Ronald Mataya

Gender distribution of adult patients on highly active antiretroviral therapy (HAART) in Southern Africa: a systematic review

BackgroundHIV and AIDS are significant and growing public health concerns in southern Africa. The majority of countries in the region have national adult HIV prevalence estimates exceeding 10 percent. The increasing availability of highly active antiretroviral therapy (HAART) has potential to mitigate the situation. There is however concern that women may experience more barriers in accessing treatment programs than men.MethodsA systematic review of the literature was carried out to describe the gender distribution of patients accessing highly active antiretroviral therapy (HAART) in Southern Africa. Data on number of patients on treatment, their mean or median age and gender were obtained and compared across studies and reports.ResultsThe median or mean age of patients in the studies ranged from 33 to 39 years. While female to male HIV infection prevalence ratios in the southern African countries ranged from 1.2:1 to 1.6:1, female to male ratios on HAART ranged from 0.8: 1 to 2.3: 1. The majority of the reports had female: male ratio in treatment exceeding 1.6. Overall, there were more females on HAART than there were males and this was not solely explained by the higher HIV prevalence among females compared to males.ConclusionIn most Southern African countries, proportionally more females are on HIV antiretroviral treatment than men, even when the higher HIV infection prevalence in females is accounted for. There is need to identify the factors that are facilitating womens accessibility to HIV treatment. As more patients access HAART in the region, it will be important to continue assessing the gender distribution of patients on HAART.

Prevalence of complications of male circumcision in Anglophone Africa: a systematic review

BackgroundThere is growing evidence that male circumcision (MC) prevents heterosexual acquisition of HIV by males in sub-Saharan Africa, the region of the world heavily affected by the HIV pandemic. While there is growing support for wide-spread availability and accessibility of MC in Africa, there is limited discussion about the prevalence of physical complications of male circumcision on the continent.MethodsA systematic literature search and review of articles in indexed journals and conference abstracts was conducted to collect and analyze prevalence of complications of MC in Anglophone sub-Saharan Africa. Information extracted included: indications for MC, complications reported, age of patients and category of circumcisers.ResultsThere were 8 articles and 2 abstracts that were suitable for the analysis. The studies were not strictly comparable as some reported on a wide range of complications while others reported just a limited list of possible complications. Prevalence of reported complications of MC ranged from 0% to 50.1%. Excluding the study with 50.1%, which was on a series of haemophilia patients, the next highest prevalence of complications was 24.1%. Most of the complications were minor. There was no firm evidence to suggest that MCs performed by physician surgeons were associated with lower prevalence of complications when compared with non-physician health professionals.ConclusionThe available data are inadequate to obtain a reasonable assessment of the prevalence of complications of MC in sub-Saharan Africa. Some of the available studies however report potentially significant prevalence of complications, though of minor clinical significance. This should be considered as public health policy makers consider whether to scale-up MC as an HIV preventative measure. Decision for the scale-up will depend on a careful cost-benefit assessment of which physical complications are certainly an important aspect. There is need for standardized reporting of complications of male circumcision.

Human resources requirements for highly active antiretroviral therapy scale-up in Malawi

BackgroundTwelve percent of the adult population in Malawi is estimated to be HIV infected. About 15% to 20% of these are in need of life saving antiretroviral therapy. The country has a public sector-led antiretroviral treatment program both in the private and public health sectors. Estimation of the clinical human resources needs is required to inform the planning and distribution of health professionals.MethodsWe obtained data on the total number of patients on highly active antiretroviral treatment program from the Malawi National AIDS Commission and Ministry of Health, HIV Unit, and the number of registered health professionals from the relevant regulatory bodies. We also estimated number of health professionals required to deliver highly active antiretroviral therapy (HAART) using estimates of human resources from the literature. We also obtained data from the Ministry of Health on the actual number of nurses, clinical officers and medical doctors providing services in HAART clinics. We then made comparisons between the human resources situation on the ground and the theoretical estimates based on explicit assumptions.ResultsThere were 610 clinicians (396 clinical officers and 214 physicians), 44 pharmacists and 98 pharmacy technicians and 7264 nurses registered in Malawi. At the end of March 2007 there were 85 clinical officer and physician full-time equivalents (FTEs) and 91 nurse FTEs providing HAART to 95,674 patients. The human resources used for the delivery of HAART comprised 13.9% of all clinical officers and physicians and 1.1% of all nurses. Using the estimated numbers of health professionals from the literature required 15.7–31.4% of all physicians and clinical officers, 66.5–199.3% of all pharmacists and pharmacy technicians and 2.6 to 9.2% of all the available nurses. To provide HAART to all the 170,000 HIV infected persons estimated as clinically eligible would require 4.7% to 16.4% of the total number of nurses, 118.1% to 354.2% of all the available pharmacists and pharmacy technicians and 27.9% to 55.7% of all clinical officers and physicians. The actual number of health professionals working in the delivery of HAART in the clinics represented 44% to 88.8% (for clinical officers and medical doctors) and 13.6% and 47.6% (for nurses), of what would have been needed based on the literature estimation.ConclusionHAART provision is a labour intensive exercise. Although these data are insufficient to determine whether HAART scale-up has resulted in the weakening or strengthening of the health systems in Malawi, the human resources requirements for HAART scale-up are significant. Malawi is using far less human resources than would be estimated based on the literature from other settings. The impact of HAART scale-up on the overall delivery of health services should be assessed.

