Availability of medical abortion medicines in eight countries: a descriptive analysis of key findings and opportunities

BACKGROUND

In recent years a growing number of manufacturers and medical abortion products have entered country markets and health systems, with varying degrees of quality and accessibility. An interplay of factors including pharmaceutical regulations, abortion laws, government policies and service delivery guidelines and provider's knowledge and practices influence the availability of medical abortion medicines. We assessed the availability of medical abortion in eight countries to increase understanding among policymakers of the need to improve availability and affordability of quality-assured medical abortion products at regional and national levels.

METHODS

Using a national assessment protocol and an availability framework, we assessed the availability of medical abortion medicines in Bangladesh, Liberia, Malawi, Nepal, Nigeria, Rwanda, Sierra Leone and South Africa between September 2019 and January 2020.

RESULTS

Registration of abortion medicines-misoprostol or a combination of mifepristone and misoprostol-was established in all countries assessed, except Rwanda. Mifepristone and misoprostol regimen for medical abortion was identified on the national essential medicines list/standard treatment guidelines for South Africa as well as in specific abortion care service and delivery guidelines for Bangladesh, Nepal, Nigeria, and Rwanda. In Liberia, Malawi, and Sierra Leone-countries with highly restrictive abortion laws and no abortion service delivery guidelines or training curricula-no government-supported training on medical abortion for public sector providers had occurred. Instead, training on medical abortion was either limited in scope to select private sector providers and pharmacists or prohibited. Community awareness activities on medical abortion have been limited in scope across the countries assessed and where abortion is broadly legal, most women do not know that it is an option.

CONCLUSION

Understanding the factors that influence the availability of medical abortion medicines is important to support policymakers improve availability of these medicines. The landscape assessments documented that medical abortion commodities can be uniquely impacted by the laws, policies, values, and degree of restrictions placed on service delivery programs. Results of the assessments can guide actions to improve access.

Population-Based Estimation of the Preterm Birth Rate in Lilongwe, Malawi: Making Every Birth Count

Objective  The objective of this study was to perform a population-based estimation of the preterm birth (PTB) rate in regions surrounding Lilongwe, Malawi. Study Design  We partnered with obstetrician specialists, community health workers, local midwives, and clinicians in a 50 km region surrounding Lilongwe, Malawi, to perform a population-based estimation of the PTB rate during the study period from December 1, 2012 to May 19, 2015. Results  Of the 14,792 births captured, 19.3% of births were preterm, including preterm early neonatal deaths. Additional PTB risk factors were similarly prevalent including domestic violence, HIV, malaria, anemia, and malnutrition. Conclusion  When performing a population-based estimation of the rate of PTB, including women without antenatal care and women delivering at home, the 19.3% rate of PTB is among the highest recorded globally. This is accompanied by a high rate of risk factors and comorbid conditions.

Implementation of the Alliance for Innovation on Maternal Health Program to Reduce Maternal Mortality in Malawi

OBJECTIVE

To evaluate maternal mortality and changes in the culture of safety before and after the implementation of the Alliance for Innovation on Maternal Health (AIM) Malawi program.

METHODS

This was a prospective cohort study at a central hospital and a district health center in Malawi from March 2016 to November 2017. The AIM Malawi program included classroom didactics on obstetric hemorrhage, teamwork protocols, skills laboratory activities, and simulation training. The time periods of comparison were preintervention, education period, and postintervention. Hospital birth paper records were used to collect data on patient demographics and obstetric and neonatal information. The Hospital Survey of Patient Safety was used to measure the culture of safety before and after the program.

RESULTS

We trained 128 participants. In the postintervention period, 16 procedural interventions were performed to manage postpartum hemorrhage, including B-lynch sutures (n=7), condom balloon catheter (n=5), nonpneumatic antishock garment (n=3), and uterine artery ligation (n=1). There was a significant increase in the use of B-lynch sutures for the management of uterine atony in the postintervention compared with preintervention period (P=.014). In the postintervention period, the rate of maternal mortality from obstetric hemorrhage decreased significantly from 1.2% to 0.2% (P=.02), a relative decrease of 82.1% from the preintervention rate. Hospital safety culture scores improved significantly from baseline in four out of five domains after the AIM Malawi training.

CONCLUSION

After implementation of the AIM Malawi program, we found an increased use of postpartum hemorrhage procedural interventions, a decreased rate of maternal mortality and an increase in Hospital Survey of Patient Safety composite safety scores. The AIM Malawi program may be an effective framework for adaptation to improve maternal mortality in a low-resource setting.

