How HIV Clients Find Their Way Back to the ART Clinic: A Qualitative Study of Disengagement and Re-engagement with HIV Care in Malawi

AIDS and Behavior - Retention in antiretroviral therapy (ART) services is critical to achieving positive health outcomes for individuals living with HIV, but accumulating evidence indicates that...     

Skills of general health workers in primary eye care in Kenya,Malawi and Tanzania

Background

Primary eye care (PEC) in sub-Saharan Africa usually means the diagnosis, treatment, and referral of eye conditions at the most basic level of the health system by primary health care workers (PHCWs), who receive minimal training in eye care as part of their curricula. We undertook this study with the aim to evaluate basic PEC knowledge and ophthalmologic skills of PHCWs, as well as the factors associated with these in selected districts in Kenya, Malawi, and Tanzania.

Methods

A standardized (26 items) questionnaire was administered to PHCWs in all primary health care (PHC) facilities of 2 districts in each country. Demographic information was collected and an examination aimed to measure competency in 5 key areas (recognition and management of advanced cataract, conjunctivitis, presbyopia, and severe trauma plus demonstrated ability to measure visual acuity) was administered.

Results

Three-hundred-forty-three PHCWs were enrolled (100, 107, and 136 in Tanzania, Kenya, and Malawi, respectively). The competency scores of PHCW varied by area, with 55.7%, 61.2%, 31.2%, and 66.1% scoring at the competency level in advanced cataract, conjunctivitis, presbyopia, and trauma, respectively. Only 8.2% could measure visual acuity. Combining all scores, only 9 (2.6%) demonstrated competence in all areas.

Conclusion

The current skills of health workers in PEC are low, with a large per cent below the basic competency level. There is an urgent need to reconsider the expectations of PEC and the content of training.

     

Task shifting for cataract surgery in eastern Africa: productivity and attrition of non-physician cataract surgeons in Kenya,Malawi and Tanzania

Background

This project examined the surgical productivity and attrition of non-physician cataract surgeons (NPCSs) in Tanzania, Malawi, and Kenya.

Methods

Baseline (2008-9) data on training, support, and productivity (annual cataract surgery rate) were collected from officially trained NPCSs using mailed questionnaires followed by telephone interviews. Telephone interviews were used to collect follow-up data annually on productivity and semi-annually on attrition. A detailed telephone interview was conducted if a surgeon left his/her post. Data were entered into and analysed using STATA.

Results

Among the 135 NPCSs, 129 were enrolled in the study (Kenya 88, Tanzania 38, and Malawi 3) mean age 42 years; average time since completing training 6.6 years. Employment was in District 44%, Regional 24% or mission/ private 32% hospitals. Small incision cataract surgery was practiced by 38% of the NPCSs. The mean cataract surgery rate was 188/year, median 76 (range 0-1700). For 39 (31%) NPCSs their surgical rate was more than 200/year. Approximately 22% in Kenya and 25% in Tanzania had years where the cataract surgical rate was zero. About 11% of the surgeons had no support staff.Factors significantly associated with increased productivity were: 1) located at a regional or private/mission hospital compared to a district hospital (OR = 8.26; 95 % CI 2.89 – 23.81); 2) 3 or more nurses in the eye unit (OR = 8.69; 95% CI 3.27-23.15); 3) 3 or more cataract surgical sets (OR = 3.26; 95% CI 1.48-7.16); 4) a separate eye theatre (OR = 5.41; 95% CI 2.15-13.65); 5) a surgical outreach program (OR = 4.44; 95% CI 1.88-10.52); and 6) providing transport for patients to hospital (OR = 6.39; 95% CI 2.62-15.59). The associations were similar for baseline and follow-up assessments. Attrition during the 3 years occurred in 13 surgeons (10.3%) and was due to retirement or promotion to administration.

Conclusions

High quality training is necessary but not sufficient to result in cataract surgical activity that meets population needs and maintains surgical skill. Needed are supporting institutions and staff, functioning equipment and programs to recruit and transport patients.

