Provider-led community antiretroviral therapy distribution in Malawi: Retrospective cohort study of retention, viral load suppression and costs

BACKGROUND

Outcomes of community antiretroviral therapy (ART) distribution (CAD), in which provider-led ART teams deliver integrated HIV services at health posts in communities, have been mixed in sub-Saharan African countries. CAD outcomes and costs relative to facility-based care have not been reported from Malawi.

METHODS

We performed a retrospective cohort study in two Malawian districts (Lilongwe and Chikwawa districts), comparing CAD with facility-based ART care. We selected an equal number of clients in CAD and facility-based care who were aged >13 years, had an undetectable viral load (VL) result in the last year and were stable on first-line ART for ≥1 year. We compared retention in care (alive and no period of ≥60 days without ART) using Kaplan-Meier survival analysis and Cox regression and maintenance of VL suppression (<1,000 copies/mL) during follow-up using logistic regression. We also compared costs (in US$) from the health system and client perspectives for the two models of care. Data were collected in October and November 2020.

RESULTS

700 ART clients (350 CAD, 350 facility-based) were included. The median age was 43 years (IQR 36-51), median duration on ART was 7 years (IQR 4-9), and 75% were female. Retention in care did not differ significantly between clients in CAD (89.4% retained) and facility-based care (89.3%), p = 0.95. No significant difference in maintenance of VL suppression were observed between CAD and facility-based care (aOR: 1.24, 95% CI: 0.47-3.20, p = 0.70). CAD resulted in slightly higher health system costs than facility-based care: $118/year vs. $108/year per person accessing care; and $133/year vs. $122/year per person retained in care. CAD decreased individual client costs compared to facility-based care: $3.20/year vs. $11.40/year per person accessing care; and $3.60/year vs. $12.90/year per person retained in care.

CONCLUSION

Clients in provider-led CAD care in Malawi had very good retention in care and VL suppression outcomes, similar to clients receiving facility-based care. While health system costs were somewhat higher with CAD, costs for clients were reduced substantially. More research is needed to understand the impact of other differentiated service delivery models on costs for the health system and clients.

Malawian caregivers' experiences with HPV vaccination for preadolescent girls: A qualitative study

Introduction

Many low- and middle-income countries have introduced the human papillomavirus (HPV) vaccine, but uptake remains extremely low. Malawi has the second-highest incidence of cervical cancer globally, and launched a national HPV vaccination program in 2019. We sought to understand attitudes about, and experiences with, the HPV vaccine among caregivers of eligible girls in Malawi.

Methods

We conducted qualitative interviews with 40 caregivers (parents or guardians) of preadolescent girls in Malawi to understand their experiences with HPV vaccination. We coded the data informed by the Behavioural and Social Drivers of vaccine uptake model and recommendations from WHO's Strategic Advisory Group of Experts Working Group on Vaccine Hesitancy.

Results

In this sample, 37% of age-eligible daughters had not received any HPV vaccine doses, 35% had received 1 dose, 19% had received 2 doses, and 10% had an unknown vaccination status. Caregivers were aware of the dangers of cervical cancer, and understood that HPV vaccine is an effective prevention tool. However, many caregivers had heard rumors about the vaccine, particularly its alleged harmful effect on girls' future fertility. Many caregivers, especially mothers, felt that school-based vaccination was efficient; but some caregivers expressed disappointment that they had not been more engaged in the school-based delivery of HPV vaccine. Caregivers also reported that the COVID-19 pandemic has been disruptive to vaccination.

Conclusions

There are complex and intersecting factors that affect caregivers' motivation to vaccinate their daughters against HPV, and the practical challenges that caregivers may encounter. We identify areas for future research and intervention that could contribute to cervical cancer elimination: better communicating about vaccine safety (particularly to address concerns about loss of fertility), leveraging the unique advantages of school-based vaccination while ensuring parental engagement, and understanding the complex effects of the COVID-19 pandemic (and vaccination program).

