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High human immunodeficiency virus (HIV)–prevalence countries in Southern and Eastern Africa continue to receive substantial external assistance (EA) for HIV programming, yet countries are at risk of transitioning out of HIV aid without achieving epidemic control. We sought to address two questions: (1) to what extent has HIV EA in the region been programmed and delivered in a way that supports long-term sustainability and (2) how should development agencies change operational approaches to support long-term, sustainable HIV control? We conducted 20 semi-structured key informant interviews with global and country-level respondents coupled with an analysis of Global Fund budget data for Malawi, Uganda, and Zambia (from 2017 until the present). We assessed EA practice along six dimensions of sustainability, namely financial, epidemiological, programmatic, rights-based, structural and political sustainability. Our respondents described HIV systems' vulnerability to donor departure, as well as how development partner priorities and practices have created challenges to promoting long-term HIV control. The challenges exacerbated by EA patterns include an emphasis on treatment over prevention, limiting effects on new infection rates; resistance to service integration driven in part by 'winners' under current EA patterns and challenges in ensuring coverage for marginalized populations; persistent structural barriers to effectively serving key populations and limited capacity among organizations best positioned to respond to community needs; and the need for advocacy given the erosion of political commitment by the long-term and substantive nature of HIV EA. Our recommendations include developing a robust investment case for primary prevention, providing operational support for integration processes, investing in local organizations and addressing issues of political will. While strategies must be locally crafted, our paper provides initial suggestions for how EA partners could change operational approaches to support long-term HIV control and the achievement of universal health coverage. [ABSTRACT FROM AUTHOR]

Previous literature reports that low male partner support is a barrier to women's adherence and retention in HIV care programs. This qualitative study explored the relationships between partners to understand what is meant by male partner support in adherence of HIV-positive women in four healthcare facilities in Southern Malawi. We conducted 8 semi-structured focus group discussions (FGDs) with 73 participants (40 men and 33 women) and 10 in-depth interviews (IDIs) between August 2018 to December 2019. Participants were HIV-positive patients, healthcare workers (HCWs), expert patients (EPs), and couples attending the clinic. All data were digitally recorded, transcribed verbatim, and analysed using a gender-responsive grounded theory approach. This study confirms previous literature, which suggests male partner support is expressed by providing access to transport to the clinic and accompaniment to appointments. However, we found that men can also control access to resources and decision-making. Support is more complex than previous literature reported and, in some cases, gender norms significantly limit women's capacity to engage in care independently of male support since women need male partner permission to access the resources to attend clinics. This paper suggests that restrictive male-partner gender norms limit women's power to engage in care. Most importantly, the gender analysis reveals that what previous literature describes as male partner support can sometimes hide male partner control in permitting access to resources to attend health facilities. For this reason, policies enhancing male support should consider the gender power relationship between partners to avoid reinforcing gender inequality. [ABSTRACT FROM AUTHOR]

This paper reports findings of a qualitative study and draws on the political ecology of health framework to examine the links between housing and health among people living with HIV/AIDS (PLWAs) in Northern Malawi in a wider context in which the epidemic has overburdened the country's hospitals, thereby transferring the responsibility for care from government to families. The findings suggest that poor housing conditions, rooted in colonial and postcolonial policy failure, may undermine the amount, as well as the quality, of palliative care available to PLWAs. It was also found that the high cost of renting, discrimination, and poor landlord-tenant relationships imposed significant financial and emotional burden on PLWAs, thereby undermining their ability to meet dietary needs, stay healthy, and adhere to treatment. Furthermore, customary norms around property inheritance hampered women's housing security and their ability to cope with the disease. The paper concludes by making relevant policy recommendations. [ABSTRACT FROM AUTHOR]

To improve outcomes among HIV-positive adolescents, the Malawi Ministry of Health is supporting scale-up of "Teen Clubs," a facility-based antiretroviral treatment (ART) delivery model. Teen Clubs are monthly ART clinics for adolescents (10–19 years old) that provide clinical services and peer psychosocial support. This paper assesses ART adherence among Teen Club attendees in Malawi. We performed a retrospective analysis of medical records and Teen Club attendance data on 589 HIV-positive adolescents at 16 Partners in Hope (PIH)—Extending Quality Improvement for HIV/AIDS in Malawi (EQUIP) supported facilities across Malawi, from January to June of 2017, who attended at least two Teen Club sessions. Multi-level logistic regression models were used to examine the role of gender and age on optimal ART adherence (≥ 95% based on pill count) among HIV-positive adolescents enrolled in Teen Clubs. The median age of adolescents in this sample was 14 years, and 47% were male. Older adolescent males (15–19 years) were 64% more likely to achieve ≥ 95% ART adherence (aOR 1.64, 95% CI 1.16–2.31, p < 0.01) compared to younger (10–14 years) males. The effect of age on adherence was smaller and not significant among females (aOR 1.36, 95% CI 0.96–1.94, p = 0.08). In the full model including males and females, older adolescence was associated with higher odds of optimal adherence (aOR 1.48, 95% CI 1.16–1.90, p < 0.01). These results reinforce the need for age-specialized programming for adolescents, and future research should evaluate this in achieving optimal ART adherence. [ABSTRACT FROM AUTHOR]

This article examines how HIV policies and the funding priorities of global institutions affect practices in prenatal clinics and the quality of healthcare women receive. Data consist of observations at health centres in Lilongwe, Malawi and interviews with providers (N = 37). I argue that neoliberal ideology, which structures the global health field, produces a fragmented healthcare system on the ground. Findings show two kinds of healthcare practices within the same clinic: donor‐funded NGOs took on HIV services while government providers focused on prenatal care. NGO practices were defined by surveillance, where providers targeted pregnant HIV‐positive women and intensively monitored their adherence to drug treatment. In contrast, state‐led practices were defined by rationing. Government providers worked with all pregnant women, but with staff and resource shortages, they limited time and services for each patient in order to serve everyone. This paper builds on concepts of therapeutic citizenship and clientship by exploring how global health priorities produce different conditions, practices and outcomes of NGO and state‐led care. [ABSTRACT FROM AUTHOR]

