Three-year outcomes for women newly initiated on lifelong antiretroviral therapy during pregnancy - Malawi option B

INTRODUCTION

Antiretroviral therapy (ART) is very effective in preventing vertical transmission of HIV but some women on ART experience different virologic, immunologic, and safety profiles. While most pregnant women are closely monitored for short-term effects of ART during pregnancy, few women receive similar attention beyond pregnancy. We aimed to assess retention in care and clinical and laboratory-confirmed outcomes over 3 years after starting ART under Malawi's Option B + program.

METHODS

We conducted a prospective cohort study of pregnant women newly diagnosed with HIV who started tenofovir disoproxil fumarate/emtricitabine/efavirenz (TDF/3TC/EFV) for the first time at Bwaila Hospital in Lilongwe, Malawi between May 2015 and June 2016. Participants were followed for 3 years. We summarized demographic characteristics, pregnancy outcomes, and clinical and laboratory adverse events findings using proportions. Log-binomial regression models were used to estimate the overall risk ratios (RR) and the corresponding 95% confidence interval (CI) for the association between index pregnancy (i.e. index pregnancy vs. subsequent pregnancy) and preterm birth, and index pregnancy and low birthweight.

RESULTS

Of the 299 pregnant women who were enrolled in the study, 255 (85.3%) were retained in care. There were 340 total pregnancies with known outcomes during the 36-month study period, 280 index pregnancies, and 60 subsequent pregnancies. The risks of delivering preterm (9.5% for index pregnancy and13.5% for subsequent pregnancy: RR = 0.70; 95% CI: 0.32-1.54), or low birth weight infant (9.8% for index pregnancy and 4.2% for subsequent pregnancy: RR = 2.36; 95% CI: 0.58-9.66) were similar between index and subsequent pregnancies. Perinatally acquired HIV was diagnosed in 6 (2.3%) infants from index pregnancies and none from subsequent pregnancies. A total of 50 (16.7%) women had at least one new clinical adverse event and 109 (36.5%) women had at least one incident abnormal laboratory finding. Twenty-two (7.3%) women switched to second line ART: of these 64.7% (8/17) had suppressed viral load and 54.9% (6/17) had undetectable viral load at 36 months.

CONCLUSION

Most of the women who started TDF/3TC/EFV were retained in care and few infants were diagnosed with perinatally acquired HIV. Despite switching, women who switched to second line therapy continued to have higher viral loads suggesting that additional factors beyond TDF/3TC/EFV failure may have contributed to the switch. Ongoing support during the postpartum period is necessary to ensure retention in care and prevention of vertical transmission.

Brief Report: Blood and Genital Fluid Viral Load Trajectories Among Treated and Untreated Persons With Acute HIV Infection in Malawi

BACKGROUND

Persons with acute HIV infection (AHI) are highly infectious and responsible for a disproportionate share of incident infections. Immediate antiretroviral therapy (ART) rapidly reduces blood viral loads (VLs), but genital VLs after ART initiation during AHI are less well described.

SETTING

Lilongwe, Malawi, 2012-2014.

METHODS

HIV-seronegative and HIV-serodiscordant persons aged ≥18 years were screened for AHI (RNA positive) and randomized to standard of care, behavioral intervention, or behavioral intervention plus short-term ART (raltegravir/emtricitabine/tenofovir) (1:2:2). Persons who were ART eligible under Malawi guidelines could receive first-line therapy. Blood and genital VLs were assessed at weeks 1, 4, 8, and 12. Fisher's Exact test was used to compare viral suppression by ART status.

RESULTS

Overall, 46 persons with AHI were enrolled; of whom, 17 started ART within 12 weeks. Median blood VL at AHI diagnosis was 836,115 copies/mL. At week 12, 7% (1/14) of those who initiated ART had a blood VL of ≥400 copies/mL, compared with 100% (23/23; P < 0.0001) of those who did not initiate ART (median VL: 61,605 copies/mL). Median genital VL at week 1 was 772 copies/mL, with 13 of 22 (59%) having VL of ≥400 copies/mL. At week 12, 0 of 10 (0%) of those who initiated ART had genital VL of ≥400 copies/mL, compared with 7 of 15 (47%) of those who did not initiate ART (P = 0.02).

CONCLUSION

Although highly correlated, VLs in blood and genital fluids occupy discrete biological compartments with distinct virologic dynamics. Our results corroborate the dramatic reduction in both compartments after ART initiation. Increasing AHI screening and rapidly initiating treatment is key to interrupting transmission.