Insulin Resistance is Associated with Higher Plasma Viral Load Among HIV-Positive Adults Receiving Longer-Term (1 Year) Combination Antiretroviral Therapy (ART)

BACKGROUND

As HIV-positive persons survive longer due to the success of combination antiretroviral therapy (ART) in decreasing mortality, the burden of non-communicable diseases including diabetes mellitus (DM) is anticipated to rise. HIV is characterized by systemic inflammations, markers of which decrease quickly following ART initiation, but typically do not completely normalize. Inflammation may be accompanied by insulin resistance (IR), and both are implicated in the pathogenesis of DM in HIV-positive individuals. Sub-Saharan Africa accounts for almost two-thirds of the global HIV burden but there are few reports of IR, DM and HIV in this region. We assessed the relationship between IR and viral suppression among HIV-positive adults in the Zambian national ART program.

METHODS

We conducted a cross-sectional survey evaluating HIV-positive adults that had received first line ART (usually TDF/FTC/EFV) for 12 months (± 3 months). Twenty clinics were sampled systematically based on the random starting-point, sampling interval and cumulative population size. Eligible patients had plasma viral load (VL), fasting insulin, and glucose performed. Insulin resistance was determined using Homeostatic model assessment (HOMA). We determined proportions for each outcome using linearized standard error 95% confidence intervals and summary estimates. Viral suppression was defined according to the detection threshold of<20 copies/mL and treatment failure was defined as VL>1,000 copies/mL.

RESULTS

Of 473 patients enrolled, 46.8% were male and 53.2% were female. 142 (30%) [95% CI: 0.26-0.34] had IR. Among those with IR, 55 (38.7%) were male whereas 87 (61.3%) were female (p value=0.104). 19% of individuals with IR had treatment failure compared to 5.7% without IR (p value<0.0001). 427 (90.3%) participants had treatment success (VL<1,000 copies/mL), and this was associated with a lower likelihood of IR (odds ratio (OR)=0.26 [0.14, 0.48], p value<0.0001). In addition, a significantly lower proportion of patients with IR were virologically suppressed at one-year compared to individuals without IR, 58% [0.54-0.70] versus 70% [0.65-0.75], respectively (p value=0.042).

CONCLUSION

In Zambian adults on ART for a year, the development of insulin resistance was strongly associated with suboptimal HIV outcomes, specifically non-viral suppression and treatment failure. Further investigations are warranted to determine if this positive association between IR and VL is causally related, and if so in which direction.

Population-Based Estimation of Dental Caries and Periodontal Disease Rates of Gravid and Recently Postpartum Women in Lilongwe, Malawi

Objectives  The objective of this study was to determine the rate of dental caries and periodontal disease among gravid and recently postpartum women at five delivery centers within and surrounding Lilongwe, Malawi. Study Design  We partnered with obstetric specialists, community health workers, and dentists to perform dental history interviews and dental examinations during the study period from December 2012 to May 2014. Dental examinations were performed according to World Health Organization standards to assess periodontal and oral health status. Results  Among the 387 gravid and recently postpartum women, the rate of dental caries was 69.3% and the rate of composite dental disease (caries and periodontal disease) was 76.7%. The majority (69.5%) of women examined had a decayed-missing-filled (DMF) index greater than or equal to one; the average DMF Index was 2.48. The majority of women had never seen a dentist (62.8%). However, most did perform oral hygiene, two or more times per day (90.2%); most women reported brushing with toothpaste (88.1%). Conclusion  When assessing this population for dental caries and periodontal disease, the rate of dental disease was high. Therefore, this may be an ideal setting to test for impactful interventions aimed at reducing caries and periodontal disease.

Qualitative assessment of knowledge transfer regarding preterm birth in Malawi following the implementation of targeted health messages over 3 years

Background

In 2012, we performed a needs assessment and gap analysis to qualitatively assess providers’ and patients’ knowledge and perceptions regarding preterm birth (PTB). During the study, we identified knowledge gaps surrounding methods to reduce the risk of occurrence of PTB and management options if preterm labor/birth occur. We targeted health messages toward these gaps. The objective of the present study was to assess the impact of our community health worker-based patient education program 3 years after it was implemented.

Methods

Fifteen focus groups including 70 participants were included in the study. The groups comprised either patients/patient couples or health providers. A minimum of two facilitators led each group using 22 a priori designed and standardized lead-in prompts for participants with four additional prompts for providers only. A single researcher recorded responses, and transcript notes were reviewed by the facilitators and interpreters immediately following each group discussion to ensure accuracy.