Drawing on 70 interviews with civil society staff in Malawi, I argue that when development trends and issues in the country change, at donors’ wishes, organizations proactively strategize to vie for donor funds. Collected over three research trips, my data show that between 2008 and 2010 there was a widespread belief among civil society in Malawi that climate change was becoming the “it” issue, surpassing HIV/AIDS in predominance. Alongside this belief, there was a dynamic, if invisible, process of organizational repositioning. Comparing the earlier interviews with those conducted in 2014, I contend that the issues of focus, while interesting, are less telling than the ways Malawian organizations endeavor to adapt and respond to them. This paper adds a critical dimension to development literature, investigating a process that occurs when development agendas change. [ABSTRACT FROM AUTHOR]

This paper examines the dynamics of condom policymaking in Malawi by analyzing debates, which took place in the Malawi National Assembly between the year 2000 and 2004. Using content analysis and key informant interviews, and situating the overall discussion within policy and science literature, we examine how scientific evidence is being applied in the policymaking process as it relates to the place of condoms within the context of HIV/AIDS prevention. The study not only shows the extent to which the policymaking process on condoms in Malawi largely embodies a tendency to blur the conventional divide between science and politics, but also demonstrates why controversy around condoms still persists at the highest level of government in a country with one of the highest HIV prevalence rates in the world. It was found that even when people are dying, consensus in HIV/AIDS policymaking can be difficult to achieve in a policy climate characterized by a binary perspective to social problems, and where different actors compete for control over the policy terrain. The paper makes recommendations that may be helpful in facilitating a more inclusive HIV/AIDS policymaking process in Malawi. [ABSTRACT FROM AUTHOR]

This paper analyses how the construction of extreme poverty, gender inequality and powerlessness among women in Malawi make them vulnerable to HIV transmission. It argues that since HIV/AIDS remains without a cure, the persistence of poverty, inequality and powerlessness violate women's right to life. The paper uses the findings of a grounded study conducted by Women and Law in Southern Africa Research and Educational Trust Malawi (WLSA-Malawi) to show how social realities in specific contexts are driving the epidemic, particularly against women. There is an urgent need for an operationalisation of human rights as a matter of State obligation in the face of a global crisis, by recognising women as true actors and effective participants in the process of development. [ABSTRACT FROM AUTHOR]

Abstract: Voluntary Medical Male Circumcision (VMMC) has been promoted as an effective biomedical intervention in the reduction of the risk of new HIV and STI infections. The government of Malawi and its stakeholders including the World Health Organization have committed a lot of resources to VMMC programming. However, research shows that its uptake among men is still low in Malawi. This study, therefore, investigated the communication-related factors that influence decision-making in the uptake of VMMC among men in Lilongwe, Malawi. To achieve this aim, twenty-five men, aged between 18 and 35 years old were interviewed on what influenced them to undergo VMMC. The study found that the respondents were influenced to uptake VMMC mostly by peer pressure and the need for conformity; partner/girlfriend demand and considerations; and advice from health personnel. The paper concludes that although the final decision was theirs to make, the men in the study underwent circumcision under duress and/or coercion. It cannot be said to be voluntary. The medical necessity of VMMC can be said to be voluntary if it is negotiated and consented to without duress. Although the respondents mentioned the HIV and STI infection risk reduction properties, hygienic advantages, and cervical cancer reduction properties of VMMC as benefits of VMMC, these had very little influence on their decision. It is recommended that current intervention messages be reviewed and modified to incorporate new ideas that can address the shortcomings that the current crop of messages has with the aim of increasing the uptake of VMMC programmes or other health focused behaviour change programmes. [ABSTRACT FROM AUTHOR]

This paper explores the causal relationship between primary schooling and adult HIV status in Malawi and Uganda, two East African countries with some of the highest HIV infection rates in the world. Using data from the 2010 Malawi Demographic Health Survey and the 2011 Uganda AIDS Indicator Survey, the paper takes advantage of a natural experiment, the implementation of Universal Primary Education policies in the mid 1990s. An instrumented regression discontinuity approach is used to model the relationship between increased primary schooling and adult women's HIV status. Results indicate that a one-year increase in schooling decreases the probability of an adult woman testing positive for HIV by 0.06 ( p < 0.01) in Malawi and by 0.03 ( p < 0.05) in Uganda. These results are robust to a variety of model specifications. In a series of supplementary analyses a number of potential pathways through which such effects may occur are explored. Findings indicate increased primary schooling positively affects women's literacy and spousal schooling attainment in Malawi and age of marriage and current household wealth in Uganda. However primary schooling has no effect on recent (adult) sexual behavior. [ABSTRACT FROM AUTHOR]

Copyright of Culture, Health & Sexuality is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Culture, Health & Sexuality is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Culture, Health & Sexuality is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

In countries with generalized HIV/AIDS epidemics, married couples have a shared risk of acquiring HIV/AIDS. Yet very little research has adopted a couple-level perspective to investigate perceived risk of HIV infection. In this paper, we used population-based data from 768 married monogamous couples in the 2004 Malawi Diffusion and Ideational Change Project (MDICP) to compare respondents’ perceptions about their spouses’ HIV status to their spouses’ actual HIV status. Using chi-squared and Kappa coefficient statistics, we evaluated how accurately respondents assess their spouse’s HIV status, and compared the assessment of their spouse’s HIV status with their assessment of their own serostatus. We found that individuals tend to overestimate their spouse’s as well as their own risk of having HIV. Husbands were generally more accurate in assessing their own risk of HIV infection than that of their wives, but wives were more accurate in assessing the HIV status of their spouses. In our multivariate logistic regression results, we found that marital infidelity is the most important correlate of overestimating individual and spousal HIV risk. [ABSTRACT FROM AUTHOR]