Correlates of cigarette smoking among school-going adolescents in Thailand: findings from the Thai global youth tobacco survey 2005

Background Many studies examining the social correlates of tobacco use among adolescents fail to recognise theories of health behaviour and health promotion in their analysis. Using the Socio-Ecologiocal Model (SEM) we assessed the demographic and social factors associated with current cigarette smoking among adolescents in Thailand. Method A secondary analysis of cross-sectional data from the Thai Global Youth Tobacco Survey (Thai GYTS) 2005 was analysed to obtain prevalence of selected attributes and assess factors associated with current cigarette smoking. Current cigarette smoking was defined as having smoked a cigarette, even a single puff, in the last 30 days. Logistic regression was conducted to estimate the level of association between the explanatory variables and current smoking. Results Of the 18,368 respondents, 22.0% males and 5.2% females reported being current smokers (p < 0.001). In multivariate logistic regression analysis, current smoking was negatively associated with the perception that smoking is harmful to health (OR = 0.47; 95% CI [0.33, 0.66]) and positively associated with male gender (OR = 3.46; 95% CI [2.72, 4.86]) and having smoking parents (OR = 1.62; 95% CI [1.25, 2.11]) and friends (OR = 5.07; 95% CI [3.54, 7.25]) for some friends smokers and OR = 26.71; 95% CI [18.26, 39.06] for most or all friends smokers. Compared to subjects 11 = 12 year olds, those who were older were less likely to report smoking (OR = 0.49; 95% CI [0.36, 0.66] for 13 years olds, OR = 0.56; 95% CI [0.40, 0.79] for 14 years olds, OR = 0.59; 95% CI [0.41, 0.86] for 15 years olds). Conclusion Current cigarette smoking was associated with male gender, smoking parents or closest peers. Perception that smoking was harmful to health was associated with less likelihood of being a current smoker.

Association between bullying victimization and physical fighting among Filipino adolescents: Results from the Global School-Based Health Survey

ObjectiveInterpersonal violence is an important, but neglected public health issue in low and middle-income countries. Adolescent physical fighting not only results in injury, disability and death, but is also associated with other potentially harmful behaviors such substance use and premarital sex. The study aims at dose-response association to prevent adolescent problem behaviors.MethodsWe used data from the 2003-2004 Global School-Based Health Survey conducted among school adolescents in the Philippines. We estimated the prevalence of bullying victimization and physical fighting. We also conducted logistic regression analysis to assess the association between a selected list of explanatory variables and physical fighting. We hypothesized that there would be a dose-response relationship between physical fighting and number of times the adolescent reported being bullied in the past 30 days.ResultsOf the 7,338 respondents, 35.5% (34.7% males and 36.1% females) were bullied and 50.0% (51.6% males and 48.8% females) reported having been in a physical fight in the past 12 months. There was a dose-response relationship between bullying victimization and physical fighting (p-trend <0.001). Compared to subjects who were not bullied, those who reported being bullied were more likely to engage in physical fighting after controlling for age, gender, substance use (smoking, alcohol drinking or drug use), and parental supervision (OR=2.38; 95% CI [1.99, 2.86] for 1-2 days of bullying victimization per month, OR=3.55; 95% CI [2.61, 4.83]) for 3-5 days/month per month, OR=4.45; 95% CI [2.61, 7.60]) for 6–9 days/ month, OR=1.91; 95% CI [1.17, 3.13]) for 10-30 days/month.)ConclusionThe dose-response relationship between physical fighting and the number of times an adolescent had been a victim of bullying deserves further study. If causal relationship exists, preventing bullying, even if not totally eliminated, may have significant results in preventing physical fighting.

On the front line of HIV virological monitoring: barriers and facilitators from a provider perspective in resource-limited settings

Scale-up of viral load (VL) monitoring for HIV-infected patients on antiretroviral therapy (ART) is a priority in many resource-limited settings, and ART providers are critical to effective program implementation. We explored provider-perceived barriers and facilitators of VL monitoring. We interviewed all providers (n = 17) engaged in a public health evaluation of dried blood spots for VL monitoring at five ART clinics in Malawi. All ART clinics were housed within district hospitals. We grouped themes at patient, provider, facility, system, and policy levels. Providers emphasized their desire for improved ART monitoring strategies, and frustration in response to restrictive policies for determining which patients were eligible to receive VL monitoring. Although many providers pled for expansion of monitoring to include all persons on ART, regardless of time on ART, the most salient provider-perceived barrier to VL monitoring implementation was the pressure of work associated with monitoring activities. The work burden was exacerbated by inefficient data management systems, highlighting a critical interaction between provider-, facility-, and system-level factors. Lack of integration between laboratory and clinical systems complicated the process for alerting providers when results were available, and these communication gaps were intensified by poor facility connectivity. Centralized second-line ART distribution was also noted as a barrier: providers reported that the time and expenses required for patients to collect second-line ART frequently obstructed referral. However, provider empowerment emerged as an unexpected facilitator of VL monitoring. For many providers, this was the first time they used an objective marker of ART response to guide clinical management. Providers’ knowledge of a patients virological status increased confidence in adherence counseling and clinical decision-making. Results from our study provide unique insight into provider perceptions of VL monitoring and indicate the importance of policies responsive to individual and environmental challenges of VL monitoring program implementation. Findings may inform scale-up by helping policy-makers identify strategies to improve feasibility and sustainability of VL monitoring.

Measures of viral load using Abbott RealTime HIV-1 Assay on venous and fingerstick dried blood spots from provider-collected specimens in Malawian District Hospitals

BACKGROUND Viral suppression is a key indicator of antiretroviral therapy (ART) response among HIV-infected patients. Dried blood spots (DBS) are an appealing alternative to conventional plasma-based virologic testing, improving access to monitoring in resource-limited settings. However, validity of DBS obtained from fingerstick in field settings remains unknown. OBJECTIVES Investigate feasibility and accuracy of DBS vs plasma collected by healthcare workers in real-world settings of remote hospitals in Malawi. Compare venous DBS to fingerstick DBS for identifying treatment failure. STUDY DESIGN We recruited patients from ART clinics at two district hospitals in Malawi, collecting plasma, venous DBS (vDBS), and fingerstick DBS (fsDBS) cards for the first 149 patients, and vDBS and fsDBS only for the subsequent 398 patients. Specimens were tested using Abbott RealTime HIV-1 Assay (lower detection limit 40 copies/ml (plasma) and 550 copies/ml (DBS)). RESULTS 21/149 (14.1%) had detectable viremia (>1.6 log copies/ml), 13 of which were detectable for plasma, vDBS, and fsDBS. Linear regression demonstrated high correlation for plasma vs. DBS (vDBS: β=1.19, R(2)=0.93 (p<0.0001); fsDBS β=1.20, R(2)=0.90 (p<0.0001)) and vDBS vs. fsDBS (β=0.88, R(2)=0.73, (p<0.0001)). Mean difference between plasma and vDBS was 1.1 log copies/ml [SD: 0.27] and plasma and fsDBS 1.1 log copies/ml [SD: 0.31]. At 5000 copies/ml, sensitivity was 100%, and specificity was 98.6% and 97.8% for vDBS and fsDBS, respectively, compared to plasma. CONCLUSIONS DBS from venipuncture and fingerstick perform well at the failure threshold of 5000 copies/ml. Fingerstick specimen source may improve access to virologic treatment monitoring in resource-limited settings given task-shifting in high-volume, low-resource facilities.

Dried blood spots for viral load monitoring in Malawi: feasible and effective.