Correlates of uptake of COVID-19 vaccines and motivation to vaccinate among Malawian adults

COVID-19 vaccine coverage in most countries in Africa remains low. Determinants of uptake need to be better understood to improve vaccination campaigns. Few studies from Africa have identified correlates of COVID-19 vaccination in the general population. We surveyed adults at 32 healthcare facilities across Malawi, purposively sampled to ensure balanced representation of adults with and without HIV. The survey, informed by the World Health Organization's Behavioural and Social Drivers of Vaccination Framework, asked about people's thoughts and feelings about the vaccine, social processes, motivation to vaccinate, and access issues. We classified respondents' COVID-19 vaccination status and willingness to vaccinate, and used multivariable logistic regression to assess correlates of these. Among 837 surveyed individuals (median age was 39 years (IQR 30-49) and 56% were female), 33% were up-to-date on COVID-19 vaccination, 61% were unvaccinated, and 6% were overdue for a second dose. Those up-to-date were more likely to know someone who had died from COVID-19, feel the vaccine is important and safe, and perceive pro-vaccination social norms. Despite prevalent concerns about vaccine side effects, 54% of unvaccinated respondents were willing to vaccinate. Access issues were reported by 28% of unvaccinated but willing respondents. Up-to-date COVID-19 vaccination status was associated with positive attitudes about the vaccine and with perceiving pro-vaccination social norms. Over half of unvaccinated respondents were willing to get vaccinated. Disseminating vaccine safety messages from trusted sources and ensuring local vaccine availability may ultimately increase vaccine uptake.

A systematic review of communication interventions for countering vaccine misinformation

BACKGROUND

Misinformation and disinformation around vaccines has grown in recent years, exacerbated during the Covid-19 pandemic. Effective strategies for countering vaccine misinformation and disinformation are crucial for tackling vaccine hesitancy. We conducted a systematic review to identify and describe communications-based strategies used to prevent and ameliorate the effect of mis- and dis-information on people's attitudes and behaviours surrounding vaccination (objective 1) and examined their effectiveness (objective 2).

METHODS

We searched CINAHL, Web of Science, Scopus, MEDLINE, Embase, PsycInfo and MedRxiv in March 2021. The search strategy was built around three themes(1) communications and media; (2) misinformation; and (3) vaccines. For trials addressing objective 2, risk of bias was assessed using the Cochrane risk of bias in randomized trials tool (RoB2).

RESULTS

Of 2000 identified records, 34 eligible studies addressed objective 1, 29 of which also addressed objective 2 (25 RCTs and 4 before-and-after studies). Nine 'intervention approaches' were identified; most focused on content of the intervention or message (debunking/correctional, informational, use of disease images or other 'scare tactics', use of humour, message intensity, inclusion of misinformation warnings, and communicating weight of evidence), while two focused on delivery of the intervention or message (timing and source). Some strategies, such as scare tactics, appear to be ineffective and may increase misinformation endorsement. Communicating with certainty, rather than acknowledging uncertainty around vaccine efficacy or risks, was also found to backfire. Promising approaches include communicating the weight-of-evidence and scientific consensus around vaccines and related myths, using humour and incorporating warnings about encountering misinformation. Trying to debunk misinformation, informational approaches, and communicating uncertainty had mixed results.

CONCLUSION

This review identifies some promising communication strategies for addressing vaccine misinformation. Interventions should be further evaluated by measuring effects on vaccine uptake, rather than distal outcomes such as knowledge and attitudes, in quasi-experimental and real-life contexts.

Uptake of the COVID-19 vaccine among healthcare workers in Malawi

BACKGROUND

Little is known about coronavirus disease 2019 (COVID-19) vaccination in Africa. We sought to understand Malawian healthcare workers' (HCWs') COVID-19 vaccination and its hypothesized determinants.

METHODS

In March 2021, as the COVID-19 vaccine roll-out commenced in Malawi, we surveyed clinical and lay cadre HCWs (n=400) about their uptake of the vaccine and potential correlates (informed by the WHO Behavioral and Social Drivers of COVID-19 Vaccination framework). We analyzed uptake and used adjusted multivariable logistic regression models to explore how 'what people think and feel' constructs were associated with HCWs' motivation to be vaccinated.