Surprisingly little is known about how or if knowledge of one’s HIV status influences the desire to have children in sub-Saharan Africa. This paper takes advantage of a unique situation in rural Malawi where no one knew their HIV status prior to testing being introduced as part of an ongoing panel study. Using a sample of men and women ( n = 1,380) who were interviewed in 2001 and 2006, we examine how HIV positive and negative test results impact respondents’ desires to continue childbearing. We then consider how prior perceptions of one’s status influence this effect. Respondents who received a positive test result reduced their childbearing desires. When self-assessed likelihood of infection was considered, however, only those who were surprised by their test result altered their fertility preferences, a finding which held true for both positive and negative results. The implications of the results and potential applications to other HIV/AIDS research are discussed. [ABSTRACT FROM AUTHOR]

Copyright of African Journal of Reproductive Health is the property of Women's Health & Action Research Centre and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract: This paper assesses the condom situation within marriage in Malawi with particular attention to people''s perceptions about the compatibility of condoms and marriage by analyzing the Malawi Demographic and Health Surveys 1992 and 2000, and via semi-structured interviews with married men and women from three districts in rural Malawi. There are four striking findings. First, condom use is negligible inside marriage. Second, there is considerable talk about condoms, especially among male social network partners. Third, virtually all the discussion of condoms, by both men and women, is in the context of preventing STI/HIV-AIDS infection in extramarital partnerships. Lastly, and critical for this paper, is that initiating a discussion of condom use for preventing infection in marriage is like bringing an intruder into the domestic space. Thus, there is evidence that change in attitudes about condom use may be occurring, but only outside marriage. This evidence concurs with Malawian government policy that advocates for condom use in marriage only if either spouse has more than one sexual partner. The AIDS epidemic is therefore bringing sexual behavior change outside marriage and not within. [Copyright &y& Elsevier]

Copyright of Culture, Health & Sexuality is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Heterosexually transmitted HIV/AIDS continues to devastate the health and economy of sub-Saharan African countries. In Malawi, 15.4% of 15-49 year olds are infected with HIV and 18-26% of pregnant women are living with HIV. Research has shown that sociocultural factors, especially gender roles and relationships, play a significant role in the transmission of HIV in Africa but little is known about Malawi women's perspective on HIV/AIDS. What do Malawi women say about the impact of HIV/AIDS on their lives, their role in prevention, and the barriers they lace in trying to stem the spread of the disease? To answer these questions, three focus groups with Malawi women were conducted and analyzed for themes. The purpose of this paper is to describe one emergent theme captured in the statement, "We are just vessels for our husbands." This theme is explicated through discussions of women's and men's images, women's roles, gender/power relationships, disempowerment, role models and empowerment. Evident in this theme are interrelated messages for those involved in HIV/AIDS prevention. Health education alone is insufficient to stem the tide of HIV in Malawi. A multidisciplinary, systematic approach that includes women's education and economic empowerment as well as modifying legal and social structures that contribute to the spread of HIV/AIDS in Malawi is suggested as necessary additions to HIV and AIDS intervention programs. Only through forging partnerships between health, education, women's development groups, and political and social leaders will we be able to reduce the impact of HIV/AIDS in Malawi. [ABSTRACT FROM AUTHOR]

Heavy alcohol use among people with HIV in sub-Saharan Africa is driven by household economics such as poverty and unemployment and has negative impacts on couple relationships. Multilevel interventions have the potential to reduce alcohol use and improve relationship outcomes by addressing the web of co-occurring economic, social, and dyadic factors. This objective of this study was to develop an economic and relationship-strengthening intervention for couples in Malawi, consisting of matched savings accounts with financial literacy training and a couples counseling component to build relationship skills. Informed by the ADAPT-ITT framework, we collected multiple rounds of focus group data with key stakeholders and couples to gain input on the concept, session content, and procedures, held team meetings with field staff and an international team of researchers to tailor the intervention to couples in Malawi, and refined the intervention manual and components. The results describe a rigorous adaptation process based on the eight steps of ADAPT-ITT, insights gained from formative data and modifications made, and a description of the final intervention to be evaluated in a pilot randomized clinical trial. The economic and relationship-strengthening intervention shows great promise of being feasible, acceptable, and efficacious for couples affected by HIV and heavy alcohol use in Malawi. [ABSTRACT FROM AUTHOR]

In this article, we consider what would happen if the resources and energy devoted to formal, school-based sex education were redirected into a syndemic sex education approach that centres the individual, social, and structural conditions that shape adolescents' sexual and reproductive health (SRH). Drawing on a case study of youth in Malawi, we argue that sex education in its current form fails to broadly prevent negative SRH outcomes and meaningfully improve wellbeing. Yet it, and the (female) sexuality it seeks to prevent, remain the subjects of considerable attention and moral anxiety. We call to move beyond sex as a focus for institutionalised teaching and learning, replacing it with holistic efforts to support the wellbeing of young people living in syndemic conditions. [ABSTRACT FROM AUTHOR]

