women, male partners of HIV-negative (N = 14) and HIV-positive (N = 14) pregnant/postpartum women, healthcare workers (N = 19) and policymakers (N = 16) in Malawi and Zambia. Interviews covered views of each partner testing approach and preferred approaches; healthcare workers were also asked about perceptions of a choice-based approach. Interviews were transcribed, translated and analysed to compare perspectives across country and participant types.

RESULTS

Most participants within each stakeholder group considered all three partner testing strategies acceptable. Relationship conflict was discussed as a potential adverse consequence for each approach. For partner notification, additional barriers included women losing letters, being fearful to give partners letters, being unable to read and men refusing to come to the clinic. For home-based testing, additional barriers included lack of privacy or confidentiality and fear of experiencing community-level HIV stigma. For HIV self-test kits, additional barriers included lack of counselling, false results and poor linkage to care. Preferred male partner testing options varied. Participants preferred partner notification due to their respect for clinical authority, home-based testing due to their desire to prioritize convenience and clinical authority, and self-test kits due to their desire to prioritize confidentiality. Less than half of couples interviewed selected the same preferred male partner testing option as their partner. Most healthcare workers felt the choice-based approach would be acceptable and feasible, but noted implementation challenges in personnel, resources or space.

CONCLUSIONS

Most stakeholders considered different approaches to partner HIV testing to be acceptable, but concerns were raised about each. A choice-based approach may allow women to select their preferred method of partner testing; however, implementation challenges need to be addressed.

Enhancing an HIV index case testing passive referral model through a behavioural skills-building training for healthcare providers: a pre-/post-assessment in Mangochi District, Malawi

INTRODUCTION

Although knowledge of HIV positivity is a necessary step towards engagement in HIV care, more than one quarter of HIV-positive Malawians remain unaware of their HIV status. Testing the sexual partners, guardians and children of HIV-positive persons (index case finding or ICF) is a promising way of identifying HIV-positive persons unaware of their HIV status. ICF can be passive where the HIV-positive individual (index) invites a partner (or contact) for HIV testing or active where a health provider assists the index with partner notification and offers HIV testing to the partner. Strategies to improve passive ICF have not been thoroughly studied. We describe the impact of a behavioural skills-building training to enhance healthcare workers' (HCWs) implementation of Malawi's passive ICF programme.

METHODS

In June 2017, HCWs from 36 health facilities in Mangochi were oriented to Malawi's ICF programme and began implementation. In February and April 2018, a total of 573 HCWs from these facilities received further training from the Tingathe Programme. The training focused on eliciting more untested sexual contacts from indexes and better equipping indexes on issuing "family referral slips" to contacts. Monthly programmatic data were abstracted from clinical registers from October 2017 to July 2018. Monthly programmatic indicators were collected from the Index Case Testing Register and the HIV Counselling and Testing Register and were entered into a data set with one record per facility per month. T-tests were used to compare the means of these indicators.

RESULTS

During the ten-month study period, there were 200 facility-months observed before and 124 facility-months observed after training. The mean number of indexes identified per facility-month remained stable after training (pre = 18.9, post = 21.2, p = 0.74), but the mean number of sexual partners listed per facility-month (pre = 6.3, post = 10.6, p < 0.001) increased. The mean number of contacts who received HIV testing (pre = 11.1, post = 24.8, p < 0.001) and the mean number of HIV-positive contacts identified per facility-month (pre = 1.3, post = 2.3, p < 0.001) also increased.

CONCLUSIONS

A brief behavioural skills-building training impacted a range of meaningful outcomes, including identification of HIV-positive individuals in a passive ICF programme. Such approaches could facilitate the identification of HIV-positive persons unaware of their HIV status, a necessary step for engagement in HIV care.

Female adherence self-efficacy before and after couple HIV testing and counseling within Malawi's Option B+ program

Adherence self-efficacy, belief in one's ability to adhere to daily medication, is strongly associated with antiretroviral therapy (ART) adherence and preventing mother-to-child HIV transmission. Couple-based interventions could enhance self-efficacy and adherence. We assessed the relationship between couple HIV testing and counseling (cHTC) and adherence self-efficacy using a 100-point culturally-adapted adherence self-efficacy scale (ASES). Secondarily, we explored the relationship between ASES and ART adherence. Ninety HIV-positive pregnant women at an antenatal clinic in Lilongwe, Malawi were enrolled in an observational cohort study. They were assessed with ASES immediately before and one month after receiving cHTC. Median ASES scores were 100 (IQR 95, 100) before and 100 (IQR 99, 100) after cHTC; there was a significant median difference (p = 0.02) for participants before and after cHTC. This change in ASES scores was associated with the odds of self-reported ART adherence in the full population (OR 1.1, p = 0.01), and there was a trend in the same direction for participants with imperfect baseline ASES scores (OR 1.1, p = 0.2). In our population, adherence self-efficacy and ART adherence were both quite high, and those who had room to improve in self-efficacy may have benefited from cHTC, which in turn could impact ART adherence and ultimately mother-to-child transmission.