     

Strategies to improve antiretroviral therapy (ART) initiation and early engagement among men in sub-Saharan Africa: A scoping review of interventions in the era of universal treatment

Objectives

Men in sub-Saharan Africa (SSA) have lower rates of antiretroviral therapy (ART) initiation and higher rates of early default than women. Little is known about effective interventions to improve men's outcomes. We conducted a scoping review of interventions aimed to increase ART initiation and/or early retention among men in SSA since universal treatment policies were implemented.

Methods

Three databases, HIV conference databases and grey literature were searched for studies published between January 2016 to May 2021 that reported on initiation and/or early retention among men. Eligibility criteria included: participants in SSA, data collected after universal treatment policies were implemented (2016–2021), quantitative data on ART initiation and/or early retention for males, general male population (not exclusively focused on key populations), intervention study (report outcomes for at least one non-standard service delivery strategy), and written in English.

Results

Of the 4351 sources retrieved, 15 (reporting on 16 interventions) met inclusion criteria. Of the 16 interventions, only two (2/16, 13%) exclusively focused on men. Five (5/16, 31%) were randomised control trials (RCT), one (1/16, 6%) was a retrospective cohort study, and 10 (10/16, 63%) did not have comparison groups. Thirteen (13/16, 81%) interventions measured ART initiation and six (6/16, 37%) measured early retention. Outcome definitions and time frames varied greatly, with seven (7/16, 44%) not specifying time frames at all. Five types of interventions were represented: optimising ART services at health facilities, community-based ART services, outreach support (such as reminders and facility escort), counselling and/or peer support, and conditional incentives. Across all intervention types, ART initiation rates ranged from 27% to 97% and early retention from 47% to 95%.

Conclusions

Despite years of data of men's suboptimal ART outcomes, there is little high-quality evidence on interventions to increase men's ART initiation or early retention in SSA. Additional randomised or quasi-experimental studies are urgently needed.     

Baseline Trachoma Mapping in Malawi with the Global Trachoma Mapping Project (GTMP)

ABSTRACT

Purpose: To determine the prevalence of trachoma in all suspected endemic districts in Malawi.

Methods: A population-based survey conducted in 16 evaluation units from 12 suspected endemic districts in Malawi (population 6,390,517), using the standardized Global Trachoma Mapping Project (GTMP) protocol. A 2-stage cluster-random sampling design selected 30 households from each of 30 clusters per evaluation unit; all residents aged 1 year and older in selected households were examined for evidence of follicular trachoma (TF), intense trachomatous inflammation (TI), and trachomatous trichiasis (TT).

Results: Four of the 16 evaluation units were found to be endemic for trachoma, with a prevalence range of 10.0–13.5% for TF and 0.2–0.6% for TT. Nine evaluation units had a TF prevalence between 5.0% and 9.9% while three evaluation units had a TF prevalence <5.0%.

Conclusion: The prevalence rates of active trachoma in Malawi were not uniform among suspected endemic evaluation units, with rates higher than the World Health Organization (WHO) threshold for implementation of community-based control measures (TF?≥?10.0%) in only 4 of the 16 evaluation units. Trachoma remains a disease of public health importance in some parts of Malawi and adjoining (unmapped) districts should be prioritized for mapping. According to the survey, an additional 3,169,362 people require intervention to reduce active disease and 1557 trichiasis surgeries are needed to reduce the prevalence of TT below WHO recommended thresholds.     

Low-dose transscleral diode laser cyclophotocoagulation (TSCPC) as a potential single treatment for primary open-angle glaucoma (POAG) in Malawi?

Purpose

To investigate if low-dose 810 nm transscleral cyclophotocoagulation (TSCPC) can be used as single treatment in Malawian glaucoma patients.

Methods

Forty-seven eyes of 28 patients with primary open-angle and pseudoexfoliation glaucoma were treated with TSCPC using 12 spots with 900 mW, 2,000 ms (1.8 J per spot); six spots in the upper half, six in the lower by sparing the 3 and 9 o’clock positions ±20°. Intraocular pressure (IOP) and uncorrected visual acuity (UVA) were measured by an independent examiner preoperatively, on the first postoperative day, after 2 weeks, and after 3 months.