Millions of orphans, created by parental deaths due to the HIV/AIDS pandemic in sub-Saharan Africa, live with, and are cared for, by grandparents. Little research has considered how grandparents and, in particular, grandfathers, are caring for orphans. Here, we employ the analytical concept of generative grandfathering to analyse rural grandfathers' roles in orphan care within communities of Zomba District, Southern Malawi. Using an ethnographic approach to investigate orphan care, we engaged children, young people and adults in multiple qualitative research activities, including interviews, focus group discussions, stakeholder and dissemination meetings. The findings suggest that although grandfathers' contributions to orphan care are on the periphery of research and policy concerned with grandparenting in Malawi and other regions of sub-Saharan Africa, grandfathers are incontrovertibly at the epicentre of their orphaned grandchildren's everyday lives. Grandfathers are providers for their orphaned grandchildren, they support their formal education, and are integral to the intergenerational transmission of both knowledge and values. However, despite performing myriad caring roles in plain sight of their communities, grandfathers remain largely invisible due to gendered (mis)conceptions of care. This highlights the dilemma of grandfathers as ageing men who find themselves in roles not traditionally associated with hegemonic notions of masculinity in their communities. [ABSTRACT FROM AUTHOR]

Research on the social impact of ART pivots on questions of individual adherence and community acceptability of treatment programmes. In this paper we examine unexpected and unintended consequences of the scale-up of treatment in rural Malawi, using a unique dataset of more than 150 observational journals from three sites, spanning 2010 to 2013, focusing on men's everyday conversations. Through thematic content analysis, we explore the emerging perception that the widespread availability of ART constitutes a form of social danger, as treatment makes it difficult to tell who does or does not have AIDS. This ambiguity introduced through ART is interpreted as putting individuals at risk, because it is no longer possible to tell who might be infected - indeed, the sick now look healthier and “plumper” than the well. This ambivalence over the social impact of ART co-exists with individual demand for and appreciation of the benefits of treatment. [ABSTRACT FROM AUTHOR]

This article shares results from a long-term participatory agroecological research project in northern Malawi. Drawing upon a political ecology of health conceptual framework, the paper explores whether and how participatory agroecological farming can improve food security and nutrition among HIV-affected households. In-depth interviews were conducted with 27 farmers in HIV-affected households in the area near Ekwendeni Trading Centre in northern Malawi. The results show that participatory agroecological farming has a strong potential to meet the food, dietary, labour and income needs of HIV-affected households, whilst helping them to manage natural resources sustainably. As well, the findings reveal that place-based politics, especially gendered power imbalances, are imperative for understanding the human impacts of the HIV/AIDS epidemic. Overall, the study adds valuable insights into the literature on the human-environment dimensions of health. It demonstrates that the onset of disease can radically transform the social relations governing access to and control over resources (e.g., land, labour, and capital), and that these altered social relations in turn affect sustainable disease management. The conclusion highlights how the promotion of sustainable agroecology could help to partly address the socio-ecological challenges associated with HIV/AIDS. [ABSTRACT FROM AUTHOR]

Malawian adolescents overestimate their HIV infection risk. Understanding why they do so is important since such overestimation is likely to be linked to later-life outcomes. This study focuses on the influence peers have on HIV infection expectations. I use novel school-based survey data collected in Malawi between October 2011 and March 2012 (n = 7910), which has more reliable measures of peers' HIV infection expectations than other studies. I employ a combined instrumental variables/fixed effects methodology designed to addresses several methodological challenges in estimating peer effects, including self-selection of friends, the issue of unobserved environmental confounders, and the bi-directionality of peer effects. Several tests are conducted in order to assess the robustness of the specifications. Results suggest that a one-percentage-point increase in the mean probabilistic expectation of HIV infection among peers increases an adolescent's own subjective expectation of infection by an average of 0.65 percentage points. This paper shows that peer influence is greater for males than for females. Results also suggest that the peer effects on HIV infection expectations are only statistically significant among those lacking more complete knowledge of HIV/AIDS. [ABSTRACT FROM AUTHOR]

An estimated 11% of the adult population in Malawi, Africa, is living with HIV/AIDS. The disease has taken a toll on communities, resulting in high morbidity and mortality. Malawian women carry the burden of being caretakers for individuals infected with HIV while also worrying about their own health. However, little is known about how HIV/ AIDS affects psychological functioning among Malawian women in areas hit hardest by the epidemic. To that end, this paper examined the influence of HIV-related stigma on symptoms of anxiety and depression among 59 women 17–46 years old who were recruited from the Namitete area of Malawi. Women who reported greater worry about being infected with HIV and greater HIV-related stigma were significantly more likely to report greater symptoms of anxiety and depression. These findings suggest that interventions that reduce HIV-related stigma are likely to enhance psychological functioning among Malawian women, which in turn will improve the women's quality of life and well-being. [ABSTRACT FROM AUTHOR]

A large and increasing proportion of HIV transmissions in sub-Saharan Africa occur within marriage. Condom use within marriage could, therefore, be an important prevention strategy, but there is considerable debate about whether married couples would be willing to use condoms. This paper contributes to this debate by identifying key factors that affect the acceptability of condom use within marriage and actual condom use among men and women in rural Malawi, using three waves of longitudinal data from 2004, 2006 and 2008. Specifically, we focused on the effect of (1) entry into first marriage, (2) respondent's HIV status, HIV perceptions, and risk behaviors, and (3) spouse's HIV characteristics on condom use acceptability within marriage and actual condom use with a spouse or steady partner. Using fixed-effects regression, we found that getting married coincides with a pronounced attitudinal shift regarding the acceptability of condom use within marriage that cannot be explained by differences in fertility status or selection into marriage. In addition, we found that, for women, perceived HIV status of the respondent and spouse generally had greater influence than actual HIV status on the acceptability of condom use within marriage and actual condom use with a spouse or steady partner, even after HIV status is known; while actual HIV status and HIV risk behaviors are generally more important among men. Although condom use within marriage remained low, these findings suggest that attitudes about and use of condoms are susceptible to change and that both marital status and perceptions of risk are important influences on condom use. [Copyright &y& Elsevier]