Results

The understanding of term vs preterm gestation was generally accurate. Every participant knew of women who had experienced PTB, and the general perception was that two to three women out of every ten had this experience. The majority of respondents thought that women should present to their local health clinic if they experience preterm contractions; few were aware of the use of antenatal steroids for promoting fetal lung maturity, but many acknowledged that the neonate may be able to receive life-sustaining treatment if born at a higher level of care facility. The majority of participants were aware that PTB could recur in subsequent pregnancies. All respondents were able to list ways that women could potentially reduce the risk of PTB.

Conclusion

After employing targeted health messages, the majority of participants expressed improved understanding of the definition of PTB, methods to prevent risk of PTB, and management options for preterm labor or PTB.

2249. Insulin Resistance Is Associated with Higher Viral Loads Among HIV-1-Infected Patients Initiated on 12 Months of First-Line Antiretroviral Therapy

Background

As HIV-infected patients are living longer due to ART and decreasing mortality, the burden of noncommunicable diseases (NCDs) is expected to rise. With the implication of Insulin resistance (IR) and inflammation in the pathogenesis of Diabetes Mellitus (DM), DM is likely to be increasing in the HIV-infected patients in the Sub-Saharan Africa (SSA). HIV is characterized with systemic inflammation and markers which quickly decrease with ART initiation regardless of type of ARV regimen though they do not normalize. We thus assessed the relationship between IR and Virologic treatment failure among HIV-1-infected individuals at 12 months of first-line ART in the Zambian ART program.

Methods

We conducted a cross-sectional survey among HIV-1-infected individuals at 12 months (±3 months) of first-line ART. Systematic sampling was performed and 20 clinics were selected based on the random starting-point, sampling interval and cumulative population size giving a sample size of 460. Eligible patients had their fasting blood specimens collected for VL, insulin, blood glucose, high sensitive c-reactive protein (hsCRP), tumour necrosis factor alfa (TNFa) and Lipogram. Anthropometric indices were also measured including visceral fat. Insulin resistance (IR) was determined using Homeostatic model assessment (HOMA). Proportions for each outcome at linearized standard error 95% confidence interval and summary estimates were determined. Viral Load suppression (VLS) was defined according to the detection threshold which was <20 copies/mL and treatment failure was defined as VL > 1,000 copies/mL.

Results

Of the 473 patients enrolled, 142 (30%): 95% CI (26%, 34%) had IR. 19% of Individuals with IR had treatment failure compared with 5.7% with treatment failure and without IR (P-value < 0.0001). Treatment success was associated with less likelihood of IR (OR 0.26 (0.14, 0.48), P-value < 0.0001. Among individuals with VLS, 82, out of 142 (58%) 95% CI (0.54%, 0.70%) had IR compared with 232 out of 331, (70%) 95% CI (65%, 75%) who did not have IR (P-value = 0.042)

Conclusion

Patients with poor virological outcomes at 12 months of first-line ART had increased likelihood of insulin resistance compared with those with treatment success. There was good evidence to suggest that the proportion of those with VLS and IR was less than those with VLS and no IR.

Disclosures

All authors: No reported disclosures.

Prevention of mother-to-child transmission of HIV: a cross-sectional study in Malawi

Objective

To estimate the use and outcomes of the Malawian programme for the prevention of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV).

Methods

In a cross-sectional analysis of 33 744 mother–infant pairs, we estimated the weighted proportions of mothers who had received antenatal HIV testing and/or maternal antiretroviral therapy and infants who had received nevirapine prophylaxis and/or HIV testing. We calculated the ratios of MTCT at 4–26 weeks postpartum for subgroups that had missed none or at least one of these four steps.

Findings

The estimated uptake of antenatal testing was 97.8%; while maternal antiretroviral therapy was 96.3%; infant prophylaxis was 92.3%; and infant HIV testing was 53.2%. Estimated ratios of MTCT were 4.7% overall and 7.7% for the pairs that had missed maternal antiretroviral therapy, 10.7% for missing both maternal antiretroviral therapy and infant prophylaxis and 11.4% for missing maternal antiretroviral therapy, infant prophylaxis and infant testing. Women younger than 19 years were more likely to have missed HIV testing (adjusted odds ratio, aOR: 4.9; 95% confidence interval, CI: 2.3–10.6) and infant prophylaxis (aOR: 6.9; 95% CI: 1.2–38.9) than older women. Women who had never started maternal antiretroviral therapy were more likely to have missed infant prophylaxis (aOR: 15.4; 95% CI: 7.2–32.9) and infant testing (aOR: 13.7; 95% CI: 4.2–83.3) than women who had.

Conclusion

Most women used the Malawian programme for the prevention of MTCT. The risk of MTCT increased if any of the main steps in the programme were missed.