Ethical issues raised by cluster randomised trials conducted in low-resource settings: identifying gaps in the Ottawa Statement through an analysis of the PURE Malawi trial

The increasing use of cluster randomised trials in low-resource settings raises unique ethical issues. The Ottawa Statement on the Ethical Design and Conduct of Cluster Randomised Trials is the first international ethical guidance document specific to cluster trials, but it is unknown if it adequately addresses issues in low-resource settings. In this paper, we seek to identify any gaps in the Ottawa Statement relevant to cluster trials conducted in low-resource settings. Our method is (1) to analyse a prototypical cluster trial conducted in a low-resource setting (PURE Malawi trial) with the Ottawa Statement; (2) to identify ethical issues in the design or conduct of the trial not captured adequately and (3) to make recommendations for issues needing attention in forthcoming revisions to the Ottawa Statement Our analysis identified six ethical aspects of cluster randomised trials in low-resource settings that require further guidance. The forthcoming revision of the Ottawa Statement should provide additional guidance on these issues: (1) streamlining research ethics committee review for collaborating investigators who are affiliated with other institutions; (2) the classification of lay health workers who deliver study interventions as health providers or research participants; (3) the dilemma experienced by investigators when national standards seem to prohibit waivers of consent; (4) the timing of gatekeeper engagement, particularly when researchers face funding constraints; (5) providing ancillary care in health services or implementation trials when a routine care control arm is known to fall below national standards and (6) defining vulnerable participants needing protection in low-resource settings.

Women's views about contraception requirements for biomedical research participation

The scientific and ethical importance of including women of reproductive age in biomedical research is widely acknowledged. Concerns about preventing fetal exposure to research interventions have motivated requirements for contraception among reproductive aged women in biomedical studies-often irrespective of risks and benefits or a woman's actual potential for pregnancy, raising important questions about when such requirements are appropriate. The perspectives of women themselves on these issues are largely unexplored. We conducted 140 interviews, 70 in the U.S. and 70 in Malawi, with women either living with or at-risk for HIV, exploring their views about the practice of requiring contraception in clinical trials. A majority of women interviewed from both countries indicated overall support for the practice, with seven themes characterizing advantages and disadvantages raised: reproductive control, health effects, prevention of fetal harm, burden on women, deferral to authority, autonomy regarding enrollment and birth control method, and relationship concerns. While women in the US frequently raised prevention of fetal harm as a key advantage, many other positives noted by women in both countries were related to contraception use in general, not specific to a trial context. With regard to disadvantages, U.S. women tended to focus on biomedical risks such as side effects and impact on fertility, whereas Malawian women focused on the social risks of contraception requirements, including violations of trust in marital relations and suspicions of potential infidelity. Given the potential benefits and burdens highlighted, contraception in research should be sensitive to actual fetal risk assessments; directed where justified at optimizing effective pregnancy prevention; responsive to women's reproductive preferences; and made available as an ancillary benefit even where risk thresholds do not justify requirement-in order to facilitate trials that are both ethical and robustly oriented around the interests and lives of women who will participate in them.

Exploring the spatial relationship between primary road distance to antenatal clinics and HIV prevalence in pregnant females of Lilongwe, Malawi

While urbanization in a sub-Saharan African (SSA) context can lead to greater independence in women, various sociological, biological, and geographical factors in urban areas may keep women at a higher risk for HIV than men. Access to major roads during Malawi's transition into rapid urbanization may leave women disproportionately vulnerable to HIV infection. It is not well established whether women who report to health clinics closer to major roads have higher or lower levels of HIV. In this study we explored the spatial heterogeneity of HIV prevalence among pregnant females in Lilongwe District, Malawi. Using Geographic Information Systems, we visually represented patterns of HIV prevalence in relation to primary roads. HIV prevalence data for 2015 were obtained from 44 antenatal clinics (ANC) in Lilongwe District. ANC prevalence data were aggregated to the administrative area and mapped. Euclidean distance between clinics and two primary roads that run through Lilongwe District were measured. A correlation was run to assess the relationship between area-level ANC HIV prevalence and clinic distance to the nearest primary road. ANC HIV prevalence ranged from 0% to 10.3%. Clinic to major road distance ranged from 0.1 to 35 km. Correlation results ( r= -0.622, p = 0.002) revealed a significant negative relationship between clinic distance to primary road and HIV prevalence, indicating that the farther the clinics stood from primary roads, the lower the reported antenatal HIV prevalence. Overall, the clinic catchments through which the major roads run reported higher ANC HIV prevalence. Antenatal HIV prevalence decreases as ANC distance from primary roads increases in Lilongwe, Malawi. As urbanization continues to grow in this region, road distance may serve as a good indicator of HIV burden and help to guide targeted prevention and treatment efforts.