Background: In Malawi, early retention in HIV care remains challenging. Depression is strongly associated with reduced anti-retroviral therapy (ART) adherence and viral suppression. Appropriate depression care for people initiating ART is likely to be supportive of early and continued engagement in the HIV care continuum. This paper aims to provide an overview of a task-shifting program that integrates depression screening and treatment into HIV care and the strategy used to evaluate this program, describes the implementation process, and discusses key challenges and lessons learned in the first phase of program implementation.Methods: We are implementing a program integrating depression screening and treatment into HIV care initiation at two clinics in Lilongwe District, Malawi. The program's effect on patients' depression and HIV outcomes will be evaluated using a multiple baseline pre-post study. In this manuscript, we draw from our experiences as program implementers and some of the quantitative data to describe the process of implementation and key lessons learned.Results: We successfully implemented the screening phase of this program at both clinics; 88.3 and 93.2% of newly diagnosed patients have been screened for depression at each clinic respectively. 25% of enrolled patients reported symptoms of mild-to-severe depression and only 6% reported symptoms of moderate-to-severe depression. Key lessons learned from the process show the importance of utilizing existing processes and infrastructure and focusing on iterative and collaborative learning. We continued to face challenges around establishing a sense of program ownership among providers, developing capacity to diagnose and manage depression, and ensuring the availability of appropriate medication. Our efforts to address these challenges provide insight into the technical and managerial support needed to prepare for, roll out, and sustain integrated models of mental health and HIV care.Conclusions: This activity demonstrates how a depression screening program can successfully be integrated into HIV care within the public health system in Malawi. While this program focuses on integrating depression management into HIV care, most of the lessons learned could apply to integration of mental health into any non-psychiatric specialist setting.Trial Registration: ClinicalTrials.gov ID [ NCT03555669 ]. Retrospectively registered on 13 June 2018. [ABSTRACT FROM AUTHOR]

Copyright of AIDS & Behavior is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract: The delivery of HIV counseling and testing programs throughout Sub-Saharan Africa relies on the work performed by trained HIV counselors. These individuals occupy a critical position: they are intermediaries between the rule-making of international and national policymakers, and the norms of the communities in which they live and work. This paper explains when, how and why HIV counselors adapt Western testing guidelines (the “3Cs” – consent, confidentiality and counseling) to local concerns, attempting to maintain the fidelity of testing principles, while reducing the harm they perceive may arise as a consequence of strict adherence to them. Data for this study come from Malawi: a poor, largely rural African country, where HIV prevalence is ranked 9th highest in the world. The analysis is based on 25 interviews with HIV counselors and a unique set of field journals, and captures local experiences and the moral quandaries that counselors in rural Sub-Saharan Africa face. The findings of this inquiry provide new insights into the implementation of HIV testing in rural African settings, insights that may guide HIV prevention policy. [Copyright &y& Elsevier]

Abstract: Few spatial studies explore relationships between people and place in sub-Saharan Africa or in the context of human immunodeficiency virus (HIV). This paper uses individual-level demographic and behavioral data linked to area-level, spatially referenced socio-economic and access data to examine how the relationships between area- and individual-level risks and individual HIV status vary in rural Malawi. The political economy of health framework guides interpretation. Geographically weighted regression models show significant, local-level variation indicating that area-level factors drive patterns of HIV above individual-level contributions. In distinct locations, women who live further from health clinics, major roads, and major cities are less likely to be infected. For men, HIV status is strongly associated with migration patterns in specific areas. Local-level, gender-specific approaches to HIV prevention are necessary in high risk areas. [ABSTRACT FROM AUTHOR]

The article presents an analysis of the role played by community-based organizations (CBOs) in combatting the HIV/AIDS pandemic in Malawi. It is said that CBOs typically distribute program resources based on demand. It is argued that this approach does not ensure that the regions which most require attention will receive it. The CBOs were found to be fairly responsive to their communities, reflecting the civic standards of Malawian culture. It is said that their performance could be improved, however, by implementing a method for allocating resources on the basis of need.

Abstract: In order to evaluate strategies to reduce HIV transmission through breast milk and optimize both maternal and infant health among HIV-infected women and their infants, we designed and implemented a large, randomized clinical trial in Lilongwe, Malawi. The development of protocols for large, randomized clinical trials is a complicated and lengthy process often requiring alterations to the original research design. Many factors lead to delays and changes, including study site-specific priorities, new scientific information becoming available, the involvement of national and international human subject committees and monitoring boards, and alterations in medical practice and guidance at local, national, and international levels. When planning and implementing a clinical study in a resource-limited setting, additional factors must be taken into account, including local customs and program needs, language and socio-cultural barriers, high background rates of malnutrition and endemic diseases, extreme poverty, lack of personnel, and limited infrastructure. Investigators must be prepared to modify the protocol as necessary in order to ensure participant safety and successful implementation of study procedures. This paper describes the process of designing, implementing, and subsequently modifying the Breastfeeding, Antiretrovirals, and Nutrition, (BAN) Study, a large, on-going, randomized breastfeeding intervention trial of HIV-infected women and their infants conducted at a single-site in Lilongwe, Malawi. We highlight some of the successes, challenges, and lessons learned at different stages during the conduct of the trial. [Copyright &y& Elsevier]

Abstract: In this paper, I argue two main points. First, in premarital, sexual partnerships in rural Malawi, the purpose of money exchange extends beyond the alleviation of female partners’ economic constraints, and, second, by clarifying this broader purpose, it becomes possible to recognize where women exert control over their own sexual selves. These findings come from field observations and a rich set of in-depth interviews , bolstered on occasion by survey data, conducted with young women and men, aged 15–24 years, in the Balaka district in the southern region of the country. This research demonstrates that, contrary to typical expectations, money and gift transfers in sexual partnerships are part and parcel of the courting practices of young Malawian women and men. Transfers are as much about the expression of love and commitment as they are about meeting the financial needs of women or the acquisition of sex for men. Using narrative information to shed light on the semiotics of the sex–money link, these findings from Malawi offer a new perspective that broadens usual interpretations of transactional sex, the understanding of which is critical in fighting AIDS. [Copyright &y& Elsevier]

