Who has access to counseling and testing and anti-retroviral therapy in Malawi – an equity analysis

Background  

The HIV and AIDS epidemic in Malawi poses multiple challenges from an equity perspective. It is estimated that 12% of Malawians are living with HIV or AIDS among the 15-49 age group. This paper synthesises available information to bring an equity lens on Counselling and Testing (CT) and Antiretroviral Therapy (ART) policy, practice and provision in Malawi.     

Results from a dose-response study using 3,3'-diindolylmethane in the K14-HPV16 transgenic mouse model: cervical histology

The human papilloma virus is the major cause of cervical cancer. Viral infection initiates cervical intraepithelial neoplasia, which progresses through several stages to cervical cancer. The objective of this study is to identify the minimum effective dose of diindolylmethane that prevents the progression from cervical dysplasia to carcinoma in situ. We document cervical histology in K14-HPV16 mice receiving different doses of diindolylmethane. Urinary diindolylmethane concentrations are reported. Diindolylmethane could enhance the efficacy of human papilloma virus vaccines, creating a new therapeutic use for these vaccines in women already infected with the virus. Five doses (0-2,500 ppm) of diindolylmethane were incorporated into each mouse diet. The reproductive tract was serially sectioned and urine was obtained for analysis of urinary diindolylmethane. The results indicate that 62% of mice receiving 1,000 ppm diindolylmethane remained dysplasia-free after 20 weeks compared with 16% of mice receiving no diindolylmethane and 18% receiving 500 ppm; 1,000 ppm of 3,3'-diindolylmethane in the diet completely suppressed the development of cervical cancer. Urinary diindolylmethane levels increased significantly as diindolylmethane in food increased. These findings imply usefulness for diindolylmethane in the search to prevent cervical cancer when used in combination with prophylactic or therapeutic vaccines.     

Quality of care in nutritional rehabilitation in HIV-endemic Malawi: caregiver perspectives

In Malawi, HIV and malnutrition are two of the most common causes of childhood morbidity and mortality. This qualitative study based in Nutrition Rehabilitation Units (NRU) in HIV‐endemic Malawi explores caregiver's (staff and family) perspectives on quality of care for severely malnourished children. Three carer focus groups and 30 carer and staff in‐depth interviews were conducted in two NRUs. The interviews and data analysis used a grounded theory approach, using both male and female Malawian researchers. Trustworthiness was enhanced through the researchers' prolonged engagement with the study setting and participants. The use of multiple methods – interviews, focus groups and observation – allowed for triangulation of the data. Data was then cross‐referenced between staff and family caregiver reports. The analysis generated five themes. ‘We have different blood’ referring to staff attitudes and underperformance, ‘What wrong did I do to God?’ referring to stigma and chronic illness, ‘My other children back home’ referring to the carer's multiple responsibilities and challenges, ‘Always in short supply’ referring to resources available in the NRU (milk, medicine, space, hygiene) and ‘you are always lagging behind’ referring to the need for change and participants recommendations. Quality of care is a complex issue, bound by resources and capacity, influenced by stigma and hierarchy and limited by caregivers' conflicting responsibilities. Valuing and involving caregivers is essential in improving quality of care. Care should be patient and family centred and HIV services should be integrated into malnutrition care at the hospital and community level.     

Programming hyperglycaemia in the rat through prenatal exposure to glucocorticoids-fetal effect or maternal influence?

In a previous study, we showed that exposure of rats to dexamethasone (Dex) selectively in late pregnancy produces permanent induction of hepatic phosphoenolpyruvate carboxykinase (PEPCK) expression and hyperglycaemia in the adult offspring. The mechanisms by which glucocorticoids cause this programming are unclear but may involve direct actions on the fetus/neonate, or glucocorticoids may act indirectly by affecting maternal postnatal nursing behaviour. Using a cross-fostering paradigm, the present data demonstrate that switching the offspring at birth from Dex-treated dams to control dams does not prevent induction of PEPCK or hyperglycaemia. Similarly, offspring born to control dams but reared by Dex-treated dams from birth maintain normal glycaemic control. During the neonatal period, injection of saline per se was sufficient to cause exaggeration in adult offspring responses to an oral glucose load, with no additional effect from Dex. However, postnatal treatment with either saline or Dex did not alter hepatic PEPCK activity. Prenatal Dex permanently raised basal plasma corticosterone levels, but under stress conditions there were no differences in circulating corticosterone levels. Likewise, Dex-exposed rats had similar plasma catecholamine concentrations to control animals. These findings show that glucocorticoids programme hyperglycaemia through mechanisms that operate on the fetus or directly on the neonate, rather than via effects that alter maternal postnatal behaviour during the suckling period. The hyperglycaemic response does not appear to result from abnormal sympathoadrenal activity or hypothalamic-pituitary-adrenal response during stress.     