Implementation of tuberculosis and cryptococcal meningitis rapid diagnostic tests amongst patients with advanced HIV at Kamuzu Central Hospital, Malawi, 2016–2017

Background

Cryptococcal meningitis (CM) and tuberculosis (TB) remain leading causes of hospitalization and death amongst people living with HIV, particularly those with advanced HIV disease. In hospitalized patients, prompt diagnosis of these diseases may improve patient outcomes. The advanced HIV rapid diagnostic tests such as determine TB urine lipoarabinomannan lateral flow assay (urine LAM), urine X-pert MTB/RIF assay (urine X-pert), and serum/blood cryptococcal antigen test (serum CrAg) are recommended but frequently not available in many resource-limited settings. We describe our experience providing these tests in a routine hospital setting.

Method

From 1 August 2016 to 31 January 2017, a prospective cohort study to diagnose TB and Cryptococcal meningitis using point of care tests was conducted in the medical wards at Kamuzu Central Hospital, in Lilongwe, Malawi. The tests offered were PIMA CD4 cell count, serum CrAg, urine LAM, and urine X-pert. The testing was integrated into an existing HIV/TB treatment room on the wards and performed close to admission time. Patients were followed until discharge or death in the ward.

Results

We included 438 HIV-positive patients; 76% had a previously known HIV diagnosis (87% already on ART). We measured CD4 count in 365/438 (83%), serum CrAg in 301/438 (69%), urine LAM in 363/438 (83%), and urine X-pert in 292/438 (67%). The median CD4 count was 144 cells/ml (IQR 46–307). Serum CrAg positivity rate was 23 /301 (8%) and CM was confirmed by CSF Crag in 13/23 (56%). The majority of CM patients 9/13 (69%) started antifungal therapy within two days of diagnosis. Urine LAM and urine X-pert positivity rates were 81/363(22%) and (14/292 (5%) respectively. The positivity rate of urine LAM was higher in patients with low CD4 cell counts (< 100 cells/ml) and low BMI (< 18.5). Most patients with positive urine LAM started TB treatment on the same day. Despite the early diagnosis and treatment of TB and CM, the inpatient mortality was high; 30% and 25% respectively.

Conclusion

Although advanced HIV rapid diagnostic tests are recommended, one key challenge in implementation is the limited trained personnel administering the tests. Despite the effective use of the point of care tests in the clinical care of hospitalized TB and CM patients, mortality among these patients remained unacceptably high. Henceforth we need to train other cadres apart from nurses, clinicians, and laboratory technicians to conduct the tests. There is an urgent need to identify and modify other risks of death from TB and CM.

Trial registration: Malawi National Health Science Research committee: Protocol # 1144. Registered 2 July 2014 and University Of North Carolina IRB #: UNCPM 21412, approved 13th October 2014.

Prospective Newborn Screening for Sickle Cell Disease and Other Inherited Blood Disorders in Central Malawi

Objectives: Newborn screening in the United States and Europe allows early identification of congenital disorders but does not yet exist in most low-resource settings, especially in sub-Saharan Africa. Newborn screening can identify multiple inherited hematological disorders, but feasibility and effectiveness for Africa are not fully determined. Methods: Surplus dried blood spot collected in Central Malawi through the HIV Early Infant Diagnosis surveillance program were repurposed and tested by isoelectric focusing for sickle cell disease and trait. Additional genetic testing identified G6PD deficiency and alpha thalassemia. Results: Testing of 10,529 cards revealed an overall sickle cell trait prevalence of 7.0% (range 3.9-9.7% by district); 10 of 14 infants identified with sickle cell disease (prevalence 0.1%) were located and received care at a specialized clinic. Subsequent testing of 1,329 randomly selected cards identified alpha thalassemia trait in 45.7% of samples, and G6PD deficiency in 20.4% of males and 3.4% of females, with 29.0% of females as heterozygous carriers. Conclusion: Inherited hematological disorders are common in Central Malawi; early identification through newborn screening can improve clinical outcomes and should be supported throughout Africa.

Beyond mobile phones: exploring using technology to support sustained engagement in care for HIV-infected women on antiretroviral therapy

Disengagement from HIV care has emerged as a challenge to the success of universal test and treat strategies for HIV-infected women. Technology may enhance efforts to monitor and support engagement in HIV care, but implementation barriers and facilitators need to be evaluated. We conducted a mixed-method study among HIV-infected, pregnant women and healthcare workers (HCWs) in Malawi to evaluate barriers and facilitators to three technologies to support monitoring HIV care: (1) text messaging, (2) SIM card scanning and (3) biometric fingerprint scanning. We included 123 HIV-infected, pregnant women and 85 HCWs in a survey, 8 focus group discussions and 5 in-depth interviews. Biometric fingerprint scanning emerged as the preferred strategy to monitor engagement in HIV care. Among HCWs, 70% felt biometrics were very feasible, while 48% thought text messaging and SIM card scanning were feasible. Nearly three quarters (72%) of surveyed women reported they would be very comfortable using biometrics to monitor HIV appointments. Barriers to using text messaging and SIM card scanning included low phone ownership (35%), illiteracy concerns, and frequent selling or changing of mobile phones. Future work is needed to explore the feasibly of implementing biometric fingerprint scanning or other technologies to monitor engagement in HIV care.