Abstract: This paper compares three interpretations of women and the transmission of HIV in rural Malawi. One is disseminated world-wide by institutions with a global reach such as the World Health Organization in Geneva and United States Agency for International Development (USAID); the second is provided by urban Malawians situated in the capital of Lilongwe, the seat of government and the site of the many international and national non-governmental agencies; the third is articulated by rural women and men in Balaka District, Malawi. We focus on women''s motivations for extramarital sex, using qualitative interview data. We find that whereas in Geneva and Lilongwe women from rural Malawi are said to engage in sexual relationships outside of marriage because they need money for survival, in Balaka they are said to be motivated not only by money for survival but also for attractive consumer goods as well as by passion and by revenge for a husband''s infidelity. We also find that data collection procedures influence explanations for women''s affairs, as does the respondent''s gender. An implication of this study is that AIDS-prevention policies based on the view from Geneva and Lilongwe need modification for Balaka, and by implication for rural Africa more generally. [Copyright &y& Elsevier]

This paper combines quantitative and qualitative data to investigate changes in perceived risk of contracting HIV/AIDS in rural Malawi. Using longitudinal survey data, we find that Malawians worried less about contracting HIV/AIDS in 2001 than in 1998. According to qualitative interviews and observational journal accounts, HIV/AIDS and strategies to prevent it are a frequent topic of conversation amongst married Malawians. Women report worrying most about their husbands as a possible source of infection, discussing with them the importance of avoiding infection, and, increasingly, using divorce to reduce their risk. Men report worrying most about their extramarital partners and adopting preventive strategies such as fewer partners and more careful partner selection. We show that the decline in perceived risk is significantly associated with declines in the behaviors that Malawians worry most about and perceptions of risk in individuals’ social networks. We interpret these findings as evidence that Malawians are changing their behavior in ways that may reduce the spread of HIV/AIDS. [Copyright &y& Elsevier]

Using the 1998 Malawi census data, this paper examined the level of orphanhood, the pattern of living arrangements and the effect of poverty on the school enrolment of children in Malawi during a period when adult HIV/AIDS prevalence had reached epidemic proportions. Results show that the proportion of orphans increases with age. By the age of 14, more than two per cent of children have lost both parents, about 11 per cent have lost a father and about 6.5 per cent have lost a mother. The rural areas are home to the majority of the orphans and the southern region has a higher proportion of orphans than the northern and central regions. Girls and boys seem to be faced by the same constraints in household circumstances and educational opportunities, suggesting that there is no gender bias in allocating household resources or providing educational opportunities in Malawi. The differences in enrolment rates between orphans and non-orphans are insignificant. These findings are consistent with results from other countries that are hit hard by the AIDS epidemic and point to the critical role of the extended family system in taking care of the disadvantaged and vulnerable children. [ABSTRACT FROM AUTHOR]

Countries in sub-Saharan Africa have been seriously affected by HIV and now face a new pandemic – COVID-19. How have prior experiences with managing HIV prepared countries for COVID-19? To what extent has the structure of the global health field enabled or constrained countries' ability to respond? Drawing on qualitative methods, this article examines the impact of HIV interventions on the healthcare system in Malawi and its implications for addressing COVID-19. I argue that the historical and continued influence of neoliberalism in global health manifests in the structures and routines of clinical practice. In Malawi's health centres, a parallel NGO system of care has become grafted onto state healthcare, with NGOs managing HIV commodities and providing care to HIV patients. While HIV NGOs do support the work of government providers, it is limited to tasks that align with their programmatic goals. Outside of donor priorities, the conditions of public healthcare are left behind, and government providers struggle with shortages of staff, medical resources, and basic infrastructure. In the context of COVID-19, risks are compounded as public healthcare facilities not only struggle with resources to treat patients, but also become a site of risk itself for COVID-19 infection. [ABSTRACT FROM AUTHOR]

Background: Despite the aging HIV epidemic, increasing age can be associated with hesitancy to test. Addressing this gap is a critical policy concern and highlights the urgent need to identify the underlying factors, to improve knowledge of HIV-related risks as well as uptake of HIV testing and prevention services, in midlife-older adults.Methods: We conducted five focus group discussions and 12 in-depth interviews between April 2013 and November 2016 among rural and urban Malawian midlife-older (≥30 years) men and women. Using a life-course theoretical framework we explored how age is enacted socially and its implications on HIV testing and sexual risk behaviours. We also explore the potential for HIV self-testing (HIVST) to be part of a broader strategy for engaging midlife-older adults in HIV testing, prevention and care. Thematic analysis was used to identify recurrent themes and variations.Results: Midlife-older adults (30-74 years of age) associated their age with respectability and identified HIV as "a disease of youth" that would not affect them, with age protecting them against infidelity and sexual risk-taking. HIV testing was felt to be stigmatizing, challenging age norms, threatening social status, and implying "lack of wisdom". These norms drove self-testing preferences at home or other locations deemed age and gender appropriate. Awareness of the potential for long-standing undiagnosed HIV to be carried forward from past relationships was minimal, as was understanding of treatment-as-prevention. These norms led to HIV testing being perceived as a threat to status by older adults, contributing to low levels of recent HIV testing compared to younger adults.Conclusions: Characteristics associated with age-gender norms and social position encourage self-testing but drive poor HIV-risk perception and unacceptability of conventional HIV testing in midlife-older adults. There is an urgent need to provide targeted messages and services more appropriate to midlife-older adults in sub-Saharan Africa. HIVST which has often been highlighted as a tool for reaching young people, may be a valuable tool for engaging midlife-older age groups who may not otherwise test. [ABSTRACT FROM AUTHOR]

