Intravaginal Practices among a Cohort of Rural Malawian Women

Background:

Intravaginal practices (IVP) are highly prevalent and commonly performed in many countries for a variety of purposes related to genital health, hygiene and sexual pleasure. However, IVP may also have harmful side effects, including associations with bacterial vaginosis and HIV.

Methods:

The prevalence and motivations for IVP among 650 women participating in the baseline survey of a community-based cohort study on sexual and reproductive health in rural Lilongwe District, Malawi, were characterised. Key variables included the type and frequency of IVP, and motivations for engaging in IVP.

Results:

Most women (95%) had engaged in IVP in the past 30 days: 88% reported internal vaginal cleansing with water only, 87% reported cleansing with soap and water, and 84% reported inserting cotton, cloth or tissue. A majority (60%) reported at least three practices. Very frequent engagement in at least one type of IVP was also common; among those who inserted cotton, cloth or tissue, 43% did so more than once a day; among those who cleansed internally with soap and water, 51% did so more than once a day. Women reported many reasons for using IVP. The most commonly reported reasons were to remove odours (91%), to remove extra moisture (58%), to prevent disease (49%), to relieve symptoms of disease (41%) and to improve sex for a partner (40%).

Conclusion:

IVP are highly prevalent and frequently performed among these rural Malawian women. Future research should investigate the associations between IVP and sexually transmissible infection prevalence.

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By:  Allahna Esber A D, Abigail Norris Turner B, Gladson Mopiwa C and Alison H. Norris A B 

A Division of Epidemiology, The Ohio State University, 1841 Neil Avenue, Columbus, OH 43210, USA. B Division of Infectious Diseases, Department of Internal Medicine, The Ohio State University, 410 W. 10th Columbus, OH 43210, USA. C Child Legacy International, Umoyo wa Thanzi Research, P.O.Box 1927, Lilongwe, Malawi. D Corresponding author. Email: esber.8@osu.edu 

Sex Health. 2016 Apr 14. doi: 10.1071/SH15139.

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Exposure to Violence & Psychological Well-Being Over Time in Children Affected by HIV/AIDS in South Africa & Malawi

Many of the risk factors for violence against children are particularly prevalent in families and communities affected by HIV/AIDS. Yet, in sub-Saharan Africa, where HIV rates are high, efforts to prevent or address violence against children and its long-lasting effects are hampered by a lack of evidence. 

We assessed the relationship between violence exposure and mental health among HIV-affected children attending community-based organisations in South Africa (n = 834) and Malawi (n = 155, total sample n = 989) at baseline and 12-15-month follow-up. Exposure to violence in the home and in the community was high. HIV-negative children who lived with an HIV-positive person experienced most violence overall, followed by HIV-positive children. Children unaffected by HIV experienced least violence (all p < .05). 

Interpersonal violence in the home predicted child depression, trauma symptoms, lower self-esteem, and internalising and externalising behavioural problems, while exposure to community violence predicted trauma symptoms and behavioural problems. Harsh physical discipline predicted lower self-esteem and behavioural problems for children. Exposure to home and community violence predicted risk behaviour. Over time, there was a decrease in depressed mood and problem behaviours, and an increase in self-esteem for children experiencing different types of violence at baseline. This may have been due to ongoing participation in the community-based programme. 

These data highlight the burden of violence in these communities and possibilities for programmes to include violence prevention to improve psychosocial well-being in HIV-affected children.

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By:  Skeen S1,2, Macedo A3, Tomlinson M1, Hensels IS3, Sherr L3.

• 1 Department of Psychology , Stellenbosch University , Stellenbosch , South Africa.
• 2 Department of Psychiatry and Mental Health , University of Cape Town , Cape Town , South Africa.
• 3 Department of Infection and Population Health , University College London , London , UK.
• AIDS Care. 2016 Mar;28 Suppl 1:16-25. doi: 10.1080/09540121.2016.1146219.

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Reproductive Intentions & Family Planning Practices of Pregnant HIV-Infected Malawian Women on Antiretroviral Therapy

The objective of this study was to describe the pregnancy intentions of pregnant HIV-infected Malawian women on antiretroviral therapy (ART) for at least 6 months prior to the current pregnancy, and to assess whether time on ART was associated with pregnancy intention. 

