Agnes Moses

Prevention of mother-to-child transmission: program changes and the effect on uptake of the Hivnet 012 regimen in Malawi

Objective(s): To evaluate uptake of HIV testing in a prevention of mother-to-child transmission program (PMTCT) in Lilongwe, Malawi from April 2002 until December 2006. Design: Retrospective analysis of monthly reports from the beginning of the program. Setting: Four antenatal clinics in Lilongwe, Malawi. Methods: Pregnant women attending urban antenatal clinics in Lilongwe were invited to participate in a PMTCT program. Women were given information and education on antenatal care and PMTCT in groups of 8 to 12. Written informed consent for HIV testing was obtained privately. Women returned for the test result 1–2 weeks later. Mothers and infants were given the HIVNET 012 regimen. Rapid HIV testing and ‘opt-out’ testing were instituted in July 2003 and April 2005, respectively. Infants were tested using HIV DNA PCR and, if HIV positive, a CD4 cell percentage was obtained and the infants were referred for further medical evaluation and treatment. Results: The program reached 20 000 pregnant women in the first 12 months. Acceptance of HIV testing increased from 45% to 73% (P < 0.001) when rapid, same day testing was instituted. When opt-out testing was instituted, 99% of the mothers agreed to testing. Of the infants tested, 15.5% were HIV positive. Conclusion: Rapid HIV testing using the opt-out method increased acceptance of HIV testing in the PMTCT program to 99% in urban Lilongwe, Malawi.

CHOP Chemotherapy for Aggressive Non-Hodgkin Lymphoma with and without HIV in the Antiretroviral Therapy Era in Malawi.

There are no prospective studies of aggressive non-Hodgkin lymphoma (NHL) treated with CHOP in sub-Saharan Africa. We enrolled adults with aggressive NHL in Malawi between June 2013 and May 2015. Chemotherapy and supportive care were standardized, and HIV+ patients received antiretroviral therapy (ART). Thirty-seven of 58 patients (64%) were HIV+. Median age was 47 years (IQR 39–56), and 35 (60%) were male. Thirty-five patients (60%) had stage III/IV, 43 (74%) B symptoms, and 28 (48%) performance status ≥2. B-cell NHL predominated among HIV+ patients, and all T-cell NHL occurred among HIV- individuals. Thirty-one HIV+ patients (84%) were on ART for a median 9.9 months (IQR 1.1–31.7) before NHL diagnosis, median CD4 was 121 cells/μL (IQR 61–244), and 43% had suppressed HIV RNA. HIV+ patients received a similar number of CHOP cycles compared to HIV- patients, but more frequently developed grade 3/4 neutropenia (84% vs 31%, p = 0.001), resulting in modestly lower cyclophosphamide and doxorubicin doses with longer intervals between cycles. Twelve-month overall survival (OS) was 45% (95% CI 31–57%). T-cell NHL (HR 3.90, p = 0.017), hemoglobin (HR 0.82 per g/dL, p = 0.017), albumin (HR 0.57 per g/dL, p = 0.019), and IPI (HR 2.02 per unit, p<0.001) were associated with mortality. HIV was not associated with mortality, and findings were similar among patients with diffuse large B-cell lymphoma. Twenty-three deaths were from NHL (12 HIV+, 11 HIV-), and 12 from CHOP (9 HIV+, 3 HIV-). CHOP can be safe, effective, and feasible for aggressive NHL in Malawi with and without HIV.

Characteristics and survival for HIV-associated multicentric Castleman disease in Malawi

Clinical reports of multicentric Castleman disease (MCD) from sub‐Saharan Africa (SSA) are scarce despite high prevalence of HIV and Kaposi sarcoma‐associated herpesvirus (KSHV). Our objective is to describe characteristics and survival for HIV‐associated MCD patients in Malawi. To our knowledge, this is the first HIV‐associated MCD case series from the region.

Clinical breast examination screening by trained laywomen in Malawi integrated with other health services.

BACKGROUNDnBreast cancer awareness and early detection are limited in sub-Saharan Africa. Resource limitations make screening mammography or clinical breast examination (CBE) by physicians or nurses impractical in many settings. We aimed to assess feasibility and performance of CBE by laywomen in urban health clinics in Malawi.nnnMETHODSnFour laywomen were trained to deliver breast cancer educational talks and conduct CBE. After training, screening was implemented in diverse urban health clinics. Eligible women were ≥30xa0y, with no prior breast cancer or breast surgery, and clinic attendance for reasons other than a breast concern. Women with abnormal CBE were referred to a study surgeon. All palpable masses confirmed by surgeon examination were pathologically sampled. Patients with abnormal screening CBE but normal surgeon examination underwent breast ultrasound confirmation. In addition, 50 randomly selected women with normal screening CBE underwent breast ultrasound, and 45 different women with normal CBE were randomly assigned to surgeon examination.nnnRESULTSnAmong 1220 eligible women, 1000 (82%) agreed to CBE. Lack of time (69%) was the commonest reason for refusal. Educational talk attendance was associated with higher CBE participation (83% versus 77%, Pxa0=xa00.012). Among 1000 women screened, 7% had abnormal CBE. Of 45 women with normal CBE randomized to physician examination, 43 had normal examinations and two had axillary lymphadenopathy not detected by CBE. Sixty of 67 women (90%) with abnormal CBE attended the referral visit. Of these, 29 (48%) had concordant abnormal physician examination. Thirty-one women (52%) had discordant normal physician examination, all of whom also had normal breast ultrasounds. Compared with physician examination, sensitivity for CBE by laywomen was 94% (confidence interval [CI] 79%-99%), specificity 58% (CI, 46%-70%), positive predictive value 48% (CI, 35%-62%), and negative predictive value 96% (CI, 85%-100%). Of 13 women who underwent recommended pathologic sampling of a breast lesion, two had cytologic dysplasia and all others benign results.nnnCONCLUSIONSnCBE uptake in Lilongwe clinics was high. CBE by laywomen compared favorably with physician examination and follow-up was good. Our intervention can serve as a model for wider implementation. Performance in rural areas, effects on cancer stage and mortality, and cost effectiveness require evaluation.