Excluding pregnancy among women initiating antiretroviral therapy: efficacy of a family planning job aid

Background

Guidelines for initiating ART recommend pregnancy testing, typically a urine test, as part of the basic laboratory package. The principal reason for this recommendation is that Efavirenz, a first-line antiretroviral medication, has the potential of causing birth defects when used in the first trimester of pregnancy and is therefore contraindicated for use by pregnant women. Unfortunately, in many African countries pregnancy tests are not routinely provided or available in ART clinics, and, when available outside clinics, are often not affordable for clients.

Recently, the World Health Organization added a family planning job aid called the 'pregnancy checklist,' developed by researchers at Family Health International, as a recommended tool for screening new ART clients to exclude pregnancy. Although the checklist has been validated for excluding pregnancy among family planning clients, there are no data on its efficacy among ART clients.

This study was conducted to assess the clinical performance of a job aid to exclude pregnancy among HIV positive women initiating ART.

Methods

Non-menstruating women eligible for ART were enrolled from 20 sites in four provinces in Zambia. The pregnancy checklist was administered followed by a urine pregnancy test as a reference standard. Sensitivity, specificity, and positive and negative predictive values were estimated.

Results

Of the 200 women for whom the checklist ruled out pregnancy, 198 were not pregnant, for an estimated negative predictive value of 99%. The sensitivity of the checklist was 90.0%, and specificity was 38.7%. Among the women, 416 out of 534 (77.9%) did not abstain from sex since their last menses. Only 72 out of the 534 women (13.4%) reported using reliable contraception. Among the 416 women who did not abstain, 376 (90.4%) did not use reliable contraception.

Conclusion

The pregnancy checklist is effective for excluding pregnancy in many women initiating ART, but its moderate sensitivity and specificity precludes its use to completely replace pregnancy testing. Its use should be encouraged in low resource settings where pregnancy tests are unavailable or must be rationed. Family planning methods should be available and integrated into ART clinics.

Environmental and climatic factors associated with epizootic ulcerative syndrome (EUS) in fish from the Zambezi floodplains, Zambia

This study was conducted to determine environmental and climatic factors associated with Epizootic Ulcerative Syndrome (EUS) in fish in the Zambezi floodplains. EUS is a fish disease that causes economic loses to the fishing industry. Streambed colour in affected water was rusty-, reddish- or yellowish- brown and pH 4.5-6.0 while pH of non affected water was 7.2. The rusty-brown precipitate on fish gills was positive for Prussian blue iron stain. Therefore, predisposing factors for EUS in the Zambezi floodplains were the acidification of ground water during drought years and eventual contamination of surface water during the floods of 2006/2007.

HIV epidemic trend and antiretroviral treatment need in Karonga District, Malawi

We describe the development of the HIV epidemic in Karonga District, Malawi over 22 years using data from population surveys and community samples. These data are used to estimate the trend in HIV prevalence, incidence and need for antiretroviral treatment (ART) using a simple mathematical model. HIV prevalence rose quickly in the late 1980s and early 1990s, stabilizing at around 12% in the mid-1990s. Estimated annual HIV incidence rose quickly, peaking in the early 1990s at 2.2% among males and 3.1% among females, and then levelled off at 1.3% among males and 1.1% among females by the late 1990s. Assuming a 2-year eligibility period, both our model and the UNAIDS models predicted 2.1% of adults were in need of ART in 2005. This prediction was sensitive to the assumed eligibility period, ranging from 1.6% to 2.6% if the eligibility period was instead assumed to be 1.5 or 2.5 years, respectively.

Bulinus nyassanus is an intermediate host for Schistosoma haematobium in Lake Malawi

At Cape Maclear on the Nankumba Peninsula, close to the southern end of Lake Malawi, Schistosoma haematobium is highly prevalent in the local people and many tourists become infected with this parasite each year. A 'Bilharzia Control Programme' was initiated in this area in August 1998, as a development collaboration between the Government of Malawi, the Danish Agency for Development Assistance (Danida), and the Danish Bilharziasis Laboratory. Although Bulinus globosus is a known host for S. haematobium, B. nyassanus has not previously been incriminated as an intermediate host. However, schistosome-infected B. nyassanus were discovered in surveys to identify transmission sites on the peninsula. Experimental infections of wild-caught B. nyassanus with S. haematobium proved successful and S. haematobium eggs were found in hamsters experimentally exposed to cercariae retrieved from schistosome-infected, field-collected B. nyassanus. These are remarkable observations since, although there are very few reports of diploid members of this species group being experimentally infected with S. haematobium, B. nyassanus is a diploid member (2n = 36) of the truncatus/tropicus group. Bulinus nyassanus is probably responsible for transmission in Lake Malawi, along rather exposed shorelines, devoid of aquatic macrophytes, with a substrate of sand or gravel.