Pathology and causes of death in a series of human immunodeficiency virus-positive and -negative pediatric referral hospital admissions in Botswana

BACKGROUND: Little is known about causes of death among children seriously affected by the AIDS epidemic in southern African countries. METHODS: Autopsies were performed on 47 children 1 month to 13 years of age in Francistown, Botswana, between July 1997 and July 1998. RESULTS: Median age was 10 months; 68% were HIV-positive. The leading cause of death was respiratory infection, accounting for 29 of 35 (83%) deaths among HIV-positive and 8 of 12 (67%) deaths among HIV-negative children. Among HIV-positive children, Pneumocystis carinii pneumonia (PCP) was responsible for 31% of all deaths and for 48% of deaths in infants < or =1 year. Among children < or =2 years with cough and dyspnea, age < or =1 year, interstitial infiltrate and HIV positivity were highly predictive of PCP (sensitivity, 100%; specificity, 63%). CONCLUSION: Respiratory disease accounted for most deaths in HIV-positive children. Children < or =1 year who are known or suspected to be HIV-positive and who have cough, dyspnea and pulmonary infiltrates should be treated presumptively for PCP.     

Decentralising diabetes care from hospitals to primary health care centres in Malawi

BackgroundNon-communicable diseases (NCDs) such as diabetes and hypertension have become a prominent public health concern in Malawi, where health care services for NCDs are generally restricted to urban centres and district hospitals, while the vast majority of Malawians live in rural settings. Whether similar quality of diabetes care can be delivered at health centres compared to hospitals is not known.MethodsWe implemented a pilot project of decentralized diabetes care at eight health centres in four districts in Malawi. We described differences between district hospitals and rural health centres in terms of patient characteristics, diabetes complications, cardiovascular risk factors, and aspects of the quality of care and used multivariate logistic regression to explore factors associated with adequate diabetes and blood pressure control.ResultsBy March 2019, 1339 patients with diabetes were registered of whom 286 (21%) received care at peripheral health centres. The median duration of care of patients in the diabetes clinics during the study period was 8.8 months. Overall, HIV testing coverage was 93.6%, blood pressure was recorded in 92.4%; 68.5% underwent foot examination of whom 35.0% had diabetic complications; 30.1% underwent fundoscopy of whom 15.6% had signs of diabetic retinopathy. No significant differences in coverage of testing for diabetes complications were observed between health facility types. Neither did we find significant differences in retention in care (72.1 vs. 77.6%; p=0.06), adequate diabetes control (35.0% vs. 37.8%; p=0.41) and adequate blood pressure control (51.3% vs. 49.8%; p=0.66) between hospitals and health centres. In multivariate analysis, male sex was associated with adequate diabetes control, while lower age and normal body mass index were associated with adequate blood pressure control; health facility type was not associated with either.ConclusionQuality of care did not appear to differ between hospitals and health centres, but was insufficient at both levels.     

Prevalent Herpes Simplex Virus-2 Increases the Risk of Incident Bacterial Vaginosis in Women from South Africa

Studies have shown that women diagnosed with herpes simplex virus-2 (HSV-2) have a higher risk for bacterial vaginosis (BV) infection. We investigated the presence of HSV-2 infections as a risk factor for incident BV infections in high risk, Human immunodeficiency virus (HIV) uninfected women enrolled in a HIV prevention trial in Durban, South Africa. The Vaginal and Oral Interventions to Control the Epidemic trial was a multicentre, double blinded, randomized controlled trial which was designed to estimate the effectiveness of daily treatment with vaginal tenofovir gel, oral tenofovir disoproxil fumarate and oral Truvada in preventing HIV-1 infection in women. Women provided samples for the diagnosis of HSV-2 and BV. The presence of HSV-2 antibodies was detected using HerpeSelect? ELISA IgG. Bacterial vaginosis was diagnosed using the Nugent scoring system. To assess the risk of BV incidence, modelled as a time-dependent variable, we used the Andersen-Gill model with robust variance estimation and Efron methods for ties. Overall, 2750 women were enrolled in the VOICE trial at our study sites. Women who had a HSV-2 infection at enrolment were shown to be at increased risk for incident BV infections (adjusted hazard ratio 1.17, 95% CI 1.08, 1.27, p ≤ 0.001). In addition, being of a young age, being unmarried and having a partner that has other partners were significantly associated with subsequent BV infection. Our findings therefore advocate the need for strengthening STI prevention efforts among women in high burden STI settings.