Much has been written about how structural (e.g. colonialism) and social (e.g. gender) determinants shape embodied health outcomes. However, little attention has been paid to the ways that marginalized populations become complicit in their own oppression. Ethnographic data collected over two years at a rural public hospital in Malawi show that the tobacco political economy produces significant intra-rural inequalities that result in the exclusion of migrant farm workers, called "tenants," from HIV care. Using an analytical framework informed by Bourdieu's concepts of social field and habitus, I illustrate how social inequalities persist unchallenged, even by the most disadvantaged people. [ABSTRACT FROM AUTHOR]

Many countries have expanded insurance programmes in an effort to achieve universal health coverage (UHC). We assess a complementary path toward financial risk protection: increased access to technologies that improve health and reduce the risk of large health expenditures. Malawi has provided free HIV treatment since 2004 with significant US Government support. We investigate the impact of treatment access on medical spending, capacity to pay and catastrophic health expenditures at the population level, exploiting the phased rollout of HIV treatment in a difference-in-differences design. We find that increased access to HIV treatment generated a 10% decline in medical spending for urban households, a 7% increase in capacity to pay for rural households and a 3-percentage point decrease in the likelihood of catastrophic health expenditure among urban households. These risk protection benefits are comparable to that found from broad-based insurance coverage in other contexts. Our findings show that targeted treatment programmes that provide free care for high burden causes of death can provide substantial financial risk protection against catastrophic health expenditure, while moving developing nations toward UHC. [ABSTRACT FROM AUTHOR]

Depressive symptoms among HIV-positive (HIV+) women may negatively impact their health and possibly that of their young children through risk of compromised caregiving. We evaluated how depression symptoms in predominantly (97%) female caregivers relate to neurodevelopmental outcomes in their HIV affected children. Data come from the IMPAACT P1104s Study, an observational cohort across six sites in four countries: Zimbabwe, South Africa, Uganda and Malawi. Participants (n = 611) were 5–11-year-old children with HIV (HIV), HIV exposed uninfected (HEU), or HIV unexposed uninfected (HUU). Primary caregivers were assessed for depression with the Hopkins Symptom Checklist (HSCL) and children with Behavior Rating Inventory for Executive Function (BRIEF) parent-report, Kauffman Assessment Battery for Children II (KABC), Bruininks-Oseretsky Test of Motor Proficiency 2nd Ed. (BOT-2), Test of Variables of Attention (TOVA), Multiple Indicators Cluster Survey, Child Disability and Development scales (MICS-4). Caregivers with higher depression scores (>1.75 mean HSCL score) reported more executive function problems in their children, regardless of HIV status. All executive function scores were significantly (p < 0.001) associated with depressive symptomatology at baseline and across time. Caregiver depressive symptomatology was not associated with other assessed neurocognitive outcomes. These results highlight the potential impact of caregiver depression on child behavioral outcomes. [ABSTRACT FROM AUTHOR]

Female sex workers (FSW) are disproportionately at risk for HIV. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention method, yet approaches for incorporating PrEP within prevention strategies used by FSW are lacking. Semistructured focus group discussions were conducted with 44 HIV-negative FSW in Lilongwe, Malawi to explore perceptions of PrEP: acceptability, integration within HIV prevention behaviors, and barriers to use. Acceptability of PrEP was high. Motivation to use PrEP was rooted in love for one's life, anticipated negative economic effects associated with HIV acquisition. PrEP was viewed as complementary to existing norms for engaging in healthy sexual behaviors. Many felt PrEP may provide extra protection from HIV, along with condoms and frequent STI testing. Unpredictable daily lives, stigma, and side effects were barriers that could affect PrEP use. Leveraging existing HIV prevention strategies and social norms surrounding HIV prevention behaviors may positively impact PrEP uptake among FSW in Malawi and sub-Saharan Africa. [ABSTRACT FROM AUTHOR]

Twelve percent of the Malawian population is HIV infected. Eighteen percent of sexual encounters are casual. A condom is used a third of the time. To analyze the Malawian epidemic, a choice‐theoretic general equilibrium search model is constructed. In the developed framework, people select between different sexual practices while knowing the inherent risk. The calibrated model is used to study several policy interventions, namely, ART, circumcision, better condoms, and the treatment of other STDs. The efficacy of public policy depends upon the induced behavioral changes and equilibrium effects. The framework complements the insights from epidemiological studies and small‐scale field experiments. [ABSTRACT FROM AUTHOR]

Background: Social protection interventions, including cash grants and care provision have been shown to effectively reduce some negative impacts of the HIV epidemic on adolescents and families. Less is known about the role of social protection on younger HIV affected populations. This study explored the impact of cash grants on children's cognitive development. Additionally, we examined whether combined cash and care (operationalised as good parenting) was associated with improved cognitive outcomes.Methods: The sample included 854 children, aged 5 - 15, participating in community-based organisation (CBO) programmes for children affected by HIV in South Africa and Malawi. Data on child cognitive functioning were gathered by a combination of caregiver report and observer administered tests. Primary caregivers also reported on the economic situation of the family, cash receipt into the home, child and household HIV status. Parenting was measured on a 10 item scale with good parenting defined as a score of 8 or above.Results: About half of families received cash (55%, n = 473), only 6% (n = 51) reported good parenting above the cut-off point but no cash, 18% (n = 151) received combined cash support and reported good parenting, and 21% (n = 179) had neither. Findings show that cash receipt was associated with enhanced child cognitive outcomes in a number of domains including verbal working memory, general cognitive functioning, and learning. Furthermore, cash plus good parenting provided an additive effect. Child HIV status had a moderating effect on the association between cash or/plus good parenting and cognitive outcomes. The association between cash and good parenting and child cognitive outcomes remained significant among both HIV positive and negative children, but overall the HIV negative group benefited more.Conclusions: This study shows the importance of cash transfers and good parenting on cognitive development of young children living in HIV affected environments. Our data clearly indicate that combined provision (cash plus good parenting) have added value. [ABSTRACT FROM AUTHOR]