RESULTS

Of the surveyed HCWs, 82.5% had received the first COVID-19 vaccine dose. Motivation (eagerness to be vaccinated) was strongly associated with confidence in vaccine benefits (adjusted OR [aOR] 9.85, 95% CI 5.50 to 17.61) and with vaccine safety (aOR 4.60, 95% CI 2.92 to 7.23), but not with perceived COVID-19 infection risk (aOR 1.38, 95% CI 0.88 to 2.16). Of all the information sources about COVID-19 vaccination, 37.5% were reportedly negative in tone.

CONCLUSIONS

HCWs in Malawi have a high motivation to be vaccinated and a high COVID-19 vaccine uptake. Disseminating vaccine benefits and safety messages via social media and social networks may be persuasive for individuals who are unmotivated to be vaccinated and less likely to accept the COVID-19 vaccine.

Health systems' capacity to provide post-abortion care: a multicountry analysis using signal functions

Background

Abortion-related mortality is one of the main causes of maternal mortality worldwide. Laws often restrict the provision of safe abortion care, yet post-abortion care is a service that all countries have committed to provide to manage abortion complications. There is minimal evidence on the capacity of national health systems to provide post-abortion care.

Methods

We did a multicountry analysis of data from nationally representative Service Provision Assessment surveys done between 2007 to 2017 in ten countries across three regions (Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda). Data were available for all ten countries from 2007 to 2015. We included facilities offering childbirth delivery services and classified facilities as primary or referral level. We measured signal functions for post-abortion care (the availability of key equipment and ability to perform services) to assess the proportion of primary-level and referral-level facilities in each country with the capacity to provide basic and comprehensive post-abortion care, respectively. We calculated the proportion of facilities providing each post-abortion care signal function to examine specific gaps in service provision.

Findings

There are critical gaps in the provision of post-abortion care at all facilities that offer delivery services. In seven (70%) of ten countries, less than 10% of primary-level facilities could provide basic post-abortion care, and in eight (80%) of ten countries less than 40% of referral-level facilities could provide comprehensive post-abortion care. In no country could all referral facilities provide all the essential services that need to be included in basic post-abortion care.

Interpretation

The capacity of primary-level and referral-level health facilities to provide basic and comprehensive post-abortion care, respectively, is low. The results highlight the gap between political commitments to address the consequences of unsafe abortion and the capacity of health systems to provide post-abortion care. Increasing the provision of good-quality post-abortion care is essential to reduce the level of abortion-related morbidity and mortality.

Estimating abortion incidence among adolescents and differences in postabortion care by age: a cross-sectional study of postabortion care patients in Uganda

Objectives:

To provide the first estimate of adolescents’ abortion incidence in Uganda and to assess differences in the abortion experiences and morbidities of adolescent and nonadolescent postabortion care (PAC) patients.

Study design:

We used the age-specific Abortion Incidence Complications Method, drawing from three surveys conducted in Uganda in 2013: a nationally representative Health Facilities Survey (n=418), a Health Professionals Survey (n=147) and a Prospective Morbidity Survey of PAC patients (n=2169). Multivariable logistic and Cox proportional hazard models were used to compare adolescent and nonadolescent PAC patients on dimensions including pregnancy intention, gestational age, abortion safety, delays to care, severity of complications and receipt of postabortion family planning. We included an interaction term between adolescents and marital status to assess heterogeneity among adolescents.

Results:

Adolescent women have the lowest abortion rate among women less than 35 years of age (28.4 abortions per 1000 women 15–19) but the highest rate among recently sexually active women (76.1 abortions per 1000 women 15–19). We do not find that adolescents face greater disadvantages in their abortion care experiences as compared to older women. However, unmarried PAC patients, both adolescent and nonadolescent, have higher odds of experiencing severe complications than nonadolescent married women.

Conclusions:

The high abortion rate among sexually active adolescents highlights the critical need to improve adolescent family planning in Uganda. Interventions to prevent unintended pregnancy and to reduce unsafe abortion may be particularly important for unmarried adolescents. Rather than treating adolescents as a homogenous group, we need to understand how marriage and other social factors shape reproductive health outcomes.

Implications:

This paper provides the first estimate of the adolescent abortion rate in Uganda. Studies of adolescent abortion and reproductive health must account for sexual activity and marital status. Further, interventions to address unintended pregnancy and unsafe abortion among unmarried women of all ages in Africa should be a priority.