Results

Twenty-four (86 %) and 18 (64 %) of 28 patients (31 of 47 eyes; 66 %) completed follow-up at 2 weeks and at 3 months respectively. After a single treatment session, IOP decreased by at least 25 % in 88 % (21 of 24) after 2 weeks, and in 50 % (nine of 18) of patients after 3 months. Mean IOP was 38.5 mmHg before TSCPC, 23.5 mmHg (p?<?0.001) after 1 day, 24.5 mmHg (p?<?0.001) after 2 weeks, and 35.6 mmHg (p?=?0.37) after 3 months. In three patients, however, IOP increased after 3 months to levels significantly higher than before TSCPC.

Conclusion

Low-dose TSCPC caused a significant IOP lowering for up to 2 weeks (15 mmHg less from baseline) in most patients. After 3 months, this effect was stable in 50 % of patients; in the other half, IOP nearly returned back to baseline.     

Completion of Baseline Trachoma Mapping in Malawi: Results of Eight Population-Based Prevalence Surveys Conducted with the Global Trachoma Mapping Project

ABSTRACT

Purpose: Following a first phase of trachoma mapping in Malawi with the Global Trachoma Mapping Project, we identified and mapped trachoma districts previously suspected to be non-endemic, although adjacent to districts with estimated trachoma prevalences indicating a public health problem.

Methods: We conducted population-based surveys in eight evaluation units (EUs) comprising eight districts in Malawi (total population 3,230,272). A 2-stage cluster random sampling design allowed us to select 30 households from each of 30 clusters per EU; all residents aged 1 year and older in selected households were examined for evidence of trachomatous inflammation–follicular (TF) and trachomatous trichiasis (TT).

Results: None of the eight EUs had a TF prevalence in 1–9-year-olds ≥10%, one district (Dedza) had a TF prevalence between 5.0% and 9.9%, and only one district (Karonga) had a trichiasis prevalence in adults ≥0.2%.

Conclusion: The prevalence of TF and TT in six of eight EUs surveyed was consistent with an original categorization of trachoma being unlikely to be a public health problem. In the absence of formal surveys, health management information system data and other locally available information about trachoma is likely to be useful in predicting areas where public health interventions against trachoma are required.     

Barriers to Uptake of Free Pediatric Cataract Surgery in Malawi

Purpose: To examine the demographic, sociocultural and socioeconomic factors that prevent families of cataract blind children from accepting free pediatric cataract surgery in Malawi.

Methods: A total 58 parents of 62 children were recruited into the study. Of these, 53 parents partook in in-depth interviews and focus group discussions after the children were screened and the parents offered free cataract surgery. Overall, 37 parents accepted (acceptors) and 16 parents did not accept (non-acceptors) cataract surgery. All interviews were transcribed and iteratively analyzed. Household economic status was quantified using the Progress out of Poverty Index for Malawi.

Results: Acceptors were better off economically (p?=?0.13). Understanding of cataract, its causing blindness and impairment, as well as treatment options, by the decision makers in the families was poor. Decision-making involved a complex array of aspects needing consideration before accepting, of which distance to the health facility was a frequently mentioned barrier. Non-acceptors were more likely to come from twice the distance compared to acceptors (p?=?0.0098). Non-acceptors were more likely to be peasant (subsistence) farmers than acceptors (p?=?0.048). Non-acceptors were more likely to live in a house made of mud bricks with a roof of grass thatch (p?=?0.001). There was no significant difference in acceptance rate between educated and non-educated mothers (p?=?0.11). Intensive counseling as provided in this project increased the likelihood of accepting surgery.

Conclusion: Economic hardship and long distances to health facilities decrease acceptance even of free pediatric cataract surgical services, highlighting that just providing surgery free of cost may not be sufficient for the most economically disadvantaged in rural Africa.