We conducted a cross-sectional analysis of HIV-infected Malawian women receiving antenatal care at a government hospital with a survey assessing ART history, reproductive history, and family planning use at conception. We used Pearson's chi-square tests and Fisher's exact tests to compare these parameters between women on ART greater than 24 months with those on ART less than 24 months. Modified Poisson regression was performed to assess the association between time on ART and pregnancy intention. 

Most women (75%) reported that their current pregnancy was unintended, defined as either Mistimed (21%) or Unwanted (79%). Women on ART for longer than 2 years were more likely to report an unintended pregnancy (79% versus 65%, p = .03), though there was no significant association between time on ART and pregnancy intention in multivariate analysis. Most women (79%) were using contraception at the time of conception, with condoms being most popular (91%), followed by injectables (9%) and the implant (9%). 

HIV-infected women on ART continue to experience high rates of unintended pregnancy in the Option B+ era. As Option B+ continues to be implemented in Malawi and increasing numbers of HIV-infected women initiate lifelong ART, ensuring that the most effective forms of contraception are accessible is necessary to decrease unintended pregnancy.

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By:  O'Shea MS1, Rosenberg NE1,2,3, Tang JH1,4,5, Mukuzunga C1, Kaliti S6, Mwale M6, Hosseinipour MC1,2,3.

• 1a UNC Project-Malawi , Lilongwe , Malawi.
• 2b UNC Institute of Global Health & Infectious Diseases , Chapel Hill , NC , USA.
• 3c Department of Medicine , University of North Carolina , Chapel Hill , NC , USA.
• 4d Department of Obstetrics & Gynecology , University of North Carolina , Chapel Hill , NC , USA.
• 5e Department of Obstetrics & Gynaecology , Malawi College of Medicine , Blantyre , Malawi.
• 6f Bwaila Hospital, Lilongwe District Health Office , Lilongwe , Malawi. 

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Changing Attitudes & Beliefs Towards a Woman's Right to Protect Against HIV Risk in Malawi

Female empowerment and positive attitudes towards women's rights in sexual relationships have been found to be key elements of successful behaviour-based HIV prevention programmes. However, HIV prevention programmes that do not specifically engage with gender issues may also affect attitudes and beliefs towards women's rights within sexual relationships. 

Using data from the Malawi Longitudinal Study of Families and Health we compare measures of female empowerment and changing gender norms between intervention participants and non-participants. 

Results suggest that female intervention participants were more likely than non-participants to believe that: 

1. women have more rights within sexual relationships in general and 
2. women have the right to protect themselves against HIV risk (indicating possible increases in female self-efficacy in making HIV prevention decisions). 

Male intervention participants showed no substantial positive change in attitudes towards women's rights. 

These results highlight an important positive effect of HIV prevention programmes on women's attitudes towards their own rights.

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By:  Fedor TM1, Kohler HP2, McMahon JM1.

• 1 School of Nursing, University of Rochester Medical Center , Rochester , USA.
• 2 Population Studies Center, University of Pennsylvania , Philadelphia , USA. 
• Cult Health Sex. 2016 Apr;18(4):435-52. doi: 10.1080/13691058.2015.1090016. Epub 2015 Oct 27.

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Cost & Quality of Life Analysis of HIV Self-Testing & Facility-Based HIV Testing & Counselling in Blantyre, Malawi

BACKGROUND:

HIV self-testing (HIVST) has been found to be highly effective, but no cost analysis has been undertaken to guide the design of affordable and scalable implementation strategies.

METHODS:

Consecutive HIV self-testers and facility-based testers were recruited from participants in a community cluster-randomised trial ( ISRCTN02004005 ) investigating the impact of offering HIVST in addition to facility-based HIV testing and counselling (HTC). Primary costing studies were undertaken of the HIVST service and of health facilities providing HTC to the trial population. Costs were adjusted to 2014 US$ and INT$. Recruited participants were asked about direct non-medical and indirect costs associated with accessing either modality of HIV testing, and additionally their health-related quality of life was measured using the EuroQol EQ-5D.