Improving Monitoring of Engagement in HIV Care for Women in Option B+: A Pilot Test of Biometric Fingerprint Scanning in Lilongwe, Malawi

Sustained engagement in HIV care is critical to the success of Option B+ for HIV-infected pregnant women. However, monitoring women's engagement in care across clinics and over time is challenging due to migration and clinic transfers. Improved strategies to identify and monitor women's engagement in HIV care across a network of clinics are needed, but have not been pilot tested. We evaluated the feasibility and acceptability of biometric fingerprint scanning to identify women and monitor HIV visit attendance among women in Option B+. Over a 3-month period, we enrolled HIV-infected pregnant women receiving care at two antenatal clinics in Lilongwe, Malawi and monitored their engagement in care using biometric fingerprint scanning and the standard-of-care electronic medical record (EMR) monitoring system. Biometric data was collected by trained research assistants, who uploaded and synced data across study sites daily using wireless internet. We collected data weekly on the biometric scanner performance, reliability, and usability. We assessed the feasibility and acceptability of using biometric fingerprint scanning to record HIV visits during exit interviews with a sample of participants and healthcare workers and by comparing visit concordance between the biometric fingerprint scanning and EMR systems. We enrolled 314 HIV-infected pregnant women and 51 HCWs (n = 365 total participants). The majority of participants felt the biometric fingerprint scanning system was easy to use (64%), required no additional assistance (69%) and met their expectations (76%). No major issues with data security, privacy, or scanner functionality were reported by HIV-infected women or healthcare workers. Of the 542 HIV visits captured during the study period among women in Option B+, 80% were recorded in the biometric fingerprint system versus 51% in the EMR system (PR 1.57, 95% CI 1.43, 1.72, p-value < 0.05). Among HIV-infected pregnant women engaged in HIV care, biometric fingerprint scanning is a feasible and acceptable way to monitor HIV visits and may improve the ability to monitor women's engagement in HIV care over time and across clinics. Biometric fingerprint scanning should be scaled-up and evaluated as an implementation strategy to support sustained engagement in HIV care for women during the perinatal period.

Frequent HIV and Young Age Among Individuals With Diverse Cancers at a National Teaching Hospital in Malawi

Purpose

Cancer surveillance provides a critical evidence base to guide cancer control efforts, yet population-based coverage in Africa is sparse. Hospital-based registries may help fill this need by providing local epidemiologic data to guide policy and forecast local health care needs. We report the epidemiology of patients with cancer recorded by a de novo hospital-based cancer registry at Kamuzu Central Hospital, Malawi, the sole provider of comprehensive oncology services for half the country and location of a high-volume pathology laboratory.

Methods

We conducted active case finding across all hospital departments and the pathology laboratory from June 2014 to March 2016. Patient demographics, tumor characteristics, treatment, and HIV status were collected. We describe epidemiology of the cancer caseload, registry design, and costs associated with registry operations.

Results

Among 1,446 registered patients, Kaposi sarcoma and cervical cancer were the most common cancers among men and women, respectively. Burkitt lymphoma was most common cancer among children. The current rate of pathology confirmation is 65%, a vast improvement in the diagnostic capacity for cancer through the hospital’s pathology laboratory. Among leading cancer types, an alarming proportion occurred at young ages; 50% of Kaposi sarcoma and 25% of esophageal, breast, and cervical cancers were diagnosed among those younger than 40 years of age. A systematic, cross-sectional assessment of HIV status reveals a prevalence of 58% among adults and 18% among children.

Conclusion

We report a high caseload among typically young patients and a significant burden of HIV infection among patients with cancer. In low- and middle-income countries with intermittent, sparse, or nonexistent cancer surveillance, hospital-based cancer registries can provide important local epidemiologic data while efforts to expand population-based registration continue.

Real-world experience using hydroxyurea in children with sickle cell disease in Lilongwe, Malawi

INTRODUCTION

Sickle cell disease (SCD) is among the most common inherited hematologic diseases in sub-Saharan Africa (SSA). Historically, hydroxyurea administration in SSA has been restricted due to limited region-specific evidence for safety and efficacy.