Breast Cancer Screening in Low- and Middle-Income Countries: A Perspective From Malawi

Breast cancer burden is high in low-resource countries. From 1980 to 2010, new breast cancer cases increased by more than 50% worldwide. Disease burden increased even more rapidly in lowandmiddle-incomecountries (LMICs), where more than half of breast cancer cases now occur. Moreover, breast cancer disproportionately affects young women in LMICs, such that 23% of new breast cancer cases occur among women age 15 to 49 years in LMICs versus 10% in high-income countries.

Leveraging HIV Research and Implementation for Cancer and Noncommunicable Diseases in Malawi

Abstract 33Background:Enabled by collaboration and political stability, Malawi is a global leader for HIV research and implementation. We undertook this work to identify ways to leverage successes in HIV treatment and research for cancer and noncommunicable diseases (NCDs).Methods:Over more than two decades, investment from the National Institutes of Health (NIH) and other funders has allowed Malawi participation in international HIV networks. As these sought to address HIV-positive cancer, investment occurred to increase pathology, improve cancer registration, scale up cervical cancer screening, and improve nursing and pharmacy skills for chemotherapy administration. This allowed Malawi to participate in multinational clinical trials for HIV-positive Kaposi sarcoma treatment and cervical cancer prevention. Building on this, Malawi was one of six countries in 2014 to receive an NIH U54 consortium award for HIV-positive malignancies and was one of six countries added to the National Cancer Institute (NCI) ...

The Malawi Cancer Consortium – Catalyzing Cancer Care and Research in Southern Africa

Abstract 68Background:Cancer burden is increasing in Malawi, particularly for HIV-associated malignancies.Methods:With support from the National Cancer Institute, the Malawi Cancer Consortium (MCC) was initiated in September 2014. Partners include the UNC Lineberger Comprehensive Cancer Center, Malawi Ministry of Health, University of Malawi College of Medicine, and Lighthouse Trust. Spanning Malawi’s two major cities, Lilongwe and Blantyre, MCC includes three support cores (administration, analysis, mentoring) and three multi-institution research projects: (1) a national HIV-cancer match study to assess cancer incidence in the ART era; (2) a longitudinal cohort to identify clinical and molecular correlates of KS chemotherapy response; and (3) a longitudinal cohort to elucidate lymphoma biology and develop better treatments for HIV-associated lymphoma.Results:For project 1, 65,500 records from the Malawi National Cancer Registry and Malawi HIV cohorts have been abstracted, and initial data harmonization c...

Uptake and Performance of Clinical Breast Exam Screening Program by Trained Laywomen in Malawi

Abstract 2Background:Breast cancer mortality is high in sub-Saharan Africa (SSA) partly due to limited breast cancer awareness and challenges in early detection. We trained laywomen to promote breast cancer awareness and perform screening - clinical breast exam (CBE) - in urban clinics. This is the first breast cancer screening study in Malawi, and the first study in SSA to assess CBE delivered by laywomen with other health services.Methods:Four laywomen were trained to deliver breast cancer educational talks and conduct CBE. After training, screening was implemented in diverse urban health clinics. Women eligible to undergo CBE were ≥30 years, with no prior breast cancer or breast surgery, and clinic attendance for reasons other than a breast concern. Women with abnormal CBE were referred to a study surgeon. All palpable masses confirmed by surgeon exam were pathologically sampled. Patients with abnormal screening CBE but normal surgeon exam underwent breast ultrasound confirmation. Additionally, 50 rand...

Factors associated with cancer pathogenesis among patients attending oncology clinic at Kamuzu Central Hospital in Malawi

Cancer is the cause of 13% of total worldwide mortality, and was the leading cause of in 2010 according to the World Health Organization. HIV prevalence in urban Malawi is approximately 20% and contributes to the pathogenesis of cancers, particularly AIDS-defining cancers. To evaluate risk factors for specific malignancies in Malawians, we designed an observational study to collect clinical data for cancer patients presenting at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi.