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Makonokaya L, Maida A, Kalitera LU, Wang A, Kapanda L, Kayira D, Bottoman M, Nkhoma H, Dunga S, Joaki Z, Chamanga R, Nkanaunena K, Hrapcak S, Nyirenda R, Chiwandira B, Maulidi M, Woelk G, Machekano R, Maphosa T. Early Effects of Scaling Up Dolutegravir-Based ARV Regimens Among Children Living with HIV in Malawi. AIDS Behav 2024:10.1007/s10461-024-04312-3. [PMID: 38615099 DOI: 10.1007/s10461-024-04312-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/15/2024]
Abstract
Viral suppression (VS) in children has remained suboptimal compared to that in adults. We evaluated the impact of transitioning children weighing < 20 kg to a pediatric formulation of dolutegravir (pDTG) on VS in Malawi. We analyzed routine retrospective program data from electronic medical record systems pooled across 169 healthcare facilities in Malawi supported by the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). We included children who weighed < 20 kg and received antiretroviral therapy (ART) between July 2021-June 2022. Using descriptive statistics, we summarized demographic and clinical characteristics, ART regimens, ART adherence, and VS. We used logistic regression to identify factors associated with post-transition VS. A total of 2468 Children Living with HIV (CLHIV) were included, 55.3% of whom were < 60 months old. Most (83.8%) had initiated on non-DTG-based ART; 71.0% of these had a viral load (VL) test result before transitioning to pDTG, and 62.5% had VS. Nearly all (99.9%) CLHIV transitioned to pDTG-based regimens. Six months after the transition, 52.7% had good ART adherence, and 38.6% had routine VL testing results; 81.7% achieved VS. Post-transition VS was associated with good adherence and pre-transition VS: adjusted odds ratios of 2.79 (95% CI 1.65-4.71), p < 0.001 and 5.32 (95% CI 3.23-9.48), p < 0.001, respectively. After transitioning to pDTG, VS was achieved in most children tested within the first 6 months. However, adherence remained suboptimal post-transition and VL testing at 6 months was limited. Interventions to improve VL testing and enhance ART adherence are still needed in CLHIV on pDTG-based regimens.
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Affiliation(s)
| | - Alice Maida
- U. S. Centers for Disease Control and Prevention, Division of Global HIV and TB, Lilongwe, Malawi
| | | | - Alice Wang
- U. S. Centers for Disease Control and Prevention, Division of Global HIV and TB, Lilongwe, Malawi
| | - Lester Kapanda
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Dumbani Kayira
- U. S. Centers for Disease Control and Prevention, Division of Global HIV and TB, Lilongwe, Malawi
| | | | - Harrid Nkhoma
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Shalom Dunga
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Zuze Joaki
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Rachel Chamanga
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Kondwani Nkanaunena
- U. S. Centers for Disease Control and Prevention, Division of Global HIV and TB, Lilongwe, Malawi
| | - Susan Hrapcak
- U. S. Centers for Disease Control and Prevention, Atlanta, USA
| | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Brown Chiwandira
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Martin Maulidi
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Godfrey Woelk
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | | | - Thulani Maphosa
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
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Conan N, Paye CP, Ortuno R, Chijuwa A, Chiwandira B, Goemaere E, Garone DB, Coulborn RM, Chihana M, Maman D. Correction: What gaps remain in the HIV cascade of care? Results of a population-based survey in Nsanje District, Malawi. PLoS One 2024; 19:e0299866. [PMID: 38412175 PMCID: PMC10898720 DOI: 10.1371/journal.pone.0299866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pone.0248410.].
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Maphosa T, Denoeud-Ndam L, Kapanda L, Khatib S, Chilikutali L, Matiya E, Munthali B, Dambe R, Chiwandira B, Wilson B, Nyirenda R, Nyirenda L, Chikwapulo B, Musopole OM, Tiam A, Katirayi L. Understanding health systems challenges in providing Advanced HIV Disease (AHD) care in a hub and spoke model: a qualitative analysis to improve AHD care program in Malawi. BMC Health Serv Res 2024; 24:244. [PMID: 38408975 PMCID: PMC10897989 DOI: 10.1186/s12913-024-10700-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 02/08/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Despite tremendous progress in antiretroviral therapy (ART) and access to ART, many patients have advanced human immunodeficiency virus (HIV) disease (AHD). Patients on AHD, whether initiating ART or providing care after disengagement, have an increased risk of morbidity and mortality. The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) launched an enhanced care package using a hub-and-spoke model to optimize AHD care in Malawi. This model improves supply availability and appropriate linkage to care. We utilized a hub-and-spoke model to share health facility challenges and recommendations on the AHD package for screening and diagnosis, prophylaxis, treatment, and adherence support. METHODS This qualitative study assessed the facility-level experiences of healthcare workers (HCWs) and lay cadres (LCs) providing AHD services to patients through an intervention package. The study population included HCWs and LCs supporting HIV care at four intervention sites. Eligible study participants were recruited by trained Research Assistants with support from the health facility nurse to identify those most involved in supporting patients with AHD. A total of 32 in-depth interviews were conducted. Thematic content analysis identified recurrent themes and patterns across participants' responses. RESULTS While HCWs and LCs stated that most medications are often available at both hub and spoke sites, they reported that there are sometimes limited supplies and equipment to run samples and tests necessary to provide AHD care. More than half of the HCWs stated that AHD training sufficiently prepared them to handle AHD patients at both the hub and spoke levels. HCWs and LCs reported weaknesses in the patient referral system within the hub-and-spoke model in providing a linkage of care to facilities, specifically improper referral documentation, incorrect labeling of samples, and inconsistent availability of transportation. While HCWs felt that AHD registers were time-consuming, they remained motivated as they thought they provided better patient services. CONCLUSIONS These findings highlight the importance of offering comprehensive AHD services. The enhanced AHD program addressed weaknesses in service delivery through decentralization and provided services through a hub-and-spoke model, improved supply availability, and strengthened linkage to care. Additionally, addressing the recommendations of service providers and patients is essential to improve the health and survival of patients with AHD.
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Affiliation(s)
- Thulani Maphosa
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi.
| | | | - Lester Kapanda
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Sarah Khatib
- George Washington University, Washington, DC, USA
| | | | | | | | - Rosalia Dambe
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Brown Chiwandira
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Bilaal Wilson
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | | | | | | | | | - Leila Katirayi
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
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Conan N, Paye CP, Ortuno R, Chijuwa A, Chiwandira B, Goemaere E, Belen Garone D, Coulborn RM, Chihana M, Maman D. What gaps remain in the HIV cascade of care? Results of a population-based survey in Nsanje District, Malawi. PLoS One 2021; 16:e0248410. [PMID: 33886575 PMCID: PMC8061928 DOI: 10.1371/journal.pone.0248410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 02/25/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The Malawi Ministry of Health (MoH) has been in collaboration with Médecins sans Frontières (MSF) to increase access to quality HIV care through decentralization of antiretroviral therapy (ART) diagnosis and treatment from hospital to clinics in Nsanje District since 2011. A population-based household survey was implemented to provide information on HIV prevalence and cascade of care to inform and prioritize community-based HIV interventions in the district. METHODS A cross-sectional survey was conducted between September 2016 and January 2017. Using two-stage cluster sampling, eligible adult individuals aged ≥15 years living in the selected households were asked to participate. Participants were interviewed and tested for HIV at home. Those tested HIV-positive had their HIV-RNA viral load (VL) measured, regardless of their ART status. All participants tested HIV-positive at the time of the survey were advised to report their HIV test result to the health facility of their choice that MSF was supported in the district. HIV-RNA VL results were made available in this health facility. RESULTS Among 5,315 eligible individuals, 91.1% were included in the survey and accepted an HIV test. The overall prevalence was 12.1% (95% Confidence Interval (CI): 11.2-13.0) and was higher in women than in men: 14.0% versus 9.5%, P<0.001. Overall HIV-positive status awareness was 80.0% (95%CI: 76.4-83.1) and was associated with sex (P<0.05). Linkage to care was 78.0% (95%CI: 74.3-81.2) and participants in care 76.2% (95%CI: 72.4-79.5). ART coverage among participants aware of their HIV-positive status was 95.3% (95%CI: 92.9-96.9) and was not associated with sex (P = 0.55). Viral load suppression among participants on ART was 89.9% (95%CI: 86.6-92.4) and was not statistically different by sex (p = 0.40). CONCLUSIONS Despite encouraging results in HIV testing coverage, cascade of care, and UNAIDS targets in Nsanje District, some gap remains in the first 90, specifically among men and young adults. Enhanced community engagement and new strategies of testing, such as index testing, could be implemented to identify those who are still undiagnosed, particularly men and young adults.
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Affiliation(s)
| | | | | | | | - Brown Chiwandira
- Ministry of Health, Department of HIV & AIDS, Programme Officer (HIV Care, Treatment & Support programme), Lilongwe, Malawi
| | - Eric Goemaere
- Southern Africa Medical Unit, Cape Town, South Africa
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Hsieh YL, Jahn A, Menzies NA, Yaesoubi R, Salomon JA, Girma B, Gunde L, Eaton JW, Auld A, Odo M, Kiyiika CN, Kalua T, Chiwandira B, Mpunga JU, Mbendra K, Corbett L, Hosseinipour MC, Cohen T, Kunkel A. Evaluation of 6-Month Versus Continuous Isoniazid Preventive Therapy for Mycobacterium tuberculosis in Adults Living With HIV/AIDS in Malawi. J Acquir Immune Defic Syndr 2020; 85:643-650. [PMID: 33177475 PMCID: PMC8564780 DOI: 10.1097/qai.0000000000002497] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND To assist the Malawi Ministry of Health to evaluate 2 competing strategies for scale-up of isoniazid preventive therapy (IPT) among HIV-positive adults receiving antiretroviral therapy. SETTING Malawi. METHODS We used a multidistrict, compartmental model of the Malawi tuberculosis (TB)/HIV epidemic to compare the anticipated health impacts of 6-month versus continuous IPT programs over a 12-year horizon while respecting a US$10.8 million constraint on drug costs in the first 3 years. RESULTS The 6-month IPT program could be implemented nationwide, whereas the continuous IPT alternative could be introduced in 14 (of the 27) districts. By the end of year 12, the continuous IPT strategy was predicted to avert more TB cases than the 6-month alternative, although not statistically significant (2368 additional cases averted; 95% projection interval [PI], -1459 to 5023). The 6-month strategy required fewer person-years of IPT to avert a case of TB or death than the continuous strategy. For both programs, the mean reductions in TB incidence among people living with HIV by year 12 were expected to be <10%, and the cumulative numbers of IPT-related hepatotoxicity to exceed the number of all-cause deaths averted in the first 3 years. CONCLUSIONS With the given budgetary constraint, the nationwide implementation of 6-month IPT would be more efficient and yield comparable health benefits than implementing a continuous IPT program in fewer districts. The anticipated health effects associated with both IPT strategies suggested that a combination of different TB intervention strategies would likely be required to yield a greater impact on TB control in settings such as Malawi, where antiretroviral therapycoverage is relatively high.
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Affiliation(s)
- Yuli L Hsieh
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT
| | - Andreas Jahn
- Department of Global Health, University of Washington, Seattle, WA
- Department for HIV and AIDS, Ministry of Health and Population, Lilongwe, Malawi
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Reza Yaesoubi
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT
| | - Joshua A Salomon
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Medicine, Stanford University, Stanford, CA
| | - Belaineh Girma
- National Tuberculosis Control Program, Ministry of Health and Population, Lilongwe, Malawi
| | - Laurence Gunde
- Division of Global HIV and TB, Center for Global Health, US Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Jeffrey W Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Andrew Auld
- Division of Global HIV and TB, Center for Global Health, US Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Michael Odo
- Department for HIV and AIDS, Ministry of Health and Population, Lilongwe, Malawi
| | - Caroline N Kiyiika
- Department of Global Health, University of Washington, Seattle, WA
- Department for HIV and AIDS, Ministry of Health and Population, Lilongwe, Malawi
| | - Thokozani Kalua
- Department for HIV and AIDS, Ministry of Health and Population, Lilongwe, Malawi
| | - Brown Chiwandira
- Department for HIV and AIDS, Ministry of Health and Population, Lilongwe, Malawi
| | - James U Mpunga
- National Tuberculosis Control Program, Ministry of Health and Population, Lilongwe, Malawi
| | - Kuzani Mbendra
- National Tuberculosis Control Program, Ministry of Health and Population, Lilongwe, Malawi
| | - Liz Corbett
- Department for HIV and AIDS, Ministry of Health and Population, Lilongwe, Malawi
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mina C Hosseinipour
- Department of Medicine, University of North Carolina-Chapel Hill, NC
- UNC-Project Malawi, Lilongwe, Malawi; and
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT
| | - Amber Kunkel
- Emerging Diseases Epidemiology Unit, Institut Pasteur, Paris, France
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