METHODS

We conducted a prospective observational cohort study of pediatric patients with SCD in Malawi. From January 2015 to November 2017, hydroxyurea at doses of 10-20 mg/kg/day was administered to children with clinically severe disease (targeted use policy). From December 2017 to July 2018, hydroxyurea was prescribed to all patients (universal use policy).

RESULTS

Of 187 patients with SCD, seven (3.7%) died and 23 (12.3%) were lost to follow-up. The majority (135, 72.2%) were prescribed hydroxyurea, 59 (43.7%) under the targeted use policy and 76 (56.3%) under the universal use policy. There were no documented severe toxicities. Under the targeted use policy, children with SCD demonstrated absolute decreases in the rates of hospitalization (-4.1 per 1000 person-days; -7.2, -1.0; P = .004), fevers (-4.2 per 1000 person-days; -7.2, -1.1; P = .002), transfusions (-2.3 per 1000 person-days; 95% confidence interval: -4.9, 0.3; P = .06), and annual school absenteeism (-51.2 per person-year; -60.1, -42.3; P < .0001) within 6 months of hydroxyurea commencement.

CONCLUSION

We successfully implemented universal administration of hydroxyurea to children with SCD at a tertiary hospital in Malawi. Similar to recently reported trials, hydroxyurea was safe and effective during routine programmatic experience, with clinical benefits particularly among high-risk children. This highlights the importance of continued widespread scale-up of hydroxyurea within SCD programs across SSA.

"A way of escaping": a qualitative study exploring reasons for clinic transferring and its impact on engagement in care among women in Option B

Clinic transfers among women in Option B+ are frequent, often undocumented, and may lead to suboptimal engagement in care and HIV outcomes. The reasons women move between HIV clinics are not well understood. We conducted four focus group discussions (FGD) among HIV-infected pregnant women in Option B+ and four FGDs and five in-depth interviews among healthcare workers (HCWs) at two large ART clinics in Lilongwe, Malawi. Mobility and fear of inadvertent HIV disclosure, particularly due to seeing neighbors or acquaintances at a clinic, were key drivers of transferring between HIV clinics. Women were aware of the need to obtain a formal transfer, but in practice this was often not feasible and led women to self-transfer clinics. Self-transferring to a new clinic frequently resulted to re-testing and re-initiating ART and concerns about disruptions in ART. Strategies to monitor women's engagement in HIV care without requiring a formal transfer are urgently needed.

Understanding Breast Cancer and Improving Outcomes in Malawi

Purpose

Despite the increasing breast cancer burden in sub-Saharan Africa, outcomes are suboptimal as a result of limited screening, limited diagnostic infrastructure, advanced stage, and limited treatment availability. In Malawi, we established the first prospective cohort of patients with breast cancer to comprehensively and longitudinally describe breast cancer in this environment.

Methods

Since December 2016, we have been enrolling patients with pathologically confirmed breast cancer at Kamuzu Central Hospital in Lilongwe, Malawi. All patients receive standardized baseline and follow-up evaluations and treatment that is consistent with National Comprehensive Cancer Network harmonized guidelines for sub-Saharan Africa.

Results

From December 2016 to May 2018, 70 women with breast cancer were enrolled. The median age was 48 years (range, 21 to 78 years) and 16 patients (23%) were HIV positive. Of 63 patients who could be formally staged, 54 (86%) had stage III and IV disease, including 40 (63%) with T4 tumors, 50 (79%) with at least N1, and 19 (30%) with distant metastases. Of 65 tumors histologically graded, 30 (46%) were grade 3 and 22 (34%) were grade 2. Of 66 biopsies evaluated, 31 (47%) were estrogen or progesterone receptor positive. Fifty biopsies were additionally evaluated for human epidermal growth factor receptor 2, of which 12 (22%) were positive and 15 (30%) triple negative. Thirty-nine women (56%) received curative-intent treatment, including eight with modified radical mastectomy followed by adjuvant chemotherapy, and 31 with neoadjuvant chemotherapy followed by modified radical mastectomy for localized bulky disease that was initially felt to be unresectable. Adjuvant/neoadjuvant chemotherapy was typically administered as doxorubicin plus cyclophosphamide. Twenty-five patients (36%) received palliative-intent chemotherapy, typically with single-agent paclitaxel. Six patients (9%) received no cancer treatment, with two patients dying before chemotherapy and four refusing cancer treatment. Median follow-up time was 7.8 months and overall survival was 88% at 12 months (95% CI, 76% to 96%) with no significant differences between HIV-positive and HIV-negative women ( P = .198).