Objectives To evaluate the feasibility and effectiveness of dried blood spots (DBS) use for viral load (VL) monitoring, describing patient outcomes and programmatic challenges that are relevant for DBS implementation in sub-Saharan Africa. Methods We recruited adult antiretroviral therapy (ART) patients from five district hospitals in Malawi. Eligibility reflected anticipated Ministry of Health VL monitoring criteria. Testing was conducted at a central laboratory. Virological failure was defined as >5000 copies/ml. Primary outcomes were program feasibility (timely result availability and patient receipt) and effectiveness (second-line therapy initiation). Results We enrolled 1,498 participants; 5.9% were failing at baseline. Median time from enrollment to receipt of results was 42 days; 79.6% of participants received results within 3 months. Among participants with confirmed elevated VL, 92.6% initiated second-line therapy; 90.7% were switched within 365 days of VL testing. Nearly one-third (30.8%) of participants with elevated baseline VL had suppressed (<5,000 copies/ml) on confirmatory testing. Median period between enrollment and specimen testing was 23 days. Adjusting for relevant covariates, participants on ART >4 years were more likely to be failing than participants on therapy 1–4 years (RR 1.7, 95% CI 1.0-2.8); older participants were less likely to be failing (RR 0.95, 95% CI 0.92-0.98). There was no difference in likelihood of failure based on clinical symptoms (RR 1.17, 95% CI 0.65-2.11). Conclusions DBS for VL monitoring is feasible and effective in real-world clinical settings. Centralized DBS testing may increase access to VL monitoring in remote settings. Programmatic outcomes are encouraging, especially proportion of eligible participants switched to second-line therapy.

Estimated financial and human resources requirements for the treatment of malaria in Malawi

BackgroundMalaria fever is a common medical presentation and diagnosis in Malawi. The national malaria policy supports self-diagnosis and self-medication for uncomplicated malaria with first line anti-malaria drugs. While a qualitative appreciation of the burden of malaria on the health system is recognized, there is limited quantitative estimation of the burden malaria exacts on the health system, especially with regard to human resources and financial burden on Malawi.MethodsThe burden of malaria was assessed based on estimated incidence rates for a high endemic country of which Malawi is one. Data on the available human resources and financial resources committed towards malaria from official Malawi government documents and programme reports were obtained. The amount of human and financial resources that would be required to treat 65% or 85% of symptomatic malaria cases as per the Roll Back Malaria partnership and the US Presidents Malaria Initiative targets.ResultsBased on a malaria incidence rate of 1.4 episodes per year per person it was estimated that there would be 3.71 million symptomatic episodes of malaria among children <5 years of age based on mid-2007 census projections. At 0.59 episodes each year per person there would be 2.13 million episodes in the 5 to 14 year age group and 1.02 million episodes in. There would be 761,848 malaria cases when HIV is not factored in among those 15 years of age or above; this figure rose to 2.2 million when the impact of HIV in increasing malaria incidence was considered. The prevalence of HIV has resulted in 42.3% increase in symptomatic malaria cases. Treating 65% to 85% of cases would result in using 8.9% to 12.2% of the national health budget or 22.2% to 33.2% of the national drug budget. Furthermore, having 65% to 85% of cases treated at a health facility would consume 55.5% to 61.1% of full-time equivalents of all the clinicians registered in the country. While this studys estimated time of 5 and 10 minutes per consultation may differ in actual practice, due to time constraints patients may not be seen for longer consultation in resources limited settings.ConclusionMalaria exacts a heavy toll on the health system in Malawi. The national recommendation of self-medication with first-line drug for uncomplicated malaria is justified as there are not enough clinicians to provide clinical care for all cases. The Malawi Ministry of Healths promotion of malaria drug prescription including other lower cadre health workers may be justified.

Correlates of HIV testing among women in Malawi: results from the 2006 Multiple Indicator Cluster Survey

We report a study of women 15–49 years aimed at assessing correlates of HIV testing and having received test results in a nationally representative survey of women in Malawi. A total of 26 259 women were recruited into the study, of whom 3712 (14.1%) had ever been tested for HIV infection and received their results. We found that age and education were not significantly associated with HIV testing but marital status, wealth, region were. Contrary to our expectations that women who had delivered a child were more likely to have been ever tested when accessing prenatal and intra‐partum care, we found that women who had delivered a child in the 2 years before the survey were less likely to have ever been tested. We suggest that by 2006 when the survey was conducted, prenatal and intra‐partum care were not important avenues for HIV testing in Malawi.