RESULTS:

A total of 1,241 participants underwent either HIVST (n = 775) or facility-based HTC (n = 446). The mean societal cost per participant tested through HIVST (US$9.23; 95 % CI: US$9.14-US$9.32) was lower than through facility-based HTC (US$11.84; 95 % CI: US$10.81-12.86). Although the mean health provider cost per participant tested through HIVST (US$8.78) was comparable to facility-based HTC (range: US$7.53-US$10.57), the associated mean direct non-medical and indirect cost was lower (US$2.93; 95 % CI: US$1.90-US$3.96). The mean health provider cost per HIV positive participant identified through HIVST was higher (US$97.50) than for health facilities (range: US$25.18-US$76.14), as was the mean cost per HIV positive individual assessed for anti-retroviral treatment (ART) eligibility and the mean cost per HIV positive individual initiated onto ART. In comparison to the facility-testing group, the adjusted mean EQ-5D utility score was 0.046 (95 % CI: 0.022-0.070) higher in the HIVST group.

CONCLUSIONS:

HIVST reduces the economic burden on clients, but is a costlier strategy for the health provider aiming to identify HIV positive individuals for treatment. The provider cost of HIVST could be substantially lower under less restrictive distribution models, or if costs of oral fluidHIV test kits become comparable to finger-prick kits used in health facilities.

Below:  Linkage into HIV treatment after HIV testing in those eligible for assessment

Full article at:  http://goo.gl/29z9aF

By:  Maheswaran H1,2, Petrou S3, MacPherson P4,5, Choko AT6, Kumwenda F6, Lalloo DG6,5, Clarke A3, Corbett EL6,7.

• 1Division of Health Sciences, University of Warwick Medical School, Gibbet Hill Campus, Coventry, CV4 7AL, UK. H.Maheswaran@warwick.ac.uk.
• 2Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi. H.Maheswaran@warwick.ac.uk.
• 3Division of Health Sciences, University of Warwick Medical School, Gibbet Hill Campus, Coventry, CV4 7AL, UK.
• 4Department of Public Health and Policy, University of Liverpool, Liverpool, Merseyside, L69 3BX, UK.
• 5Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, L3 5QA, UK.
• 6Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
• 7London School of Hygiene and Tropical Medicine, London, UK. 
• BMC Med. 2016 Feb 19;14(1):34. doi: 10.1186/s12916-016-0577-7.

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Substance Use and HIV Infection Awareness among HIV-Infected Female Sex Workers in Lilongwe, Malawi

Highlights

• Over half of HIV-infected FSW reported hazardous, harmful, or dependent alcohol use
• Increased alcohol use was associated with lack of HIV infection awareness
• Marijuana use was uncommon among HIV-infected FSW

Abstract

Background

HIV diagnosis, the first step in HIV care and treatment engagement, may be inhibited by substance use among female sex workers (FSW). We assessed the relationship between alcohol and marijuana use and lack of HIV infection awareness among HIV-infected FSW in Lilongwe, Malawi.

Methods

From July to September, 2014, 200 FSW aged ≥18 years were enrolled using venue-based sampling to examine substance use, HIV testing history, and serostatus ascertained by HIV rapid test. We used Poisson regression with robust variance estimates to estimate the associations of alcohol and marijuana use and lack of HIV infection awareness.

Results

Of the 138 HIV-infected FSW, 20% were unaware of their HIV infection, with 70% not testing within 6 months prior. According to the Alcohol Use Disorder Identification Tests (AUDIT), 55% of FSW unaware of their HIV infection reported hazardous, harmful, or dependent alcohol consumption. We observed a dose-response relationship between alcohol use and lack of HIV infection awareness, with alcohol dependency significantly associated with lack of HIV infection awareness (adjusted prevalence ratio: 3.0, 95% CI: 1.3, 6.8). Current marijuana use was uncommon (26%) among unaware HIV-infected FSW and weakly associated with lack of HIV infection awareness adjusted prevalence ratio: 1.1, 95% CI: 0.5, 2.5).

Conclusion

Increased levels of alcohol use is associated with lack of HIV infection awareness among HIV-infected FSW in Malawi. Frequent, consistent HIV testing integrated with alcohol reduction strategies could improve the health and infection awareness of substance-using FSW.

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By:  Kathryn E. Lancaster, Vivian F. Go, Thandie Lungu, Pearson Mmodzi, Mina C. Hosseinipour, Katy Chadwick, Kimberly A. Powers, Brian W. Pence, Irving F. Hoffman, William C. Miller

Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America

Correspondence

Corresponding author. University of North Carolina Institute of Global Health and Infectious Diseases 130 Mason Farm Rd Chapel Hill, NC 27599 USA. Tel.: +919 966 2536; fax: +919 966 6714.

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Why Did I Stop? Barriers and Facilitators to Uptake and Adherence to ART in Option B+ HIV Care in Lilongwe, Malawi

Causes for loss-to-follow-up, including early refusals of and stopping antiretroviral therapy (ART), in Malawi's Option B+ program are poorly understood. 

This study examines the main barriers and facilitators to uptake and adherence to ART under Option B+. In depth interviews were conducted with HIV-infected women who were pregnant or postpartum in Lilongwe, Malawi (N = 65). Study participants included women who refused ART initiation (N = 10), initiated ART and then stopped (N = 26), and those who initiated ART and remained on treatment (N = 29). 

The barriers to ART initiation were varied and included concerns about partner support, feeling healthy, and needing time to think. The main reasons for stopping ART included side effects and lack of partner support. A substantial number of women started ART after initially refusing or stopping ART. 

There were several facilitators for re-starting ART, including encouragement from community health workers, side effects subsiding, decline in health, change in partner, and fear of future sickness. Amongst those who remained on ART, desire to prevent transmission and improve health were the most influential facilitators. Reasons for refusing and stopping ART were varied. ART-related side effects and feeling healthy were common barriers to ART initiation and adherence. 

Providing consistent pre-ART counseling, early support for patients experiencing side effects, and targeted efforts to bring women who stop treatment back into care may improve long term health outcomes.

Below:  Socio-ecological framework to understand barriers and facilitators of uptake and progression through the B+ PMTCT program cascade

Full article at:   http://goo.gl/03peF5

By:  Kim MH1,2, Zhou A3, Mazenga A2, Ahmed S1,2, Markham C4, Zomba G5, Simon K2, Kazembe PN2, Abrams EJ6.

• 1Baylor College of Medicine Department of Pediatrics, Section of Global Health and Retrovirology, Texas Children's Hospital, Houston, Texas, United States of America.
• 2Baylor College of Medicine-Abbott Fund Children's Clinical Centre of Excellence, Lilongwe, Malawi.
• 3Department of Sociology, University of California Los Angeles, Los Angeles, California, United States of America.
• 4Health Promotion and Behavioral Sciences, The University of Texas School of Public Health, Houston, Texas, United States of America.
• 5HIV Unit, Malawi Ministry of Health, Lilongwe, Malawi.
• 6ICAP, Mailman School of Public Health and College of Physicians & Surgeons, Columbia University, New York, New York, United States of America. 

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The Effect of Peers on HIV Infection Expectations among Malawian Adolescents

Malawian adolescents overestimate their HIV infection risk. Understanding why they do so is important since such overestimation is likely to be linked to later-life outcomes. 

This study focuses on the influence peers have on HIV infection expectations. I use novel school-based survey data collected in Malawi between October 2011 and March 2012 (n = 7910), which has more reliable measures of peers' HIV infection expectations than other studies. I employ a combined instrumental variables/fixed effects methodology designed to addresses several methodological challenges in estimating peer effects, including self-selection of friends, the issue of unobserved environmental confounders, and the bi-directionality of peer effects. Several tests are conducted in order to assess the robustness of the specifications. 

Results suggest that a one-percentage-point increase in the mean probabilistic expectation of HIV infection among peers increases an adolescent's own subjective expectation of infection by an average of 0.65 percentage points. 

This paper shows that peer influence is greater for males than for females. Results also suggest that the peer effects on HIV infection expectations are only statistically significant among those lacking more complete knowledge of HIV/AIDS.

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By:  Kim J1.

• 1Department of Sociology, University of Wisconsin-Madison, 1180 Observatory Drive, Madison, WI 53706, USA. Electronic address: jinhokim@ssc.wisc.edu.
• Soc Sci Med. 2016 Jan 26;152:61-69. doi: 10.1016/j.socscimed.2016.01.036.

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Surprising Results: HIV Testing & Changes in Contraceptive Practices among Young Women in Malawi

This study uses eight waves of data from the population-based Tsogolo la Thanzi study (2009-2011) in rural Malawi to examine changes in young women's contraceptive practices, including the use of condoms, non-barrier contraceptive methods and abstinence, following positive and negative HIV tests. 

The analysis factors in women's prior perceptions of their HIV status that may already be shaping their behaviour and separates surprise HIV test results from those that merely confirm what was already believed. Fixed-effects logistic regression models show that HIV testing frequently affects the contraceptive practices of young Malawian women, particularly when the test yields an unexpected result. Specifically, women who are surprised to test HIV positive increase their condom use and are more likely to use condoms consistently. 

Following an HIV-negative test (whether a surprise or expected), women increase their use of condoms and decrease their use of non-barrier contraceptives; the latter may be due to an increase in abstinence following a surprise negative result. Changes in condom use following HIV testing are robust to the inclusion of potential explanatory mechanisms, including fertility preferences, relationship status and the perception that a partner is HIV positive. 

The results demonstrate that both positive and negative tests can influence women's sexual and reproductive behaviours, and emphasize the importance of conceptualizing of HIV testing as offering new information only insofar as results deviate from prior perceptions of HIV status.

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By:  Sennott C1, Yeatman S2.

• 1*Department of Sociology, Purdue University,West Lafayette, Indiana,USA.
• 2†Department of Health and Behavioral Sciences,University of Colorado Denver,Denver,Colorado,USA. 

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The HIV Care Continuum among Female Sex Workers: A Key Population in Lilongwe, Malawi

OBJECTIVE:

The HIV care continuum among female sex workers (FSW), a key population, has not been well characterized, especially within the generalized epidemics of sub-Saharan Africa. This was the first study to characterize the HIV care continuum among FSW in Lilongwe, Malawi.

METHODS:

From July through September 2014, we used venue-based sampling to enroll 200 adult FSW in Lilongwe, Malawi into a cross-sectional evaluation assessing HIV care continuum outcomes. Seropositive FSW, identified using HIV rapid testing, received rapid CD4 counts in addition to viral loads using dried blood spots. We calculated proportions of HIV-infected FSW who had history of care, were on ART, and had suppressed viral load and we used Poisson regression to estimate the associations of demographic characteristics and transmission risk behaviors with each outcome.

RESULTS:

HIV seroprevalence was 69% (n = 138). Among all FSW the median age was 24 years (IQR: 22-28). Among the 20% who were newly diagnosed and reported previously testing negative, the median time since last HIV test was 11 months (interquartile range: 3-17). The majority (69%) of HIV-infected FSW had a history of HIV care, 52% reported current ART use, and 45% were virally suppressed. Of the FSW who reported current ART use, 86% were virally suppressed. Transmission risk behaviors were not associated with continuum outcomes.

CONCLUSIONS:

FSW in Lilongwe were predominately young and have a high HIV prevalence. Only half of HIV-infected FSW reported current ART use, but the majority of those on ART were virally suppressed. To reduce ongoing transmission and improve health outcomes, increased HIV testing, care engagement, and ART coverage is urgently needed among FSW. Universal testing and treatment strategies for all FSW in Malawi must be strongly considered.

Below:  HIV Care Continuum among HIV-infected female sex workers, Lilongwe, Malawi

Full article at:   http://goo.gl/tszQCR

By:  Lancaster KE1,2, Powers KA1, Lungu T3, Mmodzi P3, Hosseinipour MC3,2, Chadwick K4, Go VF5, Pence BW1, Hoffman IF3,2, Miller WC1,2.

• 1Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
• 2Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
• 3UNC Project Malawi, University of North Carolina at Chapel Hill, Lilongwe, Malawi.
• 4Theatre for a Change, Lilongwe, Malawi.
• 5Department of Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
• PLoS One. 2016 Jan 25;11(1):e0147662. doi: 10.1371/journal.pone.0147662. eCollection 2016. 

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