The impact of HIV couple testing and counseling on social support among pregnant women and their partners in Lilongwe, Malawi: an observational study

Couples HIV testing and counseling (couple counseling) promotes safer sexual behaviors, increases communication between couples, and decreases HIV transmission. However, the impact of couple counseling on social support, critical for persons living with HIV, has not been examined. Ninety couples with a recently tested HIV-positive pregnant woman (female-positive couples) and 47 couples with a recently tested HIV-negative pregnant woman (female-negative couples) were enrolled in an observational study at an antenatal clinic in Malawi. Each couple member was assessed immediately before and one month after couple counseling for partner, family, and peer social support using the Multidimensional Scale of Perceived Social Support. Before couple counseling, social support was lower among women than men in both female-positive couples (β = -10.00, p < .01) and female-negative couples (β = -8.43, p  < .01). After couple counseling, social support increased for women in female-positive couples (β = 4.01, p < .01) and female-negative couples (β = 4.69, p < .01) but not for men in either type of couple. Couple counseling could be an effective strategy to increase social support for women, including those with recent HIV diagnoses.

Women's Views About a Paternal Consent Requirement for Biomedical Research in Pregnancy

Clinical research to inform the evidence base to guide nonobstetrical care during pregnancy is critically important for the well-being of women and their future offspring. Conversations about regulations for such research, including whether paternal consent should ever be required, should be informed by the perspectives of those most affected, namely, pregnant women. We conducted in-depth interviews with 140 pregnant women living with or at risk of HIV-70 in Malawi, 70 in the United States-exploring their views on requiring paternal consent for pregnant women's participation in trials offering the prospect of direct benefit solely to the fetus. The majority of women supported such a requirement; others raised concerns. A trio of themes-the father's or pregnant woman's rights, fetal protection, and gender/relationship dynamics-characterized views both supporting and against a paternal consent requirement, expanding the range of considerations that should inform approaches to paternal involvement in research with pregnant women.

Utilization of fine needle aspiration cytology at Kamuzu central hospital

Background

Fine needle aspiration cytology (FNAC) has been widely accepted to be a safe, accurate, prompt and inexpensive procedure for diagnosis of both neoplastic and infectious diseases in adult and pediatric populations. Despite its value for diagnosis, FNAC is underutilized in resource limited countries. We reviewed the utilization of FNAC after it was introduced at Kamuzu Central Hospital (KCH).

Methods

A retrospective review of all FNAC performed at KCH laboratory during the period of January 2012 to July 2014 was conducted using an electronic database from KCH laboratory. We evaluated factors associated with a diagnostic sample using multivariate logistic regression model.

Results

750 FNAC were reviewed from 722 patients: 56.9% were adults >15 years and 54% were female. The number of FNAC increased annually from 56 (2012) to 379 (2013) to 315 (up to July 2014). Of 750 FNAC, 56.4% were performed by non-pathologists. The most common sites were lymph nodes (38.1%), abdomen (25.8%), breast (16.3%), and head & neck (15.7%). Most of the samples (77.6%) were diagnostic. FNAC was more likely to be diagnostic if performed by pathologists versus non-pathologists (OR 1.78, 95% CI 1.20–2.64), in 2013 compared to 2012 (OR 1.95, 95% CI 1.05–3.56), or performed on a deep lesion versus a subcutaneous lesion (OR 1.71, 95% CI 1.15–2.5), or if samples were taken from the head and neck (OR 2.4, 95% CI: 1.39–4.39), and abdomen (OR 2.66, 95%CI1.59–4.42) compared to those from the lymph nodes. The odds of a diagnostic test did not differ significantly according to gender, HIV status, or age groups.

Conclusion

Most FNACs successfully diagnosed the presence or absence of disease, with substantial improvements over time. However, training for non-pathologists may facilitate more diagnostic results.

Individual, Partner, and Couple Predictors of HIV Infection among Pregnant Women in Malawi: A Case-Control Study

We aimed to understand drivers of HIV-infection in pregnant women in Malawi. The study was conducted in antenatal and labor and delivery wards. HIV-infected women and their partners (cases) were frequency matched in a 1:2 ratio based on age and screening location to HIV-uninfected women and their partners (controls) in a prevalent case-control study. Characteristics associated with female HIV infection were assessed using logistic regression modeling. At screening, HIV-infected women were more likely to have partners outside Lilongwe than HIV-uninfected women (24% vs. 0%, p < 0.0001). Case females were more likely to have HIV-infected study partners than control females (75% vs. 4%, p < 0.0001). The odds of female HIV-infection were higher if either couple member reported ≥ 2 lifetime marriages (OR 9.0, CI 2.6-30.9) or ≥ 3 lifetime partners (OR 18.0, CI 3.1-103.6) and lower if either reported past couple HIV testing and counseling (OR 0.1, CI 0.04-0.3). Targeting women with migrating partners, promoting couple HIV testing and counseling, and limiting partners could slow HIV transmission.