This essay examines how contemporary Malawian female poets writing in the post-dictatorship era engage with aspects that inflect female sexuality such as eroticism, sexual desire, marriage, sexual violence, and HIV/AIDS through their poetry and how they represent these aspects against normative expectations of gender and sexuality. I am interested in how these poets depict the complex mediation of female sexualities by the state, the family, religious, and cultural bodies and how, in turn, they represent sexuality as simultaneously a domain of restriction, repression, and danger as well as a domain of exploration, pleasure, and agency. Through an analysis of selected works by Malawian female poets, I examine how the authors negotiate issues of female sexuality within the new democratic dispensation which have traditionally been relegated to the margins in favour of more politically ‘relevant’ issues. I argue that these poets challenge the monolithic status quo through which Malawian women’s sexualities have been constructed by portraying the nuances, complexities, and ambiguities that characterize female sexuality in Malawi. [ABSTRACT FROM AUTHOR]

Background: While, lost to follow-up (LTFU) from antiretroviral therapy (ART) can be considered a catch-all category for patients who miss scheduled visits or medication pick-ups, operational definitions and methods for defining LTFU vary making comparisons across programs challenging. Using weekly cut-offs, we sought to determine the probability that an individual would return to clinic given that they had not yet returned in order to identify the LTFU cut-off that could be used to inform clinical management and tracing procedures.Methods: Individuals who initiated ART with Dignitas International supported sites (n = 22) in Zomba, Malawi between January 1 2007-June 30 2010 and were ≥ 1 week late for a follow-up visit were included. Lateness was categorized using weekly cut-offs from ≥1 to ≥26 weeks late. At each weekly cut-off, the proportion of patients who returned for a subsequent follow-up visit were identified. Cumulative Distribution Functions (CDFs) were plotted to determine the probability of returning as a function of lateness. Hazard functions were plotted to demonstrate the proportion of patients who returned each weekly interval relative to those who had yet to return.Results: In total, n = 4484 patients with n = 7316 follow-up visits were included. The number of included follow-up visits per patient ranged from 1-10 (median: 1). Both the CDF and hazard function demonstrated that after being ≥9 weeks late, the proportion of new patients who returned relative to those who had yet to return decreased substantially.Conclusions: We identified a LTFU definition useful for clinical management. The simple functions plotted here did not require advanced statistical expertise and were created using Microsoft Excel, making it a particularly practical method for HIV programs in resource-constrained settings. [ABSTRACT FROM AUTHOR]

Following a national policy shift toward universal access to antiretroviral therapy (ART) in Malawi, hospitals and clinics around the country made major changes to enable the provision of ART. In this already resource-limited environment, the provision of ART brought new health care delivery challenges to bear on both patients and health care professionals. The substance and form of these local interventions are affected by a multilayered global context. Drawing on fieldwork in an antiretroviral clinic in rural Malawi, this article discusses the daily implications of providing and receiving care in the context of a massive global shift in health policy, and argues that in order to fully understand the process of service rollout in all its complexity, care should be explored not only from the patients’ perspective but also from that of local and international health care professionals and policymakers. [ABSTRACT FROM PUBLISHER]

OBJECTIVES Since 1985, Malawi has experienced a dual epidemic of HIV and tuberculosis (TB) which has been moderated recently by the advent of antiretroviral therapy (ART). The aim of this study was to describe the association over several decades between HIV/AIDS, the scale-up of ART and TB case notifications. METHODS Aggregate data were extracted from annual reports of the National TB Control Programme, the Ministry of Health HIV Department and the National Statistics Office. ART coverage was calculated using the total HIV population as denominator (derived from UNAIDS Spectrum software). RESULTS In 1970, there were no HIV-infected persons but numbers had increased to a maximum of 1.18 million by 2014. HIV prevalence reached a maximum of 10.8% in 2000, thereafter decreasing to 7.5% by 2014. Numbers alive on ART increased from 2586 in 2003 to 536 527 (coverage 45.3%) by 2014. In 1985, there were 5286 TB cases which reached a maximum of 28 234 in 2003 and then decreased to 17 723 by 2014 (37% decline from 2003). There were increases in all types of new TB between 1998-2003 which then declined by 30% for extrapulmonary TB, by 37% for new smear-positive PTB and by 50% for smear-negative PTB. Previously treated TB cases reached a maximum of 3443 in 2003 and then declined by 42% by 2014. CONCLUSION The rise and fall of TB in Malawi between 1985 and 2014 was strongly associated with HIV infection and ART scale-up; this has implications for ending the TB epidemic in high HIV-TB burden countries. [ABSTRACT FROM AUTHOR]

We use probabilistic expectations data elicited from survey respondents in rural Malawi to investigate how risky sexual behaviour may be influenced by individuals' expectations about survival, and future HIV-status, which in turn depend on the perceived impact of HIV/AIDS on survival, expectations about own and partner's current HIV status, and expectations about HIV transmission rates. Subjective expectations, in particular about mortality risk but not the risk of living with HIV, play an important role in determining the decision to have multiple sexual partners. Using our estimated parameters, we simulate the impact of various policies that would influence expectations. An information campaign on mortality risk would decrease risky sexual behaviour on average, whereas an information campaign on HIV transmission risks, which tend to be overestimated by respondents, would actually increase risky behaviour. Also, the expansion of anti-retroviral therapy (ART) treatments to all individuals infected with HIV would increase risky sexual behaviour for a quarter of the HIV-negative individuals or those who have not been tested because they are aware that ART increases life expectancy, and thus reduces the cost of becoming HIV positive. [ABSTRACT FROM AUTHOR]