Conclusion

Women at a national teaching hospital in Lilongwe, Malawi, presented with young age and advanced, bulky, high-risk breast cancer, but short-term survival was good in the context of a structured treatment program. Continued improvements for this population are needed for all aspects of the care cascade, including early detection, diagnosis, treatment, and palliation, to improve outcomes further.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . No COIs from the authors.

Information management in Malawi's prevention of Mother-to-Child Transmission (PMTCT) Program: Health workers' perspectives

Aim

Health workers are the key drivers for strengthening Prevention of Mother-to-Child Transmission (PMTCT) program information management in the health facilities. Thus understanding how health workers perceive information management can enlighten areas that require interventions to improve information management processes in the health facilities. The purpose is to assess health workers' perceptions toward PMTCT program information management and factors affecting information management in the health facilities.

Methods

The study was conducted in five out of forty-three health facilities providing PMTCT services in Lilongwe district and thirty out of sixty-eight health workers were recruited across the study sites. Purposive and convenience sampling were used. Semi-structured questionnaires and in-depth interviews were used to collect demographic information and health workers' perceptions toward information management, respectively. Thematic and content analysis techniques were employed for qualitative data, while descriptive statistics were used for quantitative data.

Results

Most health workers perceived information management tasks as part of their job description, but less important to provision of clinical services. For many, use of information technology tools was viewed as beneficial and valuable, whereas the paper-based system was perceived as tedious and difficult to manage. In addition, some believed lack of feedback, information sharing, and poor attitude toward information management tasks were challenges.

Conclusion

Based on the study findings, there is need to find ways of motivating data quality improvement practises in the health facilities, as health workers view this as a tangential, non-essential part of their job. Health facility leadership needs to promote an information culture through enforcement of meetings, supervision and provision of feedback. The government and its partners should continue rolling out and enhancing competence of health workers on EMR in the health facilities whilst also addressing challenges mentioned in the study.

Supporting Option B+ scale up and strengthening the prevention of mother-to-child transmission cascade in central Malawi: results from a serial cross-sectional study

BACKGROUND

We established Safeguard the Family (STF) to support Ministry of Health (MoH) scale-up of universal antiretroviral therapy (ART) for HIV-infected pregnant and breastfeeding women (Option B+) and to strengthen the prevention of mother-to-child transmission (PMTCT) cascade from HIV testing and counseling (HTC) through maternal ART provision and post-delivery early infant HIV diagnosis (EID). To these ends, we implemented the following interventions in 5 districts: 1) health worker training and mentorship; 2) couples' HTC and male partner involvement; 3) women's psychosocial support groups; and 4) health and laboratory system strengthening for EID.

METHODS

We conducted a serial cross-sectional study using facility-level quarterly (Q) program data and individual-level infant HIV-1 DNA PCR data to evaluate STF performance on PMTCT indicators for project years (Y) 1 (April-December 2011) through 3 (January-December 2013), and compared these results to national averages.

RESULTS

Facility-level uptake of HTC, ART, infant nevirapine prophylaxis, and infant DNA PCR testing increased significantly from quarterly baselines of 66 % (n/N = 32,433/48,804), 23 % (n/N = 442/1,958), 1 % (n/N = 10/1,958), and 52 % (n/N = 1,385/2,644) to 87 % (n/N = 39,458/45,324), 96 % (n/N = 2,046/2,121), 100 % (n/N = 2,121/2,121), and 62 % (n/N = 1,462/2,340), respectively, by project end (all p < 0.001). Quarterly HTC, ART, and infant nevirapine prophylaxis uptake outperformed national averages over years 2-3. While transitioning EID laboratory services to MoH, STF provided first-time HIV-1 DNA PCR testing for 2,226 of 11,261 HIV-exposed infants (20 %) tested in the MoH EID program in STF districts from program inception (Y2) through Y3. Of these, 78 (3.5 %) tested HIV-positive. Among infants with complete documentation (n = 608), median age at first testing decreased from 112 days (interquartile range, IQR: 57-198) in Y2 to 76 days (IQR: 46-152) in Y3 (p < 0.001). During Y3 (only year with national data for comparison), non-significantly fewer exposed infants tested HIV-positive (3.6 %) at first testing in STF districts than nationally (4.1 %) (p = 0.4).

CONCLUSIONS

STF interventions, integrated within the MoH Option B+ program, achieved favorable HTC, maternal ART, infant prophylaxis, and EID services uptake, and a low proportion of infants found HIV-infected at first DNA PCR testing. Continued investments are needed to strengthen the PMTCT cascade, particularly around EID.